Risk Factors for Heart Failure

Serum Markers of Neurodegeneration Are Strongly Linked to Heart Failure Severity and Outcome

BACKGROUND

Cognitive impairment is prevalent in patients with heart failure with reduced ejection fraction (HFrEF), affecting self-care and outcomes. Novel blood-based biomarkers have emerged as potential diagnostic tools for neurodegeneration.

OBJECTIVES

This study aimed to assess neurodegeneration in HFrEF by measuring neurofilament light chain (NfL), total tau (t-tau), amyloid beta 40 (Aβ40), and amyloid beta 42 (Aβ42) in a large, well-characterized cohort.

METHODS

The study included 470 patients with HFrEF from a biobank-linked prospective registry at the Medical University of Vienna. High-sensitivity single-molecule assays were used for measurement. Unplanned heart failure (HF) hospitalization and all-cause death were recorded as outcome parameters.

RESULTS

All markers, but not the Aβ42:Aβ40 ratio, correlated with HF severity, ie, N-terminal pro-B-type natriuretic peptide and NYHA functional class, and comorbidity burden and were significantly associated with all-cause death and HF hospitalization (crude HR: all-cause death: NfL: 4.44 [95% CI: 3.02-6.53], t-tau: 5.04 [95% CI: 2.97-8.58], Aβ40: 3.90 [95% CI: 2.27-6.72], and Aβ42: 5.14 [95% CI: 2.84-9.32]; HF hospitalization: NfL: 2.48 [95% CI: 1.60-3.85], t-tau: 3.44 [95% CI: 1.95-6.04], Aβ40: 3.13 [95% CI: 1.84-5.34], and Aβ42: 3.48 [95% CI: 1.93-6.27]; P < 0.001 for all). These associations remained statistically significant after multivariate adjustment including N-terminal pro-B-type natriuretic peptide. The discriminatory accuracy of NfL in predicting all-cause mortality was comparable to the well-established risk marker N-terminal pro-B-type natriuretic peptide (C-index: 0.70 vs 0.72; P = 0.225), whereas the C-indices of t-tau, Aβ40, Aβ42, and the Aβ42:Aβ40 ratio were significantly lower (P < 0.05 for all).

CONCLUSIONS

Neurodegeneration is directly interwoven with the progression of HF. Biomarkers of neurodegeneration, particularly NfL, may help identify patients potentially profiting from a comprehensive neurological work-up. Further research is necessary to test whether early diagnosis or optimized HFrEF treatment can preserve cognitive function.

Classification tree obtained by artificial intelligence for the prediction of heart failure after acute coronary syndromes

BACKGROUND

Coronary heart disease is the leading cause of heart failure (HF), and tools are needed to identify patients with a higher probability of developing HF after an acute coronary syndrome (ACS). Artificial intelligence (AI) has proven to be useful in identifying variables related to the development of cardiovascular complications.

METHODS

We included all consecutive patients discharged after ACS in two Spanish centers between 2006 and 2017. Clinical data were collected and patients were followed up for a median of 53months. Decision tree models were created by the model-based recursive partitioning algorithm.

RESULTS

The cohort consisted of 7,097 patients with a median follow-up of 53months (interquartile range: 18-77). The readmission rate for HF was 13.6% (964 patients). Eight relevant variables were identified to predict HF hospitalization time: HF at index hospitalization, diabetes, atrial fibrillation, glomerular filtration rate, age, Charlson index, hemoglobin, and left ventricular ejection fraction. The decision tree model provided 15 clinical risk patterns with significantly different HF readmission rates.

CONCLUSIONS

The decision tree model, obtained by AI, identified 8 leading variables capable of predicting HF and generated 15 differentiated clinical patterns with respect to the probability of being hospitalized for HF. An electronic application was created and made available for free.

Arteriovenous fistula for haemodialysis as a predictor of de novo heart failure in kidney transplant recipients

Background

The haemodynamic effects of a functioning haemodialysis arteriovenous fistula (AVF) can cause or exacerbate heart failure (HF). We investigated whether the presence of an AVF at the time of kidney transplant (KT) is associated with de novo HF.

Methods

This was an observational cohort study including adult patients who received a KT in the West of Scotland between 2010 and 2020. We evaluated the risk and associations of pretransplant factors with de novo HF, alone and as a composite cardiovascular (CV) outcome (including non-fatal myocardial infarction, non-fatal stroke, de novo HF and CV death). Multivariable proportional hazards regression and sensitivity analyses were used to identify independent correlates of the outcomes.

Results

Among 1330 included patients, the incident rate of de novo HF after transplantation was 58/1000 person-years [95% confidence interval (CI) 50-67] in AVF patients (n = 716) compared with 33/1000 person-years (95% CI 27-41) in non-AVF patients (n = 614). De novo HF was associated with the presence of an AVF [adjusted hazard ratio (aHR) 2.14 (95% CI 1.40-3.26)], duration of dialysis [aHR 1.03/year increase (95% CI 1.01-1.04)], age at transplant [aHR 1.03/year increase (95% CI 1.02-1.05)], female sex [aHR 1.93 (95% CI 1.40-2.65)] and pretransplant diabetes [aHR 2.43 (95% CI 1.48-4.01)]. The presence of an AVF was also associated with the composite CV outcome [aHR 1.91 (95% CI 1.31-2.78)].

Conclusions

The presence of an AVF may be an underrecognized modifiable predictor of de novo HF posttransplantation.

[Morphofunctional Analysis of the Role of Epicardial Adipose Tissue in the Formation of the Obesity Paradox in Chronic Heart Failure]

Based on the available modern medical literature, the article summarizes data on the morpho-functional significance of epicardial adipose tissue (EAT) in health and heart failure, analyzes the likelihood and reliability of the formation of the obesity paradox, and also discusses its possible morpho-functional mechanisms. The authors reviewed and analyzed the consequences of the obesity paradox in the aspect of the normal EAT phenotype protectivity. The review proposed ways of further research in this direction aimed at a deep anatomical and physiological analysis and at determining the morpho-functional role of EAT in the adaptive mechanisms of myocardial trophic provision, which may be an important part of the pathogenetic connection between obesity and CHF and, therefore, can improve outcomes in such patients.

Symptoms and signs in patients with heart failure: association with 3-month hospitalisation and mortality

OBJECTIVES

To determine the association between symptoms and signs reported in primary care consultations following a new diagnosis of heart failure (HF), and 3-month hospitalisation and mortality.

DESIGN

Nested case-control study with density-based sampling.

SETTING

Clinical Practice Research Datalink, linked to hospitalisation and mortality (1998-2020).

PARTICIPANTS

Database cohort of 86 882 patients with a new HF diagnosis. In two separate analyses for (1) first hospitalisation and (2) death, we compared the 3-month history of symptoms and signs in cases (patients with HF with the event), with their respective controls (patients with HF without the respective event, matched on diagnosis date (±1 month) and follow-up time). Controls could be included more than once and later become a case.

MAIN OUTCOME MEASURES

All-cause, HF and non-cardiovascular disease (non-CVD) hospitalisation and mortality.

RESULTS

During a median follow-up of 3.22 years (IQR: 0.59-8.18), 56 677 (65%) experienced first hospitalisation and 48 146 (55%) died. These cases were matched to 356 714 and 316 810 HF controls, respectively. For HF hospitalisation, the strongest adjusted associations were for symptoms and signs of fluid overload: pulmonary oedema (adjusted OR 3.08; 95% CI 2.52, 3.64), shortness of breath (2.94; 2.77, 3.11) and peripheral oedema (2.16; 2.00, 2.32). Generic symptoms also showed significant associations: depression (1.50; 1.18, 1.82), anxiety (1.35; 1.06, 1.64) and pain (1.19; 1.10, 1.28). Non-CVD hospitalisation had the strongest associations with chest pain (2.93; 2.77, 3.09), fatigue (1.87; 1.73, 2.01), general pain (1.87; 1.81, 1.93) and depression (1.59; 1.44, 1.74).

CONCLUSIONS

In the primary care HF population, routinely recorded cardiac and non-specific symptoms showed differential risk associations with hospitalisation and mortality.

Scoping Review of Screening and Assessment Tools for Social Determinants of Health in the Field of Cardiovascular Disease

BACKGROUND

Despite the importance of implementing the concept of social determinants of health (SDOH) in the clinical practice of cardiovascular disease (CVD), the tools available to assess SDOH have not been systematically investigated. We conducted a scoping review for tools to assess SDOH and comprehensively evaluated how these tools could be applied in the field of CVD.Methods and Results: We conducted a systematic literature search of PubMed and Embase databases on July 25, 2023. Studies that evaluated an SDOH screening tool with CVD as an outcome or those that explicitly sampled or included participants based on their having CVD were eligible for inclusion. In addition, studies had to have focused on at least one SDOH domain defined by Healthy People 2030. After screening 1984 articles, 58 articles that evaluated 41 distinct screening tools were selected. Of the 58 articles, 39 (67.2%) targeted populations with CVD, whereas 16 (27.6%) evaluated CVD outcome in non-CVD populations. Three (5.2%) compared SDOH differences between CVD and non-CVD populations. Of 41 screening tools, 24 evaluated multiple SDOH domains and 17 evaluated only 1 domain.

CONCLUSIONS

Our review revealed recent interest in SDOH in the field of CVD, with many useful screening tools that can evaluate SDOH. Future studies are needed to clarify the importance of the intervention in SDOH regarding CVD.

Ethnicity-specific blood pressure thresholds based on cardiovascular and renal complications: a prospective study in the UK Biobank

BACKGROUND

The appropriateness of hypertension thresholds for triggering action to prevent cardiovascular and renal complications among non-White populations in the UK is subject to question. Our objective was to establish ethnicity-specific systolic blood pressure (SBP) cutoffs for ethnic minority populations and assess the efficacy of these ethnicity-specific cutoffs in predicting adverse outcomes.

METHODS

We analyzed data from UK Biobank, which included 444,418 participants from White, South Asian, Black Caribbean, and Black African populations with no history of cardiorenal complications. We fitted Poisson regression models with continuous SBP and ethnic groups, using Whites as the referent category, for the composite outcome of atherosclerotic cardiovascular disease, heart failure, and chronic kidney disease. We determined ethnicity-specific thresholds equivalent to the risks observed in Whites at SBP levels of 120, 130, and 140 mm Hg. We adjusted models for clinical characteristics, sociodemographic factors, and behavioral factors. The performance of ethnicity-specific thresholds for predicting adverse outcomes and associated population-attributable fraction (PAF) was assessed in ethnic minority groups.

RESULTS

After a median follow-up of 12.5 years (interquartile range, 11.7-13.2), 32,662 (7.4%) participants had incident composite outcomes. At any given SBP, the predicted incidence rate of the composite outcome was the highest for South Asians, followed by White, Black Caribbean, and Black African. For an equivalent risk of outcomes observed in the White population at an SBP level of 140 mm Hg, the SBP threshold was lower for South Asians (123 mm Hg) and higher for Black Caribbean (156 mm Hg) and Black African (165 mm Hg). Furthermore, hypertension defined by ethnicity-specific thresholds was a stronger predictor and resulted in a larger PAF for composite outcomes in South Asians (21.5% [95% CI, 2.4,36.9] vs. 11.3% [95% CI, 2.6,19.1]) and Black Africans (7.1% [95% CI, 0.2,14.0] vs. 5.7 [95% CI, -16.2,23.5]) compared to hypertension defined by guideline-recommended thresholds.

CONCLUSIONS

Guideline-recommended blood pressure thresholds may overestimate risks for the Black population and underestimate risks for South Asians. Using ethnicity-specific SBP thresholds may improve risk estimation and optimize hypertension management toward the goal of eliminating ethnic disparities in cardiorenal complications.

Response to a low-energy meal replacement plan on glycometabolic profile and reverse cardiac remodelling in type 2 diabetes: a comparison between South Asians and White Europeans

Background

South Asians (SA) constitute a quarter of the global population and are disproportionally affected by both type 2 diabetes (T2D) and heart failure. There remains limited data of the acceptability and efficacy of low-energy meal replacement plans to induce remission of T2D in SA.

Objectives

The objective of this exploratory secondary analysis of the DIASTOLIC study was to determine if there was a differential uptake, glycometabolic and cardiovascular response to a low-energy meal replacement plan (MRP) between SA and White European (WE) people with T2D.

Methods

Obese adults with T2D without symptomatic cardiovascular disease were allocated a low-energy (~810 kcal/day) MRP as part of the DIASTOLIC study (NCT02590822). Comprehensive multiparametric cardiovascular magnetic resonance imaging, echocardiography, cardiopulmonary exercise testing and metabolic profiling were undertaken at baseline and 12 weeks. A comparison of change at 12 weeks between groups with baseline adjustment was undertaken.

Results

Fifteen WE and 12 SAs were allocated the MRP. All WE participants completed the MRP versus 8/12 (66%) SAs. The degree of concentric left ventricular remodelling was similar between ethnicities. Despite similar weight loss and reduction in liver fat percentage, SA had a lower reduction in Homeostatic Model Assessment for Insulin Resistance [-5.7 (95% CI: -7.3, -4.2) versus -8.6 (-9.7, -7.6), p = 0.005] and visceral adiposity compared to WE [-0.43% (-0.61, -0.25) versus -0.80% (-0.91, -0.68), p = 0.002]. Exercise capacity increased in WE with no change observed in SA. There was a trend towards more reverse remodelling in WE compared to SAs.

Conclusions

Compliance to the MRP was lower in SA versus WE. Overall, those completing the MRP saw improvements in weight, body composition and indices of glycaemic control irrespective of ethnicity. Whilst improvements in VAT and insulin resistance appear to be dampened in SA versus WE, given the small sample, larger studies are required to confirm or challenge this potential ethnic disparity.

Trail registration

NCT02590822.

Breathing pattern and pulmonary gas exchange in elderly patients with and without left ventricular dysfunction-modification with exercise-based cardiac rehabilitation and prognostic value

Background

Inefficient ventilation is an established prognostic marker in patients with heart failure. It is not known whether inefficient ventilation is also linked to poor prognosis in patients with left ventricular dysfunction (LVD) but without overt heart failure.

Objectives

To investigate whether inefficient ventilation in elderly patients with LVD is more common than in patients without LVD, whether it improves with exercise-based cardiac rehabilitation (exCR), and whether it is associated with major adverse cardiovascular events (MACE).

Methods

In this large multicentre observational longitudinal study, patients aged ≥65 years with acute or chronic coronary syndromes (ACS, CCS) without cardiac surgery who participated in a study on the effectiveness of exCR in seven European countries were included. Cardiopulmonary exercise testing (CPET) was performed before, at the termination of exCR, and at 12 months follow-up. Ventilation (VE), breathing frequency (BF), tidal volume (VT), and end-expiratory carbon dioxide pressure (PETCO2) were measured at rest, at the first ventilatory threshold, and at peak exercise. Ventilatory parameters were compared between patients with and without LVD (based on cardio-echography) and related to MACE at 12 month follow-up.

Results

In 818 patients, age was 72.5 ± 5.4 years, 21.9% were women, 79.8% had ACS, and 151 (18%) had LVD. Compared to noLVD, in LVD resting VE was increased by 8%, resting BF by 6%, peak VE, peak VT, and peak PETCO2 reduced by 6%, 8%, and 5%, respectively, and VE/VCO2 slope increased by 11%. From before to after exCR, resting VE decreased and peak PETCO2 increased significantly more in patients with compared to without LVD. In LVD, higher resting BF, higher nadir VE/VCO2, and lower peak PETCO2 at baseline were associated with MACE.

Conclusions

Similarly to patients with HF, in elderly patients with ischemic LVD, inefficient resting and exercise ventilation was associated with worse outcomes, and ExCR alleviated abnormal breathing patterns and gas exchange parameters.

HiSorb sorptive extraction for determining salivary short chain fatty acids and hydroxy acids in heart failure patients

Variations in salivary short-chain fatty acids and hydroxy acids (e.g., lactic acid, and 3-hydroxybutyric acid) levels have been suggested to reflect the dysbiosis of human gut microbiota, which represents an additional factor involved in the onset of heart failure (HF) disease. The physical-chemical properties of these metabolites combined with the complex composition of biological matrices mean that sample pre-treatment procedures are almost unavoidable. This work describes a reliable, simple, and organic solvent free protocol for determining short-chain fatty acids and hydroxy acids in stimulated saliva samples collected from heart failure, obese, and hypertensive patients. The procedure is based on in-situ pentafluorobenzyl bromide (PFB-Br) derivatization and HiSorb sorptive extraction coupled to thermal desorption and gas chromatography-tandem mass spectrometry. The HiSorb extraction device is completely compatible with aqueous matrices, thus saving on time and materials associated with organic solvent-extraction methods. A Central Composite Face-Centred experimental design was used for the optimization of the molar ratio between PFB-Br and target analytes, the derivatization temperature, and the reaction time which were 100, 60 °C, and 180 min, respectively. Detection limits in the range 0.1-100 µM were reached using a small amount of saliva (20 µL). The use of sodium acetate-1-13C as an internal standard improved the intra- and inter-day precision of the method which ranged from 10 to 23%. The optimized protocol was successfully applied for what we believe is the first time to evaluate the salivary levels of short chain fatty acids and hydroxy acids in saliva samples of four groups of patients: i) patients admitted to hospital with acute HF symptoms, ii) patients with chronic HF symptoms, iii) patients without HF symptoms but with obesity, and iv) patients without HF symptoms but with hypertension. The first group of patients showed significantly higher levels of salivary acetic acid and lactic acid at hospital admission as well as the lowest values of hexanoic acid and heptanoic acid. Moreover, the significant high levels of acetic acid, propionic acid, and butyric acid observed in HF respect to the other patients suggest the potential link between oral bacteria and gut dysbiosis.

Hypertensive heart disease: risk factors, complications and mechanisms

Hypertensive heart disease constitutes functional and structural dysfunction and pathogenesis occurring primarily in the left ventricle, the left atrium and the coronary arteries due to chronic uncontrolled hypertension. Hypertensive heart disease is underreported and the mechanisms underlying its correlates and complications are not well elaborated. In this review, we summarize the current understanding of hypertensive heart disease, we discuss in detail the mechanisms associated with development and complications of hypertensive heart disease especially left ventricular hypertrophy, atrial fibrillation, heart failure and coronary artery disease. We also briefly highlight the role of dietary salt, immunity and genetic predisposition in hypertensive heart disease pathogenesis.

Disparities in prevalence of heart failure between the genders in relation to age, multimorbidity and socioeconomic status in southern Sweden: a cross-sectional study

OBJECTIVE

Prior studies have reported that heart failure typically affects elderly, multimorbid and socioeconomically deprived men. Women with heart failure are generally older, have a higher EF (ejection fraction) and have more heart failure-related symptoms than men. This study explored the disparities in the prevalence of heart failure between men and women in relation to age, multimorbidity level and socioeconomic status of the population in southern Sweden.

DESIGN

A register-based, cross-sectional cohort study.Setting and subjects: The inhabitants from 20 years of age onwards (N = 981,383) living in southern Sweden in 2015.Main outcome measure: Prevalence and mean probability of having heart failure in both genders. CNI (Care Need Index) percentiles depend on the socioeconomic status of their listed primary healthcare centres.

RESULTS

Men had a higher OR for HF - 1.70 (95% CI 1.65-1.75) - than women. The probability of men having heart failure increased significantly compared to women with advancing age and multimorbidity levels. At all CNI levels, the multimorbid patients had a higher prevalence of heart failure in men than in women. The disparity in the mean probability of heart failure between the most affluent and deprived CNI percentile was more apparent in women compared to men, especially from 80 years.

CONCLUSIONS

The prevalence of heart failure differs significantly between the genders. Men had an increasing mean probability of heart failure with advancing age and multimorbidity level compared to women. Socioeconomic deprivation was more strongly associated with heart failure in women than in men. The probability of having heart failure differs between the genders in several aspects.Key PointsIndependently of socioeconomic status, men had a higher prevalence of heart failure than women among the multimorbid patients.The mean probability of men having heart failure increased significantly compared to women with advancing age and multimorbidity level.Socioeconomic status was more strongly associated with heart failure in women than in men.

Association of Incident Cardiovascular Disease With Time Course and Cumulative Exposure to Multiple Risk Factors

BACKGROUND

The quantitative relationship of incident cardiovascular disease (CVD) to lifetime cumulative risk factor exposure is not well understood.

OBJECTIVES

Using CARDIA (Coronary Artery Risk Development in Young Adults) study data, we examined the quantitative associations of cumulative exposure over time to multiple, simultaneously operating risk factors with CVD incidence and the incidence of its components.

METHODS

Regression models were developed quantifying the influence of the time course and severity of multiple CVD risk factors, operating simultaneously, on risk of incident CVD. The outcomes were incident CVD and the incidence of its components: coronary heart disease, stroke, and congestive heart failure.

RESULTS

Our study included 4,958 asymptomatic adults enrolled in CARDIA from 1985 to 1986 (ages 18 to 30 years) who were followed for 30 years. Risk of incident CVD depends on the time course and severity of a series of independent risk factors, the impact of which is mediated by their effects on individual CVD components after age 40 years. Cumulative exposure (AUC vs time) to low-density lipoprotein cholesterol and triglycerides was independently associated with risk of incident CVD. Of the blood pressure variables, areas under the mean arterial pressure vs time curve and the pulse pressure vs time curve were strongly and independently associated with incident CVD risk.

CONCLUSIONS

The quantitative description of the link between risk factors and CVD informs the construction of individualized CVD mitigation strategies, design of primary prevention trials, and assessment of public health impact of risk factor-based interventions.

The Prevalence and Risk Factors of Chronic Heart Failure in the Mongolian Population

BACKGROUND

The prevalence of heart failure in the Mongolian population is unknown. Thus, in this study, we aimed to define the prevalence of heart failure in the Mongolian population and to identify significant risk factors for heart failure among Mongolian adults.

METHODS

This population-based study included individuals 20 years and older from seven provinces as well as six districts of the capital city of Mongolia. The prevalence of heart failure was based on the European Society of Cardiology diagnostic criteria.

RESULTS

In total, 3480 participants were enrolled, of which 1345 (38.6%) participants were males, and the median age was 41.0 years (IQR 30-54 years). The overall prevalence of heart failure was 4.94%. Patients with heart failure had significantly higher body mass index, heart rate, oxygen saturation, respiratory rate, and systolic/diastolic blood pressure than patients without heart failure. In the logistic regression analysis, hypertension (OR 4.855, 95% CI 3.127-7.538), previous myocardial infarction (OR 5.117, 95% CI 3.040-9.350), and valvular heart disease (OR 3.872, 95% CI 2.112-7.099) were significantly correlated with heart failure.

CONCLUSIONS

This is the first report on the prevalence of heart failure in the Mongolian population. Among the cardiovascular diseases, hypertension, old myocardial infarction, and valvular heart disease were identified as the three foremost risk factors in the development of heart failure.

Ethnic inequalities in multiple long-term health conditions in the United Kingdom: a systematic review and narrative synthesis

Indicative evidence suggests that minoritised ethnic groups have higher risk of developing multiple long-term conditions (MLTCs), and do so earlier than the majority white population. While there is evidence on ethnic inequalities in single health conditions and comorbidities, no review has attempted to look across these from a MLTCs perspective. As such, we currently have an incomplete understanding of the extent of ethnic inequalities in the prevalence of MLTCs. Further, concerns have been raised about variations in the way ethnicity is operationalised and how this impedes our understanding of health inequalities. In this systematic review we aimed to 1) describe the literature that provides evidence of ethnicity and prevalence of MLTCs amongst people living in the UK, 2) summarise the prevalence estimates of MLTCs across ethnic groups and 3) to assess the ways in which ethnicity is conceptualised and operationalised. We focus on the state of the evidence prior to, and during the very early stages of the pandemic. We registered the protocol on PROSPERO (CRD42020218061). Between October and December 2020, we searched ASSIA, Cochrane Library, EMBASE, MEDLINE, PsycINFO, PubMed, ScienceDirect, Scopus, Web of Science, OpenGrey, and reference lists of key studies/reviews. The main outcome was prevalence estimates for MLTCs for at least one minoritised ethnic group, compared to the majority white population. We included studies conducted in the UK reporting on ethnicity and prevalence of MLTCs. To summarise the prevalence estimates of MLTCs across ethnic groups we included only studies of MLTCs that provided estimates adjusted at least for age. Two reviewers screened and extracted data from a random sample of studies (10%). Data were synthesised using narrative synthesis. Of the 7949 studies identified, 84 met criteria for inclusion. Of these, seven contributed to the evidence of ethnic inequalities in MLTCs. Five of the seven studies point to higher prevalence of MLTCs in at least one minoritised ethnic group compared to their white counterparts. Because the number/types of health conditions varied between studies and some ethnic populations were aggregated or omitted, the findings may not accurately reflect the true level of ethnic inequality. Future research should consider key explanatory factors, including those at the macrolevel (e.g. racism, discrimination), as they may play a role in the development and severity of MLTCs in different ethnic groups. Research is also needed to ascertain the extent to which the COVID19 pandemic has exacerbated these inequalities.

Data-driven identification of heart failure disease states and progression pathways using electronic health records

Heart failure (HF) is a leading cause of morbidity, healthcare costs, and mortality. Guideline based segmentation of HF into distinct subtypes is coarse and unlikely to reflect the heterogeneity of etiologies and disease trajectories of patients. While analyses of electronic health records show promise in expanding our understanding of complex syndromes like HF in an evidence-driven way, limitations in data quality have presented challenges for large-scale EHR-based insight generation and decision-making. We present a hypothesis-free approach to generating real-world characteristics and progression patterns of HF. Patient disease state snapshots are extracted from the complaints mentioned in unstructured clinical notes. Typical disease states are generated by clustering and characterized in terms of their distinguishing features, temporal relationships, and risk of important clinical events. Our analysis generates a comprehensive "disease phenome" of real-world patients computed from large, noisy, secondary-use EHR datasets created in a routine clinical setting.

Cost-Utility Analysis of Combination Empagliflozin and Standard Treatment Versus Standard Treatment Alone in Thai Heart Failure Patients with Reduced or Preserved Ejection Fraction

BACKGROUND

Clinical trials reported the benefit of empagliflozin when combined with standard treatment relative to cardiovascular death or heart failure (HF) hospitalization in patients with heart failure with reduced or preserved ejection fraction (HFrEF and HFpEF, respectively). We conducted a cost-utility analysis of combination empagliflozin and standard treatment (ST) versus ST alone in Thai HF patients with HFrEF or HFpEF.

METHODS

A Markov model was employed to capture lifetime direct medical costs and outcomes from a healthcare system perspective. Two cohorts (HFrEF and HFpEF) with an average age of 60 years were enrolled. The clinical inputs were the results of the EMPEROR-Reduced and EMPEROR-Preserved studies, and a Thai database. Costs were gathered from published studies or from a Thai hospital database. Utilities were obtained from published studies. All costs and outcomes were discounted at a rate of 3% per annum. Incremental cost-effectiveness ratios (ICERs) were estimated, and sensitivity analyses were performed.

RESULTS

In patients with HFrEF, add-on empagliflozin yielded a life-year gain of 0.26, and a quality-adjusted life-year (QALY) gain of 0.20 at an increased total cost of 409.82 USD compared to ST alone [ICER: 69,218 THB/QALY (2064.98 USD/QALY gained)]. Among HFpEF patients, add-on empagliflozin yielded a life-year gain of 0.07, and a QALY gain of 0.05 at an increased total cost of 622.49 USD compared to ST alone [ICER: 395,826 THB/QALY (11,809 USD/QALY gained)].

CONCLUSIONS

At the local Thai threshold of 4773.27 USD/QALY, empagliflozin is a cost-effective add-on treatment for patients with HFrEF, but not for patients with HFpEF.

Ethnicity and prognosis following a cardiovascular event in people with and without type 2 diabetes: Observational analysis in over 5 million subjects in England

AIMS

To quantify ethnic differences in the risk of all-cause mortality and cardiovascular disease (CVD) events following a first CVD event in people with and without type 2 diabetes.

METHODS

We identified 5,349,271 subjects with a first CVD between 1 January 2002 and 31 May 2020 in England; CVD included aortic aneurism, cerebrovascular accident, heart failure, myocardial infarction, peripheral vascular disease, and other cardiovascular diseases. We estimated adjusted hazard ratios (HRs) for type 2 diabetes and ethnicity of three outcomes: fatal and nonfatal second CVD event (different phenotype compared to the first) and all-cause mortality.

RESULTS

Relative to White, HRs indicated lower rates in all ethnicities and for all outcomes in both men (from 0.64 to 0.79 for all-cause death; 0.78-0.79 for CVD-related death; and 0.85-0.98 for a second CVD event) and women (0.69-0.77; 0.77-0.83; 0.83-0.95, respectively). Irrespective of ethnicity and sex, type 2 diabetes increased rates of all outcomes by around a third.

CONCLUSIONS

Prognosis following a CVD event was consistently worse in subjects with type 2 diabetes while varied across ethnicities, suggesting the implementation of different strategies for the secondary prevention of CVD in different ethnic groups.

Histopathological and epigenetic changes in myocardium associated with cancer therapy-related cardiac dysfunction

AIMS

Cancer therapy-related cardiac dysfunction (CTRCD) is commonly reported, but its histopathology, mechanisms, and risk factors are not known. We aimed to clarify the histopathology and mechanisms of CTRCD to identify risk factors.

METHODS AND RESULTS

We performed myocardial histopathological studies on 13 endomyocardial biopsies from CTRCD patients, 35 autopsied cancer cases with or without cardiac dysfunction, and controls without cancer (10 biopsies and 9 autopsies). Cardiotoxicity risk scores were calculated based on medication; and patient-related risk factors, fibrosis, and cardiomyocyte changes were scored; and p53 and H3K27ac histone modification were evaluated by histological score (H-score). In the biopsy cases, all histopathological changes and the p53 evaluation were significantly higher in the CTRCD group than in the controls [p53 H-score; 63 (9.109) vs. 33 (5.099), P < 0.05]. In patients with a short time between drug and disease onset (<4.2 years), fibrosis and p53 positively correlated (r = 0.76, P < 0.05), and in those with late onset disease (>4.2 years), cellular abnormalities and p53 trended to a positive correlation and cardiotoxicity risk scores and p53 positively correlated (r = 0.95, P < 0.05). A year after biopsy, the short-term group had significant recovery of ejection fraction compared with the long-term group (P < 0.05). The CTRCD group had a significantly worse overall survival prognosis than the control group [hazard ratio 7.61 (95% confidence interval 1.30-44.6), P < 0.05]. Autopsy cases with cancer treatment also had a high grade of histopathological changes, with even more severe changes in patients with cardiac dysfunction, and had increased p53 and H3K27ac expression levels, compared with controls. H-scores of p53 and H3K27ac showed a positive correlation in the CTRCD group in biopsy cases (r = 0.62, P < 0.05) and a positive correlation in autopsy cases.

CONCLUSIONS

Our results indicate distinct morphological characteristics in myocardial histopathology associated with CTRCD. p53 and H3K27ac histone modification could be sensitive markers of CTRCD and suggest a mechanistic involvement of epigenetic changes.

Multimorbidity Burden and Incident Heart Failure Among People With and Without HIV: The HIV-HEART Study

Objective

To examine the association between multimorbidity burden and incident heart failure (HF) among people with HIV (PWH) and people without HIV (PWoH).

Patients and Methods

The HIV-HEART study is a retrospective cohort study that included adult PWH and PWoH aged 21 years or older at Kaiser Permanente between 2000 and 2016. Multimorbidity burden was defined by the baseline prevalence of 22 chronic conditions and was categorized as 0-1, 2-3, and 4 or more comorbidities on the basis of distribution of the overall population. People with HIV and PWoH were followed for a first HF event, all-cause death, or up to the end of follow-up on December 31, 2016. Using Cox proportional hazard regression, hazard ratios and 95% CIs were calculated to examine the association between multimorbidity burden and incident HF among PWH and PWoH, separately.

Results

The prevalences of 0-1, 2-3, and 4 or more comorbidities were 83.3%, 13.0%, and 3.7% in PWH (n=38,868), and 82.2%, 14.3%, and 3.5% in PWoH (n=386,586), respectively. After multivariable adjustment, compared with people with 0-1 comorbidities, the hazard ratios of incident HF associated with 2-3 and 4 or more comorbidities were 1.33 (95% CI, 1.04-1.71) and 2.41 (95% CI, 1.78-3.25) in PWH and 2.10 (95% CI, 1.92-2.29) and 4.09 (95% CI, 3.64-4.61) in PWoH, respectively.

Conclusion

Multimorbidity was associated with a higher risk of incident HF among PWH and PWoH, with more prominent associations in PWoH and certain patient subgroups. The identification of specific multimorbidity patterns that contribute to higher HF risk in PWH may lead to future preventative strategies.

Shift Work, Genetic Factors, and the Risk of Heart Failure: A Prospective Study of the UK Biobank

OBJECTIVE

To quantify the association of combined shift work and genetic factors with the incidence of heart failure (HF).

PARTICIPANTS AND METHODS

This study included 242,754 participants with complete shift work information in the UK Biobank. Participants were followed from baseline (2006 to 2010) through January 31, 2018. The association between shift work and HF incidence was investigated separately in males and females using a Cox proportional hazards model adjusted for covariates. In addition, we established a polygenic risk score and assessed whether shift work alters genetic susceptibility to HF.

RESULTS

The results showed a significant association of permanent night shift work with incident HF among females (hazard ratio, 2.25; 95% CI, 1.34 to 3.76; P=.002) after adjusting for age, and the association was attenuated in the fully adjusted model. Among men, we did not detect an association between shift work and HF. In addition, we observed that the association between the risk of HF and shift work was strengthened by high genetic risk. Permanent night shift work paired with high genetic risk, compared with low genetic risk, was suggested to be associated with the risk of HF in females (hazard ratio, 2.89; 95% CI, 1.05 to 7.94) but not in males.

CONCLUSION

Shift work, particularly permanent night shift work, may increase the risk of HF in females, especially in those with high genetic risk.

Predicting 31- to 60-Day Heart Failure Rehospitalization Among Older Women

The current study sought to identify social, hemodynamic, and comorbid risk factors associated with 31-to 60-day heart failure (HF) rehospitalization in African American and Caucasian older (aged >65 years) women. A non-equivalent, case-control, quantitative design study using secondary data analysis of medical records from a local community hospital in the Southeast region of the United States was performed over a 3-year period. Relationships between predictor variables and the outcome variable, 31- to 60-day HF rehospitalization, were explored. The full model containing all predictors was not able to distinguish between predictors (χ²[21, N = 188] = 35.77, p = 0.12). However, a condensed model showed that body mass index (BMI) level 1 (<25 kg/m²), BMI level 2 (>25 and <30 kg/m²), age 75 to 80 years, and those taking lipid-lowering agents were significant predictors. Subtype of HF (reduced or preserved) and race did not predict HF rehospitalization within the specified time period. Multiple comorbid risk factors failed to consistently predict rehospitalization, which may reflect dated HF-specific approaches and therapies. Future studies should evaluate contributions of current targeted post-discharge methods or therapies. [Research in Gerontological Nursing, xx(x), xx-xx.].

Interconnected Clinical and Social Risk Factors in Breast Cancer and Heart Failure

Breast cancer and heart failure share several known clinical cardiovascular risk factors, including age, obesity, glucose dysregulation, cholesterol dysregulation, hypertension, atrial fibrillation and inflammation. However, to fully comprehend the complex interplay between risk of breast cancer and heart failure, factors attributed to both biological and social determinants of health must be explored in risk-assessment. There are several social factors that impede implementation of prevention strategies and treatment for breast cancer and heart failure prevention, including socioeconomic status, neighborhood disadvantage, food insecurity, access to healthcare, and social isolation. A comprehensive approach to prevention of both breast cancer and heart failure must include assessment for both traditional clinical risk factors and social determinants of health in patients to address root causes of lifestyle and modifiable risk factors. In this review, we examine clinical and social determinants of health in breast cancer and heart failure that are necessary to consider in the design and implementation of effective prevention strategies that altogether reduce the risk of both chronic diseases

HFSA Position Statement The Impact of Healthcare Disparities on Patients with Heart Failure

Heart Failure (HF) remains a condition associated with high morbidity, mortality, and associated costs. Although the number of medical and device-based therapies available to treat HF are expanding at a remarkable rate, disparities in the risk for incident HF and treatments delivered to patients are also of growing concern. These disparities span across racial and ethnic groups, socioeconomic status, and apply across the spectrum of HF from Stage A to Stage D. The complexity of HF risk and treatment is further impacted by the number of patients who experience the downstream impact of social determinants of health. The purpose of this document is to highlight the known healthcare disparities that exist in the care of patients with HF, and to provide a context for how clinicians and researchers should assess both biologic and social determinants of HF risk in vulnerable populations. Furthermore, this document will provide a framework for future steps that can be utilized to help diminish inequalities in access and clinical outcomes over time, and offer solutions to help reduce disparities within HF care.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

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

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

Social relationships and the risk of incident heart failure: results from a prospective population-based study of older men

Aims

Limited social relationships, particularly in older adults, have been implicated as a risk factor for cardiovascular disease. However, little is known about the associations between poor social relationships and heart failure incidence.

Methods and results

Prospective study of socially representative men aged 60–79 years drawn from general practices in 24 British towns and followed up for a maximum of 18 years. A total of 3698 participants with no previous diagnosis of heart failure were included. Information on social relationships was based on a combination of marital status, living circumstances, and social contacts with friends and family. These provided information on contact frequency, contact satisfaction, and a social relationship score (low to high) combining frequency and satisfaction with contact. Heart failure included both incidents non-fatal heart failure and death from heart failure. Among 3698 participants, 330 developed heart failure. Men with low compared to high frequency of contact with family and friends had an increased risk of incident heart failure [hazard ratio (HR) 1.59, 95% confidence interval (CI) 1.15–2.18]; this remained statistically significant after adjustment for social class, behavioural, and biological risk factors. Low compared to high scores for satisfaction with contacts was associated with increased risk of heart failure (adjusted HR = 1.54; 95% CI 1.14–2.07). Lower social relationship scores (combining frequency and satisfaction with contact) were associated with greater risk of incident heart failure (adjusted HR = 1.38, 95% CI 1.02–1.87). Marital status and living alone were not significantly associated with heart failure.

Conclusion

Weaker social relationships appear to increase the risk of developing heart failure in older age. Further research is needed to investigate pathways underlying these associations and to test whether interventions to strengthen social relationships can reduce the risk of heart failure.

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

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

Race and Ethnicity in Heart Failure: JACC Focus Seminar 8/9

Heart failure (HF) affects >6 million Americans, with variations in incidence, prevalence, and clinical outcomes by race/ethnicity. Black adults have the highest risk for HF, with earlier age of onset and the highest risk of death and hospitalizations. The risk of hospitalizations for Hispanic patients is higher than White patients. Data on HF in Asian individuals are more limited. However, the higher burden of traditional cardiovascular risk factors, particularly among South Asian adults, is associated with increased risk of HF. The role of environmental, socioeconomic, and other social determinants of health, more likely for Black and Hispanic patients, are increasingly recognized as independent risk factors for HF and worse outcomes. Structural racism and implicit bias are drivers of health care disparities in the United States. This paper will review the clinical, physiological, and social determinants of HF risk, unique for race/ethnic minorities, and offer solutions to address systems of inequality that need to be recognized and dismantled/eradicated.

Work status before admission relates to prognosis in older patients with heart failure partly through social frailty

BACKGROUND

No reports explicitly examined the relationship between work defined as a certain type of social participation or role and the protective effect on the prognosis of patients with heart failure (HF) by preventing frailty. Therefore, this study examined whether social participation through work before admission relates to future adverse events in HF patients aged ≥65 years, and whether each frailty domain mediates the association between work and prognosis as a second analysis of a multi-centered prospective study (FRAGILE-HF study).

METHODS

We retrospectively reviewed 1,332 older patients with HF whose work status before admission to the hospital were investigated. We assessed the physical, cognitive, and social domains of frailty and performed causal mediation analysis to examine the mediating relationship of each frail domain between work status before admission and 1-year combined events (HF-related readmission and all-cause death).

RESULTS

The subjects' median age was 81 years, and 56.9% (758/1,332) were male. Among the three domains of frailty, work before admission reduced only social frailty after adjusting for confounding factors (odds ratio: 0.505, 95% confidence interval: 0.364-0.701). Patients with work before admission had a significantly better prognosis (hazard ratio: 0.720, 95% confidence interval: 0.523-0.989). Only social frailty partly mediated the relationship between work status and combined events (p <0.05).

CONCLUSIONS

Work status before admission is associated with 1-year combined events, in part through social frailty.

Trends in 30-day readmissions following hospitalisation for heart failure by sex, socioeconomic status and ethnicity

BACKGROUND

Reducing the high patient and economic burden of early readmissions after hospitalisation for heart failure (HF) has become a health policy priority of recent years.

METHODS

An observational study linking Hospital Episode Statistics to socioeconomic and death data in England (2002-2018). All first hospitalisations with a primary discharge code for HF were identified. Quasi-poisson models were used to investigate trends in 30-day readmissions by age, sex, socioeconomic status and ethnicity.

FINDINGS

There were 698,983 HF admissions, median age 81 years [IQR 14].In-hospital deaths reduced by 0.7% per annum (pa), whilst additional deaths at 30-days remained stable at 5%. Age adjusted 30-day readmissions (21% overall), increased by 1.4% pa (95% CI 1.3-1.5). Readmissions for HF (6%) and 'other cardiovascular disease (CVD)' (3%) remained stable, but readmissions for non-CVD causes (12%) increased at a rate of 2.6% (2.4-2.7) pa. Proportions were similar by sex but trends diverged by ethnicity. Black groups experienced an increase in readmissions for HF (1.8% pa, interaction-p 0.03) and South Asian groups had more rapidly increasing readmission rates for non-CVD causes (interaction-p 0.04). Non-CVD readmissions were also more prominent in the least (15%; 15-15) compared to the most affluent group (12%; 12-12). Strongest predictors for HF readmission were Black ethnicity and chronic kidney disease, whilst cardiac procedures were protective. For non-CVD readmissions, strongest predictors were non-CVD comorbidities, whilst cardiologist care was protective.

INTERPRETATION

In HF, despite readmission reduction policies, 30-day readmissions have increased, impacting the least affluent and ethnic minority groups the most.

FUNDING

NIHR.

Avoidable Hospitalization for Heart Failure Among a Cohort of 18- to 64-Year-Old Italian Citizens and Immigrants: Results From the Italian Network for Longitudinal Metropolitan Studies

BACKGROUND

Heart failure (HF) represents a severe public health burden. In Europe, differences in hospitalizations for HF have been found between immigrants and native individuals, with inconsistent results. Immigrants face many barriers in their access to health services, and their needs may be poorly met. We aimed to compare the rates of avoidable hospitalization for HF among immigrants and native individuals in Italy.

METHODS

All 18- to 64-year-old residents of Turin, Venice, Reggio Emilia, Modena, Bologna, and Rome between January 1, 2001 and December 31, 2013 were included in this multicenter open-cohort study. Immigrants from high migratory pressure countries (divided by area of origin) were compared with Italian citizens. Age-, sex-, and calendar year-adjusted hospitalization rate ratios and the 95% CIs of avoidable hospitalization for HF by citizenship were estimated using negative binomial regression models. The hospitalization rate ratios were summarized using a random effects meta-analysis. Additionally, we tested the contribution of socioeconomic status to these disparities.

RESULTS

Of the 4 470 702 subjects included, 15.8% were immigrants from high migratory pressure countries. Overall, immigrants showed a nonsignificant increased risk of avoidable hospitalization for HF (hospitalization rate ratio, 1.26 [95% CI, 0.97-1.68]). Risks were higher for immigrants from Sub-Saharan Africa and for males from Northern Africa and Central-Eastern Europe than for their Italian citizen counterparts. Risks were attenuated adjusting for socioeconomic status, although they remained consistent with nonadjusted results.

CONCLUSIONS

Adult immigrants from different geographic macroareas had higher risks of avoidable hospitalization for HF than Italian citizens. Possible explanations might be higher risk factors among immigrants and reduced access to primary health care services.

Clinical Characteristics and Outcomes of Hospitalized Patients With Heart Failure From the Large-Scale Japanese Registry Of Acute Decompensated Heart Failure (JROADHF)

BACKGROUND

With aging population, the prevalence and incidence of heart failure (HF) have been increasing worldwide. However, the characteristics and outcomes of patients with HF in an era of aging are not well established in Japan.Methods and Results:The Japanese Registry Of Acute Decompensated Heart Failure (JROADHF), a retrospective, multicenter, nationwide registry, was designed to study the clinical characteristics and outcomes of patients hospitalized with HF throughout Japan in 2013. One hundred and twenty-eight hospitals were selected by cluster random sampling and 13,238 hospitalized patients with HF were identified by medical record review. Demographics, medical history, severity, treatment, and in-hospital and long-term outcome data were collected from the Diagnostic Procedure Combination and medical charts. Data were analyzed using univariate and multivariate logistic regression or Cox regression analysis. The mean age of registered patients was 78.0±12.5 years and 52.8% were male. Elderly patients (age >75 years) accounted for 68.9%, and HF with preserved ejection fraction (HFpEF) accounted for 45.1%. Median length of hospital stay was 18 days and in-hospital mortality was 7.7%. The median follow-up period was 4.3 years, and the incidence rates for cardiovascular death and rehospitalization for HF were 7.1 and 21.1 per 100 person-years, respectively.

CONCLUSIONS

A contemporary nationwide registry demonstrated that hospitalized HF patients were very elderly, HFpEF was common, and their prognosis was still poor in Japan.

Predictive Value of Pro-BNP for Heart Failure Readmission after an Acute Coronary Syndrome

BACKGROUND

N-terminal pro-brain natural peptide (NT-pro-BNP) is a well-established biomarker of tissue congestion and has prognostic value in patients with heart failure (HF). Nonetheless, there is scarce evidence on its predictive capacity for HF re-admission after an acute coronary syndrome (ACS). We performed a prospective, single-center study in all patients discharged after an ACS. HF re-admission was analyzed by competing risk regression, taking all-cause mortality as a competing event. Results are presented as sub-hazard ratios (sHR). Recurrent hospitalizations were tested by negative binomial regression, and results are presented as incidence risk ratio (IRR).

RESULTS

Of the 2133 included patients, 528 (24.8%) had HF during the ACS hospitalization, and their pro-BNP levels were higher (3220 pg/mL vs. 684.2 pg/mL; p < 0.001). In-hospital mortality was 2.9%, and pro-BNP was similarly higher in these patients. Increased pro-BNP levels were correlated to increased risk of HF or death during the hospitalization. Over follow-up (median 38 months) 243 (11.7%) patients had at least one hospital readmission for HF and 151 (7.1%) had more than one. Complete revascularization had a preventive effect on HF readmission, whereas several other variables were associated with higher risk. Pro-BNP was independently associated with HF admission (sHR: 1.47) and readmission (IRR: 1.45) at any age. Significant interactions were found for the predictive value of pro-BNP in women, diabetes, renal dysfunction, STEMI and patients without troponin elevation.

CONCLUSIONS

In-hospital determination of pro-BNP is an independent predictor of HF readmission after an ACS.

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.

Cost-utility analysis of add-on dapagliflozin treatment in heart failure with reduced ejection fraction

BACKGROUND

Dapagliflozin is an antidiabetic medication that has been shown to reduce the risk of heart failure hospitalization and cardiovascular death in patients with heart failure with reduced ejection fraction (HFrEF). This study aimed to determine the cost-utility of add-on dapagliflozin treatment for HFrEF.

METHODS

An analytical decision model was constructed to assess lifetime costs and outcomes from a healthcare system perspective. The cohort comprised HFrEF patients with left ventricular ejection fraction (LVEF) ≤40%, and New York Heart Association (NYHA) class II-IV with an average age of 65 years. Clinical inputs were derived from the results of the Dapagliflozin and Prevention of Adverse-Outcomes in Heart Failure (DAPA-HF) trial. Risk of non-cardiovascular death data, readmission rate data, and treatment-related cost data were based on Thai population. The outcomes and costs were discounted at 3% annually. A series of sensitivity analyses were also conducted.

RESULTS

The increased cost of dapagliflozin add-on treatment from 17,442 THB (559 USD) to 54,405 THB (1745 USD) was associated with a QALY gain from 6.33 to 6.92 compared to standard therapy, yielding an ICER of 62,090 THB/QALY (1991 USD/QALY). Sensitivity analyses revealed that the addition of dapagliflozin to the standard treatment demonstrated an 87% cost-effectiveness strategy at a level of willingness to pay (WTP) of 160,000 THB/QALY (5131 USD/QALY). ICER was higher in non-diabetes compared to diabetes (68,304 vs 47,613 THB/QALY or 2191 vs 1527 USD/QALY).

CONCLUSIONS

Dapagliflozin is a cost-effective add-on therapy for patients with HFrEF at a WTP of 160,000 THB/QALY (5131 USD/QALY).

Design and Synthesis of an Aniline Derivative with Biological Activity on Heart Failure

BACKGROUND

Several compounds have been synthesized as a therapeutic alternative for heart failure; however, its preparation requires special conditions.

OBJECTIVE

The aim of this study, was to synthesize some aniline derivatives (4-9) from 3- ethynylaniline to evaluate their biological activity against heart failure.

METHODS

The synthesis of aniline derivatives involved a series of reactions such as etherification, addition, and cyclization. The structure of all compounds obtained was confirmed by spectroscopic and spectrometric methods. In addition, to evaluate the biological activity of compounds, an ischemia/reperfusion injury model was used.

RESULTS

The results showed that compound 8 decreases heart failure, which translates into a decrease in the infarction area compared to compounds 4-7 and 9.

CONCLUSION

This study reports a facile method for the preparation of aniline derivatives. This method offers some advantages such as; a simple procedure, low cost, and easy work up. In addition, compound 8 showed an interesting biological activity against heart failure. This phenomenon is particularly interesting because the biological activity induced by this compound could involve a molecular mechanism that is different from other drugs used for the treatment of heart failure.