1-year Rehospitalization Research Articles

Timing of coronary angiography in high-risk non-ST-elevation acute coronary syndrome: results from the Portuguese Registry for Acute Coronary Syndromes (ProACS).

Current guidelines recommend an early invasive coronary angiography (ICA) within 24 h of admission for high-risk patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). Nevertheless, meta-analyses failed to demonstrate a clear advantage of this strategy in reducing hard endpoints such as death or nonfatal myocardial infarction compared to a delayed approach. Thus, the optimal timing of ICA in high-risk NSTE-ACS remains undetermined. This study aimed to determine the optimal timing for ICA in high-risk NSTE-ACS, regarding 1-year all-cause mortality and cardiovascular rehospitalizations. We conducted a national multicenter retrospective study of high-risk NSTE-ACS patients included in the Portuguese Registry for Acute Coronary Syndromes. Patients were divided into three groups according to the time of ICA: within the first 24 h, between 24 and 48 h, and between 48 and 72 h. The incidence of in-hospital complications and mortality, 1-year mortality, and cardiovascular rehospitalizations were assessed. Of the 9949 patients included, 46.7% underwent early ICA. This was associated with a lower incidence of acute heart failure (8.5% vs. 11.1% vs. 11.5%, P < 0.001) and shorter length of stay (3 vs. 4 vs. 6 days, P = 0.012). It, however, did not reduce in-hospital complications or mortality (1.2 vs. 0.7 vs. 0.8%, P = 0.066). We also found no significant association with the composite endpoint of 1-year mortality or cardiovascular rehospitalization (15.1 vs. 15.9 vs. 15.7%, P = 0.887). Early ICA was associated with a lower incidence of acute heart failure and shorter length of stay, without a significant impact on 1-year mortality risk or cardiovascular rehospitalizations.

The sooner the better? What is the optimal timing for coronary angiography in high-risk non-ST-elevation acute coronary syndrome

Abstract Introduction current guidelines recommend an early invasive coronary angiography (ICA), in the first 24 hours, for high-risk non-ST elevation acute coronary syndrome (NSTE-ACS) patients. However, several studies have failed to demonstrate a significant improvement in all-cause mortality, with controversial results regarding recurrent ischemia and myocardial infarction. Purpose to evaluate the optimal timing of ICA in high-risk NSTE-ACS. Methods this was a national multicentre retrospective study of patients hospitalized for NSTE-ACS between October 2010 and October 2023. Patients presenting in Killip class IV, mechanical complications, life-threatening arrhythmias or cardiac arrest were excluded. Participants were divided into three groups, according to the timing of ICA: in the first 24 hours (D0), between 24 and 48 hours (D1) and between 48 and 72 hours (D2). The incidence of in-hospital complications and mortality, as well as 1-year mortality rate and cardiovascular rehospitalization, was compared for the three groups. Results a total of 9949 patients was included, 98.2% with non-ST elevation myocardial infarction (NSTEMI) and 1.8% with unstable angina with high-risk criteria (GRACE risk score &amp;gt;140 or transient ST-segment elevation). Most patients were submitted to early ICA (46.7%), with 26.7% and 26.6% in D1 and D2, respectively. Interestingly, patients in higher Killip class (II or III) were referred for ICA latter than patients in Killip class I (9.0% in D0 vs. 11.3% in D1 vs. 13.5% in D2, p&amp;lt;0.001). Regarding in-hospital complications, early ICA was associated with a lower incidence of acute heart failure (8.5% vs. 11.1% vs. 11.5%, p&amp;lt;0.001) and shorter length of stay (7 vs. 6 vs. 10 days, p=0.01). However, it did not reduce in-hospital mortality (1.2% vs. 0.7% vs. 0.8%, p=0.07), recurrent myocardial infarction (0.9% vs. 1.5% vs. 1.3%, p=0.09), cardiogenic shock (7.9% vs. 5.7% vs. 5.4%, p=0.19), mechanical complications (0.1% vs. 0.2% vs. 0.1%, p=0.50) or sustained ventricular tachycardia (0.8% vs. 0.6% vs. 0.4%, p=0.12). Left ventricular ejection fraction was also similar between groups (54%±12, p=0.97). There were also no significant differences between groups regarding 1-year mortality or cardiovascular rehospitalization (15.1% vs. 15.9% vs. 15.7%, p=0.89). Conclusion in high-risk NSTE-ACS patients, early ICA resulted in lower incidence of acute heart failure and shorter length of stay. However, timing of ICA didn’t show a significant impact on in-hospital mortality or complications, nor in 1-year mortality rate or cardiovascular rehospitalization.

The prevalence and impact of changes in the severity of secondary TR during hospitalization in acute heart failure

Abstract Background Secondary tricuspid regurgitation (TR) is a prevalent entity in patients hospitalized for acute heart failure (AHF), and concomitant moderate or severe TR at admission has been demonstrated to be associated with a poor prognosis. However, no study has described the trajectories of the severity of secondary TR during admission, and the prognostic implications of changes in the severity of secondary TR. Purpose This study aimed to investigate the dynamism of secondary TR observed during hospitalization due to worsening heart failure, and its prognostic impact in patients with AHF. Methods A post-hoc analysis of 1,061 consecutive patients hospitalized with AHF was performed, enrolled in the prospective, multicenter Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure (REALITY-AHF). Patients included in the study underwent a comprehensive echocardiographic examination within 24 hours of admission and again prior to discharge. Patients were divided into four groups based on the TR severity at admission and discharge: none to mild TR at both admission and discharge (no/no group), moderate to severe TR at admission but improved to none to mild TR at discharge (resolution group), none to mild TR at admission but moderate to severe TR at discharge (worsening group), and moderate to severe TR at both admission and discharge (persistent group). The primary endpoint was the composite of 1-year all-cause mortality and HF re-hospitalization after discharge. Results The no/no, resolution, worsening, and persistent groups included 479 (45%), 275 (26%), 85 (8%), and 222 patients (21%), respectively. The no/no group and the resolution group had significantly lower tricuspid regurgitant pressure gradients prior to discharge compared to the worsening and persistent groups (P&amp;lt;0.001). Also, right ventricular dysfunction evaluated at discharge, defined by tricuspid annular plane systolic excursion &amp;lt;17 mm, was more prevalent in the worsening (65.7%) and persistent groups (66.4%) compared to the no/no (43.7%) and resolution (53.2%) groups (P&amp;lt;0.001). Compared to the no/no group, the worsening and persistent groups, but not the resolution group, were associated with a higher incidence of the primary endpoint (Log-rank: P&amp;lt;0.001). This association remained significant in an adjusted Cox regression analysis, with the worsening group (hazard ratio: 1.48, 95% confidence interval [CI]: 1.01–2.20) and persistent group (hazard ratio: 1.35, 95% CI: 1.01–1.83) independently associated with the primary endpoint, but not the resolution group (hazard ratio: 1.10, 95% CI: 0.81–1.49). Conclusions In patients hospitalized for AHF, the severity of secondary TR is dynamic, and changes in the severity of TR are significantly associated with prognosis. Our study results underscore the importance of repetitive evaluation of TR in hospitalized patients with AHF.

Impact of residual mitral regurgitation after transcatheter edge-to-edge repair in atrial functional mitral regurgitation: Results from MITRA-PRO registry.

Transcatheter edge-to-edge repair (TEER) has emerged to address symptomatic atrial functional mitral regurgitation (aFMR) in patients who are at high operative risk. No clinical data is available on the impact of residual mitral regurgitation (MR) following TEER in aFMR compared to ventricular functional MR (vFMR). In the MITRA-PRO registry, 846 patients with FMR and MitraScore assessment for residual MR quantification were included (722 patients with vFMR and 124 patients with aFMR). Compared to vFMR similar procedural results in regard of residual MR following TEER were found in aFMR patients (MitraScore post TEER 2.5 ± 1.8 vs. 2.7 ± 1.9), while the amount of implanted TEER devices was increased in vFMR. 1-year survival was better in aFMR compared to vFMR regardless of relevant residual MR (MitraScore ≥ 4), while 1-year rehospitalization was comparable for both MR entities. Patients with aFMR and mild residual MR had a lower mortality rate (6.6% vs. 10.3%) and rehospitalization rate (29.1% vs. 46.2%) 1 year after mitral TEER. However, in contrast to vFMR a MitraScore ≥4 was no independent predictor of mortality in aFMR indicating a better tolerance toward residual MR. Residual MR is an independent predictor of 1-year mortality in vFMR patients, whereas in aFMR patients, a MitraScore of ≥4 is associated with higher mortality but is not an independent predictor in multivariate analysis. Therefore, minimizing MR through mitral TEER is crucial for survival in vFMR patients, while aFMR patients tolerate significant residual MR better 1 year after the procedure.

Neurohormonal Effects of Intravenous Dopamine in Patients with Acute Heart Failure

Background/Objectives: Many clinical trials have shown beneficial effects of low-dose dopamine on renal function, diuresis and symptom relief, or cardiac function in hospitalized patients with acute decompensated heart failure (HF). The aim is to assess the neurohormonal effects and the effects on clinical outcomes of the addition of low-dose dopamine in furosemide treatment in patients hospitalized for acute decompensated HF. Methods: A total of 62 patients hospitalized for acute decompensation of HF, were randomly allocated to one of the following three groups: i. LDF (low-dose furosemide), ii. HDF (high-dose furosemide) and, iii. LDFD (low-dose furosemide and dopamine). Primary outcomes of the present analysis were biochemical and neurohormonal indices (i.e., urea, creatinine, hemoglobin, electrolytes, natriuretic peptides, troponin, renin, angiotensin, aldosterone, adrenaline, noradrenaline). Secondary endpoints included clinical outcomes (i.e., length of stay, in-hospital mortality, 2-month mortality and rehospitalization, and 1-year mortality and rehospitalization). Results: Urea and creatinine levels were similar for each day among the three groups (p &gt; 0.05). The amount of urine was similar among the three groups per measurement at 2, 4, 6 and at 8 h (p &gt; 0.05). Biochemical and neurohormonal indices as well as clinical outcomes did not differ among patients receiving different doses of furosemide, nor in patients receiving furosemide in combination with dopamine (p &gt; 0.05). Conclusions: Although the addition of low-dose dopamine to intravenous furosemide was considered to have some theoretical advantages in maintaining renal function, no significant differences in neurohormonal effects and clinical outcomes were observed in patients hospitalized for acute decompensation of HF.

Glyburide use is associated with a greater likelihood of mortality or rehospitalization after acute coronary syndrome compared to gliclazide use in adults with type 2 diabetes: A cohort study.

To examine the likelihood of mortality or rehospitalization following acute coronary syndrome with glyburide versus gliclazide use in adults with type 2 diabetes undergoing cardiac catheterization. This retrospective cohort study used clinical data linked with administrative health data from Alberta, Canada between April 2008 and March 2021. Three methods were used to define exposure to glyburide and gliclazide in the year before catheterization. Multivariable logistic regression was used to compare the likelihood of a composite outcome of 1-year mortality or rehospitalization with use of glyburide versus use of gliclazide. A total of 11 140 individuals with type 2 diabetes had a cardiac catheterization for acute coronary syndrome. Their mean age was 66 years and 31% were female. In the year before catheterization, 5% used glyburide and 19% used gliclazide. Any glyburide or gliclazide exposure in the year before catheterization was associated with a similar likelihood of all-cause mortality or rehospitalization (adjusted odds ratio [aOR] 1.14, 95% confidence interval [CI] 0.93-1.41; p = 0.20). However, current glyburide exposure (aOR 1.37, 95% CI 1.06-1.79; p = 0.018) and long exposure to glyburide (aOR 1.37, 95% CI 1.03-1.83; p = 0.030) were associated with a higher likelihood of the composite outcome compared to current and long exposure to gliclazide, respectively. Current and long exposure to glyburide was associated with a greater likelihood of mortality or rehospitalization following cardiac catheterization for acute coronary syndrome, when compared to similar gliclazide exposure definitions. This study adds further evidence of the need to avoid using glyburide if a sulphonylurea is required for type 2 diabetes management.

Prevalence and Prognostic Implications of Changes in Tricuspid Regurgitation Severity in Acute Heart Failure

BackgroundTricuspid regurgitation (TR), prevalent in acute heart failure (AHF), has a poor prognosis; however, the dynamics of TR severity during hospitalization and its prognostic implications remain unclear. We investigated TR dynamism during hospitalization and its prognostic impact in AHF. Methods and ResultsThis is a post hoc analysis of a prospective multicenter study of patients with AHF who underwent echocardiographic TR severity evaluation at admission and before discharge. The primary end point was a combined of 1-year all-cause mortality and HF rehospitalization after discharge. Among 1079 participants, TR severity changed dynamically, with 60.3% of those with moderate TR and 29.6% of those with severe TR at admission being diagnosed as no or mild TR at discharge. In 3 groups stratified by changes in TR severity, the persistent TR groups had a higher incidence of the primary end point than the resolution and absence groups. In adjusted analyses, the persistent group (hazard ratio, 1.37; 95% confidence interval, 1.04–1.80), but not the resolution group (hazard ratio, 1.07; 95% confidence interval, 0.79–1.44), had a higher primary end point incidence than the absence group. ConclusionsTR severity at admission in patients with AHF can change dynamically and is associated with subsequent prognosis. Significant TR that remains even after decongestive therapy might be a target for further treatment in hospitalized patients with AHF.

Frailty Is More Predictive of Mortality than Age in Patients With Hip Fractures.

To investigate the association between the Comprehensive Geriatric Assessment-based Frailty Index and adverse outcomes in older adult patients undergoing hip fracture surgery. Retrospective cohort study. Academic Level 1 Trauma Center. All patients aged 65 or older who underwent surgical repair of a hip fracture between May 2018 and August 2020 were identified through institutional database review. Data including demographics, FI, injury presentation, and hospital course were collected. Patients were grouped by FI as nonfrail (FI < 0.21), frail (0.21 ≤ FI < 0.45), and severely frail (FI > 0.45). Adverse outcomes of these groups were compared using Kaplan Meier survival analysis. Risk factors for 1-year rehospitalization and 2-year mortality were evaluated using Cox hazard regression. Three hundred sixteen patients were included, with 62 nonfrail, 185 frail, and 69 severely frail patients. The total population was on average 83.8 years old, predominantly white (88.0%), and majority female (69.9%) with an average FI of 0.33 (SD: 0.14). The nonfrail cohort was on average 78.8 years old, 93.6% white, and 80.7% female; the frail cohort was on average 84.5 years old, 92.4% white, and 71.9% female; and the severely frail cohort was on average 86.4 years old, 71.0% white, and 55.1% female. Rate of 1-year readmission increased with frailty level, with a rate of 38% in nonfrail patients, 55.6% in frail patients, and 74.2% in severely frail patients (P = 0.001). The same pattern was seen in 2-year mortality rates, with a rate of 2.8% in nonfrail patients, 36.7% in frail patients, and 77.5% in severely frail patients (P < 0.0001). Being classified as frail or severely frail exhibited greater association with mortality within 2 years than age, with hazard ratio of 17.81 for frail patients and 56.81 for severely frail patients compared with 1.19 per 5 years of age. Increased frailty as measured by the Frailty Index is significantly associated with increased 2-year mortality and 1-year hospital readmission rates after hip fracture surgery. Degree of frailty predicts mortality more strongly than age alone. Assessing frailty with the Frailty Index can identify higher-risk surgical candidates, facilitate clinical decision making, and guide discussions about goals of care with family members, surgeons, and geriatricians. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Sarcopenia and frailty in patients undergoing transcatheter aortic valve replacement

BackgroundSkeletal muscle mass (SMM) plays a crucial role in risk assessment in transcatheter aortic valve replacement (TAVR) candidates, yet it remains underutilized. Traditional methods focus on weakness or performance but omit SMM. This study compared traditional and novel markers of sarcopenia and frailty in terms of their ability to predict adverse outcomes post-TAVR. MethodsThree risk models were evaluated for the composite outcome of perioperative complications, 1-year rehospitalization, or 1-year mortality: (1) sarcopenia by combining low muscle mass (LMM) and weakness/performance assessed by hand grip strength or gait speed; (2) frailty by an Adapted Green score; and (3) frailty by the Green-SMI score incorporating LMM by multi-level opportunistic pre-TAVR thoracic CT segmentation. ResultsIn this study we included 184 eligible patients from January to December of 2018, (96.7%) of which were balloon expandable valves. The three risk models identified 22.8% patients as sarcopenic, 63.6% as frail by the Adapted Green score, and 53.8% as frail by the Green-SMI score. There were higher rates of the composite outcome in patients with sarcopenia (54.8%) and frailty (41.9% with the Adapted Green and 50.5% with the Green-SMI score) compared to their non-sarcopenic (30.3%) and non-frail counterparts (25.4% with the Adapted Green and 18.8% with the Green-SMI score). Sarcopenia and frailty by Green-SMI, but not by the Adapted Green, were associated with higher risks of the composite outcome on multivariable adjustment (HR 2.2 [95% CI: 1.25-4.02], p=0.007 and HR 3.4 [95% CI: 1.75-6.65], p<0.001, respectively). ConclusionsThe integration of pre-operative CT-based SMM to a frailty score significantly improves the prediction of adverse outcomes in patients undergoing TAVR.

Association of Psychosocial Risk Factors With Quality of Life and Readmissions 1 Year After LVAD Implantation

BackgroundAmong patients with advanced heart failure (HF), treatment with a left ventricular assist device (LVAD) improves health-related quality of life (HRQOL). We investigated the association between psychosocial risk factors, HRQOL, and outcomes after LVAD implantation. MethodsA retrospective cohort (n=9832) of adults aged ≥ 19 years who received durable LVAD between 2008 – 2017 was identified using the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). Patients were considered to have psychosocial risk factors if ≥1 of the following were present: 1) substance abuse; 2) limited social support; 3) limited cognitive understanding; 4) repeated non-adherence; and 5) major psychiatric disease. Multivariable logistic and linear regression models were used to evaluate the association between psychosocial risk factors and change in Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 scores from baseline to 1-year, persistently poor HRQOL (KCCQ-12 score < 45 at baseline and 1-year), and 1-year rehospitalization. ResultsAmong the final analytic cohort, 2024 (20.6%) patients had ≥1 psychosocial risk factors. Patients with psychosocial risk factors were associated with a smaller improvement in KCCQ-12 scores from baseline to 1-year (Mean ± SD, 29.1 ± 25.9 vs 32.6 ± 26.1, p=0.015) for a difference of -3.51 (95% confidence interval [CI]: -5.88 to -1.13). Psychosocial risk factors were associated with persistently poor HRQOL (adjusted odds ratio [aOR] 1.35, 95% confidence interval [CI] 1.04 – 1.74), and 1-year all-cause readmission (adjusted hazard ratio [aHR] 1.11, 95% CI 1.05 – 1.18). Limited social support, major psychiatric disorder, and repeated non-adherence were associated with persistently poor HRQOL, while major psychiatric disorder was associated with 1-year rehospitalization. ConclusionThe presence of psychosocial risk factors is associated with lower KCCQ-12 scores and higher risk for readmission at 1-year after LVAD. While these associations are statistically significant, further research is needed to determine whether these differences are clinically meaningful.

Perceived Economic Burden, Mortality, and Health Status in Patients With Heart Failure

In the face of an emerging heart failure (HF) epidemic, describing the association between perceived economic burden (PEB) and health care outcomes is an important step toward more equitable and achievable care. To examine the association between PEB and risk of 1-year clinical outcomes and HF-specific health status in patients with acute decompensated HF. This prospective, multicenter, hospital-based cohort study prospectively enrolled adult patients hospitalized for acute decompensated HF at 52 hospitals in China from August 2016 to May 2018, with 1-year follow-up. Data were analyzed on June 17, 2022. Perceived economic burden, categorized as severe (cannot undertake expenses), moderate (can almost undertake expenses), or little (can easily undertake expenses). The clinical outcomes of the study were 1-year all-cause death and rehospitalization for HF. Heart failure-specific health status was assessed by the 12-Item Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Among 3386 patients, median age was 67 years (IQR, 58-75 years) and 2116 (62.5%) were men. Of these patients, 404 (11.9%) had severe PEB; 2021 (59.7%), moderate PEB; and 961 (28.4%), little PEB. Compared with patients with little PEB, those with severe PEB had increased risk of 1-year mortality (hazard ratio [HR], 1.61; 95% CI, 1.21-2.13; P < .001) but not 1-year HF rehospitalization (HR, 1.21; 95% CI, 0.98-1.49; P = .07). The mean (SD) adjusted KCCQ-12 score was lowest in patients with severe PEB and highest in patients with little PEB at baseline (40.0 [1.7] and 50.2 [1.0] points, respectively; P < .001) and at each visit (eg, 12 months: 61.5 [1.6] and 75.5 [0.9] points respectively; P < .001). Patients reporting severe PEB had a clinically significant lower 1-year KCCQ-12 score compared with those reporting little PEB (mean difference, -11.3 points; 95% CI, -14.9 to -7.6 points; P < .001). In this cohort study of patients with acute decompensated HF, greater PEB was associated with higher risk of mortality and poorer health status but not with risk of HF rehospitalization. The findings suggest that PEB may serve as a convenient tool for risk estimation and as a potential target for quality-improvement interventions for patients with HF.

Low Muscle Mass by Preprocedural Computed Tomography Is Associated With Worse Short-Term Outcomes in Transcatheter Aortic Valve Replacement Recipients

Low muscle mass (LMM) is associated with worse outcomes in various clinical situations. Traditional frailty markers have been used for preoperative risk stratification in patients who underwent transcatheter aortic valve replacement (TAVR). However, preoperative imaging provides an opportunity to directly quantify skeletal muscle mass to identify patients at higher risk of procedural complications. We reviewed all TAVR recipients from January to December 2018 and included subjects with preprocedural chest computed tomography. Multi-slice automated measurements of skeletal muscle mass were made from the ninth to twelfth thoracic vertebrae and normalized by height squared to obtain skeletal muscle index (cm2/m2). LMM was defined as the lowest gender-stratified skeletal muscle index tertile. Strength testing was collected during pre-TAVR evaluation. Primary outcome was a composite of perioperative complications, 1-year rehospitalization, or 1-year mortality. In our cohort, 238 patients met inclusion criteria, and 80 (33.6%) were identified to have LMM. Patients with LMM were older with lower body mass index, decreased grip strength, lower hemoglobin A1c, and higher N-terminal pro-brain natriuretic peptide. They had greater rates of the composite outcome and 2-year all-cause mortality, which remained significant on multivariable adjustment (hazard ratio 1.71, 95% confidence interval 1.05 to 2.78, p = 0.030 and hazard ratio 2.31, 95% confidence interval 1.02 to 5.24, p = 0.045, respectively) compared with patients without LMM; there was no significant difference in 5-year all-cause mortality. In conclusion, LMM was associated with an increase in the primary composite outcome and 2-year all-cause mortality in TAVR recipients. Using automatic muscle processing software on pre-TAVR computed tomography scans may serve as an additional preoperative risk stratification tool.

The effect of kidney function on guideline-directed medical therapy implementation and prognosis in heart failure with reduced ejection fraction.

Kidney dysfunction (KD) is a main limiting factor of applying guideline-directed medical therapy (GDMT) and reaching the recommended target doses (TD) in heart failure (HF) with reduced ejection fraction (HFrEF). We aimed to assess the success of optimization, long-term applicability, and adherence of neurohormonal antagonist triple therapy (TT:RASi [ACEi/ARB/ARNI] + βB + MRA) according to the KD after a HF hospitalization and to investigate its impact on prognosis. The data of 247 real-world, consecutive patients were analyzed who were hospitalized in 2019-2021 for HFrEF and then were followed-up for 1 year. The application and the ratio of reached TD of TT at hospital discharge and at 1 year were assessed comparing KD categories (eGFR: ≥90, 60-89, 45-59, 30-44, <30 mL/min/1.73 m2 ). Moreover, 1-year all-cause mortality and rehospitalization rates in KD subgroups were investigated. Majority of the patients received TT at hospital discharge (77%) and at 1 year (73%). More severe KD led to a lower application ratio (p < .05) of TT (92%, 88%, 80%, 73%, 31%) at discharge and at 1 year (81%, 76%, 76%, 68%, 40%). Patients with more severe KD were less likely (p < .05) to receive TD of MRA (81%, 68%, 78%, 61%, 52%) at discharge and a RASi (53%, 49%, 45%, 21%, 27%) at 1 year. One-year all-cause mortality (14%, 15%, 16%, 33%, 48%, p < .001), the ratio of all-cause rehospitalizations (30%, 35%, 40%, 43%, 52%, p = .028), and rehospitalizations for HF (8%, 13%, 18%, 20%, 38%, p = .001) were significantly higher in more severe KD categories. KD unfavorably affects the application of TT in HFrEF, however poorer mortality and rehospitalization rates among them highlight the role of the conscious implementation and up-titration of GDMT.

Long-term results of percutaneous coronary intervention in no-touch vein grafts are significantly better than in conventional vein grafts.

Conventional vein grafts have a high risk of thrombosis and early atherosclerosis. Percutaneous coronary intervention (PCI) in conventional vein grafts is associated with a higher incidence of late adverse cardiac events. The aim of this study was to evaluate the long-term results after PCI in saphenous vein grafts (SVG) harvested with the no-touch technique compared to the conventional technique. This was a single-center, retrospective, cohort study, based on data from the Swedeheart register. The inclusion criterion was individuals who underwent CABG using different vein graft techniques between January 1992 and July 2020, and who required a PCI in SVGs between January 2006 and July 2020. The primary end point was long-term in-stent restenosis. The secondary endpoints were long-term major adverse cardiac events (MACE) and 1-year re-hospitalization rates. The associations between the graft types and the endpoints were evaluated using the Fine and Gray competing-risk regression analysis. The study included 346 individuals (67 no-touch, 279 conventional). The mean clinical follow-up time was 6.4years with a standard deviation of 3.7years. The long-term in-stent restenosis rate for the no-touch grafts was 3.2% compared to 18.7% for the conventional grafts (p < .01), with a subdistribution hazard ratio (SHR) of 0.16 (p = .010). The long-term MACE rate was 27.0% in the no-touch group and 48.3% in the conventional group (p < .01) with a SHR of 0.53 (p = .017). The short-term results were similar in both groups. Percutaneous coronary intervention in a no-touch vein graft was associated with statistically significantly fewer in-stent restenoses and MACE at long-term follow-up compared to a conventional SVG.

Timely Cessation of Proton Pump Inhibitors in Critically Ill Patients Impacts Morbidity and Mortality: A Propensity Score-Matched Cohort Study.

Proton pump inhibitors (PPIs) are among the drugs most commonly used in critically ill patients. Although mainly applied temporarily for stress ulcer prophylaxis, their application is frequently not terminated. Potential adverse effects of PPI treatment could impact the outcome in case of unnecessary and, therefore, avoidable long-term continuation. We tested the hypotheses that nonindicated PPI therapy continued beyond hospital discharge is associated with increased morbidity, rehospitalization rate, and mortality. Nationwide retrospective cohort study considering critically ill patients treated on German ICUs between January, 2017, and December, 2018 with a 2-year follow-up. A total of 591,207 patient datasets of a German healthcare insurer were screened. We identified 11,576 ICU patients who received PPI therapy for the first time during their index ICU stay without having an indication for its continuation. The cohort was stratified into two groups: 1) patients without further PPI therapy and 2) patients with continuation of PPI therapy beyond 8 weeks after hospital discharge. Frequency of predescribed adverse events associated with PPI therapy, 1-year rehospitalization rate, and 2-year mortality were determined. The proportion of patients with continued PPI therapy without an objectifiable indication was 41.7% (4,825 of 11,576 patients). These patients had a 27% greater risk of pneumonia (odds ratio [OR] 1.27; 95% CI, 1.15-1.39; p < 0.001) and a 17% greater risk of cardiovascular events (OR 1.17; 95% CI, 1.08-1.26; p < 0.001). Continued PPI therapy was associated with a 34% greater risk of rehospitalization (OR 1.34; 95% CI, 1.23-1.47) and a nearly 20% greater 2-year mortality risk (hazard ratio 1.17; 95% CI, 1.08-1.27; p = 0.006). These data demonstrate that an unnecessary continuation of PPI therapy after hospital discharge may significantly impact morbidity and mortality. To avoid potentially harmful overuse of a PPIs, intensivists should ensure timely cessation of a temporarily indicated PPI therapy.

Daily Physical Activity Measured by Wearable Smartwatch for Patients Undergoing Transcatheter Aortic Valve Replacement: Insights From the SMART TAVR Study.

This study aims to evaluate limited data about daily physical activity patterns, influential factors, and their association with 1-year mortality or rehospitalization after transcatheter aortic valve replacement (TAVR) through smartwatches. Consecutive severe aortic stenosis patients undergoing elective transfemoral TAVR in a Chinese tertiary hospital were enrolled from July 2021 to May 2022 and received a Huawei smartwatch at least 1 day before TAVR. The primary outcome was a composite of all-cause mortality or hospital readmission within 1 year. Linear mixed-effects models were applied to determine influential factors of daily step counts, and Cox proportional hazard regression models were to estimate the association between baseline step counts within 1 month since discharge and composite outcome from months 2 to 12. The dose-response association was assessed using restricted cubic spline curves. A total of 222 participants and 59 469 valid monitoring person-day records were included (mean age, 72.7 years; 61% women). Step counts increased rapidly within the first 2 months (P<0.001), followed by a slower increase for those without composite outcomes (P=0.029) and a gradual decrease for those who developed composite outcomes (P<0.001). In multivariate linear mixed models, a 1-m increase in baseline 6-minute walk test and a 1-month delay after discharge were associated with 4 (95% CI, 1-7) and 170 (95% CI, 145-194) additional step counts, respectively. In restricted cubic spline analysis, the hazard ratio declined progressively until ≈5000 steps per day, after which they leveled. Below 5000 steps, the adjusted hazard ratio of composite outcome associated with each 1000-step count increase was 0.67 (0.50-0.89; P=0.007). However, above 5000 steps, step counts were not significantly associated with the composite outcome (P=0.645), with a hazard ratio of 1.12 (0.70-1.79). Daily step counts rapidly increased within the first 2 months post-TAVR. Increased physical activity was associated with a lower risk of 1-year mortality or rehospitalization after TAVR for patients with daily step counts below 5000. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04454177.

Systemic inflammatory response syndrome in patients undergoing transcatheter aortic valve implantation

BackgroundData on systemic inflammatory response syndrome (SIRS) after transcatheter aortic valve implantation (TAVI) are scarce and limited to small cohorts. We aimed to investigate its incidence and mid-term impact in a large cohort of TAVI patients. MethodsFrom January 2018 to December 2020, 717 patients with severe aortic valve stenosis undergoing TAVI were included. SIRS was defined as fulfilling at least two of the following criteria within 48 h from the procedure: leucocyte count >12.0 or <4.0 × 109/l, respiratory rate > 20 breaths per minute or PaCO2 ≤ 4.3 kPa/32 mmHg, heart rate > 90 beats per minute and temperature > 38.0 °C or <36.0 °C. Clinical endpoints were 1-year rehospitalization for chronic heart failure (CHF) and 2-years all-cause mortality. Event rates during follow-up were calculated as Kaplan-Meier estimates. ResultsSIRS developed in 56.3 % (404/717) of patients after TAVI. SIRS occurred more frequently in patients with post-dilatation (SIRS 34.7 % (140/404) vs. no SIRS 23.3 % (73/313); p < 0.001) and major vascular complications (SIRS 16.1 % (65/404) vs. no SIRS 8.6 % (27/313); p = 0.004). Further, ICU days were more in patients who developed SIRS (SIRS 1.56 ± 1.50 days vs. no SIRS 1.22 ± 1.02 days; p = 0.001). At 2-years, all-cause mortality in the entire population was 23.9 %. However, there was no difference in CHF at 1-year (5.9 % vs. 4.1 %; log-rank = 0.347) nor in all-cause mortality at 2-years (22.0 % vs. 26.2 %; log-rank = 0.690) between the groups. ConclusionsSIRS is a common finding after TAVI, which may prolong hospital stay but is without effect on mortality during 2-years follow-up.

Morbidity and mortality of acute heart failure patients stratified by mitral regurgitation in the Arabian Gulf: Observations from the Gulf acute heart failure registry (Gulf CARE)

This study aimed to evaluate the clinical outcomes of patients with acute heart failure (AHF) stratified by mitral regurgitation (MR) in the Arabian Gulf. Patients from the Gulf CARE registry were identified from 47 hospitals in seven Arabian Gulf countries (Yemen, Oman, Kuwait, Qatar, Bahrain, the United Arab Emirates, and Saudi Arabia) from February to November 2012. The cohort was stratified into two groups based on the presence of MR. Univariable and multivariable statistical analyses were performed. The population cohort included 5005 consecutive patients presenting with AHF, of whom 1491 (29.8 %) had concomitant MR. The mean age of patients with AHF and concomitant MR was 59.2 ± 14.9 years, and 63.1 % (n = 2886) were male. A total of 58.6 % (n = 2683) had heart failure (HF) with reduced ejection fraction (EF) (HFrEF), 21.0 % (n = 961) had HF with mildly reduced EF (HFmrEF), and 20.4 % (n = 932) had HF with preserved EF (HFpEF). Patients with MR had a lower haemoglobin (Hb) level (12.4 vs. 12.7 g/dL; p < 0.001), and a higher prevalence of left atrial enlargement (80.2 % vs. 55.1 %; p < 0.001), cardiogenic shock (9.7 % vs. 7.3 %; p = 0.006) and atrial fibrillation (7.6 % vs. 5.6 %; p = 0.006), and HFrEF (71.0 % vs. 52.6 %; P < 0.001). Multivariable analysis demonstrated that MR was independently associated with increased all-cause mortality at 1-year and 3-month HF rehospitalization [1-year all-cause mortality, adjusted odds ratio (aOR), 1.40; 95 % confidence interval (Cl): 1.13–1.74; p = 0.002; 3-month HF rehospitalization, aOR, 1.26; 95 % Cl: 1.06–1.49; p = 0.009]. In an Arabian Gulf cohort with AHF, concomitant MR was associated with an increased risk of 1-year mortality and 3-months HF rehospitalization.

One-year outcomes in cardiogenic shock triggered by supraventricular tachycardia: an analysis of the FRENSHOCK multicenter prospective registry

Abstract Background Cardiogenic shock (CS) is the most severe form of heart failure (HF), resulting in high early and long-term mortality. Characteristics of CS secondary to supraventricular tachycardia (SVT) are poorly reported. Based on a large registry of unselected CS, our aim was to compare one-year outcomes between SVT-triggered and non-SVT-triggered CS. Methods FRENSHOCK is a prospective registry including 772 CS from 49 centers. One to three triggers could be identified (ischemic, mechanical complications, ventricular/supraventricular arrhythmia, bradycardia, iatrogenesis, infection, non-compliance, others). One-year outcomes (rehospitalizations, mortality, heart transplantation (HTx), ventricular assist devices (VAD)) were analyzed, adjusted on independent predictive factors. Results Within 769 CS included, 100 were SVT-triggered (13%) with 65 with SVT as exclusive trigger (8.5%). SVT triggered CS patients were more male with more frequent history of cardiomyopathy or chronic kidney disease, and more profound CS (biventricular failure and multiorgan failure). At 1-year, there was no difference in all-cause mortality (HR 0.91 [0.66 – 1.26], p = 0.58), need for HTx or VAD (OR 0.88 [0.41 – 1.88], p = 0.74) or rehospitalizations (OR 1.24 [0.78 – 1.98], p = 0.36). Patients with SVT as exclusive trigger presented more 1-year rehospitalizations (OR 3.74 [1.05 – 10.5], p = 0.01). Conclusion SVT is a frequent trigger of CS alone or in association in more than 10% of miscellaneous CS. Although SVT-triggered CS patients were more comorbid with more pre-existing cardiomyopathies and HF, they presented similar rates of mortality, HTx and VAD at 1-year arguing for a better overall prognosis.Graphical abstract

Multicentre observational registry of patients hospitalized for heart failure and real-life adherence to international guidelines (REAL-HF): first two years (2020-2021) experience

Abstract Background Heart failure (HF) is associated with high mortality and costs mainly due to hospitalizations. Real-world data deriving from registries demonstrate gaps between guidelines recommendations and clinical practice. Purpose The REAL-HF registry aims to provide a comprehensive overview of hospital management of HF patients in Italy, and to identify critical issues and their potential determinants. Methods The registry involves 11 centers, including all adult patients hospitalized for HF in the period 2020-2026. Data are derived from discharge letters and electronic hospital records. Patients are screened based on Diagnosis Related Groups codes. Inclusion criteria are: 1. Hospitalization for HF (except for elective procedures); 2. Decompensated HF in conjunction with other pathological conditions; 3. De novo or decompensated HF during hospitalization due to non-cardiac causes. Results This analysis included 3918 patients over two years (2020-2021) from 4 tertiary hospitals (males 2135 [54%], median age of 80[IQR 71-86] years). Only 39% of patients were hospitalized in a cardiology unit. Hospital length of stay was 9(6-15) days. Median left ventricular ejection fraction (LVEF) was 45(32-55%) (HFrEF n = 1462[37%], HFmrEF n = 420[11%], HFpEF n = 1675[43%]). Coronary artery disease was the leading cause (n = 1082[28%]) of HF, and atrial fibrillation was highly prevalent (history - 22%; during hospitalization - 33%). Arterial hypertension was the most prevalent (71%) cardiovascular risk factor. Chronic kidney disease (47%) and chronic obstructive pulmonary disease (26%) were frequent comorbidities, and they resulted to be independent predictors of adverse outcomes in multiple regression analysis. Only 67% of patients with HFrEF were treated with ACEi/ARB/ARNi, 84% with a beta-blocker, 73% with MRAs, and only 48% with all three drugs classes. New SGLT2i were prescribed in 4%. Only 16% of patients with HFrEF had a defibrillator, and 13% were treated with cardiac resynchronization therapy. Patients hospitalized in non-cardiology units were older (83 vs 73 years, p&amp;lt;0.0001), more frequently females (52% vs 44%, p&amp;lt;0.001), with HFpEF (54% vs 24%, p&amp;lt;0.001), and less frequently treated with ARNi, beta-blockers, or MRAs (p&amp;lt;0.001). Overall 30-days hospital readmission rate was 8.4%, without significant differences between cardiology and non-cardiology units (7.8 vs 8.7%, p = 0.347). However, 1-year rehospitalizations and mortality were significantly higher in patients hospitalized in non-cardiac units (33.4% vs 25.3% and 23% vs 9.57%, respectively - p&amp;lt;0.001). Conclusions The REAL-HF registry confirms the clinical impact of HF, and the poor outcomes of patients hospitalized with this condition. Adherence to the guidelines is still inadequate and this may impact on patients' outcomes. Moreover, the significant differences in terms of patients’ profiles might further increase the gap between highly specialized cardiology units and internal medicine departments.