Secondary prevention in diabetic and nondiabetic coronary heart disease patients: Insights from the German subset of the hospital arm of the EUROASPIRE IV and V surveys

BACKGROUND

Patients with coronary heart disease (CHD) with and without diabetes mellitus have an increased risk of recurrent events requiring multifactorial secondary prevention of cardiovascular risk factors. We compared prevalences of cardiovascular risk factors and its determinants including lifestyle, pharmacotherapy and diabetes mellitus among patients with chronic CHD examined within the fourth and fifth EUROASPIRE surveys (EA-IV, 2012-13; and EA-V, 2016-17) in Germany.

METHODS

The EA initiative iteratively conducts European-wide multicenter surveys investigating the quality of secondary prevention in chronic CHD patients aged 18 to 79 years. The data collection in Germany was performed during a comprehensive baseline visit at study centers in Würzburg (EA-IV, EA-V), Halle (EA-V), and Tübingen (EA-V).

RESULTS

384 EA-V participants (median age 69.0 years, 81.3% male) and 536 EA-IV participants (median age 68.7 years, 82.3% male) were examined. Comparing EA-IV and EA-V, no relevant differences in risk factor prevalence and lifestyle changes were observed with the exception of lower LDL cholesterol levels in EA-V. Prevalence of unrecognized diabetes was significantly lower in EA-V as compared to EA-IV (11.8% vs. 19.6%) while the proportion of prediabetes was similarly high in the remaining population (62.1% vs. 61.0%).

CONCLUSION

Between 2012 and 2017, a modest decrease in LDL cholesterol levels was observed, while no differences in blood pressure control and body weight were apparent in chronic CHD patients in Germany. Although the prevalence of unrecognized diabetes decreased in the later study period, the proportion of normoglycemic patients was low. As pharmacotherapy appeared fairly well implemented, stronger efforts towards lifestyle interventions, mental health programs and cardiac rehabilitation might help to improve risk factor profiles in chronic CHD patients.

Mortality risk is increased in chronotropic incompetent device carriers with acute heart failure

Introduction

In heart failure (HF), chronotropic incompetence is a major factor limiting cardiac output and exercise capacity. In patients carrying cardiac implantable electronic devices (CIED), accelerometer-based rate adaption (R-mode) counterbalances chronotropic incompetence during physical activity but fails to modulate heart rate under circumstances of high metabolic demand.

Purpose

We hypothesized that an activated R-mode, a surrogate of chronotropic incompetence, indicates worse prognosis during and after episodes of acutely decompensated HF (AHF).

Methods

We analysed 632 patients enrolled between 01/2014 and 02/2018 in an ongoing registry that phenotypes and follows patients admitted for AHF. We compared CIED carriers with activated R-mode (CIED-R; n=37, 16% women) with CIED carriers not in R-mode (CIED-0; n=64, 23% women) and patients without CIEDs (no-CIED; n=511, 43% women). Information on survival status was collected up to 12 months after discharge from index hospitalisation (IH). Uni- and multivariable Cox proportional hazard regression was used to identify predictors of 12-month mortality risk.

Results

Mean age of the study sample was 74 (11) years, 39% were women, median LVEF on admission was 51 (quartiles 32, 59) % and de novo HF was detected in 20% of all patients. Median length of IH was 10 (7, 14) days. In-hospital mortality was similar across groups, but 12-month mortality risk was affected by chronotropic incompetence as indicated by R-mode activation: age- and sex-associated hazard ratio (HR) for CIED-R was 2.61 (95% CI 1.59–4.29, p<0.001) compared to group no-CIED, and 2.44 (95% CI 1.25–4.74, p=0.009) compared to group CIED-0. Amongst univariable predictors of mortality risk, strong associations were found for NT-proBNP levels (p<0.001), Charlson comorbidity index (p=0.001), and de novo HF (p=0.003). These effects persisted after multivariable adjustment for comorbidity burden. Within CIED-R, mortality risk was similar in patients with pacemakers vs. ICDs (HR 1.20, 95% CI 0.49–2.95) and in subgroups with LVEF <50% vs. ≥50% (HR 1.10, 95% CI 0.79–1.53). Mean heart rate on admission was lower in CIED-R vs. CIED-0 or no-CIED (70 bpm vs. 80 bpm or 82 bpm; both p<0.001). Heart rate on admission had no impact on frequency of in-hospital worsenings or death. However, we found a 36% increase in mortality risk per tertile of heart rate at discharge (HR 1.36, 95% CI 1.10–1.69, p=0.004) after exclusion of patients with an activated R-mode.

Conclusion

In AHF, R-mode stimulation was associated with an increased 12-month mortality risk, independent of LVEF, type of CIED, burden of comorbidities and type of presentation. Further, increased resting heart rate at discharge predicted 12-month mortality risk only in patients without an activated R-mode. Our findings suggest that chronotropic incompetence per se worsens outcome in AHF and may not be adequately treated through accelerometer-based R-mode stimulation.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Comprehensive Heart Failure Centre (CHFC) Würzburg is funded by the Federal Ministry of Education and Research, Integrated Research and Treatment Centre “Prevention of Heart Failure and its Complications”.

MR-proADM is a strong independent predictor of long-term all-cause mortality risk in patients with chronic heart failure: results from the E-INH study

Background

Mid-regional proadrenomedullin (MR-proADM) is a blood biomarker indicating critical illness. Its short-term prognostic relevance has been investigated in several conditions including heart failure (HF). Yet, the long-term prognostic utility is unknown.

Methods

We conducted a post-hoc analysis of the Extended Interdisciplinary Network for Heart Failure (E-INH) study, which investigated the long-term effects of a HF nurse-led remote patient care program (HeartNetCare-HFTM [HNC]). Patients from nine regional centers in Germany hospitalized with HF and a left ventricular ejection fraction (LVEF) <40% were randomized into HNC vs. Usual Care. MR-proADM and other standard biomarkers for disease progression and systemic inflammation were measured from venous blood collected at study inclusion, i.e. during index hospitalization. The prognostic utility was assessed using Kaplan-Meier plots and Cox proportional hazard models, and compared with other biomarkers by ROC curves.

Results

From 919 out of the 1022 recruited patients (90%), baseline levels of MR-proADM were available: median MR-proADM 0.89 (quartiles 0.63, 1.28) nmol/l; mean age 68±12 years; 28% women; 45% in class III or IV of the New York Heart Association (NYHA) classification.

Median LVEF was 31 (25, 37) %. Median levels of NT-proBNP, high sensitive C-reactive protein (hsCRP), tumor necrosis factor (TNF)-a, and interleukin-6 (IL-6) were 3045 (1087, 7759) pg/ml, 9.2 (3.3, 25.2) mg/l, 13.4 (10.4, 17.5) pg/ml, and 4.9 (2.0, 11.4) pg/ml, respectively. Higher levels of MR-proADM at baseline were associated with age, female sex, NYHA class, NT-proBNP, hsCRP, IL-6, and TNF-α, while there was an inverse association with LVEF.

In the course of 10 years of follow-up, 691 (68%) patients died. Unadjusted MR-proADM strongly predicted all-cause death when used as a continuous variable (HR 1.31 per nmol/l, 95% CI 1.26–1.37; p<0.001) or when grouped into quartiles (HR 1.85, 95% CI 1.71–2.0; p<0.001). Adjustments for age, sex and NYHA functional class did not materially alter the strong association. Plotting quartiles of MR-proADM in a Kaplan-Meier curve (see Figure 1) confirmed this findings. As shown in Figure 2, MR-proADM had the highest area under the curve (AUC) in ROC analysis when compared to other biomarkers.

Conclusion

MR-proADM appears to be a strong and independent predictor for long-term all-cause mortality risk in HF with reduced ejection fraction (HFrEF). Therefore, assessing MR-proADM may contribute to better categorization of risk and tailored care. Its clinical utility needs to be investigated in future studies.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): BMBF

Long-term safety and efficacy of anacetrapib in patients with atherosclerotic vascular disease

AIMS

REVEAL was the first randomized controlled trial to demonstrate that adding cholesteryl ester transfer protein inhibitor therapy to intensive statin therapy reduced the risk of major coronary events. We now report results from extended follow-up beyond the scheduled study treatment period.

METHODS AND RESULTS

A total of 30 449 adults with prior atherosclerotic vascular disease were randomly allocated to anacetrapib 100 mg daily or matching placebo, in addition to open-label atorvastatin therapy. After stopping the randomly allocated treatment, 26 129 survivors entered a post-trial follow-up period, blind to their original treatment allocation. The primary outcome was first post-randomization major coronary event (i.e. coronary death, myocardial infarction, or coronary revascularization) during the in-trial and post-trial treatment periods, with analysis by intention-to-treat. Allocation to anacetrapib conferred a 9% [95% confidence interval (CI) 3-15%; P = 0.004] proportional reduction in the incidence of major coronary events during the study treatment period (median 4.1 years). During extended follow-up (median 2.2 years), there was a further 20% (95% CI 10-29%; P < 0.001) reduction. Overall, there was a 12% (95% CI 7-17%, P < 0.001) proportional reduction in major coronary events during the overall follow-up period (median 6.3 years), corresponding to a 1.8% (95% CI 1.0-2.6%) absolute reduction. There were no significant effects on non-vascular mortality, site-specific cancer, or other serious adverse events. Morbidity follow-up was obtained for 25 784 (99%) participants.

CONCLUSION

The beneficial effects of anacetrapib on major coronary events increased with longer follow-up, and no adverse effects emerged on non-vascular mortality or morbidity. These findings illustrate the importance of sufficiently long treatment and follow-up duration in randomized trials of lipid-modifying agents to assess their full benefits and potential harms.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN) 48678192; ClinicalTrials.gov No. NCT01252953; EudraCT No. 2010-023467-18.

Distribution pattern of left ventricular ejection fraction in patients with decompensated heart failure depends on sex results of a latent class analysis

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): unrestricted grant from Boehringer Ingelheim

Background & Aims Since 2016, heart failure (HF) is classified using left ventricular ejection fraction (LVEF) thresholds of 40% and 50%. However, HF phenotypes may develop across the entire LVEF spectrum depending on individual patient characteristics including the risk and comorbidity profile. Using latent class analysis, we explored the sex-specific distribution of in-hospital LVEF in patients hospitalized for acute heart failure (AHF) at a tertiary care center in Germany.

Methods Consecutive patients (≥18 years) hospitalized for AHF were recruited and phenotyped prospectively on a 7/24 basis. Exclusion criteria were high output heart failure, cardiogenic shock, and being listed for high urgency cardiac transplantation. LVEF was determined by transthoracic echocardiography using Simpson´s biplane or monoplane method. First, we estimated the distribution of LVEF in both sexes using histogram and kernel density estimation methods (bandwidth was selected by biased cross-validation). Then, Gaussian Mixture Models were fitted with increasing number of components. To identify the optimal number of subgroups we calculated the Bayesian Information Criterion (BIC). The minimum of the BIC criterion suggests the optimal number of subgroups for the final model. This analysis was performed on subsets including only male and only female patients.

Results Out of 629 patients (39.8% female) admitted with AHF between 09/2014 and 12/2017, 93% patients received in-hospital echocardiography, and in 79.2% LVEF could be quantitatively assessed. The BIC suggested two subgroups each for male (Fig. A) and female patients (Fig. B). In the male two-subgroup model, mean ± SD LVEF values were 30 ± 9% and 59 ± 8%, thus covering 48% and 52% of the men, respectively (Fig. C). In the female two-subgroup model, respective LVEF values were 36 ± 13% and 65 ± 8%, thus covering 47% and 53% of patients (Fig. D). The "male" model suggested 45% as cut-point, whilst the "female" model suggested 51% as cut-point differentiating between lower and higher LVEF.

Conclusions Using non-parametric and parametric statistical approaches, specific subgroups of patients hospitalized with AHF were identified among male and female patients hospitalized for AHF, which each time comprised subgroups with impaired vs. more preserved LVEF. Future analyses in larger AHF cohorts as well as in populations with chronic stable HF are warranted which take also into consideration sex differences in HF aetiology.

Figure

A) Minimum number of components (BIC) in men. B) Minimum BIC in women. C) LVEF distribution in men (2 components). D) LVEF distribution in women (2 components). The orange line indicates the respective cut-points between low and high LVEF.

Abstract Figure.

Global wasted myocardial is unrelated to conventional markers of systolic and diastolic function in patients with acute heart failure

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The AHF Register is supported by an unrestricted grant of Behringer Ingelheim, and grants of the German Ministry of Research and Education within the Comprehensive Heart Failure Center, Würzburg (BMBF 01E01004 and 01E01504)

onbehalf

AHF Registry

Background & Aim Myocardial Work (MyW) analysis quantifies myocardial performance using non-invasively derived pressure-strain loops. It is considered less load-dependent than left ventricular ejection fraction (LVEF) and longitudinal strain, since it integrates blood pressure into the assessment. We assessed associations between MyW indices, natriuretic peptide (NT-proBNP), and conventional markers of systolic and diastolic cardiac function mirroring the hemodynamic changes occurring during hospitalization, in patients hospitalized for acute heart failure (AHF).

Methods Consecutive patients (≥18 years) hospitalized for AHF with serial high-quality pairs of echocardiograms (i.e., early after hospitalization and prior to discharge) were eligible. Exclusion criteria were high output AHF, cardiogenic shock, and being listed for high urgency transplantation. The following MyW measures [definition in brackets] were analyzed from the stored recordings: Global constructive work (GCW) [sum of positive work performed during systolic shortening plus negative work during lengthening in isovolumetric relaxation (IVR)], global wasted work (GWW) [sum of negative work performed during systolic lengthening plus work performed during shortening in IVR], global work efficiency (GWE) [constructive work/(constructive work + wasted work)]; global work index (GWI) [total work performed from mitral valve closure to mitral valve opening]. Associations were determined using scatter plots and Pearson Product-Moment correlation coefficients.

Results N = 126 patients (73 ± 12 years, 37% female) were eligible. GWI and GCW proved significantly correlated with surrogates measured both on admission and at discharge, NT-proBNP, LVEF, and e’ (Table). By contrast, GWW did not correlate with any of these variables. GWE was also correlated with NT-proBNP (and e’ at discharge), but at both time points respective correlations were more pronounced.

Conclusion In patients hospitalized for AHF, GWI, GCW and GWE were associated with conventional parameters of myocardial stress and LV dysfunction. In contrast, GWW was unrelated with any of these established markers. Future studies in larger cohorts and with longer-term follow-up need to clarify to what extent might GWW carry complementary clinical and prognostic significance.

Abstract Figure.

Prevalence, severity and clinical correlates of left ventricular diastolic dysfunction in patients hospitalized with acute cardiac decompensation – a sub-study from the Acute Heart Failure

Background

To date, there are few prospective studies which characterize left ventricular diastolic dysfunction (LVDD) in patients with acute heart failure (AHF) using contemporary echo- and Doppler-techniques and take heart failure (HF) phenotype into account. Furthermore, prevalence and clinical correlates of different degrees of LVDD are unknown.

Purpose

To determine prevalence and echo characteristics of LVDD and identify clinical and biomarker correlates in patients hospitalized for AHF with either preserved (HFpEF, LVEF ≥50%) or reduced (HFrEF, LVEF &lt;50%) LV systolic function.

Methods

The AHF Registry Würzburg enrols consecutive patients hospitalized for AHF. For the current analysis, patients with complete high-quality echo- and Doppler studies performed during the index hospitalization allowing for full quantitative analysis were eligible. Left ventricular ejection fraction (LVEF) was determined using Simpson's biplane method. LVDD was graded according to 2016 ESC recommendations based on the E/A-ratio and markers of left ventricular (LV) filling pressure: E/E'-ratio, LA volume, and estimated systolic pulmonary artery pressure (sPAP, derived from peak tricuspid regurgitant flow velocity and estimated right atrial pressure). E/A-ratio &lt;0.8 or E/A-ratio 0.8–2.0 without evidence of increased LV filling pressure was classified as LVDD°I, an E/A-ratio between 0.8–2.0 with evidence of elevated filling pressure as LVDD°II, and an E/A-ratio &gt;2.0 as LVDD°III. LVDD prevalence rates were determined overall and in patients with HFrEF and HFpEF, respectively. Furthermore, other echocardiographic, clinical, and biomarker characteristics were studied.

Results

Overall, 155 patients were eligible (37.4% female, mean age 71.6±12.0 years, LVEF 45.7±17.8%, 49.7% HFpEF, 50.3% HFrEF). Most patients (83.9%) had Doppler evidence of increased filling pressures, with either LVDD°II (48.4%, LVEF 48.6±18.6%) or LVDD°III (35.5%, LVEF 40.3±15.4%). Overall, HFrEF-patients had higher rates of LVDD°III (47.4 vs 23.4%, p=0.002), while HFpEF-patients had higher rates of LVDD°II (58.4 vs 38.5%, p=0.013) (Figure). LVDD°I was present in only 16.1% of all patients (HFpEF: n=14, HFrEF: n=11, LVEF 48.9±15.4%). Compared to patients with LVDD°II-III, this subgroup had lower E/E'-ratio (11.7 vs 19.5 p&lt;0.001), sPAP (30.9±15.8 vs 44±12.5 mmHg, p&lt;0.001) and LA volume index (36.4±17.67 vs 53.5±21.0 ml/m2, p&lt;0.001). Furthermore, NT-proBNP-levels were lower (median [IQR] 2236 [1336; 5204] vs 4125 [2390; 4125] pg/ml, p=0.042) and heart failure (HF) history shorter (56.0 vs 33.1% HF known &lt;1 year, p=0.029).

Conclusion

Among patients hospitalized for AHF, the majority had significant LVDD, irrespective of LVEF. However, LVDD°II was more common in HFpEF, whereas HFrEF patients had more LVDD°III. Furthermore, the small subgroup with LVDD°I had less severe sPAP elevation, lower LA volume and NT-proBNP and a shorter HF history indicating a less advanced HF stage.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Bundesministerium für Bildung und Forschung

Determinants and prognostic implication of improved left ventricular ejection fraction in chronic heart failure patients with reduced ejection fraction

Background

Previous studies have demonstrated that left ventricular ejection fraction (LVEF) is not associated with overall survival in patients with chronic heart failure (CHF). This study aimed to examine if improved EF is associated with better survival in these patients.

Methods

Study subjects were selected from the database in the REDEAL trial, which included all patients with CHF and a LVEF of &lt;50% referred to our hospital between 2009 and 2017. Of these, 902 patients completed at least twice echocardiography examinations (BL and FUP) at a minimal interval of 12 [median 17 (14–25)] months.

Results

At baseline, there were 522 patients with BL_EF &gt;35% (aged 68±12 years, male 74.5%, median EF 44%) and 381 patients with BL_EF ≤35% (aged 65±13 years, male 74.5%, median EF 29%). Survival was similar between groups (76.6% vs. 73.8%, P=0.322). Over a median echocardiography follow-up of 17 months, FUP_ EF increased by 1.3% (−4.0–8.0%) in the subgroup of BL-EF&gt;35% and increased by 11.0% (2.0–20.0%) in the subgroup of BL_EF≤35%. Survival analysis showed that absolute change in EF was significantly associated with survival in the subgroup of BL_EF≤35% but not in the subgroup of BL_EF&gt;35%. Therefore, further analysis was conducted among patients in the subgroup of BL_EF≤35%.

In this subset of BL_EF≤35%, improved EF was defined as a FUP_EF of &gt;40%. 171 (44.9%) patients presented with improved EF, EF remained unchanged or reduced in the rest 210 patients (55.1%, FUP_EF≤40%). Patients with improved EF was associated with better survival over a median clinical follow-up of 19 (11–32) months (80.7% vs. 68.1%, P=0.001). Multivariable Cox regression analysis showed that improved EF remained an independent determinant of overall survival after adjusted for potential clinical covariates including age, sex, diabetes, hyperuricemia, renal dysfunction, coronary artery bypass grafting, sleep-disordered breathing, and prior ICD or CRT_D implantation (HR 0.59, 95% CI 0.38–0.91, P=0.018). In this subgroup of BL_EF≤35%, age and sex-independent determinants of improved EF included without prior myocardial infarction (OR 0.40, 95% CI 0.24–0.67, P&lt;0.001), without ICD or CRT-D implantation (OR 0.32, 95% CI 0.17–0.61, P=0.001), and smaller LV end-diastolic diameter (OR=0.94, 95% CI 0.90–0.99, P=0.012).

Conclusions

Longitudinal improvement in LVEF is significantly associated with survival benefit in the subgroup of baseline EF≤35% but not in the subgroup of baseline EF&gt;35%. In the subgroup of baseline EF≤35%, improved LVEF remains an independent determinant of survival benefit Determinants of improved LVEF in HF patients with baseline EF≤35% include without myocardial infarction, without ICD implantation, and smaller LV chamber at baseline.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This work was supported by the German Federal Ministry of Education and Research

Ischemic heart disease is more prevalent in low-income-countries and more often undertreated: data from report-hf

Background

The pathogenic role of ischemic heart disease (IHD) in heart failure is well known. However, little is known about the global differences in the prognostic significance and treatment patterns of IHD in acute heart failure (AHF).

Methods

We prospectively enrolled 18,553 patients with AHF from 44 countries and 365 centers in the REPORT-HF registry. Patients with a history of coronary artery disease, an ischemic etiology of the AHF event or coronary revascularization were classified as IHD. Differences in clinical characteristics, treatment and outcome were analyzed.

Results

Compared to 9,344 (50%) patients without IHD, the 9,189 (50%) patients with IHD were older, more often had a left ventricular ejection fraction [LVEF] &lt;40%, (HFrEF) and decompensated chronic HF (DCHF) and had a greater comorbidity burden. Despite patients from lower-income countries having a higher prevalence of IHD (55% vs. 45% in high-income countries), only 27% of patients with IHD from low-income countries were treated with medicines commonly prescribed for HF (Figure A) compared to 16% of patients with IHD from high income countries. After correction for clinical confounders and medication use, patients with IHD had a shorter “door-to-nitrates and -diuretics time” and worse 1-year mortality (hazard ratio: 1.18, 95% CI: 1.09, 1.27, Figure B) irrespective of geographic region (Pinteraction &gt;0.1). We found a significant interaction for prognosis (Pinteraction &lt;0.001) between IHD and HF diagnosis (DCHF vs. new-onset HF) as well as HF subtype (HFrEF vs. HF with preserved ejection fraction) respectively, such that IHD conveyed worse outcomes in patients with new-onset HF and HFrEF respectively in all world regions.

Conclusion

In this large global contemporary cohort of patients with AHF, IHD was more common in patients from low income countries, conveyed worse 1-year mortality, particularly in patients with new onset HF and patients with HFrEF. Despite worse outcomes, patients in regions with the greatest burden of IHD were more often undertreated.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Novartis

Impact of right and left ventricular dysfunction on long-term outcome of moderate to severe secondary mitral regurgitation patients without surgical/interventional treatment

Background

Secondary mitral regurgitation (SMR) is common in aging population and related with poor outcome. Impact of right ventricular (RV) dysfunction with or without left ventricular (LV) dysfunction in this population remains unclear. The purpose of this study was to investigate the prevalence of isolated RV dysfunction and biventricular dysfunction, and to determine their prognostic implication in moderate to severe SMR without surgical/interventional treatment.

Methods

A total of 1090 consecutive moderate to severe SMR patients without surgical/interventional treatment hospitalized in our hospital center between 2009 and 2018 (aged 75±12 years, 60.4% male) were included. Transthoracic echocardiography was performed at baseline to define the cardiac morphology, function and severity of MR. Clinical and echocardiographic characteristics were analyzed. All patients completed at least 1-year clinical follow-up by reviewing the medical records or telephone interview. The primary endpoint was defined as all-cause death.

Results

A total of 521 patients (47.8%) reached the primary endpoint during the follow-up period [median 23 (8–40) months].

Mean left ventricular ejection fraction (LVEF) was 44.6±16.2%, and percent of patients with LVEF &lt;50% (LV dysfunction) was 59.3%. RV dysfunction was defined as a reduced tricuspid annular plane excursion (TAPSE&lt;17mm) or an increased systolic pulmonary artery disease (sPAP&gt;40mmHg). Patients were divided into 4 subgroups: 1) preserved biventricular function: n=136 (12.5%); 2) isolated LV dysfunction: n=97 (8.9%); 3) isolated RV dysfunction: n=308 (28.3%); 4) biventricular dysfunction: n=549 (50.4%). The mortality in above group was 27.2%, 36.1%, 50.0%*† and 53.7%*†, respectively (*P&lt;0.05 vs preserved biventricular function; †P&lt;0.05 vs. isolated LV dysfunction).

Multivariable survival analysis showed that isolated LV dysfunction (adjusted HR 1.78, P=0.016), isolated RV dysfunction (HR 1.59, P=0.013), or biventricular dysfunction (HR=2.14, P&lt;0.001) were independently associated with increased all-cause mortality, after adjustment for age, sex and other clinical covariates associated with mortality including NYHA class, atrial fibrillation, hypertension, diabetes, hyperuricemia, coronary artery diseases, chronic respiratory diseases, sleep disturbance, and kidney dysfunction.

Conclusions

Right ventricular dysfunction is associated with significantly higher mortality in patients with secondary mitral regurgitation without surgical/interventional treatment as compared to patients with preserved biventricular function and isolated LV dysfunction. Future studies are warranted to observe if operative strategy could significantly improve the outcome in SMR patients complicating with right ventricular dysfunction.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): German Federal Ministry of Education and Research

Septal mitral annular systolic excursion but not global longitudinal strain predicts outcome in non-ischemic heart failure patients with reduced ejection fraction and mild diastolic dysfunction

Background

Speckle tracking derived global longitudinal strain (GLS) could provide incremental prognostic information over left ventricular ejection fraction (LVEF) in the general population and a variety of cardiovascular diseases. Mitral annular systolic excursion (MAPSE) is a classical echocardiographic index with prognostic implication in patients with various cardiovascular diseases. Present study aimed to test the hypothesis that reduced GLS is superior to MAPSE on predicting all-cause mortality in non-ischemic heart failure patients with reduced ejection fraction.

Methods

A total of 952 patients with non-ischemic heart failure and reduced LVEF, who referred to our department between 2009 and 2017, were included in this study (mean age: 66±15 years, 68.8% male). All patients underwent a routine transthoracic echocardiography examination at baseline visit. Standard echocardiographic measurements were conducted according to recent guidelines. GLS was derived from the segmental averaging (18-segment) of the three apical views. M-mode MAPSE of septal and lateral walls were obtained from standard apical 4-chamber view. All patients completed at least one-year clinical follow-up by telephone interview or clinical visit. The primary endpoint was defined as all-cause mortality or heart transplantation (HTx).

Results

Over a median follow-up period of 27 (14–40) months, 259 (27.2%) patients died and 9 (0.9%) underwent HTx. MAPSE_septal was significantly lower in non-survivors than in survivors (6 (5–8) vs. 7 (5–8) mm, P=0.009), while LVEF (36% vs. 36%, P=0.927) and GLS (−9.6% vs. −9.8%, P=0.473) were similar between non-survivors and survivors. All-cause mortality was significant higher in patients with MAPSE_septal&lt;5mm than those with MAPSE_septal ≥5mm (34.9% vs. 26.7%, P=0.032). All-cause death increased in proportion with increased severity of diastolic dysfunction (DD, 20.4%, 29.6% and 34.0% in patients with mild, moderate and severe DD, P=0.002).

Multivariable Cox regression analysis showed that reduced MAPSE_septal (&lt;5mm, HR=1.451, 95% CI=1.079–1.951, P=0.014) was independently associated with increased all-cause mortality adjusted for clinical confounders including age, sex, NYHA class, atrial fibrillation, diabetes, hyperuricemia, chronic respiratory diseases, sleep disturbance, while MAPSE_lateral, LVEF, and GLS were not outcome determinants in this patient cohort.

Subgroup analysis showed that mild DD (n=269), reduced MAPSE_septal were significantly associated with increased all-cause mortality (adjusted HR=3.734, 95% CI=1.850–7.536, P&lt;0.001), while MAPSE_septal was not a risk factor of all-cause mortality in the subgroup of moderate to severe DD (n=667, HR=1.314, P=0.108).

Conclusions

Septal MAPSE, but not LVEF or GLS, serves as an independent determinant of all-cause mortality in non-ischemic heart failure patients with reduced LVEF and mild diastolic dysfunction.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): German Federal Ministry of Education and Research

Prevalence and determinants of the precursor stages of heart failure: results from the population-based STAAB cohort study

Aims

Prevention of heart failure relies on the early identification and control of risk factors. We aimed to identify the frequency and characteristics of individuals at risk of heart failure in the general population.

Methods and Results

We report cross-sectional data from the prospective Characteristics and Course of Heart Failure Stages A–B and Determinants of Progression (STAAB) cohort study investigating a representative sample of residents of Würzburg, Germany. Sampling was stratified 1:1 for sex and 10:27:27:27:10 for age groups of 30–39/40–49/50–59/60–69/70–79 years. Heart failure precursor stages were defined according to American College of Cardiology/American Heart Association: stage A (risk factors for heart failure), stage B (asymptomatic cardiac dysfunction). The main results were internally validated in the second half of the participants. The derivation sample comprised 2473 participants (51% women) with a distribution of 10%/28%/25%/27%/10% in respective age groups. Stages A and B were prevalent in 42% and 17% of subjects, respectively. Of stage B subjects, 31% had no risk factor qualifying for stage A (group ‘B-not-A’). Compared to individuals in stage B with A criteria, B-not-A were younger, more often women, and had left ventricular dilation as the predominant B qualifying criterion (all P &lt; 0.001). These results were confirmed in the validation sample (n = 2492).

Conclusion

We identified a hitherto undescribed group of asymptomatic individuals with cardiac dysfunction predisposing to heart failure, who lacked established heart failure risk factors and therefore would have been missed by conventional primary prevention. Further studies need to replicate this finding in independent cohorts and characterise their genetic and -omic profile and the inception of clinically overt heart failure in subjects of group B-not-A.

[Complete information technology blackout in hospitals : Development of a concept for maintaining patient care]

The complete blackout of information technology (IT) in a hospital represents a major incident with acute loss of functionality. The immediate consequence is a rapidly progressive loss of treatment capacity. The major priority for the acute management of such an event is to keep patients safe and prevent life-threatening situations. A possibility to channel the uncontrolled loss of treatment capacity in order to achieve the aforementioned protective target is the immediate organization of an analog system for baseline emergency medical care. The switch over from a fully operational routinely functioning system to a reduced emergency state occurs daily in hospitals (night shift, weekends, public holidays) and reflects the controlled reduction of the treatment capacity. This process and the procedures associated with it are universally known, the functions are clearly defined and planned in advance by duty rotas and the interplay of clinics in the organizational schedule is regulated in detail. In order to accomplish this strategy analog instruments are necessary. These must all be conceived, established, practiced and evaluated in advance with the clinics and departments. Ultimately, all isolated IT blackout concepts must be amalgamated into a compatible and functioning total framework. This structure must be maintained for as long as a partially or totally functioning IT has been reinstated.

Factors associated with smoking cessation in patients with coronary heart disease: a cohort analysis of the German subset of EuroAspire IV survey

Background

Tobacco smoking is one of the most important risk factors of coronary heart disease (CHD). Hence, smoking cessation is considered pivotal in the prevention of CHD. The current study aimed to evaluate smoking cessation patterns and determine factors associated with smoking cessation in patients with established CHD.

Methods

The fourth European Survey of Cardiovascular Disease Prevention and Diabetes investigated quality of CHD care in 24 countries across Europe in 2012/13. In the German subset, smoking cessation patterns and clinical characteristics were repetitively assessed a) during index event due to CHD by medical record abstraction, b) as part of a face-to-face interview 6 to 36 months after the index event (i.e. baseline visit), and c) by telephone-based follow-up interview two years after the baseline visit. Logistic regression analysis was performed to search for factors determining smoking status at the time of the telephone interview.

Results

Out of 469 participants available for follow-up, 104 (22.2%) had been classified as current smokers at the index event. Of those, 65 patients (62.5%) had quit smoking at the time of the telephone interview, i.e., after a median observation period of 3.5 years (quartiles 3.0, 4.1). Depressed mood at baseline visit and higher education level were less prevalent amongst quitters vs non-quitters (17.2% vs 35.9%, p = 0.03 and 15.4% vs 33.3%, p = 0.03), cardiac rehabilitation programs were more frequently attended by quitters (83.1% vs 48.7%, p < 0.001), and there was a trend for a higher prevalence of diabetes at baseline visit in quitters (37.5% vs 20.5%, p = 0.07). In the final multivariable model, cardiac rehabilitation was associated with smoking cessation (OR 5.19; 95%CI 1.87 to 14.46; p = 0.002).

Discussion

Attending a cardiac rehabilitation program after a cardiovascular event was associated with smoking cessation supporting its use as a platform for smoking cessation counseling and relapse prevention.

411 Recompensation induces distinct changes in myocardial work in patients with acutely decompensated heart failure and reduced vs preserved left ventricular ejection fraction

Funding Acknowledgements

German Research Foundation (BMBF 01EO1004 and 01EO1504)

OnBehalf

Acute Heart Failure Registry

Background & Aim A new, less load-dependent echocardiographic tool to determine left ventricular (LV) myocardial work (MyW) based on longitudinal strain and blood pressure has recently been introduced and validated against invasive measurements. We investigated the impact of change in N-terminal pro-B-natriuretic peptide (NT-proBNP; i.e. surrogate of recompensation) during the hospital phase on changes in MyW (global work efficiency [GWE]; global constructive work [GCW]; and global wasted work [GWW]), in patients admitted for acutely decompensated heart failure (AHF).

Methods The AHF registry is a monocentric prospective follow-up study that comprehensively phenotypes consecutive patients hospitalized for AHF. Echocardiography was performed and NT-proBNP measured on the day of admission and within 72 hours prior to discharge. MyW assessment was performed off-line using EchoPAC (GE, version 202). In order to quantify changes in MyW and NT-proBNP, we used the respective discharge-to-admission ratio (DAR). Local polynomial regression was applied to model these associations in patients with LV ejection fraction (LVEF) &lt;40% vs ≥40%.

Results We analyzed 111 patients: mean age 73 ± 11 yrs; 32% female; 46 patients (41.4%) with LVEF &lt; 40%. The median [Q1, Q3] NT-proBNP level at admission was 5883 pg/ml (2589, 10188). Median length of stay in hospital was 12.0 days (9.0, 16.5). The DAR for NT-proBNP was 0.55 (0.34; 0.80) indicating that the majority of patients experienced a marked lowering of NT-proBNP. The figure demonstrates that the association between DAR of MyW parameters and DAR of NT-proBNP showed distinct profiles depending on admission LVEF. E.g., in panel A, the arrows indicate that a NT-proBNP reduction by 50% was associated with a 45% increment in GCW if admission LVEF was &lt;40%, but with an 8% increment only if LVEF was ≥40%.

Conclusions Our preliminary analysis indicates that a decrease in NT-proBNP may be associated with an improvement in GCW and GWE in patients with reduced LVEF, while these parameters were non-responsive in the other patient group. Although these results require confirmation in a larger cohort, they encourage further research in to MyW as a less load-dependent measure of LV function, shedding new light on echocardiographically manifest alterations of myocardial texture and the timing of healing processes after an acute cardiac event.

Figure

Discharge-to-admission ratio (DAR) of A) global work efficiency (GWE, &gt;1= improvement), B) global constructive work (GCW, &gt;1= improvement), and C) global wasted work (GWW, &lt;1 = improvement) as a function of discharge to admission NT-proBNP in acute heart failure patients with left ventricular ejection fraction ≥ and &lt;40%.

Abstract 411 Figure

161 Impact of right ventricular dysfunction on outcome in heart failure patients with mid-range ejection fraction with and without chronic respiratory diseases

Background

The impact of right ventricular (RV) dysfunction on outcome of heart failure patients with mid-range left ventricular ejection fraction (HFmrEF, 40-49%) is not well characterized yet. In this study, we observed the association between echocardiography defined RV dysfunction with outcomes and if the outcome was jointly affected by co-existed chronic respiratory diseases (CRD: asthma, chronic obstructive pulmonary disease, occupational lung diseases, sleep apnea syndrome) in HFmrEF patients

Methods

1090 HFmrEF patients referred to our department between 2009 and 2017 were included in this study. Baseline demographic and clinical data were obtained by reviewing the medical records. All patients subsequently completed a median clinical follow-up of 26 (15-38) months. The primary endpoint was all-cause mortality or heart transplantation (HTx). Right heart morphology and function were assessed with the use of multiple echocardiographic parameters, including right atrial area (RAA), RV mid diameter (RVD), tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (sPAP).

Results

Mean age was 69 ± 13 years and 73.4% were male. The proportion of NYHA functional class III or IV was 24.8%. CRD was identified in 209 (19.2%) patients. 280 patients (25.7%, without CRD: 204, with CRD: 76) died and 2 patients (without CRD) underwent HTx. All-cause mortality/HTx was significantly higher in HFmrEF patients with CRD than without CRD (36.4% vs. 23.4%, P &lt; 0.001).

Besides CRD, Cox regression analysis showed that age, body mass index, and cardiac risk factors and comorbidities including diabetes, atrial fibrillation, dyslipidemia, coronary artery disease, kidney dysfunction (eGFR &lt;60ml/min/1.73qm), anemia were associated with increased all-cause mortality/HTx (all P &lt; 0.05). Multivariable Cox regression models showed that sPAP (HR 1.015, P = 0.002) and TAPSE (HR 0.962, P = 0.004) were independent determinants of all-cause mortality/HTx in patients without CRD, while sPAP served as independent determinant of all-cause mortality/HTx In patients with CRD (HR 1.018, P = 0.026) after adjusted for above mentioned confounders.

Patients without CRDs were further grouped into those with normal (sPAP ≤ 40mmHg and TAPSE≥14mm, n = 513); mild to moderate (sPAP &gt; 40mmHg or TAPSE &lt; 14mm, n = 387) and severe RV dysfunction (sPAP &gt; 40mmHg and TAPSE &lt; 14mm, n = 88). Severe RV dysfunction was independently associated with a 2-fold increased all-cause mortality/HTx as compared to normal RV function (HR 2.209, 95% CI 1.455-3.355, P &lt; 0.001).

Conclusions

Increased sPAP and reduced TAPSE are independent determinants of all-cause mortality in HFmrEF patients without CRD, and sPAP is an independent determinant of all-cause mortality in HFmrEF patients with CRD. Moreover, HFmrEF patients with severe RV dysfunction face a 2-fold increased all-cause mortality, as compared to patients with normal RV function and no CRD.

P803 Myocardial work in acutely decompensated heart failure patients differs between HFrEF and HFpEF

OnBehalf

AHF Registry

Background & Aim A novel echocardiographic method to non-invasively determine left ventricular (LV) myocardial work (MyW) based on speckle-tracking derived longitudinal strain and blood pressure has recently been validated against invasive reference measurements. MyW is considered less load-dependent than LV ejection fraction (EF) and LV longitudinal strain. We investigated MyW indices in patients with reduced ejection fraction (LVEF &lt;40%; HFrEF) and patients with preserved ejection fraction (LVEF ≥50%, HFpEF) admitted for acutely decompensated heart failure (AHF).

Methods The AHF registry is a monocentric prospective follow-up study that comprehensively phenotypes consecutive patients hospitalized for AHF. Echocardiography was performed on the day of admission. MyW assessment was performed off-line using EchoPAC (GE, version 202). Here we present MyW indices and performed two-sided t-tests to analyze differences in numerical baseline covariates.

Results We analyzed the echocardiograms of 94 AHF patients (72 ± 10 years; 36% female). 46 patients (49%) had an LVEF &lt;40%, while 48 patients (51%) presented with LVEF ≥50%. HFrEF patients were younger, less often female, and hat lower blood pressure (table). Consistent with lower LVEF, HFrEF patients had less negative global longitudinal strain and lower global constructive work, when compared to HFpEF patients. Since HFrEF patients also had higher global wasted work, this yielded a lower myocardial work efficiency compared to HFpEF patients (table).

Conclusions This analysis in patients with AHF exhibited marked differences in MyW indices according to subgroups with HFrEF and HFpEF, thus adding information to the classical measures of LV function. Future research has to determine whether constructive and/or wasted MyW are valuable diagnostic or therapeutic targets in patients with AHF.

Abstract P803 Figure.

P1432 Heart failure subgroups according to left ventricular ejection fraction A latent class analysis

Funding Acknowledgements

German Research Foundation (BMBF 01EO1004 and 01EO1504)

OnBehalf

AHF

Background & Aims Heart failure (HF) is classified according to left ventricular (LV) ejection fraction (EF) into heart failure with reduced (HFrEF) and heart failure with preserved EF (HFpEF). In 2016, a third subgroup, heart failure with mid-range EF (HFmrEF), has been introduced by the ESC. We aimed to identify the number of naturally occurring heart failure subgroups according to LVEF using latent class analysis.

Methods The AHF registry is a monocentric prospective follow-up study that comprehensively phenotypes consecutive patients hospitalized for acute heart failure (AHF). Echocardiography was performed within 72 hours prior to discharge. We first estimated the distribution of LVEF using histogram and kernel density estimation methods (bandwidth was selected by biased cross-validation). We then fitted Gaussian Mixture Models with increasing number of components to the data. To select the optimal number of components we calculated the Akaike Information Criterion (AIC) and the Bayesian Information Criterion (BIC). The minimum of each criterion suggests the optimal number of components for the final model. The BIC requires more data to select more components than the AIC and hence is more conservative. Finally, for each criterion the optimal model was determined.

Results Out of 629 patients, 585 (93%) patients received echocardiography and in 498 (79.2%) the LVEF could be calculated using Simpson´s biplane or monoplane method.

The BIC suggested two (panel B), the AIC three components (panel A). In the two-component model, mean ± SD LVEF values were 60.2 ± 8.7% and 30.8 ± 9.6%, thus covering 56% and 44% of patients, respectively (panel D). In the three-component model, respective LVEF values were 64.9 ± 6.2%, 50.2 ± 6.9%, and 28.4 ± 8.1%, thus covering 35%, 27%, and 38% of patients (panel C).

Conclusions Our analysis suggests that LVEF in patients with AHF is not a continuum, but clusters in two or three subgroups. In line with the HFrEF and HFpEF classification, the more conservative model suggested two subgroups of LVEF. The less restrictive model allowed for a third subgroup, compatible with HFmrEF. Future analyses will better characterize the identified subgroups.

Abstract P1432 Figure

P904 Impact of significant functional mitral regurgitation and aortic stenosis on outcome of HFrEF patients

Background

Concomitant aortic stenosis (AS) and functional mitral regurgitation (FMR) are common in patients with left ventricular dysfunction. We evaluated the impact of significant valve diseases on outcome of patients with reduced left ventricular ejection fraction (HFrEF, LVEF &lt; 40%).

Methods

A total of 1264 consecutive HFrEF patients referred to our department between 2009 and 2017 were screened. Transthoracic echocardiography was performed at baseline visit in all patients. Patients with primary MR or received mitral valve operation before or after baseline visit (n = 64) as well as patients underwent aortic valve replacement (AVR) before baseline visit (n = 66) were excluded. Finally, 1134 HFrEF patients were included for final analysis, and all completed a median clinical follow-up of 26 (12-40) months by medical record review or telephone interview. The primary endpoint was all-cause mortality or heart transplantation (HTx).

Results

Moderate or severe FMR or AS was detected in 902 (79.5%) and in 119 (10.5%) patients by echocardiography, respectively. Of patients with significant AS, 47 patients underwent AVR shortly after baseline visit. In total, 353 (31.2%, including HTx n = 11) HFrEF patients died or underwent HTx during follow-up.

Age, body mass index, diabetes, atrial fibrillation, coronary artery disease, chronic respiratory diseases, and renal dysfunction (all P &lt; 0.05) were defined as clinical covariates associated with all-cause mortality/HTx and served as potential confounders in the multivariable Cox regression models. All-cause mortality/HTx was significantly higher in HFrEF patients with significant FMR than patients without significant FMR (33.8% vs. 20.7%, P &lt; 0.001).

Multivariable Cox regression analysis showed significant FMR remained as an independent determinant of all-cause mortality/HTx in patients with HFrEF after adjusted for above mentioned confounders (HR 1.39, 95% CI 1.02-1.90, P = 0.035).

Patients with significant AS without AVR faced increased risk of all-cause mortality/HTx as compared to patients without significant AS (HR 2.34, P &lt; 0.001), while risk of all-cause mortality/HTx was significantly lower in patients with significant AS and underwent AVR as compared to patients without significant AS after adjustment for confounders (HR 0.36, P = 0.008).

In the subgroup of HFrEF patients with significant FMR, significant AS without AVR was independently associated with increased all-cause mortality/HTx as compared to patients without significant AS (HR 2.30, P &lt; 0.001), while outcome is better in AS and FMR patients underwent AVR as compared to patients with significant FMR and without significant AS (survival: 85.4% vs. 67.5%, P &lt; 0.001; HR 0.34, P = 0.010) after adjustment for potential confounding factors.

Conclusion

Moderate to severe FMR and/or AS is incrementally related to higher all-cause mortality/HTx in HFrEF patients. AVR could significantly improve the survival of HFrEF patients with concomitant significant AS and FMR.

P1751 Right ventricular dysfunction in heart failure patients with reduced ejection fraction with and without chronic respiratory diseases: A treacherous combination for the ominous outcome?

Background

Right ventricular (RV) dysfunction is common in heart failure patients. In the present study, we determined the impact of echocardiography defined RV dysfunction on outcomes in heart failure patients with reduced ejection fraction (&lt;40%, HFrEF) with and without chronic respiratory diseases (CRDs: asthma, chronic obstructive pulmonary disease, occupational lung diseases, sleep apnea syndrome).

Methods

A total of 1264 HFrEF patients (Mean age: 68 ± 13 years; male: 76.3%) referred to our department between 2009 and 2017 were included. Baseline demographic and clinical data were obtained by reviewing the medical records. All patients subsequently completed a median clinical follow-up of 26 (12-40) months by medical record review or telephone interview. The primary endpoint was all-cause mortality or heart transplantation (HTx). Right heart morphology and function were assessed by multiple echocardiographic parameters, including right atrial area (RAA), RV mid diameter (RVD), tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (sPAP).

Results

The proportion of NYHA functional class III-IV was 42.2%. Mean LVEF was 29.4 ± 7.0%. CRDs was identified in 276 (21.8%) patients, 399 (30.5%, without CRDs n = 290, with CRDs n = 109) patients died (n = 386) or underwent HTx (n = 13). All-cause mortality/HTx was significantly higher in HFrEF patients with CRDs than without CRDs (39.5% vs. 29.4%, P = 0.001).

Cox regression analysis showed that age, BMI, and other cardiac risk factors and comorbidities including diabetes, atrial fibrillation, coronary artery disease, kidney dysfunction, and anemia were associated with all-cause mortality/HTx (all P &lt; 0.05) besides CRDs. Multivariable Cox regression models showed that sPAP (HR 1.016, P &lt; 0.001), TAPSE (HR 0.964, P = 0.003), RAA (HR 1.030, P &lt; 0.001), and RVD (HR 1.029, P &lt; 0.001) were independent determinants of all-cause mortality/HTx in HFrEF patients without CRDs, but not in HFrEF patients with CRDs after adjusted for above mentioned confounders.

With the cut-off values (sPAP &gt; 40mmHg, TAPSE &lt; 12mm, RAA &gt; 25cm², and RVD &gt; 36mm) derived from the 3rd quartiles, patients without CRDs were further grouped as normal RV function (all 4 parameters normal, n = 427); mild to moderate RV dysfunction (1 or 2 parameters abnormal, n = 467) and severe RV dysfunction (≥3 parameters abnormal, n = 94). Risk of all-cause mortality/HTx was significantly higher in HFrEF patients with severe (51.1%) and mild to moderate RV dysfunction (34.7%) as compared to patients with normal RV function (18.7%, severe vs. normal: HR 1.616 , 95% CI 1.232-2.119, P = 0.001; mild to moderate vs. normal HR: 2.657, 95% CI 1.845-3.824, P &lt; 0.001).

Conclusions

RV dysfunction is significantly associated with increased all-cause mortality in HFrEF patients without CRDs. Increased sPAP, RAA, RVD and decreased TAPSE are independent determinants of worse outcomes in HFrEF patients without CRDs, but not in HFrEF patients with CRDs.

P3551Right ventricular dysfunction in heart failure patients with reduced ejection fraction with and without chronic respiratory diseases: A treacherous combination for the ominous outcome?

Background

Right ventricular (RV) dysfunction is common in heart failure patients. In the present study, we determined the impact of echocardiography defined RV dysfunction on outcomes in heart failure patients with reduced ejection fraction (<40%, HFrEF) with and without chronic respiratory diseases (CRDs: asthma, chronic obstructive pulmonary disease, occupational lung diseases, sleep apnea syndrome).

Methods

A total of 1264 HFrEF patients (Mean age: 68±13 years; male: 76.3%) referred to our department between 2009 and 2017 were included. Baseline demographic and clinical data were obtained by reviewing the medical records. All patients subsequently completed a median clinical follow-up of 26 (12–40) months by medical record review or telephone interview. The primary endpoint was all-cause mortality or heart transplantation (HTx). Right heart morphology and function were assessed by multiple echocardiographic parameters, including right atrial area (RAA), RV mid diameter (RVD), tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (sPAP).

Results

The proportion of NYHA functional class III-IV was 42.2%. Mean LVEF was 29.4±7.0%. CRDs was identified in 276 (21.8%) patients, 399 (30.5%, without CRDs n=290, with CRDs n=109) patients died (n=386) or underwent HTx (n=13). All-cause mortality/HTx was significantly higher in HFrEF patients with CRDs than without CRDs (39.5% vs. 29.4%, P=0.001).

Cox regression analysis showed that age, BMI, and other cardiac risk factors and comorbidities including diabetes, atrial fibrillation, coronary artery disease, kidney dysfunction, and anemia were associated with all-cause mortality/HTx (all P<0.05) besides CRDs. Multivariable Cox regression models showed that sPAP (HR 1.016, P<0.001), TAPSE (HR 0.964, P=0.003), RAA (HR 1.030, P<0.001), and RVD (HR 1.029, P<0.001) were independent determinants of all-cause mortality/HTx in HFrEF patients without CRDs, but not in HFrEF patients with CRDs after adjusted for above mentioned confounders.

With the cut-off values (sPAP>40mmHg, TAPSE<12mm, RAA>25cm2, and RVD>36mm) derived from the 3rd quartiles, patients without CRDs were further grouped as normal RV function (all 4 parameters normal, n=427); mild to moderate RV dysfunction (1 or 2 parameters abnormal, n=467) and severe RV dysfunction (≥3 parameters abnormal, n=94). Risk of all-cause mortality/HTx was significantly higher in HFrEF patients with severe (51.1%) and mild to moderate RV dysfunction (34.7%) as compared to patients with normal RV function (18.7%, severe vs. normal: HR 1.616, 95% CI 1.232–2.119, P=0.001; mild to moderate vs. normal HR: 2.657, 95% CI 1.845–3.824, P<0.001).

Conclusions

RV dysfunction is significantly associated with increased all-cause mortality in HFrEF patients without CRDs. Increased sPAP, RAA, RVD and decreased TAPSE are independent determinants of worse outcomes in HFrEF patients without CRDs, but not in HFrEF patients with CRDs.

P3545Association between diastolic dysfunction and two-year survival in heart failure patients with mid-range or reduced left ventricular ejection fraction

Background

Extensive studies have demonstrated prognostic impact of echocardiographic defined diastolic dysfunction (DD) in patients with preserved as well as reduced left ventricular ejection fraction (LVEF). Nevertheless, it remains controversial whether evaluation of DD could provide additional prognostic information in heart failure (HF) patients with impaired systolic function. The purpose of present study, therefore, is to investigate the prognostic impact of echocardiography-defined DD on survival in HF patients hospitalized in our centre from 2009 to 2017 with mid-range LVEF (HFmrEF, LVEF 41–49%) and reduced LVEF (HFrEF, LVEF<40%).

Methods

A total of 2018 patients with echocardiography-evidenced LVEF<50% and hospitalized in our centre between July 2009 to December 2017 were included. Baseline demographic and clinical data were obtained by reviewing the medical records. All patients subsequently completed a median clinical follow-up of 24 (IQR 13–36) months by medical record review or telephone interview. The primary endpoint was all-cause mortality or heart transplantation (HTx). Patients were divided into mild, moderate and severe DD according to recent guidelines.

Results

The mean age was 69±13 years in the HFmrEF group and 68±13 years in the HFrEF group. All-cause mortality/HTx rate was significantly higher in the HFrEF (all-cause death n=318 and HTx n=11, 30.9%) group than in patients with HFmrEF (all-cause death n=235 and HTx n=2, 24.9%, P=0.003). All-cause mortality/HTx rate increased in proportion to DD severity in HFmrEF patients: 17.1% (54/315) in the mild DD group, 25.4% (115/452) in the moderate DD group, and 37.0% (68/184) in the severe DD group (P<0.001) and in HFrEF patients: 18.9% (43/228) in the mild DD group, 30.3% (146/482) in the moderate DD group, and 39.2% (140/357) in the severe DD group (P<0.001). Multivariable Cox regression analysis showed that Doppler parameter early-diastolic mitral inflow velocity to septal mitral annular velocity ratio (E/E') >14 (HR 1.41, 95% CI 1.06–1.89, P=0.020) and peak tricuspid regurgitation velocity (TRVmax) >2.8m/s (HR 1.75, 95% CI 1.33–2.29, P<0.001) were independent determinants of all-cause mortality/HTx in patients with HFmrEF; while E/E'>14 (HR 1.48, 95% CI 1.08–2.04, P=0.015) remained as an independent determinant of all-cause mortality/HTx in patients with HFrEF after adjustment for clinical and other echocardiographic confounders. Besides DD-related parameters, after adjustment with age and sex, lower tricuspid and mitral annular plane systolic excursions (TAPSE and MAPSE) were also closely related to higher mortality/HTx rate in both HFmrEF and HFrEF patients.

Figure 1. Kaplan-Meier curves

Conclusion

Our results indicate that all-cause mortality/HTx rate increases in proportion to DD severity in both HFmrEF and HFrEF patients.

P5452First data-analysis of the prospective ETiCS-study after study-end confirms acute (microbial-induced) inflammation as a key trigger for the development of cardiac GPCR-autoantibodies

Methods

In total 13 University Hospitals (12 German, 1 Serbian) prospectively recruited 226 patients (pts.) with a first acute myocardial infarction (FAMI), and 140 pts with acute (biopsy- or cMRI-proven) myocarditis (AMitis) into the Etiology, Titer-Course and effect on Survival of cardiac autoantibodies-study (ETiCS-study). This study aimed to investigate whether the presentation of cardiac membrane antigens (e.g., the beta1-adrenoceptor) following cardiac necrosis/inflammation triggers the formation of beta1-aabs. At baseline (BL) and three follow-ups (Fup1–3), blood was sampled to analyze the time-course of beta1-aabs. Beta1-aab titers were measured by FACS using Dyna-beads® M-270-Epoxy coated with increasing amounts of beta1-ECII-peptides (2.5–100 μg/ml), checked versus scrambled peptides (a mixture of same amino-acids). After reacting, the samples were measured by FACScan flow-cytometry; obtained data were analyzed with FlowJo (Treestar). When half-maximal binding was calculable the serum was classified beta1-aab-positive.

Results

From n=366 pts (226 FAMI/140 AMitis) recruited into the ETiCS-study 45 pts had to be excluded because of unperformed cMRI's; 46 pts stopped the study before Fup-1 (month 3). Only 180/226 FAMI- and 98/140 AMitis-pts had complete Fup1–3 (after 3, 6, and 12 months with clinical assessment, echocardiograms, and cMRI's at BL and Fup-3). In all valid ETiCS-pts (197 FAMI-/123 AMitis-pts) the titer-course of beta1-aabs was compared with the development of echo-LVEF. Relevant (high-affinity) beta1-aab-titers were detected in ∼31% (37/123) of the AMitis-pts compared to only ∼21% (42/197) of the FAMI-pts. In aab-positive AMitis-pts echo-LVEF did not recover and was always significantly inferior to aab-negative AMitis-pts (BL: 38 vs. 49% LVEF; Fup-3: 49 vs. 64% LVEF) whereas such a difference was not noted in FAMI-pts. In addition, aab-positive AMitis-pts had higher NT pro-BNP-, renin-, and aldosterone-levels than aab-negative AMitis-pts.

Conclusion

The first evaluation of the completed ETiCS-study clearly suggests that acute microbial-induced rather than post-infarction myocardial inflammation triggers the formation of clinically relevant beta1-aabs. AAb-positive AMitis-patients might profit from early intensification of standard HF-therapy (including early beta-blockade) and/or novel antibody-directed experimental therapies which are currently developed.

Acknowledgement/Funding

BMBF Grant FKZ 01ES0816

P4513Impact of right ventricular dysfunction on outcome in heart failure patients with mid-range ejection fraction with and without chronic respiratory diseases

Background

The impact of right ventricular (RV) dysfunction on outcome of heart failure patients with mid-range left ventricular ejection fraction (HFmrEF, 40–49%) is not well characterized yet. In this study, we observed the association between echocardiography defined RV dysfunction with outcomes and if the outcome was jointly affected by co-existed chronic respiratory diseases (CRD: asthma, chronic obstructive pulmonary disease, occupational lung diseases, sleep apnea syndrome) in HFmrEF patients

Methods

1090 HFmrEF patients referred to our department between 2009 and 2017 were included in this study. Baseline demographic and clinical data were obtained by reviewing the medical records. All patients subsequently completed a median clinical follow-up of 26 (15–38) months. The primary endpoint was all-cause mortality or heart transplantation (HTx). Right heart morphology and function were assessed with the use of multiple echocardiographic parameters, including right atrial area (RAA), RV mid diameter (RVD), tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (sPAP).

Results

Mean age was 69±13 years and 73.4% were male. The proportion of NYHA functional class III or IV was 24.8%. CRD was identified in 209 (19.2%) patients. 280 patients (25.7%, without CRD: 204, with CRD: 76) died and 2 patients (without CRD) underwent HTx. All-cause mortality/HTx was significantly higher in HFmrEF patients with CRD than without CRD (36.4% vs. 23.4%, P<0.001).

Besides CRD, Cox regression analysis showed that age, body mass index, and cardiac risk factors and comorbidities including diabetes, atrial fibrillation, dyslipidemia, coronary artery disease, kidney dysfunction (eGFR <60ml/min/1.73qm), anemia were associated with increased all-cause mortality/HTx (all P<0.05). Multivariable Cox regression models showed that sPAP (HR 1.015, P=0.002) and TAPSE (HR 0.962, P=0.004) were independent determinants of all-cause mortality/HTx in patients without CRD, while sPAP served as independent determinant of all-cause mortality/HTx In patients with CRD (HR 1.018, P=0.026) after adjusted for above mentioned confounders.

Patients without CRDs were further grouped into those with normal (sPAP≤40mmHg and TAPSE≥14mm, n=513); mild to moderate (sPAP>40mmHg or TAPSE<14mm, n=387) and severe RV dysfunction (sPAP>40mmHg and TAPSE<14mm, n=88). Severe RV dysfunction was independently associated with a 2-fold increased all-cause mortality/HTx as compared to normal RV function (HR 2.209, 95% CI 1.455–3.355, P<0.001).

Conclusions

Increased sPAP and reduced TAPSE are independent determinants of all-cause mortality in HFmrEF patients without CRD, and sPAP is an independent determinant of all-cause mortality in HFmrEF patients with CRD. Moreover, HFmrEF patients with severe RV dysfunction face a 2-fold increased all-cause mortality, as compared to patients with normal RV function and no CRD.

P5450Evening levels and circadian changes of salivary cortisol predict adverse events in heart failure patients with comorbid depression - a MOOD-HF substudy

Background

Depression is frequent in heart failure (HF) and associated with adverse clinical outcomes. The randomized MOOD-HF trial showed that in depressed patients with systolic heart failure (HF) the selective serotonin reuptake inhibitor escitalopram (E) improved neither survival nor depression compared to placebo (P). The hypothalamic-pituitary-adrenocortical axis is known to be altered in depression or HF. This MOOD-HF substudy aimed to clarify whether circadian salivary cortisol levels (SCL) were predictive of adverse events in depressed MOOD-HF participants and whether outcomes differed according to treatment with E.

Methods

MOOD-HF participants (all suffering from symptomatic systolic HF with left ventricular ejection fraction (LVEF) <45% and current major depression) were eligible for the present analysis if providing samples for SCL determination (luminescence immunoassay) at baseline visit (BL) and if not on oral glucocorticosteroid therapy. Depression severity was determined with the Montgomery–Åsberg Depression Rating Scale (MADRS) and LVEF measured by echocardiography.

Results

In the total study cohort (146 patients on E, 147 on P) median morning SCL at BL was 0.210 μg/dL (IQR 0.141–0.338 μg/dL) and median evening (pm) SCL 0.067 μg/dL (0.036–0.128 μg/dL, p<0.001). Median circadian change was 0.124 μg/dL (0.044–0.239 μg/dL). In patients with BL pm-SCL above the median MADRS-score was 21.7±9.1 and LVEF 33.7±8.4% respectively, in patients with pm-SCL below the median these values were 19.6±9.1 and 36.5±7.8% (p=0.048; p=0.004).

During 12 months follow-up the composite endpoint (all-cause death or rehospitalization) occurred least in E-treated patients with low pm-SCL and most often in E-treated patients with high pm-SCL (HR 2.02, 95% CI 1.12–3.65, p=0.010); patients on P had comparable event rates irrespective of BL pm-SCL (Figure A). Thus, numerically patients on E with low BL pm-SCL had lower event rates compared with corresponding P-treated patients (HR 0.76 (0.41–1.40, p=0.796)), while patients with high BL pm-SCL had higher event rates (HR 1.29 (0.74–2.24, p=0.799)) than corresponding P-treated patients. Patients with circadian SCL changes above the median receiving P experienced the composite primary endpoint least, while both subgroups with circadian SCL changes below the median and also patients with circadian SCL changes above the median on E had higher event rates (HR 0.66 (0.45–0.97, p=0.039), Figure B).

Conclusion

In depressed patients with systolic HF high pm-SCL are associated with more severe disease (depression and cardiac dysfunction). Extending primary MOOD-HF results indicating unfavourable outcomes related to E, the current findings suggest a SCL x treatment interaction with higher event rates in (sicker) patients with high pm-SCL and lower event rates in (less sick) patients with low pm-SCL when treated with the antidepressant. Low circadian changes of SCL were always associated with higher event rates.

Acknowledgement/Funding

BMBF (Grant 01 KG0702) and Lundbeck A/S Denmark

P2612Anaemia and renal impairment in heart failure: prevalence and differential prognostic importance according to the AHA ACC heart failure classification

Background

Anaemia (A) and renal impairment (RI) are frequent comorbidities in heart failure (HF) and known to impact adversely on outcome.

Purpose

In this post-hoc analysis, we allocated HF patients from 4 studies of the Competence Network Heart Failure at baseline to subgroups according to American Heart Association/ American College of Cardiology (AHA/ACC) HF criteria and compared prevalence rates of A and RI at each HF stage and the individual and cumulative long-term impact of these comorbidities on all-cause mortality (ACM) over a 5-year follow-up (FUP) period.

Methods

To study A and RI prevalence, we performed a cross-sectional analysis in 3344 patients (40.6% female, 65.6±11.2 years, 7.8, 32.3, 38.5, and 21.4% in stages A, B, C1 and C2/D, respectively). FUP data were available for 2496 patients (37.4% female, 66.0±11.3 years, 8.1, 35.3, 32.9, and 23.7% in stages A, B, C1 and C2/D, respectively). A was defined as haemoglobin <13/12 g/dL in men/women and RI as estimated glomerular filtration rate <60 mL/min/1.73m2. Within each HF subgroup, participants were divided in those without these comorbidities (A-/RI-), with either A or RI (A+/RI- and A-/RI+), or with both, A and RI (A+/RI+). For survival analysis log rank tests and multivariable Cox regression models were used.

Results

Overall prevalence of A in the stages A, B, C1, and C2/D was 3.1, 7.6, 16.5, and 29.8% (p<0.001) and of RI 17.6, 21.3, 24.4, and 46.6% (p<0.001), respectively. In the 4 subgroups, prevalence rates of A-/RI- were 80.2, 74.3, 66.3, and 42.1%, (p<0.001). A+/RI- and A-/RI+ were present in 2.3, 4.4, 9.3, and 11.3% (p<0.001) and 16.8, 18.1, 17.2, and 28.1 (p<0.001). A+/RI+ was found in 0.8, 3.1, 7.1, and 18.5% (p<0.001). Kaplan Meier curves demonstrate the individual and cumulative prognostic impact of A and RI (Figure).

Conclusions

Our results demonstrate a high prevalence in particular of RI even in asymptomatic HF stages and significant individual and cumulative long-term adverse effects of A and RI across the entire HF continuum. This includes also the clinically asymptomatic HF stages. Both prevalence and the individual and cumulative negative prognostic impact increase with increasing HF severity calling for careful consideration and management of these comorbidities in the frame of holistic HF care.

Variations in cardiovascular risk factors in people with and without migration background in Germany - Results from the STAAB cohort study

BACKGROUND

About 20% of the German population have a migration background which might influence prevalence of preventable cardiovascular risk factors (CVRF).

METHODS

We report data of the prospective Characteristics and Course of Heart Failure Stages A-B and Determinants of Progression (STAAB) cohort study investigating a representative sample of inhabitants of the City of Würzburg, Germany, aged 30 to 79 years. Individuals without migration background were defined as follows: German as native language, no other native language, and/or born in Germany. All other participants were defined as individuals with migration background.

RESULTS

Of 2473 subjects (51% female, mean age 54 ± 12 years), 291 (12%) reported a migration background: n = 107 (37%) from a country within the EU, n = 117 (40%) from Russia, and n = 67 (23%) from other countries. Prevalence of hypertension, atherosclerotic disease, and diabetes mellitus was similar in individuals with and without migration background. By contrast, prevalence of obesity and metabolic syndrome was significantly higher in individuals with migration background, with the least favourable profile apparent in individuals from Russia (individuals without vs. with migration background: obesity 19 vs. 24%, p < 0.05; odds ratio: EU: 1.6, Russia: 2.2*, other countries: 0.6; metabolic syndrome 18 vs. 21%, p < 0.05; odds ratio: EU: 1.2, Russia: 1.7*, other countries: 1.5; *p < 0.05).

CONCLUSION

Individuals with migration background in Germany might exhibit a higher CVRF burden due to a higher prevalence of obesity and metabolic syndrome. Strategies for primary prevention of heart failure may benefit from deliberately considering the migration background.

CRP genetic variants are associated with mortality and depressive symptoms in chronic heart failure patients

OBJECTIVE

Heart failure (HF) is a complex medical condition with a multitude of genetic and other factors being involved in the pathogenesis. Emerging evidence points to an involvement of inflammatory mechanisms at least in subgroups of patients. The same is true for depression and depressive symptoms, which have a high prevalence in HF patients and are risk factors for the development and outcomes of cardiovascular disease.

METHODS

In 936 patients of the Interdisciplinary Network Heart Failure (INH) program, CRP and IL-6 protein blood levels were measured and genetic variants (single nucleotide polymorphisms) of the CRP and IL6 gene analyzed regarding their influence on mortality.

RESULTS

Less common recessive genotypes of two single nucleotide polymorphisms in the CRP gene (rs1800947 and rs11265263) were associated with significantly higher mortality risk (p < 0.006), higher CRP levels (p = 0.029, p = 0.006) and increased depressive symptoms in the PHQ-9 (p = 0.005, p = 0.003). Variants in the IL-6 gene were not associated with mortality.

CONCLUSION

Our results hint towards an association of less common CRP genetic variants with increased mortality risk, depressive symptoms and peripheral CRP levels in this population of HF patients thereby suggesting a possible role of the inflammatory system as link between poor prognosis in HF and depressive symptoms.

Simple screening tools predict death and cardiovascular events in patients with rheumatic disease

OBJECTIVES

Patients with rheumatic disease (RD) have an increased mortality risk compared with the general population, mainly due to cardiovascular disease (CVD). We aimed to identify patients at high risk of CVD and mortality by comparing three screening tools suitable for clinical practice.

METHOD

In this prospective, single-centre study, consecutive patients with rheumatoid arthritis (RA), systemic autoimmune disease (SAI), or spondyloarthritides (SpA) including psoriatic arthritis underwent a comprehensive cardiovascular risk assessment. Patients were predefined as being at high risk for cardiovascular events or death if any of the following were present: European Systematic COronary Risk Evaluation (SCORE) ≥ 3%, N-terminal pro-brain natriuretic peptide (NT-proBNP) ≥ 200 pg/mL, or any pathological electrocardiogram pattern.

RESULTS

The patient population (n = 764) comprised 352 patients with RA, 260 with SAI, and 152 with SpA. After a median follow-up of 5.2 years, 6.0% of RD patients had died (7.0%, 7.2%, and 1.4% of patients in the RA, SAI, and SpA subgroups), and 5.0% had experienced a cardiovascular event (5.0%, 6.4%, and 2.8%, respectively). For all RD patients and the RA and SAI subgroups, NT-proBNP ≥ 200 pg/mL and SCORE ≥ 3% identified patients with a 3.5-5-fold increased risk of all-cause death and cardiovascular events. Electrocardiogram pathology was associated with increased mortality risk, but not with cardiovascular events.

CONCLUSION

NT-proBNP ≥ 200 pg/mL or SCORE ≥ 3% identifies RA and SAI patients with increased risk of cardiovascular events and death. Both tools are suitable as easy screening tools in daily practice to identify patients at risk for further diagnostics and closer long-term follow-up.