2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines

Thirst symptoms in patients with heart failure: An integrative review

AIM

To identify the risk and protective factors affecting thirst symptoms in patients with heart failure (HF) and intervention strategies to alleviate thirst symptoms.

DESIGN

An integrative review.

METHODS

A total of 61 articles were retrieved. Screening yielded a total of 21 articles which were appraised for quality. The quality of studies was assessed using the Mixed Methods Appraisal Tool.

DATA SOURCES

Ten electronic databases were searched in October 2023, including Embase, Pubmed, CINAHL, Cochrane, Web of Science, Wiley, CNKI, VIP, CBM and WanFang. In addition, we searched grey databases and manually searched reference lists of included and relevant reviews.

RESULTS

In total, 1644 articles were retrieved, of which 21 were included. Eight studies addressed the factors. Six themes emerged as risk factors, including demographics, severity of disease, psycho-environmental, medication, fluid restriction and homeostasis. Conversely, an increase in fluid intake, a high score of sodium restriction diet attitude and using ARB were identified as protective factors. Thirteen studies focus on intervention strategies. Five unique intervention strategies were identified, including Traditional Chinese Medicine, mint-related interventions, sour-flavour interventions, improved water restriction and cluster nursing strategy.

CONCLUSION

This finding identified the factors associated with thirst symptoms in patients with HF, especially concerning the elaboration of risk factors, which suggests that healthcare professionals should focus on the risk factors for thirst in patients with HF and consciously avoid the occurrence of these risk factors. Additionally, there are considerable cultural differences in interventions, therefore, to increase adherence during symptom management, careful selection of appropriate intervention strategies based on the requirements and preferences of patients is required. While there are some therapies, there aren't enough high-quality empirical investigations. Thus, multi-centre, large-sample studies are also required in subsequent research to demonstrate the interventions' effectiveness.

IMPLICATIONS FOR THE PROFESSION

The nurse must notice the symptoms of thirst in HF to slow down the disease's progression and improve the patient's physical and emotional well-being.

REPORTING METHOD

The review complies with the PRISMA guidelines for reporting systematic reviews.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Impact of Standardized Heart Failure Management Center Construction on the Management of Patients With Chronic Heart Failure

BACKGROUND

Heart failure is extremely harmful to human health and social economics. The purpose of standardized heart failure management center (SHFMC) is to correct the non-standardization of heart failure treatment.

HYPOTHESIS

SHFMC has a positive impact on the management and prognosis of patients with chronic heart failure (CHF).

METHODS

The SHFMC database of Jiaxing First Hospital was retrospectively analyzed. Two hundred sixty-three patients with CHF who were hospitalized in the cardiovascular medicine department of Jiaxing First Hospital in Zhejiang Province from January 2020 to December 2020 were identified as study subjects. The SHFMC opening day, July 1, 2020, was used as the dividing line around which the patients were divided into Group A (before the completion of SHFMC, n = 137) and Group B (after, n = 126). The baseline data, treatment standardization, long-term efficacy, 1-year all-cause mortality, and readmission rate of the two groups were compared.

RESULTS

The use of angiotensin receptor enkephalinase inhibitors (ARNIs), β-blockers (β-Bs), and sodium-glucose cotransport protein 2 inhibitors (SGLT2is) increased significantly, and the long-term outcome, readmission rate, and 1-year all-cause mortality of patients improved in group B.

CONCLUSIONS

The construction of SHFMC has been associated with consistent improvements in the standardization of CHF treatment, long-term patient outcomes, 1-year cumulative survival rates, and readmission rates.

Exploring the efficacy of some biologically active compounds as anti-hypertensive drugs: an insightful evaluation through DFT, molecular docking and molecular dynamics simulations

Among different anti-hypertensive drugs, calcium channel blockers and human angiotensin-converting enzyme (ACE) inhibitors are the two main types. Herein, we took 25 biologically active ligands with potent anti-hypertensive activities and performed molecular docking studies with the human ACE receptor (PDB ID 1O8A) and human leukocyte antigens (HLA) complex, human voltage-dependent calcium channel alpha1 subunit (PDB ID 3LV3). Beforehand, we had performed density functional theory (DFT) studies to find out their structure-property relationships. In-silico ADMET studies were conducted, and we found that all 25 ligands follow Lipinski's Rule of 5, which confirms their oral bioavailability and high gastrointestinal absorption as a drug. Finally, molecular dynamics (MD) simulation studies were performed for the two top-scored drugs for 100 ns which reveal that a strong influence of the ligand (flunarizine) is there over the respective proteins.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40203-024-00291-4.

Finerenone in Heart Failure-A Novel Therapeutic Approach

This review will discuss heart failure, introduce a new drug finerenone, and discuss clinical studies with a focus on its effects on heart failure. Heart failure is a condition or syndrome characterized by an impairment of the pumping ability of the heart, thus no longer keeping up with the demands of the body. There are several types of heart failure; among them are heart failure with reduced ejection fraction, with mildly reduced ejection fraction and with preserved ejection fraction. Heart failure can be caused by several factors including lifestyle factors and diseases such as hypertension, type 2 diabetes mellitus and other cardiovascular diseases. Chronic kidney disease is also a risk factor of heart failure, as it leads to a state of inflammation that can impair the cardiovascular system over time. The novel nonsteroidal mineralocorticoid receptor antagonist finerenone antagonizes the mineralocorticoid receptor and thereby decreases the amount of fibrosis and inflammation that is observed in many heart failure patients. It shows an equal tissue distribution among heart and kidney, a high affinity and selectivity for the mineralocorticoid receptor and little risk of hyperkalemia and feminization. It also exhibits a reduction in the incidence of cardiovascular outcomes among patients with chronic kidney disease and type 2 diabetes mellitus. Therefore, finerenone has been proposed as a beneficial medication for reducing heart failure, especially in patients with diabetes and chronic kidney disease. Further studies are to be conducted to clarify the effects of finerenone alone and in combination with other drugs.

Soluble suppression of tumorigenicity 2 associated with microvascular obstruction in patients with ST-segment elevation myocardial infarction

BACKGROUND

Microvascular obstruction (MVO) develops in approximately 50% of patients with ST-segment elevation myocardial infarction (STEMI) after undergoing percutaneous coronary intervention (PCI). MVO is strongly linked to inflammation, myocardial fibrosis, and adverse clinical outcomes. Soluble suppression of tumorigenicity 2 (sST2) serves as a biomarker for inflammation and myocardial fibrosis. Yet, the correlation between sST2 and MVO in STEMI patients has not been fully elucidated. This study attempts to evaluate the association between sST2 levels and MVO in STEMI patients following pPCI.

METHODS

In this retrospective study, 315 STEMI patients who underwent pPCI at the Affiliated Hospital of Xuzhou Medical University between June 2018 and August 2023 were included. Cardiac magnetic resonance imaging (CMR) was used to assess the characteristics of myocardial infarction and microvascular obstruction (MVO), while sST2 levels were measured upon admission.

RESULTS

The median time for completion of CMR after hospitalization was 5 (4, 6) days. Multivariate regression analysis showed that sST2 (OR 1.01, 95% CI 1.01-1.02, p < 0.001), peak high-sensitivity troponin T (OR 2.40, 95% CI 1.66-3.47, p < 0.001), peak high-C-reactive protein (OR 1.01, 95% CI 1.01-1.02, p < 0.001), left ventricular ejection fraction (OR 0.93, 95% CI 0.89- 0.98, p = 0.009) and age (OR 1.03, 95% CI 1.01- 1.05, p = 0.042)were independently associated with MVO.

CONCLUSION

sST2 is associated with MVO after pPCI in STEMI patients. Incorporating soluble ST2 (sST2) into the risk model for MVO leads to significant improvement.

Sodium-Glucose Cotransporter 2 (SGLT2) Inhibitors: Guardians against Mitochondrial Dysfunction and Endoplasmic Reticulum Stress in Heart Diseases

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are an innovative class of antidiabetic drugs that provide cardiovascular benefits to both diabetic and nondiabetic patients, surpassing those of other antidiabetic drugs. Although the roles of mitochondria and endoplasmic reticulum (ER) in cardiovascular research are increasingly recognized as promising therapeutic targets, the exact molecular mechanisms by which SGLT2 inhibitors influence mitochondrial and ER homeostasis in the heart remain incompletely elucidated. This review comprehensively summarizes and discusses the impacts of SGLT2 inhibitors on mitochondrial dysfunction and ER stress in heart diseases including heart failure, ischemic heart disease/myocardial infarction, and arrhythmia from preclinical and clinical studies. Based on the existing evidence, the effects of SGLT2 inhibitors may potentially involve the restoration of mitochondrial biogenesis and alleviation of ER stress. Such consequences are achieved by enhancing adenosine triphosphate (ATP) production, preserving mitochondrial membrane potential, improving the activity of electron transport chain complexes, maintaining mitochondrial dynamics, mitigating oxidative stress and apoptosis, influencing cellular calcium and sodium handling, and targeting the unfolded protein response (UPR) through three signaling pathways including inositol requiring enzyme 1α (IRE1α), protein kinase R like endoplasmic reticulum kinase (PERK), and activating transcription factor 6 (ATF6). Therefore, SGLT2 inhibitors have emerged as a promising target for treating heart diseases due to their potential to improve mitochondrial functions and ER stress.

Comparative analysis of scoring systems for predicting mortality in Fournier gangrene: single center, 15 years experience

To compare 5 published scoring systems (Fournier gangrene severity index [FGSI], Uludag FGSI [UFGSI], age-adjusted Charlson Comorbidity Index [ACCI] and the Quick Sequential Organ Failure Assessment (qSOFA) and the Laboratory Risk Indicator for Necrotizing fasciitis (LRINEC) scores and to evaluate risk factors for outcome prediction in patients with Fournier gangrene (FG). Between 2010 and 2024, 311 patients were included in the study. The data of 276 survivors and 55 non-survivors were compared. Univariate and multivariate analyses were performed to determine which of the 5 scoring systems calculated according to demographic, laboratory and clinical data predicted mortality better. In addition, a cut-off value for these scoring systems was determined by ROC analysis. The mortality rate was 17.6% in FG patients. In all 5 scoring systems, univariate analyses showed higher values in non-survivor patients, while UFGSI and FGSI scoring systems were superior to other scoring systems in multivariate analyses (p < 0.001). ROC analysis using mortality-based sensitivity and specificity revealed that the optimal cut-off values for FGSI, UFGSI, ACCI, SOFA and LRINEC should be equal to or higher than 10, 12, 4, 2 and 8, respectively. UFGSI and FGSI scores had the highest AUC values among all scores. This was followed by ACCI, qSOFAand LRINEC. For a UFGSI score ≥ 12, the sensitivity was 84%, specificity 97%, PPV 85% and NPV 97%. Among the scoring systems used to predict mortality, UFGSI was the most accurate, while LRINEC was the least accurate.

Sodium glucose cotransporter 2 inhibitors in the management of heart failure: Veni, Vidi, and Vici

Heart failure (HF) is a chronic disease associated with high morbidity and mortality rates. Renin-angiotensin-aldosterone system blockers (including angiotensin receptor/neprilysin inhibitors), beta-blockers, and mineralocorticoid receptor blockers remain the mainstay of pharmacotherapy for HF with reduced ejection fraction (HFrEF). However, despite the use of guideline-directed medical therapy, the mortality from HFrEF remains high. HF with preserved ejection fraction (HFpEF) comprises approximately half of the total incident HF cases; however, unlike HFrEF, there are no proven therapies for this condition. Sodium glucose cotransporter-2 inhibitors (SGLT-2is) represent a new class of pharmacological agents approved for diabetes mellitus (DM) that inhibit SGLT-2 receptors in the kidney. A serendipitous finding from seminal trials of SGLT-2is in DM was the significant improvement in renal and cardiovascular (CV) outcomes. More importantly, the improvement in HF hospitalization (HHF) in the CV outcomes trials of SGLT-2is was striking. Multiple mechanisms have been proposed for the pleiotropic effects of SGLT-2is beyond their glycemic control. However, as patients with HF were not included in any of these trials, it can be considered as a primary intervention. Subsequently, two landmark studies of SGLT-2is in patients with HFrEF, namely, an empagliflozin outcome trial in patients with chronic HF and a reduced ejection fraction (EMPEROR-Reduced) and dapagliflozin and prevention of adverse outcomes in HF (DAPA-HF), demonstrated significant improvement in HHF and CV mortality regardless of the presence of DM. These impressive results pitchforked these drugs as class I indications in patients with HFrEF across major guidelines. Thereafter, empagliflozin outcome trial in patients with chronic HF with preserved ejection fraction (EMPEROR-Preserved) and dapagliflozin evaluation to improve the lives of patients with preserved ejection fraction HF (DELIVER) trials successively confirmed that SGLT-2is also benefit patients with HFpEF with or without DM. These results represent a watershed as they constitute the first clinically meaningful therapy for HFpEF in the past three decades of evolution of HF management. Emerging positive data for the use of SGLT-2is in acute HF and post-myocardial infarction scenarios have strengthened the pivotal role of these agents in the realm of HF. In a short span of time, these classes of drugs have captivated the entire scenario of HF.

Improving effect of physical exercise on heart failure: Reducing oxidative stress-induced inflammation by restoring Ca2+ homeostasis

Heart failure (HF) is associated with the occurrence of mitochondrial dysfunction. ATP produced by mitochondria through the tricarboxylic acid cycle is the main source of energy for the heart. Excessive release of Ca2+ from myocardial sarcoplasmic reticulum (SR) in HF leads to excessive Ca2+ entering mitochondria, which leads to mitochondrial dysfunction and REDOX imbalance. Excessive accumulation of ROS leads to mitochondrial structure damage, which cannot produce and provide energy. In addition, the accumulation of a large number of ROS can activate NF-κB, leading to myocardial inflammation. Energy deficit in the myocardium has long been considered to be the main mechanism connecting mitochondrial dysfunction and systolic failure. However, exercise can improve the Ca2+ imbalance in HF and restore the Ca2+ disorder in mitochondria. Similarly, exercise activates mitochondrial dynamics to improve mitochondrial function and reshape intact mitochondrial structure, rebalance mitochondrial REDOX, reduce excessive release of ROS, and rescue cardiomyocyte energy failure in HF. In this review, we summarize recent evidence that exercise can improve Ca2+ homeostasis in the SR and activate mitochondrial dynamics, improve mitochondrial function, and reduce oxidative stress levels in HF patients, thereby reducing chronic inflammation in HF patients. The improvement of mitochondrial dynamics is beneficial for ameliorating metabolic flow bottlenecks, REDOX imbalance, ROS balance, impaired mitochondrial Ca2+ homeostasis, and inflammation. Interpretation of these findings will lead to new approaches to disease mechanisms and treatment.

Association between biomarkers of zinc and copper status and heart failure: a meta-analysis

AIMS

Previous studies have investigated the relationship between heart failure (HF) and levels of zinc and copper, but conflicting results have been reported. This meta-analysis aims to clarify the role of zinc and copper in HF progression by examining the associations between HF and concentrations of these minerals.

METHODS AND RESULTS

We utilized STATA 12.0 software to calculate the standard mean difference (SMD) and 95% confidence interval (CI) for serum zinc and copper levels in patients with HF compared with healthy controls (HCs). The meta-analysis indicated a lower serum zinc level in patients with HF compared with HCs, using a random effects model (SMD = -0.77; 95% CI: -1.01, -0.54; I2 = 61.9%, the P-value for Q test = 0.002). Additionally, the meta-analysis showed an increased serum copper level in patients with HF compared with HCs, using a random effects model (SMD = 0.66; 95% CI: 0.09, 1.23; I2 = 93.8%, the P-value for Q test < 0.001). Meta-regression analysis indicated that publication year, age, and gender were not responsible for heterogeneity across studies.

CONCLUSIONS

This meta-analysis demonstrates that patients with HF have lower serum zinc and higher copper concentrations compared with healthy subjects. However, the potential of zinc supplementation as a therapy for HF should be approached with caution. The heterogeneity among the included studies was found to be high. It is recommended that further well-designed large sample studies be conducted to validate these findings.

Cognitive impairment in young and middle-aged patients with acute heart failure

AIMS

This study aimed to investigate the prevalence, risk factors and prognostic implications of cognitive impairment in young and middle-aged patients with acute heart failure (HF).

METHODS

In a prospective cohort of patients with acute HF, we assessed cognitive function by the Mini-Cog, predictors of the cognitive impairment and its associations with 30 day and 1 year cardiovascular death or HF rehospitalization among young and middle-aged patients (<65 years old).

RESULTS

Among 1958 young and middle-aged patients, the prevalence of cognitive impairment was 19.6%. Predictors of cognitive impairment included older age, females, lower education levels and prior strokes. Compared with patients having normal cognitive function, cognitive impairment was associated with a higher risk of 30 day cardiovascular death or HF rehospitalization [hazard ratio (HR), 1.52, 95% confidence interval (CI), 1.07-2.17, P = 0.02], but not for 1 year cardiovascular death or HF rehospitalization (HR, 1.06, 95% CI, 0.87-1.30, P = 0.55).

CONCLUSIONS

Cognitive impairment is present in a notable proportion of young and middle-aged patients with acute HF and is associated with an increased risk of short-term adverse outcomes. Strategies for screening and intervention for cognitive impairment at a younger age are necessary, particularly for those at high risk.

Serum Soluble Corin and Long-Term Clinical Outcomes After Acute Ischemic Stroke

BACKGROUND

Corin plays important roles in the regulation of blood volume and pressure and cardiac function by activating natriuretic peptide pathway, exerting multiple cardioprotective effects. But the impacts of soluble corin on clinical outcomes after ischemic stroke are unclear. We aimed to investigate the associations between serum soluble corin and long-term clinical outcomes after acute ischemic stroke.

METHODS AND RESULTS

We measured the concentrations of serum soluble corin in 3162 participants (2010 men and 1152 women) from the China Antihypertensive Trial in Acute Ischemic Stroke. The clinical outcomes were recurrent stroke, cardiovascular events, all-cause mortality, and unfavorable functional outcome within 24 months after stroke. Risk reclassification for study clinical outcomes of models with soluble corin were evaluated. Serum soluble corin was inversely associated with recurrent stroke, cardiovascular events, and unfavorable functional outcome after ischemic stroke. After adjusting for multiple covariates, each additional SD of log-corin was associated with a 21% (95% CI, 11-30), 16% (95% CI, 6-26), and 12% (95% CI, 3-21) decreased risk for recurrent stroke, cardiovascular events, and unfavorable functional outcome, respectively. Furthermore, the addition of soluble corin to the basic model with conventional risk factors significantly improved risk discrimination for recurrent stroke, cardiovascular events, and the composite outcome of all-cause mortality and cardiovascular events, as shown by C-statistics (all P<0.05).

CONCLUSIONS

Serum soluble corin was associated with decreased risks of long-term clinical outcomes, and may be a promising prognostic biomarker for risk stratification in patients with acute ischemic stroke.

Use of Palliative Care Among Adults With Newly Diagnosed Heart Failure: Insights From a US National Insured Patient Sample

BACKGROUND

Despite the known benefits for individuals with heart failure (HF), incomplete data suggest a low use of palliative care (PC) for HF in the United States. We aimed to investigate the national PC use for adults with HF by determining when they received their first PC consultation (PCC) and the associations with clinical factors following diagnosis of HF.

METHODS AND RESULTS

We conducted a retrospective cohort study in a national all-payer electronic health record database to identify adults (aged ≥18 years) with newly diagnosed HF between 2011 and 2018. The proportion of those who received PCC within 5 years following a diagnosis of HF, and associations of time to first PCC with patient characteristics and HF-specific clinical markers were determined. We followed 127 712 patients for a median of 792 days, of whom 18.3% received PCC in 5 years. Shorter time to receive PCC was associated with diagnoses of HF in 2016 to 2018 (compared with 2010-2015: adjusted hazard ratio [aHR], 1.421 [95% CI, 1.370-1.475]), advanced HF (aHR, 2.065 [95% CI, 1.940-2.198]), cardiogenic shock (aHR, 2.587 [95% CI, 2.414-2.773]), implantable cardioverter-defibrillator (aHR, 5.718 [95% CI, 5.327-6.138]), and visits at academic medical centers (aHR, 1.439 [95% CI, 1.381-1.500]).

CONCLUSIONS

Despite an expanded definition of PC and recommendations by professional societies, PC for HF remains low in the United States. Racial and geographic variations in access and use of PC exist for patients with HF. Future studies should interrogate the mechanisms of PC underusage, especially before advanced stages, and address barriers to PC services across the health care system.

Clinical implication of sarcopenia in patients with acute decompensated heart failure: Design and rationale

BACKGROUND

Sarcopenia is widely recognized as an age-related syndrome that involves a progressive loss of skeletal muscle mass and muscle strength. Many studies have shown that sarcopenia is associated with disease severity and exercise intolerance, as well as an independent predictor of mortality in patients with chronic heart failure. However, there is little research on the impact of sarcopenia on patients hospitalized with acute decompensated heart failure (ADHF).

METHODS

This is a prospective, multicentre, observational cohort study. Enrolment of at least 500 participants adults aged over 18 years hospitalized for ADHF is planned, with a minimum of 195 cases each for patients with and without sarcopenia. Each patient is followed up for 6 months, 1 year, 2 years or until the occurrence of endpoint. The primary clinical outcome is all-cause mortality at 6 months. Other clinical outcomes of interest include cardiovascular mortality, all-cause hospitalization, heart failure hospitalization and survival time from enrolment to event occurrence. The sympathetic nervous activity, psychosocial factors, quality of life, physical function, and physical activity will be assessed and recorded at baseline. This study will examine the correlation between sarcopenia and prognosis in different subgroups of patients, and explore the additive effect of different comorbidities and sarcopenia on prognosis in patients with ADHF.

CONCLUSIONS

This study will provide important information and evidence on the clinical aspects of sarcopenia in patients with ADHF, potentially contributing to accurate risk stratification and optimal clinical management for patients with ADHF.

REGISTRATION

(URL: https://www.

CLINICALTRIALS

gov); Unique identifier: NCT06298825.

2024 Update to the 2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure: A Report of the American Heart Association/American College of Cardiology Joint Committee on Performance Measures

This document describes performance measures for heart failure that are appropriate for public reporting or pay-for-performance programs and is meant to serve as a focused update of the "2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures." The new performance measures are taken from the "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines" and are selected from the strongest recommendations (Class 1 or Class 3). In contrast, quality measures may not have as much evidence base and generally comprise metrics that might be useful for clinicians and health care organizations for quality improvement but are not yet appropriate for public reporting or pay-for-performance programs. New performance measures include optimal blood pressure control in patients with heart failure with preserved ejection fraction, the use of sodium-glucose cotransporter-2 inhibitors for patients with heart failure with reduced ejection fraction, and the use of guideline-directed medical therapy in hospitalized patients. New quality measures include the use of sodium-glucose cotransporter-2 inhibitors in patients with heart failure with mildly reduced and preserved ejection fraction, the optimization of guideline-directed medical therapy prior to intervention for chronic secondary severe mitral regurgitation, continuation of guideline-directed medical therapy for patients with heart failure with improved ejection fraction, identifying both known risks for cardiovascular disease and social determinants of health, patient-centered counseling regarding contraception and pregnancy risks for individuals with cardiomyopathy, and the need for a monoclonal protein screen to exclude light chain amyloidosis when interpreting a bone scintigraphy scan assessing for transthyretin cardiac amyloidosis.

How to Optimize Goal-Directed Medical Therapy (GDMT) in Patients with Heart Failure

PURPOSE OF REVIEW

Heart failure is a clinical syndrome with signs and symptoms from underlying cardiac abnormality and evidence of pulmonary or systemic congestion on laboratory testing or other objective findings (Bozkurt et al. in Eur J Heart Fail 23:352-380, 2021). Heart failure with reduced ejection fraction (HFrEF), when heart failure is due to underlying reduction in ejection fraction to ≤ 40. The goal of this review is to briefly describe the mechanisms and benefits of the various pharmacological interventions described in the 2022 AHA/ACC/HFSA Guidelines focusing on Stage C: Symptomatic Heart Failure HFrEF, while providing basic guidance on safe use of these medications.

RECENT FINDINGS

Use of medications from each class as recommended in the 2022 Guidelines can provide significant morbidity and mortality benefits for our patients. Despite advances in therapeutics for patients with HFrEF, patients are frequently under treated and more research is needed to help optimize management of these complicated patients.

Kidney Dysfunction, Hepatic Impairment, and Lipid Metabolism Abnormalities in Patients with Precapillary Pulmonary Hypertension

BACKGROUND

Pulmonary hypertension (PH) is a global health issue that has profound medical and research implications.

METHODS

This retrospective study examined changes in renal and liver function, as well as lipid metabolism, over a 12-month period in 49 adult patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). All cases were admitted, managed, and followed up with in the PH Center, County Emergency Clinical Hospital of Targu Mures, Romania.

RESULTS

Kidney dysfunction was observed in 12.24% of cases at baseline, decreasing to 8.16% at 12 months, and CTEPH patients were more affected. In particular, CTEPH patients exhibited an improvement in renal function, confirmed by an increase in their glomerular filtration rates. Hepatic impairment was present in 57.14% of subjects at baseline, declining to 42.86% at 12 months, with significant improvements noted in the PAH group. Lipid metabolic dysregulations were experienced by 22.45% of all patients at baseline, decreasing to 16.33% at 6 months, with a slow elevation to 24.49% at 12 months, but with no statistically significant differences. Pharmacological regimens were adjusted in accordance with the PH groups, a patient's functional and clinical response, and laboratory tests.

CONCLUSIONS

Our results demonstrate the multi-organ damage in PH and the importance of individualized treatment approaches.

Impact of β-blockers on in-hospital mortality in patients with heart failure: a retrospective propensity-score matched analysis based on MIMIC-IV database

Introduction

This study assessed the relationship between β-blockers treatment and in-hospital mortality among individuals diagnosed with heart failure (HF).

Methods

A retrospective cohort study was carried out on 9,968 HF patients sourced from the Medical Information Mart for Intensive Care (MIMIC)-IV database. Propensity score matching (PSM) was employed to balance the baseline differences. A multivariate regression analysis was utilized to evaluate the impact of β-blockers therapy on in-hospital mortality.

Results

Among the 9,968 patients, 6,439 (64.6%) were β-blockers users. Before matching, the overall in-hospital mortality rate was 12.2% (1,217/9,968). Following PSM, a total of 3,212 patient pairs were successfully matched. The analysis revealed a correlation between β-blockers therapy and decreased in-hospital mortality (odds ratio 0.51 [0.43-0.60], P < 0.001), as well as shorter Los (length of stay) hospital (β -1.43 [-1.96∼-0.09], P < 0.001). Notably, long-acting β-blockers treatment was linked to a decreased risk of in-hospital mortality (odds ratio 0.55 [0.46-0.65], P < 0.001) and a shorter Los hospital (β -1.21 [-1.80∼-0.63], P < 0.001). Conversely, the research results did not show a notable decrease in-hospital mortality (odds ratio 0.66 [0.44-1.01], P = 0.051) or Los hospital (β -1.01 [-2.2∼-0.25], P = 0.117) associated with short-acting β-blocker therapy.

Discussion

β-blockers therapy in the intensive care unit demonstrates potential benefits in lowering the risk of in-hospital mortality and reducing the duration of hospitalization among patients with HF. Specifically, long-acting β-blockers exhibit a protective effect by significantly decreasing both in-hospital mortality and Los hospital. Conversely, the study did not observe a substantial impact on in-hospital mortality or Los hospital duration in this cohort of patients following the administration of short-acting β-blockers.

Nitroxyl donating and visualization with a coumarin-based fluorescence probe

Nitroxyl (HNO), the single-electron reduction product of nitric oxide (NO), has attracted great interest in the treatment of congestive heart failure in clinical trials. In this paper, we describe the first coumarin-based compound N-hydroxy-2-oxo-2H-chromene-6-sulfonamide (CD1) as a dualfunctional HNO donor, which can release both an HNO signaling molecule and a fluorescent reporter. Under physiological conditions (pH 7.4 and 37 °C), the CD1 HNO donor can readily decompose with a half-life of ∼90 min. The corresponding stoichiometry HNO from the CD1 donor was confirmed using both Vitamin B12 and phosphine compound traps. In addition to HNO releasing, specifically, the degradation product 2-oxo-2H-chromene-6-sulfinate (CS1) was generated as a fluorescent marker during the decomposition. Therefore, the HNO amount released in situ can be accurately monitored through fluorescence generation. As compared to the CD1 donor, the fluorescence intensity increased by about 4.9-fold. The concentration limit of detection of HNO releasing was determined to be ∼0.13 μM according to the fluorescence generation of CS1 at physiological conditions. Moreover, the bioimaging of the CD1 donor was demonstrated in the cell culture of HeLa cells, where the intracellular fluorescence signals were observed, inferring the site of HNO release. Finally, we anticipate that this novel coumarin-based CD1 donor opens a new platform for exploring the biology of HNO.

Cardioembolic stroke in an HIV endemic region: underdiagnosed and severe

Background and objectives

Cardioembolic stroke (CES) appears to be a rare cause of stroke (4%-9%) in people living with HIV (PLWH) in sub-Saharan Africa (SSA). However, due to limited access to diagnostic resources, this may be an underestimate. It is also unclear which cardiac pathologies are the major contributors to CES in this region. We sought to determine the prevalence and aetiology of CES in PLWH and to determine whether there are any differences compared with HIV negative stroke patients.

Methods

This cross-sectional study recruited PLWH with new-onset stroke at a quaternary-level hospital in Johannesburg, South Africa, from 2014 to 2017, and compared them to age-matched and sex-matched HIV negative stroke patients. Comprehensive investigations were performed to determine the underlying stroke aetiology, including electrocardiography, echocardiography, CT angiography and cerebrospinal fluid examination.

Results

85 PLWH with ischaemic stroke were recruited and compared with 109 HIV negative controls. CES was identified in 17/85 (20.0%) of PLWH. These patients had more severe strokes than PLWH with non-CES (National Institutes of Health Stroke Scale score 14.9±6.7 vs 11.7±5.4, p=0.04). Cardiomyopathy was the predominant cardiac pathology in PLWH (76.4% vs 45.5% in HIV negative, p=0.04) while valvulopathy was more common in HIV negative patients (42.4% vs 11.8% in PLWH, p=0.03). Arrhythmia (n=1) and ischaemic heart disease (n=1) were uncommon in PLWH.

Conclusion

CES is underdiagnosed in SSA and is more severe than non-CES. The identification of cardiomyopathy as the predominant underlying cardiac pathology may assist to target resources towards its detection using accessible cost-effective biomarkers.

Factors Associated With Early Palliative Care Among Patients With Heart Failure

Background: Heart failure (HF) is a progressive, life-limiting illness for which palliative care (PC) is considered standard of care. Among patients that do receive PC, consultation tends to occur late in the illness course. Objective: Our primary aim was to examine patient factors associated with receiving PC in HF. Secondarily, we sought to determine factors associated with early PC encounters. Design: This was a retrospective cohort study of U.S. Veterans with prior hospitalization who died between January 1, 2011 and December 31, 2020. Setting/Subjects: Subjects were Veterans with HF who died with a prior admission to a Veterans Affairs hospital in the United States. Measurements: We calculated the time from PC encounter to death. We characterized HF patients who died without PC, with late PC (≤90 days before death), and with early PC (>90 days before death). Results: We identified 232,079 Veterans with a mean age of (76.5 ± 10.7) years. Within the cohort, 56.5% (n = 131,122) of Veterans died with no PC, 22.5% (n = 52,114) had PC <90 days before death, and 21.0% (n = 48,843) had PC >90 days before death. Veterans who died without PC tended to be younger with fewer comorbidities. Conclusions: While more than 20% of HF patients in our cohort had PC well in advance of death, more than half died without PC. PC involvement seemed to be driven by comorbidities rather than HF. Effective collaboration with Cardiology is needed to identify patients who would benefit from earlier PC involvement.

The 30-second chair stand test (CS30) as a predictor of exercise tolerance in elderly individuals (≥75 years) with stage A/B heart failure

Background

In Japan, the number of very elderly individuals with heart failure (HF) is on the rise. One indicator of HF stage progression is a decrease in exercise tolerance (ET). While peak oxygen uptake (peak VO₂) determined by cardiopulmonary exercise testing (CPX) is the gold standard for ET assessment, the wide-scale applicability of CPX is constrained owing to expensive equipment and challenges in this population. The 30-second chair stand test (CS30), a simple and quick alternative, is widely used among community-dwelling elderly individuals. The objective of this study was to investigate whether CS30 is a predictor of ET in elderly individuals with stage A/B HF.

Methods

Of 748 outpatients aged 75 years and over who visited our center between March 2021 and December 2022, 493 patients (296 males and 197 females) were included in this study. CS30 was measured using a seat height of 40 cm, and peak VO₂ was assessed using CPX.

Results

The findings showed a statistically significant positive association between CS30 and peak VO₂ for both males and females (males: β = 0.255, 95 % CI = 0.102-0.407; females: β = 0.282, 95 % CI = 0.043-0.521). Receiver operating characteristic (ROC) analyses showed moderate accuracy of CS30 in predicting low ET in both sexes (males AUC = 0.740, 95 % CI = 0.640-0.841, p < 0.001; females AUC = 0.725, 95 % CI = 0.644-0.807, p < 0.001). The cut-off values of CS30 were established as 18 times for males and 16 times for females.

Conclusions

CS30 is a potentially convenient method for estimating current ET in older adults, providing a feasible alternative to CPX.

Diagnostic Modalities in Heart Failure: A Narrative Review

Heart failure (HF) can present acutely or progress over time. It can lead to morbidity and mortality affecting 6.5 million Americans over the age of 20. The HF type is described according to the ejection fraction classification, defined as the percentage of blood volume that exits the left ventricle after myocardial contraction, undergoing ejection into the circulation, also called stroke volume, and is proportional to the ejection fraction. Cardiac catheterization is an invasive procedure to evaluate coronary artery disease leading to HF. Several biomarkers are being studied that could lead to early detection of HF and better symptom management. Testing for various biomarkers in the patient's blood is instrumental in confirming the diagnosis and elucidating the etiology of HF. There are various biomarkers elevated in response to increased myocardial stress and volume overload, including B-type natriuretic peptide (BNP) and its N-terminal prohormone BNP. We explored online libraries such as PubMed, Google Scholar, and Cochrane to find relevant articles. Our narrative review aims to extensively shed light on diagnostic modalities and novel techniques for diagnosing HF.

Associating factors of cognitive frailty among older people with chronic heart failure: Based on LASSO-logistic regression

AIM

To analyse factors associated with cognitive frailty among older chronic heart failure patients in China.

DESIGN

A cross-sectional design.

METHODS

Between August 2021 and November 2022, a total of 421 chronic heart failure patients (age ≥60 years) were randomly selected from the cardiology department of the affiliated hospital of Zunyi Medical University. The FRAIL scale, Mini-Mental State Examination, 15-item Geriatric Depression Scale, Social Support Rating Scale, Short-form Mini Nutritional Assessment and Pittsburgh Sleep Quality Index were utilized for measurement and evaluation. The demographic and clinical characteristics of patients were collected. To select initial variables, the Least Absolute Shrinkage Selection Operator was applied, and then logistic regression analysis was used to confirm associating factors.

RESULTS

Among 421 elderly people with chronic heart failure, 83 cases (19.7%) showed cognitive frailty. Of 31 variables, seven were selected by Least Absolute Shrinkage Selection Operator regression. Finally, multivariate logistic regression revealed that the age, monthly salary, drinking, NYHA classification, length of hospital stay, depression and malnutrition risk/malnutrition were independently associated with cognitive frailty.

CONCLUSION

The high proportion of cognitive frailty in older people with chronic heart failure should be concerned. Additionally, in the setting of cognitive frailty, efforts to diagnose it and develop interventions to prevent or reverse cognitive frailty status among older chronic heart failure patients are necessary.

IMPACT

The findings of our study highlight the necessity to evaluate cognitive frailty in older people with chronic heart failure and provide a new perspective and scientific basis for medical staff to develop individualized and specific interventions to prevent or reverse cognitive frailty status.

REPORTING METHOD

This study has been reported in compliance with STROBE reporting guidelines for cross-sectional studies.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Pediatric dilated cardiomyopathy: a review of current clinical approaches and pathogenesis

Pediatric dilated cardiomyopathy (DCM) is a rare, yet life-threatening cardiovascular condition characterized by systolic dysfunction with biventricular dilatation and reduced myocardial contractility. Therapeutic options are limited with nearly 40% of children undergoing heart transplant or death within 2 years of diagnosis. Pediatric patients are currently diagnosed based on correlating the clinical picture with echocardiographic findings. Patient age, etiology of disease, and parameters of cardiac function significantly impact prognosis. Treatments for pediatric DCM aim to ameliorate symptoms, reduce progression of disease, and prevent life-threatening arrhythmias. Many therapeutic agents with known efficacy in adults lack the same evidence in children. Unlike adult DCM, the pathogenesis of pediatric DCM is not well understood as approximately two thirds of cases are classified as idiopathic disease. Children experience unique gene expression changes and molecular pathway activation in response to DCM. Studies have pointed to a significant genetic component in pediatric DCM, with variants in genes related to sarcomere and cytoskeleton structure implicated. In this regard, pediatric DCM can be considered pediatric manifestations of inherited cardiomyopathy syndromes. Yet exciting recent studies in infantile DCM suggest that this subset has a distinct etiology involving defective postnatal cardiac maturation, such as the failure of programmed centrosome breakdown in cardiomyocytes. Improved knowledge of pathogenesis is central to developing child-specific treatment approaches. This review aims to discuss the established biological pathogenesis of pediatric DCM, current clinical guidelines, and promising therapeutic avenues, highlighting differences from adult disease. The overarching goal is to unravel the complexities surrounding this condition to facilitate the advancement of novel therapeutic interventions and improve prognosis and overall quality of life for pediatric patients affected by DCM.

The Relationship Between Insulin Resistance Indicated by Triglyceride and Glucose Index and Left Ventricular Hypertrophy and Decreased Left Ventricular Diastolic Function with Preserved Ejection Fraction

Aim

The evidence on the association between insulin resistance (IR) and the prevalence or incidence of cardiac dysfunction has been controversial, and the relationship between pre-diabetic IR and cardiac function is lacking. Large sample studies in the Chinese general population are urgently needed to explore the association between IR and the risk of left ventricular hypertrophy (LVH) and decreased left ventricular diastolic function with preserved ejection fraction (LVDFpEF).

Methods

Based on a National Health Check-up database in China, we conducted a multicenter cross-sectional retrospective study in 344,420 individuals. Furthermore, at a single center, we performed two retrospective longitudinal studies encompassing 8270 and 5827 individuals to investigate the association between IR and the development of new-onset LVH and LVDFpEF, respectively. The median follow-up duration exceeded 2.5 years. The triglyceride and glucose (TyG) index, known for its high sensitivity in detecting IR, serves as a reliable alternative marker of IR. The logistic and cox proportional hazard regression models were used to determine the relationships.

Results

In the cross-sectional study, IR showed a positive association with the prevalence of LVH and decreased LVDFpEF after adjusting for confounders. In the longitudinal cohort, IR was also correlated with the new onset of LVH and decreased LVDFpEF, with hazard ratios (HR) of 1.986 (95% CI: 1.307, 3.017) and 1.386 (95% CI: 1.167, 1.647) in the fourth quartile of TyG levels compared to the lowest quartile, respectively, after adjusting for confounders. The subgroup analysis in non-hypertensive or non-diabetic people and the sensitivity analysis in the population with homeostasis model assessment of insulin resistance (HOMA-IR) further verified the above-mentioned results.

Conclusion

IR was associated with LVH and decreased LVDFpEF. Effective management of IR may prevent or delay the development of adverse LVH and decreased LVDFpEF.

2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy" provides recommendations to guide clinicians in the management of patients with hypertrophic cardiomyopathy.

METHODS

A comprehensive literature search was conducted from September 14, 2022, to November 22, 2022, encompassing studies, reviews, and other evidence on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through May 23, 2023, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Hypertrophic cardiomyopathy remains a common genetic heart disease reported in populations globally. Recommendations from the "2020 AHA/ACC Guideline for the Diagnosis and Treatment of Patients With Hypertrophic Cardiomyopathy" have been updated with new evidence to guide clinicians.

Therapy-naïve malignancy causes cardiovascular disease: a state-of-the-art cardio-oncology perspective

Cardiovascular disease (CVD) and cancer are the leading causes of mortality worldwide. Although generally thought of as distinct diseases, the intersectional overlap between CVD and cancer is increasingly evident in both causal and mechanistic relationships. The field of cardio-oncology is largely focused on the cardiotoxic effects of cancer therapies (e.g., chemotherapy, radiation). Furthermore, the cumulative effects of cardiotoxic therapy exposure and the prevalence of CVD risk factors in patients with cancer lead to long-term morbidity and poor quality of life in this patient population, even when patients are cancer-free. Evidence from patients with cancer and animal models demonstrates that the presence of malignancy itself, independent of cardiotoxic therapy exposure or CVD risk factors, negatively impacts cardiac structure and function. As such, the primary focus of this review is the cardiac pathophysiological and molecular features of therapy-naïve cancer. We also summarize the strengths and limitations of preclinical cancer models for cardio-oncology research and discuss therapeutic strategies that have been tested experimentally for the treatment of cancer-induced cardiac atrophy and dysfunction. Finally, we explore an adjacent area of interest, called "reverse cardio-oncology," where the sequelae of heart failure augment cancer progression. Here, we emphasize the cross-disease communication between malignancy and the injured heart and discuss the importance of chronic low-grade inflammation and endocrine factors in the progression of both diseases.

Prognostic Value of Depressive Symptoms for Cardiovascular Events in Female Patients With Heart Failure With Reduced Ejection Fraction and Heart Failure With Preserved Ejection Fraction

BACKGROUND

Among those with heart failure (HF), women are more likely to develop depression than men. Few studies have focused on the outcomes of female patients with HF with depressive symptoms.

METHODS AND RESULTS

A total of 506 female patients with HF with preserved ejection fraction were included in this secondary analysis from the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) cohort, and 439 female patients with HF with reduced ejection fraction were included from the HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) cohort. Depressive symptoms were measured using the Patient Health Questionnaire-9 and Beck Depression Inventory-II. The depression class was categorized by severity, and the change in clinical depression class was defined as aggravated (1-grade increase) or improved (1-grade decrease). The prognostic value of depressive symptoms was determined by using multivariable Cox proportional hazards models. Female patients with improved depressive symptoms had worse depressive status at baseline and lower baseline Kansas City Cardiomyopathy Questionnaire scores. Depression class at the 12-month visit and depression class change were the dominant prognostic factors for cardiovascular death in female patients with HF with preserved ejection fraction (hazard ratio [HR], 1.43 [95% CI, 1.02-2.01], P=0.036; HR, 1.71 [95% CI, 1.14-2.55], P=0.009). Among the patients with HF with reduced ejection fraction, both the depression class at baseline and depression class change had significant prognostic effects on cardiovascular death (HR, 3.30 [95% CI, 1.70-6.39], P<0.001; HR, 2.21 [95% CI, 1.28-3.80], P=0.004). However, the prognostic value of depressive assessments for hospitalization in patients with HF is unclear.

CONCLUSIONS

In female patients with HF with reduced ejection fraction, the depression class at baseline was most strongly associated with cardiovascular death, whereas in female patients with HF with preserved ejection fraction, the change in depression class exhibited a more significant prognostic trend.

Cardiorespiratory fitness and risk of heart failure with preserved ejection fraction

AIMS

Preventive strategies for heart failure with preserved ejection fraction (HFpEF) include pharmacotherapies and lifestyle modifications. However, the association between cardiorespiratory fitness (CRF) assessed objectively by a standardized exercise treadmill test (ETT) and the risk of HFpEF has not been evaluated. Thus, we evaluated the association between CRF and HFpEF incidence.

METHODS AND RESULTS

We assessed CRF in US Veterans (624 551 men; mean age 61.2 ± 9.7 years and 43 179 women; mean age 55.0 ± 8.9 years) by a standardized ETT performed between 1999 and 2020 across US Veterans Affairs Medical Centers. All had no evidence of heart failure or myocardial infarction prior to completion of the ETT. We assigned participants to one of five age- and gender-specific CRF categories (quintiles) based on peak metabolic equivalents (METs) achieved during the ETT and four categories based on CRF changes in those with two ETT evaluations (n = 139 434) ≥1.0 year apart. During a median follow-up of 10.1 years (interquartile range 6.0-14.3 years), providing 6 879 229 person-years, there were 16 493 HFpEF events with an average annual rate of 2.4 events per 1000 person-years. The adjusted risk of HFpEF decreased across CRF categories as CRF increased, independent of comorbidities. For fit individuals (≥10.5 METs) the hazard ratio (HR) was 0.48 (95% confidence interval [CI] 0.46-0.51) compared with least fit (≤4.9 METs; referent). Being unfit carried the highest risk (HR 2.88, 95% CI 2.67-3.11) of any other comorbidity. The risk of unfit individuals who became fit was 37% lower (HR 0.63, 95% CI 0.57-0.71), compared to those who remained unfit.

CONCLUSIONS

Higher CRF levels are independently associated with lower HFpEF in a dose-response manner. Changes in CRF reflected proportional changes in HFpEF risk, suggesting that the HFpEF risk was modulated by CRF.

Congestive Hepatopathy: A Review of the Literature

Congestive hepatopathy (CH), stemming from compromised hepatic venous flow or heightened intrahepatic pressure, represents a significant consequence of cardiovascular conditions like congestive heart failure (CHF). This review of literature encapsulates the core aspects of this condition, characterized by hepatic congestion, cellular injury, and impaired liver function. Diagnostic challenges arise due to symptoms mirroring primary liver diseases. Management revolves around addressing the underlying cause and mitigating fluid retention. This review of literature provides a snapshot of CH's complexity, emphasizing its clinical implications and the need for comprehensive understanding in clinical practice.

Phosphodiesterase in heart and vessels: from physiology to diseases

Phosphodiesterases (PDEs) are a superfamily of enzymes that hydrolyze cyclic nucleotides, including cyclic adenosine monophosphate (cAMP) and cyclic guanosine monophosphate (cGMP). Both cyclic nucleotides are critical secondary messengers in the neurohormonal regulation in the cardiovascular system. PDEs precisely control spatiotemporal subcellular distribution of cyclic nucleotides in a cell- and tissue-specific manner, playing critical roles in physiological responses to hormone stimulation in the heart and vessels. Dysregulation of PDEs has been linked to the development of several cardiovascular diseases, such as hypertension, aneurysm, atherosclerosis, arrhythmia, and heart failure. Targeting these enzymes has been proven effective in treating cardiovascular diseases and is an attractive and promising strategy for the development of new drugs. In this review, we discuss the current understanding of the complex regulation of PDE isoforms in cardiovascular function, highlighting the divergent and even opposing roles of PDE isoforms in different pathogenesis.

Cardiac progenitor cell therapy: mechanisms of action

Heart failure (HF) is an end-stage of many cardiac diseases and one of the main causes of death worldwide. The current management of this disease remains suboptimal. The adult mammalian heart was considered a post-mitotic organ. However, several reports suggest that it may possess modest regenerative potential. Adult cardiac progenitor cells (CPCs), the main players in the cardiac regeneration, constitute, as it may seem, a heterogenous group of cells, which remain quiescent in physiological conditions and become activated after an injury, contributing to cardiomyocytes renewal. They can mediate their beneficial effects through direct differentiation into cardiac cells and activation of resident stem cells but majorly do so through paracrine release of factors. CPCs can secrete cytokines, chemokines, and growth factors as well as exosomes, rich in proteins, lipids and non-coding RNAs, such as miRNAs and YRNAs, which contribute to reparation of myocardium by promoting angiogenesis, cardioprotection, cardiomyogenesis, anti-fibrotic activity, and by immune modulation. Preclinical studies assessing cardiac progenitor cells and cardiac progenitor cells-derived exosomes on damaged myocardium show that administration of cardiac progenitor cells-derived exosomes can mimic effects of cell transplantation. Exosomes may become new promising therapeutic strategy for heart regeneration nevertheless there are still several limitations as to their use in the clinic. Key questions regarding their dosage, safety, specificity, pharmacokinetics, pharmacodynamics and route of administration remain outstanding. There are still gaps in the knowledge on basic biology of exosomes and filling them will bring as closer to translation into clinic.

Cost of Cardiovascular Disease Event and Cardiovascular Disease Treatment-Related Complication Hospitalizations in the United States

BACKGROUND

Cardiovascular disease (CVD) is among the costliest conditions in the United States, and cost-effectiveness analyses can be used to assess economic impact and prioritize CVD treatments. We aimed to develop standardized, nationally representative CVD events and selected possible CVD treatment-related complication hospitalization costs for use in cost-effectiveness analyses.

METHODS

Nationally representative costs were derived using publicly available inpatient hospital discharge data from the 2012-2018 National Inpatient Sample. Events were identified using the principal International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes. Facility charges were converted to costs using charge-to-cost ratios, and total costs were estimated by applying a published professional fee ratio. All costs are reported in 2021 US dollars. Mean costs were estimated for events overall and stratified by age, sex, and survival status at discharge. Annual costs to the US health care system were estimated by multiplying the mean annual number of events by the mean total cost per discharge.

RESULTS

The annual mean number of hospital discharges among CVD events was the highest for heart failure (1 087 000 per year) and cerebrovascular disease (800 600 per year). The mean cost per hospital discharge was the highest for peripheral vascular disease ($33 700 [95% CI, $33 300-$34 000]) and ventricular tachycardia/ventricular fibrillation ($32 500 [95% CI, $32 100-$32 900]). Hospitalizations contributing the most to annual US health care costs were heart failure ($19 500 [95% CI, $19 300-$19 800] million) and acute myocardial infarction ($18 300, [95% CI, $18 200-$18 500] million). Acute kidney injury was the most frequent possible treatment complication (515 000 per year), and bradycardia had the highest mean hospitalization costs ($17 400 [95% CI, $17 200-$17 500]).

CONCLUSIONS

The hospitalization cost estimates and statistical code reported in the current study have the potential to increase transparency and comparability of cost-effectiveness analyses for CVD in the United States.

Multidisciplinary approach in cardiomyopathies: From genetics to advanced imaging

Cardiomyopathies are myocardial diseases characterized by mechanical and electrical dysfunction of the heart muscle which could lead to heart failure and life-threatening arrhythmias. Certainly, an accurate anamnesis, a meticulous physical examination, and an ECG are cornerstones in raising the diagnostic suspicion. However, cardiovascular imaging techniques are indispensable to diagnose a specific cardiomyopathy, to stratify the risk related to the disease and even to track the response to the therapy. Echocardiography is often the first exam that the patient undergoes, because of its non-invasiveness, wide availability, and cost-effectiveness. Cardiac magnetic resonance imaging allows to integrate and implement the information obtained with the echography. Furthermore, cardiomyopathies' genetic basis has been investigated over the years and the list of genetic mutations deemed potentially pathogenic is expected to grow further. The aim of this review is to show echocardiographic, cardiac magnetic resonance imaging, and genetic features of several cardiomyopathies: dilated cardiomyopathy (DMC), hypertrophic cardiomyopathy (HCM), arrhythmogenic cardiomyopathy (ACM), left ventricular noncompaction cardiomyopathy (LVNC), myocarditis, and takotsubo cardiomyopathy.

Estimated Glomerular Filtration Rate and Implantable Cardioverter-Defibrillator in Nonischemic Systolic Heart Failure: Extended Follow-Up of DANISH

BACKGROUND

Patients with heart failure and chronic kidney disease (CKD) may have an increased risk of death from causes competing with arrhythmic death, which could have implications for the efficacy of implantable cardioverter-defibrillators (ICDs). We examined the long-term effects of primary prophylactic ICD implantation, compared with usual care, according to baseline CKD status in an extended follow-up study of DANISH (Danish Study to Assess the Efficacy of ICDs in Patients With Nonischemic Systolic Heart Failure on Mortality).

METHODS AND RESULTS

In the DANISH trial, 1116 patients with nonischemic heart failure with reduced ejection fraction were randomized to receive an ICD (N=556) or usual care (N=550). Outcomes were analyzed according to CKD status (estimated glomerular filtration rate ≥/<60 mL/min per 1.73 m2) at baseline. In total, 1113 patients had an available estimated glomerular filtration rate measurement at baseline (median estimated glomerular filtration rate 73 mL/min per 1.73 m2), and 316 (28%) had CKD. During a median follow-up of 9.5 years, ICD implantation, compared with usual care, did not reduce the rate of all-cause mortality (no CKD, HR, 0.82 [95% CI, 0.64-1.04]; CKD, HR, 1.02 [95% CI, 0.75-1.38]; Pinteraction=0.31) or cardiovascular death (no CKD, HR, 0.77 [95% CI, 0.58-1.03]; CKD, HR, 1.05 [95% CI, 0.73-1.51]; Pinteraction=0.20), irrespective of baseline CKD status. Similarly, baseline CKD status did not modify the beneficial effects of ICD implantation on sudden cardiovascular death (no CKD, HR, 0.57 [95% CI, 0.32-1.00]; CKD, HR, 0.65 [95% CI, 0.34-1.24]; Pinteraction=0.70).

CONCLUSIONS

ICD implantation, compared with usual care, did not reduce the overall mortality rate, but it did reduce the rate of sudden cardiovascular death, regardless of baseline kidney function in patients with nonischemic heart failure with reduced ejection fraction.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT00542945.

Immune checkpoint inhibitors associated cardiovascular immune-related adverse events

Immune checkpoint inhibitors (ICIs) are specialized monoclonal antibodies (mAbs) that target immune checkpoints and their ligands, counteracting cancer cell-induced T-cell suppression. Approved ICIs like cytotoxic T-lymphocyte antigen-4 (CTLA-4), programmed death-1 (PD-1), its ligand PD-L1, and lymphocyte activation gene-3 (LAG-3) have improved cancer patient outcomes by enhancing anti-tumor responses. However, some patients are unresponsive, and others experience immune-related adverse events (irAEs), affecting organs like the lung, liver, intestine, skin and now the cardiovascular system. These cardiac irAEs include conditions like myocarditis, atherosclerosis, pericarditis, arrhythmias, and cardiomyopathy. Ongoing clinical trials investigate promising alternative co-inhibitory receptor targets, including T cell immunoglobulin and mucin domain-containing protein 3 (Tim-3) and T cell immunoreceptor with immunoglobulin and ITIM domain (TIGIT). This review delves into the mechanisms of approved ICIs (CTLA-4, PD-1, PD-L1, and LAG-3) and upcoming options like Tim-3 and TIGIT. It explores the use of ICIs in cancer treatment, supported by both preclinical and clinical data. Additionally, it examines the mechanisms behind cardiac toxic irAEs, focusing on ICI-associated myocarditis and atherosclerosis. These insights are vital as ICIs continue to revolutionize cancer therapy, offering hope to patients, while also necessitating careful monitoring and management of potential side effects, including emerging cardiac complications.

Novel Biomarkers in Early Detection of Heart Failure: A Narrative Review

Heart failure (HF) represents a significant global health challenge, characterized by a variety of symptoms resulting from cardiac dysfunction. This dysfunction often leads to systemic and pulmonary congestion. The pathophysiology of HF is complex, involving stimulation of the sympathetic nervous system, which is insufficiently balanced by the release of natriuretic peptide. This imbalance leads to progressive hypertrophy and dilatation of the heart's chambers, impairing its pumping efficiency and increasing the risk of arrhythmias and conduction disorders. The prevalence of HF is exceptionally high in industrialized nations and is expected to increase owing to an aging population and advancements in diagnostic methods. This study emphasizes the critical role of early diagnosis in reducing morbidity and mortality associated with HF, focusing specifically on the evolving importance of biomarkers in managing this condition. Biomarkers have played a key role in transforming the diagnosis and treatment of HF. Traditional biomarkers such as b-type natriuretic peptide and N-terminal pro-b-type natriuretic peptide have been widely adopted for their cost-effectiveness and ease of access. However, the rise of novel biomarkers such as growth differentiation factor 15 and adrenomedullin has shown promising results, offering superior sensitivity and specificity. These new biomarkers enhance diagnostic accuracy, risk stratification, and prognostic evaluation in HF patients. Despite these advancements, challenges remain, such as limited availability, high costs, and the need for further validation in diverse patient populations. Through a comprehensive literature review across databases such as PubMed, Google Scholar, and the Cochrane Library, this study compiles and analyzes data from 18 relevant studies, offering a detailed understanding of the current state of HF biomarkers. The study examines both traditional and emerging biomarkers such as galectin-3 and soluble suppression of tumorigenicity 2 in HF, exploring their clinical roles and impact on patient outcomes.

From Collapse to Recovery: Thiamine Intervention in Cardiac Beriberi

This case report details the challenging presentation of a 68-year-old patient of cardio-circulatory collapse with pericardial effusion and recurrent pleural effusions. Hypotension did not respond to conventional intensive care measures. Despite comprehensive investigations, the underlying cause remained unidentified until intravenous thiamine replacement therapy was administered, restoring normotension and preventing pericardial or pleural effusion recurrence. The case underscores the importance of early recognition of thiamine deficiency in patients with pericardial and pleural effusions or critical illness, emphasizing the need to expand vigilance for thiamine deficiency and consider replacement therapy without a definitive diagnosis.

Effectiveness and safety of morphine administration for refractory dyspnoea among hospitalised patients with advanced heart failure: the Morphine-HF study

OBJECTIVES

Morphine is effective in alleviating dyspnoea in patients with cancer. We aimed to investigate the effectiveness and safety of morphine administration for refractory dyspnoea in patients with advanced heart failure (HF).

METHODS

We conducted a multicentre, prospective, observational study of hospitalised patients with advanced HF in whom morphine was administered for refractory dyspnoea. Morphine effectiveness was evaluated by dyspnoea intensity changes, assessed regularly by both a quantitative subjective scale (Visual Analogue Scale (VAS; graded from 0 to 100 mm)) and an objective scale (Support Team Assessment Schedule-Japanese (STAS-J; graded from 0 to 4 points)). Safety was assessed by vital sign changes and new-onset severe adverse events, including nausea, vomiting, constipation and delirium based on the Common Terminology Criteria for Adverse Events.

RESULTS

From 15 Japanese institutions between September 2020 and August 2022, we included 28 hospitalised patients with advanced HF in whom morphine was administered (mean age: 83.8±8.7 years, male: 15 (54%), New York Heart Association class IV: 26 (93%) and mean left ventricular ejection fraction: 38%±19%). Both VAS and STAS-J significantly improved from baseline to day 1 (VAS: 67±26 to 50±31 mm; p=0.02 and STAS-J: 3.3±0.8 to 2.6±1.1 points; p=0.006, respectively), and thereafter the improvements sustained through to day 7. After morphine administration, vital signs including blood pressure, pulse rate and oxygen saturation did not change, and no new-onset severe adverse events occurred through to day 7.

CONCLUSIONS

This study suggested acceptable effectiveness and safety for morphine administration in treating refractory dyspnoea in hospitalised patients with advanced HF.

Relationship between independence in activities of daily living at discharge and physical activity at admission of older postoperative hip fracture rehabilitation inpatients: A retrospective case-control study

BACKGROUND AND PURPOSE

Hip fractures are associated with a reduction in activities of daily living (ADL) and require long-term care. The physical activity of patients with hip fractures is temporarily impaired immediately after surgery, causing difficulty in the measurement of physical activities at the time of rehabilitation admission. This study examined the relationship between ADL at discharge and light- and moderate-intensity physical activity at the time of rehabilitation admission by determining a cut-off value predicting ADL independence.

METHODS

This retrospective case control study analyzed 43 postoperative hip fracture patients aged ≥65 years admitting into inpatient rehabilitation. ADL at discharge was assessed using the Functional Independent Measure motor items (FIM-m). The duration of physical activity at the time of rehabilitation admission was measured using an activity tracker equipped with an accelerometer. Prehospital frailty was evaluated using Clinical Frailty Scale. The relationship between these variables was examined using Spearman's product-moment correlation coefficient. Differences in physical activity between patients requiring and not requiring assistance with ADLs were examined using the analysis of covariance. A receiver operating characteristic curve of the need for ADL assistance at discharge was constructed from the duration of physical activity.

RESULTS

The duration of physical activity at the time of rehabilitation admission was related to FIM-m at discharge. The cut-off value of the duration of physical activity for predicting the need for ADL assistance at discharge was 135 s, with a sensitivity of 83.3% and specificity of 68.4% (area under the curve: 0.76).

DISCUSSION

The duration of physical activity at the time of rehabilitation admission may be a factor that can quantitatively predict the risk of requiring assistance with ADLs at discharge in older hip fracture patients. The duration of light-and-moderate intensity physical activity may be a component of multidisciplinary inpatient rehabilitation to improve patients' ADL.

Tako-Tsubo Syndrome Triggered by a Fibroscopy: Case Report

Tako-Tsubo cardiomyopathy, also called stress cardiopathy, is a rare syndrome characterized by transient regional systolic dysfunction. It can mimic myocardial infarction but the absence of coronary obstruction allows to redress the diagnosis. Its pathogenesis is not well understood. However, the role of physical or emotional stress has often been associated with this pathology. Here we report, a rare case of a 63-year-old female, with no cardiac risk factors, who presented Tako-Tsubo syndrome after a fibroscopy. This case aims to show that Tako-Tsubo syndrome should be suspected in patients, especially women, with no cardiac risk factors, who present acute chest pain in the context of physical or emotional stress, after excluding differential diagnoses.

Prognostic utility of serum NT-proBNP (fragments 1-76aa and 13-71aa) and galectin-3 in predicting death and re-hospitalisation due to cardiovascular events in patients with heart failure

Patients with heart failure (HF) are at a higher risk of rehospitalisation. In this study, we investigated the prognostic utility of galectin-3 (Gal-3) and NT-proBNP fragments (1-76aa and 13-71aa) as biomarkers to predict outcomes for patients with HF. We collected blood samples from patients with HF (n = 101). Gal-3 and NT-proBNP fragments (1-76aa and 13-71aa) concentrations were measured by immunoassay. Survival analysis and Cox proportional regression models were used to determine the prognostic utility of Gal-3 and NT-proBNP fragments. In patients with increased baseline levels of NT-proBNP1-76 the time to primary endpoint (cardiovascular death or re-hospitalisation) was significantly shorter (p = 0.0058), but not in patient with increased baseline levels of Gal-3 or NTproBNP13-71. Patients with increased levels of NT-proBNP13-71aa at 1 month showed reduced time to the primary endpoint (p = 0.0123). Our findings demonstrated that Gal-3 and NT-proBNP can be used as prognostic biomarkers to stratify patients with HF.

A Case Report: Lithium-Induced Neurotoxicity, a Differential to Always Consider

Lithium, a mood stabilizer commonly prescribed for bipolar disorder, has a narrow therapeutic index that increases the risk of toxicity for patients who are prescribed this medication. Patients presenting with lithium toxicity could have a wide array of symptoms triggered by several factors that mimic other neurological conditions. In this paper, we discuss the case of an 81-year-old male who presented to the emergency department with worsening tremors and visual hallucinations, ataxia, and cognitive decline. He was initially thought to have Parkinson's disease with dementia in the outpatient setting and was later found to have lithium toxicity. Swift identification and management, involving fluid diuresis, led to the complete resolution of the patient's neurological symptoms by the fourth day of hospitalization. This case calls attention to the challenges of diagnosing lithium toxicity due to the variability in presentation as well as precipitating factors that clinicians must be cognizant of when working up patients who are prescribed lithium.

Cognitive transitions based on functional status in older adults with heart failure: a population-based study

AIMS

Cognitive impairment and functional status are both important determinants of poor outcomes in heart failure (HF). However, little is known about how functional status impacts the changes in cognitive status during the disease course. This study aimed to describe the cognitive transitions in patients with HF and assess the relationship of these transitions to functional status, which was assessed by the dependency of activities of daily living (ADL).

METHODS AND RESULTS

This retrospective cohort study included 1764 patients with an International Classification of Diseases-10 code of HF (≥65 years, mean age 82.3 ± 7.9 years, 39% male) from a long-term care and medical insurance database from Nobeoka city, a rural city of south-western Japan. Cognitive status at baseline and 6, 12, 18, and 24 month time points was collected, and participants were stratified based on ADL status at baseline. Generalized estimating equations and multi-state modelling were used to examine associations between ADL dependency and cognitive changes/mortality. Transition probabilities were estimated using multi-state modelling. At baseline, there were 1279 (73%) and 485 (27%) patients with independent and dependent ADL, respectively. In overall patients, 1656 (93.9%) patients had normal/mild cognitive status and 108 (6%) patients had a moderate/severe cognitive status at baseline. The majority [104 (96%) patients] of patients with moderate/severe cognitive status at baseline had dependent ADL. In patients with moderate/severe cognitive status, the number of patients with dependent ADL always outnumbered that of the independent ADL throughout the follow-up. Multi-state modelling estimated that patients with dependent ADL and normal/mild cognitive status at baseline had 47% probability of maintaining the same cognitive status at 24 months, while the probability of maintaining the same cognitive status was 86% for those with independent ADL. Patients with normal/mild cognitive status in the dependent ADL group at baseline had a higher risk of experiencing a transition to moderate/severe cognitive status at any time point during 24 months compared with those with independent ADL [hazard ratio 5.24 (95% confidence interval 3.47-7.90)].

CONCLUSIONS

In older patients with HF, the prevalence of cognitive impairment was always higher for those with reduced functional status. Despite having a normal/mild cognitive status at baseline, patients with dependent ADL are at high risk of experiencing cognitive decline over 24 months with substantially less chance of maintaining their cognitive status. ADL dependency was an important risk factor of cognitive decline in patients with HF.

Exosomes and their derivatives as biomarkers and therapeutic delivery agents for cardiovascular diseases: Situations and challenges

Microvesicles known as exosomes have a diameter of 40 to 160 nm and are derived from small endosomal membranes. Exosomes have attracted increasing attention over the past ten years in part because they are functional vehicles that can deliver a variety of lipids, proteins, and nucleic acids to the target cells they encounter. Because of this function, exosomes may be used for the diagnosis, prognosis and treatment of many diseases. All throughout the world, cardiovascular diseases (CVDs) continue to be a significant cause of death. Because exosomes are mediators of communication between cells, which contribute to many physiological and pathological aspects, they may aid in improving CVD therapies as biomarkers for diagnosing and predicting CVDs. Many studies demonstrated that exosomes are associated with CVDs, such as coronary artery disease, heart failure, cardiomyopathy and atrial fibrillation. Exosomes participate in the progression or inhibition of these diseases mainly through the contents they deliver. However, the application of exosomes in diferent CVDs is not very mature. So further research is needed in this field.

Prealbumin level is a predictor of activities of daily living at discharge in older patients with heart failure who became ADL-independent after hospitalization: - Acute and early recovery cardiac rehabilitation trials

Chiba T, Yokota J, Takahashi R, Sasaki K, Suzuki H. Prealbumin level is a predictor of activities of daily living at discharge in older patients with heart failure who became ADL-independent after hospitalization - Acute and early recovery cardiac rehabilitation trials. Jpn J Compr Rehabil Sci 2023; 14: 69-77.

Objective

To determine the relationship between prealbumin level and activities of daily living (ADL) at discharge in patients with heart failure (HF) and assess the usefulness of prealbumin measurement in predicting discharge Barthel Index (BI) in older patients with HF who become non-independent in ADL after hospital admission.

Methods

Patients with HF, aged ≥75 years, who were admitted to an acute hospital and underwent acute and early recovery cardiac rehabilitation (CR) were studied retrospectively. The exclusion criteria were non-independent ADL before admission (BI < 85 points) and independent ADL at the start of CR (BI ≥ 85 points). The usefulness of prealbumin level in predicting discharge BI was compared between four models. Albumin and Controlling Nutritional Status (CONUT) were used as comparison variables. The models and independent variables were model 1 (covariates only), model 2 (prealbumin + covariates), model 3 (albumin + covariates), and model 4 (CONUT score + covariates). Adjusted R2, a measure of model fit, was used to compare predictive ability.

Results

A total of 152 patients were included in the analysis. Prealbumin level was a significant variable for BI at discharge but not albumin or CONUT. The adjusted R2 was higher in model 2 with the addition of prealbumin than that in model 1 (0.362 vs. 0.347).

Conclusion

Prealbumin levels are useful in predicting discharge BI in older patients with HF who become non-independent in ADL after hospitalization.

Patient Awareness of Heart Failure Diagnosis: A Community Study

Background Heart failure (HF) is a complex disease that contributes to a high number of hospitalizations, deaths, and economic health care costs each year. However, among patients with HF, there is a lack of awareness of their HF diagnosis that has not been fully examined. Methods and Results Residents from 3 counties of southeast Minnesota with a first-ever International Classification of Diseases, Ninth Revision (ICD-9) code 428 or Tenth Revision (ICD-10) code I50 between January 1, 2013 and March 31, 2016 (N=2461) were prospectively surveyed to measure HF self-awareness. A total of 1114 patients returned the survey (response rate, 45%), and 787 had validated HF upon medical record review. Among these 787 patients with HF (mean age, 76 years; 53% men), 37% (n=293) were aware of their HF diagnosis. After adjustment, being a woman (odds ratio [OR], 1.56 [95% CI, 1.10-2.22]), having HF with reduced ejection fraction (OR, 1.58 [95% CI, 1.13-2.22]), attending the HF clinic (OR, 4.07 [95% CI, 2.25-7.36]), and having coronary artery disease (OR, 1.65 [95% CI, 1.16-2.37]) were all associated with increased awareness of an HF diagnosis. Conversely, having diabetes was associated with decreased awareness of an HF diagnosis (adjusted OR, 0.69 [95% CI, 0.50-0.95]). Conclusions Awareness of an HF diagnosis is low in a community population of patients with HF. Strategies to improve patient awareness of their diagnosis should be implemented to improve self-care behaviors and outcomes in patients with HF.

Sacubitril/Valsartan in the Treatment of Heart Failure With Reduced Ejection Fraction Focusing on the Impact on the Quality of Life: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

There exists a paucity of research data reported by analyses performed on randomized clinical trials (RCTs) that encompass quality of life (QOL) and the aftermath for patients suffering from heart failure with reduced ejection fraction (HFrEF). This systematic review and meta-analysis of randomized clinical trials (RCTs) have been done to evaluate the drug sacubitril/valsartan in the treatment of heart failure (HF) with reduced ejection fraction (HFrEF) with a clear focus on the effect it bestows on measures of physical exercise tolerance and quality of life. A thorough systematic search was done in databases including Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, Embase, and PubMed from 1 January 2010 to 1 January 2023. The search only included published RCTs on adult patients aged 18 and above, with heart failure with reduced ejection fraction (HFrEF). Data analysis was performed by using the software RevMan 5.4 (Cochrane Collaboration, London, United Kingdom). The included studies' bias risk was assessed using the Cochrane Collaboration's Risk of Bias tool. The quality of evidence for the primary outcome was done using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework. This systematic review and meta-analysis of RCTs yielded 458 studies, of which eight randomized clinical trials were included and analyzed. The meta-analysis of the included trials shows that the I2 value is 61% (i.e., I2 > 50%), demonstrating a substantial heterogeneity within the studies. The left ventricular ejection fraction (LVEF) expressed in percentage was reported in the five studies, and thereby, a subgroup analysis that yielded a confidence interval (CI) of 95% had the standard mean difference of 0.02 (-0.02, 0.07). The trials had disparity between the reporting of effect on peak oxygen consumption (VO2), measured through cardiopulmonary exercise testing (CPET) methods, six-minute walking test (6MWT), overall physical activity, and exercise capacity. Sacubitril/valsartan did not exponentially improve peak VO2 or 6MWT in these trials; however, the patient-reported data suggested that the quality of life was modestly influenced by the drug. A subgroup analysis was performed using the pooled effect value by the random effects model. The findings showed that the sacubitril/valsartan group significantly was better than the control group in improving HFrEF-associated health-related quality of life (HRQoL). This study is a systematic review and meta-analysis of randomized clinical trials that evaluated the drug sacubitril/valsartan in treating heart failure with reduced ejection fraction (HFrEF) and focused on its tangible effect on the measures of physical exercise tolerance and quality of life. It depicts that the statistical scrutiny due to the lack of significant data and parity across studies did not impart significant improvement of either LVEF, peak VO2, or 6MWT with the use of sacubitril/valsartan; however, the reported exercise tolerance, including daytime physical activity, had a modest impact with the said drug. The pooled values demonstrated that the sacubitril/valsartan group significantly outperformed the control group in improving HFrEF HRQoL.