Impact on long-term cardiovascular outcomes of different cardiac resynchronization therapy response criteria

Introduction

There is a lack of consensus on the definition of response to cardiac resynchronization therapy (CRT), and it is not clear which response criteria have most influence on cardiac event-free survival.

Coexistence of dynamic mitral regurgitation and dynamic left ventricular dyssynchrony in a patient with repeated episodes of acute pulmonary edema: Improvement with cardiac resynchronization therapy

A 69-year-old woman with idiopathic dilated cardiomyopathy and chronic heart failure experienced repeated hospital admissions for acute pulmonary edema with no recognizable precipitating factor. Worsening mitral regurgitation was triggered by exercise echocardiography and significant intraventricular dyssynchrony was elicited by low-dose dobutamine stress echocardiography. After cardiac resynchronization therapy she remained free of hospitalizations for 12 months. This case highlights the dynamic nature of both functional mitral regurgitation and left ventricular dyssynchrony and illustrates how in some patients stress echocardiography can help to clarify clinical scenarios and help with the challenging task of selecting patients who will benefit from cardiac resynchronization therapy.     

Telemonitoring in heart failure: A state-of-the-art review

Heart failure is associated with high costs which are mainly the result of recurrent hospital admissions. New strategies to detect early decompensation and prevent heart failure-related hospitalizations and reduce total health care costs are needed.Telemonitoring is a novel tool based on the use of recent communication technologies to monitor simple clinical variables, in order to enable early detection of heart failure decompensation, providing an opportunity to prevent hospitalization.From conventional telemonitoring to more recent strategies using implantable cardiac devices or implantable hemodynamic monitors, the subject is under active investigation. Despite the beneficial effects reported by meta-analyses of small non-controlled studies, major randomized controlled trials have failed to demonstrate a positive impact of this strategy. Additionally, evidence regarding the value of newer monitoring devices is somewhat contradictory, as some studies show benefits in prognosis which are not confirmed by others.This paper provides an overview of the existing evidence on telemonitoring in heart failure and a comprehensive state-of-the-art discussion on this topic.     

Cardiac resynchronization therapy in patients with atrial fibrillation: A meta-analysis

Background and ObjectiveTo combine the results of the best scientific evidence in order to compare the effects of cardiac resynchronization therapy (CRT) in heart failure patients with atrial fibrillation (AF) and in sinus rhythm (SR) and to determine the effect of atrioventricular nodal ablation in AF patients.MethodsThe electronic databases PubMed, B-On and Cochrane CENTRAL were searched, and manual searches were performed, for randomized controlled trials and cohort studies up to November 2012. The endpoints analyzed were all-cause and cardiovascular mortality and response to CRT.ResultsWe included 19 studies involving 5324 patients: 1399 in AF and 3925 in SR. All-cause mortality was more likely in patients with AF compared to patients in SR (OR=1.69; 95% CI: 1.20–2.37; p=0.002). There were no statistically significant differences in cardiovascular mortality (OR=1.36; 95% CI: 0.92–2.01; p=0.12). AF was associated with an increased likelihood of lack of response to CRT (OR=1.41; 95% CI: 1.15–1.73; p=0.001). Among subjects with AF, ablation of the atrioventricular node was associated with a reduction in all-cause mortality (OR=0.42; 95% CI: 0.22–0.80; p=0.008), cardiovascular death (OR=0.39; 95% CI: 0.20–0.75; p=0.005) and the number of non-responders to CRT (OR=0.30; 95% CI: 0.10–0.90; p=0.03).ConclusionsThe presence of AF is associated with increased likelihood of all-cause death and non-response to CRT, compared to patients in SR. However, many patients with AF benefit from CRT. Atrioventricular nodal ablation appears to increase the benefits of CRT in patients with AF.     

Remote invasive monitoring of pulmonary artery pressures in heart failure patients: Initial experience in Portugal in the context of the Covid-19 pandemic

BackgroundDecompensated heart failure (HF) is associated with poor short- and long-term prognosis. Remote invasive monitoring of pulmonary artery pressures (PAP) enables early detection of HF decompensation before symptoms occur and may improve clinical outcomes. We aimed to describe our initial experience with the use of the CardioMEMS? remote monitoring system in patients with HF, including its safety and effectiveness.Methods and resultsFive patients with HF in New York Heart Association class III and at least one hospitalization due to decompensated HF in last 12 months, who underwent invasive remote monitoring of PAP, were included in this prospective registry. The median age was 66.0 years (interquartile range [IQR] 50.5-77.5 years), 80.0% were men and all had HF with reduced ejection fraction. The pulmonary artery (PA) sensor was placed in a left PA branch in all patients and no major procedural complications occurred. In median follow-up of 40 days (IQR 40-61 days), a total of 271 pressure readings were transmitted, patient compliance was 100% and freedom from sensor failure 98.1%. In three patients, PAP remained within the goal during follow-up. Two patients presented an increase in PAP to values above the targets, despite the absence of symptom worsening. These required dietary and diuretic dose adjustment, without the need for outpatient clinic visits, which reduced PAP. No hospitalizations for HF or deaths occurred during follow-up.ConclusionHemodynamic-guided HF monitoring was safe and effective and may be a useful adjunctive tool to the standard-of-care management in selected HF patients, particularly in the context of the COVID-19 pandemic, where a reduction in the number of health care visits may be desirable.     

Protocol-based follow-up program for heart failure patients: Impact on prognosis and quality of life

IntroductionHeart failure is associated with high rates of readmission and mortality, and there is a need for measures to improve outcomes. This study aims to assess the impact of the implementation of a protocol-based follow-up program for heart failure patients on readmission and mortality rates and quality of life.MethodsA quasi-experimental study was performed, with a prospective registry of 50 consecutive patients discharged after hospitalization for acute heart failure. The study group was followed by a cardiologist at days 7-10 and the first, third, sixth and 12th month after discharge, with predefined procedures. The control group consisted of patients hospitalized for heart failure prior to implementation of the program and followed on a routine basis.ResultsNo significant differences were observed between the two groups regarding mean age (67.1±11.2 vs. 65.8±13.4 years, p=0.5), NYHA functional class (p=0.37), or median left ventricular ejection fraction (27% [19.8-35.3] vs. 29% [23.5-40]; p=0.23) at discharge. Mean follow-up after discharge was similar (11±5.3 vs. 10.9±5.5 months, p=0.81).The protocol-based follow-up program was associated with a significant reduction in all-cause readmission (26% vs. 60%, p=0.003), heart failure readmission (16% vs. 36%, p=0.032), and mortality (4% vs. 20%, p=0.044). In the study group there was a significant improvement in all quality of life measures (p<0.001).ConclusionA protocol-based follow-up program for patients with heart failure led to a significant reduction in readmission and mortality rates, and was associated with better quality of life.     

Cost-effectiveness of cardio-oncology clinical assessment for prevention of chemotherapy-induced cardiotoxicity

IntroductionCancer chemotherapy increases the risk of heart failure. This cost-effectiveness study analyzes cardio-oncology imaging assessment of left ventricular ejection fraction (LVEF) using a Portuguese healthcare payer perspective and a five-year time horizon.MethodsTwo cardioprotective strategies were assessed: universal cardioprotection (UCP) for all patients and cardioprotection initiated on diagnosis of LVEF-defined cardiotoxicity (EF-CTX). A Markov model, informed by the retrospective clinical course of breast cancer patients followed in a Portuguese public hospital, was developed to assess the cost-effectiveness of LVEF cardio-oncology imaging assessment. Data on transition probabilities, costs and utilities were retrieved from both the retrospective data and published literature to assess the cost-effectiveness of LVEF echocardiographic assessment. Costs and utilities of the cardioprotective strategies were assessed over a five-year range, using probabilistic sensitivity analyses.ResultsIn the reference case of a 63-year-old breast cancer patient treated with cardioprotection initiated on diagnosis of EF-CTX, the five-year time horizon (4.22 QALYs and €2594 cost over five years) dominated UCP (3.42 QALYS and €3758 cost over five years). Under a time horizon of five years at a willingness-to-pay threshold of €22 986, over 65.7% of simulations provided additional QALYs. Monte Carlo simulation of the Markov model had no effect on the model's conclusions.ConclusionIn the Portuguese public healthcare system and under specific hypotheses, from a healthcare payer perspective, EF-CTX-guided cardioprotection for patients at risk of chemotherapy-related cardiotoxicity provides more QALYs at lower cost than UCP.     

Impact of catheter ablation for atrial fibrillation in patients with heart failure and left ventricular systolic dysfunction

Introduction and AimsCatheter ablation has been shown to improve left ventricular (LV) ejection fraction (LVEF) in patients with atrial fibrillation (AF) and heart failure (HF). Our aim was to assess the impact of AF ablation on the outcome of patients with HF and LV systolic dysfunction.MethodsWe performed a retrospective observational cohort study of all patients with HF and LVEF <50% and with no apparent cause for systolic dysfunction other than AF who underwent catheter ablation in a tertiary referral center between July 2016 and November 2018. The primary endpoint was a ≥5% improvement in LVEF. Secondary endpoints included improvement in New York Heart Association (NYHA) class and reduction in LV end-diastolic diameter (LVEDD) and left atrial diameter (LAD).ResultsOf 153 patients who underwent AF ablation in this period, 22 (77% male, median age 61 [IQR 54-64] years) fulfilled the inclusion criteria. Median follow-up was 11.1 months (IQR 6.1-19.0). After ablation, median LVEF increased from 40% (IQR 33-41) to 58% (IQR 55-62) (p<0.01), mean NYHA class improved from 2.35±0.49 to 1.3±0.47 (p<0.001), and median LAD and LVEDD decreased from 48.0 (IQR 43.5-51.5) mm to 44 (IQR 40-49) mm (p<0.01) and from 61.0 (IQR 54.0-64.8) mm to 55.0 (52.2-58.0) mm (p<0.01), respectively.ConclusionIn patients with HF and LV systolic dysfunction, AF ablation is associated not only with improved functional status but also with favorable structural remodeling, including improvement in LVEF and decreases in LAD and LVEDD.     

Evaluating three biomarkers as prognostic factors of in-hospital mortality and severity in heart failure: A prospective cohort

ObjectiveTo identify the relationship between red blood cell distribution width (RDW, %), interleukin-6 (IL-6) (pg/ml), high sensitivity-c-reactive protein (hs-CRP) (mg/l), in-hospital mortality and disease severity among patients with heart failure (HF).MethodsProspective cohort. We included adults diagnosed with acute non-ischemic HF in 2015. The dependent variables were in-hospital mortality (yes or no) and disease severity. The latter was assessed with the Get With The Guidelines-HF score. We used hierarchical regression models to describe the pattern of association between biomarkers, mortality, and severity. We used the Youden index to identify the best cut-off for mortality prediction.ResultsWe included 167 patients; the mean age was 72.61 (SD: 11.06). The majority of patients presented with New York Heart Association classification II (40.12%) or III (43.11%). After adjusting for age and gender, all biomarkers were associated with mortality. After adding comorbidities, only IL-6 was associated. The final model with all clinical variables showed no effect from any biomarker. The best cut-off for RDW, hs-CRP and IL-6 for mortality were 14.8, 68.7 and 52.9, respectively. IL-6 presented the highest sensitivity (100%), specificity (75.35%) and area under the curve (0.91).ConclusionsNo biomarker is independent from the most important clinical variables; therefore it should not be used for management modifications.     

Long-term outcomes after radiofrequency catheter ablation of the atrioventricular node: The experience of a Portuguese tertiary center

IntroductionIn patients with supraventricular arrhythmias and high ventricular rate, unresponsive to rate and rhythm control therapy or catheter ablation, atrioventricular (AV) node ablation may be performed.ObjectivesTo assess long-term outcomes after AV node ablation and to analyze predictors of adverse events.MethodsWe performed a detailed retrospective analysis of all patients who underwent AV node ablation between February 1997 and February 2019, in a single Portuguese tertiary center.ResultsA total of 123 patients, mean age 69±9 years and 52% male, underwent AV node ablation. Most of them presented atrial fibrillation at baseline (65%). During a median follow-up of 8.5 years (interquartile range 3.8-11.8), patients improved heart failure (HF)functional class (NYHA class III-IV 46% versus 13%, p=0.001), and there were reductions in hospitalizations due to HF (0.98±1.3 versus 0.28±0.8, p=0.001) and emergency department (ED) visits (1.1±1 versus 0.17±0.7, p=0.0001). There were no device-related complications. Despite permanent pacemaker stimulation, left ventricular ejection fraction did not worsen (47±13% vs. 47%±12, p=0.63). Twenty-eight patients died (23%). The number of ED visits due to HF before AV node ablation was an independent predictor of the composite adverse outcome (OR 1.8, 95% CI 1.24-2.61, p=0.002).ConclusionsDespite pacemaker dependency, the clinical benefit of AV node ablation persisted at long-term follow-up. The number of ED visits due to HF before AV node ablation was an independent predictor of the composite adverse outcome. AV node ablation should probably be considered earlier in the treatment of patients with supraventricular arrhythmias and HF, especially in cases that are unsuitable for selective ablation of the specific arrhythmia.     

Optimization of heart failure with reduced ejection fraction prognosis-modifying drugs: A 2021 heart failure expert consensus paper

Heart failure (HF) with reduced ejection fraction (HFrEF) is associated with high rates of hospitalization and death. It also has a negative impact on patients’ functional capacity and quality of life, as well as on healthcare costs. In recent years, new HFrEF prognosis-modifying drugs have emerged, leading to intense debate within the international scientific community toward a paradigm shift for the management of HFrEF. In this article, we report the contribution of a Portuguese HF expert panel to the ongoing debate.Based on the most recently published clinical evidence, and the panel members’ clinical judgment, three key principles are highlighted: (i) sacubitril/valsartan should be preferred as first-line therapy for HFrEF, instead of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker; (ii) the four foundation HFrEF drugs are the angiotensin receptor/neprilysin inhibitor, beta-adrenergic blocking agents, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors, regardless of the presence of type-2 diabetes mellitus; (iii) these four HFrEF drug classes should be introduced over a short-term period of four to six weeks, guided by a safety protocol, followed by a dose up-titration period of 8 weeks.     

The MAGGIC risk score in the prediction of death or hospitalization in patients with heart failure: Comparison with natriuretic peptides

BackgroundThe MAGGIC risk score has been validated to predict mortality in patients with heart failure (HF).ObjectivesTo assess the score ability to predict hospitalization and death and to compare with natriuretic peptides.MethodsNinety-three consecutive patients (mean age 62±10 years) with chronic HF and left ventricular ejection fraction (EF) <50% were studied. The MAGGIC score was applied at baseline and the patients were followed for 219±86 days. MAGGIC score was compared with NT-proBNP in the prediction of events. The primary end point was the time to the first event, which was defined as cardiovascular death or hospitalization for HF.ResultsThere were 23 (24.7%) events (3 deaths and 20 hospitalizations). The median score in patients with and without events was, respectively, 20 [interquartile range 14.2–22] vs. 15.5 [11/21], p=0.16. A ROC curve was performed and a cutoff point of 12 points showed a sensitivity of 87% and specificity of 37% with an area under the curve of 0.59 (95% CI 0.48–0.69) which was lower than that of NT-proBNP (AUC 0.67; 95% CI 0.56–0.76). The mean event-free survival time for patients above and below this cutpoint was 248.8±13 vs. 290±13.7 days (log rank test with p=0.044). Using the COX proportional hazard model, age (p=0.004), NT-proBNP >1000 pg/mL (p=0.014) and the MAGGIC score (p=0.025) were independently associated with the primary outcome.ConclusionThe MAGGIC risk score was an independent predictor of events, including heart failure hospitalization. The addition of biomarkers improved the accuracy of the score.     

Optimizing risk stratification in heart failure and the selection of candidates for heart transplantation

Introduction and Aims

Selecting patients for heart transplantation is challenging. We aimed to identify the most important risk predictors in heart failure and an approach to optimize the selection of candidates for heart transplantation.

New less invasive ventricular reconstruction technique in the treatment of ischemic heart failure

Ischemic cardiomyopathy is the leading cause of heart failure. In patients with left ventricular (LV) dilatation, low ejection fraction, and transmural scar in an anteroseptal distribution, surgical ventricular reconstruction (SVR) is a treatment option.We describe our first experience with the Less Invasive Ventricular Enhancement (LIVE) technique using the Revivent™ system (Bioventrix Inc., San Ramon, CA), in the treatment of a large anteroapical aneurysm.     

Clinical characteristics and one-year mortality according to admission renal function in patients with a first acute heart failure hospitalization

Introduction and Objectives

Chronic kidney disease is related to poor outcomes in patients with heart failure (HF). Few studies have assessed whether renal function influences one-year mortality risk in patients admitted for the first time for acute HF.

Importância dos dispositivos eletrónicos cardíacos implantáveis no diagnóstico da Síndrome da Apneia do Sono

IntroductionSleep Apnea Syndrome (SAS) is a prevalent respiratory disease with marked expression in the population with cardiovascular disease. The diagnosis is based on polysomnography. In patients with cardiac implantable electronic devices (CIED), the prevalence of SAS may reach 60%. The objective of this study was to evaluate the value of DEC in the SAS screening.MethodsProspective study that included patients with CIED with sleep apnea algorithm. The frequency response function was activated and simplified polygraphy was performed. The data of the device were collected on the day of the polygraph.ResultsThe sample included 29 patients, with a mean age of 76.1 years, 71.4% of the male gender. The prevalence of SAS was 77%. For SAS, the agreement between polysomnography and the Pacemaker was Kappa = 0.54 (p = 0.001), 95% CI (0.28, 0.81) (moderate agreement); for moderate to severe SAS, the agreement was Kappa = 0.73 (p <0.001), 95% CI (0.49, 0.976) (substantial agreement). Severe SAS was obtained: sensitivity 60%, specificity 100%, positive predictive value 100%, negative predictive value 60% and diagnostic accuracy 75%; for moderate to severe SAS: sensitivity of 90%, specificity of 83%, positive predictive values of 90% and negative of 87.5%, with a diagnostic accuracy of 87.5%.ConclusionSAS is highly prevalent in patients with CIED. The values obtained through these devices have a strong positive correlation with the Apnea‐Hypopnea Índex, which makes them a good tool for the screening of severe SAS.     

Neurohormonal modulation: The new paradigm of pharmacological treatment of heart failure

The current paradigm of medical therapy for heart failure with reduced ejection fraction (HFrEF) is triple neurohormonal blockade with an angiotensin-converting enzyme inhibitor (ACEI), a beta-blocker (BB) and a mineralocorticoid receptor antagonist (MRA). However, three-year mortality remains over 30%.Stimulation of counter-regulatory systems in addition to neurohormonal blockade constitutes a new paradigm, termed neurohormonal modulation. Sacubitril/valsartan is the first element of this new strategy.PARADIGM-HF was the largest randomized clinical trial conducted in HFrEF. It included 8442 patients and compared the efficacy and safety of sacubitril/valsartan versus enalapril. The primary endpoint was the composite of cardiovascular mortality and hospitalization due to HF, which occurred in 914 (21.8%) patients receiving sacubitril/valsartan and in 1117 (26.5%) patients receiving enalapril (HR 0.8, 95% CI 0.73-0.87, p=0.0000002; NNT 21). Sacubitril/valsartan reduced both primary endpoint components, as well as sudden cardiac death, death due to worsening HF, and death from all causes. Patients on sacubitril/valsartan reported less frequent deterioration of HF and of quality of life, and discontinued study medication less frequently because of an adverse event.PARADIGM-HF demonstrated the superiority of sacubitril/valsartan over enalapril, with a 20% greater impact on cardiovascular mortality compared to ACEIs. Accordingly, in 2016, the European (ESC) and American (ACC/AHA/HFSA) cardiology societies simultaneously issued a class I recommendation for the replacement of ACEIs by sacubitril/valsartan in patients resembling PARADIGM-HF trial participants.     

Sacubitril/valsartan: A practical guide

Renin-angiotensin-aldosterone system (RAAS) inhibitors are a cornerstone in the treatment of heart failure with reduced ejection fraction (HFrEF). Sacubitril/valsartan modulates the neurohormonal axis by inhibiting both angiotensin receptors and neprilysin, and improves neurohormonal balance more than blocking the RAAS alone.The PARADIGM-HF trial validated this new treatment option for patients with HFrEF. Sacubitril/valsartan was also more effective than enalapril in slowing disease progression by decreasing the risk of worsening heart failure requiring hospitalization or emergency admission and the need for intensified therapy, heart failure devices or cardiac transplantation. More than 70% of patients included in PARADIGM-HF were in NYHA class II, and overall, the results indicate that sacubitril/valsartan should be started in the earliest symptomatic stages of the disease.As PARADIGM-HF has excellent robustness for a cardiovascular trial, sacubitril/valsartan has been included as a new treatment option with a strong level of recommendation in the main international guidelines.This expert task force proposes a practical guide to the use of this new drug that has been endorsed by the Working Group on Heart Failure of the Portuguese Society of Cardiology.     

Implantação de dispositivos de ressincronização e/ou desfibrilhação em doentes com insuficiência cardíaca: dados da vida real ‐ o Estudo Síncrone

Introduction

The aim of this study was to document clinical practice in Portugal regarding the use of electronic cardiac devices in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF).