Clinical and Prognostic Significance of sST2 in Heart Failure: JACC Review Topic of the Week

Soluble suppression of tumorigenesis-2 (sST2) is released in response to vascular congestion and inflammatory and pro-fibrotic stimuli, and is a strong, independent predictor of mortality and heart failure (HF) hospitalization in patients with acute or chronic HF. sST2 meets 2 fundamental criteria for clinically useful biomarkers: accurate, repeated measurements are available at a reasonable cost, and the biomarker provides information not already available from a careful clinical assessment. In particular, the prognostic value of sST2 is additive to natriuretic peptides and (in the case of chronic HF) to high-sensitivity troponin T. Nevertheless, the need for a multibiomarker approach to risk stratification and the role of sST2 as a guide to therapy decision-making remain to be established. Four years after a consensus document on sST2, and following major advances in the comprehension of the clinical value of this biomarker, the authors felt it worthwhile to reappraise current knowledge on sST2 in HF.

Central and Obstructive Apneas in Heart Failure With Reduced, Mid-Range and Preserved Ejection Fraction

Background: Although central apneas (CA) and obstructive apneas (OA) are highly prevalent in heart failure (HF), a comparison of apnea prevalence, predictors and clinical correlates in the whole HF spectrum, including HF with reduced ejection fraction (HFrEF), mid-range EF (HFmrEF) and preserved EF (HFpEF) has never been carried out so far.

Materials and methods: 700 HF patients were prospectively enrolled and then divided according to left ventricular EF (408 HFrEF, 117 HFmrEF, 175 HFpEF). All patients underwent a thorough evaluation including: 2D echocardiography; 24-h Holter-ECG monitoring; cardiopulmonary exercise testing; neuro-hormonal assessment and 24-h cardiorespiratory monitoring.

Results: In the whole population, prevalence of normal breathing (NB), CA and OA at daytime was 40, 51, and 9%, respectively, while at nighttime 15, 55, and 30%, respectively. When stratified according to left ventricular EF, CA prevalence decreased (daytime: 57 vs. 43 vs. 42%, p = 0.001; nighttime: 66 vs. 48 vs. 34%, p < 0.0001) from HFrEF to HFmrEF and HFpEF, while OA prevalence increased (daytime: 5 vs. 8 vs. 18%, p < 0.0001; nighttime 20 vs. 29 vs. 53%, p < 0.0001).

In HFrEF, male gender and body mass index (BMI) were independent predictors of both CA and OA at nighttime, while age, New York Heart Association functional class and diastolic dysfunction of daytime CA. In HFmrEF and HFpEF male gender and systolic pulmonary artery pressure were independent predictors of CA at daytime, while hypertension predicted nighttime OA in HFpEF patients; no predictor of nighttime CA was identified. When compared to patients with NB, those with CA had higher neuro-hormonal activation in all HF subgroups. Moreover, in the HFrEF subgroup, patients with CA were older, more comorbid and with greater hemodynamic impairment while, in the HFmrEF and HFpEF subgroups, they had higher left atrial volumes and more severe diastolic dysfunction, respectively. When compared to patients with NB, those with OA were older and more comorbid independently from background EF.

Conclusions: Across the whole spectrum of HF, CA prevalence increases and OA decreases as left ventricular systolic dysfunction progresses. Different predictors and specific clinical characteristics might help to identify patients at risk of developing CA or OA in different HF phenotypes.

Body mass index and outcomes in ischaemic versus non-ischaemic heart failure across the spectrum of ejection fraction

Aims

Obesity is related to better prognosis in heart failure with either reduced (HFrEF; left ventricular ejection fraction (LVEF) &lt; 40%) or preserved LVEF (HFpEF; LVEF ≥50%). Whether the obesity paradox exists in patients with heart failure and mid-range LVEF (HFmrEF; LVEF 40–49%) and whether it is independent of heart failure aetiology is unknown. Therefore, we aimed to test the prognostic value of body mass index (BMI) in ischaemic and non-ischaemic heart failure patients across the whole spectrum of LVEF.

Methods

Consecutive ambulatory heart failure patients were enrolled in two tertiary centres in Italy and Spain and classified as HFrEF, HFmrEF or HFpEF, of either ischaemic or non-ischaemic aetiology. Patients were stratified into underweight (BMI &lt; 18.5 kg/m2), normal-weight (BMI 18.5–24.9 kg/m2), overweight (BMI 25–29.9 kg/m2), mild-obese (BMI 30–34.9 kg/m2), moderate-obese (BMI 35–39.9 kg/m2) and severe-obese (BMI ≥40 kg/m2) and followed up for the end-point of five-year all-cause mortality.

Results

We enrolled 5155 patients (age 70 years (60–77); 71% males; LVEF 35% (27–45); 63% HFrEF, 18% HFmrEF, 19% HFpEF). At multivariable analysis, mild obesity was independently associated with a lower risk of all-cause mortality in HFrEF (hazard ratio, 0.78 (95% confidence interval (CI) 0.64–0.95), p = 0.020), HFmrEF (hazard ratio 0.63 (95% CI 0.41–0.96), p = 0.029), and HFpEF (hazard ratio 0.60 (95% CI 0.42–0.88), p = 0.008). Both overweight and mild-to-moderate obesity were associated with better outcome in non-ischaemic heart failure, but not in ischaemic heart failure.

Conclusions

Mild obesity is independently associated with better survival in heart failure across the whole spectrum of LVEF. Prognostic benefit of obesity is maintained only in non-ischaemic heart failure.

Sacubitril-valsartan treatment is associated with decrease in central apneas in patients with heart failure with reduced ejection fraction

BACKGROUND

To assess the impact of sacubitril-valsartan on apneic burden in patients with heart failure with reduced ejection fraction (HFrEF), 51 stable HFrEF patients planned for switching from an ACE-i/ARB to sacubitril-valsartan were prospectively enrolled.

METHODS AND RESULTS

At baseline and after 6 months of treatment, all patients underwent echocardiography, 24-h cardiorespiratory monitoring, neurohormonal evaluation, and cardiopulmonary exercise testing. At baseline 29% and 65% of patients presented with obstructive and central apneas, respectively. After 6 months, sacubitril-valsartan was associated with a decrease in NT-proBNP, improvement in LV function, functional capacity and ventilatory efficiency. After treatment, the apnea-hypopnea index (AHI) decreased across the 24-h period (p < 0.001), as well as at daytime (p < 0.001) and at nighttime (p = 0.026), proportionally to baseline severity. When subgrouping according to the type of apneas, daytime, nighttime and 24-h AHI decreased in patients with central apneas (all p < 0.01). Conversely, in patients with obstructive apneas, the effect of drug administration was neutral at nighttime, with significant decrease only in daytime events (p = 0.007), mainly driven by reduction in hypopneas.

CONCLUSIONS

Sacubitril-valsartan on top of medical treatment is associated with a reduction in the apneic burden among a real-life cohort of HFrEF patients. The most marked reduction was observed for central apneas.

Remdesivir, Renal Function and Short-Term Clinical Outcomes in Elderly COVID-19 Pneumonia Patients: A Single-Centre Study

BACKGROUND

Remdesivir, an antiviral agent able to reduce inflammatory cascade accompanying severe, life-threatening pneumonia, became the first drug approved by the Food and Drug Administration for the treatment of hospitalized patients with coronavirus 2 related severe acute respiratory syndrome (SARS CoV2). As from its previously known clinical indications, the use of remdesivir in the presence of severe renal impairment is contraindicated; however, the impact of remdesivir on renal function in aging patients has not been elucidated.

SUBJECTS AND METHODS

This retrospective observational study involved 109 individuals consecutively admitted in internal medicine section, Azienda Ospedaliero Universitaria Pisana hospital, in November-December 2020 due to a confirmed diagnosis of SARS CoV2 and receiving remdesivir according to international inclusion criteria. Biochemical variables at admission were evaluated, together with slopes of estimated glomerular filtration rate (eGFR) built during remdesivir treatment. Participants were followed until discharge or exitus.

RESULTS

Patients were stratified according to age (80 formed the study cohort and 29 served as controls); CKD stage III was present in 46% of them. No patients showed any sign of deteriorated renal function during remdesivir. Fourteen patients in the elderly cohort deceased; their eGFR at baseline was significantly lower. Recovered patients were characterized by a relevant eGFR gaining during remdesivir treatment.

CONCLUSION

We show here for the first time as remdesivir does not influence eGFR in a cohort of elderly people hospitalized for SARS CoV2, and that eGFR gain during such treatment is coupled with a better prognosis.

Central Apneas Are More Detrimental in Female Than in Male Patients With Heart Failure

Background

Central apneas (CA) are a frequent comorbidity in patients with heart failure (HF) and are associated with worse prognosis. The clinical and prognostic relevance of CA in each sex is unknown.

Methods and Results

Consecutive outpatients with HF with either reduced or mildly reduced left ventricular ejection fraction (n=550, age 65±12 years, left ventricular ejection fraction 32%±9%, 21% women) underwent a 24‐hour ambulatory polygraphy to evaluate CA burden and were followed up for the composite end point of cardiac death, appropriate implantable cardioverter‐defibrillator shock, or first HF hospitalization. Compared with men, women were younger, had higher left ventricular ejection fraction, had lower prevalence of ischemic etiology and of atrial fibrillation, and showed lower apnea‐hypopnea index (expressed as median [interquartile range]) at daytime (3 [0–9] versus 10 [3–20] events/hour) and nighttime (10 [3–21] versus 23 [11–36] events/hour) (all P<0.001), despite similar neurohormonal activation and HF therapy. Increased chemoreflex sensitivity to either hypoxia or hypercapnia (evaluated in 356 patients, 65%, by a rebreathing test) was less frequent in women (P<0.001), but chemoreflex sensitivity to hypercapnia was a predictor of apnea‐hypopnea index in both sexes. At adjusted survival analysis, daytime apnea‐hypopnea index ≥15 events/hour (hazard ratio [HR], 2.70; 95% CI, 1.06–7.34; P=0.037), nighttime apnea‐hypopnea index ≥15 events/hour (HR, 2.84; 95% CI, 1.28–6.32; P=0.010), and nighttime CA index ≥10 events/hour (HR, 5.01; 95% CI, 1.88–13.4; P=0.001) were independent predictors of the primary end point in women but not in men (all P>0.05), also after matching women and men for possible confounders.

Conclusions

In chronic HF, CA are associated with a greater risk of adverse events in women than in men.

Effect of therapeutic plasma exchange on plasma levels of oxidative biomarkers in a patient with thrombotic thrombocytopenic purpura

BACKGROUND

The role of oxidative stress in the initiation and progression of endothelial damage in thrombotic thrombocytopenic purpura (TTP) syndrome has been the subject of much speculation in the recent past.

OBJECTIVES

The aim of this study was to measure the concentration of plasma advanced oxidation protein products (AOPPs), advanced glycation end products (AGEs), and carbonyl groups (CG) as markers of oxidative stress in plasma of a patient with TTP during the course of the disease until recovery and to evaluate the effect of plasmapheresis (PE) on these biomarkers.

MATERIALS AND METHODS

The study consisted of plasma analysis of the patient, and 23 healthy subjects served as controls. In the patient with TTP, AOPP, AGE, and CG analysis was performed before and after each PE at the days +1 (Tα), +2, +4, +6, +10, +9, and +17 after the last plasmapheresis (Tω).

RESULTS

Plasma concentrations of AOPPs were increased in the acute phase of TTP, and at Tα, the patient had AOPPs levels higher than 99°‰ of controls. AOPPs decreased in the recovery phase, and at Tω, their values were between 84° and 85°‰ of controls. No significant difference was found in AOPP levels before and after each PE. No significant differences for AGEs or CG concentrations were found at Tα with respect to the control group, while only a trend was observed for reduction of plasma AGEs after each plasmapheresis.

CONCLUSION

Our data seem to confirm the hypothesis that oxidative stress is a critical component of the pathogenesis of TTP.

Effects of hyperventilation length on muscle sympathetic nerve activity in healthy humans simulating periodic breathing

Background: Periodic breathing (PB) is a cyclical breathing pattern composed of alternating periods of hyperventilation (hyperpnea, HP) and central apnea (CA). Differences in PB phenotypes mainly reside in HP length. Given that respiration modulates muscle sympathetic nerve activity (MSNA), which decreases during HP and increases during CA, the net effects of PB on MSNA may critically depend on HP length.

Objectives: We hypothesized that PB with shorter periods of HP is associated with increased MSNA and decreased heart rate variability.

Methods: 10 healthy participants underwent microelectrode recordings of MSNA from the common peroneal nerve along with non-invasive recording of HRV, blood pressure and respiration. Following a 10-min period of tidal breathing, participants were asked to simulate PB for 3 min following a computed respiratory waveform that emulated two PB patterns, comprising a constant CA of 20 s duration and HP of two different lengths: short (20 s) vs long (40 s). Results: Compared to (3 min of) normal breathing, simulated PB with short HP resulted in a marked increase in mean and maximum MSNA amplitude (from 3.2 ± 0.8 to 3.4 ± 0.8 µV, p = 0.04; from 3.8 ± 0.9 to 4.3 ± 1.1 µV, p = 0.04, respectively). This was paralleled by an increase in LF/HF ratio of heart rate variability (from 0.9 ± 0.5 to 2.0 ± 1.3; p = 0.04). In contrast, MSNA response to simulated PB with long HP did not change as compared to normal breathing. Single CA events consistently resulted in markedly increased MSNA (all p &lt; 0.01) when compared to the preceding HPs, while periods of HP, regardless of duration, decreased MSNA (p &lt; 0.05) when compared to normal breathing.

Conclusion: Overall, the net effects of PB in healthy subjects over time on MSNA are dependent on the relative duration of HP: increased sympathetic outflow is seen during PB with a short but not with a long period of HP.

Autonomic and respiratory consequences of altered chemoreflex function: clinical and therapeutic implications in cardiovascular diseases

The importance of chemoreflex function for cardiovascular health is increasingly recognized in clinical practice. The physiological function of the chemoreflex is to constantly adjust ventilation and circulatory control to match respiratory gases to metabolism. This is achieved in a highly integrated fashion with the baroreflex and the ergoreflex. The functionality of chemoreceptors is altered in cardiovascular diseases, causing unstable ventilation and apnoeas and promoting sympathovagal imbalance, and it is associated with arrhythmias and fatal cardiorespiratory events. In the last few years, opportunities to desensitize hyperactive chemoreceptors have emerged as potential options for treatment of hypertension and heart failure. This review summarizes up to date evidence of chemoreflex physiology/pathophysiology, highlighting the clinical significance of chemoreflex dysfunction, and lists the latest proof of concept studies based on modulation of the chemoreflex as a novel target in cardiovascular diseases.

Effects of nasal high flow on sympathovagal balance, sleep, and sleep-related breathing in patients with precapillary pulmonary hypertension

BACKGROUND

In precapillary pulmonary hypertension (PH), nasal high flow therapy (NHF) may favorably alter sympathovagal balance (SVB) and sleep-related breathing through washout of anatomical dead space and alleviation of obstructive sleep apnea (OSA) due to generation of positive airway pressure.

OBJECTIVES

To investigate the effects of NHF on SVB, sleep, and OSA in patients with PH, and compare them with those of positive airway pressure therapy (PAP).

METHODS

Twelve patients with PH (Nice class I or IV) and confirmed OSA underwent full polysomnography, and noninvasive monitoring of SVB parameters (spectral analysis of heart rate, diastolic blood pressure variability). Study nights were randomly split into four 2-h segments with no treatment, PAP, NHF 20 L/min, or NHF 50 L/min. In-depth SVB analysis was conducted on 10-min epochs during daytime and stable N2 sleep at nighttime.

RESULTS

At daytime and compared with no treatment, NHF20 and NHF50 were associated with a flow-dependent increase in peripheral oxygen saturation but a shift in SVB towards increased sympathetic drive. At nighttime, NHF20 was associated with increased parasympathetic drive and improvements in sleep efficiency, but did not alter OSA severity. NHF50 was poorly tolerated. PAP therapy improved OSA but had heterogenous effects on SVB and neutral effects on sleep outcomes. Hemodynamic effects were neutral for all interventions.

CONCLUSIONS

In sleeping PH patients with OSA NHF20 but not NHF50 leads to decreased sympathetic drive likely due to washout of anatomical dead space. NHF was not effective in lowering the apnea-hypopnoea index and NHF50 was poorly tolerated.

Renin profiling predicts neurohormonal response to sacubitril/valsartan

AIMS

Clinical trials and observational cohorts show that beneficial effects of sacubitril/valsartan are less strong in an appreciable proportion of patients with heart failure with reduced ejection fraction (HFrEF). Lower blood pressure and impaired renal function predict suboptimal sacubitril/valsartan titration and a less favourable response. Circulating renin encompasses neurohormonal activation, intravascular volume, and renal function. We hypothesized that renin may predict response to sacubitril/valsartan, assessed by changes in N-terminal fraction of pro-brain natriuretic peptide (NT-proBNP).

METHODS AND RESULTS

We performed a prospective, open-label, real-life cohort study. The study population consisted of 80 consecutive HFrEF patients (age 66 ± 10 years, 83% men) planned to initiate sacubitril/valsartan. Clinical and biohumoral assessment, including a full neurohormonal panel, was performed at baseline and at 1, 3, and 6 month follow-up. Response to sacubitril/valsartan was defined as ≥30% reduction in NT-proBNP levels from baseline to 6 months. Patients in the lower renin tertile had higher blood pressure and plasma sodium concentration (all P < 0.05). At follow-up, 38 patients (48%) were classified as responders. Circulating renin was lower in the responder group compared with non-responders (19.8 mU/L, IQR 3.7-78.0 mU/L vs. 55.0 mU/L, IQR 16.4-483.1 mU/L; P = 0.004). After adjustment for age, renal function, and blood pressure, renin was independently associated to response to sacubitril/valsartan (P = 0.018).

CONCLUSIONS

In our preliminary study, we show that circulating renin predicts reduction in NT-proBNP levels after sacubitril/valsartan initiation in HFrEF patients. Renin assessment might be useful to discriminate potential responders from the subgroup with a weaker expected benefit, thus needing a closer, tailored management strategy.

Prognostic impact of echocardiographic derived precapillary wedge pressure and pulmonary vascular resistances in patients with heart failure

Background

A reliable echocardiographic algorithm for the estimation of precapillary wedge pressure (PCWP) and pulmonary vascular resistances (PVR) has been recently validated by our group in a large cohort of patients undergoing right heart catheterization (RHC) (1). Those metrics may add relevant clinical and prognostic information in patients with heart failure (HF).

Objective

To assess the clinical/prognostic significance of echocardiographic derived PCWP and PVR in a large cohort of chronic HF patients on modern treatments.

Methods

Outpatients with chronic HF with either reduced (≤40%) or mildly reduced LVEF (41–49%) underwent a thorough clinical multiparametric assessment and were followed-up for a composite endpoint of cardiac death, appropriate ICD shock, or first HF hospitalization.

Results

Out of 1,483 patients prospectively enrolled (70±12 years, 73% males, 42% ischemic etiology, LVEF 35±8%), PCWP (16.4±5.8 mmHg) was elevated (&gt;15 mmHg) in 53% of cases, while PVR (1.7±0.7) was elevated (&gt;3 WU) in 6% of cases. Of the latter group, most (92%) had also elevated PCWP. Patients with increased PCWP were older, had a higher heart rate and lower cardiac output, showed a higher degree of left and right chamber remodeling, had a higher neurohormonal activation, worse renal function, worse functional capacity and ventilatory efficiency on effort (all p&lt;0.001). Those patients with high PCWP and PVR showed higher heart rate and pulmonary pressures, lower cardiac output, and right ventricular function, higher neurohormonal activation, lower functional capacity and ventilatory efficiency on effort compared to patients with high PCWP but normal PVR (all p&lt;0.01). The optimal prognostic cut-point was identified for both PCWP (16.2 mmHg) and PVR (2 WU) by log-rank maximal likelihood ratio. Over a median follow-up of 22 (8–37) months, both measures significantly stratified patients for the risk of the primary endpoint at Kaplan-Meier analysis (log-rank 92.9, p&lt;0.001 for PCWP; log-rank 17.3, p&lt;0.001 for PVR). At multivariable Cox regression analysis (adjusted for age, sex, ischemic HF etiology, renal function, LVEF, and NT-proBNP), PCWP (hazard ratio, HR 1.77 [95% CI 1.30–2.40], p&lt;0.001) but not PVR (HR 1.15 [95% CI 0.88–1.51], p=0.31) remained an independent predictor of the primary outcome.

Conclusion

The estimation of PCWP and PVR by echocardiography add relevant clinical and prognostic information and may help in the decision making in patients with HF.

Funding Acknowledgement

Type of funding sources: None.

Central and obstructive apneas prevalence in heart failure with reduced, mid-range and preserved ejection fraction

Background

Central apneas (CA) and obstructive apneas (OA) are highly prevalent in heart failure (HF) both with reduced and preserved systolic function. However, a comprehensive evaluation of apnea prevalence across HF according to ejection fraction (i.e HF with patients with reduced, mid-range and preserved ejection fraction- HFrEf, HFmrEF and HFpEF, respectively) throughout the 24 hours has never been done before.

Materials and methods

700 HF patients were prospectively enrolled and then divided according to left ventricular EF (408 HFrEF, 117 HFmrEF, 175 HFpEF). All patients underwent a thorough evaluation including: 2D echocardiography; 24-h Holter-ECG monitoring; cardiopulmonary exercise testing; neuro-hormonal assessment and 24-h cardiorespiratory monitoring.

Results

In the whole population, prevalence of normal breathing (NB), CA and OA at daytime was 40%, 51%, and 9%, respectively, while at nighttime 15%, 55%, and 30%, respectively.

When stratified according to left ventricular EF, CA prevalence decreased from HFrEF to HFmrEF and HFpEF: (daytime CA: 57% vs. 43% vs. 42%, respectively, p=0.001; nighttime CA: 66% vs. 48% vs. 34%, respectively, p&lt;0.0001), while OA prevalence increased (daytime OA: 5% vs. 8% vs. 18%, respectively, p&lt;0.0001; nighttime OA: 20 vs. 29 vs. 53%, respectively, p&lt;0.0001).

When assessing moderte-severe apneas, defined with an apnea/hypopnea index &gt;15 events/hour, prevalence of CA was again higher in HFrEF than HFmrEF and HFpEF both at daytime (daytime moderate-severe CA: 28% vs. 19% and 23%, respectively, p&lt;0.05) and at nighttime (nighttime moderate-severe CA: 50% vs. 39% and 28%, respectively, p&lt;0.05). Conversely, moderate-severe OA decreased from HFrEF to HFmrEF to HFpEF both at daytime (daytime moderate-severe OA: 1% vs. 3% and 8%, respectively, p&lt;0.05) and nighttime (noghttime moderate-severe OA: 10% vs. 11% and 30%, respectively, p&lt;0.05).

Conclusions

Daytime and nighttime apneas, both central and obstructive in nature, are highly prevalent in HF regardless of EF. Across the whole spectrum of HF, CA prevalence increases and OA decreases as left ventricular systolic dysfunction progresses, both during daytime and nighttime.

Funding Acknowledgement

Type of funding source: None

Sacubitril/valsartan improves ventilation stability in patients with chronic heart failure

Background

Sacubitril/valsartan (SV) ameliorates symptoms and prognosis in patients with heart failure and reduced ejection fraction (HFrEF), but the reasons for such effects are unclear. The impact of SV on ventilation has never been investigated. In HFrEF, apneas are highly prevalent both at daytime and nighttime and are associated with increased mortality.

Purpose

We hypothesize that treatment with SV could favourably stabilize ventilation by reducing the severity of central apneas in patients with HFrEF.

Methods

51 patients with HFrEF (mean age 67±9 years, mean left ventricular ejection fraction, LVEF 27±7%) and apneas defined by an apnea-hypopnea index, AHI≥5 (median 16, interquartile range 8–28) events/hour, eligible to treatment with SV and previously on optimal medical therapy for HFrEF, were enrolled. An extensive evaluation including cardiac ultrasound and a 24-hour cardiorespiratory monitoring was performed.

Results

After six months of treatment with SV, left ventricle systolic and diastolic function, mitral regurgitation (MR), left atrial volume (LAVI) and systolic pulmonary artery pressure (sPAP) were improved. Severity of apneas was reduced by 50%, 65% and 36% throughout the 24-hour, at daytime and nighttime, respectively.

Conclusion

Besides its known efficacy on cardiac remodeling, SV positively decreases the apneic burden in patients with HFrEF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics unrestricted grant

Clinical and prognostic significance of left ventricular outflow tract velocity time integral (LVOT-VTI) in patients with chronic heart failure

Background

The echocardiographic evaluation of cardiac output relies on the product of the flow across the left ventricular outflow tract (LVOT), estimated through its velocity time integral (LVOT-VTI), and its cross-sectional area, estimated through the formula πr2. Considering the geometrical assumption behind such formula, LVOT-VTI has been proposed as a more reproducible surrogate of cardiac systolic function and showed prognostic value in the critical care setting. However, the role of such measure in patients with chronic heart failure (HF) remains unexplored.

Objective

To assess the clinical and prognostic significance of LVOT-VTI in a contemporary cohort of patients with chronic HF.

Methods

Outpatients with chronic HF with a LV ejection fraction &lt;50% were prospectively enrolled to undergo a clinical, echocardiographic, and biohumoral assessment, and were followed-up for the endpoint of all-cause death.

Results

Finally, 971 patients were enrolled (71±12 years, 72% men, 50% ischemic etiology, LVEF 35±9%). Most patients showed a NYHA class I-II (74%) and were treated with ACE-inhibitors/ARBs or ARNI (81%), beta-blockers (95%), and mineralocorticoid receptor antagonists (71%). Patients were distinguished in three subgroups according to LVOT-VTI tertiles &lt;19 (n=324), 19–24 (n=324), or ≥24 (n=323). Compared with the other two subgroups, patients with LVOT-VTI &lt;19 showed worse NYHA class, lower LVEF and tricuspid annular plane systolic excursion (TAPSE), and higher E/e', left atrial volume index (LAVi), estimated systolic pulmonary arterial pressure (sPAP), and NT-proBNP concentration (all p&lt;0.001). No differences were observed as for patients' age, HF etiology, and therapies (all p&gt;0.05). Over a median follow-up of 22 (9–34) months, 103 (11%) patients met the primary endpoint. LVOT-VTI significantly stratified the risk of death, observing 65 (20%), 21 (7%), and 17 (5%) events across the subgroups with values &lt;19, 19–24, or ≥24 (log-rank 33, p&lt;0.001). At multivariable regression analysis, LVOT-VTI &lt;19 (HR 2.06 [95% 1.21–3.49], p=0.008), but not LVEF &lt;30% (p=0.614) was an independent predictor of all-cause death in a model adjusted for age, sex, ischemic etiology, renal function, hemoglobin, E/e', LAVi, TAPSE, sPAP, and NT-proBNP.

Conclusion

LVOT-VTI is associated with disease severity and is a strong predictor of all-cause death in patients with chronic HF.

Funding Acknowledgement

Type of funding sources: None.

737 CLINICAL AND PROGNOSTIC SIGNIFICANCE OF LEFT VENTRICULAR OUTFLOW TRACT VELOCITY TIME INTEGRAL (LVOT-VTI) IN PATIENTS WITH CHRONIC HEART FAILURE

Background

The echocardiographic evaluation of cardiac output relies on the product of the flow across the left ventricular outflow tract (LVOT), estimated through its velocity time integral (LVOT-VTI), and its cross-sectional area, estimated through the formula πr2. Considering the geometrical assumption behind such formula, LVOT-VTI may be a more reproducible surrogate of systolic function and showed prognostic value in the critical care setting. However, the role of this measure in patients with chronic heart failure (HF) remains unexplored.

Objective

To assess the clinical and prognostic significance of LVOT-VTI in a contemporary cohort of patients with chronic HF.

Methods

Outpatients with chronic HF with either reduced (≤40%) or mildly reduced (41-49%) LV ejection fraction (LVEF) were prospectively enrolled to undergo a clinical, echocardiographic, and biohumoral assessment, and were followed-up for the endpoint of cardiac death.

Results

Finally, 971 patients were enrolled (71±12 years, 72% men, 50% ischemic etiology, LVEF 35±9%, 74% HFrEF). Most patients showed a NYHA class I-II (74%) and were treated with ACE-inhibitors/ARBs or ARNI (81%), beta-blockers (95%), and mineralocorticoid receptor antagonists (71%). Patients were distinguished in three subgroups according to LVOT-VTI tertiles, i.e., ≤19 (n=324), 20-24 (n=324), or &gt;24 (n=323). Compared with the other two subgroups, patients with LVOT-VTI ≤19 showed worse NYHA class, lower LVEF and tricuspid annular plane systolic excursion (TAPSE), and higher E/e’, left atrial volume index (LAVi), estimated systolic pulmonary arterial pressure, and NT-proBNP concentration (all p&lt;0.001). No differences were observed as for patients’ age, HF etiology, and therapies (all p&gt;0.05). Over a median follow-up of 22 (9-34) months, 68 (7%) patients met the primary endpoint. LVOT-VTI significantly stratified the risk of cardiac death, observing 44 (13%), 15 (5%), and 9 (3%) events across the subgroups with values ≤19, 20-24, or &gt;24 (log-rank 25.9, p&lt;0.001). At multivariable regression analysis, LVOT-VTI ≤19 (HR 2.32 [95% 1.20-4.49], p=0.002), but not LVEF &lt;30% (p=0.614) was an independent predictor of cardiac death in a model adjusted for age, sex, ischemic etiology, renal function, hemoglobin, E/e’, LAVi, TAPSE, and NT-proBNP. Of note, this finding was consistent both in the HFrEF and HFmrEF subsets (p for interaction =0.899).

Conclusion

LVOT-VTI is associated with disease severity and is a strong predictor of all-cause death in patients with chronic HF.

Left ventricular outflow tract velocity-time integral improves outcome prediction in patients with secondary mitral regurgitation

AIMS

Left ventricular outflow velocity-time integral (LVOT-VTI) has been shown to improve outcome prediction in different patients' subsets, with or without heart failure (HF). Nevertheless, the prognostic value of LVOT-VTI in patients with HF and secondary mitral regurgitation (MR) has never been investigated so far. Therefore, in the present study, we aimed to assess the prognostic value different metrics of LV forward output, including LVOT-VTI, in HF patients with secondary MR.

METHODS AND RESULTS

Consecutive patients with HF and moderate-to-severe/severe secondary MR and systolic dysfunction (i.e., left ventricular ejection fraction [LVEF] <50%) were retrospectively selected and followed-up for the primary endpoint of cardiac death. Out of the 287 patients analyzed (aged 74 ± 11 years, 70% men, 46% ischemic etiology, mean LVEF 30 ± 9%, mean LVOT-VTI 20 ± 5 cm), 71 met the primary endpoint over a 33-month median follow-up (16-47 months). Patients with an LVOT-VTI ≤17 cm (n = 96, 32%) showed the greatest risk of cardiac death (Log Rank 44.3, p < 0.001) and all-cause mortality (Log rank 8.6, p = 0.003). At multivariable regression analysis, all the measures of LV forward volume (namely LVOT-VTI, stroke volume index, cardiac output, and cardiac index) were predictors of poor outcomes. Among these, LVOT-VTI was the most accurate in risk prediction (univariable C-statistics 0.70 [95%CI 0.64-0.77]).

CONCLUSION

Left ventricular forward output, noninvasively estimated through LVOT-VTI, improves outcome prediction in HF patients with low LVEF and secondary MR.

790 LEFT VENTRICULAR OUTFLOW TRACT VELOCITY TIME INTEGRAL OUTPERFORMS LEFT VENTRICULAR EJECTION FRACTION IN HEART FAILURE PATIENTS WITH SIGNIFICANT MITRAL REGURGITATION

Background

Reduced left ventricular ejection fraction (LVEF) has been used as a key criterion for the management of mitral regurgitation (MR) in patients with heart failure (HF), including the decision about mitral valve repair. However, LVEF, not taking into account mitral regurgitant volume, may be an imprecise predictor of outcome in HF patients with MR. Conversely, the estimation of the forward volume through the LV outflow tract (LVOT) may be a better metric in this setting. In this regard, LVOT velocity time integral (LVOT-VTI), not relying on geometrical assumptions, has been shown to be more reproducible than the calculated stroke volume (i.e., LVOT-VTI * LVOT cross sectional area), at least in the acute setting.

Objective

To assess the prognostic significance of LVOT-VTI in a contemporary cohort of patients with chronic HF and significant MR.

Methods

Consecutive patients with chronic HF with reduced (≤40%) or mildly reduced (41-49%) LVEF and moderate-to-severe or severe MR, according to the latest European Society of Cardiology criteria, were selected and followed-up for the endpoint of cardiovascular death.

Results

203 patients were enrolled in the study (74±11 years, 66% men, 47% ischemic etiology, HFrEF 86%, LVEF 31±9%, mean LVOT-VTI 21±6 cm). Most patients showed a NYHA class II (40%) or III (31%) and received beta-blockers (95%), ACE-inhibitors/ARBs or ARNI (77%), and mineralocorticoid receptor antagonists (82%). Seventy-seven patients (38%) had permanent atrial fibrillation and 46 (23%) a cardiac resynchronization therapy device. Over a median follow-up of 18 (7-33) months, 30 patients died, 24 of whom for a cardiovascular cause, and 10 underwent mitral valve repair/replacement. When stratified according to the optimal prognostic cut-off of LVOT-VTI, patients with a LVOT-VTI &lt;16 cm (n=36) showed the greater risk of cardiovascular death (Log Rank 18.2, p&lt;0.001, Figure). Similarly, patients with a LVEF &lt;33% (n=122) showed a higher risk of cardiovascular death (Log Rank 5.5, p=0.019). Nevertheless, at Cox regression analysis, a unit decrease in LVOT-VTI (hazard ratio, HR 0.87 [95%CI 0.79-0.95], p=0.002) but not in LVEF (p=0.729) was associated with a higher risk of cardiovascular death (Figure).

Conclusion

Left ventricular forward volume, noninvasively estimated through LVOT-VTI, but not LVEF, predicts the risk of cardiac death in patients with chronic HF and significant MR.

Performance of risk stratification scores and role of comorbidities in older vs younger patients with pulmonary arterial hypertension

BACKGROUND

Risk scores are important tools for the prognostic stratification of pulmonary arterial hypertension (PAH). Their performance and the additional impact of comorbidities across age groups is unknown.

METHODS

Patients with PAH enrolled from 2001 to 2021 were divided in ≥65 years old vs <65 years old patients. Study outcome was 5-year all-cause mortality. French Pulmonary Hypertension Network (FPHN), FPHN noninvasive, Comparative, Prospective Registry of Newly Initiated Therapies for Pulmonary Hypertension (COMPERA) and Registry to Evaluate Early and Long-term PAH Disease Management (REVEAL 2.0) risk scores were calculated and patients categorized at low, intermediate and high risk. Number of comorbidities was calculated.

RESULTS

Among 383 patients, 152 (40%) were ≥65 years old. They had more comorbidities (number of comorbidities 2, IQR 1-3, vs 1, IQR 0-2 in <65 years patients). Five-year survival was 63% in ≥65 vs 90% in <65 years. Risk scores correctly discriminated the different classes of risk in the overall cohort and in the older and younger groups. REVEAL 2.0 showed the best accuracy in the total cohort (C-index 0.74, standard error-SE- 0.03) and older (C-index 0.69, SE 0.03) patients, whereas COMPERA 2.0 performed better in younger patients (C-index 0.75, SE 0.08). Number of comorbidities was associated with higher 5-year mortality, and consistently increased the accuracy of risk scores, in younger but not in older patients.

CONCLUSIONS

Risk scores have similar accuracy in the prognostic stratification of older vs younger PAH patients. REVEAL 2.0 had the best performance in older patients and COMPERA 2.0 had it in younger patients. Comorbidities increased the accuracy of risk scores only in younger patients.

Incremental Prognostic Value of Echocardiography Measures of Right Ventricular Systolic Function in Patients With Chronic Heart Failure

BACKGROUND

Tricuspid annular plane systolic excursion (TAPSE), Doppler tissue imaging-derived tricuspid lateral annular systolic wave velocity (S'), and right ventricular fractional area change (RV-FAC) are the most widely used echocardiographic measures of right ventricular systolic function. This study aimed to compare the prognostic value of TAPSE, S', and RV-FAC in a large cohort of patients with chronic heart failure.

METHODS

Consecutive outpatients with heart failure and left ventricular ejection fraction <50% on guideline-recommended therapies undergoing echocardiography were followed up for the end point of cardiac and all-cause death.

RESULTS

Among 1590 patients (71±12 years, 77% men, left ventricular ejection fraction 34%±9%), 202 (13%) died from cardiac causes during a median follow-up of 28 (interquartile range, 14-40) months. According to the recommended cut points for TAPSE (<17 mm), S' (<9.5 cm/s), or RV-FAC (<35%), right ventricular systolic dysfunction was found in 37%, 40%, and 35% of patients, respectively, with 21%, 31%, and 33% of discordant cases comparing TAPSE versus S', TAPSE versus RV-FAC, and S' versus RV-FAC. Both TAPSE <17 mm and RV-FAC <35% were more accurate than S' <9.5 cm/s in predicting the risk of cardiac death (P<0.001), and their combination showed incremental prognostic power (P<0.001). Adding S' to the combination of TAPSE and RV-FAC did not provide further incremental value (P=0.145). Similar findings were obtained when all-cause death was considered as the end point.

CONCLUSIONS

In patients with chronic heart failure and left ventricular ejection fraction <50%, TAPSE, and RV-FAC are more accurate than S' in predicting the risk of cardiac and all-cause death. Considering both RV-FAC and TAPSE provides incremental prognostic value.

679 PROGNOSTIC IMPACT OF ECHOCARDIOGRAPHIC DERIVED PRECAPILLARY WEDGE PRESSURE AND PULMONARY VASCULAR RESISTANCES IN PATIENTS WITH HEART FAILURE

Background

A reliable echocardiographic algorithm for the estimation of precapillary wedge pressure (PCWP) and pulmonary vascular resistances (PVR) has been recently validated by our group in a large cohort of patients undergoing right heart catheterization (RHC). Those metrics may add relevant clinical and prognostic information in patients with heart failure (HF).

Objective

To assess the clinical/prognostic significance of echocardiographic derived PCWP and PVR in a large cohort of chronic HF patients on modern treatments.

Methods

Outpatients with chronic HF with either reduced (≤40%) or mildly reduced LVEF (41-49%) underwent a thorough clinical multiparametric assessment and were followed-up for a composite endpoint of cardiac death, appropriate ICD shock, or first HF hospitalization.

Results

Out of 1,483 patients prospectively enrolled (70±12 years, 73% males, 42% ischemic etiology, LVEF 35±8%, 74% HFrEF), PCWP (16.4±5.8 mmHg) was elevated (&gt;15 mmHg) in 53% of cases, while PVR (1.7±0.7) was elevated (&gt;2 WU) in 25% of cases. Of the latter group, most (83%) had also elevated PCWP. Patients with increased PCWP were older, had a higher heart rate and lower cardiac output, showed a higher degree of left and right chamber remodeling, had a higher neurohormonal activation, worse renal function, worse functional capacity and ventilatory efficiency on effort, particularly when also PVR were elevated (all p&lt;0.001). The optimal prognostic cut-point was identified for both PCWP (16.2 mmHg) and PVR (2 WU) by log-rank maximal likelihood ratio. Over a median follow-up of 27 (12-43) months, both measures significantly stratified patients for the risk of the primary endpoint at Kaplan-Meier analysis (Log Rank 99.5, p&lt;0.001 for PCWP; Log Rank 18.4, p&lt;0.001 for PVR). While both increased PCWP and PVR were associated with a higher risk of events in the HFrEF subgroup (both p&lt;0.001), only increased PCWP significantly stratified the outcome in HFmrEF patients (Figure). At multivariable Cox regression analysis (adjusted for age, sex, ischemic HF etiology, glomerular filtrate, LVEF, and NT-proBNP), increased PCWP (hazard ratio, HR 1.67 [95%CI 1.28-2.18], p&lt;0.001) but not PVR (HR 1.25 [95%CI 0.98-1.60], p=0.07) remained an independent predictor of the primary outcome.

Conclusion

The estimation of PCWP and PVR by echocardiography add relevant clinical and prognostic information and may help in the decision making in patients with HF.