Prognostic role of tricuspid annular plane systolic excursion/pulmonary artery systolic pressure ratio in patients hospitalized for acute heart failure

Prognostic role of TAPSE to PASP ratio in outpatients with left ventricular systolic dysfunction

AIMS

Few data are available regarding the role of tricuspid annulus plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP), a measurement of right ventricular to pulmonary artery coupling, in patients with chronic heart failure and left ventricular systolic dysfunction.

METHODS AND RESULTS

This retrospective single-centre study included outpatients with left ventricular systolic dysfunction (ejection fraction ≤ 50%) evaluated between January 2022 and December 2022. TAPSE/PASP was evaluated as a continuous variable and as tertiles according to its value on the first visit. The primary outcome of the study was a composite of all-cause mortality or heart failure (HF) events at the last available follow-up.

RESULTS

A total of 642 patients were included (mean age 71 ± 13 years, 78% male, mean left ventricular ejection fraction 40% [interquatile range 35-46]). Patients with lower TAPSE/PASP had more co-morbidities (i.e., atrial fibrillation, chronic kidney disease or previous cardiovascular implantable electronic device), an higher New York Heart Association class (P < 0.001), more signs of congestion (P = 0.007), and had more probability to receive intravenous furosemide during the visit (P < 0.001). After a median follow-up of 474 days [interquartile range 392-507 days], a total of 51 patients (8.0%) died (with 24 patients [3.8%] experiencing cardiovascular-related deaths), a total of 179 patients (28.1%) experienced a composite outcome, and 158 patients (24.8%) had HF events. Kaplan-Meier analysis showed that the estimated 1-year rate of the primary outcome was higher in the lowest tertile (38.0%), as compared with the intermediate (19.6%) and highest tertiles (14.9%; P-value log-rank <0.001). TAPSE/PASP ratio as a continuous variable was independently associated with the primary outcome (adjusted hazard ratio for 0.1 mm/mmHg increase 0.91, 95% CI 0.84-0.98, P = 0.009), predominantly driven by a higher risk of HF events during follow-up. Analysing the impact of TAPSE/PASP tertiles on the primary outcome, an independent associated was confirmed at multivariate analisys for the highest versus lowest tertile (adjusted hazard ratio 0.61, 95% CI 0.38-0.99, P = 0.044).

CONCLUSIONS

TAPSE/PASP was independently associated with mortality or HF events among ambulatory patients with left ventricular systolic dysfunction.

In-hospital evolution of secondary mitral regurgitation in acutely decompensated heart failure

AIMS

Secondary mitral regurgitation (MR) negatively affects prognosis in acutely decompensated heart failure (ADHF), but can be rapidly sensitive to changes in volume status and medical interventions. We sought to assess the evolution of secondary MR in patients hospitalized for ADHF and its prognostic implications.

METHODS

We retrospectively enrolled 782 patients admitted for ADHF with at least two in-hospital echocardiographic evaluations of MR. We classified MR severity as none-mild or moderate-severe. Based on MR evolution, patients were divided into 'persistent moderate-severe MR', 'improved MR' (from moderate-severe to none-mild) and 'persistent none-mild MR'.

RESULTS

Four hundred and forty patients (56%) had moderate-severe MR at first evaluation, of whom 144 (33% of patients with baseline moderate-severe MR) had 'improved MR', while 296 (67%) had 'persistent moderate-severe MR'. Patients with improved MR had better clinical, laboratory and echocardiographic parameters of decongestion at discharge compared with those with persistent moderate-severe MR and showed a higher up-titration of recommended therapies. Left ventricular volume, ejection fraction and serum urea were the predictors of improved MR at multivariable analysis. After adjustment, no differences in 5-years survival (primary outcome) were observed according to baseline MR severity. When patients were stratified according to the in-hospital changes in MR severity, improved MR was associated with lower risk of 5-years mortality, compared with both persistent none-mild MR [hazard ratio (HR) = 0.505, P = 0.032] and persistent moderate-severe MR (HR = 0.556, P = 0.040).

CONCLUSIONS

The severity of MR frequently improved during hospitalization for ADHF; the extent and the changes in MR severity during the in-hospital stay identified distinct patient phenotypes, and seemed to portend different long-term outcomes, with higher 5-years survival associated with improvement in MR.

Right ventricular dysfunction in chronic heart failure: clinical laboratory and echocardiographic characteristics. (the RIVED-CHF registry)

BACKGROUND

Right ventricular dysfunction (RVD) and pulmonary hypertension have been recognized as two important prognostic features in patients with left side heart failure. Current literature does not distinguish between right heart failure (RHF) and RVD, and the two terms are used indiscriminately to describe pulmonary hypertension and RVD as well as clinical sign of RHF. Therefore, the right ventricle (RV) adaptation across the whole spectrum of left ventricular ejection fraction (LVEF) values has been poorly investigated.

METHODS

This is a multicenter observational prospective study endorsed by the Italian Society of Cardiology aiming to analyze the concordance between the signs and symptoms of RHF and echocardiographic features of RVD. The protocol will assess patients affected by chronic heart failure in stable condition regardless of the LVEF threshold by clinical, laboratory, and detailed echocardiographic study. During the follow-up period, patients will be observed by direct check-up visit and/or virtual visits every 6 months for a mean period of 3 years. All clinical laboratory and echocardiographic data will be recorded in a web platform system accessible for all centers included in the study.

RESULTS

The main study goals are: to investigate the concordance and discordance between clinical signs of RHF and RVD measured by ultrasonographic examination; to evaluate prognostic impact (in terms of cardiovascular mortality and heart failure hospitalization) of RVD and RHF during a mean follow-up period of 3 years; to investigate the prevalence of different right ventricular maladaptation (isolated right ventricular dilatation, isolated pulmonary hypertension, combined pattern) and the related prognostic impact.

CONCLUSIONS

With this protocol, we would investigate the three main RVD patterns according to heart failure types and stages; we would clarify different RVD and pulmonary hypertension severity according to the heart failure types. Additionally, by a serial multiparametric analysis of RV, we would provide a better definition of RVD stage and how much is it related with clinical signs of RHF (ClinicalTrials.gov Identifier: NCT06002321).

Characteristics and outcomes of patients with tricuspid regurgitation and advanced heart failure

AIMS

To evaluate the role of tricuspid regurgitation in advanced heart failure.

METHODS

The multicenter observational HELP-HF registry enrolled consecutive patients with heart failure and at least one 'I NEED HELP' criterion evaluated at four Italian centers between January 2020 and November 2021. Patients with no data on tricuspid regurgitation and/or receiving tricuspid valve intervention during follow-up were excluded. The population was stratified by no/mild tricuspid regurgitation vs. moderate tricuspid regurgitation vs. severe tricuspid regurgitation. Variables independently associated with tricuspid regurgitation, as well as the association between tricuspid regurgitation and clinical outcomes were investigated. The primary outcome was all-cause mortality.

RESULTS

Among the 1085 patients included in this study, 508 (46.8%) had no/mild tricuspid regurgitation, 373 (34.4%) had moderate tricuspid regurgitation and 204 (18.8%) had severe tricuspid regurgitation. History of atrial fibrillation, any prior valve surgery, high dose of furosemide, preserved left ventricular ejection fraction, moderate/severe mitral regurgitation and pulmonary hypertension were found to be independently associated with an increased likelihood of severe tricuspid regurgitation. Estimated rates of 1-year all-cause death were of 21.4, 24.5 and 37.1% in no/mild tricuspid regurgitation, moderate tricuspid regurgitation and severe tricuspid regurgitation, respectively (log-rank P  < 0.001). As compared with nonsevere tricuspid regurgitation, severe tricuspid regurgitation was independently associated with a higher risk of all-cause mortality (adjusted hazard ratio 1.38, 95% confidence interval 1.01-1.88, P  = 0.042), whereas moderate tricuspid regurgitation did not.

CONCLUSION

In a contemporary, real-world cohort of patients with advanced heart failure, several clinical and echocardiographic characteristics are associated with an increased likelihood of severe tricuspid regurgitation. Patients with severe tricuspid regurgitation have an increased risk of mortality.

Soluble ST2 as a possible biomarker for inflammation in patients with acute heart failure

AIM

The aim of this study was to explore the relationship between peripheral circulating serum soluble suppression of tumorigenicity-2 (sST2) levels and inflammatory biomarkers in patients with acute heart failure (AHF).

METHODS

One hundred and eleven consecutive AHF patients with NYHA class II-IV were enrolled, and peripheral blood was collected within 24 h of admission for the detection of NT-ProBNP, sST2, hypersensitive troponin I, cytokines, precalcitoninogen, C-reactive protein, in addition to routine standard of care blood tests.

RESULTS

The median sST2 of 111 patients was 47.50 ng/ml (24.25-86.15 IQR), of whom 43 patients (38.7%) had sST2 35 ng/ml or less; linear correlation analysis showed that serum sST2 correlated with NT-ProBNP ( r2  = 0.32), NEU% ( r2  = 0.41), NLR ( r2  = 0.36), CRP ( r2  = 0.50), IL-18 ( r2  = 0.43) ( P  < 0.001), and correlated with Hs-cTnI ( r2  = 0.19), NUE ( r2  = 0.25), LYM ( r2  = -0.23), IL-2RA ( r2  = 0.29) ( P  < 0.05). Multiple linear regression analysis depicted that CRP (β = 0.318), IL-18 (β = 0.368), NEU% (β = 0.346), NLR (β = -0.304), and NT-ProBNP (β = 0.324) significantly correlated with sST2 values, respectively ( P  < 0.05). ST2 levels have a linear association with length of hospitalization.

CONCLUSION

Peripheral blood inflammatory markers (CRP, IL-18, NEU%, NLR) in patients with AHF had a close relationship with sST2 levels, and the mechanism of action of sST2 may be related to the inflammatory response.

Clinical and prognostic implications of heart failure hospitalization in patients with advanced heart failure

BACKGROUND

Hospitalization is associated with poor outcomes in patients with heart failure, but its prognostic role in advanced heart failure is still unsettled. We evaluated the prognostic role of heart failure hospitalization in patients with advanced heart failure.

METHODS

The multicenter HELP-HF registry enrolled consecutive patients with heart failure and at least one high-risk 'I NEED HELP' marker. Characteristics and outcomes were compared between patients who were hospitalized for decompensated heart failure (inpatients) or not (outpatients) at the time of enrolment. The primary endpoint was the composite of all-cause mortality or first heart failure hospitalization.

RESULTS

Among the 1149 patients included [mean age 75.1 ± 11.5 years, 67.3% men, median left ventricular ejection fraction (LVEF) 35% (IQR 25-50%)], 777 (67.6%) were inpatients at the time of enrolment. As compared with outpatients, inpatients had lower LVEF, higher natriuretic peptides and a worse clinical profile. The 1-year rate of the primary endpoint was 50.9% in inpatients versus 36.8% in outpatients [crude hazard ratio 1.70, 95% confidence interval (CI) 1.39-2.07, P < 0.001]. At multivariable analysis, inpatient status was independently associated with a higher risk of the primary endpoint (adjusted hazard ratio 1.54, 95% CI 1.23-1.93, P < 0.001). Among inpatients, the independent predictors of the primary endpoint were older age, lower SBP, heart failure association criteria for advanced heart failure and glomerular filtration rate 30 ml/min/1.73 m2 or less.

CONCLUSION

Hospitalization for heart failure in patients with at least one high-risk 'I NEED HELP' marker is associated with an extremely poor prognosis supporting the need for specific interventions, such as mechanical circulatory support or heart transplantation.

Outcome of Patients With Cardiogenic Shock and Previous Right Ventricular Impairment Represented by Decreased Tricuspid Annular Plane Systolic Excursion and Tricuspid Annular Plane Systolic Excursion to Pulmonary Artery Systolic Pressure Ratio

This study investigates the prognostic impact of known decreased ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) and TAPSE in patients with cardiogenic shock (CS). In patients with pulmonary artery hypertension and in critically ill patients, decreased TAPSE and TAPSE/PASP ratio are known to be negative predictors. However, studies regarding the prognostic impact in patients with CS are limited. Consecutive patients with CS from June 2019 to May 2021 treated at a single center were included. Medical history including echocardiographic parameters such as TAPSE and PASP was documented for each patient. The primary endpoint was all-cause mortality at 30 days. Statistical analyses included univariable t test, Spearman's correlation, C-statistics, Kaplan-Meier analyses, and Cox proportional regression analyses. A total of 90 patients with CS and measurement of TAPSE and TAPSE/PASP ratio were included. TAPSE and TAPSE/PASP ratio measured several months before intensive care unit admission were both able to predict 30-day survival in CS patients, and were both lower in 30-day nonsurvivors. TAPSE/PASP ratio <0.4 mm/mmHg (log-rank p = 0.006) and TAPSE <18 mm (log-rank p = 0.004) were associated with increased risk of 30-day all-cause mortality. After multivariable adjustment, TAPSE/PASP ratio <0.4 mm/mmHg was not able to predict 30-day all-cause mortality, whereas TAPSE <18 mm was still significantly associated with the primary endpoint (hazard ratio 2.336, confidence interval 1.067 to 5.115, p = 0.034). In consecutive patients presenting with CS, compared to TAPSE alone, previously determined TAPSE/PASP ratio did not improve risk prediction for 30-day all-cause mortality.