Reverse epidemiology in systolic and nonsystolic heart failure: cumulative prognostic benefit of classical cardiovascular risk factors

Blood pressure and heart failure: focused on treatment

Heart failure (HF) remains a significant global health burden, and hypertension is known to be the primary contributor to its development. Although aggressive hypertension treatment can prevent heart changes in at-risk patients, determining the optimal blood pressure (BP) targets in cases diagnosed with HF is challenging owing to insufficient evidence. Notably, hypertension is more strongly associated with HF with preserved ejection fraction than with HF with reduced ejection fraction. Patients with acute hypertensive HF exhibit sudden symptoms of acute HF, especially those manifested with severely high BP; however, no specific vasodilator therapy has proven beneficial for this type of acute HF. Since the majority of medications used to treat HF contribute to lowering BP, and BP remains one of the most important hemodynamic markers, targeted BP management is very concerned in treatment strategies. However, no concrete guidelines exist, prompting a trend towards optimizing therapies to within tolerable ranges, rather than setting explicit BP goals. This review discusses the connection between BP and HF, explores its pathophysiology through clinical studies, and addresses its clinical significance and treatment targets.

Novel Pulse Waveform Index by Ambulatory Blood Pressure Monitoring and Cardiac Function: A Pilot Study

Background

A simple ambulatory measure of cardiac function could be helpful for monitoring heart failure patients.

Objectives

The purpose of this paper was to determine whether a novel pulse waveform analysis using data obtained by our developed multisensor-ambulatory blood pressure monitoring (ABPM) device, the 'Sf/Am' ratio, is associated with echocardiographic left ventricular ejection fraction (LVEF).

Methods

Multisensor-ABPM was conducted twice at baseline in 20 heart failure (HF) patients with HF-reduced LVEF or HF-preserved LVEF (median age 66 years, male 65%) and over a 6- to 12-month follow-up after patient-tailored treatment. We assessed the changes in the pulse waveform index Sf/Am and LVEF that occurred between the baseline and follow-up. The Sf/Am consists of the area of the ejection part in the square forward wave (Sf) and the amplitude of the measured wave (Am). We divided the patients into the recovered (n = 11) and not-recovered (n = 9) groups defined by a ≥10% increase in LVEF.

Results

Although the ambulatory BP levels and variabilities did not change in either group, the Sf/Am increased significantly in the recovered group (baseline 21.4 ± 4.5; follow-up, 25.6 ± 3.7, P = 0.004). The not-recovered group showed no difference between the baseline and follow-up. The follow-up/baseline Sf/Am ratio was significantly associated with the LVEF ratio (r = 0.469, P = 0.037). The Sf/Am was significantly correlated with the LVEF in overall measurements (n = 40, r = 0.491, P = 0.001).

Conclusions

These results demonstrated that a novel noninvasive pulse waveform index, the Sf/Am measured by multisensor-ABPM is associated with LVEF. The Sf/Am may be useful for estimating cardiac function.

Impact of Low Baseline Low-Density Lipoprotein Cholesterol on Long-Term Postdischarge Cardiovascular Outcomes in Patients With Acute Myocardial Infarction

Background

Real‐world data on low baseline low‐density lipoprotein cholesterol (LDL‐C) levels and long‐term postdischarge cardiovascular outcomes in patients with acute coronary syndrome are limited.

Methods and Results

Of the 10 719 patients enrolled in the Korean registry of acute myocardial infarction between January 2004 and August 2014, we identified 5532 patients who were event free from death, recurrent myocardial infarction, or stroke during the in‐hospital period after successful percutaneous coronary intervention. The co–primary outcomes were 3‐point major adverse cardiovascular events (a composite of nonfatal stroke, nonfatal myocardial infarction, and cardiovascular death) and cardiovascular death at 5 years. Of 5532 patients with acute myocardial infarction (mean age, 62.1±12.8 years; 75.0% men), 446 cardiovascular deaths (8.1%) and 695 three‐point major adverse cardiovascular events (12.6%) occurred at 5 years. In the continuous analysis of LDL‐C, the risk of cardiovascular events increased steeply as LDL‐C levels decreased from 100 mg/dL. For categorical analysis of LDL‐C (<70, 70–99, and ≥100 mg/dL), as LDL‐C levels decreased, clinical outcomes worsened (237/3759 [6.3%] in LDL‐C ≥100 mg/dL versus 123/1291 [9.5%] in LDL‐C 70–99 mg/dL versus 86/482 [17.8%] in LDL‐C <70 mg/dL for cardiovascular death; P‐trend<0.001; and 417/3759 [11.1%] in LDL‐C ≥100 mg/dL versus 172/1291 [13.3%] in LDL‐C 70–99 mg/dL versus 106/482 [22.2%] in LDL‐C <70 mg/dL for 3‐point major adverse cardiovascular event; P‐trend<0.001). In a Cox time‐to‐event multivariable model with LDL‐C levels ≥100 mg/dL as the reference, the baseline LDL‐C level <70 mg/dL was independently associated with an increased incidence of cardiovascular death (adjusted hazard ratio, 1.68 [95% CI, 1.30–2.17]) and 3‐point major adverse cardiovascular event (adjusted hazard ratio, 1.37 [95% CI, 1.10–1.71]).

Conclusions

In this Korean acute myocardial infarction registry, the baseline LDL‐C level <70 mg/dL was significantly associated with an increased incidence of long‐term cardiovascular events after discharge. (COREA [Cardiovascular Risk and Identification of Potential High‐Risk Population]‐Acute Myocardial Infarction Registry; NCT02806102).

Registration

URL: https://www.clinicaltrials.gov/; Unique identifier: NCT02806102.

Hypotension on cardiopulmonary stress test predicts 90 day mortality after LVAD implantation in INTERMACS 3-6 patients

AIMS

Cardiopulmonary stress test (CPX) is routinely performed when evaluating patient candidacy for left ventricular assist device (LVAD) implantation. The predictive value of hypotensive systolic blood pressure (SBP) response during CPX on clinical outcomes is unknown. This study aims to determine the effect of hypotensive SBP response during to clinical outcomes among patients who underwent LVAD implantation.

METHODS AND RESULTS

This was a retrospective single center study enrolling consecutive patients implanted with a continuous flow LVAD between 2011 and 2022. Hypotensive SBP response was defined as peak exercise SBP below the resting value. Multivariable Cox-regression analysis was performed to evaluate the relationship between hypotensive SBP response and all-cause mortality within 30 and 90 days of LVAD implantation. A subgroup analysis was performed for patients implanted with a HeartMate III (HM III) device. Four hundred thirty-two patients underwent LVAD implantation during the pre-defined period and 156 with INTERMACS profiles 3-6 met our inclusion criteria. The median age was 63 years (IQR 54-69), and 52% had ischaemic cardiomyopathy. Hypotensive SBP response was present in 35% of patients and was associated with increased 90 day all-cause mortality (unadjusted HR 9.16, 95% CI 1.98-42; P = 0.0046). Hazard ratio remained significant after adjusting for age, INTERMACS profile, serum creatinine, and total bilirubin. Findings were similar in the HM III subgroup.

CONCLUSIONS

Hypotensive SBP response on pre-LVAD CPX is associated with increased perioperative and 90 day mortality after LVAD implantation. Additional studies are needed to determine the mechanism of increased mortality observed.

Initiation of anti-hypertensive drugs and outcomes in patients with heart failure with preserved ejection fraction and persistent hypertension

BACKGROUND

National heart failure (HF) guidelines recommend that in patients with HF with preserved ejection fraction (EF;HFpEF) and hypertension, systolic blood pressure (SBP) should be maintained below 130 mmHg. The objective of the study is to examine the association between initiation of anti-hypertensive drugs and outcomes in patients with HFpEF with persistent hypertension.

METHODS

Of the 8873 hospitalized patients with HFpEF (EF ≥50%) with a history of hypertension without renal failure in Medicare-linked OPTIMIZE-HF, 3315 had a discharge SBP ≥130 mmHg, of whom 1971 were not receiving anti-hypertensive drugs, thiazides and calcium channel blockers, before hospitalization. Of these, 366 received discharge prescriptions for those drugs. We assembled a propensity score-matched cohort of 365 pairs of patients initiated and not initiated on anti-hypertensive drugs, balanced on 37 baseline characteristics. Hazard ratios (HR) and 95% confidence intervals (CI) for outcomes associated with anti-hypertensive drug initiation were estimated in the matched cohort.

RESULTS

Matched patients (n = 730) had a mean age of 78 years; 67% were women and 17% African Americans. During 6 (median 2.5) years of follow-up, 66% of the patients died and 45% had HF readmission. HRs (95% CIs) for all-cause mortality at 30 days, 12 months and 6 years associated with anti-hypertensive drug initiation were 0.64 (0.30-1.36), 0.70 (0.51-0.97), and 0.95 (0.79-1.13), respectively. Respective HRs (95% CIs) for HF readmission were 1.65 (0.97-2.80), 1.18 (0.90-1.56) and 1.09 (0.88-1.35).

CONCLUSIONS

Among hospitalized older patients with HFpEF with uncontrolled hypertension, the initiation of therapy with anti-hypertensive drugs was not associated with all-cause mortality or hospital readmission.

Prognostic Potential of the Controlling Nutritional Status (CONUT) Score in Predicting All-Cause Mortality and Major Adverse Cardiovascular Events in Patients With Coronary Artery Disease: A Meta-Analysis

Background

As defined by the Controlling Nutrition Status (CONUT) score, the prognostic significance of nutritional status has attracted attention in patients with cardiovascular disease. This meta-analysis aimed to determine the importance of CONUT score for prediction of all-cause mortality and major adverse cardiovascular events (MACE) in adult patients with coronary artery disease (CAD).

Methods

Observational studies conducted to evaluate the association of CONUT score with adverse clinical outcomes in patients with CAD were included. We searched MEDLINE, Embase, Scopus, Cochrane library, Google scholar, medRxiv pre-print as well as Science Direct search engine for studies published from the inception of each database until March 21, 2022. Studies reporting the utility of CONUT score in prediction of all-cause mortality and MACE among patients with CAD were eligible. Predictive potential of the CONUT score were summarized by pooling the multivariable adjusted hazard ratio (aHR) with 95% CI for the malnourished vs. normal nutritional status or per point CONUT score increase.

Results

Of 2,547 screened citation, nine observational studies involving 81,257 patients with CAD were analyzed. Malnutrition defined by the CONUT score was associated with significantly increased risk of all-cause mortality when compared with the normal nutritional state (aHR for mild, moderate, and severe malnutrition, respectively: (1.21 [95% CI: 1.15–1.27], I² = 0%), (1.53 [95% CI: 1.26–1.84], I² = 84%), and (2.24 [95% CI: 1.57–3.19], I² = 77%). Similarly, moderate (aHR 1.71 [95% CI: 1.44–2.03], I² = 0%) and severe (aHR 2.66 [95% CI: 1.82–3.89], I² = 0%) malnutrition was associated with a significantly higher risk of MACE compared with the normal nutritional state. Additionally, per point increase in the CONUT score was correlated with 20 and 23% additional risk of all-cause mortality and MACE, respectively.

Conclusion

As defined by the CONUT score, malnutrition is an independent predictor of all-cause mortality and MACE in CAD patients. Nutritional assessment with CONUT score could allow clinicians to identify patients with CAD at high risk for adverse clinical outcomes.

Prognostic value of blood pressure in ambulatory heart failure: a meta-analysis and systematic review. Ambulatory blood pressure predicts heart failure prognosis

Previous primary studies have explored the association between blood pressure (BP) and mortality in ambulatory heart failure (HF) patients reporting varying and contrasting associations. The aim is to determine the pooled BP prognostic value and explore potential reasons for between-study inconsistency. We searched Medline, Cochrane, EMBASE and CINAHL from January 2005 to October 2018 for studies with ≥ 50 events (mortality and/or hospitalization) and included BP in a multivariable model in ambulatory HF patients. We pooled hazard ratios (random effects model) for systolic BP (SBP) or diastolic BP (DBP) effect on mortality and/or hospitalization risk. We used a priori defined sub-group analyses to explore heterogeneity and GRADE approach to assess the certainty of the evidence. Seventy-one eligible articles (239,467 screened) at low to moderate risk of bias included 235,752 participants. Higher SBP was associated with reduced all-cause mortality (HR 0.93, 95%CI 0.91-0.95, I2 = 87.13%, moderate certainty), all-cause hospitalization events (HR 0.91, 95%CI 0.88-0.93, I2 = 44.4%, high certainty) and their composite endpoint (HR 0.93 per 10 mmHg, 95%CI 0.91-0.94, I2 = 86.3%, high certainty). DBP did not demonstrate a statistically significant effect for all outcomes. The association strength was significantly weaker in studies following patients with either LVEF > 40%, higher average SBP (> 130 mmHg), increasing age and diabetes. All other a priori subgroup hypotheses did not explain between study differences. Higher ambulatory SBP is associated with reduced risk of all-cause mortality and hospitalization. Patients with lower BP and reduced LVEF are in a high-risk group of developing adverse events with moderate certainty of evidence.

Low serum cholesterol level as a risk factor for out-of-hospital cardiac arrest: a case-control study

OBJECTIVE

We aimed to identify the association between low serum total cholesterol levels and the risk of out-of-hospital cardiac arrest (OHCA).

METHODS

This case-control study was performed using datasets from the Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance (CAPTURES) project and the Korea National Health and Nutrition Examination Survey (KNHANES). Cases were defined as emergency medical service-treated adult patients who experienced OHCA with a presumed cardiac etiology from the CAPTURES project dataset. Four controls from the KNHANES dataset were matched to each case based on age, sex, and county. Multivariable conditional logistic regression analysis was conducted to evaluate the effect of total cholesterol levels on OHCA.

RESULTS

A total of 607 matched case-control pairs were analyzed. We classified total cholesterol levels into six categories (<148, 148-166.9, 167-189.9, 190-215.9, 216-237.9, and ≥238 mg/dL) according to the distribution of total cholesterol levels in the KNHANES dataset. Subjects with a total cholesterol level of 167-189.9 mg/dL (25th-49th percentile of the KNHANES dataset) were used as the reference group. In both the adjusted models and sensitivity analysis, a total cholesterol level of <148 mg/dL was significantly associated with OHCA (adjusted odds ratio [95% confidence interval], 6.53 [4.47-9.56]).

CONCLUSION

We identified an association between very-low total cholesterol levels and an increased risk of OHCA in a large, community-based population. Future prospective studies are needed to better understand how a low lipid profile is associated with OHCA.

The Global Ambulatory Blood Pressure Monitoring (ABPM) in Heart Failure with Preserved Ejection Fraction (HFpEF) Registry. Rationale, design and objectives

Hypertension is a major risk factor for the development of heart failure with preserved ejection fraction (HFPEF) and blood pressure (BP) in itself is an important marker of prognosis. The association of BP levels, and hemodynamic parameters, measured by ambulatory blood pressure monitoring (ABPM), with outcomes, in patients with HFPEF is largely unknown. Patients with HFPEF have a substantial burden of co-morbidities and frailty. In addition there are marked geographic differences in HFPEF around the world. How these difference influence the association between BP and outcomes in HFPEF are unknown. The Global Ambulatory Blood Pressure Monitoring (ABPM) in Heart Failure with Preserved Ejection Fraction (HFpEF) Registry aims to assess the relevance of BP parameters, measured by ABPM, on the outcome of HFPEF patients worldwide. Additionally, the influence of other relevant factors such as frailty and co-morbidities will be assessed. Stable HFPEF patients with a previous hospitalization, will be included. Patients should be clinically and hemodynamically stable for at least 4 weeks before study inclusion. Specific data related to HF, biochemical markers, ECG and echocardiography will be collected. An ABPM and geriatric and frailty evaluation will be performed and the association with morbidity and mortality assessed. Follow up will be at least one year.

Impact of initial very low-level low-density lipoprotein cholesterol on the prognosis of acute myocardial infarction patients

BACKGROUND

Cholesterol control with statins has been shown to have beneficial effects in coronary artery disease. However, the relationship between initial very low low-density lipoprotein (LDL) cholesterol levels and long-term clinical outcomes in patients with acute myocardial infarction (AMI) remains unclear.

METHODS

A total of 8741 (mean age: 64.6 ± 12.7 years, men) consecutive AMI patients treated with drug-eluting stents were entered into the Korea Acute Myocardial Infarction Registry from November 2011 to December 2015. Patients were divided into six groups according to whether they were taking statins (on-statin group) or not (statin naive group) and depending on their LDL cholesterol level at admission (<70, 70-99, 100-129, 130-159, >160 mg/dl). Clinical outcomes at 24 months in patients with AMI were examined.

RESULTS

The incidence of risk factors including hypertension, diabetes, coronary artery disease and heart failure was lower as LDL cholesterol increased, except in the on-statin group. Clinical outcomes, including total mortality at 24 months, showed better outcomes in those with high LDL cholesterol than those with low LDL cholesterol, except in the statin group. In the statin-naïve group, the higher the LDL cholesterol level, the higher the rate of 24-month survival. In a Cox regression model, initial low LDL cholesterol was an independent predictor of mortality at 24 months after adjusting for baseline confounding factors.

CONCLUSIONS

At admission, a very low LDL cholesterol level (<70 mg/dL) in statin-naïve AMI patients undergoing percutaneous coronary intervention was independently associated with higher mortality at 24 months.

Association between low-density lipoprotein cholesterol level and mortality in patients with cardiogenic shock: a retrospective cohort study

AIMS

Inflammation plays a key role in the pathophysiology of cardiogenic shock (CS). Low-density lipoprotein cholesterol (LDL-C) is a biomarker of inflammation and is used to predict prognostic outcomes of several diseases. The primary purpose of this study was to evaluate if LDL-C can be used as a biomarker to predict the mortality of CS.

METHODS AND RESULTS

Records of critically ill patients with CS were identified from the Medical Information Mart for Intensive Care III database. A multivariate Cox regression model was employed to adjust for imbalances by incorporating parameters and potential confounders.A total of 551 critically ill patients with CS were enrolled for this analysis, including 207 with LDL-C <1.8 mmol/L and 344 with LDL-C ≥1.8 mmol/L. Results of multivariate Cox regression models found that higher concentration of LDL-C (LDL-C ≥1.8mmol/L) was associated with a reduced risk of in-hospital mortality (HR 0.66, 95% CI 0.50 to 0.87; p=0.003) and 28-day mortality (HR 0.61, 95% CI 0.46 to 0.80; p=0.002) LDL-C in patients with CS. Patients with LDL-C ≥1.8 mmol/L were independently associated with improved in-hospital survival (HR 0.32, 95% CI 0.20 to 0.52, p<0.001) and 28-day survival (HR 0.51, 95% CI 0.33 to 0.73, p=0.002) compared with patients with LDL-C <1.8 mmol/L. The impact of LDL-C on in-hospital mortality and 28-day mortality persisted in patients with acute coronary syndrome (ACS) and was not statistically significant in the non-ACS subgroup.

CONCLUSIONS

Our study observed that increased LDL-C level was related with improved survival in patients with CS, but not with improved outcomes in patients with uncomplicated ACS. The results need to be verified in randomised controlled trials.

Association of Body Mass Index With Clinical Outcomes in Patients With Heart Failure With Reduced Ejection Fraction Treated With Sacubitril/Valsartan

BACKGROUND

Only limited data are available that address the association between body mass index (BMI) and clinical outcomes in patients with heart failure with reduced ejection fraction who are receiving sacubitril/valsartan.

METHODS

We performed a retrospective multi-center cohort study in which we compared 3 body mass index groups (normal, overweight and obese groups) in patients with heart failure with reduced ejection fraction receiving sacubitril/valsartan. The follow-up period was at least 1 year. Propensity score weighting was performed. The primary outcomes were hospitalization for heart failure and all-cause mortality.

RESULTS

Of the 721 patients in the original cohort, propensity score weighting generated a cohort of 540 patients in 3 groups: normal weight (n = 78), overweight (n = 181), and obese (n = 281). All baseline characteristics were well-balanced between 3 groups after propensity score weighting. Among our results, we found no significant differences in hospitalization for heart failure (normal weight versus overweight: average hazard ratio [AHR] 1.29, 95% confidence interval [CI] = 0.76-2.20, P = 0.35; normal weight versus obese: AHR 1.04, 95% CI = 0.63-1.70, P = 0.88; overweight versus obese groups: AHR 0.81, 95% CI = 0.54-1.20, P = 0.29) or all-cause mortality (normal weight versus overweight: AHR 0.99, 95% CI = 0.59-1.67, P = 0.97; normal weight versus obese: AHR 0.87, 95% CI = 0.53-1.42, P = 0.57; overweight versus obese: AHR 0.87, 95% CI = 0.58-1.32, P = 0.52).

CONCLUSION

We identified no significant associations between BMI and clinical outcomes in patients diagnosed with heart failure with a reduced ejection fraction who were treated with sacubitril/valsartan. A large-scale study should be performed to verify these results.

Systolic Blood Pressure and Outcomes in Older Patients with HFpEF and Hypertension

BACKGROUND

New hypertension and heart failure guidelines recommend that systolic blood pressure (SBP) in patients with heart failure with preserved ejection fraction (HFpEF) and hypertension be lowered to <130 mm Hg.

METHODS

Of the 6778 hospitalized patients with HFpEF and a history of hypertension in the Medicare-linked OPTIMIZE-HF registry, 3111 had a discharge SBP <130 mm Hg. Using propensity scores for SBP <130 mm Hg, we assembled a matched cohort of 1979 pairs with SBP <130 versus ≥130 mm Hg, balanced on 66 baseline characteristics (mean age, 79 years; 69% women; 12% African American). We then assembled a second matched cohort of 1326 pairs with SBP <120 versus ≥130 mm Hg. Hazard ratios (HRs) and 95% confidence intervals (CIs) for outcomes associated with SBP <130 and <120 mm Hg were separately estimated in the matched cohorts using SBP ≥130 mm Hg as the reference.

RESULTS

HRs (95% CIs) for 30-day, 12-month, and 6-year all-cause mortality associated with SBP <130 mm Hg were 1.20 (0.91-1.59; P = 0.200), 1.11 (0.99-1.26; P = 0.080), and 1.05 (0.98-1.14; P = 0.186), respectively. Respective HRs (95% CIs) associated with SBP <120 mm Hg were 1.68 (1.21-2.34; P = 0.002), 1.28 (1.11-1.48; P = 0.001), and 1.11 (1.02-1.22; P = 0.022). There was no association with readmission.

CONCLUSIONS

Among older patients with HFpEF and hypertension, compared with SBP ≥130 mm Hg, the new target SBP <130 mm Hg had no association with outcomes but SBP <120 mm Hg was associated with a higher risk of death but not of readmission. Future prospective studies need to evaluate optimal SBP treatment goals in these patients.

Model-based comorbidity clusters in patients with heart failure: association with clinical outcomes and healthcare utilization

BACKGROUND

Comorbidities affect outcomes in heart failure (HF), but are not reflected in current HF classification. The aim of this study is to characterize HF groups that account for higher-order interactions between comorbidities and to investigate the association between comorbidity groups and outcomes.

METHODS

Latent class analysis (LCA) was performed on 12 comorbidities from patients with HF identified from administrative claims data in the USA (OptumLabs Data Warehouse®) between 2008 and 2018. Associations with admission to hospital and mortality were assessed with Cox regression. Negative binomial regression was used to examine rates of healthcare use.

RESULTS

In a population of 318,384 individuals, we identified five comorbidity clusters, named according to their dominant features: low-burden, metabolic-vascular, anemic, ischemic, and metabolic. Compared to the low-burden group (minimal comorbidities), patients in the metabolic-vascular group (exhibiting a pattern of diabetes, obesity, and vascular disease) had the worst prognosis for admission (HR 2.21, 95% CI 2.17-2.25) and death (HR 1.87, 95% CI 1.74-2.01), followed by the ischemic, anemic, and metabolic groups. The anemic group experienced an intermediate risk of admission (HR 1.49, 95% CI 1.44-1.54) and death (HR 1.46, 95% CI 1.30-1.64). Healthcare use also varied: the anemic group had the highest rate of outpatient visits, compared to the low-burden group (IRR 2.11, 95% CI 2.06-2.16); the metabolic-vascular and ischemic groups had the highest rate of admissions (IRR 2.11, 95% CI 2.08-2.15, and 2.11, 95% CI 2.07-2.15) and healthcare costs.

CONCLUSIONS

These data demonstrate the feasibility of using LCA to classify HF based on comorbidities alone and should encourage investigation of multidimensional approaches in comorbidity management to reduce admission and mortality risk among patients with HF.

Impact of sarcopenia on prognosis in patients with heart failure with reduced and preserved ejection fraction

AIMS

Sarcopenia, one of the extracardiac factors for reduced functional capacity and poor outcome in heart failure (HF), may act differently between HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF). We sought to investigate the impact of sarcopenia on mortality in HFpEF and HFrEF.

METHODS AND RESULTS

We performed a post hoc analysis of a multicentre prospective cohort study, including 942 consecutive older (age ≥65 years) hospitalized patients: 475 with HFpEF (ejection fraction ≥45%, age 81 ± 7 years, 48.8% men) and 467 with HFrEF (ejection fraction <45%, age 78 ± 8 years, 68.1% men). Sarcopenia was diagnosed according to the international criteria incorporating muscle strength (handgrip strength), physical performance (gait speed), and skeletal muscle mass (appendicular skeletal mass). The HFpEF group consisted of fewer patients with low appendicular skeletal muscle mass index measured using bioelectrical impedance analysis [<7.0 kg/m2 (men) and <5.7 (women); 22.1% vs. 31.0%, P = 0.003], and more patients with low handgrip strength [<26 kg (men) and <18 (women); 67.8% vs. 55.5%, P < 0.001], and slow gait speed [<0.8 m/s (both sexes); 54.5% vs. 41.1%, P < 0.001] than the HFrEF group, resulting in a similar sarcopenia prevalence in the two groups (18.1% vs. 21.6%, P = 0.191). Sarcopenia was an independent predictor of 1-year mortality in both HFpEF and HFrEF [hazard ratio (95% confidence interval) 2.42 (1.36-4.32), P = 0.003 in HFpEF and 2.02 (1.08-3.75), P = 0.027 in HFrEF; P for interaction = 0.666] after adjustment for other predictors.

CONCLUSIONS

In older patients with HF, sarcopenia contributes to mortality similarly in HFpEF and HFrEF.

The other side of the medallion in heart failure: Reverse metabolic syndrome

BACKGROUND AND AIMS

Lower levels of cardiovascular risk factors are associated with an increase in mortality in H.F. To explain this paradox, the term reverse metabolic syndrome (RMetS) has recently been proposed. We suggest defining these patients with lower levels of three risk factors can be combined under the heading "RMetS." We aimed to investigate the effect of MetS and RMetS on hemodynamic parameters and prognosis in patients with H.F. and reduced ejection fraction (HFrEF).

METHODS AND RESULTS

We included 304 patients who were performed right heart catheterization and followed up for a median of 16 (0-48) months. We first grouped patients according to the presence of MetS or not, then we added the RMetS category and stratified patients into three groups as MetS, RMetS, and metabolic healthy. Compared with not MetS group, Pulmonary arterial pressures and VO₂ were higher in MetS group. In the second step, LVEF, CI, VO₂I, O₂ delivery, and LVSWI were lowest in RMetS, pulmonary artery pressures were higher in MetS group. In multivariate Cox regression analysis, being in RMetS group was associated with 2.4 times and 1.8 times increased risk for composite end point (CEP) and all-cause mortality, respectively. In Kaplan Meier analysis, RMetS had the highest all-cause mortality and CEP.

CONCLUSIONS

We determined that RMetS patients had the worst prognosis with unfavorable hemodynamic profile. Hence, a better understanding of the pathophysiology of RMetS may help refine the treatment targets of CV risk factors, may yield new interventions targeting catabolic syndrome.

Impact of high triglyceride/high-density lipoprotein cholesterol ratio (insulin resistance) in ST-segment elevation myocardial infarction

The ratio of triglyceride (TG)/high-density lipoprotein cholesterol (HDL-C) has been proposed as an easily obtainable atherogenic marker and high TG/HDL-C ratio is associated with insulin resistance. This study investigated the associated between a high TG/HDL-C ratio and cardiovascular mortality in patients with ST-segment elevation myocardial infarction (STEMI), with or without diabetes mellitus (DM).Between January 2005 and December 2014, 1661 patients with STEMI underwent primary percutaneous coronary intervention in our hospital. Of these, 289 were classified into group 1 (with both DM and a high TG/HDL-C ratio), 295 into group 2 (with DM, but without a high TG/HDL-C ratio), 501 into group 3 (without DM, but a high TG/HDL-C ratio), and 576 into group 4 (without DM or a high TG/HDL-C ratio).Older age, longer chest pain to reperfusion time, poor hemodynamic condition, and higher prevalence of multiple vessel coronary artery disease were noted in those with DM. Poor outcomes including higher 30-day and 1-year cardiovascular mortality and all-cause mortality rates were noted in those with DM but without a high TG/HDL-C ratio. Patients with DM but without a high TG/HDL-C ratio had a Hazard ratio of 3.637 for cardiovascular mortality relative to those without DM, but without a high TG/HDL-C ratio.Even though a high TG/HDL-C ratio is associated with insulin resistance, patients with or without DM, but with a high TG/HDL-C ratio had better 30-day and 1-year outcomes.

The effect of protein and essential amino acid supplementation on muscle strength and performance in patients with chronic heart failure: a systematic review

PURPOSE

Critically low skeletal muscle mass and strength, observed in 20% of people with chronic heart failure (CHF), reduces functional capacity, quality of life (QoL) and survival. Protein and essential amino acid (EAA) supplementation could be a viable treatment strategy to prevent declines in muscle strength and performance, and subsequently improve QoL and survival. This systematic review (PROSPERO: CRD42018103649) aimed to assess the effect of dietary protein and/or EAA supplementation on muscle strength and performance in people with CHF.

METHODS

Searches of PubMed, MEDLINE and Embase identified studies that reported changes in strength or muscle performance following protein and/or EAA supplementation in patients with CHF. Following PRISMA guidelines and using predefined inclusion/exclusion criteria relating to participants, intervention, control, outcome and study design, two reviewers independently screened titles, abstracts and full manuscripts for eligibility. Risk of bias was assessed using Cochrane Risk of Bias Tool (RCTs) or Mixed Methods Appraisal Tool (cohort studies). Data were extracted for analysis using predefined criteria.

RESULTS

Five randomised controlled trials (RCT) and one cohort study met our inclusion criteria. All RCTs had a high risk of bias. The methodological quality of the cohort study was moderate. Heterogeneity of extracted data prevented meta-analyses, qualitative synthesis was therefore performed. Data from 167 patients with CHF suggest that protein and/or EAA supplementation does not improve strength, but may increase six-minute walk test distance, muscle mass and QoL.

CONCLUSIONS

The limited quality of the studies makes firm conclusions difficult, however protein and/or EAA supplementation may improve important outcome measures related to sarcopenia. High-quality randomised controlled studies are needed.

The cholesterol paradox may be attenuated in heart failure patients with diabetes

BACKGROUND

In heart failure (HF) patients, a lower total cholesterol (TC) appears to portend an ominous prognosis. We studied if the prognostic impact of TC was different according to diabetes mellitus (DM) status in a chronic HF population.

METHODS

Patients with systolic HF under optimized and stable evidence-based therapy were prospectively recruited from our HF clinic. We excluded patients on renal replacement therapy and those hospitalized in the previous 2 months. A venous blood sample was collected. Patients were followed for up to 5 years and all-cause mortality was the endpoint under analysis. The prognostic impact of TC was analyzed using a Cox-regression analysis. Analysis was stratified according to coexistence of DM.

RESULTS

We studied 262 chronic HF patients, 182 males, mean age 69 years, 98 (37.4%) diabetic and 62.2% with severe left ventricular systolic dysfunction. Median B-type natriuretic peptide: 237.8 pg/mL; median TC: 169 mg/dL. During follow-up 121 (46.2%) patients died. Patients with TC>200 mg/dL had better survival than those with lower TC; however, this protective effect was mostly observed in non-diabetic HF patients. In non-diabetics the multivariate adjusted 5-year mortality hazard ratio (HR) was 0.36 (95% CI: 0.16-0.79) for those with TC>200 mg/dL. In diabetic HF patients, there was a non-significant survival benefit of TC>200 mg/dL; HR 0.51 (95% CI: 0.20-1.30).

CONCLUSIONS

Non-diabetic chronic HF patients with TC>200 mg/dL have a 64% lower risk of 5-year death. In diabetics, there is a non-significant 49% protective effect of elevated TC. The cholesterol paradox may be attenuated in diabetic HF patients.

Correlation of Paraoxonase-1 with the Severity of Crohn's Disease

Diagnostics of Crohn’s disease (CD) requires noninvasive biomarkers facilitating early detection and differentiation of the disease. Therefore, in this study, we aimed to determine the relationship between paraoxonase-1 (PON-1), the severity of CD, oxidative stress, and inflammation in CD. The CD activity index was based on the current classification. Plasma PON-1 was measured in 47 patients with CD, and in 23 control volunteers. Using quantitative variables such as receiver operating characteristics (ROC) (area under the curve (AUC)), the diagnostic utility of PON-1 in differentiating the severity of CD was assessed. Circulating PON-1 was found to be decreased in the CD group compared to the control group (269.89 vs. 402.56 U/L, respectively), and it correlated well with the disease activity. PON-1 correlated positively with hemoglobin (Hb) (r = 0.539, p < 0.001), hematocrit (Ht) (r = 0.48, p < 0.001), total cholesterol (TC) (r = 0.343, p < 0.001), high density lipoprotein (HDL) (r = 0.536, p < 0.001), low density lipoprotein (LDL) (r = 0.54, p < 0.001), and triglyceride (TG) (r = 0.561, p < 0.001) and correlated negatively with white blood cell count (WBC) (r = −0.262, p = 0.029), platelet count (PLT) (r = −0.326, p = 0.006), C-reactive protein (CRP) (r = −0.61, p < 0.001), and malondialdehyde (MDA) (r = −0.924, p < 0.001). PON-1 as a marker for CD differentiation possessed a sensitivity and specificity of 93.62% and 91.30%, respectively. CD was found to be associated with the decrease in the levels of PON-1, which correlates well with activity of the disease and reflects the intensification of inflammation, as well as intensified lipid peroxidation. High sensitivity and specificity of PON-1 determines its selection as a good screening test for CD severity.

Atorvastatin, but not pravastatin, inhibits cardiac Akt/mTOR signaling and disturbs mitochondrial ultrastructure in cardiac myocytes

Statins, which reduce LDL-cholesterol by inhibition of 3-hydroxy-3-methylglutaryl-coenzyme A reductase, are among the most widely prescribed drugs. Skeletal myopathy is a known statin-induced adverse effect associated with mitochondrial changes. We hypothesized that similar effects would occur in cardiac myocytes in a lipophilicity-dependent manner between 2 common statins: atorvastatin (lipophilic) and pravastatin (hydrophilic). Neonatal cardiac ventricular myocytes were treated with atorvastatin and pravastatin for 48 h. Both statins induced endoplasmic reticular (ER) stress, but only atorvastatin inhibited ERK1/2^T202/Y204, Akt^Ser473, and mammalian target of rapamycin signaling; reduced protein abundance of caveolin-1, dystrophin, epidermal growth factor receptor, and insulin receptor-β; decreased Ras homolog gene family member A activation; and induced apoptosis. In cardiomyocyte-equivalent HL-1 cells, atorvastatin, but not pravastatin, reduced mitochondrial oxygen consumption. When male mice underwent atorvastatin and pravastatin administration per os for up to 7 mo, only long-term atorvastatin, but not pravastatin, induced elevated serum creatine kinase; swollen, misaligned, size-variable, and disconnected cardiac mitochondria; alteration of ER structure; repression of mitochondria- and endoplasmic reticulum-related genes; and a 21% increase in mortality in cardiac-specific vinculin-knockout mice during the first 2 months of administration. To our knowledge, we are the first to demonstrate in vivo that long-term atorvastatin administration alters cardiac ultrastructure, a finding with important clinical implications.-Godoy, J. C., Niesman, I. R., Busija, A. R., Kassan, A., Schilling, J. M., Schwarz, A., Alvarez, E. A., Dalton, N. D., Drummond, J. C., Roth, D. M., Kararigas, G., Patel, H. H., Zemljic-Harpf, A. E. Atorvastatin, but not pravastatin, inhibits cardiac Akt/mTOR signaling and disturbs mitochondrial ultrastructure in cardiac myocytes.

Lipid Paradox in Statin-Naïve Acute Ischemic Stroke But Not Hemorrhagic Stroke

Background: Low lipid level is associated with better cardiovascular outcome. However, lipid paradox indicating low lipid level having worse outcomes could be seen under acute injury in some diseases. The present study was designed to clarify the prognostic significance of acute-phase lipid levels within 1 day after admission for stroke on mortality in first-ever statin-naïve acute ischemic stroke (IS) and hemorrhagic stroke (HS). Methods: This observational study was conducted using the data collected from Stroke Registry In Chang-Gung Healthcare System (SRICHS) between 2009 and 2012. Patients with recurrent stroke, onset of symptoms >1 day, and history of the use of lipid-lowering agents prior to index stroke were excluded. Stroke was classified into IS and hypertension-related HS. The primary outcomes were 30-day and 1-year mortality identified by linkage to national death registry for date and cause of death. Receiver operating characteristic (ROC) curve analysis and multivariate Cox proportional hazard models were used to examine the association of lipid profiles on admission with mortality. Results: Among the 18,268 admitted stroke patients, 3,746 IS and 465 HS patients were eligible for analysis. In IS, total cholesterol (TC) <163.5 mg/dL, triglyceride (TG) <94.5 mg/dL, low-density lipoprotein (LDL) <100 mg/dL, non-high-density lipoprotein cholesterol (non-HDL-C) <130.5 mg/dL, and TC/HDL ratio <4.06 had significantly higher risk for 30-day/1-year mortality with hazard ratio (HR) of 2.05/1.37, 1.65/1.31, 1.68/1.38, 1.80/1.41, and 1.58/1.38, respectively, compared with high TC, TG, LDL, non-HDL-C, and TC/HDL ratio (p < 0.01 in all cases). In HS, lipid profiles were not associated with mortality, except HDL for 30-day mortality (p = 0.025) and high uric acid (UA) concentrations for 30-day and 1-year mortality (p = 0.002 and 0.012, respectively). High fasting glucose and high National Institute of Health Stroke Scale (NIHSS) score at admission were associated with higher 30-day and 1-year mortality in both IS and HS and low blood pressure only in IS (p < 0.05). Synergic effects on mortality were found when low lipids were incorporated with high fasting glucose, low blood pressure, and high NIHSS score in IS (p < 0.05). Conclusions: Lipid paradox showing low acute-phase lipid levels with high mortality could be seen in statin-naïve acute IS but not in HS. The mortality in IS was increased when low lipids were incorporated with high fasting glucose, low blood pressure, and high NIHSS score.

Lower admission blood pressure as an independent predictor of 1-year mortality in elderly patients experiencing a first hospitalization for acute heart failure

BACKGROUND

Systolic blood pressure (SBP) is an acknowledged prognostic factor in patients with heart failure (HF). Admission SBP should be a risk factor for 1-year mortality even in elderly patients experiencing a first admission for HF, and this risk may persist in the oldest subset of patients.

DESIGN

Methods: We reviewed the medical records of 1031 patients aged 70 years or older admitted within a 3-year period for a first episode of acute heart failure (AHF). The cohort was divided according to admission SBP values in quartiles. We analyzed all-cause mortality as a function of these admission SBP quartiles.

RESULTS

Mean age was 82.2 ± 6 years; their mean admission SBP was 138.6 ± 25 mmHg. A statistically significant association was present between mortality at 30 (p < 0.0001), 90 (p < 0.0001), and 365 days (p < 0.0001) after hospital discharge and lower admission SBP quartiles. One-year mortality ranged from 14.7% for patients within the upper SBP quartile to 41.4% for those in the lowest quartile. The multivariate analysis confirmed this association (HR: 0.884; 95% CI: 0.615-0.76; p = 0.0001), which remained significant when admission SBP was evaluated as a continuous variable (HR: 0.980; 95% CI: 0.975-0.985; p = 0.0001). The association between SBP and 1-year mortality remained when the sample was divided into old (70-82 years) and "oldest-old" (>82 years) patients.

CONCLUSIONS

Lower SBP at admission is an independent predictor of midterm postdischarge mortality for elderly patients experiencing a first admission for AHF.

Risk of stroke in chronic heart failure patients with preserved ejection fraction, but without atrial fibrillation: analysis of the CHARM-Preserved and I-Preserve trials

Aims

The incidence and predictors of stroke in patients with heart failure and preserved ejection fraction (HF-PEF), but without atrial fibrillation (AF), are unknown. We described the incidence of stroke in HF-PEF patients with and without AF and predictors of stroke in those without AF.

Methods and results

We pooled data from the CHARM-Preserved and I-Preserve trials. Using Cox regression, we derived a model for stroke in patients without AF in this cohort and compared its performance with a published model in heart failure patients with reduced ejection fraction (HF-REF)—predictive variables: age, body mass index, New York Heart Association class, history of stroke, and insulin-treated diabetes. The two stroke models were compared and Kaplan–Meier curves for stroke estimated. The risk model was validated in a third HF-PEF trial. Of the 6701 patients, 4676 did not have AF. Stroke occurred in 124 (6.1%) with AF and in 171 (3.7%) without AF (rates 1.80 and 1.00 per 100 patient-years, respectively). There was no difference in performance of the stroke model derived in the HF-PEF cohort and the published HF-REF model (c-index 0.71, 95% confidence interval 0.57–0.84 vs. 0.73, 0.59–0.85, respectively) as the predictive variables overlapped. The model performed well in the validation cohort (0.86, 0.62–0.99). The rate of stroke in patients in the upper third of risk approximated to that in patients with AF (1.60 and 1.80 per 100 patient-years, respectively).

Conclusions

A small number of clinical variables identify a subset of patients with HF-PEF, but without AF, at elevated risk of stroke.

Influence of blood pressure at the beginning of decompensations in the prognosis of patients with heart failure

BACKGROUND AND OBJECTIVE

An inverse relationship has been described between blood pressure and the prognosis in heart failure (HF). The characteristics of this relationship are not well unknown. The objective of this study was to determine if this relationship is maintained in a non-selected cohort of patients with HF and if it can be modified by treatment.

MATERIAL AND METHODS

Prospective study of cohorts including patients hospitalized for decompensated HF in Internal Medicine departments and followed as outpatients in a monographic consultation. Patients were classified according to their levels of systolic (SBP) and diastolic blood pressure (DBP). Clinical characteristics, all-cause mortality and readmissions after the first, third and sixth month of follow-up were analysed.

RESULTS

Two hundred and twenty-one patients were included after their admission to the hospital for acute HF. Mean patient age was 79.5 years(SD 8.09); 115 patients were male. No significant differences between SBP quartiles and basal characteristics were found. Patients with lower SBP (Q1) had higher mortality rates (20%, P<.05). No significant differences between mortality/readmissions and DBP were found. However, the Kaplan-Meier analysis showed higher all-cause mortality rates for the group of patients with lower SBP and DBP (log-rank=0.011 and 0.041, respectively). The pharmacological treatment did not differ significantly between both study groups.

CONCLUSION

For non-selected patients suffering HF, higher SBP upon the admission is associated with significantly lower all-cause mortality rates during follow-up. Pharmacological treatment of HF does not seem to influence this inverse relationship between SBP at admission and patient mortality.

Heart failure in patients with coronary heart disease: Prevalence, characteristics and guideline implementation - Results from the German EuroAspire IV cohort

Background

Adherence to pharmacotherapeutic treatment guidelines in patients with heart failure (HF) is of major prognostic importance, but thorough implementation of guidelines in routine care remains insufficient. Our aim was to investigate prevalence and characteristics of HF in patients with coronary heart disease (CHD), and to assess the adherence to current HF guidelines in patients with HF stage C, thus identifying potential targets for the optimization of guideline implementation.

Methods

Patients from the German sample of the European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EuroAspire) IV survey with a hospitalization for CHD within the previous six to 36 months providing valid data on echocardiography as well as on signs and symptoms of HF were categorized into stages of HF: A, prevalence of risk factors for developing HF; B, asymptomatic but with structural heart disease; C, symptomatic HF. A Guideline Adherence Indicator (GAI-3) was calculated for patients with reduced (≤40%) left ventricular ejection fraction (HFrEF) as number of drugs taken per number of drugs indicated; beta-blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers, and mineralocorticoid receptor antagonists (MRA) were considered.

Results

509/536 patients entered analysis. HF stage A was prevalent in n = 20 (3.9%), stage B in n = 264 (51.9%), and stage C in n = 225 (44.2%) patients; 94/225 patients were diagnosed with HFrEF (42%). Stage C patients were older, had a longer duration of CHD, and a higher prevalence of arterial hypertension. Awareness of pre-diagnosed HF was low (19%). Overall GAI-3 of HFrEF patients was 96.4% with a trend towards lower GAI-3 in patients with lower LVEF due to less thorough MRA prescription.

Conclusions

In our sample of CHD patients, prevalence of HF stage C was high and a sizable subgroup suffered from HFrEF. Overall, pharmacotherapy was fairly well implemented in HFrEF patients, although somewhat worse in patients with more reduced ejection fraction. Two major targets were identified possibly suited to further improve the implementation of HF guidelines: 1) increase patients´ awareness of diagnosis and importance of HF; and 2) disseminate knowledge about the importance of appropriately implementing the use of mineralocorticoid receptor antagonists.

Trial registration

This is a cross-sectional analysis of a non-interventional study. Therefore, it was not registered as an interventional trial.

Prognostic value of long-term blood pressure changes in patients with chronic heart failure

BACKGROUND

Chronic heart failure (CHF) is the final stage of many heart diseases. To improve outcomes, important risk factors for adverse clinical events in the CHF population need to be identified. The aim of the present study was to delineate the influence of long-term blood pressure (BP) changes on prognosis and mortality in a real-world cohort of CHF patients.

METHODS AND RESULTS

This is a retrospective longitudinal analysis. Repeated office BP measurements were scheduled during follow-up visits every 3-6 months. The primary endpoint was time to death or heart transplantation (HTx). A Cox regression with time-dependent strata was used to analyse the effect of systolic BP (SBP) values and its change during follow-up on the primary endpoint. A total of 927 patients presented with a median survival of 7.7 [95% confidence interval (CI) 6.6-9.8] years. During follow-up, 220 patients died and 70 patients underwent HTx. The BP stratum with the most stable values showed the best survival. Blood pressure changes with an increase or decrease greater than ±10 mmHg per year led to a significantly worse outcome [hazard ratio (HR) 1.8 and 2.0, respectively]. The stratum with the lowest SBP levels (<90 mmHg) had the highest mortality. Multiple regression analysis showed a HR factor of 17 (95% CI 9.7-29) in comparison with the stratum with SBP ≥130 mmHg.

CONCLUSION

Low SBP (<90 mmHg) and pronounced long-term changes in SBP were associated with poor survival in patients with CHF. Additional prospective studies are warranted to further specify optimal BP targets in patients with CHF.

Statins attenuate but do not eliminate the reverse epidemiology of total serum cholesterol in patients with non-ischemic chronic heart failure

BACKGROUND

In patients with chronic heart failure (CHF) increasing levels of total serum cholesterol are associated with improved survival - while statin usage is not. The impact of statin treatment on the "reverse epidemiology" of cholesterol is unclear.

METHODS

2992 consecutive patients with non-ischemic CHF due to left ventricular systolic dysfunction from the Norwegian CHF Registry and the CHF Registries of the Universities of Hull, UK, and Heidelberg, Germany, were studied. 1736 patients were individually double-matched on both cholesterol levels and the individual propensity scores for statin treatment. All-cause mortality was analyzed as a function of baseline cholesterol and statin use in both the general and the matched sample.

RESULTS

1209 patients (40.4%) received a statin. During a follow-up of 13,740 patient-years, 360 statin users (29.8%) and 573 (32.1%) statin non-users died. When grouped according to total cholesterol levels as low (≤3.6mmol/L), moderate (3.7-4.9mmol/L), high (4.8-6.2mmol/L), and very high (>6.2mmol/L), we found improved survival with very high as compared with low cholesterol levels. This association was present in statin users and non-users in both the general and matched sample (p<0.05 for each group comparison). The negative association of total cholesterol and mortality persisted when cholesterol was treated as a continuous variable (HR 0.83, 95%CI 0.77-0.90, p<0.001 for matched patients), but it was less pronounced in statin users than in non-users (F-test p<0.001).

CONCLUSIONS

Statins attenuate but do not eliminate the reverse epidemiological association between increasing total serum cholesterol and improved survival in patients with non-ischemic CHF.

Position paper for management of elderly patients with pacemakers and implantable cardiac defibrillators: Groupe de Rythmologie et Stimulation Cardiaque de la Société Française de Cardiologie and Société Française de Gériatrie et Gérontologie

Despite the increasingly high rate of implantation of pacemakers (PMs) and implantable cardioverter defibrillators (ICDs) in elderly patients, data supporting their clinical and cost-effectiveness in this age stratum are ambiguous and contradictory. We reviewed the data regarding the applicability, safety and effectiveness of conventional pacing, ICDs and cardiac resynchronization therapy (CRT) in elderly patients. Although periprocedural risk may be slightly higher in the elderly, the implantation procedure for PMs and ICDs is still relatively safe in this age group. In older patients with sinus node disease, the general consensus is that DDD pacing with the programming of an algorithm to minimize ventricular pacing is preferred. In very old patients presenting with intermittent or suspected atrioventricular block, VVI pacing may be appropriate. In terms of correcting potentially life-threatening arrhythmias, the effectiveness of ICD therapy is similar in older and younger individuals. However, the assumption of persistent ICD benefit in the elderly population is questionable, as any advantageous effect of the device on arrhythmic death may be attenuated by higher total non-arrhythmic mortality. While septuagenarians and octogenarians have higher annual all-cause mortality rates, ICD therapy may remain effective in selected patients at high risk of arrhythmic death and with minimum comorbidities despite advanced age. ICD implantation among the elderly, as a group, may not be cost-effective, but the procedure may reach cost-effectiveness in those expected to live more than 5-7years after implantation. Elderly patients usually experience significant functional improvement after CRT, similar to that observed in middle-aged patients. Management of CRT non-responders remains globally the same, while considering a less aggressive approach in terms of reinterventions (revision of left ventricular [LV] lead placement, addition of a right ventricular or LV lead, LV endocardial pacing configuration). Overall, physiological age, general status and comorbidities rather than chronological age per se should be the decisive factors in making a decision about device implantation selection for survival and well-being benefit in elderly patients.

Higher BMI in heart failure patients is associated with longer survival only in the absence of diabetes

AIMS

Obesity and diabetes are associated with an increased cardiovascular risk and mortality. Paradoxically, higher BMI is associated with longer survival in heart failure patients. The association between BMI and risk of death in heart failure patients depends on diabetes history.

METHODS

We conducted a retrospective cohort study on 503 ambulatory systolic heart failure patients attending a heart failure clinic, based on abstraction of data from clinical records. Patients were compared according to diabetes history. BMI was analyzed as a continuous variable and dichotomized using 25 kg/m as cut-off. Patients' follow-up was censored at 5 years and all-cause death was the endpoint under study.

RESULTS

The median age was 69 years and 68% were men; 184 (36.6%) patients had diabetes upon referral. During follow-up, 95 nondiabetic and 69 diabetic patients died. Higher BMI was associated with longer survival in the whole sample, but this association was only reproduced in the subgroup of patients without diabetes [hazard ratio = 0.93; 95% confidence interval (CI): 0.89-0.98 per kg/m vs. hazard ratio = 0.99; 95% CI: 0.94-1.04 in diabetic patients; P for interaction = 0.009]. BMI below 25 kg/m increased the risk of death by 1.90-fold (95% CI: 1.23-2.94) with a null association in diabetic patients (P for interaction = 0.012). The association between BMI and mortality in nondiabetic heart failure patients was independent of other predictors of prognosis.

CONCLUSION

The reported obesity paradox in heart failure can only be observed in nondiabetic patients.

Nutritional risk is associated with long term mortality in hospitalized patients with chronic heart failure

BACKGROUND & AIMS

Mortality among patients with chronic heart failure (CHF) is still high despite progress in medical and surgical treatment. The patients' nutritional condition may play an important role, and needs further investigation. The aim of this study was to evaluate whether nutritional risk in hospitalized patients with CHF was associated with three-year mortality.

METHODS

A prospective study was conducted in 131 hospitalized Norwegian patients with CHF. Nutritional screening was performed using Nutritional Risk Screening (NRS-2002). The primary clinical outcome was death from any cause.

RESULTS

The prevalence of nutritional risk was 57% (NRS-2002 score ≥ 3). The overall mortality rate was 52.6% within three-year follow up. More patients at nutritional risk (N = 51) died compared to patients not at nutritional risk (N = 18) (P < 0.001). In adjusted analyses patients at nutritional risk had more than five-time higher odds (OR 5.85; 95% CI 2.10-16.24) to die before three-year follow-up than those not at nutritional risk. In adjusted Cox multivariate analysis, the nutritional risk was associated with increased mortality (HR 2.78; 95% CI 1.53-5.03). Furthermore, in adjusted analysis components in NRS-2002 were associated with mortality, i.e. nutritional status (HR 1.82; 95% CI 1.03-3.22), severity of disease (NYHA-class IV) (HR 1.78; 95% CI 1.00-3.16) and age (≥ 70 year) (HR 3.24; 95% CI 1.48-7.10).

CONCLUSION

Nutritional risk as defined by NRS-2002 in hospitalized patients with CHF was significantly associated with long term mortality.

Impact of clinical characteristics and management on the prognosis of unselected heart failure patients

PURPOSE

Heart failure (HF) is a major public health issue. This study conducted a real-life analysis of the impact of clinical characteristics and medical management of HF on its prognosis.

METHODS

Analysis was based on the EGB ("Echantillon Généraliste des Bénéficiaires") database. A cohort comprising 1825 adult patients with a first admission for HF between 2009 and 2011 was created and followed until June 2013 (median 22.3 [7.7-34.5] months) for survival analysis.

RESULTS

Mean age was 77.3 ± 13.2 years (53 % ≥80 years). The overall incidence of HF admission was 117 [112-122] per 100,000 population with a marked increase in patients >80 years (1297 [1217-1348]). At discharge, only 8 % of patients received recommended combination of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB), beta-blockers (BB) and mineralocorticoid receptor antagonists (MRA). Only prescription levels of BB and vitamin K antagonists, at discharge, increased during the study period. In-hospital mortality was 9 % and survival was 71.6 %[69.5-73.6] and 52.0 %[49.4-54.6] at 12 and 36 months, respectively. In multivariate analysis, female gender [HR:0.78 (0.67-0.91), p = 0.001], ACEi/ARB + BB + MRA [0.41 (0.28-0.60), p < 0.001] and ACEi/ARB + BB [0.47 (0.39-0.57) p < 0.001] treatments were associated with improved survival, conversely to age 70-79 [1.90 (1.20-3.00), p = 0.003] and ≥80 [3.50 (2.30-5.40), p < 0.001], cardiogenic shock [3.00 (2.10-4.40), p < 0.001], acute pulmonary edema [1.70 (1.10-2.50), p = 0.01], denutrition [1.80 (1.45-2.24), p < 0.001], dilated cardiomyopathy [1.20 (1.00-1.40), p = 0.02] and in-hospital acute renal failure [1.36 (1.05-1.78), p = 0.002].

CONCLUSIONS

These real-life HF data provide insight into prognostic factors and "real-world" pharmacological management in this unselected HF population, confirming the benefit of ACEi/ARB + BB ± MRAs on patient survival.

The Heart Failure Overweight/Obesity Survival Paradox: The Missing Sex Link

OBJECTIVES

This study sought to determine whether body mass index (BMI) has a differential impact on survival for females versus males with advanced systolic heart failure (HF).

BACKGROUND

Females have a survival advantage in HF, the mechanisms of which are unclear. There is also a proposed "obesity survival paradox" in which excess adiposity promotes HF survival.

METHODS

We reviewed 3,811 patients with left ventricular ejection fraction ≤40% who had undergone cardiopulmonary exercise testing between 1995 and 2011. The endpoint was all-cause mortality. Multivariable analysis was performed using a Cox proportional hazards model. Because of the nonlinearity of BMI, a restricted cubic spline was used. An interaction term was added to investigate the impact of BMI on mortality by sex.

RESULTS

The unadjusted data demonstrated an overall obesity survival paradox in HF. This survival paradox disappeared for males after adjustment for potential confounders, with overweight and obese males showing higher adjusted mortality hazard ratios compared with normal weight males. Conversely, females in the overweight BMI range (25.0 to 29.9 kg/m(2)) had the lowest adjusted mortality (hazard ratio: 0.84; 95% confidence interval: 0.77 to 0.93; p = 0.0005 compared with normal weight females) with a nadir in mortality hazard just below BMI 30 kg/m(2). The multivariable model supported a differential impact of BMI on mortality in males versus females (p for interaction <0.0001).

CONCLUSIONS

In this advanced HF cohort, an unadjusted obesity survival paradox disappeared after adjustment for confounders. Overweight and obese males had higher adjusted mortality than normal weight males, whereas a BMI in the overweight range was associated with a significant survival benefit in females.

Republished: The association between inflammatory markers, serum lipids and the risk of cardiovascular events in patients with rheumatoid arthritis

OBJECTIVE

To examine the association of serum inflammatory markers (erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)) and serum lipid measures (low-density lipoprotein (LDL)- and high-density lipoprotein (HDL)-cholesterol) with risk of myocardial infarction (MI) and ischaemic stroke (IS) among rheumatoid arthritis (RA) patients.

METHODS

We conducted a retrospective cohort study using 2005-2010 data from a US commercial health plan. Eligible patients had two or more physician diagnoses of RA during a baseline period of at least 180 days with continuous medical and pharmacy coverage. We computed age-adjusted incidence rates of MI and IS, and used spline regression to assess non-linear associations and Cox-regression to quantify the independent association between the laboratory values and the outcomes.

RESULTS

We identified 44 418 eligible RA patients (mean age 49 years; 76% women). CRP>10 mg/L compared with <1 mg/L was associated with increased MI risk (HR 2.12; 95% CI 1.02 to 4.38). ESR>42 mm/h compared with <14 mm/h was associated with increased risk of MI (HR 2.53; 95% CI 1.48 to 4.31) and IS (HR 2.51; 95% CI 1.33 to 4.75) risk. HDL-cholesterol ≥60 mg/dL (1.6 mmol/L) compared with <40 mg/dL (1.0 mmol/L) was associated with reduced MI risk (HR 0.37; 0.21 to 0.66). The association between LDL and MI was not linear; the lowest risk was observed among patients with LDL between 70 mg/L (1.8 mmol/L) and 100 mg/L (2.6 mmol/L). We did not observe a significant association between LDL and IS.

CONCLUSIONS

This study provides evidence supporting the hypothesis that RA-related systemic inflammation plays a role in determining cardiovascular risk and a complex relationship between LDL and cardiovascular risk.

Epidemiology of heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFPEF) is a common condition, and the prevalence is projected to increase further. Studies differ in the reported incidence and mortality associated with this condition, although there is agreement that between a third and one-half of all patients with heart failure have HFPEF. Although several consensus statements and guidelines have been published, some recent randomized clinical trials have reported low mortality, raising doubts about whether all patients diagnosed with HFPEF have HFPEF or whether the condition is heterogeneous in its cause and prognosis. The overall reported prognosis of patients with HFPEF remains poor.

Hemoglobin A1c, comorbid conditions and all-cause mortality in older patients with diabetes: a retrospective 9-year cohort study

AIMS

To examine whether hemoglobin A1c levels and comorbid conditions are related to all-cause mortality in a cohort of patients with type 1 or 2 diabetes receiving continuous care for 9 years. In patients with comorbid congestive heart failure (CHF), we test for 'reverse epidemiology,' or whether greater HbA1c values are associated with lower risk of mortality.

METHODS

The population for this longitudinal cohort study was 8820 Group Health enrollees in the Seattle area with type 1 or 2 diabetes in 1997 and enrolled continuously from 1997 to 2006. Comorbid conditions were hypertension, coronary artery disease, congestive heart failure, depression, and chronic pulmonary disease. Mistimed HbA1c scores were addressed by multiple imputation, and Cox proportional hazards models estimated associations controlling for other risk factors.

RESULTS

About 30% of the enrollees died in 1998-2006. CHF had the strongest association with all-cause mortality. Compared to enrollees with HbA1c ≥ 7.1% (54 mmol/mol) and < 7.5% (58 mmol/mol; 5th decile), enrollees with HbA1c < 6.4% (46 mmol/mol) had a significantly greater risk of death (HR range: 1.28-2.26). HbA1c > 7.5% had HR < 1.0 but were not significant. For enrollees with diabetes and CHF at baseline, HbA1c scores ≥ 8.7% (72 mmol/mol) had a significantly lower risk of death (HR range: 0.64-0.69).

CONCLUSIONS

In our patient population, HbA1c scores<6.4% have significantly higher all-cause mortality. CHF is a major determinant of all-cause mortality. Adults with comorbid CHF and high HbA1c scores have lower all-cause mortality.

Body mass index in dementia

This review comprehensively examines the current knowledge on the relationship between body mass index (BMI) and dementia. The association between BMI and cognition is complex: in younger adults, higher BMIs are associated with impaired cognition. Overweight and obesity in middle age are linked to increased future dementia risk in old age. However, when examined in old age, higher BMIs are associated with better cognition and decreased mortality. Little is known about the optimal BMI for well-being and survival in populations already suffering from dementia. Lifetime trends in weight, rather than single measures, might predict prognosis better and help untangle these apparent contradictions. Thus, the need arises to properly monitor BMI trends in affected dementia patients. Registries can include BMI, improving the management of dementia patients throughout the whole course of the disease. The role of central obesity and systemic inflammation on brain pathology and cognitive decline are discussed in this review. Understanding the life-course changes in BMI and their influence on dementia risk, cognitive prognosis and mortality after diagnosis may provide new insights into the underlying pathophysiology of dementia and shape possible intervention and treatment strategies.

Acute heart failure: patient characteristics and pathophysiology

The number of hospitalizations for acute heart failure (HF) continues to increase and it remains the most common discharge diagnosis among Medicare beneficiaries. Prognosis after hospitalization for HF is poor, with high in-hospital mortality and even higher post-discharge mortality and rehospitalization rates. It is a complex clinical syndrome that varies widely with respect to clinical presentation and underlying pathophysiology. This paper reviews what is documented in the literature regarding the known pathophysiologic mechanisms reported in patients hospitalized for HF.

Clinical characteristics and short-term outcomes in patients with elevated admission systolic blood pressure after acute ST-elevation myocardial infarction: a population-based study

OBJECTIVE

Prognostic value of lower admission systolic blood pressure (SBP) in patients with acute myocardial infarction has been confirmed, but the impact of elevated admission SBP on short-term outcomes has been evaluated only by a limited number of studies and they have reported conflicting results. The aim of our study was to investigate the characteristics and short-term outcomes in patients with elevated admission SBP after ST-elevation myocardial infarction (STEMI).

DESIGN

A population-based, observational study.

SETTING

The multicentre registry in China.

PARTICIPANTS

A total of 7510 consecutive patients with STEMI were registered. Patients were divided into three groups according to admission SBP: normal admission SBP (100-139 mm Hg), modestly elevated admission SBP (140-179 mm Hg) and excessively elevated admission SBP (≥180 mm Hg). The primary outcomes were 7-day and 30-day all-cause mortality, major adverse cardiac events (MACE) and bleeding rate.

RESULTS

Of 6591 patients, 4182 (63.5%) had normal admission SBP, 2187 (33.2%) modestly elevated admission SBP and 222 (3.4%) excessively elevated admission SBP. Patients with elevated admission SBP had a high-risk profile, such as were more likely to be older, with more concomitant cardiovascular morbidities, presenting with more events of anterior myocardial infarction and less reperfusion treatment. However, 7-day and 30-day all-cause mortality, MACE and bleeding rate were comparable among groups (all p>0.05). Survival curves and MACE curves were similar among groups (p=0.377 and 0.375, respectively). After multivariate adjustment, elevated admission SBP was not associated with increased risk of short-term death and bleeding, and MACE was comparable with normal admission SBP.

CONCLUSIONS

Although those with elevated admission SBP after STEMI were at a higher risk for cardiovascular events, they did not have poorer short-term outcomes compared with patients with normal admission SBP.