Integration of implantable device therapy in patients with heart failure. A clinical consensus statement from the Heart Failure Association (HFA) and European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC)

Implantable devices form an integral part of the management of patients with heart failure (HF) and provide adjunctive therapies in addition to cornerstone drug treatment. Although the number of these devices is growing, only few are supported by robust evidence. Current devices aim to improve haemodynamics, improve reverse remodelling, or provide electrical therapy. A number of these devices have guideline recommendations and some have been shown to improve outcomes such as cardiac resynchronization therapy, implantable cardioverter-defibrillators and long-term mechanical support. For others, more evidence is still needed before large-scale implementation can be strongly advised. Of note, devices and drugs can work synergistically in HF as improved disease control with devices can allow for further optimization of drug therapy. Therefore, some devices might already be considered early in the disease trajectory of HF patients, while others might only be reserved for advanced HF. As such, device therapy should be integrated into HF care programmes. Unfortunately, implementation of devices, including those with the greatest evidence, in clinical care pathways is still suboptimal. This clinical consensus document of the Heart Failure Association (HFA) and European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC) describes the physiological rationale behind device-provided therapy and also device-guided management, offers an overview of current implantable device options recommended by the guidelines and proposes a new integrated model of device therapy as a part of HF care.

Diagnostic benefits of 18F-FDG PET/CT in cases of prosthetic infective endocarditis

Infective endocarditis (IE) is a difficult-to-diagnose provocative disease that causes significant morbidity and mortality. The first-line imaging test for the diagnosis of IE is echocardiography. However, in cases of prosthetic IE or IE associated with intracardiac devices, its sensitivity is limited. A new diagnostic tool, 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET/CT), improves diagnosis in these difficult cases. The most recent European guidelines for IE (2015) include this imaging modality as a primary diagnostic criterion. We present a case of culture-negative prosthetic IE diagnosed with 18F-FDG PET/CT.

Revascularization methods in patients with carotid stenosis and concomitant coronary heart disease

A major feature of the atherosclerotic process is its systemic and progressive character. The plaque pathogenetic mechanisms, morphology, evolution, and predilection site (bifurcation zones) determine the frequent coincidence of carotid and coronary atherosclerosis in the same patient.The present overview chronologically traces the history, effectiveness, and benefit of surgical and continuously improving interventional carotid revascularization. It thereby analyzes the indications, results, and complications based on a number of randomized clinical trials, industry-sponsored registries, and large single-center series in the last 3 decades. Carotid endarterectomy (CEA) and percutaneous carotid angioplasty (CAS) have evolved from 'dubious' procedures to a modern strategy resulting in a significantly lower incidence of stroke and death compared to medical treatment only. Although almost every second patient with carotid stenosis and indications for CAS has coronary atherosclerosis, studies on therapeutic modeling in such a combination are few, showing controversial results. Having both CHD and CS doubles the risk of myocardial infarction, stroke, HF, and death. An isolated revascularization approach compromises the results of therapeutic strategies and worsens patient survival. The high risk associated with coronary heart disease in CAS and CEA is a fact and minimization requires both an individualized and uniform stepwise revascularization strategy.

Sequencing and titrating approach of therapy in heart failure with reduced ejection fraction following the 2021 European Society of Cardiology guidelines: an international cardiology survey

AIMS

In symptomatic patients with heart failure and reduced ejection fraction (HFrEF), recent international guidelines recommend initiating four major therapeutic classes rather than sequential initiation. It remains unclear how this change in guidelines is perceived by practicing cardiologists versus heart failure (HF) specialists.

METHODS AND RESULTS

An independent academic web-based survey was designed by a group of HF specialists and posted by email and through various social networks to a broad community of cardiologists worldwide 1 year after the publication of the latest European HF guidelines. Overall, 615 cardiologists (38 [32-47] years old, 63% male) completed the survey, of which 58% were working in a university hospital and 26% were HF specialists. The threshold to define HFrEF was ≤40% for 61% of the physicians. Preferred drug prescription for the sequential approach was angiotensin-converting enzyme inhibitors or angiotensin receptor-neprilysin inhibitors first (74%), beta-blockers second (55%), mineralocorticoid receptor antagonists third (52%), and sodium-glucose cotransporter 2 inhibitors (53%) fourth. Eighty-four percent of participants felt that starting all four classes was feasible within the initial hospitalization, and 58% felt that titration is less important than introducing a new class. Age, status in training, and specialization in HF field were the principal characteristics that significantly impacted the answers.

CONCLUSION

In a broad international cardiology community, the 'historical approach' to HFrEF therapies remains the preferred sequencing approach. However, accelerated introduction and uptitration are also major treatment goals. Strategy trials in treatment guidance are needed to further change practices.

Atrial fibrillation in patients with high-risk acute myocardial infarction – the PARADISE-MI trial

Background

Atrial fibrillation or flutter (AFF) is common in both patients with myocardial infarction (MI) and those with heart failure (HF). However, its impact on the risk of adverse outcomes in MI complicated by either reduced LVEF and/or transient pulmonary congestion is less known.

Purpose

To assess the relationship between AFF and outcomes and whether AFF modified the treatment response to sacubitril/valsartan in the PARADISE-MI (Prospective ARNI versus ACEi trial to determine superiority in reducing HF events after MI) trial.

Methods

5656 patients enrolled in the PARADISE-MI trial were divided into 3 groups: no known AFF, history of AFF without AFF at enrolment, and AFF occurring with the index MI event. We assessed outcomes and the treatment response to sacubitril/valsartan in all groups. The primary outcome of the PARADISE-MI trial was death from cardiovascular (CV) causes or incident HF. The outcome analyses were adjusted for the number of risk augmenting factors, age, pulmonary congestion, percutaneous coronary intervention, LVEF and hypertension.

Results

259 patients (4.6%) had only a history of AFF, 525 patients (9.3%) had AFF associated with index MI. Patients with a history of AFF and AFF with index MI were older, with a higher rate of pulmonary congestion and hypertension, lower eGFR values but lower rates of diabetes, compared with those without AFF (Table 1). In unadjusted analyses, history of AFF and AFF with index MI were associated with a significant increase in the risk of the primary outcome (hazard ratio (HR): 1.76; 95% confidence interval (CI): 1.32–2.35 and HR 1.69, 95% CI 1.37–2.10, respectively), remaining significant after adjustment only in those with AFF with index MI (HR=1.40, 95% CI 1.12–1.74) (Fig. 1). This was primarily driven by an increase in the crude and adjusted risk of incident HF, both in those with a history of AFF and AFF with index MI (adjusted HR=1.56, 95% CI 1.10–2.22 and HR=1.55, 95% CI 1.18–2.03, respectively). An increase in the crude risk of CV death was present in patients with a history of AFF and AFF with index MI (HR=1.57, 95% CI 1.04–2.39 and HR=1.66, 95% CI 1.23–2.24, respectively), yet did not remain significant after adjustment. The risk of the composite outcome of death from coronary heart disease, non-fatal MI, hospitalisation for angina or coronary was not associated with either a history of AFF or AFF with index MI, in unadjusted or adjusted analyses (adjusted HR=0.83, 95% CI 0.57–1.19 and HR=1.00, 95% CI 0.78–1.29, respectively) (Fig. 1). Neither history of AFF nor AFF with index MI modified the treatment effect of sacubitril/valsartan (p>0.05).

Conclusions

In this post-MI cohort, history of AFF and AFF occurring with the index MI event were associated with an increased risk of CV death or incident heart failure, primarily driven by an increased risk of incident HF. However, the risk of the composite coronary outcome was not associated with AFF status, compared to other studied outcomes.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The PARADISE-MI trial was funded by Novartis

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Familial Hypercholesterolemia Identification Algorithm in Patients with Acute Cardiovascular Events in A Large Hospital Electronic Database in Bulgaria: A Call for Implementation

Background

Familial hypercholesterolemia (FH) is a genetic disorder characterized by a high level of low-density lipoprotein cholesterol (LDL-C) and is an important cause for premature cardiovascular disease. Because of underdiagnoses, an acute event is often the first clinical manifestation of FH. There are limited data on the prevalence and treatment of FH among adults admitted for treatment of acute cardiovascular events in Bulgaria. Our objective was to assess the proportion and management of FH patients from those admitted to hospital for treatment of acute symptomatic acute atherosclerotic cardiovascular events (ASCVD), the achievement of LDL-C targets of European Society of Cardiology/European Atherosclerosis Society guidelines and related public healthcare resources.

Objective

Digitalized healthcare records for patients admitted for treatment of symptomatic ASCVD acute events between August 2018 and August 2019 were used for the analysis. Five cardiology hospitals provided data for hospitalizations, laboratory tests, and ambulatory follow-ups up to February 2020. Patients’ hospital and ambulatory records were linked, and medical histories were extracted via a specifically developed algorithm, and analyzed. Outcomes included the proportion of patients classified as FH as defined by the Dutch Lipid Network Criteria (DLNC), use of lipid-lowering therapy, LDL-C achieved by 1, 3, 6, and 12 months post-index event, and public resources spent on hospital and ambulatory treatment.

Results

We reviewed 11,090 hospital records of patients admitted for treatment of acute events in the period August 2018–August 2019 with ICD codes for ASCVD (Supplementary Table S3). FH was identified in 731 (6.6%) patients, with DLNC score ≥ 3, (682 with coronary artery disease, 32 with cerebrovascular disease, and 17 with peripheral artery disease). We did not find the criteria for FH in 5797 patients. The remaining 4562 records were inconclusive due to lack of data in the hospital dossier. Less than half of FH patients (274/731, 37%) were discharged on high-intensity statin therapy prescribed (34/731, 5%) with combination therapy. The vast majority (96.2% with LDL-C ≥ 1.8 mmol/l) had poorly controlled LDL-C during the first year after discharge. Patients with a probable/definite DLNC score ≥ 6 points and those with recurrent events contributed to the higher cost paid both by the healthcare system and the patients themselves.

Conclusion

These findings reinforce the need for more aggressive lipid-lowering therapy, and underline the efficiency of using an electronic medical records search tool to support physicians in improving early FH diagnosis, aiming to minimize residual and future ASCVD events among FH patients and their family members.

A non-invasively determined surrogate of cardiac power ('circulatory power') at peak exercise is a powerful prognostic factor in chronic heart failure

OBJECTIVES

This study was designed to assess the prognostic value of a new variable derived from a cardiopulmonary exercise test, the circulatory power, a surrogate of cardiac power, at peak exercise, in patients with chronic heart failure.

BACKGROUND

Peak exercise cardiac power and stroke work are invasive parameters with recently proven prognostic value. It is unclear whether these variables have better prognostic value than peak oxygen uptake (VO(2)).

METHODS

The study population comprised 175 patients with chronic heart failure (ejection fraction <45%) who underwent a cardiopulmonary exercise test. Circulatory power and circulatory stroke work were defined as the product of systolic arterial pressure and VO(2) and oxygen pulse, respectively. Prognostic value was assessed by survival curves (Kaplan-Meier method) and uni- and multivariate Cox analyses.

RESULTS

With a mean follow-up of 25+/-10 months, ejection fraction, heart rate, systolic arterial pressure, peak VO(2), VCO(2), the anaerobic threshold, minute ventilation, the ventilatory equivalents of oxygen and carbon dioxide, the half times of VO(2) and VCO(2) recoveries, and the circulatory stroke work and power predicted outcome. Multivariate analysis demonstrated that the peak circulatory power (chi-square=19.9, P<0.001) (but not peak circulatory stroke work) was the only variable predictive of prognosis.

CONCLUSION

The prognostic value of cardiopulmonary exercise tests in heart failure patients can be improved by assessing a new variable, the circulatory power - a surrogate of cardiac power - at peak exercise.

Evidence of cardiac myolysis in severe nonischemic heart failure and the potential role of increased wall strain

BACKGROUND

Myocyte death could play a role in heart failure (HF) irrespective of the presence of coronary artery disease. The study aimed to assess this hypothesis by use of the cardiac troponin I (cTnI) assay.

METHODS AND RESULTS

Seventy-one patients with nonischemic HF, New York Heart Association (NYHA) class II-IV, with a normal coronary angiogram and after exclusion of myocardiopathies were evaluated in the study. The control group included 9 healthy subjects and 15 patients hospitalized for severe noncardiac dyspnea. Cardiac TnI concentrations were determined at admission with a research reagent (cTnIus) characterized by a detection limit of 0.026 ng/mL and a high analytic sensitivity of 0.002 ng/mL. cTnIus levels were more than 0.026 ng/mL in 19 HF patients, ranging between 0.027 and 0.463 ng/mL, whereas no cTnIus level was detectable in the control group. With use of a reference assay, only 2 HF patients had abnormal cTnI values. Severe HF was observed in 17 of these 19 patients, assessed by NYHA class IV or by the presence of pulmonary edema. Patients with an increased cTnIus level had a more restrictive mitral Doppler pattern (P <.001) and a more distinctive left ventricular (LV) concentric remodeling (P <.0001), whereas LV ejection fraction was similar in both HF groups. The increased cTnIus level was also associated with a LV wall strain biologic marker (ie, an increased brain natriuretic peptide plasma level) (P <.001).

CONCLUSIONS

cTnI assay is a promising biochemical method for detecting cardiac myolysis in HF, independent of the presence of coronary artery disease. This subtle myolysis could be in part related to the severely increased LV wall strain.

Comprehensive assessment of ventilatory functions of patients with chronic heart failure

OBJECTIVE

A comprehensive assessment of the ventilatory functions of patients with chronic heart failure (CHF) both at rest and during a cardiopulmonary exercise test (CPET). We studied 42 males, divided into two groups--patients with CHF (n = 21) and age, weight, height and BMI matched healthy controls (n = 21). All subjects underwent a symptom-limited ramp CPET, arterial blood gas analysis, and complex functional examination of the pulmonary system. Subjective rating of dyspnea and exertion were measured by the Borg and ATS dyspnea scales. CHF patients showed a slight, but statistically significant decrease of the spirographic and diffusion parameters, as well as of the indices of respiratory muscle strength. There were no changes in blood gases and in tidal breathing parameters. The exercise capacity was markedly reduced (VO2peak ml.min-1 1352 +/- 335 CHF patients vs 2077 +/- 276 healthy controls; p < 0.001) and the anaerobic threshold occurred earlier (< 40% of predicted VO2peak) during CPET in CHF patients. The increase in VE/VCO2 in CHF patients (35.7 +/- 5.1 CHF; 28.9 +/- 2.5 HC, p < 0.001) indicates a compromised ventilatory efficiency which leads to a higher dyspneic cost of exercise (Borg peak 9.5 +/- 1.03 CHF; 6.0 +/- 1.28 HC; p < 0.001) as compared with healthy controls.

Effects of short-term exercise training in patients with heart failure

Heart failure is a debilitating disorder which limits exercise capacity and produces a poor quality of life. The present study was designed to determine the effects of an exercise training program on patients with CHF NYHA functional class II-III, attributed to left ventricular systolic dysfunction and dilated left ventricle. Twenty-two ambulatory male patients with stable CHF were randomised to a training (n = 15) and a control group (n = 7). A symptom limited ramp cardiopulmonary exercise test with gas exchange analysis was performed at baseline after 4 and 8 weeks. The training group underwent an exercise training program at 50% of peak oxygen uptake for eight weeks. The control group was not exercised. After 8 weeks, compared with baseline, there were statistically significant increase in peak oxygen uptake, peak workload, anaerobic threshold, oxygen pulse, RPP, ventilation and the duration of the test only in trained patients. The reduction in scores tested by the Minnesota Living with Heart Failure questionnaire (p < 0.001) and Borg dyspnea rating score (p < 0.001) reflect the reduction of symptoms and the improvement in health-related quality of life. Carefully selected patients with moderate to severe CHF can achieve significant improvements of exercise capacity and quality of life with exercise training and can safely participate in a conditioning program.

Analysis of the results from an early low-level predischarge and late symptom-limited exercise tests and coronary angiographic examination in patients with uncomplicated myocardial infarction

The aim of our study was to evaluate the prognostic value of an early predischarge and late symptom-limited exercise tests as opposed to the evidence from the coronary angiographic examination. Twenty patients with an uncomplicated myocardial infarction were studied with an early predischarge exercise test (14-21 days) and a following postdischarge late symptom-limited veloergometric test. All the patients underwent an exercise test designed according to the protocol of the International Health Organization. A coronary angiographic examination was carried out in all the studied patients. Thirteen of the patients were with two positive veloergometric tests and significant stenosis from the selective coronary angiography. Seven of the patients had two negative tests. Two of them did not have significant coronary stenosis from the angiografic assessment. Generally 40% of the patients undergoing late exercise test reached a higher workload. There was no significant difference between the results from an early predischarge and late symptom-limited veloergometric test. A higher physical work load reached during the late exercise test did not show an improved coronary blood flow. Positive early and late exercise tolerance tests proved significant coronary stenosis. A negative exercise test did not exclude significant coronary stenosis.

Cardiopulmonary stress test--general characteristics and clinical value

Dyspnea on exertion and exercise intolerance are common problems in many conditions and diseases. Cardiopulmonary exercise testing makes possible to assess the exercise response in patients with abnormalities which are either underestimated or not detectable at rest. The method permits simultaneous assessment of circulatory and ventilatory reserves and can determine aerobic capacity, anaerobic threshold, the ventilatory response and the appearance of hypoxemia. Peak exercise oxygen uptake is the variable most often used, because of its physiological and prognostic value. One can use this information to evaluate the nature and severity of disease, its progression over time and its response to therapy.