Assessing the impact of haemodynamic monitoring with CardioMEMS on heart failure patients: a cost-benefit analysis

AIMS

The objective of this study was to perform a cost-benefit analysis of the CardioMEMS HF System (Abbott Laboratories, Abbott Park, IL, USA) in a heart failure (HF) clinic in Spain by evaluating the real-time remote monitoring of pulmonary artery pressures, which has been shown to reduce HF-related hospitalizations and improve the quality of life for selected HF patients. Particularly, the study aimed to determine the value of CardioMEMS in Southern Europe, where healthcare costs are significantly lower and its effectiveness remains uncertain.

METHODS AND RESULTS

This single-centre study enrolled all consecutive HF patients (N = 43) who had been implanted with a pulmonary artery pressure sensor (CardioMEMS HF System); 48.8% were females, aged 75.5 ± 7.0 years, with both reduced and preserved left ventricular ejection fraction; 67.4% of them were in New York Heart Association Class III. The number of HF hospitalizations in the year before and the year after the sensor implantation was compared. Quality-adjusted life years gained based on a literature review of previous studies were calculated. The rate of HF hospitalizations was significantly lower at 1 year compared with the year before CardioMEMS implantation (0.25 vs. 1.10 events/patient-year, hazard ratio 0.22, P = 0.001). At the end of the first year, the usual management outperformed the CardioMEMS HF System. By the end of the second year, the CardioMEMS system is estimated to reduce costs compared with usual management (net benefits of €346).

CONCLUSIONS

Based on the results, we suggest that remote monitoring of pulmonary artery pressure with the CardioMEMS HF System represents a midterm and long-term efficient strategy in a healthcare setting in Southern Europe.

Soluble ST2, BCN-Bio-HF calculator and MAGGIC-HF score in long-term risk prediction after an urgent visit for heart failure

Soluble ST2 (sST2) is the expression of a pathogenic process related to adverse remodeling that ultimately leads to increased mortality in heart failure (HF). Risk score models provide a comprehensive approach for mortality prediction, beyond the use of biomarkers alone. The objective was to determine the additional value of sST2 and two well-validated contemporary risk scores, BCN-Bio-HF and MAGGIC-HF, in predicting mortality and readmission in the acute setting. This prospective study included 129 patients (mean age 75 ± 9 years; 52% males) after an urgent HF visit. Baseline sST2 levels were measured and the two risk scores were calculated. The primary endpoint was all-cause mortality, and the secondary endpoint was HF readmissions. The follow-up period was 3.6 ± 1.9 years. Patients who died (46%) had higher sST2 concentrations (80.5 vs. 42.7 ng/ml; p < 0.001). The BCN-Bio-HF calculator with sST2 demonstrated the best discriminative ability for mortality prediction (area under the ROC curve: 0.792; p < 0.001). In multivariate analysis for each risk score, the MAGGIC-HF score retained its predictive value only in the model without sST2 (3-year risk: HR = 1.036; 95% CI 1.019-1.054; p < 0.001). However, the BCN-Bio-HF score maintained its prognostic value with sST2 (HR = 1.032; 95%CI 1.020-1.044; p < 0.001), as well as without sST2 (HR = 1.035; 95% CI 1.021-1.049; p < 0.001). sST2 was not associated with readmission, and only the BCN-Bio-HF risk of HF hospitalization showed independent predictive value (OR = 1.040; 95% CI 1.005-1.076; p = 0.023). For predicting long-term mortality in HF in the emergency department, the BCN-Bio-HF calculator with sST2 demonstrated superior discrimination and allows estimation of the risk of HF hospitalizations.

Trajectories of Kidney Function in Heart Failure Over a 15-Year Follow-Up: Clinical Profiling and Mortality

BACKGROUND

Limited data are available on the long-term trajectory of estimated glomerular filtration rate (eGFR) in patients with chronic heart failure.

OBJECTIVES

The authors evaluated eGFR dynamics using the 2009 Chronic Kidney Disease Epidemiology Collaboration equation and its prognostic significance in a real-world cohort over a 15-year follow-up.

METHODS

A prospective observational registry of ambulatory heart failure outpatients was conducted, with regular eGFR assessments at baseline and on a 3-month schedule for ≤15 years. Urgent kidney function assessments were excluded. Locally weighted error sum of squares curves were plotted for predefined subgroups. Multivariable longitudinal Cox regression analyses were conducted to assess associations with all-cause and cardiovascular death.

RESULTS

A total of 2,672 patients were enrolled consecutively between August 2001 and December 2021. The average age was 66.8 ± 12.6 years, and 69.8% were men. Among 40,970 creatinine measurements, 28,634 were used for eGFR analysis, averaging 10.7 ± 8.5 per patient. Over the study period, a significant decline in eGFR was observed in the entire cohort, with a slope of -1.70 mL/min/1.73 m2 per year (95% CI: -1.75 to -1.66 mL/min/1.73 m2 per year). Older patients, those with diabetes, a preserved ejection fraction, a higher baseline eGFR, elevated hospitalization rates, and those who died during follow-up experienced more pronounced decreases in the eGFR. Moreover, the decrease in kidney function correlated independently with all-cause mortality and cardiovascular death.

CONCLUSIONS

These findings highlight the sustained decline in eGFR over 15 years in patients with heart failure, with variations based on clinical characteristics, and emphasize the importance of regular eGFR monitoring in this population.

Clinical and prognostic implications of left ventricular dilatation in heart failure

AIMS

To assess the agreement between left ventricular end-diastolic diameter index (LVEDDi) and volume index (LVEDVi) to define LV dilatation and to investigate the respective prognostic implications in patients with heart failure (HF).

METHODS AND RESULTS

Patients with HF symptoms and LV ejection fraction (LVEF) < 50% undergoing cardiac magnetic resonance (CMR) were evaluated retrospectively. LV dilatation was defined as LVEDDi or LVEDVi above the upper normal limit according to published reference values. Patients were followed-up for the combined endpoint of cardiovascular death or HF hospitalization during 5 years. A total of 564 patients (median age 64 years; 79% men) were included. LVEDDi had a modest correlation with LVEDVi (r = 0.682, p < 0.001). LV dilatation was noted in 84% of patients using LVEDVi-based definition and in 73% using LVEDDi-based definition, whereas 20% of patients displayed discordant definitions of LV dilatation. During a median follow-up of 2.8 years, patients with both dilated LVEDDi and LVEDVi had the highest cumulative event rate (HR 3.00, 95% CI 1.15-7.81, p = 0.024). Both LVEDDi and LVEDVi were independently associated with the primary outcome (hazard ratio 3.29, 95%, p < 0.001 and 2.8, p = 0.009; respectively).

CONCLUSIONS

The majority of patients with HF and LVEF < 50% present both increased LVEDDi and LVEDVi whereas 20% show discordant linear and volumetric definitions of LV dilatation. Patients with increased LVEDDi and LVEDVi have the worst clinical outcomes suggesting that the assessment of these two metrics is needed for better risk stratification.

Meteorin-like protein is associated with a higher risk profile and predicts a worse outcome in patients with STEMI

INTRODUCTION AND OBJECTIVES

Meteorin-like protein (Metrnl) is a cytokine involved in the attenuation of inflammation. In patients with heart failure, high levels of this biomarker are associated with a worse outcome. In this study, we evaluated the circulating levels and prognostic value of Metrnl in patients with ST-segment elevation myocardial infarction (STEMI).

METHODS

We enrolled STEMI patients undergoing primary percutaneous coronary intervention. Circulating Metrnl levels were measured in peripheral blood 12hours after symptom onset. The primary endpoint was a composite of all-cause mortality or nonfatal myocardial infarction (MI) at 3 years.

RESULTS

We studied 381 patients (mean age 61 years, 21% female, 8% Killip class III/IV). Metrnl levels were associated with age, cardiovascular risk factors and the extent of coronary artery disease, as well as with STEMI complications, particularly heart failure and cardiogenic shock. Multivariable Cox regression analysis revealed that Metrnl independently predicted all-cause death or nonfatal MI at 3 years (HR, 1.86; 95%CI, 1.23-2.81; P=.003). Moreover, patients in the highest tertile (> 491.6 pg/mL) were at higher risk for the composite endpoint than those in the lowest tertiles (HR, 3.24; 95%CI, 1.92-5.44; P <.001), even after adjustment by age, diabetes mellitus, cardiac arrest, Killip-Kimball III/IV class, left ventricular ejection fraction, and creatinine clearance (HR, 1.90; 95%CI, 1.10-3.29; P=.021).

CONCLUSIONS

Circulating Metrnl levels are associated with complications during the acute phase of STEMI and independently predict a worse outcome in these patients.

Biomarkers to Improve Decision-making in Acute Heart Failure

Acute heart failure (AHF) is a complex clinical syndrome that requires prompt diagnosis, risk stratification and effective treatment strategies to reduce morbidity and mortality. Biomarkers are playing an increasingly important role in this process, offering valuable insights into the underlying pathophysiology and facilitating personalised patient management. This review summarises the significance of various biomarkers in the context of AHF, with a focus on their clinical applications to stratify risk and potential for guiding therapy choices.

Heart failure risk scores in advanced heart failure patients: insights from the LEVO-D registry

AIMS

The prevalence of advanced heart failure (HF) is increasing due to the growing number of patients with HF and their better treatment and survival. There is a scarcity of data on the accuracy of HF web-based risk scores in this selected population. This study aimed to assess mortality prediction performance of the Meta-Analysis Global Group in Chronic HF (MAGGIC-HF) risk score and the model of the Barcelona Bio-HF Risk Calculator (BCN-Bio-HF) containing N terminal pro brain natriuretic peptide in HF patients receiving intermittent inotropic support with levosimendan as destination therapy.

METHODS AND RESULTS

Four hundred and three advanced HF patients from 23 tertiary hospitals in Spain receiving intermittent inotropic support with levosimendan as destination therapy were included. Discrimination for all-cause mortality was compared by area under the curve (AUC) and Harrell's C-statistic at 1 year. Calibration was assessed by calibration plots comparing observed versus expected events based on estimated risk by each calculator. The included patients were predominantly men, aged 71.5 [interquartile range 64-78] years, with reduced left ventricular ejection fraction (27.5 ± 9.4%); ischaemic heart disease was the most prevalent aetiology (52.5%). Death rate at 1 year was 26.8%, while the predicted 1-year mortality by BCN-Bio-HF and MAGGIC-HF was 17.0% and 22.1%, respectively. BCN-Bio-HF AUC was 0.66 (Harrell's C-statistic 0.64), and MAGGIC-HF AUC was 0.62 (Harrell's C-statistic 0.61).

CONCLUSIONS

The two evaluated risk scores showed suboptimal discrimination and calibration with an underestimation of risk in advanced HF patients receiving levosimendan as destination therapy. There is a need for specific scores for advanced HF.

Evolocumab has no effects on heart failure with reduced ejection fraction injury biomarkers: The EVO-HF trial

AIM

Patients with heart failure with reduced ejection fraction (HFrEF) have not been shown to benefit from statins. We hypothesized that, by limiting disease progression in stable HFrEF of ischaemic etiology, the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor evolocumab could reduce circulating troponin levels, a surrogate biomarker of myocyte injury and atherosclerosis progression.

METHODS AND RESULTS

The EVO-HF multicentre prospective randomized trial compared evolocumab (420 mg/month administered subcutaneously) plus guideline-directed medical therapy (GDMT; n = 17) versus GDMT alone (n = 22) for 1 year in patients with stable coronary artery disease and left ventricular ejection fraction (LVEF) <40%, ischaemic aetiology, New York Heart Association class II, N-terminal pro-B-type natriuretic peptide (NT-proBNP) ≥400 pg/ml, high-sensitivity troponin T (hs-TnT) >10 pg/ml, low-density lipoprotein cholesterol (LDL-C) ≥70 mg/dl. The primary endpoint was change in hs-TnT concentration. Secondary endpoints included NT-proBNP, interleukin-1 receptor-like 1 (ST2), high-sensitivity C-reactive protein (hs-CRP), LDL, low-density lipoprotein receptor (LDLR), high-density lipoprotein cholesterol (HDL-C), and PCSK9 levels at 1 year. Patients were mainly Caucasian (71.8%), male (79.5%), relatively young (mean age 68.1 ± 9.4 years), with a mean LVEF of 30.4 ± 6.5%, and managed with contemporary treatments. No significant changes in hs-TnT levels were observed in any group at 1 year. NT-proBNP and ST2 levels decreased in the GDMT plus evolocumab group (p = 0.045 and p = 0.008, respectively), without changes in hs-CRP, HDL-C, or LDLR. Total and LDL-C decreased in both groups, significantly higher in the intervention group (p = 0.003), and PCSK9 levels increased in the intervention group.

CONCLUSIONS

This prospective randomized pilot trial, although with the limitation of the small sample size, does not support the benefit of evolocumab in reducing troponin levels in patients with elevated LDL-C levels, history of coronary artery disease, and stable HFrEF.

Left-to-right ventricular volume ratio and outcome in heart failure with preserved ejection fraction

BACKGROUND

Age-specific and gender-specific reference values for left ventricular (LV) and right ventricle volumes are available. The prognostic implications of the ratio between these volumes in heart failure and preserved ejection fraction (HFpEF) have never been evaluated.

METHODS

We examined all HFpEF outpatients undergoing a cardiac magnetic resonance from 2011 to 2021. The left-to-right ventricular volume ratio (LRVR) was defined as the ratio between the LV and right ventricle end-diastolic volume indexes (LVEDVi/RVEDVi).

RESULTS

Among 159 patients [median age 58 years (interquartile range 49-69), 64% men, LV ejection fraction 60% (54-70%)] the median LRVR was 1.21 (1.07-1.40). Over 3.5 years (1.5-5.0), 23 patients (15%) experienced all-cause death or heart failure hospitalization, and 22 (14%) cardiovascular death or heart failure hospitalization. The risk of all-cause death or heart failure hospitalization increased with an LRVR less than 1.0 or at least 1.4. An LRVR less than 1.0 was associated with a higher risk of all-cause death or heart failure hospitalization [hazard ratio 5.95, 95% confidence interval (CI) 1.67-21.28; P = 0.006] and cardiovascular death or heart failure hospitalization (hazard ratio 5.68, 95% CI 1.58-20.35; P = 0.008) as compared with LRVR 1.0-1.3. Furthermore, an LRVR at least 1.4 was associated with a higher risk of all-cause death or heart failure hospitalization (hazard ratio 4.10, 95% CI 1.58-10.61; P = 0.004) and cardiovascular death or heart failure hospitalization (hazard ratio 3.71, 95% CI 1.41-9.79; P = 0.008) as compared with LRVR 1.0-1.3. These results were confirmed in patients without dilation of either ventricle.

CONCLUSION

LRVR values less than 1.0 or at least 1.4 are associated with worse outcomes in HFpEF. LRVR may become a valuable tool for risk prediction in HFpEF.

Durable ventricular assist device in Spain (2007-2020). First report of the REGALAD registry

INTRODUCTION AND OBJECTIVES

This report presents the clinical characteristics, outcomes and complications of all consecutive patients implanted with a long-term mechanical circulatory support device in Spain between 2007 and 2020.

METHODS

Analysis of the Spanish Registry of durable ventricular assist devices (REGALAD) including data form Spanish centers with a mechanical circulatory support program.

RESULTS

During the study period, 263 ventricular assist devices were implanted in 22 hospitals. The implanted device was an isolated continuous-flow left ventricular assist device in 182 patients (69%), a pulsatile-flow device (58 isolated left ventricular and 21 biventricular) in 79 (30%), and a total artificial heart in 2 patients (1%). The strategy of the implant was as bridge to heart transplant in 78 patients (30%), bridge to candidacy in 110 (42%), bridge to recovery in 3 (1%) and destination therapy in 72 patients (27%). Overall survival at 6, 12 and 24 months was 79%, 74% and 69%, respectively, and was better in continuous-flow left ventricular assist devices (84%, 80%, and 75%). The main adverse events related to this therapy were infections (37% of patients), bleeding (35%), neurological (29%), and device malfunction (17%).

CONCLUSIONS

Durable ventricular assist devices have emerged in Spain in the last few years as a useful therapy for patients with advanced heart failure. As in other international registries, the current trend is to use continuous-flow intracorporeal left ventricular devices, which are associated with better results. Adverse events continue to be frequent and severe.

Intermittent inotropic support with levosimendan in advanced heart failure as destination therapy: The LEVO-D registry

AIM

Patients with advanced heart failure (AHF) who are not candidates to advanced therapies have poor prognosis. Some trials have shown that intermittent levosimendan can reduce HF hospitalizations in AHF in the short term. In this real-life registry, we describe the patterns of use, safety and factors related to the response to intermittent levosimendan infusions in AHF patients not candidates to advanced therapies.

METHODS AND RESULTS

Multicentre retrospective study of patients diagnosed with advanced heart failure, not HT or LVAD candidates. Patients needed to be on the optimal medical therapy according to their treating physician. Patients with de novo heart failure or who underwent any procedure that could improve prognosis were not included in the registry. Four hundred three patients were included; 77.9% needed at least one admission the year before levosimendan was first administered because of heart failure. Death rate at 1 year was 26.8% and median survival was 24.7 [95% CI: 20.4-26.9] months, and 43.7% of patients fulfilled the criteria for being considered a responder lo levosimendan (no death, heart failure admission or unplanned HF visit at 1 year after first levosimendan administration). Compared with the year before there was a significant reduction in HF admissions (38.7% vs. 77.9%; P < 0.0001), unplanned HF visits (22.7% vs. 43.7%; P < 0.0001) or the combined event including deaths (56.3% vs. 81.4%; P < 0.0001) during the year after. We created a score that helps predicting the responder status at 1 year after levosimendan, resulting in a score summatory of five variables: TEER (+2), treatment with beta-blockers (+1.5), Haemoglobin >12 g/dL (+1.5), amiodarone use (-1.5) HF visit 1 year before levosimendan (-1.5) and heart rate >70 b.p.m. (-2). Patients with a score less than -1 had a very low probability of response (21.5% free of death or HF event at 1 year) meanwhile those with a score over 1.5 had the better chance of response (68.4% free of death or HF event at 1 year). LEVO-D score performed well in the ROC analysis.

CONCLUSION

In this large real-life series of AHF patients treated with levosimendan as destination therapy, we show a significant decrease of heart failure events during the year after the first administration. The simple LEVO-D Score could be of help when deciding about futile therapy in this population.

Fatty Acid Binding Proteins 3 and 4 Predict Both All-Cause and Cardiovascular Mortality in Subjects with Chronic Heart Failure and Type 2 Diabetes Mellitus

Subjects with type 2 diabetes mellitus (T2D) are at increased risk for heart failure (HF). The cardiac-specific (FABP3) and adipose-tissue-specific (FABP4) types of the fatty acid binding proteins have been associated with both all-cause and cardiovascular (CV) mortality. The aim of this study was to explore the prognosis value of FABP3 and FABP4 in ambulatory subjects with chronic HF (CHF), with and without T2D. A prospective study involving 240 ambulatory CHF subjects was performed. Patients were followed-up for a mean of 5.78 ± 3.30 years and cause of death (if any) was recorded. Primary endpoints were defined as all-cause and CV death, and a composite endpoint that included CV death or hospitalization for HF was included as a secondary endpoint. Baseline serum samples were obtained and the serum FABP3 and FABP4 concentrations were assessed by sandwich enzyme-linked immunosorbent assay. Survival analysis was performed with multivariable Cox regressions, using Fine and Gray competing risks models when needed, to explore the prognostic value of FABP3 and FABP4 concentrations, adjusting for potential confounders. Type 2 diabetes mellitus was highly prevalent, accounting for 47.5% for total subjects with CHF. Subjects with T2D showed higher mortality rates (T2D: 69.30%; non-T2D: 50.79%, p = 0.004) and higher serum FABP3 (1829.3 (1104.9–3440.5) pg/mL vs. 1396.05 (820.3–2362.16) pg/mL, p = 0.007) and FABP4 (45.5 (27.6–79.8) ng/mL vs. 34.1 (24.09–55.3) ng/mL, p = 0.006) concentrations compared with non-T2D CHF subjects. In the whole study cohort, FABP3 was independently associated with all-cause death, and both FABP3 and FABP4 concentrations were associated with CV mortality. The predictive values of these two molecules for all-cause (FABP3: HR 1.25, 95% CI 1.09–1.44; p = 0.002. FABP4: HR 2.21, 95% CI 1.12–4.36; p = 0.023) and CV mortality (FABP3: HR 1.28, 95% CI 1.09–1.50; p = 0.002. FABP4: HR 4.19, 95% CI 2.21–7.95; p < 0.001) were only statistically significant in the subgroup of subjects with T2D. Notably, FABP4 (HR 2.07, 95% CI 1.11–3.87; p = 0.022), but not FABP3, also predicted the occurrence of the composite endpoint (death or hospitalization for HF) only in subjects with T2D. All these associations were not found in CHF subjects without T2D. Our findings support the usefulness of serum FABP3 and FABP4 concentrations as independent predictors for the occurrence of all-cause and CV mortality in ambulatory subjects with CHF with T2D.

Sudden Cardiac Death in Heart Failure: A 20-Year Perspective From a Mediterranean Cohort

BACKGROUND

The prediction of sudden cardiac death (SCD) in heart failure (HF) remains an unmet need. The aim of our study was to assess the prevalence of SCD over 20 years in outpatients with HF managed in a Mediterranean multidisciplinary HF Clinic, and to compare the proportion of SCD (SCD/all-cause death) to the expected proportional occurrence based on the validated Seattle Proportional Risk Model (SPRM) score.

METHODS AND RESULTS

This prospective observational registry study included 2772 outpatients with HF admitted between August 2001 and May 2021. Patients were included when the cause of death was known and SPRM score was available. Over the 20-year study period, 1351 patients (48.7%) died during a median follow-up period of 3.8 years (interquartile range 1.6-7.6). Among these patients, the proportion of SCD out of the total of deaths was 13.6%, whereas the predicted by SPRM was 39.6%. This lower proportion of SCD was observed independently of left ventricular ejection fraction, ischemic etiology, and the presence of an implantable cardiac defibrillator.

CONCLUSIONS

In a Mediterranean cohort of outpatients with HF, the proportion of SCD was lower than expected based on the SPRM score. Future studies should investigate to what extend epidemiological and guideline-directed medical therapy patterns influence SCD.

Relationship of Circulating Vegetable Omega-3 to Prognosis in Patients With Heart Failure

BACKGROUND

There is an urgent need for cost-effective strategies to promote quality of life in patients with heart failure (HF). Several studies reported benefits in HF prognosis for marine omega-3 fatty acids and plant-based dietary patterns.

OBJECTIVES

The aim of this study was to explore whether dietary alpha-linolenic acid (ALA), the main plant omega-3, relates to a better HF prognosis.

METHODS

ALA was determined in serum phospholipids (which reflect long-term dietary ALA intake and metabolism) by gas chromatography in 905 ambulatory patients with HF caused by different etiologies.

RESULTS

After a median follow-up of 2.4 years (range: 0.02-3 years), 140 all-cause deaths, 85 cardiovascular (CV) deaths, and 141 first HF hospitalizations (composite of all-cause death and first HF hospitalization, n = 238) were documented. Using Cox regression analyses, we observed that, compared with patients at the lowest quartile of ALA in serum phospholipids (Q1), those at the 3 upper quartiles (Q2-Q4) exhibited a reduction in the risk of composite of all-cause death and first HF hospitalization (HR: 0.61; 95% CI: 0.46-0.81). Statistically significant reductions were observed for all-cause death (HR: 0.58; 95% CI: 0.41-0.82), CV death (HR: 0.51; 95% CI: 0.32-0.80), first HF hospitalization (HR: 0.58; 95% CI: 0.40-0.84), and the composite of CV death and HF hospitalization (HR: 0.58; 95% CI: 0.42-0.79).

CONCLUSIONS

HF patients with bottom 25% ALA levels in serum phospholipids had a worse prognosis during a mid-term follow-up compared with those with the highest levels. This might be a target population in whom to test dietary ALA-rich interventions to promote quality of life.

1H-magnetic resonance spectroscopy lipoprotein profile in patients with chronic heart failure versus matched controls

INTRODUCTION AND OBJECTIVES

Advanced lipoprotein phenotyping is a better predictor of atherosclerotic cardiovascular risk than cholesterol concentration alone. Lipoprotein profiling in heart failure (HF) is incompletely characterized. We aimed to describe the lipoprotein profile in patients with chronic HF compared with a matched control population.

METHODS

This cross-sectional study was performed from May 2006 to April 2014 and included ambulatory patients with chronic HF. Lipid concentrations and the size of main lipoprotein fractions (high-density lipoprotein [HDL], low-density lipoprotein [LDL], and very low-density lipoprotein) and the particle concentration of their 3 subfractions (large, medium and small) were assessed using 1H magnetic resonance spectroscopy.

RESULTS

The 429 included patients with chronic HF were compared with 428 matched controls. Patients with chronic HF had lower total cholesterol and lower mean LDL (1115 vs 1352 nmol/L; P<.001) and HDL (25.7 vs 27.9μmol/L; P <.001) particle concentrations, with this last difference being mediated by a significantly lower concentration of the small subfraction of HDL (15.2 vs 18.6μmol/L; P <.001). Mean very low-density lipoprotein, LDL, and HDL particle size was significantly higher in patients with HF vs controls. All HDL-related differences from controls persisted after adjustment for New York Heart Association functional class or body mass index. We found strong negative correlations of known cardiac biomarkers (N-terminal pro-brain natriuretic peptide and interleukin-1 receptor-like 1) with total and small LDL and HDL fractions and HDL particle size.

CONCLUSIONS

Patients with chronic HF significantly differ in their lipoprotein profile compared with unaffected controls. Further research is needed to better understand the pathogenic relevance of this difference.

Bending oxygen saturation index and risk of worsening heart failure events in chronic heart failure

AIMS

Bendopnea is a clinical symptom of advanced heart failure with uncertain prognostic value. We aimed to evaluate whether bendopnea and the change in oxygen saturation when bending forward (bending oxygen saturation index [BOSI]) are associated with adverse outcomes in ambulatory chronic heart failure (CHF) patients.

METHODS AND RESULTS

We prospectively evaluated 440 subjects with symptomatic CHF. BOSI was defined as the difference between sitting and bending oxygen saturation (SpO₂ ). The endpoint was the total number of worsening heart failure (WHF) events (heart failure hospitalization or urgent heart failure visit requiring parenteral diuretic therapy). The mean age was 74 ± 10 years, 257 (58.6%) were male, and 226 (51.4%) had a left ventricular ejection fraction <50%. Bendopnea was present in 94 (21.4%) patients, and 120 (27.3%) patients had a BOSI ≥-3%. The agreement between BOSI ≥-3% and bendopnea was moderate (Gwet's AC 0.482, p < 0.001). At a median (p25%-p75%) follow-up of 2.17 years (0.88-3.16), we registered 441 WHF events in 148 patients. After multivariable adjustment, BOSI was independently associated with the risk for total WHF episodes (overall, p < 0.001). Compared to improvement/no change in SpO₂ when bending (BOSI 0%), those with BOSI ≥-3% showed an increased risk of WHF events (incidence rate ratio [IRR] 2.16, 95% confidence interval [CI] 1.67-2.79; p < 0.001). In contrast, bendopnea was not associated with the risk of total WHF episodes (IRR 1.04, 95% CI 0.83-1.31; p = 0.705).

CONCLUSIONS

In ambulatory and stable CHF patients, BOSI ≥-3% and not bendopnea was independently associated with an increased risk of total (first and recurrent) WHF episodes. Awareness of SpO₂ while assessing bendopnea may be a useful tool for predicting heart failure decompensations.

Long-Term Prognostic Impact of Estimated Glomerular Filtration Rate on Admission in Patients Hospitalized for Acute Heart Failure

INTRODUCTION

Although small-sample size studies have shown that basal alterations of estimated glomerular filtration rate (eGFR) are related to short- and mid-term higher mortality in acute heart failure (AHF), there is scarce information on the influence of an altered eGFR on long-term mortality and readmissions. Therefore, this multicenter study sought to investigate the relationship between eGFR on admission for AHF and both long-term mortality and readmissions in a large sample of patients.

METHODS

We retrospectively evaluated 4,595 patients consecutively discharged after admission for AHF at three tertiary-care hospitals from January 1, 2008, to January 1, 2020. To investigate the effect of eGFR on admission with long-term morbimortality, we stratified the patients according to four eGFR categories: <30 mL·min-1·1.73 m-2 (G4 and G5 patients, n = 534), 30-44 mL·min-1·1.73 m-2 (G3b patients, n = 882), 45-59 mL·min-1·1.73 m-2 (G3a patients, n = 1,080), and ≥60 mL·min-1·1.73 m-2 (G1 and G2 patients, n = 2,099). eGFR was calculated by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation within the first 24 h following admission.

RESULTS

At a median follow-up of 2.20 years, multivariate analyses revealed that compared to G1 and G2 patients, G4 and G5 patients exhibited a higher risk of all-cause (HR = 1.15, 95% CI: 01.02-1.30, p = 0.020) and cardiovascular (CV) (HR = 1.20, 95% CI: 1.04-1.39, p = 0.013) mortality. Similarly, multivariate analyses also showed that the lower the eGFR, the higher the risk of readmissions. In fact, compared to G1 and G2 patients, G4 and G5 patients displayed significantly increased incident rate ratios of total all-cause (28%), CV (26%), and HF-related (30%) readmissions.

CONCLUSION

Data from this large study provide evidence that an eGFR below 30 mL·min-1·1.73 m-2 on admission could be an independent predictor for long-term mortality and readmissions in patients with AHF.

Effect of diuretic down-titration on pulmonary congestion assessed by lung ultrasound when introducing sodium-glucose cotransporter 2 inhibitors

Background

Mechanistic pathways of sodium-glucose cotransporter 2 inhibitors (SGLT2i) benefits in heart failure (HF) remain unclear.

Purpose

To investigate the effects of SGLT2i and simultaneous diuretic down-titration on pulmonary congestion assessed by lung ultrasound (LUS) and by HF biomarkers.

Methods

Prospective observational study in outpatients with HF and type 2 diabetes assigned to a SGLT2i. LUS was performed at baseline (just before starting SGLT2i), at 15 days and at 3-months of follow-up. Eight thoracic areas were examined. Diuretic regime was reduced at baseline, when LUS and clinical assessment allowed. The main outcome was short-time change in B-lines sum. Secondary endpoints evaluated N-terminal pro-B-type natriuretic peptide (NTproBNP), cancer antigen 125 (CA125) and interleukin-1 receptor-like 1 (ST2)

Results

88 patients were included (age, 66.8±9.9 years; 93.2% male; 77.3% in NYHA II functional class; 75% treated with loop diuretics). The median of lines B was 2 (RIQ 1–4), 2 (RIQ 1–4) and 2 (RIQ 0–4) at the initial visit, 15 days and 3 months, respectively (initial vs. 3 months, p=0.21) (Table 1). The number of patients treated with loop diuretics decreased from 66 to 33 (p&lt;0.001) and the mean dose of furosemide (or equivalent) in those who continued decreased from 61±5 mg/day to 45.8±20 mg/day (p&lt;0.001). There were no hospitalizations for HF in the 3 months of follow-up. None of the biomarkers showed statistically differences at 3 months of follow-up (Table 1).

Conclusions

The introduction of SGLT2i allowed a significant reduction of diuretics in chronic HF patients and diabetes, without evidence of worsening lung congestion assessed neither by LUS nor by HF biomarkers.

Funding Acknowledgement

Type of funding sources: None.

Global warming, renal function and heart failure: a 20-year follow-up study

Background

There is a growing concern about the possible effects of global warming on human health. In HF outpatients, renal function significantly worsens during summer. More specific analyses on the impact of increasing temperatures on body homeostasis are lacking.

Purpose

We investigated the relationship between the trend of temperatures from 2002 to 2021 and renal function in heart failure (HF) outpatients.

Methods

All creatinine and estimated glomerular filtration rate (eGFR) values of HF outpatients followed at one tertiary hospital in a Mediterranean area of Spain were retrieved from electronic health records. eGFR was calculated through the CKD-EPI formula. Temperature data from the local municipality were derived from the Meteocat service; as temperatures from the years 2004–2005 were not available, these years were not analysed. Summer was defined as the timespan from June to September included. We calculated average values of creatinine and eGFR during summer and the rest of the same year, considering each patient and each year. Similarly, we averaged temperature values during summer and the rest of the same year.

Results

We derived 6,307 couples of average creatinine/eGFR values in summer and in the rest of the year from 2,194 patients. Across all the years (2002–2003 and 2006–2021), creatinine was slightly higher in summer than in the rest of the year (1.26 vs. 1.21 mg/dL, p&lt;0.001), and eGFR was lower (65 vs. 67 mL/min/1.73 m2, p&lt;0.001). Temperatures in summer and the rest of the year increased gradually, albeit not linearly, from 2002 to 2021 (Figure 1). The absolute (Δ) and percent changes (Δ%) in median temperatures between summer and the rest of the year increased across years (r=0.149, p=0.001 and r=0.144, p=0.002, respectively), as well as Δ and Δ% of the monthly median of maximal temperatures (r=0.119, p&lt;0.001 and r=0.052, p&lt;0.001, respectively) (Figure 1). The Δ and Δ% temperatures between summer and the rest of the year displayed several significant correlations with Δ and Δ% creatinine and eGFR after adjusting for several variables including age, sex, HF therapies, and creatinine outside of summer (Figure 2).

Conclusions

Over a 20-year timespan there has been an increase in 1) temperatures in summer and in the rest of the year, and 2) the temperature excursion between summer and the rest of the year. Changes in temperatures between summer and the rest of the year correlated with the magnitude of the decrease in renal function during summer, likely because of worse dehydration with higher temperatures. Therefore, the progressive rise in temperature may have detrimental effects on renal function during summer in HF outpatients.

Funding Acknowledgement

Type of funding sources: None.

Should we continue trusting bodyweight for HF volume telemonitoring?

Background

Telemonitoring of body weight, blood pressure and heart rate has extensively been used to facilitate early recognition of heart failure (HF) decompensations in order to prevent hospital admissions. Mixed results have been shown by different clinical trials regarding the effectiveness of telemonitoring in HF management. It is recognized that HF decompensation starts with an increase in intra cardiac filling pressure. The relationship between daily pulmonary artery pressure (PAP) values measurements and body weight is not completely established.

Purpose

To study the relationship between daily changes in body weight and invasive daily measurements such as diastolic PAP assessed by a pulmonary artery pressure sensor (CardioMEMS).

Methods

Eleven patients with left sided chronic HF implanted with a CardioMEMS device were included in the study (age 75±9 years, ejection fraction 52±10%). Daily measured body weight and pulmonary artery pressures were recorded during 6 months. The primary endpoint was to assess the correlation between the “PAP deviation” – defined as the difference between daily diastolic PAP and mean diastolic PAP over the study period – and the “weight deviation” – defined as the difference between daily body weight determinations and mean body weight.

Results

During the 6-months study period, 1766 body weight and diastolic PAP measurements were recorded (158±47 daily measurements per patient). We found a weak although significant correlation between changes in body weight and changes in diastolic PAP (Figure 1). When analyzing data individually, no patient presented a strong correlation between the two variables.

Conclusions

Our results suggest that repeated measurements of body weight have limited utility in detecting left sided heart failure decompensations. More complex and patient-specific thresholds for the biometric measurements are needed to improve early detection of decompensation in HF patients. For the development of early detection algorithms, we may learn from invasive methods, such as the CardioMEMS device.

Funding Acknowledgement

Type of funding sources: None.

Alcohol abstinence vs. persistent alcohol consumption in alcoholic cardiomyopathy: impact on long-term prognosis

Background

Alcoholic Cardiomyopathy (ACM) remains a prevalent form of toxic-induced heart damage. Whether ACM prognosis depends on the persistence of alcohol consumption is a matter of debate.

Purpose

We sought to determine predictors of adverse events during long-term follow-up and left ventricular ejection fraction (LVEF) changes between abstainers and non-abstainers.

Methods

Consecutive patients admitted to a HF clinic from 2001 to 2020 with ACM were included. The primary endpoint was the composite of all-cause death or HF hospitalization. HF hospitalization was analyzed as a secondary outcome. Changes in LVEF at 1- and 3-years follow-up according to discontinuation of alcohol consumption was also analyzed. Multivariable Cox regression analyses were performed using the competing risk strategy for the secondary endpoint.

Results

A total of 122 patients were included with a mean age of 57.8±10.0 years and 95.1% (n=116) of males. The mean LVEF was 27.5% ± 10.6 and 11.5% (n=14) exhibited NYHA functional class 3. A total of 92 (75.4%) patients remained abstinent during follow-up; the rest continued with at least moderate alcohol intake. After a median follow-up of 6.8 years (interquartile range: 3.2 to 11.3 years), 59 (48.4%) presented the primary endpoint (45 [36.9%] died and 34 [27.9%] experienced HF readmission). Independent predictors of the primary outcome were age (hazard ratio [HR]: 1.03; 95% confidence interval [CI]: 1.00–1.06; p=0.042), hemoglobin (HR: 0.68; 95% CI: 0.56–0.82; p&lt;0.001) and alcohol abstinence (HR: 0.35; 95% CI: 0.20–0.61; p&lt;0.001). Predictors of HF readmission were hemoglobin (HR: 0.65; 95% CI: 0.50–0.83; p=0.001) and alcohol abstinence (HR: 0.39; 95% CI: 0.17–0.92; p=0.032). Improvement in LVEF was higher in abstainers (27.5±10.6% from baseline to 46.7±13.1% and 49.1±14.3% at 1- and 3-years respectively) than in non-abstainers (27.8±10.3% to 40.3±14.0% and 39.2±16.3% at 1- and 3-years respectively), being these changes in LVEF significantly different between both groups (p=0.004).

Conclusions

Patients with ACM and who remain abstainers during follow-up exhibit better outcomes and higher LVEF improvement in comparison to non-abstainers. These findings should help to inform lifestyle modification for patients with ACM.

Funding Acknowledgement

Type of funding sources: None.

Ratio between left and right ventricular end-diastolic volumes and outcomes in patients with heart failure and preserved ejection fraction

Background

Reference left and right ventricular (LV/RV) volumes normalized to age and gender have been published. However, the relative dilation of the LV compared to the RV in patients with heart failure (HF) symptoms and its prognostic association have not been evaluated.

Purpose

The present study investigated the relative dilation of the LV compared to the RV among patients with HF and preserved LV ejection fraction (HFpEF). We explored the association between LV/RV ratio (defined as the ratio between LV end-diastolic volume index [LVEDVi] and RV end-diastolic volume index [RVEDVi]) and outcomes.

Methods

Clinical and imaging data from consecutive ambulatory patients diagnosed with HFpEF between April 2011 and November 2021, and undergoing a cardiac magnetic resonance examination were retrieved. The endpoints were 1) all-cause death or first HF hospitalization, and 2) cardiovascular death or first HF hospitalization, 3) repeated HF hospitalizations.

Results

A total of 159 patients (median age 58 years [interquartile range 49–69], 64% men) were included. Median LVEF was 60% (54–70%), and the LV/RV ratio was 1.21 (1.07–1.40). Over a 3.5-year follow-up (1.5–5.0), all-cause death or first HF hospitalization occurred in 23 patients (15%) and cardiovascular death or first HF hospitalization in 22 (14%). Spline curve analysis showed a bimodal relationship between LV/RV and both outcomes, with a steep increase in risk &lt;1.0 and ≥1.4 (Figure 1). Accordingly, patients with either LV/RV &lt;1.0 or ≥1.4 had a much shorter survival free from both endpoints than patients with LV/RV 1.0–1.3 (Figure 2). An LV/RV &lt;1 was associated with a higher risk of all-cause death or first HF hospitalization (hazard ratio [HR] 5.95, 95% confidence interval [CI] 1.67–21.28; p=0.006) and a higher risk of cardiovascular death or first HF hospitalization (HR 5.68, 95% CI 1.58–20.35; p=0.008). Furthermore, an LV/RV ≥1.4 was associated with a higher risk of all-cause death or first HF hospitalization (HR 4.10, 95% CI 1.58–10.61; p=0.004) and a higher risk of cardiovascular death or first HF hospitalization (HR 3.71, 95% CI 1.41–9.79; p=0.008). Nine patients (6%) had more than 1 HF hospitalization. The crude incidence of HF hospitalizations was much higher in patients with an LV/RV &lt;1.0 (16.6 per 100 patient/years) or ≥1.4 (10.29 per 100 patient/years) than in those with LV/RV 1–1.3 (1.88 per 100 patient/years). Multivariable binomial negative regression showed significant association between LV/RV and recurrent HF hospitalizations after adjustment by age, gender and New York Heart Association class: LV/RV &lt;1.0 vs. 1.0–1.3, incidence rate ratio 9.0 per 100 patient/years (4.1–19.6), p&lt;0.001; LV/RV ≥1.4 vs. 1.0–1.3, incidence rate ratio 5.3 per 100 patient/years (1.5–8.4), p=0.009.

Conclusions

Among patients with HFpEF, an RVEDVi larger than the LVEDVi, or an LVEDVi ≥40% larger than the RVEDVi were significantly associated with worse outcomes.

Funding Acknowledgement

Type of funding sources: None.

Quality of life in patients with heart failure and improved ejection fraction: one year changes and prognostic implication

Background

Inconsistent and controversial results have been reported about the association of quality of life (QoL) and left ventricular ejection fraction (LVEF) in patients with heart failure (HF). The 2021 universal definition of HF specifically describes the criteria for the patients with HF and improved LVEF (HFimpEF): HF with a baseline LVEF ≤40%, a ≥10 point increase from baseline LVEF, and a second measurement of LVEF &gt;40%.

Purpose

1) To assess whether patients with HF and reduced LVEF (HFrEF) at first visit in an outpatient HF Clinic that fulfil the HFimpEF criteria one year later presented a higher improvement in QoL assessed by the Minnesota Living With Heart Failure Questionnaire (MLWHFQ) than those patients that did not fulfil HFimpEF criteria. 2) To assess the prognostic role of QoL on outcomes in HFimpEF patients.

Methods

In a prospective registry of real-life HF outpatients LVEF and QoL evaluated by MLWHFQ were assessed at first visit at the HF Clinic and at one year of follow-up.

Results

From August 2001 to August 2021, baseline and one year LVEF and MLWFQ scores were available in 1040 patients with an initial LVEF ≤40%. Table 1 shows baseline demographic and clinical characteristics of patients. In summary, mean age was 65.2±11.7 years, 75.9% of the patients were men, the main aetiology was ischaemic heart disease (52.9%) and patients were mostly in New York heart Association (NHYA) class II (71.1%) and III (21.6%). Baseline LVEF was 28.5% ± 7.3 and baseline MLWHFQ score was 30.2±19.5. At one year, mean LVEF increased to 38.0±12.2 while MLWHFQ scores improved to 17.4±16.0. There were 361 patients that fulfilled the HFimpEF criteria (34.7%). These patients significantly and markedly improved both LVEF (from 28.7±6.6 to 50.9±7.6, p&lt;0.001) and QoL (from 32.9±20.6 to 16.9±16.0, p&lt;0.001). Although in patients that did not fulfil the criteria of HFimpEF both LVEF (from 28.4±7.6 to 31.1±7.9, p&lt;0.001) and QoL (from 28.7±18.8 to 17.6±15.9, p&lt;0.001) also significantly improved, the improvement in QoL was significantly higher in HFimpEF patients (−16.0±23.8 vs. −11.1±20.3, p=0.001), taking into account that baseline MLWHFQ score was worse in HFimpEF patients (p=0.001). However, at one year QoL was similar when both groups were compared (p=0.50). MLWHFQ score at one year proved to be superior to QoL improvement (using a cut-off of at least 5 points) from the prognostic point of view.

Conclusions

QoL improved both in patients with and without HFimpEF criteria, and QoL perception at one year was similar in both groups, suggesting the influence of other factors other than LVEF in QoL perception. QoL at one year revealed to be superior to QoL changes from baseline from the prognostic point of view.

Funding Acknowledgement

Type of funding sources: None.

GlycA and GlycB as Inflammatory Markers in Chronic Heart Failure

The role of inflammation in heart failure (HF) has been extensively described, but it is uncertain whether inflammation exerts a different prognostic influence according to etiology. We aimed to examine the inflammatory state in chronic HF by measuring N-acetylglucosamine/galactosamine (GlycA) and sialic acid (GlycB), evolving proton nuclear magnetic resonance biomarkers of systemic inflammation, and explore their prognostic value in patients with chronic HF. The primary end point was a composite of all-cause death and HF readmission. A total of 429 patients were included. GlycB correlated with interleukin-1 receptor-like 1 in the whole cohort (r² = 0.14, p = 0.011) and the subgroup of nonischemic etiology (r² = 0.31, p <0.001). No association was found with New York Heart Association functional class or left ventricular ejection fraction. In patients with nonischemic HF (52.2%, n = 224), GlycA and GlycB exhibited significant association with the composite end point (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.06 to 1.33, p = 0.004 and HR 2.13, 95% CI 1.43 to 3.13, p <0.001; respectively) and GlycB with HF readmission after multivariable adjustment (HR 2.25, 95% CI 1.54 to 3.30, p <0.001). GlycB levels were also associated with a greater risk of HF-related recurrent admissions (adjusted incidence rate ratio 1.33, 95% CI = 1.07 to 1.65, p = 0.009). None of the markers were associated with the clinical end points in patients with ischemic HF. In conclusion, GlycA and GlycB represent an evolving approach to inflammation status with prognostic value in long-term outcomes in patients with nonischemic HF.

Quality of life in patients with heart failure and improved ejection fraction: one-year changes and prognosis

AIMS

The criteria for patients with heart failure (HF) and improved ejection fraction (HFimpEF) are a baseline left ventricular ejection fraction (LVEF) ≤40%, a ≥10-point increase from baseline LVEF, and a second LVEF measurement >40%. We aimed to (i) assess patients with HF and reduced LVEF (HFrEF) at baseline and compare quality of life (QoL) changes between those that fulfilled and those that did not fulfil the HFimpEF criteria 1 year later and (ii) assess the prognostic role of QoL in patients with HFimpEF.

METHODS

We reviewed data from a prospective registry of real-world outpatients with HF that were assessed for LVEF and QoL at a first visit to the HF clinic and 1 year later. QoL was evaluated with the Minnesota Living with Heart Failure Questionnaire (MLWHFQ). The primary prognostic endpoint was the composite of all-cause death or HF hospitalization.

RESULTS

Baseline and 1-year LVEF and MLWFQ scores were available for 1040 patients with an initial LVEF ≤40% (mean age, 65.2 ± 11.7 years; 75.9% men). The main aetiology was ischaemic heart disease (52.9%), and patients were mostly in New York heart Association Classes II (71.1%) and III (21.6%). At baseline, the mean LVEF was 28.5% ± 7.3, and the mean MLWHFQ score was 30.2 ± 19.5. After 1 year, the mean LVEF increased to 38.0% ± 12.2, and the MLWHFQ scores improved to 17.4 ± 16.0. In 361 patients that fulfilled the HFimpEF criteria (34.7%), significant improvements were observed in both LVEF (from 28.7% ± 6.6 to 50.9% ± 7.6, P < 0.001) and QoL (from 32.9 ± 20.6 to 16.9 ± 16.0, P < 0.001). Patients that did not fulfil the HFimpEF criteria also showed significant improvements in LVEF (from 28.4% ± 7.6 to 31.1% ± 7.9, P < 0.001) and QoL (from 28.7 ± 18.8 to 17.6 ± 15.9, P < 0.001). However, the QoL improvement was significantly higher in the HFimpEF group (-16.0 ± 23.8 vs. -11.1 ± 20.3, P = 0.001), despite the worse mean baseline MLWHFQ score, compared with the non-HFimpEF group (P = 0.001). The 1-year QoL was similar between groups (P = 0.50). The 1-year MLWHFQ score was independently associated with outcomes; the hazard ratio for the composite endpoint was 1.02 (95% CI: 1.01-1.03, P = 0.006). In contrast, the QoL improvement (with a cut-off ≥5 points) was not independently associated with the composite outcome.

CONCLUSIONS

Patients with HFrEF showed improved QoL after 1 year, regardless of whether they met the HFimpEF criteria. The similar 1-year QoL perception between groups suggested that factors other than LVEF influenced QoL perception. The 1-year QoL was superior to the QoL change from baseline for predicting prognosis in patients with HFimpEF.

Biomarkers in Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous disorder developing from multiple aetiologies with overlapping pathophysiological mechanisms. HFpEF diagnosis may be challenging, as neither cardiac imaging nor physical examination are sensitive in this situation. Here, we review biomarkers of HFpEF, of which the best supported are related to myocardial stretch and injury, including natriuretic peptides and cardiac troponins. An overview of biomarkers of inflammation, extracellular matrix derangements and fibrosis, senescence, vascular dysfunction, anaemia/iron deficiency and obesity is also provided. Finally, novel biomarkers from -omics technologies, including plasma metabolites and circulating microRNAs, are outlined briefly. A cardiac-centred approach to HFpEF diagnosis using natriuretic peptides seems reasonable at present in clinical practice. A holistic approach including biomarkers that provide information on the non-cardiac components of the HFpEF syndrome may enrich our understanding of the disease and may be useful in classifying HFpEF phenotypes or endotypes that may guide patient selection in HFpEF trials.

Sacubitril/valsartan affects pulmonary arterial pressure in heart failure with preserved ejection fraction and pulmonary hypertension

AIMS

Prior studies have not fully characterized the haemodynamic effects of the angiotensin receptor-neprilysin inhibitor (ARNI) sacubitril/valsartan in heart failure with preserved ejection fraction and pulmonary hypertension (HFpEF-PH). The aim of the Treatment of PH With Angiotensin II Receptor Blocker and Neprilysin Inhibitor in HFpEF Patients With CardioMEMS Device (ARNIMEMS-HFpEF) study is to assess pulmonary artery pressure (PAP) dynamics by means of implanted PAP monitors in patients with HFpEF-PH treated with sacubitril/valsartan.

METHODS AND RESULTS

This single-arm, investigator-initiated, interventional study included 14 consecutive ambulatory symptomatic HFpEF-PH patients who underwent CardioMEMS implantation prior to enrolment [mean ejection fraction 60.4 ± 7.2%, baseline mean PAP (mPAP) 33.9 ± 7.6 mmHg]. Daily PAP values were examined during three periods: a 6 week period after CardioMEMS implantation and before sacubitril/valsartan treatment (pre-ARNI), a 6 week period with sacubitril/valsartan treatment (ARNI ON), and a 6 week period of sacubitril/valsartan withdrawal (ARNI OFF). The primary endpoint was change in mPAP with and without sacubitril/valsartan. Secondary endpoints included changes in 6 min walking distance, B-line sum in lung ultrasound, and quality of life (QoL). During the study period, 1717 mPAP measurements were recorded. Between pre-ARNI vs. ARNI ON, mPAP significantly declined by -4.99 mmHg [95% confidence interval (CI) -5.55 to -4.43]. Between ARNI ON vs. ARNI OFF, mPAP significantly increased by +2.84 mmHg [95% CI +2.26 to +3.42]. Between pre-ARNI vs. ARNI ON, we found an improvement in 6 min walking distance, B-lines, and QoL. Mean loop diuretic management did not differ between periods.

CONCLUSIONS

Sacubitril/valsartan significantly reduced mPAP in patients with HFpEF-PH, independent of loop diuretic management, together with improvement in functional capacity, lung congestion, and QoL. Sacubitril/valsartan may be a therapeutic alternative in HFpEF-PH.

Mortality Risk Prediction Dynamics After Heart Failure Treatment Optimization: Repeat Risk Assessment Using Online Risk Calculators

Objectives

Heart failure (HF) management has significantly improved over the past two decades, leading to better survival. This study aimed to assess changes in predicted mortality risk after 12 months of management in a multidisciplinary HF clinic.

Materials and Methods

Out of 1,032 consecutive HF outpatients admitted from March-2012 to November-2018, 357 completed the 12-months follow-up and had N-terminal pro-B-type natriuretic peptide (NTproBNP), high sensitivity troponin T (hs-TnT), and interleukin-1 receptor-like-1 (known as ST2) measurements available both at baseline and follow-up. Three contemporary risk scores were used: MAGGIC-HF, Seattle HF Model (SHFM), and the Barcelona Bio-HF (BCN Bio-HF) calculator, which incorporates the three above mentioned biomarkers. The predicted risk of all-cause death at 1 and 3 years was calculated at baseline and re-evaluated after 12 months.

Results

A significant decline in predicted 1-and 3-year mortality risk was observed at 12 months: MAGGIC ~16%, SHFM ~22% and BCN Bio-HF ~15%. In the HF with reduced ejection fraction (HFrEF) subgroup guideline-directed medical therapy led to a complete normalization of left ventricular ejection fraction (≥50%) in almost a third of the patients and to a partial normalization (41–49%) in 30% of them. Repeated risk assessment after 12 months with SHFM and BCN Bio-HF provided adequate discrimination for all-cause 3-year mortality (C-Index: MAGGIC-HF 0.762, SHFM 0.781 and BCN Bio-HF 0.791).

Conclusion

Mortality risk declines in patients with HF managed for 12 months in a multidisciplinary HF clinic. Repeating the mortality risk assessment after optimizing the HF treatment is recommended, particularly in the HFrEF subgroup.

Cause of Death in Heart Failure Based on Etiology: Long-Term Cohort Study of All-Cause and Cardiovascular Mortality

We assessed differences in long-term all-cause and cardiovascular (CV) mortality in heart failure (HF) outpatients based on the etiology of HF. Consecutive patients admitted to the HF Clinic from August 2001 to September 2019 (N = 2587) were considered for inclusion. HF etiology was divided into ischemic heart disease (IHD), dilated cardiomyopathy (DCM), hypertensive heart disease, alcoholic cardiomyopathy, drug-induced cardiomyopathy (DICM), valvular heart disease, and hypertrophic cardiomyopathy. All-cause death and CV death were the primary end points. Among 2387 patients included in the analysis (mean age 66.5 ± 12.5 years, 71.3% men), 1317 deaths were recorded (731 from CV cause) over a maximum follow-up of 18 years (median 4.1 years, interquartile range (IQR) 2–7.8). Considering IHD as the reference, only DCM had a lower risk of all-cause death (adjusted hazard ratio (aHR) 0.68, 95% confidence interval (CI) 0.56–0.83, p < 0.001), and only DICM had a higher risk of all-cause death (aHR 1.47, 95% CI 1.02–2.11, p = 0.04). However, almost all etiologies had a significantly lower risk of CV death than IHD. Among the studied HF etiologies, DCM and DICM have the lowest and highest risk of all-cause death, respectively, whereas IHD has the highest adjusted risk of CV death.

Lung ultrasound in outpatients with heart failure: the wet-to-dry HF study

AIMS

In ambulatory patients with chronic heart failure (HF), congestion and decongestion assessment may be challenging. The aim of this study is to assess the value of lung ultrasound (LUS) in outpatients with HF in characterizing decompensation and recompensation, and in outcomes prediction.

METHODS AND RESULTS

Heart failure outpatients attended to establish HF decompensation were included. LUS was blindly performed at baseline (LUS1) and at clinical recompensation (LUS2). B-lines were counted in eight scanned areas. Diagnosis of no HF decompensation vs. right-sided, left-sided, or global HF decompensation, and patients' management were performed by physicians blinded to LUS1. Outcome was the composite of all-cause death or HF-related hospitalization. Two hundred and thirty-three suspicions of HF decompensation were included in 187 patients (71.4 ± 11.3 years, 66.8% men). Mean B-line (LUS1) was 17.6 ± 11.2 vs. 3.7 ± 4.5 for episodes with and without HF decompensation, respectively (P < 0.001). Global HF decompensation showed the highest number of B-lines (20.6 ± 11), followed by left-sided (19.7 ± 11.6) and right-sided (13.5 ± 9.8). B-lines declined to 6.9 ± 6.7 (LUS2) (P < 0.001 vs. LUS1) after treatment, within a mean time of 24.2 ± 23.7 days [median 13.5 days (interquartile range 6-40)]. B-lines were significantly associated with the composite endpoint at 30 days (hazard ratio [HR] 1.04 [95% confidence interval 1.01-1.07], P = 0.02), but not at 60 (P = 0.22) or 180 days (P = 0.54). In multivariable analysis, B-line number remained as an independent predictor of the composite endpoint at 30 days, [HR 1.04 (1.01-1.07), P = 0.014], with a 4% increase risk per B-line added. B-lines correlated significantly with CA125 (R = 0.30, P = 0.001).

CONCLUSIONS

Lung ultrasound supports the diagnostic work-up of congestion and decongestion in chronic HF outpatients and identifies patients at high risk of short-term events.

Differences in long-term all-cause and cardiovascular mortality according to heart failure aetiology in ambulatory patients

Background

Heart failure (HF) is the final stage of many cardiac disorders. Mortality in heart HF remains challenging despite improvement in outcomes proved in clinical trials in HF with reduced ejection fraction and it can be influenced by the aetiology of HF.

Purpose

To assess differences in long-term mortality (up to 18 years) in a real-life cohort of HF outpatients according to the aetiology of HF.

Methods

Consecutive patients with HF admitted at the HF Clinic from August 2001 to September 2019 were included. Follow-up was closed at 30.9.2020. HF aetiology was divided into ischemic heart disease (IHD), dilated cardiomyopathy (CM) –including non-compaction CM–, hypertensive CM, alcohol-derived CM, drug-derived CM, valvular disease, hypertrophic CM and others. For the present analysis, this latter group was excluded due to the big heterogeneity and limited number of patients in each subtype of aetiology. All-cause death and cardiovascular death were the primary end-points. Fine & Gray method for competing risk was used for cardiovascular mortality analysis.

Results

Out of 2387 patients included (age 66.5±12.5 years, 71.3% men, LVEF 35.4%±14.2, mainly in NYHA class II [65.5%] and III [26.5%]), 1317 deaths were recorded (731 from cardiovascular cause) during a maximum follow-up of 18 years (median 4.1 years [IQR 2–7.8] for the total cohort, 5.3 years [IQR 2.6–9.7] for survivors). Figure 1 shows Cox regression multivariable analysis for all-cause death and cardiovascular mortality. Considering IHD aetiology as reference, only dilated CM showed significantly lower risk of all-cause death, and only drug-induced CM showed higher risk of all-cause death. However, when cardiovascular mortality was considered almost all aetiologies showed significant lower risk of cardiovascular death than IHD. Figure 2 shows adjusted survival curves (A) and adjusted incidence curves of cardiovascular death (B) based on HF aetiology.

Conclusions

After adjusting for multiple prognostic factors among the studied HF aetiologies, dilated CM and drug-related CM showed the lowest and the highest risk of all-cause death, respectively. Patients with IHD showed the highest adjusted risk of cardiovascular death.

Funding Acknowledgement

Type of funding sources: None.

Clinical and prognostic significance of the inflammatory markers GlycA and GlycB in chronic heart failure of both ischemic and non-ischemic etiologies

Background

N-acetylglucosamine/galactosamine (GlycA) and sialic acid (GlycB) constitute evolving nuclear magnetic resonance (NMR) biomarkers of systemic inflammation. They have been increasingly studied and associated with cardiovascular (CV) disease and incident heart failure (HF), but little is known about its value in chronic HF population.

Purpose

We aimed to examine the association on long-term CV outcomes of GlycA and GlycB in chronic HF relative to aetiology.

Methods

We prospectively included a cohort of 429 HF patients admitted to an ambulatory HF Unit. Plasma GlycA and GlycB concentrations were determined using NMR spectroscopy. The primary endpoint was a composite of CV death and readmission due to HF. Competing risk regression models were performed with non-CV death as the competing event. Because an interaction existed between GlycA and GlycB with ischemic etiology (p&lt;0.01), we examined this further.

Results

The mean (SD) follow-up was 4.5±2.9 years. Median concentrations (IQR) for GlycA and GlycB were 5.4 (4.9–6.2) mmol/L and 1.9 (1.7–2.2) mmol/L, respectively. A total of 92 (41.1%) and 123 (60.0%) patients from non-ischemic and ischemic etiology, respectively, the clinical endpoint. In ischaemic HF patients (47.8%; n=205) both markers were not associated with the primary endpoint. Conversely, in non-ischemic HF patients (52.2%; n=224), GlycA and GlycB exhibited association with the primary endpoint in univariable and after multivariable adjustment (HR 1.14; 95% confidence interval [CI]: 1.02–1.28, p=0.018 and HR 1.91; 95% CI: 1.27–2.88, p=0.002; respectively. Figure 1 and 2). In this subgroup, a correlation analysis with well-known biomarkers (NT-proBNP, hs-TnT and ST2) only evidenced a positively and significantly correlation of GlycB with ST2 (r=0.26, p&lt;0.001). No association was found with NYHA functional class.

Conclusions

GlycA and GlycB represent an evolving approach of inflammation status with prognostic value of long-term CV related events in non-ischemic HF patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Probability of MACE by GlycA tertilesFigure 2. Probability of MACE by GlycB tertiles

Kidney function derangements during summer in ambulatory heart failure patients

Background

Heart failure (HF) is characterized by alterations in kidney function that are associated with poor prognosis and can be related to the evolution of the disease or induced by medical treatment. High temperatures during summer may result in some degree of dehydration, especially in patients treated with diuretics, and may contribute to transient glomerular filtration rate (eGFR) reduction.

Objective

To assess creatinine and eGFR changes during summer in ambulatory heart failure patients.

Methods

Consecutive patients with HF admitted at our HF Clinic (Spain) from August 2001 to December 2020 were included. eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula. We included in the analysis creatinine and eGFR values that were assessed at planned visits only, discarding urgent renal function assessments. Creatinine and eGFR values were grouped according to the period of the year (summer [from June to September, both included] vs. the rest of the year). Changes in creatinine and eGFR between the rest of the year and summer for each patient were evaluated using paired samples t-test.

Results

Out of 37360 creatinine and eGFR values, 25458 were included in the analysis for a total of 2423 patients (median number of observations for each patient: 8, IQR 4–15). Mean creatinine and eGFR were 1.4±1.0 mg/dl and 63.0±27.7 ml/min, respectively. Table 1 shows baseline patient characteristics. Creatinine increased significantly during summer (1.44±0.9 mg/dl vs. 1.48±1.1 mg/dl, p&lt;0.001). Similarly, eGFR was lower in summer as compared to the rest of the year 60.6±25.4 ml/min vs. 59.4±26.0 ml/min, p&lt;0.001.

Conclusions

In ambulatory HF patients in a Mediterranean area, we found significant worsening of renal function during summer, likely related to an imbalance between water intake and fluid loss. To prevent summer-driven kidney stress, diuretic treatment should be carefully adjusted during the hottest months of the year.

Funding Acknowledgement

Type of funding sources: None. Table 1

How predict right ventricular-pulmonary circulation coupling improvement in chronic heart failure

Background

Right ventricular-pulmonary circulation coupling (RVPAC), which can be measured by the relation between tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (SPAP) by echocardiography, has been postulated as an independent prognostic factor of hospitalizations and mortality in heart failure (HF) patients.

Purpose

Our aim was to know the predictors of RVPAC improvement in a chronic HF cohort.

Methods

Retrospective analysis of a prospectively studied cohort of HF outpatients of different aetiologies attended in a multidisciplinary HF Unit. Prospectively scheduled echo-Doppler studies were performed at first visit and 1 year. A TAPSE/SPAP ratio &lt;0.36 mm/mmHg was identified as the most deleterious. Significant RVPAC improvement at 1 year was defined as TAPSE/SPAP ratio ≥0.36 mm/mmHg together with a ≥10% improvement from baseline RVPAC. Multivariable logistic regression analysis (conditional backward stepwise) was performed to select variables independently associated with significant RVPAC improvement. A predictive model including age and the previously selected variables was created.

Results

From August 2001 to July 2017, 554 patients with TAPSE and SPAP data in the initial visit were included. Mean follow-up time was 4.6±3.7 years. At first visit 252 (45.5%) patients had RVPAC &lt;0.36 mm/mmHg. Out of them, RVPAC at 1 year improved in 55 (21.8%). In multivariable analysis, the presence of baseline atrial fibrillation/flutter (OR 0.12 [95% CI 0.05–0.28], p&lt;0.001), SPAP (OR 0.96 [95% CI 0.92–0.99], p=0.014) and female gender (OR 0.34 [95% CI 0.12–0.91], p=0.03) were related to lesser probability of RVPAC improvement at 1 year. A model with such variables, together with age, showed an AUC of 0.824 to predict significant RVPAC improvement.

Conclusions

Atrial fibrillation/flutter, increasing SPAP and female gender hamper RVPAC improvement at 1 year in HF patients with baseline TAPSE/SPAP ratio &lt;0.36.

Funding Acknowledgement

Type of funding sources: None. Multivariate regression analysis

Head-to-head comparison of NT-proBNP and soluble ST2 for long-term prognosis of patients with hypertrophic cardiomyopathy

Background

N-terminal pro-brain natriuretic peptide (NT-proBNP) predicts mortality and the development of heart failure (HF) in hypertrophic cardiomyopathy (HCM), however, evidence regarding soluble interleukin-1 receptor-like 1 (ST2) in this population is lacking.

Purpose

To assess the ST2 and NT-proBNP significance for risk stratification of patients with HCM during long-term follow-up.

Methods

We prospectively enrolled a cohort of consecutive patients with HCM admitted to an ambulatory HF Unit in a Tertiary University Hospital. All patients had clinical and echocardiographic evaluation and measurement of NT-proBNP and ST2 at inclusion. The primary endpoint was the composite of all-cause death or HF-related hospitalization.

Results

103 patients were enrolled, 68% (n=70) males with a median (IQR) age of 60 (50–71) years. The median (IQR) of ST2 was 31.5 (IQR: 24.5 – 40.7) pg/mL. During a median follow-up of 2.5 years, 17 patients had the primary endpoint. Both, NT-proBNP and ST2 (both log-transformed) were associated with the primary endpoint in the univariable analyses (p&lt;0.01). However, after adjustment by age, sex, NYHA functional class and left ventricular ejection fraction (LVEF), this association remained statistically significant only for ST2 (HR: 4.62, 95% CI 1.80–11.87, p=0.001 vs HR: 1.57, 95% CI 0.97–2.54, p=0.068 for NT-proBNP). The addition of ST2 to a clinical model (age, sex, NYHA functional class and LVEF) increased the Harrel's C statistic from 0.70 to 0.76, while the addition of NT-proBNP increase this C-statistic only to 0.73.

Conclusions

ST2 appears to be a valuable biomarker for the prediction of death and heart failure related hospitalization in patients with HCM, outperforming the prognostic value of NT-proBNP. Future research should delve into this association.

Funding Acknowledgement

Type of funding sources: None.

Natriuretic peptide dynamics with remote pulmonary artery pressure monitoring

Background

Real-life clinical practice has confirmed the value of pulmonary artery (PA) pressure-guided therapy in patients with heart failure (HF) and history of repeated HF hospitalizations (HFH), to greater extent to that reported in the pivotal clinical trial CHAMPION-HF. The value of hemodynamic monitoring in a population of patients with HF and elevated natriuretic peptides, but without recent HFH, is unknown.

Objective

To assess N-terminal-pro-brain natriuretic peptide (NTproBNP) dynamics before and 6 months after PA pressure sensor implantation.

Methods

Ten patients managed in a multidisciplinary HF clinic implanted with the CardioMEMS PA pressure sensor were consecutively included from June 2019 to July 2020. Mean age was 63.1±23.5 years, 30% were women, 40% had HF with reduced EF (EF &lt;40%). NTproBNP was measured at baseline and six months after sensor implantation. Wilcoxon matched-pairs signed-rank test was used to compare NTproBNP values at baseline and at 6 months. Fractional polynomial fit plot was used to represent changes in mean PA pressure over time. Linear regression was used to predict the change in NTproBNP based on the change in PA pressures.

Results

Mean daily pressure transmission rate was 92.4±5.1%. During the six-month study period 90% of patients had a change in medication related to PA pressure, with an average of 0.21 [0.17–0.66] changes per patient per month. Mean PA pressure at baseline was 28.5±9.5 mmHg, and decreased by 5.5 mmHg at 6 months (p=0.01) (Figure 1). NTproBNP was also significantly lower six months post CardioMEMS implantation; decreasing from 1696 pg/ml [976–2930] at baseline to 1046 pg/ml [616–2076] after six months (p=0.04) (Figure 2). There was a weak correlation between the change in NTproBNP and the change in mean PA pressure (R2=0.22, p=0.17).

Conclusions

NTproBNP values were significantly lower 6-months following implantation of a PA pressure sensor to guide HF management. Mean PA pressures were also significantly reduced.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Hospital Universitari Germans Trias i Pujol Figure 1. Change in mean PA pressure over time.Figure 2. Change in NTproBNP after PAP monitoring.

Empagliflozin in heart failure with preserved ejection fraction: decoding its molecular mechanism of action using artificial intelligence

 

Rationale The use of sodium-glucose co-transporter 2 inhibitors (SGLT2i) to treat heart failure with preserved ejection fraction (HFpEF) is under investigation in ongoing clinical trials, but the exact mechanism of action is unclear. Here we aimed to use artificial intelligence (AI) to characterize the mechanism of action of empagliflozin in HFpEF at the molecular level.

Methods

We retrieved information regarding HFpEF pathophysiological motifs and differentially expressed genes/proteins, together with empagliflozin target information and bioflags, from specialized publicly available databases. Artificial neural networks and deep learning AI were used to model the molecular effects of empagliflozin in HFpEF.

Results

The model predicted that empagliflozin could reverse 59% of the protein alterations found in HFpEF. The effects of empagliflozin in HFpEF appeared to be predominantly mediated by inhibition of NHE1 (Na+/H+ exchanger 1), with SGLT2 playing a less prominent role. The elucidated molecular mechanism of action had an accuracy of 94%. Empagliflozin's pharmacological action mainly affected cardiomyocyte oxidative stress modulation, and greatly influenced cardiomyocyte stiffness, myocardial extracellular matrix remodelling, heart concentric hypertrophy, and systemic inflammation. Validation of these in silico data was performed in vivo in patients with HFpEF by measuring the declining plasma concentrations of NOS2, the NLPR3 inflammasome, and TGF-β1 during 12 months of empagliflozin treatment.

Conclusion

Using AI modelling, we identified that the main effect of empagliflozin in HFpEF treatment is exerted via NHE1 and is focused on cardiomyocyte oxidative stress modulation. These results support the potential use of empagliflozin in HFpEF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos IIICentro de investigaciόn biomédica en red cardiovascular (CIBERCV) Summary figureTable 1

Caval Valve Implantation (CAVI): An Emerging Therapy for Treating Severe Tricuspid Regurgitation

Severe tricuspid regurgitation remains a challenging heart-valve disease to effectively treat with high morbidity and mortality at mid-term. Currently guideline-directed medical treatment is limited to escalating dose of diuretics, and the rationale and timing of open-heart surgery remains controversial. Emerging percutaneous therapies for severe tricuspid regurgitation continue to show promising results in early feasibility studies. However, randomized trial data is lacking. Additionally, many patients are deemed unsuitable for these emerging therapies due to anatomical or imaging constraints. Given the technical simplicity of the bicaval valve implantation (CAVI) technique compared to other transcatheter devices, CAVI is postulated as a suitable alternative for a wide variety of patients affected with severe+ tricuspid regurgitation. In this review we illustrate the current evidence and ongoing uncertainties of CAVI, focusing on the novel CAVI-specific devices.

Head-to-head comparison of contemporary heart failure risk scores

AIMS

Several heart failure (HF) web-based risk scores are currently used in clinical practice. Currently, we lack head-to-head comparison of the accuracy of risk scores. This study aimed to assess correlation and mortality prediction performance of Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC-HF) risk score, which includes clinical variables + medications; Seattle Heart Failure Model (SHFM), which includes clinical variables + treatments + analytes; PARADIGM Risk of Events and Death in the Contemporary Treatment of Heart Failure (PREDICT-HF) and Barcelona Bio-Heart Failure (BCN-Bio-HF) risk calculator, which also include biomarkers, like N-terminal pro B-type natriuretic peptide (NT-proBNP).

METHODS AND RESULTS

A total of 1166 consecutive patients with HF from different aetiologies that had NT-proBNP measurement at first visit were included. Discrimination for all-cause mortality was compared by Harrell's C-statistic from 1 to 5 years, when possible. Calibration was assessed by calibration plots and Hosmer-Lemeshow test and global performance by Nagelkerke's R² . Correlation between scores was assessed by Spearman rank test. Correlation between the scores was relatively poor (rho value from 0.66 to 0.79). Discrimination analyses showed better results for 1-year mortality than for longer follow-up (SHFM 0.817, MAGGIC-HF 0.801, PREDICT-HF 0.799, BCN-Bio-HF 0.830). MAGGIC-HF showed the best calibration, BCN-Bio-HF overestimated risk while SHFM and PREDICT-HF underestimated it. BCN-Bio-HF provided the best discrimination and overall performance at every time-point.

CONCLUSIONS

None of the contemporary risk scores examined showed a clear superiority over the rest. BCN-Bio-HF calculator provided the best discrimination and overall performance with overestimation of risk. MAGGIC-HF showed the best calibration, and SHFM and PREDICT-HF tended to underestimate risk. Regular updating and recalibration of online web calculators seems necessary to improve their accuracy as HF management evolves at unprecedented pace.

Decoding empagliflozin's molecular mechanism of action in heart failure with preserved ejection fraction using artificial intelligence

The use of sodium-glucose co-transporter 2 inhibitors to treat heart failure with preserved ejection fraction (HFpEF) is under investigation in ongoing clinical trials, but the exact mechanism of action is unclear. Here we aimed to use artificial intelligence (AI) to characterize the mechanism of action of empagliflozin in HFpEF at the molecular level. We retrieved information regarding HFpEF pathophysiological motifs and differentially expressed genes/proteins, together with empagliflozin target information and bioflags, from specialized publicly available databases. Artificial neural networks and deep learning AI were used to model the molecular effects of empagliflozin in HFpEF. The model predicted that empagliflozin could reverse 59% of the protein alterations found in HFpEF. The effects of empagliflozin in HFpEF appeared to be predominantly mediated by inhibition of NHE1 (Na⁺/H⁺ exchanger 1), with SGLT2 playing a less prominent role. The elucidated molecular mechanism of action had an accuracy of 94%. Empagliflozin’s pharmacological action mainly affected cardiomyocyte oxidative stress modulation, and greatly influenced cardiomyocyte stiffness, myocardial extracellular matrix remodelling, heart concentric hypertrophy, and systemic inflammation. Validation of these in silico data was performed in vivo in patients with HFpEF by measuring the declining plasma concentrations of NOS2, the NLPR3 inflammasome, and TGF-β1 during 12 months of empagliflozin treatment. Using AI modelling, we identified that the main effect of empagliflozin in HFpEF treatment is exerted via NHE1 and is focused on cardiomyocyte oxidative stress modulation. These results support the potential use of empagliflozin in HFpEF.

Particle size and cholesterol content of circulating HDL correlate with cardiovascular death in chronic heart failure

Evidence regarding any association of HDL-particle (HDL-P) derangements and HDL-cholesterol content with cardiovascular (CV) death in chronic heart failure (HF) is lacking. To investigate the prognostic value of HDL-P size (HDL-Sz) and the number of cholesterol molecules per HDL-P for CV death in HF patients. Outpatient chronic HF patients were enrolled. Baseline HDL-P number, subfractions and HDL-Sz were measured using 1H-NMR spectroscopy. The HDL-C/P ratio was calculated as HDL-cholesterol over HDL-P. Endpoint was CV death, with non-CV death as the competing event. 422 patients were included and followed-up during a median of 4.1 (0–8) years. CV death occurred in 120 (30.5%) patients. Mean HDL-Sz was higher in CV dead as compared with survivors (8.39 nm vs. 8.31 nm, p < 0.001). This change in size was due to a reduction in the percentage of small HDL-P (54.6% vs. 60% for CV-death vs. alive; p < 0.001). HDL-C/P ratio was higher in the CV-death group (51.0 vs. 48.3, p < 0.001). HDL-Sz and HDL-C/P ratio were significantly associated with CV death after multivariable regression analysis (HR 1.22 [95% CI 1.01–1.47], p = 0.041 and HR 1.04 [95% CI 1.01–1.07], p = 0.008 respectively). HDL-Sz and HDL-C/P ratio are independent predictors of CV death in chronic HF patients.