Admission For Acute Heart Failure Research Articles

#2334 Elevated serum admission creatinine in acute heart failure hospitalizations: lifting the veil to understand outcome differences

Abstract Background and Aims Organ crosstalk in heart failure and kidney dysfunction is prevalent and is associated to a high event rate. In this setting elevated serum creatinine (sCr) at acute decompensated heart failure (ADHF) admissions is a strong risk factor for poor outcomes. Current accepted cardiorenal syndrome (CRS) classification is based on timing and initial organ dysfunction and fails at capturing its nature and prognosis. We sought to describe patient (P) profile and outcomes in P hospitalized for ADHF with high admission sCr in function of current CRS classification and assess for stratifying predictors. Method We conducted an observational, analytical and cross-sectional study, with prospective and consecutive data acquisition. We included P over 18 years-old, who were admitted to the Intensive Care Telemetry Unit in our Hospital between July, 2011 and Dec, 2023 due to ADHF. P who received a heart transplant during index admission or those on chronic dialysis were excluded. Clinical, epidemiological and biochemical variables were registered. Renal dysfunction was defined under admission sCr >1.4 mg/dl and divided according to Ronco et al classification, as initially cardiac (type 2) or renal (type 4) origin. We constructed multivariate logistic and survival regression models, with selection of relevant predictors by resampling and regularization of a Lasso regression model. Statistical significance was considered with a 5% of alpha error level. Analysis was conducted using R (R Core Team, 2023). Results A total of 1868 consecutive P were included. P population consisted in type 2: 124 and type 4: 258 P, respectively. We found no differences in gender (p = 0.47), while type 4 were older (75 ± 12 vs 71 ± 12; p < 0.01). Ventricular dysfunction was more severe in type 2 (left ventricular ejection fraction 34 ± 17 vs 41 ± 16%; p < 0.001). While ischaemic heart disease was more prevalent in type 4 (32.8 vs 23.5%; p = 0.001), idiopathic cardiomyopathy was more frequent in type 2 (18.8 vs 7.2%; p = 0.001). Clinical phenotypes differed between groups, being clinical hypoperfusion more frequent in type 2 (32.4 vs 12.3%; p < 0.001). Admission sCr was higher in type 4 (1.9 [0.8] vs 1.6 [0.58] mg/dl; p < 0.001), as was 1st day natriuresis (81 vs 67 mEq; p = 0.01). Both groups experienced a similar diuretic resistance rate (21.2 vs 17.1%; p = 0.34), while type 4 received rescue ultrafiltration more frequently (11.3 vs 3.5%; p < 0.01). Type 2 received a higher inotropic support rate (47.1 vs 19.5%; p < 0.01) and had a longer length of stay (9 vs 7 days; p = 0.01). In-hospital (11.8 vs 11.3%; p = 0.99); 6-month and 1-year mortality rates (66.8 vs 72.8% and 55.1 vs 64.6% respectively; p = 0.3). In a similar way, 1-month (94.8 vs 94.7%), 6-month (72 vs 74.7%) and 1-year readmission rates (59.2 vs 60.9%; p = 0.6) were similar in both groups. A multiple logistic regression model (AUCROC 0.82) identified admission sCr (OR 2.6; CI 95% 2.2-3.2; p < 0.001), inotropic need (OR 1.87; CI 95% 1.4-2.6; p < 0.001), anasarca phenotype (OR 1.63; CI 95% 1.06-2.5; p = 0.02), moderate to severe right ventricular dysfunction (OR 1.4; CI 95% 1.03-1.9; p = 0.03) as independent predictors for a descending sCr behavior during hospitalization, while the lower T3 levels were associated with less probability for a descent of sCr (OR 0.21; CI 95% 0.1-0.46; p < 0.001). Conclusion Organ crosstalk in ADHF hospitalizations was associated with a high event rate. One-year mortality and readmission rates were similar in both groups. Renal support therapies were more frequent under lower kidney reserve conditions. Ventricular dysfunction and systemic congestion phenotype are relevant to a better understanding for potential reversibility at the admission time and may promote actions for outcome enhancing.

Long-term impact of home-based monitoring after an admission for acute decompensated heart failure: a systematic review and meta-analysis of randomised controlled trials

Patients with heart failure have high rehospitalisation rates and poor cardiovascular outcomes. Home-based monitoring (HBM) has emerged with promising results in different settings. However, its long-term effects on patients recently admitted for acute decompensated heart failure (ADHF) remain uncertain. We systematically searched PubMed, Embase, and Cochrane Library for randomised controlled trials (RCTs) comparing HBM with usual care (UC) that were published between database inception and June 24, 2023. We included studies with patients admitted for ADHF in the previous 6 months and with a minimum follow-up of 6 months. We excluded studies with patients hospitalised for reasons other than ADHF and studies with disproportional education interventions between arms. Statistical analyses were performed using R software version 4.3.2. We pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) for categorical and continuous outcomes, respectively. Cochrane Collaboration's tool for assessing risk of bias in RCTs (RoB 2) was used to assess study quality. Publication bias was assessed via funnel plots and Egger's test, and heterogeneity was assessed through I2 statistics and sensitivity analysis. The protocol for this systematic review and meta-analysis was registered in the International Prospective Register of Systematic Reviews (PROSPERO, CRD42023465359). We included 16 RCTs comprising 4629 patients, of whom 2393 (51.7%) were randomised to HBM and 3150 (68%) were men. Follow-up ranged from six to fifteen months. As compared with UC, HBM significantly reduced all-cause mortality (RR 0.75; 95% CI 0.61, 0.91; p=0.005), all-cause hospitalisations (RR 0.82; 95% CI 0.70, 0.97; p=0.018), cardiovascular (CV) mortality (RR 0.53; 95% CI 0.36, 0.79; p=0.002), hospitalisations for heart failure (RR 0.75; 95% CI 0.62, 0.91; p=0.004), and CV hospitalisations (RR 0.72; 95% CI 0.55, 0.95; p=0.018). There were no significant differences in length of hospital stay (MD 0.97 days; 95% CI -0.90, 2.84; p=0.308). In patients recently admitted with ADHF, HBM significantly reduces long-term all-cause mortality and hospitalisations, CV mortality and hospitalisations, and hospitalisations for heart failure, as compared with UC. This supports the implementation of HBM as a standard practice to optimise patient outcomes following admissions for ADHF. However, future studies are warranted to evaluate the efficacy and safety of implementing HBM in the real-world setting. None.

Differential sex-related effect of left ventricular ejection fraction trajectory on the risk of mortality and heart failure readmission following hospitalization for acute heart failure: A longitudinal study.

There is limited information on the sex-specific longitudinal changes of left ventricular ejection fraction (LVEF) after an acute heart failure (AHF) hospitalization. We aimed to investigate whether LVEF trajectories over time and their impact on mortality and AHF readmission rates differ between men and women. We conducted a retrospective sex-specific analysis of longitudinal LVEF measurements (n = 9581) in 3383 patients with an index hospitalization for AHF in a single tertiary-level hospital. Statistical techniques suited for longitudinal data analysis were used. The mean age of the sample was 73.8 ± 11.2 years, and 47.9% were women. The mean LVEF was 49.4 ± 15.3%. At a median follow-up of 2.58 years (interquartile range 0.77-5.62), we registered 2197 deaths (64.9%) and 2597 AHF readmissions in 1302 (38.5%) patients. The longitudinal analysis showed that women had consistently higher LVEF values throughout the follow-up with both trajectories characterized by an early peak-approximately at 1 year-followed by decreasing values in men but a plateau in women. Multivariate between-sex comparisons across LVEF categories revealed that women had lower rates of AHF readmissions when LVEF ≤40%. On the contrary, women displayed an excess risk of AHF readmissions when LVEF >60%. A trend in the same direction was found for cardiovascular and all-cause mortality. Sex was a significant factor in determining the follow-up trajectory of LVEF and predicting differences in outcomes after an AHF admission. The findings suggest that women have a higher risk of AHF readmissions at higher LVEF values, while men have a higher risk at lower LVEF values. For all-cause and cardiovascular mortality, the same direction of the association was inferred but they were not significant.

Timing of Worsening Renal Function in Patients Hospitalized for Heart Failure Exacerbation Who Were Being Treated With Intravenous Diuretic Therapy.

This retrospective observational study investigated the incidence of worsening renal function (WRF) in patients hospitalized for heart failure (HF) and treated with intravenous diuretics in Japan.Methods and Results: Associations between WRF at any point and HF treatments, and the effects of WRF on outcomes were evaluated (Diagnosis Procedure Combination database). Of 1,788 patients analyzed (mean [±SD] age 80.5±10.2 years; 54.4% male), 641 (35.9%) had WRF during a course of hospitalization for worsening HF: 208 (32.4%) presented with WRF before admission (BA-WRF; estimated glomerular filtration rate decreased by ≥25% from baseline at least once between 30 days prior to admission and admission); 44 (6.9%) had WRF that persisted before and after admission (P-WRF); and 389 (60.7%) had WRF develop after admission (AA-WRF). Delayed initial diuretic administration, higher maximum doses of intravenous diuretics during hospitalization, and diuretic readministration during hospitalization were associated with a significantly higher incidence of AA-WRF. Patients with WRF at any time point were at higher risk of death during hospitalization compared with patients without WRF, with adjusted hazard ratios of 3.56 (95% confidence interval [CI] 2.23-5.69) for BA-WRF, 3.23 (95% CI 2.21-4.71) for AA-WRF, and 13.16 (95% CI 8.19-21.15) for P-WRF (all P<0.0001). Forty percent of WRF occurred before admission for acute HF; there was no difference in mortality between patients with BA-WRF and AA-WRF.

Timing of previous heart failure hospitalization as a prognostic factor for emergency department heart failure patients.

To investigate whether the timing of a previous hospital admission for acute heart failure (AHF) is a prognostic factor for AHF patients revisiting the emergency department (ED) in the subsequent 12-month follow-up. All ED AHF patients enrolled in the previously described EAHFE registry were stratified by the presence or absence of an AHF hospitalization admission in the prior 12months. The primary outcome was 12-month all-cause mortality postED visit. Secondary end points were hospital admission, prolonged hospitalization (> 7days), mortality during hospitalization and a 90-day post-discharge adverse composite event (ACE) rate, defined as ED revisits due to AHF, hospitalizations due to AHF, or all-cause mortality. Outcomes were adjusted for baseline and AHF episode characteristics.Of 5,757 patients included, the median age was 84years (IQR 77-88); 57% were women, and 3,759 (65.3%) had an AHF hospitalization in the previous 12months. The 12-month mortality was 37% (41.7% vs. 28.3% p < 0.001), hospital admission was 76.1% (78.8% vs. 71.1% p < 0.001) ACE was 60.2% (65.1% vs. 50.5% p < 0.001). In the adjusted analysis, patients with AHF hospitalization in the prior 12months had a higher mortality (HR = 1.41; 95% CI 1.27-1.56), 90-day ACE rate (HR = 1.45: 95% CI 1.32-1.59), and more hospital admissions (OR = 1.32; 95% CI 1.16-1.51), with shorter times since the previous hospitalization being related to the outcomes analyzed. One-year mortality, adverse events at 90days, and readmission rates are increased in ED AHF patients previously admitted within the last 12months.

Factors Affecting Late Atrial Fibrillation and Its Association With Coronary Artery Bypass Outcomes

BackgroundAlthough predictors and outcomes of postoperative atrial fibrillation (POAF) are well studied, evidence is lacking concerning postdischarge late/recurrent atrial fibrillation (AF). This study evaluated factors affecting late/recurrent AF and its association with coronary artery bypass grafting (CABG) outcomes in a real-world setting. MethodsFrom 2012 through 2016, 5175 patients were included. Independent factors associated with late/recurrent AF were identified in a competing risk setting. Cox proportional hazard regression was used to evaluate the association between late/recurrent AF and study outcomes, consisting of all-cause mortality, major adverse cardio-cerebrovascular events, acute coronary syndrome, cerebrovascular events, and heart failure admissions. ResultsDuring a median follow-up of 60 months (quartile 1-quartile 3, 59.3-60.7 months), late/recurrent AF developed in 85 patients (1.64%). Independent factors associated with late/recurrent AF were age (subdistribution hazard ratio [sHR], 1.04; 95% CI, 1.02-1.07), left-ventricular ejection fraction (sHR, 0.97; 95% CI, 0.95-0.99), length of stay (sHR, 1.02; 95% CI, 1.01-1.04), and POAF (sHR, 4.02; 95% CI, 2.50-6.45). Late/recurrent AF was not significantly associated with all-cause mortality and major adverse cardio-cerebrovascular events at unadjusted or adjusted levels (adjusted hazard ratio, 0.80 [95% CI, 0.50-1.28] and 0.74 [95% CI, 0.48-1.13], respectively). Nevertheless, it significantly increased the unadjusted risk of cerebrovascular events (hazard ratio, 2.28; 95% CI, 01.07-4.87), which disappeared after adjustments. ConclusionsPatients with advanced age, a lower left-ventricular ejection fraction, and POAF are more likely to have late/recurrent clinical AF. Albeit counterintuitive, late/recurrent AF was not independently associated with worse midterm post-CABG outcomes. These observations need to be further elucidated in larger-scale studies and interpreted in the context of a developing country with limited resources for late AF surveillance.

Safety Indicators In Patients Receiving High-intensity Care After Acute Heart Failure Admission: The STRONG-HF Trial

Safety Indicators In Patients Receiving High-intensity Care After Acute Heart Failure Admission: The STRONG-HF Trial

Optimization of Evidence-Based Heart Failure Medications After an Acute Heart Failure Admission

The Safety, Tolerability, and Efficacy of Rapid Optimization, Helped by N-Terminal Pro-Brain Natriuretic Peptide Testing of Heart Failure Therapies (STRONG-HF) trial strived for rapid uptitration aiming to reach 100% optimal doses of guideline-directed medical therapy (GDMT) within 2 weeks after discharge from an acute heart failure (AHF) admission. To assess the association between degree of GDMT doses achieved in high-intensity care and outcomes. This was a post hoc secondary analysis of the STRONG-HF randomized clinical trial, conducted from May 2018 to September 2022. Included in the study were patients with AHF who were not treated with optimal doses of GDMT before and after discharge from an AHF admission. Data were analyzed from January to October 2023. The mean percentage of the doses of 3 classes of HF medications (renin-angiotensin system inhibitors, β-blockers, and mineralocorticoid receptor antagonists) relative to their optimal doses was computed. Patients were classified into 3 dose categories: low (<50%), medium (≥50% to <90%), and high (≥90%). Dose and dose group were included as a time-dependent covariate in Cox regression models, which were used to test whether outcomes differed by dose. Post hoc secondary analyses of postdischarge 180-day HF readmission or death and 90-day change in quality of life. A total of 515 patients (mean [SD] age, 62.7 [13.4] years; 311 male [60.4%]) assigned high-intensity care were included in this analysis. At 2 weeks, 39 patients (7.6%) achieved low doses, 254 patients (49.3%) achieved medium doses, and 222 patients (43.1%) achieved high doses. Patients with lower blood pressure and more congestion were less likely to be uptitrated to optimal GDMT doses at week 2. As a continuous time-dependent covariate, an increase of 10% in the average percentage optimal dose was associated with a reduction in 180-day HF readmission or all-cause death (primary end point: adjusted hazard ratio [aHR], 0.89; 95% CI, 0.81-0.98; P = .01) and a decrease in 180-day all-cause mortality (aHR, 0.84; 95% CI, 0.73-0.95; P = .007). Quality of life at 90 days, measured by the EQ-5D visual analog scale, improved more in patients treated with higher doses of GDMT (mean difference, 0.10; 95% CI, -4.88 to 5.07 and 3.13; 95% CI, -1.98 to 8.24 points in the medium- and high-dose groups relative to the low-dose group, respectively; P = .07). Adverse events to day 90 occurred less frequently in participants with HIC who were prescribed higher GDMT doses at week 2. Results of this post hoc analysis of the STRONG-HF randomized clinical trial show that, among patients randomly assigned to high-intensity care, achieving higher doses of HF GDMT 2 weeks after discharge was feasible and safe in most patients. ClinicalTrials.gov Identifier: NCT03412201.

Treatment patterns and trajectories in patients after acute heart failure hospitalization.

The trajectories of systolic function after admission for acute heart failure (HF) and their effect on clinical outcomes have not been fully elucidated. We aimed to assess changes in left ventricular ejection fraction (LVEF) between the index and 1year after discharge and to examine their prognostic implications. We extracted data from a prospective multicentre registry of patients hospitalized for acute HF and identified 1636 patients with LVEF data at admission and 1year after discharge. We categorized them into five groups based on LVEF changes: HF with unchanged-preserved EF [HFunc-pEF (EF≥50%); N=527, 32.2%], unchanged-mildly reduced EF [HFunc-mrEF (EF 41-49%); N=86, 5.3%], unchanged-reduced EF [HFunc-rEF (EF≤40%); N=377, 23.0%], worsened EF (HFworEF; N=83, 5.1%), and improved EF (HFimpEF; N=563, 34.4%). We then evaluated the subsequent composite outcome of cardiovascular death and HF readmission. During 1year after discharge, 53% of patients with HF with reduced EF and 67% of those with HF with mildly reduced EF (HFmrEF) transitioned to other categories, whereas 92% of those with HF with preserved EF (HFpEF) remained within the same category. Patients with HFimpEF were more likely to be younger and had relatively preserved renal function, whereas those with HFworEF were the oldest and had more comorbidities among the five groups. After multivariable adjustment, patients with HFimpEF and HFunc-pEF had a lower risk for composite outcomes when referenced to patients with HFunc-rEF [hazard ratio (95% confidence interval), P-value: 0.28 (0.16-0.49), P<0.001, and 0.40 (0.25-0.63), P<0.001, respectively]. Conversely, patients with HFunc-mrEF and HFworEF had a comparable risk [0.44 (0.18-1.07), P=0.07, and 0.63 (0.29-1.39), P=0.26, respectively]. A substantial number of patients with HF experienced transitions to other categories after discharge. Notably, patients with decreased EF experienced a worse prognosis, even with slight decreases (e.g. HFpEF transitioning to HFmrEF). These findings emphasize the significance of longitudinal assessments of systolic function to better manage patients following acute decompensation.

Forecasting the Acute Heart Failure Admissions: Development of Deep Learning Prediction Model Incorporating the Climate Information

BackgroundClimate is known to influence the incidence of cardiovascular events. However, their prediction with traditional statistical models remain imprecise. Methods and ResultsWe analyzed 27,799 acute heart failure (AHF) admissions within the Tokyo CCU Network Database from January 2014 to December 2019. High-risk AHF (HR-AHF) day was defined as a day with the upper 10th percentile of AHF admission volume. Deep neural network (DNN) and traditional regression models were developed using the admissions in 2014-2018 and tested in 2019. Explanatory variables included 17 meteorological parameters. Shapley additive explanations were used to evaluate their importance. The median number of incidences of AHF was 12 (9-16) per day in 2014–2018 and 11 (9-15) per day in 2019. The predicted AHF admissions correlated well with the observed numbers (DNN: R2 = 0.413, linear regression: R2 = 0.387). The DNN model was superior in predicting HR-AHF days compared with the logistic regression model [c-statistics: 0.888 (95%CI: 0.818-0.958) vs. 0.827 (95%CI: 0.745-0.910): p=0.0013]. Notably, the strongest predictive variable was the 7-day moving average of the lowest ambient temperatures. ConclusionsThe DNN model had good prediction ability for incident AHF using climate information. Forecasting AHF admissions could be useful for the effective management of AHF.

Real world data on adopting guideline directed medical therapy post 2021 ESC HF guidelines and effect on renal function

Abstract Introduction This single-centre cohort study aims to compare the use of guideline-directed medical therapies (GDMT) before and after the 2021 ESC HF guidelines and the effect on renal function. There has been good adoption of these guidelines worldwide following the publication in 2021. We know HF patients will have less decline in renal function when GDMT is better optimised. This study aims to compare renal function on admission (adm) and discharge (dc) following acute heart failure admission. Methods Our database is composed of 460 patients with AHF admitted to our HF unit from 01/08/2020 till 31/07/2022inclusive. We divided this group into two; Group A was composed of 187 patients from August 2020 to Aug 2021(pre-ESC guidelines) and Group B included 273 patients from August 2021 to Aug 2022 (post-ESC guidelines). We compared the number of patients initiated on the 4 pillars of HF medication on admission and discharge. Both groups were analysed based on their ejection fraction (HFrEF, HFmrEF and HFpEF). Baseline parameters were were similar between the two groups. We analyzed eGFR (mL/min) on admission (adm), eGFR on discharge (dc), K+ (mmol/l) on dc and the 8 medications for HFrEF and HFmrEF. We also reviewed three medications for HFpEF. Results Group A (Aug 2020-Aug 2021): HFrEF patients had an average eGFR of 52.4 on adm and 47,0 at dc, average K+ was 4.34 on dc. HFmrEF subgroup had an average eGFR of 48.8 on adm and 45.4 at dc, average K+ was 4.23 on dc. HFpEF subgroup had an average eGFR of 51.2 on adm and 44.2 at dc, average K+ was 4.24 on dc. Group B (Aug 2021-Aug 2022): HFrEF patients had an average eGFR of 53.5 on adm and 50.7 dc, average K+ was 4.38 on dc. HFmrEF subgroup had an average eGFR of 49.4 on adm and 47.0 at dc, average K+ was 4.34 on dc. HFpEF subgroup had an average eGFR of 45.9 on adm and 41.7 at dc, average K+ was 4.35 on dc. Group A and B comparison (Table1): In Group A, HFrEF patients had a drop of eGFR of 5.4 between adm and dc. However, HFrEF patients in Group B, where they had their GDMT optimized, had an eGFR drop of only 2.8 (less by 2.6). In Group A, HFmrEF patients had an eGFR drop of 3.4 in comparison to HFmrEF patients in Group B where eGFR dropped by 2.4 (less by 1.0). In Group A, HFpEF subgroup had an eGFR drop of 7.0 versus Group B HFpEF where eGFR dropped by 4.2 only (less by 2.8). Despite better GDMT in group B, K+ was comparable to group A. Conclusions Patients with AHF managed in the HF Unit have better optimization of GDMT post 2021 HF ESC guidelines. In Group B, all patient subgroups (HFrEF; HFmrEF and HFpEF) in the year following publication of the ESC HF guidelines had a reduced decline in eGFR i.e. less worsening of renal function despite higher dose and a greater percentage of patients on the 4 pillars of GDMT. This study demonstrates that renal function of patients admitted with AHF is better preserved with optimization of GMDT during their admission.MEDICATIONS (GDMT)RENAL FUNCTION

Myocardial performance index improves prediction of major adverse cardiovascular events and heart failure in type 1 and type 2 diabetes without known heart disease: Thousand&amp;1 and Thousand&amp;2 study

Abstract Background Cardiovascular disease (CVD) is the leading cause of mortality and morbidity in type 1 (T1D) and type 2 diabetes (T2D). Despite myocardial involvement in diabetes, current risk prediction models do not include parameters of the myocardial function. Myocardial performance index (MPI) reflects left ventricular systolic and diastolic function. The prognostic value of MPI has not been evaluated in larger-scale diabetes populations. Purpose To assess the prognostic value of MPI in a larger-scale diabetes population. Methods We evaluated two prospective cohort studies: The Thousand&amp;1 Study (1093 individuals with T1D) and The Thousand&amp;2 Study (1030 individuals with T2D). Clinical data, including echocardiography, were collected at baseline. We excluded 480 individuals with heart disease. We collected follow-up data from national registries. We defined major adverse cardiovascular events (MACE) as the first incident of all-cause death, hospital admission for acute coronary syndrome, heart failure, or stroke. Results For included individuals (56% male, 54±15 years, MPI 0.51±0.1, 63% T1D), follow-up was 100% after a median of 5.3 years (interquartile range: 4.8 to 6.3). MPI was significantly associated with MACE (Hazard ratio 1.2, 95% confidence interval 1.0-1.3, p=0.012, per 0.10-unit increase) and heart failure (Hazard ratio 1.3, 95% confidence interval 1.1-1.6, p=0.005, per 0.10-unit increase) after adjusting for clinical and echocardiographic variables. MPI predicted MACE better in T1D than in T2D (p=0.031 for interaction). MPI added discriminatory power to the Steno T1D Risk Engine (1,2) in predicting heart failure, but not MACE. Conclusions MPI is an independent predictor of MACE and heart failure in T1D and T2D, with the strongest prediction in T1D. Echocardiographic assessment in diabetes may enhance risk prediction.

Epidemiology of acute heart failure admissions in Iceland: phenotype distribution and prognostic implications

Abstract Background/Introduction Contemporary data that describe underlying causes of acute heart failure (AHF) epidemiology in a nation-wide unselected real-life cohort is lacking. Advances in diagnostics, including imaging and genetics, have facilitated the identification of the underlying cause of heart failure (HF). This is the first Icelandic nation-wide study on HF epidemiology of patients hospitalised for AHF. Purpose Investigate the underlying causes of AHF in Iceland and the patients‘ prognosis according to phenotypes. Methods This study used data from the Icelandic Heart Failure Registry (IHFR) and included all hospital admissions for AHF at Landspitali University Hospital from January 2020 to June 2022 (n = 1723). Differences in survival between HF phenotypes were analysed using a multivariate log-rank test, both after diagnosis and after the first discharge. Results The study found that 39.8% of the cases had heart failure with reduced ejection fraction (HFrEF), 17.4% had HF with mildly reduced ejection fraction (HFmrEF), 40.3% had HF with preserved ejection fraction (HFpEF), 0.9% had HF with improved ejection fraction (HFimpEF), and 1.5% had unknown ejection fraction (EF). The average length of hospital admission varied by phenotype, ranging from 8.1 to 15.9 days. Women accounted for 41.15% of all admissions, with the most common phenotype amongst women being HFpEF (57.8%) and the least common being HFrEF (25.1%). The mean age at admission was 75.8 years. Roughly 79% of the whole cohort had NYHA class III-IV at admission; 33% of HFrEF, 13% of HFmrEF and 32% of HFpEF admissions. The most common underlying cause of AHF was coronary artery disease (CAD, 30.9%) followed by atrial fibrillation (15.0%), hypertension (9.8%), diastolic dysfunction (9.4%) and valvular heart disease (9.2%). Other more rare causes were dilated cardiomyopathy (4.4%), amyloidosis (3.2%), broken heart disease (1.5%), myocarditis (0.4%), postpartum cardiomyopathy (0.2%) and Fabry disease (0.1%). During the study period, 422 mortalities were recorded, with 106 in-hospital deaths. After excluding in-hospital mortalities, no significant difference in survival between phenotypes was observed after the first discharge. However, a significant difference in survival was observed with respect to the date of diagnosis (p = 0.0191). Conclusion This study provides new insights into the underlying causes of AHF and patients' prognosis according to phenotypes in Iceland. Our results demonstrate that the most common underlying cause of AHF was CAD, followed by atrial fibrillation and hypertension and that the cohort was highly symptomatic, with a large proportion of patients having NYHA class III-IV at admission. Our findings also highlight significant differences in the prevalence of HF phenotypes between genders, with women more commonly presenting with HFpEF and less commonly with HFrEF.

Novel Nebulized Milrinone Formulation for the Treatment of Acute Heart Failure Requiring Inotropic Therapy: A Phase 1 Study

Nonintravenous inotropic-delivery options are needed for patients with inotropic-dependent heart failure (HF) to reduce the costs, infections and thrombotic risks associated with chronic central venous catheters and home infusion services. We developed a novel, concentrated formulation of nebulized milrinone for inhalation and evaluated the feasibility, safety and pharmacokinetic profile in a prospective, single-arm, phase I clinical trial. We enrolled 10 patients with stage D HF requiring inotropic therapy during a hospital admission for acute HF. Milrinone 60 mg/4 mL was inhaled via nebulization 3 times daily for 48 hours. The coprimary outcomes were adverse events and pharmacokinetic profiles of inhaled milrinone. Acute changes in hemodynamic parameters were secondary outcomes. A concentrated nebulized milrinone formulation was well tolerated, without hypotensive events, arrhythmias or inhalation-related adverse events requiring discontinuation. Nebulized milrinone produced serum concentrations in the goal therapeutic range with a median plasma milrinone trough concentration of 39 (17-66) ng/mL and a median peak concentration of 207 (134-293) ng/mL. There were no serious adverse events. From baseline to 24 hours, mean pulmonary artery saturation increased (60% ± 7%-65 ± 5%; P = 0.001), and mean cardiac index increased (2.0 ± 0.5 mL/min/1.73m2-2.5 ± 0.1 mL/min/1.73m2; P = 0.001) with nebulized milrinone. In a proof-of-concept study, a concentrated, nebulized milrinone formulation for inhalation was safe and produced therapeutic serum milrinone concentrations. Nebulized milrinone was associated with improved hemodynamic parameters of cardiac output in a population with advanced HF. These promising results require further investigation in a longer-term trial in patients with inotrope-dependent advanced HF.

Safety Indicators in Patients Receiving High-intensity Care After Hospital Admission for Acute Heart Failure: The STRONG-HF Trial

BackgroundSafety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies (STRONG-HF) demonstrated the safety and efficacy of rapid up-titration of guideline-directed medical therapy (GDMT) with high-intensity care (HIC) compared with usual care in patients hospitalized for acute heart failure (HF). In the HIC group, the following safety indicators were used to guide up-titration: estimated glomerular filtration rate of <30 mL/min/1.73 m2, serum potassium of >5.0 mmol/L, systolic blood pressure (SBP) of <95 mmHg, heart rate of <55 bpm, and N-terminal pro-B-type natriuretic peptide concentration of >10% higher than predischarge values. Methods and ResultsWe examined the impact of protocol-specified safety indicators on achieved dose of GDMT and clinical outcomes. Three hundred thirteen of the 542 patients in the HIC arm (57.7%) met ≥1 safety indicator at any follow-up visit 1–6 weeks after discharge. As compared with those without, patients meeting ≥1 safety indicator had more severe HF symptoms, lower SBP, and higher heart rate at baseline and achieved a lower average percentage of GDMT optimal doses (mean difference vs the HIC arm patients not reaching any safety indicator, –11.0% [95% confidence interval [CI] –13.6 to –8.4%], P < .001). The primary end point of 180-day all-cause death or HF readmission occurred in 15.0% of patients with any safety indicator vs 14.2% of those without (adjusted hazard ratio 0.84, 95% CI 0.48–1.46, P = .540). None of each of the safety indicators, considered alone, was significantly associated with the primary end point, but an SBP of <95 mm Hg was associated with a trend toward increased 180-day all-cause mortality (adjusted hazard ratio 2.68, 95% CI 0.94–7.64, P = .065) and estimated glomerular filtration rate decreased to <30 mL/min/1.73 m2 with more HF readmissions (adjusted hazard ratio 3.60, 95% CI 1.22–10.60, P = .0203). The occurrence of a safety indicator was associated with a smaller 90-day improvement in the EURO-QoL 5-Dimension visual analog scale (adjusted mean difference –3.32 points, 95% CI –5.97 to –0.66, P = .015). ConclusionsAmong patients with acute HF enrolled in STRONG-HF in the HIC arm, the occurrence of any safety indicator was associated with the administration of slightly lower GDMT doses and less improvement in quality of life, but with no significant increase in the primary outcome of 180-day HF readmission or death when appropriately addressed according to the study protocol.

Safety and Performance of the Aortix Device in Acute Decompensated Heart Failure and Cardiorenal Syndrome

BackgroundCardiorenal syndrome (CRS) complicates 33% of acute decompensated heart failure (ADHF) admissions, and patients with persistent congestion at discharge have high 30-day event rates. ObjectivesThe purpose of this study was to evaluate a novel catheter-deployed intra-aortic entrainment pump (IAEP) in patients with ADHF with CRS and persistent congestion. MethodsA multicenter (n = 14), nonrandomized, single-arm, safety and feasibility study of IAEP therapy was conducted. Within patient changes (post–pre IAEP therapy) in fluid loss, hemodynamics, patient-reported dyspnea, and serum biomarkers were assessed using Wilcoxon signed-rank testing. ResultsOf 21 enrolled patients, 18 received Aortix therapy. Mean ± SD patient age was 60.3 ± 7.9 years. The median left ventricular ejection fraction was 22.5% (25th-75th percentile: 10.0%-53.5%); 27.8% had a left ventricular ejection fraction ≥50%. Pre-therapy, patients received 8.7 ± 4.1 days of loop diuretic agents and 44% were on inotropes. Pump therapy averaged 4.6 ± 1.6 days, yielding net fluid losses of 10.7 ± 6.5 L (P < 0.001) and significant (P < 0.01) reductions in central venous pressure (change from baseline: −8.5 mm Hg [25th-75th percentile: −3.5 to −10.0 mm Hg]), pulmonary capillary wedge pressure (−11.0 mm Hg [25th-75th percentile: −5.0 to −14.0 mm Hg]), and serum creatinine (−0.2 mg/dL [25th-75th percentile: −0.1 to −0.5 mg/dL]) with improved estimated glomerular filtration rate (+5.0 mL/min/1.73 m2 [25th-75th percentile: 2.0-9.0 mL/min/1.73 m2]) and patient-reported dyspnea score (+16 [25th-75th percentile: 3-37]). Dyspnea scores, natriuretic peptides, and renal function improvements persisted through 30 days. ConclusionsThis pilot study of patients with ADHF, persistent congestion, and worsening renal function due to CRS supports the potential for safely achieving decongestion using IAEP therapy. These initial promising results provide the basis for future randomized clinical trials of this novel pump. (An Evaluation of the Safety and Performance of the Aortix System for Intra-Aortic Mechanical Circulatory Support in Patients with Cardiorenal Syndrome [The Aortix CRS Pilot Study]; NCT04145635)

Psychological impact of first admission with cardiovascular disease in a tertiary hospital in Oman

Background and objectivesCardiovascular diseases (CVD) are associated with substantial psychological effects that can adversely influence long term prognosis. The aim of this study was to determine the psychological effect of the first hospital admission for acute coronary syndrome (ACS) or congestive heart failure (CHF) in an adult Omani population. MethodsThis cross-sectional questionnaire based study used the Hospital Anxiety and Depression Scale. Patients were recruited from the in-patient cardiology and medical wards of our institution. Patients with a prior hospital admission for CHF and ACS were excluded. The questionnaire was administered between days 3 and 7 after admission once patients were clinically stable. ResultsThe study included 116 patients (mean age 60.3 + 13.8 years; 78 (67.8%) men), comprising 52 patients with ACS and 64 patients with CHF. Based on the scores, a total of 45 (38.8%) patients had moderate to severe anxiety, and 32 (27.6%) had moderate to severe depression. Patients with severe anxiety tended to be younger, and no other factors predicted anxiety or depression. The proportion of patients with severe depression was higher among patients with CHF (31.4%), and no other differences were observed between patients with ACS or CHF. ConclusionA substantial proportion of patients admitted to our institution in Oman with CVD had severe anxiety and depression. Treating physicians and caregivers should be more open to identifying these patients, and steps should be taken to address their psychological wellbeing along with the medical management of their illness.

Prognostic value of myocardial performance index in individuals with type 1 and type 2 diabetes: Thousand&1 and Thousand&2 studies.

Cardiovascular disease (CVD) is the leading cause of mortality and morbidity in type 1 (T1D) and type 2 diabetes (T2D). Despite diabetes affects the myocardium, risk prediction models do not include myocardial function parameters. Myocardial performance index (MPI) reflects left ventricular function. The prognostic value of MPI has not been evaluated in large-scale diabetes populations. We evaluated two prospective cohort studies: Thousand&1 (1093 individuals with T1D) and Thousand&2 (1030 individuals with T2D). Clinical data, including echocardiography, were collected at baseline. We collected follow-up data from national registries. We defined major adverse cardiovascular events (MACE) as incident events of hospital admission for acute coronary syndrome, heart failure, stroke, or all-cause mortality. For included individuals (56% male, 54 ± 15 years, MPI 0.51 ± 0.1, 63% T1D), follow-up was 100% after median of 5.3 years (range: 4.8-6.3). MPI was associated with MACE (HR 1.2, 95%CI 1.0-1.3, P = 0.012, per 0.10-unit increase) and heart failure (HR 1.3, 95%CI 1.1-1.6, P = 0.005, per 0.10-unit increase) after adjusting for clinical and echocardiographic variables. MPI predicted MACE and heart failure better in T1D than T2D (P = 0.031 for interaction). MPI added discriminatory power to the Steno T1 Risk Engine, based on clinical characteristics, in predicting MACE [area under the curve (AUC) from 0.77 to 0.79, P = 0.030] and heart failure (AUC from 0.77 to 0.83, P = 0.009) in T1D. MPI is independently associated with MACE and heart failure in T1D but not T2D and improves prediction in T1D. Echocardiographic assessment in T1D may enhance risk prediction.

Morbimortalidad no cardiovascular en función de la fracción de eyección del ventrículo izquierdo tras una hospitalización por insuficiencia cardiaca

Introduction and objectivesNoncardiovascular events represent a significant proportion of the morbidity and mortality burden in patients with heart failure (HF). However, the risk of these events appears to differ by left ventricular ejection fraction (LVEF) status. In this study, we sought to evaluate the risk of noncardiovascular death and recurrent noncardiovascular readmission by LVEF status following an admission for acute HF. MethodsWe retrospectively assessed a cohort of 4595 patients discharged after acute HF in a multicenter registry. We evaluated LVEF as a continuum, stratified in 4 categories (LVEF ≤ 40%, 41%-49%, 50%-59%, and ≥ 60%). Study endpoints were the risks of noncardiovascular mortality and recurrent noncardiovascular admissions during follow-up. ResultsAt a median follow-up of 2.2 [interquartile range, 0.76-4.8] years, we registered 646 noncardiovascular deaths and 4014 noncardiovascular readmissions. After multivariable adjustment including cardiovascular events as a competing event, LVEF status was associated with the risk of noncardiovascular mortality and recurrent noncardiovascular admissions. When compared with patients with LVEF ≤ 40%, those with LVEF 51%-59%, and especially those with LVEF ≥ 60%, were at higher risk of noncardiovascular mortality (HR, 1.31; 95%CI, 1.02-1,68; P=.032; and HR, 1.47; 95%CI, 1.15-1.86; P=.002; respectively), and at higher risk of recurrent noncardiovascular admissions (IRR, 1.17; 95%CI, 1.02-1.35; P=.024; and IRR, 1.26; 95%CI, 1.11-1.45; P=.001; respectively). ConclusionsFollowing an admission for HF, LVEF status was directly associated with the risk of noncardiovascular morbidity and mortality. Patients with HFpEF were at higher risk of noncardiovascular death and total noncardiovascular readmissions, especially those with LVEF ≥ 60%.

Development of a nurse-led follow-up pathway for patients discharged from cardiology unit: the DIMACC project

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Novartis Background The first year after hospitalisation for Acute Coronary Syndrome (ACS) or Acute Heart Failure (AHF) is the most critical period, with the highest incidence of complications and re-hospitalisations. Multiple epidemiological studies have documented that while hospital mortality in the acute phase has gradually decreased, the mortality trend after discharge remains stable or even increased. These trends may be an expression of inadequate follow-up and poor patient involvement, resulting in poor control of risk factors, and suboptimal adherence to treatments. Aim To present a protocol design for a quality improvement intervention regarding a supported discharge pathway for ACS and AHF patients. Methods The construction of the DIMACC protocol is based on the Plan, Do, Check, Act methodology. Pre-intervention phase: A research project has been developed to introduce a supported discharge pathway from Cardiology wards. The objective and motivation for the change from the existing situation were defined and supported by the theoretical model and international guidelines. Development of the study tools: This phase included the Consensus Conference held with the local institutions, the University delegation, the Head Manager of the District, doctors and nurses, where the actors shared intentions, thus proceeding to their formal approval. Data collection instrument was set. Intervention phase: The group identified strategies to ensure the best possible dissemination of the procedure and the professionals' adherence. A data processing company was involved, which created an online platform to collect the study data. Recruitment within the pilot study started in November 2022. Results The DIMACC project is a PROSPECTIVE OBSERVATIONAL STUDY evaluating the feasibility and performance of a quality improvement intervention on patients discharged from Cardiology following admission for ACS and AHF. The study consists of TWO phases. Phase one aims to implement a structured follow-up in the first year after discharge, with examinations and visits planned according to the severity of the single case. As primary endpoint, there is the achievement of clinical objectives defined on discharge, based on ESC guidelines, improve disease control and reduce the number of admissions to the Emergency dept. and re-hospitalisations. In the second phase, the group plans a series of structured educational interventions held by community nurses care to promote patient engagement and further reduce the elements listed in phase one. In the first two months of the pilot phase, 41 patients were included, with a progressive increase compared to total admissions for ACS or AHF (41% in November and 72% in December). Conclusions This study will generate essential knowledge on CVD patients' experiences and self-empowerment. Findings will be of considerable interest and benefit to many health and care organizations beyond the immediate community of interest.