An integrated multiple marker modality is superior to NT-proBNP alone in prognostic prediction in all-cause mortality in a prospective cohort of elderly heart failure patients

BackgroundIdentifying the individual mortality risk for elderly heart failure (HF) patients is challenging because of heterogeneity, comorbidity and higher age. To overcome this, an integrated multiple marker modality has been proposed for better prognostic prediction than a single variable, this has not been evaluated.AimThe aim of this study is to identify whether a multiple marker modality is better than N-terminal pro-B-type natriuretic peptide (NT-proBNP) alone for all-cause mortality in elderly HF patients.MethodsA prospective cohort of 361 patients (65 ± 15 years) referred for echocardiography because of suspected HF was studied, among them, 179 had HF (71 ± 13). In this cohort blood sampling, electrocardiogram and clinical examinations were performed within approximately 24 hours after the echocardiography. To assess prognostic value of multiple marker modality for all-cause mortality, patients were followed up for 24 ± 7 months.ResultsIn the three multivariate analyses, NT-proBNP, cystatin C, red blood cell distribution width (RDW), midregional pro-atrial natriuretic peptide (MR-proANP), pulmonary artery pressure, estimated glomerular filtration rate (eGFR) less than 60 mL/min, anemia, diuretics and sinus rhythm are prognostic predictors of all-cause mortality in elderly HF patients. When analyzing all these variables in one multivariate analysis, only NT-proBNP, eGFR less than 60 mL/min, anemia and diuretics are prognostic predictors of all-cause mortality in elderly HF patients. Two different multiple marker models incorporating NT-proBNP, clinical and laboratory variables were created. The sensitivity and specificity of the two different multiple marker modalities are higher than for NT-proBNP alone. The risk score based on multivariate analysis Wald X² values is preferred considering its simplicity and feasibility in daily clinical practice.ConclusionA multiple marker modality was proven to improve prognostic prediction in elderly HF patients compared to NT-proBNP alone.     

Seasonal variation of decompensated heart failure admissions and mortality rates in sub-Saharan Africa,Cameroon

BackgroundEpidemiological data of heart failure (HF) decompensation from the northern hemisphere suggests higher rates during winter.ObjectivesWe aimed to explore the seasonal variation in decompensated HF admission and mortality rates in a country with equatorial climate.MethodsWe conducted a retrospective cross-sectional study by chart review of the admission, discharge registries and patient files from 2016 to 2018 in the cardiology unit of the Yaoundé Central Hospital, Cameroon. Data was collected on HF morbidity and mortality from the registers and patients’ files. Corresponding seasonal climatic data was obtained from the meteorology office of the Cameroonian ministry of transports. Analysis of variance and Chi-square test were respectively used to compare the continuous and categorical data between across seasons. Correlation between continuous data was assess with the Spearman correlation.ResultsDecompensated HF accounted for 636 (36.2%) out 1755 cardiology unit admission and an 18% lethality rate. Decompensated HF admission, mortality and lethality rates were respectively 38.2%, 6.7% and 17.9% higher during the long rainy season (all P values > 0.05). We observed a borderline-to-significant inverse linear continuous correlation between monthly temperatures and admission rate (r = ?0.301; P = 0.070), lethality rate (r = ?0.361; P = 0.030) and mortality rate (r = ?0.385; P = 0.020). There was no significant difference of the distribution of precipitating factors between seasons.ConclusionAlthough statistically insignificant, decompensated HF admissions and mortality increase in rainy season where the temperature is lower in an equatorial climate.     

Cardiothyreosis: Prevalence and risk factors

Cardiothyreosis (CT) or thyrotoxic heart disease is associated with higher morbidity and mortality than the other forms of hyperthyroidism. Its risk factors have been analyzed in a limited number of studies. The aims of our study were to investigate the prevalence of CT and its risk factors in patients with hyperthyroidism.MethodsWe identified 538 patients with a hospital discharge diagnosis of hyperthyroidism from January 2000 to December 2015. Among them, 35 patients were diagnosed as having CT. Their demographic, clinical and biological characteristics were studied and compared with those of 72 controls (patients admitted for hyperthyroidism without CT) randomly selected using univariate and multivariate analysis.ResultsThe prevalence of CT in patients hospitalized with overt hyperthyroidism was 6.5%. The cardiac complications seen were atrial fibrillation (AF) in 33 cases (6.1%) and cardiac heart failure (CHF) in 11 cases (2%). The risk factors of CT were age greater than 50 years (OR = 13.1; 95% CI [4.9–34.4]), low socioeconomic status (OR = 2.8; 95% CI [1.2–6.7]), low educational level (OR = 3.1; 95% CI [1.2–8.3]), personal history of hypertension (OR = 3.5; 95% CI [1.1–11.2]) and a multinodular toxic goiter as the etiology of hyperthyroidism (OR = 4.6; 95% CI [1.6–13.9]). After multivariate analysis, age greater than 50 years was the only independent risk factor of CT (adjusted OR = 11.6; 95% CI [2.7–49.5]). Severe biological hyperthyroidism (FT4 > 3 times normal) was associated with a lower risk of CT (adjusted OR = 0.2; 95% CI [0.1–0.9]).ConclusionsThe prevalence of CT in patients with overt hyperthyroidism was relatively low. Cardiac complications were AF and CHF with a clear predominance of AF. Advanced age was the only independent risk factor of CT. Cardiac complications may be seen even if hyperthyroidism is not biologically severe.     

Effectiveness of a follow-up program for elderly heart failure patients after hospital discharge. A randomized controlled trial

PurposeManagement programs for high-risk heart failure (HF) patients reduce admission rates, improve quality of life and survival, and lower costs. These benefits are controversial in elderly patients because these individuals are frequently excluded from the studies. Our aim was to evaluate the effectiveness of disease management programs (DMPs) for HF elderly patients attending a geriatric day care hospital (GDCH) subsequent to hospital discharge.MethodsA randomized prospective study was performed using 117 HF patients who were divided into two groups as follows: 59 patients undergoing an interventional program including health education, therapeutic control, and close follow-up in a GDCH; and 58 patients receiving standard healthcare. Results were measured in terms of event-free survival, where “event” is defined as readmission or mortality for any cause.ResultsThe mean age was 85 years, and 73% of the patients were women. After a year of follow-up, the intervention group had fewer patients with events compared with the control group (27 vs. 38 patients), which indicates a 30% reduction (RR: 2.25; 95% CI: 1.07–4.74; P = 0.032). The probability of having an event between the first visit and the year of follow-up was significantly lower in the intervention group (log-rank: 5.79; P = 0.016). Moreover, the quality of life improved significantly in the intervention group (P = 0.035).ConclusionA developed DMP in a GDCH improves the event-free survival and the quality of life in elderly patients with HF.Trial registrationisrctn.org identifier: ISRCTN10823032.     

Improvement in Health-related Quality of Life After Hospitalization Predicts Event-free Survival in Patients With Advanced Heart Failure

BackgroundHealth-related quality of life (HRQOL) is a major clinical outcome for heart failure (HF) patients. We aimed to determine the frequency, durability, and prognostic significance of improved HRQOL after hospitalization for decompensated HF.Methods and ResultsWe analyzed HRQOL, measured serially using the Minnesota Living with Heart Failure Questionnaire (MLHFQ), for 425 patients who survived to discharge in a multicenter randomized clinical trial of pulmonary artery catheter versus clinical assessment to guide therapy for patients with advanced HF. All patients enrolled had 1 or more prior HF hospitalizations or chronic high diuretic doses and 1 or more symptom and 1 sign of fluid overload at admission. Improvement, defined as a decrease of more than 5 points in MLHFQ total score, occurred in 68% of patients by 1 month and stabilized. The degree of 1-month improvement differed (P < .0001 group × time interaction) between 6-month survivors and non-survivors. In a Cox regression model, after adjustment for traditional risk factors for HF morbidity and mortality, improvement in HRQOL by 1 month compared to worsening at 1 month or no change predicted time to subsequent event-free survival (P = .013).ConclusionsIn patients hospitalized with severe HF decompensation, HRQOL is seriously impaired but improves substantially within 1 month for most patients and remains improved for 6 months. Patients for whom HRQOL does not improve by 1 month after hospital admission merit specific attention both to improve HRQOL and to address high risk for poor event-free survival.     

Prevalence of obstructive sleep apnoea in acute coronary syndrome: Routine screening in intensive coronary care units

IntroductionIncreased evidence has shown that, despite the maximum care afforded to patients admitted with acute coronary syndromes (ACS), a residual risk of mortality remains, in which obstructive sleep apnoea (OSA) appears to be a largely undiagnosed factor, particularly in the intensive cardiac care unit (ICCU). The purpose of this study is to determine whether the systematic screening for sleep-disordered breathing (SDB) is feasible and may be recommended. The aims of our study are to determine: (1) The estimated prevalence of OSA in patients admitted to the ICCU for ACS determined by a validated, user-friendly portable screening device; (2) The feasibility of the screening in this context; (3) To assess any negative impact of OSA on the severity of ACS.Patients and methodsThis is an observational study of 101 patients admitted to the ICCU for ACS showing no clinical evidence of heart failure (HF). In the 24–72 hours following admission, they underwent an overnight sleep study using a 3-channel portable screening device with automatic analysis.ResultsSixty-two out of the 101 patients proved positive to the screening test, and its feasibility was acceptable. OSA patients tended to have greater peak levels of hs-cTnT (3685 ± 3576 ng/L versus 2830 ± 3333 ng/L, P = 0.08) than the non-OSA group. Compared with the non-OSA group, OSA patients presented more severe ACS, with a greater average GRACE score at admission of 112.2 ± 26.3 (versus 98.4 ± 19.2, P < 0.001). In the OSA group, we found a statistically significant inverse correlation between the apnoea-hypopnea index (AHI) and the left ventricular ejection fraction (LVEF) in the linear regression analysis (r = −0.26; P = 0.037).ConclusionsA systematic screening of patients in the ICCU is acceptable. OSA is frequently found in the acute phase of ischaemic heart disease and its presence is associated with more severe ACS and a poorer left ventricle systolic function.     

Analyse médico-économique de l’impact d’une prise en charge de l’insuffisance cardiaque chronique en unité thérapeutique d’insuffisance cardiaque versus prise en charge habituelle de ville

Chronic heart failure remains a frequent, severe and costly disease. Despite encouraging data from different countries, heart failure clinics are scarce in France. We have analyzed the impact of a heart failure clinic (UTIC of Pontoise) in terms of reduction of rehospitalizations and in hospitalization costs in 4855 consecutive patients. In our study, heart failure clinic management dramatically reduces HF related hospitalizations (RRR: −28 %, P = 0.001) and HF related costs (55% reduction, P < 0.001) regardless of comorbidities or disease severity. HF clinics have to be developed in France in order to optimize management of CHF and reduce the HF related costs.     

Fragilidad y pronóstico de los pacientes mayores con insuficiencia cardiaca

Introduction and objectivesHeart failure (HF) is prevalent in advanced ages. Our objective was to assess the impact of frailty on 1-year mortality in older patients with ambulatory HF.MethodsOur data come from the FRAGIC study (Spanish acronym for “Study of the impact of frailty and other geriatric syndromes on the clinical management and prognosis of elderly outpatients with heart failure”), a multicenter prospective registry conducted in 16 Spanish hospitals including outpatients ≥ 75 years with HF followed up by cardiology services in Spain.ResultsWe included 499 patients with a mean age of 81.4 ± 4.3 years, of whom 193 (38%) were women. A total of 268 (54%) had left ventricular ejection fraction < 40%, and 84.6% was in NYHA II functional class. The FRAIL scale identified 244 (49%) pre-frail and 111 (22%) frail patients. Frail patients were significantly older, were more frequently female (both, P < .001), and had higher comorbidity according to the Charlson index (P = .017) and a higher prevalence of geriatric syndromes (P < .001). During a median follow-up of 371 [361-387] days, 58 patients (11.6%) died. On multivariate analysis (Cox regression model), frailty detected with the FRAIL scale was marginally associated with mortality (HR = 2.35; 95%CI, 0.96-5.71; P = .059), while frailty identified by the visual mobility scale was an independent predictor of mortality (HR = 2.26; 95%CI, 1.16-4.38; P = .015); this association was maintained after adjustment for confounding variables (HR = 2.13; 95%CI, 1.08-4.20; P = .02).ConclusionsIn elderly outpatients with HF, frailty is independently associated with mortality at 1 year of follow-up. It is essential to identify frailty as part of the comprehensive approach to elderly patients with HF.     

Hyponatremia is an independent predictor of adverse clinical outcomes in hospitalized patients due to worsening heart failure

Background and purposeHyponatremia is common and is associated with poor in-hospital outcomes in patients hospitalized with heart failure (HF). However, it is unknown whether hyponatremia is associated with long-term adverse outcomes. The purpose of this study was to clarify the characteristics, clinical status on admission, and management during hospitalization according to the serum sodium concentration on admission, and determine whether hyponatremia was associated with in-hospital as well as long-term outcomes in 1677 patients hospitalized with worsening HF on index hospitalization registered in the database of the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD).Methods and subjectsWe studied the characteristics and in-hospital treatment in 1659 patients hospitalized with worsening HF by using the JCARE-CARD database. Patients were divided into 2 groups according to serum sodium concentration on admission <135 mEq/mL (n = 176; 10.6%) or ≥135 mEq/mL (n = 1483; 89.4%).ResultsThe mean age was 70.7 years and 59.2% were male. Etiology was ischemic in 33.9% and mean left ventricular ejection fraction was 42.4%. After adjustment for covariates, hyponatremia was independently associated with in-hospital death [adjusted odds ratio (OR) 2.453, 95% confidence interval (CI) 1.265–4.755, p = 0.008]. It was significantly associated also with adverse long-term (mean 2.1 ± 0.8 years) outcomes including all-cause death (OR 1.952, 95% CI 1.433–2.657), cardiac death (OR 2.053, 95% CI 1.413–2.983), and rehospitalization due to worsening HF (OR 1.488, 95% CI 1.134–1.953).ConclusionsHyponatremia was independently associated with not only in-hospital but also long-term adverse outcomes in patients hospitalized with worsening HF.     

Optimisation du traitement de l’insuffisance cardiaque chronique par les médecins généralistes en sortie d’hospitalisation : les recommandations sont-elles appliquées ?

Heart failure is a common and serious disease, with constantly increasing incidence. General practitioners have an essential role in its management.Aim of the studyDescribe general practitioner's practice in optimizing heart failure treatment after hospital discharge.Patients and methodAll patients admitted for heart failure with altered ejection fraction in Nanterre's hospital cardiology department between February 2014 and January 2015 and having a general practitioner were included. Demographic, clinical, biological, ultrasound data and treatments were collected. A questionnaire was submitted to general practitioners two months after discharge.ResultsA total of 82 patients (age 76 ± 12 years, left ventricular ejection fraction 36 ± 8%) were included. The target dose of angiotensin-converting-enzyme inhibitors and beta-blockers was reached for 18% of patients during hospitalization. Forty-two general practitioners answered the questionnaire, which concerned 60% of patients (n = 49). None of them modified angiotensin-converting-enzyme inhibitors nor beta-blockers. The reasons were the lack of patient consultation (43%), the good tolerance (43%), the absence of habit (24%), and the attribution of this role to the cardiologist (41%). Possible improvements are: more precise hospitalization reports, alternating consultations and educational sessions.ConclusionPatients with heart failure are under-treated at discharge and general practitioners do not optimize the treatment after hospital discharge. The main axis of improvement is to establish a better defined care pathway.     

Safety and efficacy of adaptive servo-ventilation in patients with severe systolic heart failure

Background and purposeIt is unclear whether adaptive servo-ventilation (ASV) is safe and effective in patients with severe systolic heart failure (HF). Our aim in this study was to estimate the safety and efficacy of ASV therapy for patients with severe systolic HF.Methods and subjectsSeventy-six HF patients (age: 69 ± 12 years; 53 men), categorized as New York Heart Association (NYHA) Class II–IV, with left ventricular ejection fraction (LVEF) of <50%, received ASV therapy after optimal medical therapy to determine the safety and efficacy of ASV. Patients were divided into 2 groups based on their LVEF: group L (LVEF < 30%; n = 42) and group H (LVEF ≥ 30%; n = 34). After 6 months of ASV therapy, we compared the changes in LVEF, brain natriuretic peptide (BNP), and incidence of fatal cardiovascular events between the groups.ResultsThe groups differed significantly with respect to beta-blocker treatment before ASV therapy (p < 0.0001). After 6 months of ASV therapy, LVEF and BNP levels had improved in both groups. In group L, LVEF had improved from 24.1 ± 5.6% to 35.2 ± 10.6% (p < 0.0001) and BNP from 591 (273–993) pg/ml to 142 (39–325) pg/ml (p = 0.002). Moreover, 1-year follow-up data showed a tendency toward improvement of NYHA classification in group L (group L: 50%; group H: 29%; p = 0.07), and showed no significant difference with regard to fatal cardiovascular events between the 2 groups (group L: 11.9%; group H: 5.9%; p = 0.36).ConclusionsOur study demonstrated that ASV therapy is safe and effective for use in very severe systolic HF patients as well as in relatively mild systolic HF patients.     

The Effect of Renin-Angiotensin System Inhibitors on Mortality and Heart Failure Hospitalization in Patients With Heart Failure and Preserved Ejection Fraction: A Systematic Review and Meta-Analysis

BackgroundAlthough renin-angiotensin system (RAS) inhibitors have little demonstrable effect on mortality in patients with heart failure and preserved ejection fraction (HF-PEF), some trials have suggested a benefit with regard to reduction in HF hospitalization.Methods and ResultsHere, we systematically review and evaluate prospective clinical studies of RAS inhibitors enrolling patients with HF-PEF, including the 3 major trials of RAS inhibition (Candesartan in Patients with Chronic Heart Failure and Preserved Left Ventricular Ejection Fraction [CHARM-Preserved], Irbesartan in Patients with Heart Failure and Preserved Ejection Fraction [I-PRESERVE], and Perindopril in Elderly People with Chronic Heart Failure [PEP-CHF]). We also conducted a pooled analysis of 8021 patients in the 3 major randomized trials of RAS inhibition in HF-PEF (CHARM-Preserved, I-PRESERVE, and PEP-CHF) in fixed-effect models, finding no clear benefit with regard to all-cause mortality (odds ratio [OR] 1.03, 95% confidence interval [CI], 0.92-1.15; P = .62), or HF hospitalization (OR 0.90, 95% CI 0.80-1.02; P = .09).ConclusionsAlthough RAS inhibition may be valuable in the management of comorbidities related to HF-PEF, RAS inhibition in HF-PEF is not associated with consistent reduction in HF hospitalization or mortality in this emerging cohort.     

Prevalence and spectrum of iron deficiency in heart failure patients in south Rajasthan

ObjectiveTo estimate the prevalence and pattern of iron deficiency (ID) in heart failure (HF) patients with or without anemia.MethodsThis is a single-center observational study, conducted at a tertiary care hospital of south Rajasthan. Patients admitted to hospital with clinical diagnosis of HF based on validated clinical criteria were included in the study. ID was diagnosed based on complete Iron profile, including serum iron, serum ferritin, total iron binding capacity, and transferrin saturation (TSAT). Anemia was defined as hemoglobin (Hb) <13 g/dl for males and <12 g/dl for females, based on World Health Organization definition. Absolute ID was taken as serum ferritin < 100 μg/L and functional ID was defined as normal serum ferritin (100–300 μg/L) with low TSAT (<20%).ResultsA total of 150 patients of HF (68% males and 32% females) were studied. Most of the patients were of high-functional NYHA class (mean NYHA 2.89 ± 0.95). ID was present in 76% patients with 48.7% patients having absolute and 27.3% patients having functional ID. Females were having significantly higher prevalence of ID than males (91.6% vs 68.6%; p = 0.002). Nearly one-fourth of the patients were having ID but without anemia, signifying importance of workup of ID other than Hb.ConclusionOur study highlights the yet underestimated and neglected burden of ID in HF patients in India. This study suggests further large-scale studies to better characterize this easily treatable condition and considering routine testing in future Indian guidelines.     

Cardiac rehabilitation for heart failure: Do older people want to attend and are they referred?

PurposeUptake of cardiac rehabilitation services by older people is suboptimal. Offering suitable services may increase participation. This study investigated older heart failure patients’ preferences between hospital, community and home-based service models and sociodemographic and clinical factors associated with these preferences. Rates of referral were examined.MethodsCross-sectional survey of patients aged 65 years and older consecutively admitted to elderly care, cardiology and general medicine wards in a large UK hospital with confirmed heart failure between March–December 2009. A 57-item interview schedule incorporating open and closed questions and standard measures was developed enabling both quantitative and qualitative analysis. Associations between patients’ preferences and characteristics including disease severity (New York Heart Association [NYHA] classification) and comorbidity (Charlson comorbidity score) were analysed using Chi-squared tests and one-way ANOVA.ResultsOne hundred and six interviews were completed (mean age 77.8 ± 7.3, 62% male, 47% lived alone). Most patients had moderate–severe heart failure (55% NYHA class III; 34% class II) and co-morbidities (mean Charlson score 3.3 ± 1.7). Most opted for cardiac rehabilitation (72%), preferring hospital to community classes. Those preferring hospital programmes were younger (mean 5.1 years, 95% CI –10.1 to –0.1, P = 0.043) than those preferring not to participate. Neither disease severity nor comorbidity was associated with preferences. Only 21% were referred to any cardiac rehabilitation service.ConclusionMost of these older heart failure patients wanted to attend cardiac rehabilitation, but few were referred. Age was related to preferring certain cardiac rehabilitation service models but not to an overall preference to attend. Referral processes need urgent improvement and offering choice of service models may increase participation.     

Endocardite infectieuse compliquée d’insuffisance cardiaque

BackgroundAlthough the progress of antibiotic prophylactic field, infective endocarditis remains a frequent pathology. Heart failure represents his main complication.AimThe aim of the study was to determine the various characteristics of patients suffering from heart failure complicated by infective endocarditis and to define its impact on the mortality.Patients and methodsFrom the infective endocarditis register of our service comparing 241 patients and responding to criteria of DURAK DUKE University which collected retrospectively, we included patients with heart failure on admission, namely dyspnea greater or equal to NYHA stage II. A total of 85 patients were enrolled in the heart failure (35.2% of register).ResultsHeart failure complicating infective endocarditis of native valve had occurred in 66 cases (77.6%). The microbiological investigation was positive in 43.5% of cases with a predominance of staphylococcus. The using of surgery was necessary in 65.8% of cases. Hemodynamic instability was the main indication. The total mortality in our registry was 19.5%, but higher in the group with heart failure (28.2% vs. 14.7%; P = 0.006). In the multivariate analysis we found, as predictive factors for mortality of infective endocarditis complicated by heart failure group, the significant influence of anemia (OR = 5.2; 95% CI: [1.6–24]; P = 0.02), infection by Staphylococcus aureus (OR = 5.7; 95% CI: [0.8–29.8]; P = 0.03) and surgery delay (OR = 3.1 ; 95% CI: [1.1–14.7]; P = 0.01).ConclusionHeart failure is the most frequent complication of infectious endocarditis, and its first cause of death.     

Heart rate manipulation in dilated cardiomyopathy: Assessing the role of Ivabradine

BackgroundHeart rate (HR) reduction is of benefit in chronic heart failure (HF). The effect of heart rate reduction using Ivabradine on various echocardiographic parameters in dilated cardiomyopathy has been less investigated.MethodsOf 187 patients with HF (DCM, NYHA II–IV, baseline HR > 70/min), 125 patients were randomized to standard therapy (beta blockers, ACEI, diuretics, n = 62) or add-on Ivabradine (titrated to maximum 7.5 mg BD, n = 63). Beta-blockers were titrated in both the groups.ResultsAt 3 months both groups had improvement in NYHA class, 6 min walk test, Minnesota Living With Heart Failure (MLWHF) scores and fall in BNP, however the magnitude of change was greater in Ivabradine group. Those on Ivabradine also had lower LV volumes, higher LVEF (28.8 ± 3.6 vs 27.2 ± 0.5, p = 0.01) and more favorable LV global strain (11 ± 1.7vs 12.2 ± 1.1, p = <0.001), MPI (0.72 ± 0.1 vs 0.6 ± 0.1, p = <0.001), LV mass (115.2 ± 30 vs 131.4 ± 35, p = 0.007), LV wall stress (219.8 ± 46 vs 238 ± 54) and calculated LV work (366 ± 101 vs 401 ± 102, p = 0.05). The benefit of Ivabradine was sustained at 6 months follow up. The % change in HR was significantly higher in Ivabradine group (−32.2% vs −19.3%, p = 0.001) with no difference in blood pressure. Resting HR < 70/min was achieved in 96.8% vs 27.9%, respectively in the two groups.ConclusionAddition of Ivabradine to standard therapy in patients with DCM and symptomatic HF and targeting a heart rate < 70/min improves symptoms, quality of life and various echocardiographic parameters.     

Usefulness of right atrial volume index in predicting outcome in chronic systolic heart failure

BackgroundRight ventricular (RV) dysfunction is associated with poor prognosis in patients with heart failure (HF). Echocardiographic assessment of RV systolic function is challenging. The ability to visualize the right atrium (RA) allows a quantitative, highly reproducible assessment of RA volume.ObjectiveThe aim is to study the relationship between the right atrial volume index (RAVI) and prognosis in patients with chronic systolic HF.Methods120 patients with chronic systolic HF and left ventricular ejection fraction (LVEF) <40% were enrolled. The RA volume was calculated by Simpson’s method using single-plane RA area and indexed to body surface area (RAVI). RV systolic assessment was done using the RV fractional area change (RVFAC), and peak systolic velocity (Sa_tri) using tissue Doppler imaging at the tricuspid annulus. The primary endpoint was death, urgent transplantation, or acute HF episode requiring hospital admission during a follow-up of 1 year.ResultsFollow up was complete for 117 of 120 patients. Fifty-two patients reached the primary endpoint. The mean RAVI was higher in patients with adverse events (45.5 ± 15 ml/m² versus 25.2 ± 11 ml/m², p < 0.001), and increased with worsening LVEF, RVFAC, Sa_tri (Spearman’s r = −0.46, r = −0.45, r = −0.59, p < 0.001 for all). RAVI was not correlated with estimates of RV diastolic dysfunction. The cut-off threshold for RAVI to predict the primary endpoint using receiver-operating characteristic curve was 29 ml/m² (area under the curve was 0.89%, 95% confidence interval: 0.82–0.95) with a sensitivity of 92%, and a specificity of 75%. NYHA > 2 (OR = 2.1, p < 0.01), and RAVI (OR = 1.6, p < 0.05) were found to be independent predictors of adverse outcome.ConclusionIn patients with chronic systolic HF, RAVI is an independent predictor of adverse outcome with a threshold value of 29 ml/m².     

Efecto pronóstico diferencial de la diabetes mellitus tipo 2 en mujeres y varones con insuficiencia cardiaca y fracción de eyección conservada

Introduction and objectivesType 2 diabetes mellitus (DM2) is a common comorbidity in patients with heart failure (HF) with preserved ejection fraction (HFpEF). Previous studies have shown that diabetic women are at higher risk of developing HF than men. However, the long-term prognosis of diabetic HFpEF patients by sex has not been extensively explored. In this study, we aimed to evaluate the differential impact of DM2 on all-cause mortality in men vs women with HFpEF after admission for acute HF.MethodsWe prospectively included 1019 consecutive HFpEF patients discharged after admission for acute HF in a single tertiary referral hospital. Multivariate Cox regression analysis was used to evaluate the interaction between sex and DM2 regarding the risk of long-term all-cause mortality. Risk estimates were calculated as hazard ratios (HR).ResultsThe mean age of the cohort was 75.6 ± 9.5 years and 609 (59.8%) were women. The proportion of DM2 was similar between sexes (45.1% vs 49.1%, P = .211). At a median (interquartile range) follow-up of 3.6 (1-4-6.8) years, 646 (63.4%) patients died. After adjustment for risk factors, comorbidities, biomarkers, echo parameters and treatment at discharge, multivariate analysis showed a differential prognostic effect of DM2 (P value for interaction = .007). DM2 was associated with a higher risk of all-cause mortality in women (HR, 1.77; 95%CI, 1.41-2.21; P < .001) but not in men (HR, 1.23; 95%CI, 0.94-1.61; P = .127).ConclusionsAfter an episode of acute HF in HFpEF patients, DM2 confers a higher risk of mortality in women. Further studies evaluating the impact of DM2 in women with HFpEF are warranted.Full English text available from:www.revespcardiol.org/en     

Valor pronóstico de la fibrosis hepática valorada por el índice FIB4 en pacientes ingresados por síndrome coronario agudo

Introduction and objectivesLiver fibrosis is present in nonalcoholic liver disease (NAFLD) and both precede liver failure. Subclinical forms of liver fibrosis might increase the risk of cardiovascular events. The objective of this study was to describe the prognostic value of the FIB-4 index on in-hospital mortality and postdischarge outcomes in patients with acute coronary syndrome (ACS).MethodsRetrospective study including all consecutive patients admitted for ACS between 2009 and 2019. According to the FIB-4 index, patients were categorized as < 1.30, 1.30-2.67 or > 2.67. Heart failure (HF) and major bleeding (MB) were assessed taking all-cause mortality as a competing event and subhazard ratios (sHR) are presented. Recurrent events were evaluated by the incidence rate ratio (IRR).ResultsWe included 3106 patients and 6.66% had a FIB-4 index ≥ 1.3. A multivariate analysis verified a higher risk of in-hospital mortality associated with the FIB-4 index (OR, 1.24; P = .016). Patients with a FIB-4 index > 2.67 had a 2-fold higher in-hospital mortality risk (OR, 2.35; P = .038). After discharge (median follow-up 1112 days), the FIB-4 index had no prognostic value for mortality. In contrast, patients with FIB-4 index ≥ 1.3 had a higher risk of first (sHR, 1.61; P = .04) or recurrent (IRR, 1.70; P = .001) HF readmission. Similarly, FIB-4 index ≥ 1.30 was associated with a higher MB risk (sHR, 1.62; P = .030).ConclusionsThe assessment of liver fibrosis by the FIB-4 index identifies ACS patients not only at higher risk of in-hospital mortality but also at higher risk of HF and MB after discharge.Full English text available from:www.revespcardiol.org/en     

Transition from angiotensin-converting enzyme inhibitor/angiotensin-II-receptor-blocker to sacubitril/valsartan in chronic heart failure patients: Initial experiences in clinical practice

BackgroundSacubitril/valsartan (S/V) therapy has been demonstrated to improve prognosis of systolic heart failure (HF) patients when compared to standard therapy with ACEi. The purpose of this investigation was to document the safety and consequences of transition from ACEi/angiotensin-II receptor blocker (ARB) to S/V in chronic stable HF patients.MethodsA group of 12 stable HF outpatients (11 males, 1 female) was enrolled (NYHA 2.7 ± 0.7, 42% with coronary artery disease (CAD), average left-ventricle ejection fraction (LVEF) 26.5%). Patients were converted from ACEi/ARB to S/V. Laboratory evaluation, Minnesota Living with Heart Failure Questionnaire (MLHFQ), six-minute walk test (6MWT) were performed before the conversion and at 3-month follow-up visit.ResultsConversion from ACEi/ARB to S/V was not associated with any adverse event. After 3 months, S/V therapy decreased blood pressure (−14.8 mmHg for systolic BP, −9.6 mmHg for diastolic BP) and serum potassium (−0.27 mmol·l⁻¹, all p < 0.05). No worsening of renal function occurred (creatinine −7.8 μmol·l⁻¹, p = 0.12, estimated glomerular filtration rate +0.08 ml·s⁻¹·1.73 m⁻², p = 0.14). B-type natriuretic peptide (BNP) level remained unchanged (p = 0.18), but NT-proBNP level decreased significantly (median 1012 ng·l⁻¹ at baseline, 559.4 ng·l⁻¹ at follow-up, p = 0.005). A slight but significant decrease in high-sensitivity cardiac troponin T (hs-cTnT) was observed (median 14.76 ng·l⁻¹ at baseline, 12.63 ng·l⁻¹ at follow-up, p = 0.001). An improvement in MLHFQ total score (−8 points, p = 0.006) and in 6MWT by 55 m (p = 0.0007) was noted, which was not due to increased effort.ConclusionThe transition from ACEi/ARB to S/V therapy appears to be safe and leads to an improvement in exercise tolerance and quality of life.