Epidemiology and clinical management of cardiomyopathies and heart failure in China

Prospective study of sleep duration, snoring and risk of heart failure

OBJECTIVE

To investigate whether nighttime sleep duration and snoring status were associated with incident heart failure (HF).

METHODS

A prospective study was conducted based on Kailuan cohort including 93 613 adults free of pre-existing cardiovascular diseases. Sleep duration and snoring status were assessed by self-reported questionnaire. Incident HF cases were ascertained by medical records. Cox proportional hazards model was applied to calculate the HR and 95% CI of risk of developing HF. Mediation analysis was used to understand whether hypertension and diabetes mediated the association between sleep duration, snoring and HF. Data analysis was performed from 1 June 2021 to 1 June 2022.

RESULTS

During a median follow-up of 8.8 years, we documented 1343 incident HF cases. Relative to sleep duration of 7.0-7.9 hour/night, short sleep duration was associated with higher risk of developing HF: adjusted HR was 1.24 (95% CI 1.01 to 1.55) for <6 hours/night and 1.29 (95% CI 1.06 to 1.57) for 6.0-6.9 hours/night, after adjustment for potential confounders such as age, sex, smoking, hypertension and diabetes. A similar 20%-30% higher risk of incident HF was found in individuals reporting occasional or frequent snoring relative to never/rare snorers: adjusted HR was 1.32 for occasional snoring (95% CI 1.14 to 1.52) and 1.24 (95% CI 1.06 to 1.46) for frequent snoring. Presence of diabetes significantly mediated the association between both short sleep duration and snoring and HF risk and hypertension significantly mediated the snoring-HF relationship.

CONCLUSION

Short sleep duration and snoring were associated with high risk of HF.

Patient profiles on outcomes in patients hospitalized for heart failure: a 10-year history of the Malaysian population

Aims

Heart failure (HF) affects an estimated 38 million people worldwide and is the leading cause of hospitalization among adults and the elderly. Evidence suggests that there may be regional and ethnic differences in the prevalence, outcomes and management of HF. The aim of this study was to understand the disease burden and treatment patterns of patients hospitalized for HF in multi‐ethnic Malaysia.

Methods and results

A retrospective, non‐interventional study was conducted utilizing 10 years of medical records from the National Heart Institute Malaysia (IJN) from 1 January 2009 to 31 December 2018. Of the 4739 patients in the IJN database, 3923 were eligible and were included in this analysis. The study recorded a high male prevalence (72.3%) with a mean age of 62.0 (±13.26) years. The 30‐day and 1‐year rehospitalization rate was 6.8% and 24.7%, respectively. In‐hospital mortality was 7.2% with 27.0% due to cardiovascular causes and 14.2% non‐cardiovascular causes. The 30‐day and 1‐year rehospitalization rates were significantly higher in patients with lower systolic blood pressure (SBP, P < 0.001 and P = 0.002), diastolic blood pressure (DBP, P < 0.001 and P = 0.017), sodium (P < 0.001 and P = 0.029) and estimated glomerular filtration rate (eGFR, P < 0.001 and P = 0.002) and higher urea (P < 0.001 for both), serum creatinine (P < 0.001 and P = 0.003), and uric acid (P < 0.001 for both), respectively. Risk of hospitalization within 1 year varied significantly by ethnicity and was relatively higher in Indian (28.3%), followed by Malay (24.4%) and Chinese (21.9%; P = 0.008). In‐hospital mortality within 1‐year post‐index date was higher in patients with lower weight (P = 0.002), body mass index (P = 0.009), SBP (P < 0.001), DBP (P < 0.001), sodium (P < 0.001), eGFR (P < 0.001) and higher heart rate (P = 0.039), urea (P < 0.001), serum potassium (P = 0.038), serum creatinine (P < 0.001), and uric acid (P < 0.001). In‐hospital mortality within 1‐year post‐index date was also higher in patients with severe or end‐stage chronic kidney disease (CKD) compared with mild/moderate CKD (P < 0.001) and in patients with HF with reduced ejection fraction (HFrEF) compared with those with mid‐range or preserved ejection fraction (P < 0.001). The most commonly prescribed HF medications at discharge were loop diuretics (89.2%), β‐blockers (68.5%), mineralocorticoid receptor antagonists (56.2%), angiotensin‐converting enzyme inhibitors (31.5%), and angiotensin receptor blockers (20.8%).

Conclusions

This study provides a greater understanding of the characteristics, treatment patterns, and outcome of hospitalized HF patients in a leading referral centre in Malaysia and will aid the implementation of meaningful interventions to improve patient outcome for HF patients.

Long-Term Cost-Effectiveness Comparison of Catheter Ablation and Antiarrhythmic Drugs in Atrial Fibrillation Treatment Using Discrete Event Simulation

OBJECTIVES

To evaluate the lifetime cost-effectiveness of 3 widely used atrial fibrillation (AF) treatments from the perspectives of Chinese healthcare system: antiarrhythmic drugs (AADs), ThermoCool SmartTouch guided by ablation index (STAI), and second-generation cryoballoon (CB2).

METHODS

A discrete event simulation (DES) model was implemented to compare the lifetime cost-effectiveness of AADs, STAI, and CB2. AF disease progression was explicitly modeled based on the Atrial Fibrillation Progression Trial clinical study results. The base-case analysis assumed that patients with paroxysmal AF (PAF) entered the model at the age of 55 years and had a CHA2DS2-VASc (Congestive heart failure, Hypertension, Age ( > 65 = 1 point, > 75 = 2 points), Diabetes, previous Stroke/transient ischemic attack (2 points)-Vascular disease (peripheral arterial disease, previous myocardial infarction, aortic atheroma), Age 65 to 74 years, and Sex category) score of 2 for males and 3 for females. Model parameter uncertainties were incorporated throughout the DES simulation with full probabilistic model parameterization.

RESULTS

The lifetime cost-effectiveness evaluations showed that patients treated with AADs gained an average of 4.98 quality-adjusted life-years (QALYs) and 9.63 life-years (LYs) at an average cost of US dollar (USD) 15 374. Patients treated with CB2 gained 5.92 QALYs and 10.74 LYs at an average cost of USD 26 811. The STAI group gained an average of 6.55 QALYs and 11.57 LYs at an average cost of USD 24 722. The incremental cost-effectiveness ratios was USD 5927 and USD 12 167 per QALY for STAI versus AADs and CB2 versus AADs, respectively. Assuming the willingness-to-pay threshold for China is USD 30 390 per QALY, both ablation treatments will be cost-effective compared with AADs for patients with PAF.

CONCLUSIONS

The DES model demonstrated that catheter ablations are more cost-effective than AADs for patients with PAF under the healthcare system in China. Among catheter ablation technologies, STAI provides better outcomes at lower costs.

Eight years follow-up of a patient with triple vessel disease patient complicated with heart failure without invasive intervention for home-based exercise rehabilitation combined traditional Chinese medicine: A case report

We report 8‐year follow‐up of a home‐based exercise rehabilitation program combined traditional Chinese medicine for a patient with triple vessel disease patient complicated with heart failure without invasive intervention. Improvements were observed in all outcomes.

For this patient with triple vessel disease patient complicated heart failure, we did not perform percutaneous coronary intervention, after applying home‐based cardiac rehabilitation combined with traditional Chinese medicine, the long‐term follow‐up.

Preventing heart failure: a position paper of the Heart Failure Association in collaboration with the European Association of Preventive Cardiology

The heart failure epidemic is growing and its prevention, in order to reduce associated hospital readmission rates and its clinical and economic burden, is a key issue in modern cardiovascular medicine. The present consensus document aims to provide practical evidence-based information to support the implementation of effective preventive measures. After reviewing the most common risk factors, an overview of the population attributable risks in different continents is presented, to identify potentially effective opportunities for prevention and to inform preventive strategies. Finally, potential interventions that have been proposed and have been shown to be effective in preventing HF are listed.

Preventing heart failure: a position paper of the Heart Failure Association in collaboration with the European Association of Preventive Cardiology

The heart failure epidemic is growing and its prevention, in order to reduce associated hospital readmission rates and its clinical and economic burden, is a key issue in modern cardiovascular medicine. The present position paper aims to provide practical evidence-based information to support the implementation of effective preventive measures. After reviewing the most common risk factors, an overview of the population attributable risks in different continents is presented, to identify potentially effective opportunities for prevention and to inform preventive strategies. Finally, potential interventions that have been proposed and have been shown to be effective in preventing heart failure are listed.

A Simple Clinical Risk Score to Predict Post-Discharge Mortality in Chinese Patients Hospitalized with Heart Failure

BACKGROUND

Cardiovascular diseases are the leading causes of death in China. However, present efforts to identify the risk factors for death in patients hospitalized with heart failure (HF) are primarily focused on in-hospital mortality and 30-day mortality in the United States. Thus, a model similar to the model used for predicting the risk in patients considered for cardiovascular surgical procedures is needed to evaluate the risk of the patients admitted with a diagnosis of HF.

OBJECTIVE

To identify variables that can predict post-discharge one-year HF mortality and develop a risk score to assess the risk of dying within one year.

METHODS

In the present study, 1,742 Chinese patients with HF were randomly divided into two groups: a derivation sample group and a test sample group. A Markov Chain Monte Carlo simulation method was used to identify variables that can predict the one-year post-discharge mortality. Variables with a frequency of >1% in the bivariate analysis and that were considered clinically meaningful were eligible for further modeling analyses. The posterior probability that a variable was statistically and significantly associated with the outcome was calculated as the total number of times that the variable's 95% CI did not overlap with 1 (i.e., the reference point) divided by the total number of iterations. A variable with a probability of 0.9 or higher was considered a robust risk factor for predicting the outcome, and this was included in the final variable list. The level of statistical significance adopted was 5%.

RESULTS

Five variables that could robustly predict the one-year post-discharge mortality were identified: age, female gender, New York Heart Association functional classification score >3, left atrial diameter, and body mass index. Both derivation and test models had a receiver operating curve area of 0.79. These selected variables were used to assess the one-year HF mortality risk score, and these were divided into three groups (low, moderate, and high). The high-risk group corresponds to nearly 86% of the deaths, while the moderate group corresponds to 12% of the deaths.

CONCLUSION

A simple 5-variable risk score can be used to assess the one-year post-discharge mortality of hospitalized Chinese patients with HF.

Efficacy and Safety of Different Aerobic Exercise Intensities in Patients With Heart Failure With Reduced Ejection Fraction: Design of a Multicenter Randomized Controlled Trial (HF-EI Trial)

Background: Heart failure (HF) is one of the major causes of mortality worldwide, representing the terminal stage of several cardiovascular diseases. Exercise-based rehabilitation is a beneficial therapy for patients with chronic heart failure (CHF). However, there is a lack of specific guidance on clinical decision-making regarding optimal exercise intensity. It is necessary to optimize the clinical recommendations for HF exercises. We will evaluate the efficacy and safety of different aerobic exercise intensities in patients with heart failure with reduced ejection fraction (HFrEF): the HF-EI trial. This trial aims to assess the appropriate exercise intensity for patients with HFrEF.

Methods: After a baseline assessment to determine the safety of exercise, 180 patients will be randomly assigned to supervised high-intensity exercise training (ET) group, supervised moderate intensity training (MIT) group, and control group at a ratio of 1:1:1. Patients randomly receiving high intensity training (HIT) undergo supervised ET (3 times/week, 30 min) for aerobic endurance at 70% peak oxygen consumption (peak VO₂) intensity for 12 weeks. The MIT patients will perform supervised aerobic ET (3 times/week, 35–42 min) at the anaerobic threshold (AT) intensity for 12 weeks. The control group will continue to maintain their daily activities and will not receive ET. During the baseline and follow-up period, physical examination, laboratory tests, cardiology diagnostic tests, cardiopulmonary exercise tests (CPET), 6-min walk distance (6MWD), scale scores, exercise steps, medications, and clinical events will be monitored. Throughout the research, sport bracelets and patient diaries will be used to monitor and record overall physical activity, training courses, and compliance.

Discussion: The HF-EI trial will evaluate the effects of different aerobic exercise intensities on peak VO₂, quality of life (QoL), and clinical events among patients with HFrEF. The findings of this trial will provide a basis for formulating exercise prescriptions for patients with HFrEF.

Clinical Trial Registration:http://www.chictr.org.cn/, identifier: ChiCTR2000036381.

Clinical characteristics and long-term prognosis of ischemic and non-ischemic cardiomyopathy

Objectives

The different etiology of HF has different prognostic risk factors. Prognosis assessment of ICM and NICM has important clinical value. This study is aimed to explore the predicting factors for ICM and NICM.

Methods

1082 HFrEF patients were retrospectively enrolled from Jan. 01, 2016 to Dec. 31, 2017. On Jan. 31, 2019, 873 patients were enrolled for analysis excluding incomplete, unfollowed, and unexplained data. The patients were divided into ischemic and non-ischemic group. The differences in clinical characteristics and long-term prognosis between the two groups were analyzed, and multivariate Cox analysis was used to predict the respective all-cause mortality, SCD and rehospitalization of CHF.

Results

873 patients aged 64(53,73) were divided into two groups: ICM (403, 46.16%) and NICM. At the end, 203 died (111 in ICM, 54.68%), of whom 87 had SCD (53 in ICM, 60.92%) and 269 had rehospitalization for HF(134 in ICM, 49.81%). Independent risk factors affecting all-cause mortality in ICM: DM, previous hospitalization of HF, age, eGFR, LVEF; for SCD: PVB, eGFR, Hb, revascularization; for readmission of HF: low T3 syndrome, PVB, DM, previous hospitalization of HF, eGFR. Otherwise; factors affecting all-cause mortality in NICM: NYHA III-IV, paroxysmal AF/AFL, previous hospitalization of HF, β-blocker; for SCD: low T3 syndrome, PVB, nitrates, sodium, β-blocker; for rehospitalization of HF: paroxysmal AF/AFL, previous admission of HF, LVEF.

Conclusions

Both all-cause mortality and SCD in ICM is higher than that in NICM. Different etiologies of CHF have different risk factors affecting the prognosis.

Kaempferol Regulates miR-15b/Bcl-2/TLR4 to Alleviate OGD-Induced Injury in H9c2 Cells

Ischemic heart disease (IHD) is one of the world's leading causes of human death. Kaempferol (Kae) was proved to have anti-inflammatory, antioxidant, and anticancer effects. Such properties suggested that it might play protective roles in IHD. In this study, we have attempted to disclose the potential regulating mechanisms of Kae in primary cardiomyocytes and H9c2 cells.Cells were first stimulated by oxygen-glucose deprivation (OGD) and then exposed to Kae. CCK-8 assay and flow cytometry were used to examine cell characteristics. Quantitative reverse-transcription polymerase chain reaction was utilized to test the expression levels of miR-15b and TLR4. Afterward, cell transfection, dual-luciferase activity assay, and western blot were used to explore the potential mechanisms.OGD treatment suppressed cell viability, whereas it enhanced cell apoptosis. Besides, OGD treatment enhanced the expression of apoptosis-associated proteins. Kae exposure, however, attenuated the effects that OGD-induced. Further experiments showed that Kae exposure promoted down-regulation of miR-15b, Bcl-2 and TLR4 were a target of miR-15b. Moreover, Kae enhanced the expression of key factors involved in PI3K/AKT and Wnt/β-catenin pathways, whereas miR-15b mimic reversed the Kae-triggered effects.This investigation revealed that Kae diminished OGD-triggered cell damage through down-regulating miR-15b expression via activating PI3K/AKT and Wnt3a/β-catenin pathways.

Quality of Care for Patients Hospitalized for Heart Failure in China

IMPORTANCE

Given the emerging heart failure (HF) epidemic in China, monitoring and improving the quality of care for heart failure is a top priority.

OBJECTIVES

To assess the quality of HF care provided to inpatients by examining the adherence to quality measures for HF care at the hospital level and to identify factors associated with the quality of care.

DESIGN, SETTING, AND PARTICIPANTS

In this multicenter, hospital-based, retrospective cross-sectional study in China, medical records of patients hospitalized for HF from January 1, 2015, to December 31, 2015, were analyzed from January 1, 2018, to May 20, 2019. In the first stage, simple random sampling stratified by economic-geographical regions in China was used to generate a list of participating hospitals. In the second stage, 15 538 hospitalizations from the 189 selected hospitals were systematically sampled, and 10 004 HF hospitalizations were included in the final sample.

MAIN OUTCOMES AND MEASURES

Adherence to the following 4 core performance measures at the hospital level: (1) left ventricular ejection fraction assessment during hospitalization; (2) evidence-based β-blocker (bisoprolol, carvedilol, or metoprolol succinate) for eligible patients at discharge; (3) angiotensin-converting enzyme inhibitors or angiotensin receptor blockers for eligible patients at discharge; and (4) scheduled follow-up appointment at discharge. At the hospital level, a composite performance score (ranging from 0-1) was also calculated by averaging these measures.

RESULTS

In total, 10 004 hospital admissions for HF at 189 hospitals were included in this study. The median (interquartile range [IQR]) patient age at admission was 73 (65-80) years, and 5117 (51.1%) of the patients were men. Among all hospitals, the median rate of adherence to measure 1 was 66.7% (IQR, 45.5%-80.7%; range, 0%-100%). The rate for adherence to measure 2 was 14.8% (IQR, 0%-37.5%; range, 0%-81.8%), and the rate for measure 3 was 57.1% (IQR, 36.4%-75.0%; range, 0%-100%). For measure 4, the median rate of adherence was 11.5% (IQR, 3.3%-32.8%; range, 0%-96.7%). The median (IQR) composite performance score across all hospitals was 40.0% (26.9%-51.9%), with a range from 2.2% to 85.4%. The median odds ratios of adherence were 2.2 (95% CI, 2.0-2.4) for measure 1, 2.1 (95% CI, 1.8-2.4) for measure 2, 2.4 (95% CI, 2.0-2.9 for measure 3, and 4.8 (95% CI, 3.9-5.8) for measure 4 among hospitals.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that quality of care for patients with HF in China may be substandard, and there is wide heterogeneity in the quality of care for HF among hospitals. The findings also suggest the need for a national strategy to improve and standardize the quality of HF care in China.

First-in-man study of Heartech® percutaneous left ventricular partitioning device for treatment of heart failure postmyocardial infarction

OBJECTIVE

This first-in-man (FIM) study aimed to determine the safety and efficacy of the Heartech® left ventricular partitioning device (LVPD) in patients with chronic heart failure (HF) postmyocardial infarction.

METHODS

Sixteen patients were enrolled from three cardiac intervention centers in China. All patients underwent percutaneous ventricular restoration (PVR) procedures with implantation of the Heartech® LVPD. Safety and immediate success rates were recorded. Major adverse cardiovascular and cerebrovascular events (MACCEs) including all-cause mortality, myocardial infarction, stroke, emergent or selective surgery or interventional therapy, renal failure requiring hemodialysis, and major bleeding were recorded. Efficacy features included functional status, echocardiographic characteristics, life quality characteristics including peak oxygen consumption of cardiopulmonary exercise testing (CPET), European five-dimensional health scale (EQ-5D), 6-min walk test (6MWT) at baseline and during follow-up (NCT02938637).

RESULTS

The device success rate was 93.75% (15 successes in 16 patients) with 100% safety. During follow-up of 36 ± 4.5 days, no MACCEs were found. The left ventricular end-systolic volume index decreased significantly (LVESVi, 72.47 ± 22.77 mL/m² vs. 50.13 ± 13.36 mL/m² , p < .001) as did left ventricular end diastolic volume index (LVEDVi, 106.27 ± 28.01 mL/m² vs. 83.20 ± 16.87 mL/m² , p = .001). Left ventricular ejection fraction (LVEF, 32.47 ± 6.98% vs. 40.41 ± 6.15, p < .001), 6MWT (383.13 ± 108.70 vs. 453.47 ± 88.24, p < 0.001) and EQ-5D (65.93 ± 11.25 vs. 78.67 ± 8.35, p < .001) improved significantly.

CONCLUSIONS

Heartech® LVPD appeared to be safe and effective for treatment of HF postmyocardial infarction.

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

Background

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

Methods

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

Results

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

Conclusions

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

Impact of serum 25-hydroxyvitamin D on cardiac prognosis in Chinese patients with heart failure

There is growing evidence that suggests the association of vitamin D status with the development and progression of heart failure (HF). The objective of the present study is to assess the impact of concentration of serum 25-hydroxyvitamin D (25(OH)D) on cardiac prognosis in patients with HF. Between 1 January 2015 and 31 December 2016, we consecutively recruited patients with HF. Patients were followed prospectively for a median duration of 1 year. Serum concentration of 25(OH)D was measured with competitive chemiluminescent immunoassay. The endpoints were cardiac events, including CVD death and rehospitalisation for worsening HF. Univariate and multivariable adjustments were performed with Cox proportional-hazard regression analyses. The 25(OH)D concentration was obtained in 343 patients with a median value of 17·4 (interquartile range 12·6-23·4) ng/ml. There were 102 cardiac events, including forty-three deaths and fifty-nine rehospitalisations. Multivariate Cox hazard analysis found that the serum concentration 25(OH)D was independently associated with cardiac events (hazard ratio 0·93, 95 % CI 0·88, 0·97) and CVD mortality (hazard ratio 0·83; 95 % CI 0·77, 0·89) after adjustment for confounding factors. We divided the HF patients into four groups according to the 25(OH)D quartiles. Kaplan-Meier analysis found that the patients with lower serum 25(OH)D concentration had a higher risk of cardiac events or CVD mortality than those with high serum 25(OH)D concentration (log-rank test P < 0·001 and P = 0·032). Decreased serum concentrations of 25(OH)D were associated with cardiac prognosis and CVD mortality in a Chinese population with HF independent of other baseline HF markers.

Yixinshu capsule combined with conventional treatment for chronic heart failure: Protocol for a systematic review and trial sequential analysis

BACKGROUND

Yixinshu Capsule is widely utilized in Asia for the treatment of chronic heart failure (CHF) as a conventional drug, but a comprehensive conclusion is lacking. Here, we will provide a protocol to perform a meta-analysis and trial sequential analysis to evaluate the efficacy of Yixinshu Capsule combined with conventional treatment for chronic heart failure.

METHODS

We will conduct a thorough search in six databases, PubMed, EMBASE, Cochrane Library Database, Chinese National Knowledge Infrastructure (CNKI), Chinese Science Journal Database (VIP), and Chinese Biomedical and Medical Database (CBM). Inclusion criteria will be randomized control trials (RCTs) with one group receiving Yixinshu Capsule based on conventional treatment and another group receiving conventional treatment alone. Modified Jadad scale and Cochrane's risk of bias assessment will be used to assess methodological quality. Only studies with modified Jadad scale score ≥3 will be included in meta-analysis for efficacy, which will be defined as moderate methodological quality. The total effective rate will be considered as the primary outcome and the secondary outcome will include mortality, rehospitalized rate, left ventricular ejection fraction (LVEF), 6-minute walking distance, E/A, left ventricular end-diastolic diameter (LVEDD), BNP, and NT-proBNP. We will conduct trial sequential analysis to evaluate the reliability of the primary outcome.

RESULTS

This study will provide a rational synthesis of current evidences for Yixinshu Capsule on chronic heart failure.

CONCLUSION

The conclusion of this study will provide evidence for judging the efficacy of Yixinshu Capsule on chronic heart failure.

REGISTRATION

PROS-PERO CRD42019119612.

Palliative care needs of heart failure patients in China: putting people first

PURPOSE OF REVIEW

Recognizing the rising prevalence of heart failure in China, patients with heart failure have substantial palliative needs. This review highlights recent evidence on the epidemic of heart failure, identifies needs and potential benefit of palliative care in heart failure, and sets future strategic policy and research directions in China.

RECENT FINDINGS

Epidemiological studies demonstrate the prevalence of heart failure among women is higher than men in China and increases substantially with age. However, few studies have addressed the palliative needs of Chinese heart failure patients. The main themes from this review include: Healthcare providers should be culturally sensitive whenever assessing symptoms and needs. Locally validated, brief outcome measures are called for to identify symptoms and needs of Chinese heart failure patients. Palliative care should be better integrated into the management of heart failure through increased training for healthcare providers, policy development, financial support, and cultural acceptance of palliative care.

SUMMARY

Large-scale epidemiological studies are urgently needed to assess the current situation of heart failure in China, alongside interventional studies to drive the development of innovative palliative care services to address the needs of Chinese heart failure patients.

Cytoprotective and antioxidant effects of the red alga Alsidium corallinum against hydrogen peroxide-induced toxicity in rat cardiomyocytes

CONTEXT

Sepsis is the manifestation of the immune and inflammatory responses to infection that may ultimately result in multiorgan failure. Many substances are involved in myocardial dysfunction in sepsis, including hydrogen peroxide.

OBJECTIVE

This study evaluates the protective activity of the red alga Alsidium corallinum against hydrogen peroxide (H₂O₂)-induced toxicity in H9c2 cardiomyocytes.

MATERIAL AND METHODS

The biological properties of A. corallinum were firstly investigated. Secondly, the H9c2 cells were pre-treated with alga extract, and then exposed to H₂O₂.

RESULTS

Our results showed richness of the alga in antioxidant compounds, and its biological activities. H₂O₂ induced a morphological changes and decrease in H9c2 cell viability correlating with an increase in enzymatic and non-enzymatic antioxidants. Pre-treatment with A. corallinum, reduces toxicity and decreased the antioxidants status induced by H₂O₂.

CONCLUSION

These findings indicated for the first time the protective effect of A. corallinum against H₂O₂-induced toxicity in H9c2 cells.

Fuling Sini decoction for patients with chronic heart failure: A protocol for a systematic review and meta-analysis

BACKGROUND

Chronic heart failure (CHF) is one of the most important cardiovascular diseases worldly, with high morbidity and mortality. Fuling Sini decoction (FSD) has been used in the management of CHF widely in China, while its effective evidence is not clear. A systematic review and meta-analysis to evaluate FSD for CHF is lacking. Hence, we propose a protocol for systematic evaluation of its efficacy and safety for CHF.

METHODS

We will search the following electronic databases from inception to October 2018, including EMBASE, Cochrane Center Registration Controlled trials (Cochrane Library), PubMed, Medline, WHO International Clinical Trials Registry Platform, China Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP), and Wan-fang database. Only randomized controlled trials (RCTs) of FSD alone or combined with other management for CHF will be included. Two independent reviewers will screen the literature and extract data according to the Cochrane Handbook method. The assessment of bias risk, data synthesis, subgroup analysis, and meta-analyses and finally meta-analysis will be performed by using RevMan V.5.3.5 software.

RESULTS

This systematic review will provide high-quality evidence and may be the first to evaluate efficacy and safety of FSD in the treatment of CHF.

CONCLUSION

This systematic review will provide evidence for judging whether FSD is an effective management for CHF or not.

PROSPERO REGISTRATION NUMBER

CRD 42018110210.

Post-discharge short message service improves short-term clinical outcome and self-care behaviour in chronic heart failure

Aims

In addition to giving optimal medical and device therapy, promoting self‐care of chronic heart failure (CHF) patients also plays an important role in comprehensive disease management for better outcomes. The study was aimed to investigate whether short message service (SMS) would help to improve death or readmission‐free survival and self‐care behaviour in CHF patients.

Methods and results

This was a randomized controlled trial. Between December 2011 and September 2015, patients admitted with decompensated CHF in a tertiary referral hospital who fulfilled the inclusion criteria were enrolled and randomized to receive SMS, structured telephone support (STS), or usual care after discharge. All patients were followed up to 180 days after discharge by phone call or clinic visit. Primary endpoint was the 180 day composite event, defined as all‐cause mortality or readmission. Secondary endpoints included self‐care behaviour and quality of life. Seven hundred sixty‐seven patients (61 ± 15 years, 56.5% male) were finally randomized to receive SMS (n = 252), STS (n = 255), or usual care (n = 260). Baseline characteristics were similar among the three groups. Five hundred twenty‐five (68.4%) patients were in New York Heart Association Class III or IV, and 472 (61.5%) patients had an ejection fraction of <50%. During a 180 day follow‐up, 76 (9.9%) patients died and 274 (35.7%) patients experienced at least one readmission. In a short‐term follow‐up of 30 days, there was no difference in mortality and the composite endpoint among the three groups (SMS vs. STS vs. usual care: 2.8% vs. 3.1% vs. 3.8% for mortality, P = 0.786; 12.3% vs. 14.5% vs. 15.4% for the composite endpoint, P = 0.588). The 180 day composite event rate was significantly lower in the SMS and STS groups (50.4% vs. 41.3% and 36.5%, both P < 0.05) than in the usual care group, but no difference was observed between the two phone‐based intervention groups (P = 0.268). Although there was no difference between the two groups, better self‐care behaviour was reported in the SMS and STS groups than in the control group (medication compliance, 78.9% vs. 81.4% vs. 69.5%, P = 0.011; water restriction, 70.8% vs. 74.5% vs. 61.5%, P = 0.013). Quality‐of‐life score was similar among the three groups at 180 days (P = 0.526).

Conclusions

In CHF patients, post‐discharge SMS, which appeared as efficient as STS, reduced the 180 day composite event and improved self‐care behaviour. SMS intervention could be integrated into CHF management.

Care pathways and treatment patterns for patients with heart failure in China: results from a cross-sectional survey

Purpose

The objective of this study was to describe the clinical care pathways, management and treatment patterns, and hospitalizations for patients with heart failure (HF) in China.

Subjects and methods

A cross-sectional survey of cardiologists and their patients with HF was conducted. Patient record forms were completed by 150 cardiologists for 10 consecutive patients. Patients for whom a patient record form was completed were invited to complete a patient self-completion questionnaire.

Results

Most of the 1,500 patients (mean [SD] age 66 [10] years; 55% male) included in the study received care in tier-2 and -3 hospitals in large cities. Cardiologists were responsible for initial consultation, diagnosis, and treatment of patients with HF. The use of guideline-recommended diagnostics was high. However, guideline-recommended double- and triple-combination therapy was received by only 51% and 18% of patients, respectively. In total, 20% of patients with HF reported that they were not consulted on the choice of therapy. Concordance was high (≥80%) between matched cardiologist and patient pairs for the occurrence of side effects, while cardiologists more often under- than overreported the occurrence of side effects of treatment reported by patients.

Conclusion

The management of HF was predominantly overseen by cardiologists. The use of diagnostic tests was high, but the use of guideline-recommended treatment was low in this population. Improved communication between patients and cardiologists is essential to optimize treatment decision making and to increase awareness of treatment side effects.

Honokiol Protects against Anti-β1-Adrenergic Receptor Autoantibody-Induced Myocardial Dysfunction via Activation of Autophagy

Myocardial diseases are prevalent syndromes with high mortality rate. The exploration of effective interference is important. Anti-β1-adrenergic receptor autoantibody (β1-AAB) is highly correlated with myocardial dysfunction. The actions and underlying mechanisms of honokiol (HNK) in β1-AAB-positive patients await to be unraveled. In this study, we established a rat model of β1-AAB positive with myocardial dysfunction. Cardiac function following β1-AR-ECII administration was analyzed using the VisualSonics Vevo 770 High-Resolution In Vivo Imaging System. The levels of autophagy-related proteins were detected by Western blotting. Our data revealed that HNK reversed β1-AAB-induced effects and protected myocardial tissues from dysfunction. After HNK treatment, the cardiac contractile ability increased and the LDH activity decreased. HNK attenuated myocardial degeneration. In addition, HNK promoted the activation of the AMP-dependent protein kinase/Unc-51-like autophagy activating kinase (AMPK/ULK) pathway and activated autophagy. These results suggest that HNK protects against β1-AAB-induced myocardial dysfunction via activation of autophagy and it may be a potentially therapeutic compound for β1-AAB-positive myocardial diseases.

Perceptions and Acceptability of Receiving SMS Self-care Messages in Chinese Patients With Heart Failure: An Inpatient Survey

BACKGROUND

Self-care is critical for postdischarge heart failure (HF) patients. Short message service (SMS) is a promising way to promote HF self-care.

OBJECTIVE

The aim of this study is to investigate knowledge status in Chinese HF patients, as well as the acceptance of SMS as a way to improve self-care.

METHODS

A survey using a self-developed questionnaire was conducted in patients with decompensated HF 2 days before discharge.

RESULTS

A total of 540 patients completed the survey. Among them, only 69.8% and 63.3% of patients were aware of their HF status and medication regimen, respectively. A total of 95.6% patients were willing to receive SMS. Patient himself/herself, caregiver, or both patient and caregiver were almost equally selected as the preferred receiver of SMS. Educational and/or reminder SMS was considered "very helpful" by 50.2% of the patients as a way of promoting self-care, similar to that of telephone education and brochure education. "Take your medicine", "avoid getting flu," and "keep follow-up" were regarded as the most important self-care contents, whereas "weigh yourself every day" and "restrict fluid intake" were considered the least important.

CONCLUSION

As a way of promoting HF self-care, SMS intervention combining educational and reminder function might be well accepted by HF patients in China. The status of HF, medication, weight control, and fluid restriction should be emphasized during the practice. Caution should be drawn as the survey was not tested elsewhere. Further clinical trials would be conducted to examine the effect of SMS intervention on self-care behaviors and outcomes of HF patients.

Effect of an exercise-based cardiac rehabilitation program "Baduanjin Eight-Silken-Movements with self-efficacy building" for heart failure (BESMILE-HF study): study protocol for a randomized controlled trial

BACKGROUND

Exercise-based cardiac rehabilitation is a beneficial therapy for patients with chronic heart failure. The delivery of exercise-based cardiac rehabilitation should adopt an evidence-based approach, as well as be culturally appropriate and sensitive to individual needs and preferences. The Baduanjin Eight-Silken-Movements with Self-efficacy Building for Heart Failure (BESMILE-HF) program is the first to apply a traditional Chinese exercise, Baduanjin, as the core component in an exercise-based cardiac rehabilitation program. This trial aims to assess the efficacy, safety, and acceptability of the addition of the BESMILE-HF program to usual medications for patients with chronic heart failure.

METHODS/DESIGN

The BESMILE-HF study is a mixed-design study. It includes a two-group, parallel, randomized controlled trial with 200 chronic heart failure patients, as well as a qualitative component. Patients will be randomized into either an intervention group receiving the 12-week BESMILE-HF program plus usual medications, or a control group receiving only usual medications. The primary outcomes are peak oxygen consumption assessed using a cardiopulmonary exercise test, and disease-specific quality of life using the Minnesota Living with Heart Failure Questionnaire. The secondary outcomes are: exercise performance, exercise self-efficacy, general quality of life, dyspnea and fatigue, depression, cardiac function, prognostic and inflammatory indicator levels, hospitalization, use of medications, and major adverse cardiac events. Assessments will be carried out at baseline, and at the 4th week, 8th week, and 12th week. The qualitative component will include a semi-structure interview describing patients' experiences with the intervention.

DISCUSSION

This study can provide evidence for how to deliver a contextually adapted exercise-based cardiac rehabilitation program with the potential to be scaled up throughout China.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03180320 . Registered on 2 June 2017.

A single-center observational study on the efficacy of percutaneous coronary intervention for ischemic heart failure: A cohort study

The effects of revascularization by percutaneous coronary intervention (PCI) on cardiac function and clinical outcomes in patients with confirmed coronary artery disease (CAD) and heart failure (HF), on the basis of the optimal medical treatment recommended by current guidelines, remain to be determined.A cohort study was performed to evaluate the efficacy of PCI on the basis of optimal medical treatment in patients with CAD and HF. Patients who received PCI were subsequently grouped according to partial and complete revascularization (CR) depending on the PCI outcome. The primary outcome was defined as a composite outcome of major adverse cardiovascular events (MACEs). Changes in left ventricular ejection fraction (LVEF) also were compared.A total of 69 patients (12 who received medical treatment and 57 who received PCI) were included. Patients in the PCI group showed significantly improved LVEF (P < .001), but patients in the medical treatment group did not (P > .05) after 3 months of follow-up. MACEs occurred in 50% patients in the medical treatment group and 19.3% patients of the PCI group, with this difference almost reaching statistical significance (P = .06). Compared with patients who received medical therapy only, patients who received PCI experienced better survival (P = .02). Moreover, survival seemed to be better in patients who achieved CR with PCI of the coronary arteries than in those who had partial revascularization of the coronary arteries (P = .06).PCI may be effective for improving survival in patients with CAD and HF.

Self-emulsifying drug delivery system improves preventive effect of curcuminoids on chronic heart failure in rats

Several studies have reported the preventive or therapeutic effect of curcuminoids on chronic heart failure (CHF), but their application was limited due to low solubility and bioavailability. Our previous study indicates that self-emulsifying drug delivery system (SEDDS) improves the solubility and bioavailability of curcuminoids. Thus, the aim of this work was to investigate whether SEDDS could improve preventive effect of curcuminoids on CHF in rats. CHF model was were established by coronary artery ligation. Ninety rats were randomly and averagely divided into sham, model, low- or high-dose suspension or SEDDS of curcuminoids (66.68 or 266.68 mg/kg) groups. Hemodynamic indices were recorded by multipurpose polygraph. Serum oxidative indices, B-type natriuretic peptide (BNP) and heart weight index were determined by kits and electronic balance. Myocardial infarct area, ventricular dilatation degree and collagen volume fraction of myocardial interstitium were analyzed by Masson staining, picric acid and sirius red staining, light microscopy and image analysis system. Myocardial histopathology was observed by hematoxylin and eosin staining, Masson staining and light microscopy. Reduction of ventricular pump function, increase of BNP level and heart weight index, myocardial lipid peroxidation damage, myocardial infarction, myocardial fibrosis, and cardiac enlargement were detected or observed in model group relative to those in sham group. After treatment with suspension or SEDDS of curcuminoids, the above-mentioned pathological changes were obviously reversed relative to those in model group. Meanwhile, the ameliorative effect of SEDDS of curcuminoids was markedly better than that of suspension of curcuminoids. This work provides a valuable reference from pharmacodynamics for development of curcuminoids pharmaceutics.

Insurance status, inhospital mortality and length of stay in hospitalised patients in Shanxi, China: a cross-sectional study

OBJECTIVES

To determine insurance-related disparities in hospital care for patients with acute myocardial infarction (AMI), heart failure (HF) and pneumonia.

SETTING AND PARTICIPANTS

A total of 22 392 patients with AMI, 8056 patients with HF and 17 161 patients with pneumonia were selected from 31 tertiary hospitals in Shanxi, China, from 2014 to 2015 using the International Classification of Diseases, Tenth Revision codes. Patients were stratified by health insurance status, namely, urban employee-based basic medical insurance (UEBMI), urban resident-based basic medical insurance (URBMI), new cooperative medical scheme (NCMS) and self-payment.

OUTCOME MEASURES

Inhospital mortality and length of stay (LOS).

RESULTS

The highest unadjusted inhospital mortality rate was detected in NCMS patients independent of medical conditions (4.7%, 4.4% and 11.1% for AMI, HF and pneumonia, respectively). The lowest unadjusted inhospital mortality rate and the longest LOS were observed in UEBMI patients. After controlling patient-level and hospital-level covariates, the adjusted inhospital mortality was significantly higher for NCMS and self-payment among patients with AMI, for NCMS among patients with HF and for URBMI, NCMS and self-payment among patients with pneumonia compared with UEBMI. The LOS of the URBMI, NCMS and self-payment groups was significantly shorter than that of the UEBMI group.

CONCLUSION

Insurance-related disparities in hospital care for patients with three common medical conditions were observed in this study. NCMS patients had significantly higher adjusted inhospital mortality and shorter LOS compared with UEBMI patients. Policies on minimising the disparities among different insurance schemes should be established by the government.

Heart Transplant in Asia

The prevalence of heart failure has increased in Asia. A significant proportion of patients with heart failure and left ventricular dysfunction end up with advanced heart failure or end-stage heart disease. These patients may be placed on the waiting list for heart transplant. There are more than 10 countries in Asia that have an active heart transplant program. The number of heart transplants performed is limited despite an increase in the number of patients with end-stage heart failure mainly because of donor shortage, which may be related to religious belief and inefficient allocation policy.

Effect of B-Type Natriuretic Peptide Level on Long-Term Outcome in Patients With End-Stage Heart Failure

Previous studies have demonstrated elevated B-type natriuretic peptide (BNP) level indicates a poor outcome in patients with heart failure (HF). However, some patients with end-stage HF presented with low BNP level and the impact of the nearly "normal" BNP level on long-term outcome is not well understood. Our study aimed to evaluate the association of BNP level with long-term outcome in 218 consecutive patients with dilated cardiomyopathy and end-stage HF. Sixty-two patients (28%) presented with admission BNP level ≤400 pg/ml. During a median follow-up period of 20 months (4 to 26 months), the all-cause mortality rate in patients with BNP ≤400 pg/ml was higher than in patients with BNP >400 pg/ml (76% vs 48%, p <0.001). Patients were then divided into 5 groups according to the BNP level (≤400, 401 to 1,000, 1,001 to 2,000, 2,001 to 3,000, and >3,000 pg/ml), the all-cause mortality were 76%, 41%, 40%, 49%, and 75%, respectively (p <0.001). After multivariate adjustment, both BNP ≤400 and >3,000 pg/ml were independently associated with increased risk of all-cause mortality (hazard ratios 1.87, 95% CI 1.02 to 3.42, p = 0.043 and hazard ratio 2.31, 95% CI 1.16 to 4.60, p = 0.018, respectively). In conclusion, our present study demonstrated a "U-like" shape between BNP level and all-cause mortality in end-stage HF, and the seemingly "normal" BNP level might also be a risk factor for poor outcome. Low BNP level may be a reflection of impaired neurohormonal response or altered metabolism of BNP and is associated with increased risk of poor outcome.

Therapeutic effects of intravenous urapidil in elderly patients with hypertension and acute decompensated heart failure: A pilot clinical trial

Urapidil has been proposed to be an effective vasodilator for the treatment of acute decompensated heart failure (ADHF); however, its effect on cardiac function, as compared with that of nitroglycerin, in elderly patients with hypertension and ADHF has yet to be determined. In the present study, a multicenter, open-label clinical trial was performed, in which 120 elderly patients with hypertension and ADHF were randomly assigned to the treatment (50–400 µg/min intravenous urapidil) or control group (5–40 µg/min intravenous nitroglycerin). The dosages of the medications were adjusted according to the blood pressure of the patients. The systolic and diastolic blood pressure, heart rate and serum level of N-terminal pro B-type natriuretic peptide (NT-proBNP) were evaluated at hospital admission and at days 1, 2, 3 and 7 after treatment. In addition, the left ventricular function was assessed by measuring the left ventricular ejection fraction (LVEF) and left ventricular end-diastolic volume at hospital admission and at days 2 and 7 after treatment. The results indicated that intravenous administration of urapidil and nitroglycerin were effective in lowering the blood pressure and heart rate within 7 days, with no significant differences observed between the two groups (P>0.05). By contrast, greater reduction in the serum NT-proBNP level (2,410.4±546.1 vs. 4,234.1±876.4 pg/ml; P<0.05) and greater improvement in the LVEF (55.3±3.4 vs. 45.2±2.4%; P<0.05) were observed in the urapidil-treated group, as compared with the nitroglycerin-treated group. No adverse events were reported during the treatment period in the two groups. The clinical outcomes at 6 months following discharge were evaluated and were not found to be significantly different between the two groups. In conclusion, the present results of the present study suggested that urapidil was as effective as nitroglycerin in controlling blood pressure and heart rate and was more effective in improving cardiac systolic function in elderly patients with hypertension and ADHF.

Influence of heart failure on the prognosis of patients with acute myocardial infarction in southwestern China

The impact of heart failure (HF) on acute myocardial infarction (AMI) in patients from southwestern China remains unclear. The present study aimed to compare in-hospital cardiovascular events, mortality and clinical therapies in AMI patients with or without HF in southwestern China. In total, 591 patients with AMI hospitalized between February 2009 and December 2012 were examined; those with a history of HF were excluded. The patients were divided into four groups according to AMI type (ST-elevated or non-ST-elevated AMI) and the presence of HF during hospitalization. Clinical characteristics, in-hospital cardiovascular events, mortality, coronary angiography and treatment were compared. Clinical therapies, specifically evidence-based drug use were analyzed in patients with HF during hospitalization, including angiotensin converting enzyme inhibitors (ACEIs) and β-blockers (BBs). AMI patients with HF had a higher frequency of co-morbidities, lower left ventricular ejection fraction, longer length of hospital stay and a greater risk of in-hospital mortality compared with AMI patients without HF. AMI patients with HF were less likely to be examined by cardiac angiography or treated with reperfusion therapy or recommended medications. AMI patients with HF co-treated with ACEIs and BBs had a significantly higher survival rate (94.4 vs. 67.5%; P<0.001) compared with untreated patients or patients treated with either ACEIs or BBs alone. Logistic regression analysis revealed that HF and cardiogenic shock in patients with AMI were the strongest predictors of in-hospital mortality. AMI patients with HF were at a higher risk of adverse outcomes. Cardiac angiography and timely standard recommended medications were associated with improved clinical outcomes.

Heart Failure in Africa, Asia, the Middle East and South America: The INTER-CHF study

BACKGROUND

There are few data on heart failure (HF) patients from Africa, Asia, the Middle East and South America.

METHODS

INTER-CHF is a prospective study that enrolled HF patients in 108 centers in 16 countries from 2012 to 2014. Consecutive ambulatory or hospitalized adult patients with HF were enrolled. Baseline data were recorded on sociodemographics, clinical characteristics, HF etiology and treatments. Age- and sex-adjusted results are reported.

RESULTS

We recruited 5813 HF patients: mean(SE) age=59(0.2)years, 39% female, 65% outpatients, 31% from rural areas, 26% with HF with preserved ejection fraction, with 1294 from Africa, 2661 from Asia, 1000 from the Middle-East, and 858 from South America. Participants from Africa-closely followed by Asians-were younger, had lower literacy levels, and were less likely to have health or medication insurance or be on beta-blockers compared with participants from other regions, but were most likely to be in NYHA class IV. Participants from South America were older, had higher insurance and literacy levels, and, along with Middle Eastern participants, were more likely to be on beta-blockers, but had the lowest proportion in NYHA IV. Ischemic heart disease was the most common HF etiology in all regions except Africa where hypertensive heart disease was most common.

CONCLUSIONS

INTER-CHF describes significant regional variability in socioeconomic and clinical factors, etiologies and treatments in HF patients from Africa, Asia, the Middle East and South America. Opportunities exist for improvement in health/medication insurance rates and proportions of patients on beta blockers, particularly in Africa and Asia.

Heart failure in low- and middle-income countries: background, rationale, and design of the INTERnational Congestive Heart Failure Study (INTER-CHF)

BACKGROUND

Although heart failure (HF) has been referred to as a global epidemic, most HF information comes from high-income countries, with little information about low-income countries (LIC) and middle-income countries (MIC) in Africa, Asia, the Middle East, and South America, which make up the majority of the world's population.

METHODS

The INTERnational Congestive Heart Failure Study is a cohort study of 5,813 HF patients enrolled in 108 centers in 16 LIC and MIC. At baseline, data were recorded on sociodemographic and clinical risk factors, HF etiology, laboratory variables, management, and barriers to evidence-based HF care at the patient, physician, and system levels. We sought to enroll consecutive and consenting patients ≥18 years of age with a clinical diagnosis of HF seen in outpatient clinics (2/3 of patients) or inpatient hospital wards (1/3 of patients). Patients were followed up at 6 and 12 months post-enrollment to record clinical status, treatments, and clinical outcomes such as death and hospitalizations. In the 5,813 enrolled HF patients, the mean age was 59 ± 15 years, 40% were female, 62% had a history of hypertension, 30% had diabetes, 21% had prior myocardial infarction, 64% were recruited from outpatient clinics, 36% lived in rural areas, and 29% had HF with preserved left ventricular ejection fraction.

CONCLUSIONS

This unique HF registry aims to systematically gather information on sociodemographic and clinical risk factors, etiologies, treatments, barriers to evidence-based care, and outcomes of HF in LIC and MIC. This information will help improve the management of HF globally.

Common Variants in TRDN and CALM1 Are Associated with Risk of Sudden Cardiac Death in Chronic Heart Failure Patients in Chinese Han Population

Background

Recent studies suggest that variants in two calcium handling genes (RyR2 and CASQ2) associated with sudden cardiac death (SCD) and non-sudden cardiac death (NSCD) in subjects with heart failure and coronary artery disease, respectively. The purpose of this study was to identify other calcium handling genes associated with SCD in the long-term of chronic heart failure (CHF) in Chinese Han population.

Methods and Results

We investigated 20 SNPs representing 10 genes that regulated calcium handling in 1429 patients with CHF, and the genetic association with SCD and all-cause death was analysed. During a median follow-up period of 63 months, 538 patients (37.65%) died from CHF, of whom 185 (34.38%) had SCD and the others were NSCD. SNPs that pass a P value cut-off of 0.0025 were considered as significant. We found that patients carrying the CC genotype of rs3814843 on CALM1 gene had greater risks of SCD (HR 5.542, 95% CI 2.054–14.948, P = .001) and all cause death (HR 3.484, 95% CI 1.651–7.350, P = .001). After adjusting for other risk factors, significant associations remained. Moreover, patients carrying G allele of rs361508 on TRDN gene also had increased risk of SCD.

Conclusions

Common variants in TRDN and CALM1 are associated with increased risk of SCD in patients with CHF. These findings provide further evidence for association of variants in calcium handling regulating proteins and SCD in chronic heart failure.

Association of SNP Rs9943582 in APLNR with Left Ventricle Systolic Dysfunction in Patients with Coronary Artery Disease in a Chinese Han GeneID Population

Heart failure affects 1–2% of the adult population worldwide and coronary artery disease (CAD) is the underlying etiology of heart failure in 70% of the patients. The pathway of apelin and its apelin receptor (APJ) was implicated in the pathogenesis of heart failure in animal models, but a similar role in humans is unknown. We studied a functional variant, rs9943582 (-154G/A), at the 5’-untranslated region, that was associated with decreased expression of the APJ receptor gene (APLNR) in a population consisting of 1,751 CAD cases and 1,022 controls. Variant rs9943582 was not associated with CAD, but among CAD patients, it showed significant association with left ventricular systolic dysfunction (431 CAD patients with left ventricular systolic dysfunction (LV ejection fraction or LVEF< 40%) versus 1,046 CAD patients without LV systolic dysfunction (LVEF>50%) (P-adj = 6.71×10^-5, OR = 1.43, 95% CI, 1.20–1.70). Moreover, rs9943582 also showed significant association with quantitative echocardiographic parameters, including left ventricular end-diastolic diameter (effect size: increased 1.67±0.43 mm per risk allele A, P = 1.15×10^-4), left atrial size (effect size: increased 2.12±0.61 mm per risk allele A, P = 9.56×10^-4) and LVEF (effect size: decreased 2.59±0.32 percent per risk allele A, P = 7.50×10^-15). Our findings demonstrate that allele A of rs9943582 was significantly associated with left ventricular systolic dysfunction, left ventricular end-diastolic diameter, the left atrial diameter and LVEF in the CAD population, which suggests an important role of the apelin/APJ system in the pathology of heart failure associated with ischemic heart disease.

Image-guided left ventricular lead placement in cardiac resynchronization therapy for patients with heart failure: a meta-analysis

Background

Heart failure (HF) is a debilitating condition that affects millions of people worldwide. One means of treating HF is cardiac resynchronization therapy (CRT). Recently, several studies have examined the use of echocardiography (ECHO) in the optimization of left ventricular (LV) lead placement to increase the response to CRT. The objective of this study was to synthesize the available data on the comparative efficacy of image-guided and standard CRT.

Methods

We searched the PubMed, Cochrane, Embase, and ISI Web of Knowledge databases through April 2014 with the following combinations of search terms: left ventricular lead placement, cardiac resynchronization therapy, image-guided, and echocardiography-guided. Studies meeting all of the inclusion criteria and none of the exclusion criteria were eligible for inclusion. The primary outcome measures were CRT response rate, change in LV ejection fraction (LVEF), and change in LV end systolic volume (LVESV). Secondary outcomes included the rates of all-cause mortality and HF-related hospitalization.

Results

Our search identified 103 articles, 3 of which were included in the analysis. In total, 270 patients were randomized to the image-guided CRT and 241, to the standard CRT. The pooled estimates showed a significant benefit for image-guided CRT (CRT response: OR, 2.098, 95 % CI, 1.432–3.072; LVEF: difference in means, 3.457, 95 % CI, 1.910–5.005; LVESV: difference in means, −20.36, 95 % CI, −27.819 – −12.902).

Conclusions

Image-guided CRT produced significantly better clinical outcomes than the standard CRT. Additional trials are warranted to validate the use of imaging in the prospective optimization of CRT.

Levocarnitine protects H9c2 rat cardiomyocytes from H2O2-induced mitochondrial dysfunction and apoptosis

BACKGROUND

Although the protective effects of levocarnitine in patients with ischemic heart disease are related to the attenuation of oxidative stress injury, the exact mechanisms involved have yet to be fully understood. Our aim was to investigate the potential protective effects of levocarnitine pretreatment against oxidative stress in rat H9c2 cardiomyocytes.

METHODS

Cardiomyocytes were exposed to H2O2 to create an oxidative stress model. The cells were pretreated with 50, 100, or 200 μM levocarnitine for 1 hour before H2O2 exposure.

RESULTS

H2O2 exposure led to significant activation of oxidative stress in the cells, characterized by reduced viability, increased intracellular reactive oxygen species, lipid peroxidation, and reduced intracellular antioxidant activity. Mitochondrial dysfunction was also observed following H2O2 exposure, reflected by the loss of mitochondrial transmembrane potential and intracellular adenosine triphosphate. These pathophysiological processes led to cardiomyocyte apoptosis through activation of the intrinsic apoptotic pathway. More importantly, the levocarnitine pretreatment attenuated the H2O2-induced oxidative injury significantly, preserved mitochondrial function, and partially prevented cardiomyocyte apoptosis during the oxidative stress reaction. Western blotting analyses suggested that levocarnitine pretreatment increased plasma protein levels of Bcl-2, reduced Bax, and attenuated cytochrome C leakage from the mitochondria in the cells.

CONCLUSION

Our in vitro study indicated that levocarnitine pretreatment may protect cardiomyocytes from oxidative stress-related damage.

Heart failure in China: a review of the literature

Heart failure (HF) is a serious disease associated with high morbidity and mortality. In China, as in other countries, it is a common cause for hospital admission; however, as yet there are few data documenting the epidemiology and management of HF in China, or quality of life-related considerations in this population. This review aims to identify relevant Chinese and English language publications that discuss the causes, risks, treatment, and health outcomes (costs, health-related quality of life) of HF in China (excluding Taiwan and Hong Kong). The prevalence of HF in China appears to be lower than that reported in many Western countries, including the US. Hypertension and coronary heart disease are the leading causes of HF in China, as they are in many Western nations, potentially highlighting the improvement in socioeconomic conditions in China. Evidence suggests that use of newer pharmacological agents for the treatment of HF is increasing; however, it is still believed that there is a lack of physician knowledge regarding newer, more effective treatment options, with rural (poor) areas appearing to be the most reliant on older, less expensive, medications. Interest in Chinese quality of life measures for HF has risen recently, with the development of valid and reliable rating scales in the Chinese population. Although the amount of available literature on HF in China is improving, there remain significant gaps in our understanding of the issue, and further research is needed to provide a reliable Chinese evidence base for the improvement of clinical practice.

Shengmai (a traditional Chinese herbal medicine) for heart failure

BACKGROUND

Heart failure is a major public health problem worldwide. Shengmai, a traditional Chinese herbal medicine, has long been used as a complementary treatment for heart failure in China. This is an update of a Cochrane Review published in 2012.

OBJECTIVES

To determine the effect (both benefits and harms) of Shengmai in treatment of people with heart failure.

SEARCH METHODS

We searched CENTRAL on The Cochrane Library (Issue 5 of 12, April 2013); DARE on The Cochrane Library (Issue 2 of 4, April 2013); MEDLINE (1948 to June Week 1 2013); EMBASE (1980 to 2013 Week 23); AMED (1985 to August 2008); BIOSIS (1969 to 7 June 2013); CBM (1978 to June 2013); VIP (1989 to June 2013); and CNKI (1979 to June 2013). We also handsearched Chinese journals and did not apply any language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of Shengmai plus usual treatment for heart failure versus usual treatment alone, or Shengmai versus placebo, irrespective of blinding status. In this update we only included studies with a clear description of randomisation methods and classified as true RCTs.

DATA COLLECTION AND ANALYSIS

Two authors independently selected trials, assessed methodological quality and extracted data. We calculated dichotomous data as risk ratios (RRs) and continuous data as mean differences (MDs) or standardized mean differences (SMDs) with corresponding 95% confidence intervals (CIs). We used a fixed-effect model to perform meta-analysis for outcomes without heterogeneity; and a random-effects model to perform meta-analysis for outcomes with heterogeneity.

MAIN RESULTS

We included a total of 14 RCTs (858 patients) in this review update, four of which were new trials. Of these 14 RCTs, 11 trials compared Shengmai plus usual treatment with usual treatment alone, and three trials compared Shengmai with placebo. Improvement of NYHA functional classification was more common in patients taking Shengmai plus usual treatment than in those receiving usual treatment alone (RR 0.37; 95% CI 0.26 to 0.51; 10 trials, 672 participants; low quality evidence). Beneficial effects of Shengmai in treating heart failure were also observed in other outcomes, including exercise test, ejection fraction and cardiac output. The three RCTs (106 patients) comparing Shengmai with placebo reported improvement in NYHA functional classification and in stroke volume. Three of the 14 RCTs reported a total of six patients with mild adverse effects and two were withdrawn due to the adverse effects. The adverse events rate was 1.21%.

AUTHORS' CONCLUSIONS

Shengmai may exert a positive effect on heart failure, especially for improving NYHA functional classification when Shengmai plus usual treatment is used. The review results should be interpreted with caution due to the high risk of bias of the included studies (particularly regarding allocation concealment and blinding), the small sample size of these studies, and the significant heterogeneity in outcomes such as ejection function, cardiac output and stroke volume. There was no evidence available concerning the effect of Shengmai on mortality, and more high quality studies with long-term follow-up are warranted.

Identification of symptom clusters among patients with heart failure: an international observational study

BACKGROUND

Virtually all patients with heart failure experience multiple symptoms simultaneously, yet clinicians and researchers usually consider symptoms in isolation. Recognizing and responding early to escalating symptoms is essential to preventing hospitalizations in heart failure, yet patients have considerable difficulty recognizing symptoms. Identification of symptom clusters could improve symptom recognition, but cultural differences may be present that must be considered.

OBJECTIVES

To identify and compare symptom clusters in heart failure patients from the United States, Europe and Asia.

DESIGN

Cross-sectional, observational study.

SETTINGS

In- and out-patient settings in three regions of the world: Asia (i.e., China and Taiwan); Europe (i.e., the Netherlands and Sweden); and the United States.

PARTICIPANTS

A total of 720 patients with confirmed heart failure. Propensity scoring using New York Heart Association Classification was used to match participants from each of the three regions.

METHODS

Symptoms were identified using the Minnesota Living with Heart Failure Questionnaire. To identify symptom clusters we used cluster analysis with the hierarchical cluster agglomerative approach. We used the Euclidean distance to measure the similarity of variables. Proximity between groups of variables was measured using Ward's method. The resulting clusters were displayed with dendrograms, which show the proximity of variables to each other on the basis of semi-partial R-squared scores.

RESULTS

There was a core group of symptoms that formed two comparable clusters across the countries. Dyspnea, difficulty in walking or climbing, fatigue/increased need to rest, and fatigue/low energy were grouped into a cluster, which was labeled as a physical capacity symptom cluster. Worrying, feeling depressed, and cognitive problems were grouped into a cluster, which was labeled as an emotional/cognitive symptom cluster. The symptoms of edema and trouble sleeping were variable among the countries and fell into different clusters.

CONCLUSION

Despite the diversity in cultures studied, we found that symptoms clustered similarly among the cultural groups. Identification of similar symptoms clusters among patients with heart failure may improve symptom recognition in both patients and healthcare providers.

The annual global economic burden of heart failure

BACKGROUND

Heart failure (HF) imposes both direct costs to healthcare systems and indirect costs to society through morbidity, unpaid care costs, premature mortality and lost productivity. The global economic burden of HF is not known.

METHODS

We estimated the overall cost of heart failure in 2012, in both direct and indirect terms, across the globe. Existing country-specific heart failure costs analyses were expressed as a proportion of gross domestic product and total healthcare spend. Using World Bank data, these proportional values were used to interpolate the economic cost of HF for countries of the world where no published data exists. Countries were categorized according to their level of economic development to investigate global patterns of spending.

RESULTS

197 countries were included in the analysis, covering 98.7% of the world's population. The overall economic cost of HF in 2012 was estimated at $108 billion per annum. Direct costs accounted for ~60% ($65 billion) and indirect costs accounted for ~40% ($43 billion) of the overall spend. Heart failure spending varied widely between high-income and middle and low-income countries. High-income countries spend a greater proportion on direct costs: a pattern reversed for middle and low-income countries.

CONCLUSIONS

Heart failure imposes a huge economic burden, estimated at $108 billion per annum. With an aging, rapidly expanding and industrializing global population this value will continue to rise.

Decreased autophagy in rat heart induced by anti-β1-adrenergic receptor autoantibodies contributes to the decline in mitochondrial membrane potential

It has been recognized that changes in mitochondrial structure plays a key role in development of cardiac dysfunction, and autophagy has been shown to exert maintenance of mitochondrial homeostasis effects. Our previous study found that anti-β₁-adrenergic receptor autoantibodies (β₁-AABs) could lead to cardiac dysfunction along with abnormalities in mitochondrial structure. The present study tested the hypothesis that β₁-AABs may induce the decline in mitochondrial membrane potential (ΔΨm) by suppression of cardiac autophagy, which contributed to cardiac dysfunction. Male adult rats were randomized to receive a vehicle or peptide corresponding to the second extracellular loop of the β₁ adrenergic receptor (β₁-AAB group, 0.4 μg/g every two weeks for 12 weeks) and treated with rapamycin (RAPA, an autophagy agonist) at 5 mg/kg/day for two days before detection. At the 4th week, 8th week and 12th week of active immunization, the rats were sacrificed and cardiac function and the levels of cardiac LC3 and Beclin-1 were detected. ΔΨm in cardiac myocytes was determined by myocardial radionuclide imaging technology and JC-1 staining. In the present study, β₁-AABs caused cardiac dysfunction, reduced ΔΨm and decreased cardiac autophagy. Treatment with RAPA markedly attenuated β₁-AABs-induced cardiac injury evidenced by recovered ΔΨm. Taken together, these results suggested that β₁-AABs exerted significant decreased ΔΨm, which may contribute to cardiac dysfunction, most likely by decreasing cardiac autophagy in vivo. Moreover, myocardial radionuclide imaging technology may be needed to assess the risk in developing cardiac dysfunction for the people who have β₁-AABs in their blood.

The epidemiology of heart failure, based on data for 2.1 million inhabitants in Sweden

AIMS

The epidemiology of congestive heart failure (CHF) is likely to have changed due to changes in demography, risk factors, diagnostic procedures, and medical care. Prevailing information is in part old, incomplete, and to some extent contradictory. We determined the current prevalence, incidence, mortality, and 5-year survival rate of CHF, and possible temporal changes in Sweden.

METHODS AND RESULTS

This was a cross-sectional study on individual patient data from an administrative health data register in the Stockholm region, Sweden, comprising 2.1 million inhabitants. This contained all recorded diagnoses on all consultations in primary and secondary care (defined as specialist outpatient care), and on all hospitalizations. Prevalence, incidence, and mortality were estimated for the entire Swedish population, adjusted for demographic composition in 2010. The study population consisted of 88 038 patients (51% women). The prevalence was 2.2% (both women and men), the incidence was 3.8/1000 person-years (both women and men), and mortality was 3.2/1000 person-years in women and 3.0/1000 person-years in men (P < 0.001); the 5-year survival rate was 48%. Mortality (age adjusted; hazard ratio and 95% confidence intervals) was higher in men, 1.29, 1.24-1.34; P < 0.001. Prevalence remained essentially unchanged from 2006 to 2010, while incidence decreased by 24% (P < 0.001) and mortality by 19% (both women and men; P < 0.001).

CONCLUSIONS

The estimated prevalence of CHF in Sweden is 2.2%, incidence 3.8/1000 person-years, and mortality 3.1/1000 person-years. There has been a decrease in incidence and mortality from 2006 to 2010 in both women and men, with no major change in prevalence over time.