Improvement of left ventricular ejection fraction in patients with heart failure with reduced ejection fraction: Predictors and clinical impact

BACKGROUND

A percentage of patients with heart failure with reduced ejection fraction (HFrEF) improve left ventricular ejection fraction (LVEF) in the evolution. This entity, defined for the first time in an international consensus as heart failure with improved ejection fraction (HFimpEF), could have a different clinical profile and prognosis than HFrEF. Our main aim was to analyze the differential clinical profile between the two entities, as well as the mid-term prognosis.

MATERIAL-METHODS

Prospective study of a cohort of patients with HFrEF who had echocardiographic data at baseline and follow-up. A comparative analysis of patients who improved LVEF with those who did not was made. Clinical, echocardiographic and therapeutic variables were analyzed, and the mid-term impact in terms of mortality and hospital readmissions for HF was assessed.

RESULTS

Ninety patients were analyzed. Mean age was 66.5(10.4) years, with a male predominance (72.2%). Forty five patients (50%) improved LVEF (Group-1,HFimpEF) and forty five patients (50%) sustained reduced LVEF (Group-2,HFsrEF). The mean time to LVEF improvement in Group-1 was 12.6(5.7) months. Group-1 had a more favorable clinical profile: lower prevalence of cardiovascular risk factors, higher prevalence of de novo HF (75.6% vs. 42.2%; p<0.05), lower prevalence of ischemic etiology (22.2% vs. 42.2%; p<0.05), with less basal dilatation of the left ventricle. At the end of follow-up (mean 19(1) months) Group-1 had a lower hospital readmission rate (3.1% vs. 26.7%; p<0.01), as well as lower mortality (0% vs. 24.4%; p<0.01).

CONCLUSION

Patients with HFimpEF seem to have a better mid-term prognosis in terms of reduced mortality and hospital admissions. This improvement could be conditioned by the clinical profile of patients HFimpEF.

P1702ARIADNA: first steps in the development of a collaborative initiative to create a map of automated external defibrillators and improve survival in out-of-hospital cardiac arrest in Spain

Background

Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of mortality worldwide. Although some geographical variation in the incidence of OHCA can be found, clinical outcomes are globally poor, with an expected percentage of survival to hospital discharge below 10% worldwide. Up to 60% of public OHCAs present with ventricular tachycardia or ventricular fibrillation. Early OHCA recognition and early defibrillation are key elements to increase the chances of survival with a favorable neurological outcome. To make this possible, easy access to automated external defibrillators (AEDs) must be warranted. Public AED programs have been implemented worldwide and have shown a significant improvement in survival and better functional outcome after OHCA. However, installation of public-access AEDs without linking them to responders appears to be meaningless and might not improve survival.

Ariadna is the first collaborative approach to improve survival in OHCA in Spain. Endorsed by the Spanish Society of Cardiology and the Spanish Red Cross, Ariadna is a smartphone app that aims to create a map of all available AEDs within the Spanish territory using GPS functions available on smartphones. This app is also directed at establishing the first national network of lay responders trained in cardiopulmonary resuscitation (CPR). In the future, this network will serve as an enhancing tool to provide a rapid response to OHCA under the coordination of the emergency medical services.

Purpose

To analyze the preliminary results in terms of dissemination and implementation of Ariadna in the first months after the release of the final version of the app.

Methods

Ariadna app is available for free on iOS and Android. Users can sign up as “seekers” to locate and validate AEDs within the Spanish territory. All AEDs are displayed on a map, including those pending validation. “Seekers” who provide proof of valid CPR training can become “responders” and agree to be alerted in case of OHCA nearby in the future.

In this preliminary analysis, the number of registered users along with the amount of registered and validated AEDs were retrieved from the app database.

Results

The final version of app was released September, 8, 2018. Since then and until February 2019, Ariadna has recruited 10846 users. A total of 3975 AEDs have been registered, 1037 of which (26%) have received validation from at least a different user. These numbers represent a growth rate of 70 new users and 26 new AEDs every day.

Ariadna App growth in numbers

Conclusion

Ariadna has experienced an exponential growth in the first months of functioning and is already helping raise awareness for cardiac arrest in Spain. This proves the social engagement and successful dissemination of this collaborative initiative. Every effort will be made to progressively increase the number of users and registered AEDs in order to link them to trained responders and finally improve survival in cardiac arrest.

Acknowledgement/Funding

Financial support from the Spanish Society of Cardiology

B-type natriuretic peptide-guided therapy for heart failure (HF): a systematic review and meta-analysis of individual participant data (IPD) and aggregate data

BACKGROUND

We estimated the effectiveness of serial B-type natriuretic peptide (BNP) blood testing to guide up-titration of medication compared with symptom-guided up-titration of medication in patients with heart failure (HF).

METHODS

Systematic review and meta-analysis of randomised controlled trials (RCTs). We searched: MEDLINE (Ovid) 1950 to 9/06/2016; Embase (Ovid), 1980 to 2016 week 23; the Cochrane Library; ISI Web of Science (Citations Index and Conference Proceedings). The primary outcome was all-cause mortality; secondary outcomes were death related to HF, cardiovascular death, all-cause hospital admission, hospital admission for HF, adverse events, and quality of life. IPD were sought from all RCTs identified. Random-effects meta-analyses (two-stage) were used to estimate hazard ratios (HR) and confidence intervals (CIs) across RCTs, including HR estimates from published reports of studies that did not provide IPD. We estimated treatment-by-covariate interactions for age, gender, New York Heart Association (NYHA) class, HF type; diabetes status and baseline BNP subgroups. Dichotomous outcomes were analysed using random-effects odds ratio (OR) with 95% CI.

RESULTS

We identified 14 eligible RCTs, five providing IPD. BNP-guided therapy reduced the hazard of hospital admission for HF by 19% (13 RCTs, HR 0.81, 95% CI 0.68 to 0.98) but not all-cause mortality (13 RCTs; HR 0.87, 95% CI 0.75 to 1.01) or cardiovascular mortality (5 RCTs; OR 0.88, 95% CI 0.67 to 1.16). For all-cause mortality, there was a significant interaction between treatment strategy and age (p = 0.034, 11 RCTs; HR 0.70, 95% CI 0.53-0.92, patients < 75 years old and HR 1.07, 95% CI 0.84-1.37, patients ≥ 75 years old); ejection fraction (p = 0.026, 11 RCTs; HR 0.84, 95% CI 0.71-0.99, patients with heart failure with reduced ejection fraction (HFrEF); and HR 1.33, 95% CI 0.83-2.11, patients with heart failure with preserved ejection fraction (HFpEF)). Adverse events were significantly more frequent with BNP-guided therapy vs. symptom-guided therapy (5 RCTs; OR 1.29, 95% CI 1.04 to 1.60).

CONCLUSION

BNP-guided therapy did not reduce mortality but reduced HF hospitalisation. The overall quality of the evidence varied from low to very low. The relevance of these findings to unselected patients, particularly those managed by community generalists, are unclear.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013005335.

Choice of New Oral Anticoagulant Agents Versus Vitamin K Antagonists in Atrial Fibrillation: FANTASIIA Study

INTRODUCTION

Atrial fibrillation (AF) is associated with an increased risk of thromboembolic events. Many patients with AF receive chronic anticoagulation, either with vitamin K antagonists (VKAs) or with non-VKA oral anticoagulants (NOACs). We sought to analyze variables associated with prescription of NOAC.

METHODS

Patients with AF under anticoagulation treatment were prospectively recruited in this observational registry. The sample comprised 1290 patients under chronic anticoagulation for AF, 994 received VKA (77.1%) and 296 NOAC (22.9%). Univariate and multivariate analyses were performed to identify variables associated with use of NOAC.

RESULTS

Mean age was 73.8 ± 9.4 years, and 42.5% of the patients were women. The CHA2DS2-VASc score was 0 in 4.9% of the population, 1 in 24.1%, and ≥2 in 71% (median = 4, interquartile range = 2). Variables associated with NOAC treatment were major bleeding (odds ratio [OR] = 3.36; confidence interval [CI] 95%: 1.73-6.51; P < .001), hemorrhagic stroke (OR = 3.19; CI 95% 1.00-10.15, P = .049), university education (OR = 2.44; CI 95%: 1.55-3.84; P < .001), high diastolic blood pressure (OR = 1.02; CI 95%: 1.00-1.03; P = .006), and higher glomerular filtration rate (OR 1.01, CI 95% 1.00-1.01; P = .01). And variables associated with VKA use were history of cancer (OR = 0.46; CI 95%: 0.25-0.85; P = .013) and bradyarrhythmia (OR = 0.40; CI 95% 0.19-0.85; P = .020).

CONCLUSION

Medical and social variables were associated with prescription of NOAC. Major bleeding, hemorrhagic stroke, university education, and higher glomerular filtration rate were more frequent among patients under NOAC. On the contrary, patients with history of cancer or bradyarrhythmias more frequently received VKA.