The two different profiles in heart failure with preserved ejection fraction and type 2 diabetes mellitus: ischemic and diabetic

OBJECTIVE

Two profiles of patients with heart failure with preserved ejection fraction (HFpEF) and type 2 diabetes mellitus (T2DM) can be discerned: those with ischemic and those with diabetic cardiomyopathy (DMC). We aim to analyze clinical differences and prognosis between patients of these two profiles.

MATERIAL AND METHODS

This cohort study analyzes data from the Spanish Heart Failure Registry, a multicenter, prospective registry that enrolled patients admitted for decompensated heart failure and followed them for one year. Three groups were created according to the presence of T2DM and heart disease depending on the etiology (ischemic when coronary artery disease was present, or DMC when no coronary, valvular, or congenital heart disease; no hypertension; nor infiltrative cardiovascular disease observed on an endomyocardial biopsy). The groups and outcomes were compared.

RESULTS

A total of 466 patients were analyzed. Group 1 (n = 210) included patients with ischemic etiology and T2DM. Group 2 (n = 112) included patients with DMC etiology and T2DM. Group 3 (n = 144), a control group, included patients with ischemic etiology and without T2DM. Group 1 had more hypertension and dyslipidemia; group 2 had more atrial fibrillation (AF) and higher body mass index; group 3 had more chronic kidney disease and were older. In the regression analysis, group 3 had a better prognosis than group 1 (reference group) for cardiovascular mortality and HF readmissions (HR 0.44;95%CI 0.2-1; p = .049).

CONCLUSIONS

Patients with T2DM and HFpEF, who had the poorest prognosis, were of two different profiles: either ischemic or DMC etiology. The first had a higher burden of cardiovascular disease and inflammation whereas the second had a higher prevalence of obesity and AF. The first had a slightly poorer prognosis than the second, though this finding was not significant.

Conduction system pacing and atrioventricular node ablation in heart failure: The PACE-FIB study design

AIMS

Atrial fibrillation (AF) worsens the prognosis of patients with heart failure (HF). Successful treatments are still very scarce for those with permanent AF and preserved (HFpEF) or mildly reduced (HFmrEF) ejection fraction. In this study, the long-term benefits and safety profile of heart rate regularization through left-bundle branch pacing (LBBP) and atrioventricular node ablation (AVNA) will be explored in comparison with pharmacological rate-control strategy.

METHODS AND RESULTS

The PACE-FIB trial is a multicentre, prospective, open-label, randomized (1:1) clinical study that will take place between March 2022 and February 2027. A total of 334 patients with HFpEF/HFmrEF and permanent AF will receive either LBBP followed by AVNA (intervention arm) or optimal pharmacological treatment for heart rate control according to European guideline recommendations (control arm). All patients will be followed up for a minimum of 36 months. The primary outcome measure will be the composite of all-cause mortality, HF hospitalization, and worsening HF at 36 months. Other secondary efficacy and safety outcome measures such as echocardiographic parameters, functional status, and treatment-related adverse events, among others, will be analysed too.

CONCLUSION

LBBP is a promising stimulation mode that may foster the clinical benefit of heart rate regularization through AV node ablation compared with pharmacological rate control. This is the first randomized trial specifically addressing the long-term efficacy and safety of this pace-and-ablate strategy in patients with HFpEF/HFmrEF and permanent AF.

Impact of previous macrolide use on invasive pneumococcal disease due to erythromycin-resistant serotypes in adults over 59 years of age

The major goals of the study were to describe the invasive pneumococcal disease (IPD) cases due to erythromycin-resistant serotypes and to evaluate the association between these cases and recent macrolide use in individuals aged over 59 years. We selected cases of IPD reported between 2007 and 2016 in persons aged over 59 years living in the Community of Madrid (CM). We followed the European Committee on Antimicrobial Susceptibility Testing (EUCAST). The explanatory variables (age, sex, year of onset of symptoms, clinical presentation, serotypes, vaccination status) were taken from the Mandatory Notification System for Infectious Diseases System and from the Vaccination Information System. The cases were classified as either included in the 13-valent pneumococcal conjugate vaccine (PCV13) or not (nonPCV13). Associations between cases due to erythromycin-resistant serotypes and previous macrolide use (total, long and short-term) were adjusted with a logistic regression multivariate analysis. A total of 1,831 cases were identified, of whom 408 were erythromycin-resistant serotypes. PCV13 cases were associated with previous macrolide use (OR: 5.07), particularly long-acting types (OR: 8.61). NonPCV13 cases were associated with the use of total macrolides (OR: 3.48) and long-acting macrolides (OR: 4.26) suggesting that PCV13 did not reduce the IPD cases in patients with previous use of macrolides. Our results confirmed that previous macrolide consumption was associated with the presence of IPD due to erythromycin-resistant serotypes. The risk was higher with the use of long-term macrolides.

Effect of a Therapeutic Strategy Guided by Lung Ultrasound on 6-Month Outcomes in Patients with Heart Failure: Randomized, Multicenter Trial (EPICC Study)

INTRODUCTION AND OBJECTIVES

Pulmonary congestion (PC) is associated with an increased risk of hospitalization and death in patients with heart failure (HF). Lung ultrasound has shown to be highly sensitive for detecting PC in HF. The aim of this study is to evaluate whether lung ultrasound-guided therapy improves 6-month outcomes in patients with HF compared with conventional treatment.

MATERIALS AND METHODS

Randomized, multicenter, single-blind clinical trial in patients discharged from Internal Medicine Departments after hospitalization for decompensated HF. Participants will be assigned 1:1 to receive treatment guided according to the presence of lung ultrasound signs of congestion (semi-quantitative evaluation of B lines and the presence of pleural effusion) versus clinical assessment of congestion. The primary outcome is the combination of cardiovascular death and readmission for HF at 6 months.

CONCLUSIONS

The results of this study will provide more evidence about the impact of lung ultrasound on treatment monitoring in patients with chronic HF.

Ambulatory blood pressure monitoring in heart failure and serum sodium levels

AIMS

To determine whether there are differences in blood pressure profile on dynamic assessment by ambulatory blood pressure monitoring (ABPM) according to serum sodium levels in stable heart failure patients.

METHODS

Data were collected from the Spanish National Registry on Ambulatory Blood Pressure Monitoring in Heart Failure (DICUMAP). Patients underwent ABPM by the oscillometric principle using a Spacelabs 90121 monitor. The sample was divided into three groups according to sodium levels and their clinical and laboratory data and echocardiographic findings were analyzed. Robust statistical methods were used to compare the groups in univariate and multivariate models.

RESULTS

A total of 175 patients (44.57% male) were analyzed. We found a predominance of anomalous circadian blood pressure profiles in all three groups, with a significantly higher percentage of risers in the lowest serum sodium group (p=0.05). In addition, in this group there were significant differences in mean 24-hour systolic blood pressure (SBP) (24-h SBP, p=0.05) and in mean daytime SBP (dSBP, p=0.008), with significant differences in nocturnal fall in SBP (p=0.05) and in diastolic blood pressure (p=0.005). In multivariate analysis a significant relationship was found between sodium levels and 24-h SBP (OR 0.97, 95% CI 0.95-0.99, p=0.01) and dSBP (OR 0.96, 95% CI 0.94-0.99, p=0.004).

CONCLUSION

A relationship was found between lower sodium levels and lower systolic blood pressure, especially during waking hours, with a lower decline between daytime and night-time blood pressure.

[Consensus on improving the care integrated of patients with acute heart failure]

Acute heart failure (AHF) requires considerable use of resources, is an economic burden, and is associated with high complication and mortality rates in emergency departments, on hospital wards, or outpatient care settings. Diagnosis, treatment, and continuity of care are variable at present, leading 3 medical associations (for cardiology, internal medicine, and emergency medicine) to undertake discussions and arrive at a consensus on clinical practice guidelines to support those who manage AHF and encourage standardized decision making. These guidelines, based on a review of the literature and clinical experience with AHF, focus on critical points in the care pathway. Regarding emergency care, the expert participants considered the initial evaluation of patients with signs and symptoms that suggest AHF, the initial diagnosis, first decisions about therapy, monitoring, assessment of prognosis, and referral criteria. For care of the hospitalized patient, the group developed a protocol for essential treatment. Objectives for the management and treatment of AHF on discharge were also covered through the creation or improvement of multidisciplinary care systems to provide continuity of care.

Impaired mitogenic response of peripheral blood T cells in ulcerative colitis is not due to apoptosis

An abnormal immune response may play a pathogenic role in ulcerative colitis (UC). Animal models suggest that T-cell regulation may be of central importance in the inflammatory process. Our aims were the characterization of the phenotype and functional status of circulating T-cells in ulcerative colitis patients and to determine if activation-induced cell death in CD4 and CD8 lymphocytes in patients differs from healthy controls. Forty-eight patients (24 women and 24 men) fulfilling the histopathological, clinical, and immunological criteria for UC were studied. T-cell phenotype and function were studied in blood lymphocytes from patients with ulcerative colitis and healthy donors by flow cytometric analysis, as well as [3H]thymidine incorporation. There were no significant differences in the percentage of T-cell subpopulations (CD3, CD4, CD8) and NK cells in the different groups. The percentage of cells in growth phase S+G2M at two and three days of phytohemagglutinin (PHA) stimulation was significantly decreased in UC patients, but the percentage of CD4+ and CD8+ cells in UC patients that showed apoptosis was not significantly different than that in the control group. Proliferative responses to IL-4 also suggested that a reduced responsiveness to this cytokine may be involved in UC. In conclusion, the impaired proliferative response to PHA of T lymphocytes from UC patients is not associated with an in vitro increase in the apoptotic response in CD4+ or CD8+ cells. A reduced IL-4 response may be involved in this peculiar mitogenic response. These changes may be pathogenic or a favorable adaptive mechanism.

Pregnancy in patients with autoimmune thrombocytopenic purpura

The obstetric and hematologic problems in 21 pregnancies of 18 patients with ATP are analyzed: one maternal and one fetal death occurred. Urinary estriol and oxytocinase were measured. Eighteen infants were born by vaginal delivery and three by cesarean section. None of the 20 liveborn infants died, but they had NIP due to the passage of maternal antibodies to the fetus. These results are compared to those reported in previous publications. The obstetric management of these patients should be individualized and carefully planned; it should not be based on the platelet count.