Update on heart failure management and future directions

Lactobacillus rhamnosus HN001 facilitates the efficacy of dual PI3K/mTOR inhibition prolonging cardiac transplant survival and enhancing antitumor effect

Solid organ transplantation is a crucial treatment for patients who have reached the end stage of heart, lung, kidney, or liver failure. However, the likelihood of developing cancer post-transplantation increases. Additionally, primary malignant tumors remain a major obstacle to the long-term survival of transplanted organs. Therefore, it is essential to investigate effective therapies that can boost the immune system's ability to combat cancer and prevent allograft rejection. We established a mouse orthotopic liver tumor model and conducted allogeneic heterotopic heart transplantation. Various treatments were administered, and survival curves were generated using the Kaplan-Meier method. We also collected graft samples and measured inflammatory cytokine levels in the serum using an inflammatory array. The specificity of the histochemical techniques was tested by staining sections. We administered a combination therapy of phosphoinositide 3-kinase/mammalian target of rapamycin (PI3K/mTOR) dual inhibitor BEZ235 and Lactobacillus rhamnosus HN001 to primary liver cancer model mice with cardiac allografts. Consistent with our prior findings, L. rhamnosus HN001 alleviated the intestinal flora imbalance caused by BEZ235. Our previous research confirmed that the combination of BEZ235 and L. rhamnosus HN001 significantly prolonged cardiac transplant survival.

IMPORTANCE

We observed that the combination of phosphoinositide 3-kinase/mammalian target of rapamycin (PI3K/mTOR) dual inhibitor BEZ235 and Lactobacillus rhamnosus HN001 notably prolonged cardiac transplant survival while also inhibiting the progression of primary liver cancer. The combination therapy was efficacious in treating antitumor immunity and allograft rejection, as demonstrated by the efficacy results. We also found that this phenomenon was accompanied by the regulation of inflammatory IL-6 expression. Our study presents a novel and effective therapeutic approach to address antitumor immunity and prevent allograft rejection.

Circadian assessment of heart failure using explainable deep learning and novel multi-parameter polar images

BACKGROUND AND OBJECTIVE

Heart failure (HF) is a multi-faceted and life-threatening syndrome that affects more than 64.3 million people worldwide. Current gold-standard screening technique, echocardiography, neglects cardiovascular information regulated by the circadian rhythm and does not incorporate knowledge from patient profiles. In this study, we propose a novel multi-parameter approach to assess heart failure using heart rate variability (HRV) and patient clinical information.

METHODS

In this approach, features from 24-hour HRV and clinical information were combined as a single polar image and fed to a 2D deep learning model to infer the HF condition. The edges of the polar image correspond to the timely variation of different features, each of which carries information on the function of the heart, and internal illustrates color-coded patient clinical information.

RESULTS

Under a leave-one-subject-out cross-validation scheme and using 7,575 polar images from a multi-center cohort (American and Greek) of 303 coronary artery disease patients (median age: 58 years [50-65], median body mass index (BMI): 27.28 kg/m2 [24.91-29.41]), the model yielded mean values for the area under the receiver operating characteristics curve (AUC), sensitivity, specificity, normalized Matthews correlation coefficient (NMCC), and accuracy of 0.883, 90.68%, 95.19%, 0.93, and 92.62%, respectively. Moreover, interpretation of the model showed proper attention to key hourly intervals and clinical information for each HF stage.

CONCLUSIONS

The proposed approach could be a powerful early HF screening tool and a supplemental circadian enhancement to echocardiography which sets the basis for next-generation personalized healthcare.

Telehealth care and remote monitoring strategies in heart failure patients: A systematic review and meta-analysis

BACKGROUND

Heart failure (HF) is a cardiac clinical syndrome that involves complex pathological aetiologies. It represents a growing public health issue and affects a significant number of people worldwide.

OBJECTIVES

To synthesize evidence related to the impact of telemonitoring strategies on mortality and hospital readmissions of heart failure patients.

METHODS

A systematic literature review was conducted using PubMed, Scopus, CINAHL, IEEE Xplore Digital Library, Engineering Source, and INSPEC. To be included, studies had to be in English or Italian and involve heart failure patients of any NYHA class, receiving care through any telecare, remote monitoring, telemonitoring, or telehealth programmes. Articles had to contain data on both mortality and number of patients who underwent rehospitalizations during follow-ups. To explore the effectiveness of telemonitoring strategies in reducing both one-year all-cause mortality and one-year rehospitalizations, studies were synthesized through meta-analyses, while those excluded from meta-analyses were summarized narratively.

RESULTS

Sixty-one studies were included in the review. Narrative synthesis of data suggests a trend towards a reduction in deaths among monitored patients, but the number of rehospitalized patients was higher in this group. Meta-analysis of studies reporting one-year all-cause mortality outlined the protective power of care models based on telemonitoring in reducing one-year all-cause mortality. Meta-analysis of studies reporting the number of rehospitalized patients in one-year outlined that telemonitoring is effective in reducing the number of rehospitalized patients when compared with usual care strategies.

CONCLUSION

Evidence from this review confirms the benefits of telemonitoring in reducing mortality and rehospitalizations of HF patients. Further research is needed to reduce the heterogeneity of the studies.

Temporal Trends, Risk Factors, and Clinical Outcomes of De Novo Lymphoproliferative Disorders After Heart Transplantation

BACKGROUND

Post-transplant lymphoproliferative disorder (PTLD) is an important cause of morbidity and mortality in heart transplant (HTx) recipients. However, previous studies of PTLD after HTx are limited to single-center analyses or extrapolated from all solid organ transplantations.

OBJECTIVES

The authors analyzed the temporal trends, risk factors, and clinical outcome of de novo PTLD specifically after HTx.

METHODS

Using multi-institutional, multinational data from the International Society for Heart and Lung Transplantation Thoracic Organ Transplant Registry, the authors evaluated the real-world data of PTLD after HTx, transplanted between January 2000 and June 2015. Multivariable analysis was done to identify risk factors for PTLD development after HTx.

RESULTS

Among 28,136 HTx recipients, 1,069 (3.8%) developed PTLD within 10 years of transplantation. PTLD showed a bimodal age pattern with peak incidence in patients of pediatric age and late adulthood at transplantation. The early transplant era (2000-2007 vs 2008-2015), male recipient, and EBV donor-positive-recipient-negative match were independent risk factors of PTLD development within 3 years of transplantation, whereas maintenance therapy with cyclosporine vs tacrolimus at initial discharge was associated with a lower incidence. PTLD development within 3 years of transplantation was significantly associated with mortality (HR: 2.42 [95% CI: 2.01-2.91]; P < 0.001). Survival after PTLD diagnosis was higher in the recent transplant era.

CONCLUSIONS

PTLD is relatively rare, but potentially fatal, post-transplant malignancy. PTLD incidence and mortality after HTx have decreased in the recent era. Strategies to minimize the risk of PTLD, and ensure early diagnosis and effective treatment are likely to improve outcomes in HTx.

A review of the conservative versus invasive management of ischemic heart failure with reduced ejection fraction

Heart failure is increasing in terms of prevalence, morbidity, and mortality rates. Clinical trials and studies are focusing on heart failure as it is the destiny end-stage for several cardiovascular disorders. Recently, medical therapy has dramatically progressed with novel classes of medicines providing better quality of life and survival outcomes. However, heart failure remains a heavy impactful factor on societies and populations. Current guidelines from the American and European cardiac societies are not uniform with respect to the class and level of treatment recommendations for coronary artery disease patients with heart failure and reduced ejection fraction. The discrepancy among international recommendations, stemming from the lack of evidence from adequately powered randomized trials, challenges physicians in choosing the optimal strategy. Hybrid therapy including optimal medical therapy with revascularization strategies are commonly used for the management of ischemic heart failure. Coronary artery bypass graft (CABG) has proved its efficacy on improving long term outcome and prognosis while no large randomized clinical trials for percutaneous coronary intervention (PCI) are still available. Regardless of the lack of data and recommendations, the trends of performing PCI in ischemic heart failure prevailed over CABG whereas lesion complexity, chronic total occlusion and complete revascularization achievement are limiting factors. Lastly, regenerative medicine seems a promising approach for advanced heart failure enhancing cardiomyocytes proliferation, reverse remodeling, scar size reduction and cardiac function restoration.

Exosomal Cargo: Pro-angiogeneic, anti-inflammatory, and regenerative effects in ischemic and non-ischemic heart diseases - A comprehensive review

Heart diseases are the primary cause of mortality and morbidity worldwide which inflict a heavy social and economic burden. Among heart diseases, most deaths are due to myocardial infarction (MI) or heart attack, which occurs when a decrement in blood flow to the heart causes injury to cardiac tissue. Despite several available diagnostic, therapeutic, and prognostic approaches, heart disease remains a significant concern. Exosomes are a kind of small extracellular vesicles released by different types of cells that play a part in intercellular communication by transferring bioactive molecules important in regenerative medicine. Many studies have reported the diagnostic, therapeutic, and prognostic role of exosomes in various heart diseases. Herein, we reviewed the roles of exosomes as new emerging agents in various types of heart diseases, including ischemic heart disease, cardiomyopathy, arrhythmia, and valvular disease, focusing on pathogenesis, therapeutic, diagnostic, and prognostic roles in different areas. We have also mentioned different routes of exosome delivery to target tissues, the effects of preconditioning and modification on exosome's capability, exosome production in compliance with good manufacturing practice (GMP), and their ongoing clinical applications in various medical contexts to shed light on possible clinical translation.

Translation, Cross-Cultural Adaptation, and Psychometric Evaluation of the Third Version of the Atlanta Heart Failure Knowledge Test

Background and Purpose: This study is aimed at translating the third version of the Atlanta Heart Failure Knowledge Test (AHFKTv3) into the Persian language and evaluating its psychometric properties. Methods: In this methodological study, the AHFKTv3 was translated into Persian and its face, content, construct validity, and reliability were assessed. Results: The content validity of AHFKTv3 items was >0.78 and the validity of the instrument was 0.96. The standardized factor loading value of all items, except for item 16, was >0.3. The scores of the AHFKTv3 and European Heart Failure Self-Care Behavior Scale had a significant correlation with each other (p < .001). The AHFKTv3 score had a significant relationship with the educational level. The Kuder-Richardson Formula 20 coefficient was 0.908. Conclusion: The Persian AHFKTv3 is a valid and reliable instrument for assessing HF-related knowledge; therefore, it can be used in nursing practice to identify and address the deficits aiming for better patient care and in research to evaluate treatment and healthcare programs.

A Correlative Relationship Between Heart Failure and Cognitive Impairment: A Narrative Review

Heart failure (HF) is a chronic condition affecting millions of people worldwide. While the cardinal manifestations of HF are related to the cardiovascular system, it has become progressively evident that mild cognitive impairment (MCI) is also a significant complication of the disease. In fact, a significant number of patients with HF may experience MCI, which can manifest as deficits in attention, memory, executive function, and processing speed. The mechanisms responsible for cognitive dysfunction in HF are intricate and multifactorial. Possible factors contributing to this condition include decreased cerebral blood flow, thrombogenicity associated with HF, systemic inflammatory conditions, and proteotoxicity. MCI in HF has significant clinical implications, as it is linked to poorer quality of life, increased morbidity and mortality, and higher healthcare costs. Additionally, MCI can disrupt self-care behaviors, adherence to medication, and decision-making abilities, all of which are crucial for effectively managing HF. However, there is currently no gold standard diagnostic tool and follow-up strategy for MCI in HF patients. There is limited knowledge on the prevention and treatment of MCI. In conclusion, MCI is a common and clinically important complication of HF. Considering the substantial influence of MCI on patient outcomes, it is imperative for healthcare providers to be cognizant of this issue and integrate cognitive screening and management strategies into the care of HF patients.

Three year post heart transplant outcomes of desensitized durable mechanical circulatory support patients

BACKGROUND

The risks and benefits of desensitization therapy (DST) in highly sensitized mechanical circulatory support (MCS) patients are not well known. We investigated 3 year post-transplant outcomes of desensitized durable MCS patients.

METHODS

Among 689 consecutively enrolled heart transplantation recipients between 2010 and 2016, we categorized them into Group A (desensitized MCS patients, n = 21), Group B (desensitized non-MCS patients, n = 28) and Group C (all nondesensitized patients, n = 640). Post-transplant outcomes included the incidence of primary graft dysfunction, 3-year survival, freedom from cardiac allograft vasculopathy, nonfatal major adverse cardiac events, any treated rejection, acute cellular rejection, antibody mediated rejection (AMR) and infectious complications.

RESULTS

The types of DST in Groups A and B were similar and included combinations of rituximab/intravenous immunoglobulin and plasmapheresis/bortezomib. Group A, compared with Group B, showed significantly higher pre-DST panel reactive antibody (PRA) (92.2 ± 9.8 vs. 83.3 ± 15.6, P = 0.007) and higher PRA reduction after DST (-22.2 ± 26.9 vs. -6.3 ± 7.5, P = 0.015). Groups A and C showed comparable primary graft dysfunction, 3-year survival, freedom from cardiac allograft vasculopathy, nonfatal major adverse cardiac events, any treated rejection, acute cellular rejection, and AMR. Although statistically not significant, Group A showed numerically higher 3-year freedom from AMR than Group B. Infectious complications were similar in both Groups A and B.

CONCLUSIONS

DST for MCS patients showed significant PRA reduction, resulting in an expansion of the donor pool. The post-transplant outcome of desensitized MCS patients showed comparable clinical outcomes to non-desensitized control patients in the same study period, revealing the safety and efficacy of DST.

Optimization of guideline-directed medical treatment for heart failure patients with reduced ejection fraction

With the increasing number of medications demonstrating mortality benefits in heart failure with reduced ejection fraction (HFrEF), the pharmacological treatment of HFrEF is entering a new phase. To enhance outcomes in heart failure patients through medical treatment, the choice of appropriate medications and simultaneous and rapid uptitration are critical. However, there are several challenges encountered during this medication uptitration, including issues like hypotension, fatigue, worsening renal function, and hyperkalemia. This paper addresses strategies for effectively managing these challenges to successfully reach the maximum tolerated dose in patients. Additionally, it will discuss the management of comorbidities often associated with heart failure, the importance of exercise and rehabilitation, and the significance of proper nutrition intake, in addition to guideline-directed medical therapy.

Health-related quality of life and its associated factors among outpatients with heart failure: a cross-sectional study

BACKGROUND

Heart Failure (HF) is a chronic disease associated with life-limiting symptoms that could negatively impact patients' health-related quality of life (HRQOL). This study aimed to evaluate HRQOL and explore the factors associated with poor HRQOL among patients with HF in Jordan.

METHODS

This cross-sectional study used the validated Arabic version of the Minnesota Living with Heart Failure Questionnaire to assess HRQOL in outpatients with HF visiting cardiology clinics at two public hospitals in Jordan. Variables were collected from medical records and custom-designed questionnaires, including socio-demographics, biomedical variables, and disease and medication characteristics. Ordinal regression analysis was used to explore variables associated with poor HRQOL among HF patients.

RESULTS

Ordinal regression analysis showed that the number of HF medications (P < 0.05) and not taking a loop diuretic (P < 0.05) significantly increased HRQOL, while the number of other chronic diseases (P < 0.05), stage III/IV of HF (P < 0.01), low monthly income (P < 0.05), and being unsatisfied with the prescribed medications (P < 0.05) significantly decreased HRQOL of HF patients.

CONCLUSIONS

Although the current study demonstrated low HRQOL among patients with HF in Jordan, HRQOL has a considerable opportunity for improvement in those patients. Variables identified in the present study, including low monthly income, higher New York Heart Association (NYHA) classes, a higher number of comorbidities, and/or taking a loop diuretic, should be considered in future intervention programs, aiming to improve HRQOL in patients with HF.

Two-Year Changes in Diabetic Kidney Disease Phenotype and the Risk of Heart Failure: A Nationwide Population-Based Study in Korea

BACKGRUOUND

Diabetic kidney disease (DKD) is a risk factor for hospitalization for heart failure (HHF). DKD could be classified into four phenotypes by estimated glomerular filtration rate (eGFR, normal vs. low) and proteinuria (PU, negative vs. positive). Also, the phenotype often changes dynamically. This study examined HHF risk according to the DKD phenotype changes across 2-year assessments.

METHODS

The study included 1,343,116 patients with type 2 diabetes mellitus (T2DM) from the Korean National Health Insurance Service database after excluding a very high-risk phenotype (eGFR <30 mL/min/1.73 m2) at baseline, who underwent two cycles of medical checkups between 2009 and 2014. From the baseline and 2-year eGFR and PU results, participants were divided into 10 DKD phenotypic change categories.

RESULTS

During an average of 6.5 years of follow-up, 7,874 subjects developed HHF. The cumulative incidence of HHF from index date was highest in the eGFRlowPU- phenotype, followed by eGFRnorPU+ and eGFRnorPU-. Changes in DKD phenotype differently affect HHF risk. When the persistent eGFRnorPU- category was the reference, hazard ratios for HHF were 3.10 (95% confidence interval [CI], 2.73 to 3.52) in persistent eGFRnorPU+ and 1.86 (95% CI, 1.73 to 1.99) in persistent eGFRlowPU-. Among altered phenotypes, the category converted to eGFRlowPU+ showed the highest risk. In the normal eGFR category at the second examination, those who converted from PU- to PU+ showed a higher risk of HHF than those who converted from PU+ to PU-.

CONCLUSION

Changes in DKD phenotype, particularly with the presence of PU, are more likely to reflect the risk of HHF, compared with DKD phenotype based on a single time point in patients with T2DM.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Treatment

The Korean Society of Heart Failure (KSHF) guidelines aim to provide physicians with evidence-based recommendations for the management of patients with heart failure (HF). After the first introduction of the KSHF guidelines in 2016, newer therapies for HF with reduced ejection fraction, HF with mildly reduced ejection fraction, and HF with preserved ejection fraction have since emerged. The current version has been updated based on international guidelines and research data on Korean patients with HF. Herein, we present Part II of these guidelines, which comprises treatment strategies to improve the outcomes of patients with HF.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Treatment

The Korean Society of Heart Failure (KSHF) guidelines aim to provide physicians with evidence-based recommendations for the management of patients with heart failure (HF). After the first introduction of the KSHF guidelines in 2016, newer therapies for HF with reduced ejection fraction, HF with mildly reduced ejection fraction, and HF with preserved ejection fraction have since emerged. The current version has been updated based on international guidelines and research data on Korean patients with HF. Herein, we present Part II of these guidelines, which comprises treatment strategies to improve the outcomes of patients with HF.

m6A RNA methylation modification is involved in the disease course of heart failure

We explored N⁶-methyladenosine (m6A) RNA methylation as one of the gene regulatory mechanisms in heart failure (HF) biology. Understanding the different physiological mechanisms will facilitate the prevention and individualized treatment of HF. The Gene Expression Omnibus (GEO) database served as the source of the data. In GSE116250, differential analysis between ischemic cardiomyopathy (ICM), dilated cardiomyopathy (DCM) and controls yielded differentially expressed m6A regulators. Differential analysis between HF and controls in GSE131296 identifies m6A-modified genes and then performs enrichment analysis. Protein-protein interaction (PPI) network analysis was performed for the differentially expressed ICM- or DCM-associated genes in GSE116250 and GSE55296, respectively. Finally, the diagnostic genes for ICM and DCM were predicted using receiver operating characteristic (ROC) curve. YTHDC1, HNRNPC and HNRNPA2B1 were significantly downregulated in GSE116250 in DCM and ICM compared with controls. A total of 195 genes were identified in GSE131296 as subject to m6A alteration. These genes may play a role in HF through the MAPK signaling pathway and p53 signaling pathway. PPI network analysis identified CCL5, CXCR4 and CCL2 as key genes for ICM and IL-6 as a key gene for DCM. Through ROC curves, we identified m6A-modified APLP1, KLF2 as potential diagnostic genes for ICM, and m6A-modified FGF7, FREM1 and C14orf132 as potential diagnostic genes for DCM. Our findings support m6A modifying mechanisms in HF etiology that contribute to the treatment of HF. Thus, our data suggest that m6A methylation may be an interesting target for therapeutic intervention.

The effect of metabolic dysfunction-associated fatty liver disease and diabetic kidney disease on the risk of hospitalization of heart failure in type 2 diabetes: a retrospective cohort study

BACKGROUND

Diabetes mellitus is a major risk factor for heart failure. A recent consensus statement recommended annual cardiac biomarker testing (e.g. natriuretic peptide or high-sensitivity cardiac troponin) for all patients with diabetes. We aimed to identify patients at a higher risk of hospitalization for heart failure among patients with type 2 diabetes to prioritize those who would require screening.

METHODS

Overall, 1,189,113 patients who underwent two medical health checkup cycles (2009-2012 and 2011-2014) and had stable diabetic kidney disease (DKD) phenotype in the Korean National Health Insurance Service database were included in this study. After excluding those with concurrent proteinuria (PU) and reduced estimated glomerular filtration rate, three groups (no-DKD, PU⁺DKD, and PU^-DKD) were identified. A fatty liver index of ≥ 60 was defined as metabolic dysfunction-associated fatty liver disease (MAFLD). Patients were followed up until December 2018 or until outcomes developed. The Cox proportional hazard model was used to compare the risk of hospitalization for heart failure across groups.

RESULTS

During an average of 6.6 years of follow-up, 5781 patients developed hospitalization for heart failure. After adjusting for covariates, the risk of hospitalization for heart failure was highest in the PU⁺DKD group [HR 3.12, 95% CI (2.75-3.55)], followed by the PU^-DKD group [HR 1.85, 95% CI (1.73-1.99)] using the no-DKD group as the reference category. The risk of hospitalization for heart failure was comparable regardless of MAFLD status in patients who already had DKD. However, in the no-DKD group, the risk of hospitalization for heart failure was 1.4 times higher in patients with MAFLD than in those without [HR 1.41, 95% CI (1.31-1.52)].

CONCLUSIONS

In lines with the international consensus statement, we suggest that annual cardiac biomarker testing should be conducted at least in patients with DKD and/or MAFLD.

The role of discharge checklist in guideline-directed medical therapy for heart failure patients

BACKGROUND/AIMS

Initiation of guideline-directed medical therapy (GDMT) during hospitalization is recommended for patients with heart failure (HF). However, GDMT is underutilized in real-world practice. This study evaluated the role of a discharge checklist on GDMT.

METHODS

This was a single-center, observational study. The study included all patients hospitalized for HF between 2021 and 2022. The clinical data were retrieved from the electronic medical records and discharge checklist published by the Korean Society of Heart Failure. The adequacy of GDMT prescriptions was evaluated in three ways: the total number of GDMT drug classes and two types of adequacy scores. The primary endpoint was the incidence of all-cause mortality or rehospitalization due to HF within 2 months of discharge.

RESULTS

Overall, the checklist was completed by 244 patients (checklist group) and was not completed in 171 patients (non-checklist group). The baseline characteristics were comparable between two groups. At discharge, a higher proportion of patients in the checklist group received GDMT than in the non-checklist group (67.6% vs. 50.9%, p = 0.001). The incidence of primary endpoint was lower in the checklist group compared to the non-checklist group (5.3% vs. 11.7%, p = 0.018). The use of the discharge checklist was associated with significantly lower risk of death and rehospitalization in the multivariable analysis (hazard ratio, 0.45; 95% confidence interval, 0.23-0.92; p = 0.028).

CONCLUSION

Discharge checklist usage is a simple but effective strategy for GDMT initiation during hospitalization. The discharge checklist was associated with better outcome in patients with HF.

Characteristics and outcomes of heart transplant recipients with a pretransplant history of malignancy

We aimed to investigate the characteristics and outcomes of HTx recipients with a history of pretransplant malignancy (PTM). Among 1062 HTx recipients between 1997 and 2013, 73 (7.1%) patients had PTMs (77 cancer cases). We analyzed post-HTx outcome, recurrence of PTM, and development of de novo malignancies. Post-HTx outcome included overall survival, 10-year survival, 10-year freedom from cardiac allograft vasculopathy (CAV), non-fatal major adverse cardiac events (NF-MACE), any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). Four most common PTMs were lymphoproliferative disorders (18.2%), prostate cancers (18.2%), non-melanoma skin cancers (18.2%), and breast cancers (13.0%). Median time from PTM and HTx was 9.0 years. During a median follow-up of 8.6 years after HTx, patients with PTM, compared to those without, showed significantly higher incidence of posttransplant malignancies (43.8% vs. 20.8%, p < .001) including 9.6% (n = 7) of PTM recurrences. However, patients with PTM, compared to those without, showed comparable overall survival, 10-year survival, 10-year freedom from CAV, NF-MACE, ATR, ACR, and AMR. Therefore, a history of PTM should not disqualify patients from HTx listing, while further research is necessary for early detection of posttransplant malignancies in these patients.

A dose-response relationship of renin-angiotensin system blockers and beta-blockers in patients with acute heart failure syndrome: a nationwide prospective cohort study

AIMS

It remains unclear if patients with acute heart failure syndrome (AHFS) need to reach the maximally tolerated doses of renin-angiotensin system blockers (RASBs) or beta-blockers (BBs) to obtain a survival benefit. This study evaluated the dose-response relationship between RASBs or BBs and survival in AHFS patients.

METHODS AND RESULTS

In total, 5331 patients in the Korean Acute Heart Failure registry were analysed based on the doses of RASBs and BBs at discharge. In AHFS patients, RASB use at discharge was associated with a significant reduction in all-cause mortality risk. This effect was dose-dependent for heart failure with reduced ejection fraction (HFrEF) but did not attain statistical significance for heart failure with preserved ejection fraction (HFpEF). BB use at discharge was associated with reduced all-cause mortality in HFrEF patients but not in HFpEF patients. In an additional analysis of 4613 patients with dosage information at the first post-discharge follow-up visit, a significantly higher mortality risk was associated with the maintenance or withdrawal of RASBs compared with up-titrating the dose in HFrEF patients.

CONCLUSION

Using RASBs or BBs at discharge was associated with improved survival. A dose-response relationship between RASBs and all-cause mortality was evident in AHFS patients with a reduced ejection fraction but not BBs. It is important to initiate and up-titrate RASBs to the maximally tolerated dose in AHFS patients during the transition period, especially for patients with a reduced ejection fraction.

End-of-Life Care for End-stage Heart Failure Patients

Although recent heart failure (HF) guidelines highlight integrative palliative care, including end-of-life (EOL), appropriate discussing EOL issues can be challenging due to possibility of unexpected deterioration throughout HF trajectory. Open communication and discussions with multidisciplinary team are important for setting patient and family expectations and establishing mutually agreed goals of care based firmly on the patient’s ‘human dignity’ and ‘right to self-determination.’ Especially when quality-of-life outweighs expanding quantity-of-life, transition to EOL care should be considered. Advanced care planning including resuscitation, device deactivation, site for last days, and bereavement support should focus on ensuring a good death, and be reviewed regularly.

Efforts to improve end-of-life (EOL) care have generally been focused on cancer patients, but high-quality EOL care is also important for patients with other serious medical illnesses including heart failure (HF). Recent HF guidelines offer more clinical considerations for palliative care including EOL care than ever before. Because HF patients can experience rapid, unexpected clinical deterioration or sudden death throughout the disease trajectory, choosing an appropriate time to discuss issues such as advance directives or hospice can be challenging in real clinical situations. Therefore, EOL issues should be discussed early. Conversations are important for understanding patient and family expectations and developing mutually agreed goals of care. In particular, high-quality communication with patient and family through a multidisciplinary team is necessary to define patient-centered goals of care and establish treatment based on goals. Control of symptoms such as dyspnea, pain, anxiety/depression, fatigue, nausea, anorexia, and altered mental status throughout the dying process is an important issue that is often overlooked. When quality-of-life outweighs expanding quantity-of-life, the transition to EOL care should be considered. Advanced care planning including resuscitation (i.e., do-not resuscitate order), device deactivation, site for last days and bereavement support for the family should focus on ensuring a good death and be reviewed regularly. It is essential to ensure that treatment for all HF patients incorporates discussions about the overall goals of care and individual patient preferences at both the EOL and sudden changes in health status. In this review, we focus on EOL care for end-stage HF patients.

Characteristics, outcomes, and predictors of de novo malignancy after heart transplantation

Background

Post-transplant malignancy (PTM) causes long-term morbidity and mortality in heart transplant (HTx) recipients. However, the detailed characteristics or predictors of PTM are not well-known. We evaluated the incidence, characteristics, long-term outcomes, and predictors of de novo PTM using a single center large-volume database.

Methods

We retrospectively analyzed the types and characteristics of de novo PTM in 989 patients who underwent HTx. Univariate and multivariate logistic regression analyses were used for the PTM prediction model.

Results

Two hundred and six patients (20.8%) had de novo PTMs (241 cancers) during a median follow-up of 11.5 years. PTM patients were older than non-PTM patients, received immunosuppressive therapy for a longer period, and were more likely to be male and white. Skin cancers were the most frequent types of malignancy (60.6%) followed by prostate (9.5%), lung (7.1%), and breast (4.1%) cancers. Although most cancers (88.8%) were surgically resected at initial presentation, about half (47.3%) recurred or progressed. Patients with skin cancer and non-skin cancer had significantly lower overall survival (P < 0.001) than patients without cancer. Older age (P < 0.001), white race (P = 0.001), and longer time receiving immunosuppressive therapy (P < 0.001) were independent predictors for PTM.

Conclusion

Older age, white race, and longer administration of immunosuppressive therapies were independent risk factors for PTM, which was associated with increased mortality. Further research is necessary for the prevention and early detection of PTM in HTx recipients.

Na+/H+ Exchanger 1, a Potential Therapeutic Drug Target for Cardiac Hypertrophy and Heart Failure

Cardiac hypertrophy is defined as increased heart mass in response to increased hemodynamic requirements. Long-term cardiac hypertrophy, if not counteracted, will ultimately lead to heart failure. The incidence of heart failure is related to myocardial infarction, which could be salvaged by reperfusion and ultimately invites unfavorable myocardial ischemia-reperfusion injury. The Na⁺/H⁺ exchangers (NHEs) are membrane transporters that exchange one intracellular proton for one extracellular Na⁺. The first discovered NHE isoform, NHE1, is expressed almost ubiquitously in all tissues, especially in the myocardium. During myocardial ischemia-reperfusion, NHE1 catalyzes increased uptake of intracellular Na⁺, which in turn leads to Ca²⁺ overload and subsequently myocardial injury. Numerous preclinical research has shown that NHE1 is involved in cardiac hypertrophy and heart failure, but the exact molecular mechanisms remain elusive. The objective of this review is to demonstrate the potential role of NHE1 in cardiac hypertrophy and heart failure and investigate the underlying mechanisms.

Study Protocol for the Peruvian Registry of Advanced Heart Failure (REPICAV)

Background

Heart failure (HF) is a global problem with a high mortality rate, and advanced HF (AHF) represents the stage with the highest morbidity and mortality. We have no local data on this population and its treatment. The aim of this study will be to determine the epidemiological, clinical, therapeutic, and annual survival characteristics of patients diagnosed with AHF treated in hospitals with HF units in the city of Lima, Peru.

Methods and Analysis

An observational, prospective, multicenter study will be conducted with evaluation at baseline and follow-up at 1, 3, 6, and 12 months after study entry. Patients over 18 years of age with AHF seen in referral health facilities in metropolitan Lima will be included. The cumulative mortality during follow-up will be estimated by the Kaplan-Meier method, and Cox regression models will calculate hazard ratios (HRs) and 95% confidence intervals (CI). Likewise, risk ratio (RR) and 95% CI will be estimated using generalized linear models with binomial family and log link function. This study was approved by the Ethics and Research Committee of the National Cardiovascular Institute (Instituto Nacional Cardiovascular “Carlos Alberto Peschiera Carrillo”—INCOR [in Spanish]; Approval report 46/2021-CEI).

Discussion

In Peru, there are no scientific data on the epidemiology of AHF in the population. This means that physicians are not adequately trained in the characteristics of the Peruvian population to identify patients who could be candidates for advanced therapies and to recognize the optimal time to refer these patients to more complex HF units. This study will be the first to examine the clinical-epidemiological characteristics of AHF in Peru with a follow-up of 1 year after the event and will provide relevant information on these observable characteristics for the management of high-complexity patients.

Physician adherence and patient-reported outcomes in heart failure with reduced ejection fraction in the era of angiotensin receptor-neprilysin inhibitor therapy

This Korean nationwide, multicenter, noninterventional, prospective cohort study aimed to analyze physician adherence to guideline-recommended therapy for heart failure (HF) with reduced ejection fraction (HFrEF) and its effect on patient-reported outcomes (PROs). Patients diagnosed with or hospitalized for HFrEF within the previous year were enrolled. Treatment adherence was considered optimal when all 3 categories of guideline-recommended medications (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor-neprilysin inhibitors; beta-blockers; and mineralocorticoid receptor antagonists) were prescribed and suboptimal when ≤ 2 categories were prescribed. The 36-Item Short Form Survey (SF-36) scores were compared at baseline and 6 months between the 2 groups. Overall, 854 patients from 30 hospitals were included. At baseline, the optimal adherence group comprised 527 patients (61.7%), whereas during follow-up, the optimal and suboptimal adherence groups comprised 462 (54.1%) and 281 (32.9%) patients, respectively. Patients in the suboptimal adherence group were older, with a lower body mass index, and increased comorbidities, including renal dysfunction. SF-36 scores were significantly higher in the optimal adherence group for most domains (P < 0.05). This study showed satisfactory physician adherence to contemporary treatment for HFrEF. Optimal adherence to HF medication significantly correlated with better PROs.

The Era of Polypills in the Management of Cardiovascular Diseases: Are We There Yet?

Cardiovascular Diseases (CVD) are the leading cause of mortality globally. Wald and Law proposed the idea of a 'polypill'; a fixed dose combination therapy (FDC) in the form of a single pill to curb the CVD epidemic. Such a drug would include the combination of a broad spectrum of drugs including cholesterol lowering drugs, antihypertensive drugs, anti-platelet drugs, anti-coagulation drugs, anti-arrhythmic drugs, which are frequently integrated to combat specific CVDs. This 'polypill' holds the potential to pose several advantages like increased compliance, improved quality of life, risk factor control, psychological relief, and cost effectiveness along with minimal side effects. Several trials (like TIPS, UMPIRE, PolyIran etc.) have tested different treatment strategies to test the hypothesis of Wald and Law. Unlike the past physicians are now highly aware of this new strategy.The future of polypill in the management of CVD lies in a strategy where polypills are treated supplementary to the already existing preventive care, which includes lifestyle modifications and efforts to reduce tobacco use.

Multimodal Imaging and Biomarkers in Cardiac Amyloidosis

Amyloidosis is a progressive infiltrative disease instigated by the extracellular deposition of amyloid fibrils in various organs such as the heart, kidney, and peripheral nerves. Cardiac amyloid deposits cause restrictive cardiomyopathy, leading to a poor prognosis in systemic amyloidosis. The most common etiologies of cardiac amyloidosis (CA) are immunoglobulin light chain deposits (AL-CA) and misfolded transthyretin deposits (ATTR-CA). In recent years, many developments have been accomplished in the field of diagnosis and treatment of CA. At present, ATTR-CA can be noninvasively diagnosed if the following two conditions are fulfilled in the setting of typical echocardiographic/cardiac MRI findings: (1) grade 2 or 3 myocardial uptake in bone scintigraphy confirmed by SPECT and (2) absence of monoclonal protein confirmed by serum-free light chain assay, and serum/urine protein electrophoresis with immunofixation test. Effective therapies are evolving in both types of CA (tafamidis for ATTR-CA and immunologic treatments for AL-CA). Thus, early suspicion and prompt diagnosis are crucial for achieving better outcomes. In this review, we have summarized the role of multimodal imaging (e.g., echocardiography, cardiac MRI, and bone scintigraphy) and biomarkers (e.g., troponin, BNP) in the diagnosis, risk stratification, and treatment monitoring of CA.

Clinical outcome in patients with end-stage heart failure who underwent continuous-flow left ventricular assist devices in a single center

BACKGROUND/AIMS

The continuous flow left ventricular assist device (cf-LVAD) has improved the survival of chronic end-stage heart failure (HF) patients. Here we describe our clinical experience of the initial 50 LVAD patients from a single center.

METHODS

A total of 50 patients underwent LVAD implantation as bridge to transplantation (BTT; n = 28, 56%), bridge to candidacy (BTC; n = 2, 4%), or as destination therapy (DT; n = 20, 40%) from 2012 to 2019. Pre-implant characteristics and clinical outcomes were compared between BTT/BTC and DT.

RESULTS

The median age of patients was 67 years (range, 59 to 73). Men were more likely to receive LVAD (76% vs. 24%) than women. DT patients were older, had smaller body surface area, and worse laboratory profiles than BTT/BTC patients. There was no in-hospital mortality. During an average of 14 months (range, 8 to 23), the all-cause mortality was 22%. The first-year survival was 86 and 90% in BTT/BTC and DT groups, respectively. Hemorrhagic stroke was the most common cause (27%) of death. In the BTT/BTC group, 22 patients successfully underwent heart transplantation during median duration of 10 months (range, 7 to 14). The most common post-LVAD complication during the first year of LVAD implantation was major bleeding (44%). A significant proportion (76%) of patients experienced rehospitalization with gastrointestinal bleeding as the most common cause.

CONCLUSION

We describe short-term clinical outcome of LVAD patients from a single center for the first time in Korea. With the newer generation LVAD and a dedicated team approach, improved clinical outcomes of LVAD for end-stage HF are expected.

Psychometric Validation of the Korean Version of the Heart Failure-Specific Health Literacy Scale

BACKGROUND AND PURPOSE

The goals of heart failure (HF) management include lowering adverse outcomes through optimal self-care. Health literacy has a significant role in ensuring optimal and effective HF self-care. Unfortunately, the proportion of low health literacy in HF patients is higher than those with other chronic diseases as well as the general population. Thus, healthcare providers need to screen HF patients. The HF-Specific Health Literacy Scale is a specific questionnaire to screen the health literacy in HF patients; however, the Korean version has not yet been validated. The study aimed to investigate the reliability and validity of the Korean version of the HF-Specific Health Literacy Scale.

METHODS

We adopted a cross-sectional study design with 386 outpatients with chronic HF from a tertiary care hospital in Cheonan, South Korea. Data were collected from April to December 2020.

RESULTS

The exploratory factor analysis revealed a three-factor (functional, communicative, and critical health literacy) 12-item structure of the scale. The result of the confirmatory factor analysis confirmed a good statistical fit for the data. The Korean version of the tool demonstrated satisfactory convergent and discriminant validity. The criterion validity analysis revealed significant correlation with general health literacy and knowledge about HF. The Korean version of the tool for 12 items had adequate overall internal consistency.

IMPLICATIONS FOR PRACTICE

The Korean version of the HF-Specific tool can be easily utilized for assessing health literacy level for HF patient education. Moreover, the tool can help healthcare providers develop strategies for promoting HF patients' health literacy.

Treatment of heart failure with a preserved ejection fraction

Background: Heart failure with preserved ejection fraction (HFpEF) is increasingly prevalent, is associated with high morbidity, and has very few effective treatments.Current Concepts: HFpEF is a heterogeneous syndrome arising from the interplay of cardiac (diastolic, systolic dysfunction, pulmonary hypertension, right ventricular dysfunction, left atrial dysfunction, and chronotropic incompetence) and extracardiac (endothelial dysfunction, skeletal muscle abnormality, pulmonary disease, and renal dysfunction) abnormalities. Although various pharmacological therapies of HFpEF have been introduced and studied, most of them showed a limited clinical benefit. With some advancement in the specific phenotype of HFpEF, diuretics, mineralocorticoid antagonists, sacubitril/valsartan, and lifestyle modifications are recommended as important treatments. Recently, EMPEROR-Preserved trials showed that empagliflozin reduced the combined risk of cardiovascular death or hospitalization for patients with HFpEF, regardless of the presence or absence of diabetes. Several non-pharmacological therapies, including interatrial septal shunt and pacing therapies, have been introduced and are under investigation.Discussion and Conclusion: HFpEF has been recognized as the single greatest unmet need in cardiovascular medicine. Further research is required to understand the concrete pathophysiology for each phenotype of HFpEF. Prevention and management of comorbidities and risk factors for HFpEF are of great importance. Sodiumglucose cotransporter 2 inhibitors may contribute to a change in clinical practice, given the lack of therapeutic options available for patients with HFpEF.

Treatment of heart failure with reduced ejection fraction

Background: Heart failure with reduced ejection fraction (HFrEF) is a syndrome consisting of typical symptoms and/or signs of heart failure (HF) due to left ventricular systolic dysfunction (ejection fraction ≤40%) caused by various underlying cardiac diseases. We report conventional and recently established pharmacologic and nonpharmacologic treatments of HFrEF in this review article.Current Concepts: So far, various pharmacologic treatments have been proven beneficial in reducing HFassociated hospitalization or cardiac death. The mainstay of the treatments is renin-angiotensin-aldosterone system inhibitors, which are sympathetic nervous system blockers on top of the diuretics to relieve symptoms of systemic or pulmonary congestion. Recently, new treatment targets for natriuretic peptide and sodium-glucose cotransporter have emerged in HFrEF, allowing the use of these novel drugs in addition to the optimal conventional medications. Device therapies, such as implantable cardioverter-defibrillator and cardiac resynchronization therapy, can improve the outcome in a special population. Heart transplantation is the final treatment for patients with advanced HF. However, due to the limitation of the donor pool, mechanical circulatory support is necessary.Discussion and Conclusion: Current guidelines recommend using the four pillars of medications in HFrEF, including angiotensin-converting enzyme inhibitors (angiotensin-neprilysin inhibitors or angiotensin receptor blockers), beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter inhibitors. Appropriate device therapy, mechanical circulatory support, and heart transplantation can enhance survival in advanced HF patients. Balanced treatment, including conventional and newer therapies, is necessary.

Is there sufficient evidence to justify changes in dietary habits in heart failure patients? A systematic review

The incidence and prevalence of heart failure (HF) is increasing worldwide, leading to high morbidity and mortality. The global management of HF involves lifestyle changes in addition to pharmacological treatments. Changes include exercise and dietary recommendations, mainly salt and fluid restriction, but without any clear evidence. We conducted a systematic review to analyse the degree of evidence for these dietary recommendations in HF. Only randomized controlled trials (RCT), and observational studies in humans were selected. Studies were considered eligible if they included participants with HF and sodium and/or fluid restriction. Publications in languages other than English or Spanish were excluded. We included 15 studies related to sodium or fluid restriction. Nine RCT and six observational studies showed some improvements in symptoms and quality of life and a degree of reduction in new hospitalizations, but the results are based on limited population groups, applying different methodologies, and with different restriction goals. We found a lack of clear evidence of the benefits of sodium/fluid restriction in chronic HF. The evidence is limited to few studies with conflicting results. Randomized clinical trials are needed to fill this gap in our knowledge.

New Perspectives in the Treatment of Acute and Chronic Heart Failure with Reduced Ejection Fraction

Acute and chronic heart failure with reduced ejection fraction (HFrEF) is a major public health problem, studies showing a 25% survival rate at 5 years after hospitalization. If left untreated, it is a common and potentially fatal disease. In recent years, the medical and device therapies of patients with HFrEF have significantly improved. The aim of our review is to provide an evidence-based update on new therapeutic strategies in acute and chronic settings, to prevent hospitalization and death in patients with HFrEF. We performed a systematic literature search on PubMed, EMBASE, and the Cochrane Database of Systemic Reviews, and we included a number of 23 randomized controlled trials published in the last 30 years. The benefit of beta-blockers and renin-angiotensin-aldosterone system inhibitors in patients with HFrEF is well known. Recent developments, such as sodium-glucose cotransporter 2 inhibitors, vericiguat, transcatheter mitral valve repair, wireless pulmonary artery pressure monitor and cardiac contractility modulation, have also proven effective in improving prognosis. In addition, other new therapeutic agents showed encouraging results, but they are currently being studied. The implementation of personalized disease management programs that directly target the cause of HFrEF is crucial in order to improve prognosis and quality of life for these patients.

Deep Learning Predicts Heart Failure With Preserved, Mid-Range, and Reduced Left Ventricular Ejection Fraction From Patient Clinical Profiles

Background: Left ventricular ejection fraction (LVEF) is the gold standard for evaluating heart failure (HF) in coronary artery disease (CAD) patients. It is an essential metric in categorizing HF patients as preserved (HFpEF), mid-range (HFmEF), and reduced (HFrEF) ejection fraction but differs, depending on whether the ASE/EACVI or ESC guidelines are used to classify HF. Objectives: We sought to investigate the effectiveness of using deep learning as an automated tool to predict LVEF from patient clinical profiles using regression and classification trained models. We further investigate the effect of utilizing other LVEF-based thresholds to examine the discrimination ability of deep learning between HF categories grouped with narrower ranges. Methods: Data from 303 CAD patients were obtained from American and Greek patient databases and categorized based on the American Society of Echocardiography and the European Association of Cardiovascular Imaging (ASE/EACVI) guidelines into HFpEF (EF > 55%), HFmEF (50% ≤ EF ≤ 55%), and HFrEF (EF < 50%). Clinical profiles included 13 demographical and clinical markers grouped as cardiovascular risk factors, medication, and history. The most significant and important markers were determined using linear regression fitting and Chi-squared test combined with a novel dimensionality reduction algorithm based on arc radial visualization (ArcViz). Two deep learning-based models were then developed and trained using convolutional neural networks (CNN) to estimate LVEF levels from the clinical information and for classification into one of three LVEF-based HF categories. Results: A total of seven clinical markers were found important for discriminating between the three HF categories. Using statistical analysis, diabetes, diuretics medication, and prior myocardial infarction were found statistically significant (p < 0.001). Furthermore, age, body mass index (BMI), anti-arrhythmics medication, and previous ventricular tachycardia were found important after projections on the ArcViz convex hull with an average nearest centroid (NC) accuracy of 94%. The regression model estimated LVEF levels successfully with an overall accuracy of 90%, average root mean square error (RMSE) of 4.13, and correlation coefficient of 0.85. A significant improvement was then obtained with the classification model, which predicted HF categories with an accuracy ≥93%, sensitivity ≥89%, 1-specificity <5%, and average area under the receiver operating characteristics curve (AUROC) of 0.98. Conclusions: Our study suggests the potential of implementing deep learning-based models clinically to ensure faster, yet accurate, automatic prediction of HF based on the ASE/EACVI LVEF guidelines with only clinical profiles and corresponding information as input to the models. Invasive, expensive, and time-consuming clinical testing could thus be avoided, enabling reduced stress in patients and simpler triage for further intervention.

Post-transplantation outcomes of sensitized patients receiving durable mechanical circulatory support

BACKGROUND

Sensitization, defined as the presence of circulating antibodies, presents challenges, particularly in patients undergoing heart transplantation (HTx) bridged with durable mechanical circulatory support (MCS). We aimed to investigate the post-transplantation outcomes of sensitized MCS patients.

METHODS

Among 889 consecutively enrolled heart transplant (HTx) recipients between 2010 and 2018, 86 (9.7%) sensitized MCS patients (Group A) were compared with sensitized non-MCS patients (Group B, n = 189), non-sensitized MCS patients (Group C, n = 162), and non-sensitized non-MCS patients (Group D, n = 452) regarding post-HTx outcomes, including the incidence of primary graft dysfunction (PGD), 1-year survival, and 1-year freedom from antibody-mediated rejection (AMR).

RESULTS

Sensitized MCS patients (Group A) showed comparable rates of PGD, 1-year survival, and 1-year freedom from AMR with Groups C and D. However, Group A showed significantly higher rates of 1-year freedom from AMR (95.3% vs 85.7%, p = 0.02) and an earlier decline in panel-reactive antibody (PRA) levels (p < 0.01) than sensitized non-MCS patients (Group B). Desensitization therapy effectively reduced the levels of PRA in both Groups A and B. When Group A was further divided according to the presence of preformed donor-specific antibodies (DSA), patients with preformed DSA showed significantly lower rates of 1-year freedom from AMR than those without (84.2% vs 98.5%, p = 0.01).

CONCLUSIONS

Sensitized MCS patients showed significantly lower rates of AMR and an earlier decline in PRA levels following HTx than sensitized non-MCS patients. Removal of MCS at the time of transplantation might underlie these observations.

Mechanism and prevention strategy of a bidirectional relationship between heart failure and cancer (Review)

The relationship between cancer and heart failure has been extensively studied in the last decade. These studies have focused on describing heart injury caused by certain cancer treatments, including radiotherapy, chemotherapy and targeted therapy. Previous studies have demonstrated a higher incidence of cancer in patients with heart failure. Heart failure enhances an over-activation of the sympathetic nervous system and the renin-angiotensin-aldosterone system, and subsequently promotes cancer development. Other studies have found that heart failure and cancer both have a common pathological origin, flanked by chronic inflammation in certain organs. The present review aims to summarize and describe the recent discoveries, suggested mechanisms and relationships between heart failure and cancer. The current review provides more ideas on clinical prevention strategies according to the pathological mechanism involved.

Oral N-acetylcysteine as an adjunct to standard medical therapy improved heart function in cases with stable class II and III systolic heart failure

BACKGROUND

This research attempted to assess whether N-acetylcysteine (NAC) as adjunctive therapy can be useful in the treatment of patients with heart failure (HF).

METHODS

Fifty-five cases with diagnosed systolic HF and stable symptomatic New York Heart Association (NYHA) functional class II and III and on optimal medical treatment of HF for at least 3 months were assigned for receiving oral NAC (600 mg twice daily) or placebo for 12 weeks. The outcomes were changes in the echocardiographic hemodynamic indices as well as the patients' functional capacity assessed by NYHA classification over a 12-week treatment.

RESULTS

Compared to placebo, NAC more significantly improved the systolic left ventricular (LV) function expressed as the ejection fraction and Tei index. These changes are accompanied by more improvement in other LV echocardiographic indices including LV end-diastolic volume index and LV global longitudinal strain in the patients receiving NAC in comparison with those receiving placebo. In parallel with the improvement of LV function, right ventricular (RV) function expressed as RV fractional area change and RV Tei-index also got more improvement in those receiving NAC than those receiving placebo. However, the change in RV global longitudinal strain did not show a significant difference between study groups. Additionally, at week 12, the distribution of the NYHA functional class also shifted toward a better outcome in the NAC group in comparison with the placebo group; however, it was not significant.

CONCLUSIONS

These preliminary data support experimental findings showing that NAC supplementation is able to improve heart function.

TRIAL REGISTRATION

The registration of the trial was done at the Iranian Registry of Clinical Trials ( www.irct.ir ). Identifier code: IRCT20120215009014N333. Registration date: 2020-01-11.

Development and Validation of a Risk Score Model for Predicting the Cardiovascular Outcomes After Breast Cancer Therapy: The CHEMO-RADIAT Score

Background Cardiovascular disease is an important cause of mortality among survivors of breast cancer (BC). We developed a prediction model for major adverse cardiovascular events after BC therapy, which is based on conventional and BC treatment-related cardiovascular risk factors. Methods and Results The cohort of the study consisted of 1256 Asian female patients with BC from 4 medical centers in Korea and was randomized in a 1:1 ratio into the derivation and validation cohorts. The outcome measures comprised cardiovascular mortality, myocardial infarction, congestive heart failure, and transient ischemic attack/stroke. To correct overfitting, a penalized Cox proportional hazards regression was performed with a cross-validation approach. Number of cardiovascular diseases (myocardial infarction, peripheral artery disease, heart failure, and transient ischemic attack/stroke), number of baseline cardiovascular risk factors (hypertension, age ≥60, body mass index ≥30 kg/m², estimated glomerular filtration rate <60 mL/min per 1.73 m², dyslipidemia, and diabetes mellitus), radiation to the left breast, and anthracycline dose per 100 mg/m² were included in the risk prediction model. The time-dependent C-indices at 3 and 7 years after BC diagnosis were 0.876 and 0.842, respectively, in the validation cohort. Conclusions A prediction score model, including BC treatment-related risk factors and conventional risk factors, was developed and validated to predict major adverse cardiovascular events in patients with BC. The CHEMO-RADIAT (congestive heart failure, hypertension, elderly, myocardial infarction/peripheral artery occlusive disease, obesity, renal failure, abnormal lipid profile, diabetes mellitus, irradiation of the left breast, anthracycline dose, and transient ischemic attack/stroke) score may provide overall cardiovascular risk stratification in survivors of BC and can assist physicians in multidisciplinary decision-making regarding the BC treatment.

Development and Validation of a Risk Score Model for Predicting the Cardiovascular Outcomes After Breast Cancer Therapy: The CHEMO-RADIAT Score

Background Cardiovascular disease is an important cause of mortality among survivors of breast cancer (BC). We developed a prediction model for major adverse cardiovascular events after BC therapy, which is based on conventional and BC treatment-related cardiovascular risk factors. Methods and Results The cohort of the study consisted of 1256 Asian female patients with BC from 4 medical centers in Korea and was randomized in a 1:1 ratio into the derivation and validation cohorts. The outcome measures comprised cardiovascular mortality, myocardial infarction, congestive heart failure, and transient ischemic attack/stroke. To correct overfitting, a penalized Cox proportional hazards regression was performed with a cross-validation approach. Number of cardiovascular diseases (myocardial infarction, peripheral artery disease, heart failure, and transient ischemic attack/stroke), number of baseline cardiovascular risk factors (hypertension, age ≥60, body mass index ≥30 kg/m2, estimated glomerular filtration rate <60 mL/min per 1.73 m2, dyslipidemia, and diabetes mellitus), radiation to the left breast, and anthracycline dose per 100 mg/m2 were included in the risk prediction model. The time-dependent C-indices at 3 and 7 years after BC diagnosis were 0.876 and 0.842, respectively, in the validation cohort. Conclusions A prediction score model, including BC treatment-related risk factors and conventional risk factors, was developed and validated to predict major adverse cardiovascular events in patients with BC. The CHEMO-RADIAT (congestive heart failure, hypertension, elderly, myocardial infarction/peripheral artery occlusive disease, obesity, renal failure, abnormal lipid profile, diabetes mellitus, irradiation of the left breast, anthracycline dose, and transient ischemic attack/stroke) score may provide overall cardiovascular risk stratification in survivors of BC and can assist physicians in multidisciplinary decision-making regarding the BC treatment.

Current concept in the diagnosis, treatment and rehabilitation of patients with congestive heart failure

Heart failure (HF) is a major public health problem with a prevalence of 1%-2% in developed countries. The underlying pathophysiology of HF is complex and as a clinical syndrome is characterized by various symptoms and signs. HF is classified according to left ventricular ejection fraction (LVEF) and falls into three groups: LVEF ≥ 50% - HF with preserved ejection fraction (HFpEF), LVEF < 40% - HF with reduced ejection fraction (HFrEF), LVEF 40%-49% - HF with mid-range ejection fraction. Diagnosing HF is primarily a clinical approach and it is based on anamnesis, physical examination, echocardiogram, radiological findings of the heart and lungs and laboratory tests, including a specific markers of HF - brain natriuretic peptide or N-terminal pro-B-type natriuretic peptide as well as other diagnostic tests in order to elucidate possible etiologies. Updated diagnostic algorithms for HFpEF have been recommended (H2FPEF, HFA-PEFF). New therapeutic options improve clinical outcomes as well as functional status in patients with HFrEF (e.g., sodium-glucose cotransporter-2 - SGLT2 inhibitors) and such progress in treatment of HFrEF patients resulted in new working definition of the term “HF with recovered left ventricular ejection fraction”. In line with rapid development of HF treatment, cardiac rehabilitation becomes an increasingly important part of overall approach to patients with chronic HF for it has been proven that exercise training can relieve symptoms, improve exercise capacity and quality of life as well as reduce disability and hospitalization rates. We gave an overview of latest insights in HF diagnosis and treatment with special emphasize on the important role of cardiac rehabilitation in such patients.

ACE2 and Apelin-13: Biomarkers with a Prognostic Value in Congestive Heart Failure

The progression of heart failure is the result of the interaction of several pathogenetic processes that involve the activation of biomarkers belonging to the renin angiotensin aldosterone system (RAAS), to its counterregulatory mechanisms, to the sympathetic nervous system and inflammation, and to oxidative stress. This study is aimed at determining the prognostic role of biomarkers in the evolution of patients with heart failure. These biomarkers are representative of different pathogenetic pathways involved in the progression of heart failure and the possible interrelationships between them and heart remodelling. Method. This is a progressive observational study on 53 hospitalized patients with low ejection fraction heart failure, who were followed up for 12 months. The aetiology of heart failure was ischemic heart disease and dilated cardiomyopathy. The patients were clinically and biochemically evaluated by EKG (echocardiography) on admission and at 6 and 12 months. The biomarkers included in the present study were angiotensin-converting enzyme type 2 (ACE2), apelin-13, NT-proBNP (biomarkers involved in the counterregulation of RAAS), interleukin 17 (IL-17), hsCRP (inflammatory biomarkers), and urinary 8-iso-PGF2α (oxidative stress biomarker). The evolution was considered unfavourable if the patients presented complications during hospitalization, were readmitted for decompensated heart failure, or died. Results. From the study group, 14 patients (24.52%) presented an unfavourable clinical evolution. The biomarkers that were associated with the evolution of patients during hospitalization were ACE2, apelin-13, NT-proBNP, and hsCRP. Multivariate logistic regression analysis identified ACE2 and apelin-13 as independent, predictive biomarkers for the unfavourable evolution of patients over the study period. Values of ACE2 above 4000.75 pg/mL and of apelin-13 less than 402.5 pg/mL were associated with an unfavourable evolution (poor clinical outcomes). Conclusion. The serum values of ACE2 and apelin-13 correlate with the unfavourable evolution of patients with reduced ejection fraction heart failure.

Pathophysiology of Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is a major public health problem that affects half of all patients with HF. It is rising in prevalence, is associated with high morbidity and mortality, and has very few effective treatments. HFpEF is currently understood as a heterogeneous syndrome originating from the interplay of cardiac and extracardiac abnormalities. The most important pathophysiology in patients with HFpEF is diastolic dysfunction, which presents with impairments in relaxation or increases in chamber stiffness that lead to an increase in left ventricular filling pressures at rest or during exercise that causes dyspnea.

Palliative key aspects are of importance for symptom relief during the last week of life in patients with heart failure

AIMS

This study aimed to describe symptom prevalence of pain, shortness of breath, anxiety, and nausea and to identify factors associated with symptom relief in patients with heart failure during their last week of life.

METHODS AND RESULTS

This nationwide study used data from the Swedish Register of Palliative Care and the Swedish Causes of Death Certificate Register. The sample included 4215 patients with heart failure as the underlying cause of death. Descriptive statistics and logistic regression were used to analyse data. Pain was the most prevalent symptom (64.0%), followed by anxiety (45.1%), shortness of breath (28.8%), and nausea (11.4%). Pain was the most often totally relieved (77.5%), followed by anxiety (68.4%), nausea (54.7%), and shortness of breath (37.1%). Key aspects of palliative care such as documented palliative care in the patient record, individual medication prescriptions by injection, symptom assessment with validated scales, documented end-of-life discussions with patients and/or family members, and external consultation were significantly associated with symptom relief. Relief of pain, shortness of breath, anxiety, and nausea were significantly better managed in nursing homes and hospice/inpatient palliative care compared with care in hospitals.

CONCLUSIONS

The results show that key aspects of palliative care during the last week of life are significantly associated with symptom relief. Increased access to palliative care could provide a way to improve care during the last week of life for patients with heart failure. Home-based settings provided more symptom relief than hospitals, which may indicate that the latter focuses on treatments and saving lives rather than promoting life before death.

Remote Monitoring in Chronic Heart Failure Patients: Is Non-Invasive Remote Monitoring the Way to Go?

Heart failure (HF) is a major health care issue, and the incidence of HF is only expected to grow further. Due to the frequent hospitalizations, HF places a major burden on the available hospital and healthcare resources. In the future, HF care should not only be organized solely at the clinical ward and outpatient clinics, but remote monitoring strategies are urgently needed to guide, monitor, and treat chronic HF patients remotely from their homes as well. The intuitiveness and relatively low costs of non-invasive remote monitoring tools make them an appealing and emerging concept for developing new medical apps and devices. The recent COVID-19 pandemic and the associated transition of patient care outside the hospital will boost the development of remote monitoring tools, and many strategies will be reinvented with modern tools. However, it is important to look carefully at the inconsistencies that have been reported in non-invasive remote monitoring effectiveness. With this review, we provide an up-to-date overview of the available evidence on non-invasive remote monitoring in chronic HF patients and provide future perspectives that may significantly benefit the broader group of HF patients.

Prognostic Value of Leg Muscle Strength in Acute Heart Failure Syndrome

INTRODUCTION

Leg muscle strength (LMS) may be useful as a frailty index in patients with heart failure. However, LMS, until recently, has been indirectly estimated, and its prognostic value in acute heart failure syndrome (AHFS) is unclear. Therefore, we evaluated the prognostic value of direct LMS assessment and its relationship with proinflammatory mediators in patients with AHFS.

METHODS

We directly measured LMS at predischarge using a dynamometer in 110 prospectively and consecutively enrolled patients with AHFS (75 male; 60 ± 14 yr; mean ejection fraction, 29.9% ± 14.6%). The primary end point was cardiovascular (CV) events, defined as CV mortality, cardiac transplantation, or rehospitalization due to heart failure aggravation. Patients were divided into impaired and preserved LMS groups according to Contal and O'Quigley's method.

RESULTS

CV events occurred in 28 patients (25.5%) (including 5 CV deaths and 6 cardiac transplantations) during follow-up (median, 246 d; range = 11-888 d). Impaired LMS was associated with significantly higher levels of serum monokine induced by gamma interferon and poor clinical outcomes (P < 0.001). Multivariable Cox proportional hazard analysis (controlling for age, sex, body mass index, heart failure type, hemoglobin level, N-terminal pro-b-type natriuretic peptide level, and beta-blocker use) revealed LMS as an independent predictor of CV events (P = 0.017).

CONCLUSION

Impaired LMS, which might be used as a marker of frailty, is associated with increased levels of a proinflammatory chemokine and independently predicts clinical outcomes in patients with AHFS. The direct measurement of LMS is simple and feasible and might have important implications for the risk stratification of patients with AHFS.

Heart Transplant Immunosuppression Strategies at Cedars-Sinai Medical Center

Heart transplant is the optimal treatment for selected patients with end-stage heart failure. Immunosuppression after heart transplantation has significantly reduced the incidence of rejection and improved patient outcomes with the routine use of calcineurin inhibitors. Antimetabolites and proliferation signal inhibitors add to the improvement in patient outcomes as well. The goal of induction therapy is to provide intense immunosuppression when the risk of allograft rejection is highest. Most maintenance immunosuppressive protocols employ a 3-drug regimen consisting of a calcineurin inhibitor, an antimetabolite agent and glucocorticoids. The management of rejection proceeds in a stepwise fashion based on the severity of rejection detected on biopsy and the patient's clinical presentation. This review will cover induction, maintenance, rejection therapy and some special considerations including sensitization, renal sparing protocol, and corticosteroid weaning. It will end in consideration of potential future directions in immunosuppressive strategies to promote patient and graft survival.