Episode Of Acute Heart Failure Research Articles

ANMCO Position paper: Use of sacubitril/valsartan in hospitalized patients with acute heart failure

Sacubitril/valsartan (S/V) has been shown to reduce the risk of cardiovascular death or heart failure hospitalization and improve symptoms in chronic heart failure with reduced ejection fraction compared to enalapril. After 7 years since the publication of the results of PARADIGM-HF, further insight has been gained with potential new indications. Two prospective randomized multicenter studies (PIONEER-HF and TRANSITION) in patients hospitalized for acute heart failure (AHF) have shown an improved clinical outcome and biomarker profile as compared to enalapril, and good tolerability, safety and feasibility of initiating in-hospital administration of S/V. Furthermore, some studies have highlighted the favorable effects of S/V in attenuating adverse myocardial remodeling, supporting an early benefit after treatment. Observational data from non-randomized studies in AHF report that in-hospital and pre-discharge prescription of evidence-based drugs associated with better survival still remains suboptimal. Additionally, the COVID-19 pandemic has also negatively impacted on outpatient activities. Therefore, hospitalization, a real crossroads in the history of heart failure, must become a management and therapeutic opportunity for our patients. The objective of this ANMCO position paper is to encourage and facilitate early S/V administration in stabilized patients during hospitalization after an AHF episode, with the aim of improving care efficiency and clinical outcome.

Effect of hyperbaric oxygen treatment on patients with reduced left ventricular ejection fraction.

Hyperbaric oxygen treatment (HBOT) is available to a wide spectrum of patients, many with significant co-morbidities. Considering its effects on cardiac physiology and reports of pulmonary oedema following exposure, concerns exist about the safety of patients with compromised cardiac function. Few studies have described adverse events occurring during HBOT and even fewer reports address events arising in the hours following HBOT. A relation between adverse events and cardiac function has not been established. As medical guidance is limited, we aimed to evaluate the risk for patients with reduced left ventricular ejection fraction (LVEF) receiving HBOT. This retrospective chart review of patients receiving HBOT from April 2003 through December 2019 at our hospital was designed to describe clinical characteristics of patients and to identify adverse events during HBOT and within 24 hours after HBOT. Patients ≥ 40 years of age with a documented LVEF of ≤ 40% were included. Data are presented as mean (SD) [range] or counts, as appropriate. A total of 23 patients were included in the final analysis, 2 (1) [0-4] patients per year. Patients received 25 (19) [1-60] treatments. Two patients had an episode of acute decompensated heart failure possibly linked to HBOT. This study described the clinical characteristics of patients with reduced LVEF receiving HBOT and showed reassuring results, with a majority of patients with reduced LVEF tolerating HBOT well. Prospective research is required to more fully assess the risk.

Применение диуретиков при застойной сердечной недостаточности: официальное заявление Ассоциации сердечной недостаточности Европейского общества кардиологов

Для большинства эпизодов острой сердечной недостаточности характерно усиление симптомов и признаков застойных явлений с объемной перенагрузкой. Цель терапии у таких пациентов заключается в облегчении застойных явлений путем достижения нормоволемии, главным образом с помощью терапии диуретиками. Однако должное применение диуретиков остается сложным, особенно при ухудшении функции почек, резистентности к диуретикам и нарушениях баланса электролитов. В этом официальном заявлении рассматривается применение диуретиков при застойной сердечной недостаточности. В работе рассматриваются распространенные проблемы, такие как: 1) оценка застойных явлений и клинической нормоволемии; 2) оценка ответа на диуретики/резистентности к диуретикам при лечении острой сердечной недостаточности; 3) подход к поэтапным фармакологическим стратегиям применения диуретиков на основе ответа на диуретики; 4) лечение распространенных нарушений баланса электролитов. Рекомендации приведены в соответствии с доступними руководствами, свидетельствами и экспертными выводами.

EDS and diagnosis of cardiogenic pulmonary oedema

Acute cardiogenic pulmonary oedema in the elderly does not differ fundamentally from that seen in the young patient. Appropriate pathways must be established, with regular nursing follow-up, to enable rapid detection and treatment of episodes of acute heart failure. The paramedical team plays an essential role in liaising with families, providing nursing care and listening to the patient at the bedside.

Expanding the limits of TAVI: First in man report of valve implantation in a 25-year-old patient with mucolipidosis

Transcatheter aortic valve implantation (TAVI) is commonly used in older patients with aortic stenosis considered at high or intermediate risk for surgical replacement. To our knowledge, TAVI has not been used in young patients or in patients with paediatric dimensions. We report a case of a 25-year-old patient followed since childhood for mucolipidosis type III with thoraco-lombar cyphosis, chronic kidney disease and evolving aortic regurgitation (AR). Two acute heart failure episodes occurred during the last year requiring intravenous loop diuretics, on top of chronic dyspnea (NYHA III–IV). Patient height was 114 cm and weight 27 kg. Echocardiography showed severe aortic regurgitation with dilated LV (Z-value LVED + 4.5) and LV dysfunction (LVEF = 35%). The annulus was measured at 21 mm. TAVI was considered as surgery was considered at too high-risk. CT scan showed appropriate aortic valve anatomy but also a tortuous abdominal aorta ( Fig. 1 ). Femoral access was obtained under loco-regional anaesthesia, and heparin was administered. A Corevalve EVOLUT™ R 29 mm valve (Medtronic) was deployed, using rapid pacing ( Fig. 2 ). Post-implantation echocardiography showed no significant leak, patent coronary arteries and a satisfactory transvalvular gradient at 7 mmHg. The procedure was complicated by a left bundle branch block without indication for a pacemaker. Femoral access was complicated by asymptomatic thrombosis of the external illiac artery with good vascular recovery. At last follow-up, patient was improved (NYHA II). Echocardiography showed good position of aortic prosthesis, transvalvular gradient at 4 mmHg without aortic regurgitation or paravalvular leak. Our case report confirms that TAVI may be considered for young adults or patients with paediatric dimensions, in whom surgery is at too high-risk, due to important comorbidities. Vascular access remains an important issue when dealing with small patients.

ANMCO POSITION PAPER: Use of sacubitril/valsartan in hospitalized patients with acute heart failure.

Sacubitril/valsartan (S/V) has been shown to reduce the risk of cardiovascular death or heart failure hospitalization and improve symptoms in chronic heart failure with reduced ejection fraction compared with enalapril. After 7 years since the publication of the results of PARADIGM-HF, further insight has been gained with potential new indications. Two prospective randomized multicentre studies (PIONEER-HF and TRANSITION) in patients hospitalized for acute heart failure (AHF) have shown an improved clinical outcome and biomarker profile as compared with enalapril, and good tolerability, safety, and feasibility of initiating in-hospital administration of S/V. Furthermore, some studies have highlighted the favourable effects of S/V in attenuating adverse myocardial remodelling, supporting an early benefit after treatment. Observational data from non-randomized studies in AHF report that in-hospital and pre-discharge prescription of evidence-based drugs associated with better survival still remain suboptimal. Additionally, the COVID-19 pandemic has also negatively impacted on outpatient activities. Therefore, hospitalization, a real crossroad in the history of heart failure, must become a management and therapeutic opportunity for our patients. The objective of this ANMCO position paper is to encourage and facilitate early S/V administration in stabilized patients during hospitalization after an AHF episode, with the aim of improving care efficiency and clinical outcome.

Outcomes of patients with heart failure with preserved ejection fraction discharged on treatment with neurohormonal antagonists after an episode of decompensation

AimsTo analyze the frequency with which patients with heart failure with preserved ejection fraction (HFpEF) discharged after an acute heart failure (AHF) episode are treated with antineurohormonal drugs (ANHD), the variables related to ANHD prescription and their relationship with outcomes. MethodsWe included consecutive HFpEF patients (left ventricular ejection fraction ≥50%) discharged after an AHF episode from 45 Spanish hospitals whose chronic medications and treatment at discharge were available. Patients were classified according to whether they were discharged with or without ANHD, including beta-blockers (BB), renin-angiotensin-aldosterone-system inhibitors (RAASi) and mineralcorticosteroid-receptor antagonists (MRA). Co-primary outcomes consisted of 1-year all-cause mortality and 90-day combined adverse event (revisit to emergency department –ED-, hospitalization due to AHF or all-cause death). Secondary outcomes were 90-day adverse events taken individually. Adjusted associations of ANHD treatment with outcomes were calculated. ResultsWe analyzed 3,305 patients with HFpEF (median age: 83, 60% women), 2,312 (70%) discharged with ANHD. The ANHD most frequently prescribed was BB (45.8%). The 1-year mortality was 26.9% (adjusted HR for ANHD patients:1.17, 95%CI=0.98-1.38) and the 90-day combined adverse event was 54.4% (HR=1.14, 95%CI=0.99-1.31). ED revisit was significantly increased by ANHD (HR=1.15, 95%CI=1.01-1.32). MRA and BB were associated with worse results in some co-primary or secondary endpoints, while RAASi (alone) reduced 90-day hospitalization (HR=0.73, 98%CI=0.56-0.96). Conclusion70% of HFpEF patients are discharged with ANHD after an AHF episode. ANHD do not seem to reduce mortality or adverse events in HFpEF patients, only RAASi could provide some benefits, reducing the risk of hospitalization for AHF.

Experiences of Using a Self-management Mobile App Among Individuals With Heart Failure: Qualitative Study.

BackgroundInterventions that focus on the self-management of heart failure are vital to promoting health in patients with heart failure. Mobile health (mHealth) apps are becoming more integrated into practice to promote self-management strategies for chronic diseases, optimize care delivery, and reduce health disparities.ObjectiveThe purpose of this study was to explore the experience of using a self-management mHealth intervention in individuals with heart failure to inform a future mHealth intervention study.MethodsThis study used a qualitative descriptive design. Participants were enrolled in the intervention groups of a larger parent study using a mobile app related to self-management of heart failure. The purposive, convenient, criterion-based sample for this qualitative analysis comprised 10 patients who responded to phone calls and were willing to be interviewed. Inclusion criteria for the parent study were adults who were hospitalized at Nebraska Medical Center with a primary diagnosis and an episode of acute decompensated heart failure; discharged to home without services such as home health care; had access to a mobile phone; and were able to speak, hear, and understand English.ResultsStudy participants were middle-aged (mean age 55.8, SD 12 years; range 36-73 years). They had completed a mean of 13.5 (SD 2.2) years (range 11-17 years) of education. Of the 10 participants, 6 (60%) were male. Half of them (5/10, 50%) were New York Heart Association Classification Class III patients and the other half were Class IV patients. The intervention revealed four self-management themes, including (1) I didn’t realize, and now I know; (2) It feels good to focus on my health; (3) I am the leader of my health care team; and (4) My health is improving.ConclusionsParticipants who used a self-management mHealth app intervention for heart failure reported an overall positive experience. Their statements were organized into four major themes. The education provided during the study increased self-awareness and promoted self-management of their heart failure. The mHealth app supported patient empowerment, resulting in better heart failure management and improved quality of life. Participants advocated for themselves by becoming the leader of their health, especially when communicating with their health care team. Finally, the mHealth app was used by the participants as a self-management tool to assist in symptom management and improve their overall health. Future research should study symptom evaluation, medication tracking, and possibly serve as a health provider communication platform to empower individuals to be leaders in their chronic disease management.

Ferric carboxymaltose for the treatment of iron deficiency in heart failure: a multinational cost-effectiveness analysis utilising AFFIRM-AHF.

AimsIron deficiency is common in patients with heart failure (HF). In AFFIRM‐AHF, ferric carboxymaltose (FCM) reduced the risk of hospitalisations for HF (HHF) and improved quality of life vs. placebo in iron‐deficient patients with a recent episode of acute HF. The objective of this study was to estimate the cost‐effectiveness of FCM compared with placebo in iron‐deficient patients with left ventricular ejection fraction <50%, stabilised after an episode of acute HF, using data from the AFFIRM‐AHF trial from Italian, UK, US and Swiss payer perspectives.Methods and resultsA lifetime Markov model was built to characterise outcomes in patients according to the AFFIRM‐AHF trial. Health states were defined using the 12‐item Kansas City Cardiomyopathy Questionnaire (KCCQ‐12). Subsequent HHF were incorporated using a negative binomial regression model with cardiovascular and all‐cause mortality incorporated via parametric survival analysis. Direct healthcare costs (2020 GBP/USD/EUR/CHF) and utility values were sourced from published literature and AFFIRM‐AHF. Modelled outcomes indicated that treatment with FCM was dominant (cost saving with additional health gains) in the UK, USA and Switzerland, and highly cost‐effective in Italy [incremental cost‐effectiveness ratio (ICER) EUR 1269 per quality‐adjusted life‐year (QALY)]. Results were driven by reduced costs for HHF events combined with QALY gains of 0.43–0.44, attributable to increased time in higher KCCQ states (representing better functional outcomes). Sensitivity and subgroup analyses demonstrated data robustness, with the ICER remaining dominant or highly cost‐effective under a wide range of scenarios, including increasing treatment costs and various patient subgroups, despite a moderate increase in costs for de novo HF and smaller QALY gains for ischaemic aetiology.ConclusionFerric carboxymaltose is estimated to be a highly cost‐effective treatment across countries (Italy, UK, USA and Switzerland) representing different healthcare systems.

The effect of intravenous ferric carboxymaltose on health-related quality of life in iron-deficient patients with acute heart failure: the results of the AFFIRM-AHF study.

AimsPatients with heart failure (HF) and iron deficiency experience poor health-related quality of life (HRQoL). We evaluated the impact of intravenous (IV) ferric carboxymaltose (FCM) vs. placebo on HRQoL for the AFFIRM-AHF population.Methods and resultsThe baseline 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12), which was completed for 1058 (535 and 523) patients in the FCM and placebo groups, respectively, was administered prior to randomization and at Weeks 2, 4, 6, 12, 24, 36, and 52. The baseline KCCQ-12 overall summary score (OSS) mean ± standard error was 38.7 ± 0.9 (FCM group) and 37.1 ± 0.8 (placebo group); corresponding values for the clinical summary score (CSS) were 40.9 ± 0.9 and 40.1 ± 0.9. At Week 2, changes in OSS and CSS were similar for FCM and placebo. From Week 4 to Week 24, patients assigned to FCM had significantly greater improvements in OSS and CSS scores vs. placebo [adjusted mean difference (95% confidence interval, CI) at Week 4: 2.9 (0.5–5.3, P = 0.018) for OSS and 2.8 (0.3–5.3, P = 0.029) for CSS; adjusted mean difference (95% CI) at Week 24: 3.0 (0.3–5.6, P = 0.028) for OSS and 2.9 (0.2–5.6, P = 0.035) for CSS]. At Week 52, the treatment effect had attenuated but remained in favour of FCM.ConclusionIn iron-deficient patients with HF and left ventricular ejection fraction <50% who had stabilized after an episode of acute HF, treatment with IV FCM, compared with placebo, results in clinically meaningful beneficial effects on HRQoL as early as 4 weeks after treatment initiation, lasting up to Week 24.

FC 021EFFICACY OF INTRAVENOUS FERRIC CARBOXYMALTOSE IN PATIENTS WITH IRON DEFICIENCY FOLLOWING ACUTE HEART FAILURE, ACCORDING TO BASELINE EGFR: A SUBGROUP ANALYSIS OF THE AFFIRM-AHF TRIAL

Abstract Background and Aims In the AFFIRM-AHF trial, treatment with intravenous (IV) ferric carboxymaltose (FCM) reduced the risk of heart failure (HF) hospitalisations vs placebo in patients with iron deficiency after an episode of acute HF. Of these patients, 41% had a medical history of chronic kidney disease (CKD). This prespecified subanalysis of AFFIRM-AHF data was performed to investigate the effect of renal function on FCM efficacy. Methods In AFFIRM-AHF, patients stabilised following hospitalisation for acute HF with concomitant iron deficiency (defined as ferritin &amp;lt;100 μg/L, or 100–299 μg/L with transferrin saturation &amp;lt;20%) were randomised to receive either IV FCM or placebo before discharge for the index hospitalisation. In this analysis, patients who had received at least one dose of the study drug, and who had at least one post-randomisation data point and a baseline value for estimated glomerular filtration rate (eGFR; calculated using the CKD-EPI formula and baseline creatinine value), were stratified into tertiles according to baseline eGFR. The primary outcome was a composite of total HF hospitalisations and CV death. Secondary outcomes included total HF hospitalisations, CV death, time to first HF hospitalisation or CV death, composite of total CV hospitalisations and CV death, and days lost due to HF hospitalisations or CV death. All outcomes were evaluated up to 52 weeks post-randomisation. Results Of the 1,108 patients included in primary AFFIRM-AHF analyses, 967 (FCM: 487; placebo: 480) had a baseline eGFR value and were included in this analysis. In both groups, 60% of patients had an eGFR &amp;lt;60 mL/min/1.73 m2 following the index acute HF episode. Patients were divided into eGFR tertiles 1, 2 and 3, with corresponding respective baseline eGFR values of &amp;lt;42.96, 42.96 to &amp;lt;64.32, and ≥64.32 mL/min/1.73 m2. At baseline, the mean age, proportion of females, and proportions of patients with ischaemic HF aetiology, a documented history of HF, and a medical history of percutaneous coronary intervention, coronary artery bypass graft and/or cardiac resynchronisation therapy, were highest in eGFR tertile 1 and lowest in eGFR tertile 3. In eGFR tertiles 1, 2 and 3, the number of total HF hospitalisations and CV deaths in the FCM group vs placebo group were, respectively, 115 vs 152, 76 vs 83, and 56 vs 79, with respective annualised rate ratios (95% confidence interval [CI]) of 0.76 (0.50, 1.16), 0.76 (0.48, 1.22) and 0.69 (0.42, 1.12) (Figure). In eGFR tertile 3, the total number of CV hospitalisations and CV deaths was significantly lower in the FCM group vs the placebo group (69 vs 107; rate ratio [95% CI] 0.60 [0.39, 0.93]), with a nominally lower number of total HF hospitalisations with FCM vs placebo (44 vs 66; rate ratio [95% CI] 0.62 [0.38, 1.01]). In the time to first event analysis, FCM significantly reduced HF hospitalisation or CV death vs placebo in eGFR tertile 3 (hazard ratio [95% CI] 0.64 [0.42, 0.98]). In eGFR tertiles 1 and 2, differences between FCM and placebo arms for secondary endpoints did not reach statistical significance. The p-trend for treatment by baseline eGFR subgroup was non-significant for the primary outcome (0.941) and also for the secondary outcomes specified here. Conclusion In patients with iron deficiency who were stabilised after an episode of acute HF, numerically fewer primary and secondary events, endpoints or outcomes were consistently observed with FCM vs placebo across the eGFR tertiles. In addition, no significant interaction between kidney function and FCM efficacy was noted. Given that this analysis was limited by small patient numbers following subgroup stratification, further studies in larger cohorts with CKD may help to clarify the effect of IV FCM in this patient population.

Discharge FGF23 level predicts one year outcome in patients admitted with acute heart failure

BackgroundPatients with acute heart failure (AHF) show high levels of fibroblast growth factor-23 (FGF23) on admission. We examined if plasma FGF23 changes during an episode of AHF, and if FGF23 holds prognostic significance in this setting. MethodsConsecutive AHF patients were enrolled. Blood samples were collected on admission and at discharge. Patients were then followed for all-cause death or HF hospitalization. ResultsPatients (n = 125; median age 76 years [interquartile interval 71–83], 63% men, left ventricular ejection fraction 35% [25%–56%]) had median admission FGF23 70 ng/L (47–100), N-terminal pro-B-type natriuretic peptide (NT-proBNP) 5844 ng/L (2,503-10,468), high-sensitivity troponin T (hs-TnT) 40 ng/L (25–72), and soluble suppression of tumorigenesis-2 (sST2) 26 ng/mL (17–37). While other biomarkers decreased, FGF23 increased by 15% from admission to discharge (p = 0.033), with a significant correlation with percent changes in estimated glomerular filtration rate (rho = 0.306, p = 0.001). Over a 12-month follow-up, 64 patients (51%) experienced the endpoint. They were more often men, older, with higher systolic pulmonary artery pressure (sPAP), higher NT-proBNP, hs-TnT and discharge FGF23. The best FGF23 cut-off at discharge from receiver operating characteristics analysis was 78 ng/L. Both discharge FGF23 and the 78 ng/L cut-off independently predicted outcome in models including gender, sPAP, age, and 1) admission NT-proBNP, 2) discharge NT-proBNP, 3) admission NT-proBNP and hs-TnT, 4) discharge NT-proBNP and hs-TnT. The 78 ng/L cut-off also refined risk reclassification. ConclusionsDuring an AHF episode, FGF23 increases from admission to discharge, and patients with higher discharge FGF23 have a higher risk of worse outcome.

Adaptive anti-myocardial immune response following hospitalization for acute heart failure.

AimsIt has been hypothesized that cardiac decompensation accompanying acute heart failure (AHF) episodes generates a pro‐inflammatory environment boosting an adaptive immune response against myocardial antigens, thus contributing to progression of heart failure (HF) and poor prognosis. We assessed the prevalence of anti‐myocardial autoantibodies (AMyA) as biomarkers reflecting adaptive immune responses in patients admitted to the hospital for AHF, followed the change in AMyA titres for 6 months after discharge, and evaluated their prognostic utility.Methods and resultsAMyA were determined in n = 47 patients, median age 71 (quartiles 60; 80) years, 23 (49%) female, and 24 (51%) with HF with preserved ejection fraction, from blood collected at baseline (time point of hospitalization) and at 6 month follow‐up (visit F6). Patients were followed for 18 months (visit F18). The prevalence of AMyA increased from baseline (n = 21, 45%) to F6 (n = 36, 77%; P < 0.001). At F6, the prevalence of AMyA was higher in patients with HF with preserved ejection fraction (n = 21, 88%) compared with patients with reduced ejection fraction (n = 14, 61%; P = 0.036). During the subsequent 12 months after F6, that is up to F18, patients with newly developed AMyA at F6 had a higher risk for the combined endpoint of death or rehospitalization for HF (hazard ratio 4.79, 95% confidence interval 1.13–20.21; P = 0.033) compared with patients with persistent or without AMyA at F6.ConclusionsOur results support the hypothesis that AHF may induce patterns of adaptive immune responses. More studies in larger populations and well‐defined patient subgroups are needed to further clarify the role of the adaptive immune system in HF progression.

Angiotensin receptor-neprilysin inhibition in patients with acute decompensated heart failure: an expert consensus position paper.

The short-term mortality and rehospitalization rates after admission for acute heart failure (AHF) remain high, despite the high level of adherence to contemporary practice guidelines. Observational data from non-randomized studies in AHF strongly support the in-hospital administration of oral evidence-based modifying chronic heart failure (HF) medications (i.e., b-blockers, ACE inhibitors, mineralocorticoid receptor antagonists) to reduce morbidity and mortality. Interestingly, a well-designed prospective randomized multicenter study (PIONEER-HF) showed an improved clinical outcome and stress/injury biomarker profile after in-hospital administration of sacubitril/valsartan (sac/val) as compared to enalapril, in hemodynamically stable patients with AHF. However, sac/val implementation during hospitalization remains suboptimal due to the lack of an integrated individualized plan or well-defined appropriateness criteria for transition to oral therapies, an absence of specific guidelines regarding dose selection and the up-titration process, and uncertainty regarding patient eligibility.In the present expert consensus position paper, clinical practical recommendations are proposed, together with an action plan algorithm, to encourage and facilitate sac/val administration during hospitalization after an AHF episode with the aim of improving efficiencies of care and resource utilization.

Efficacy of intravenous ferric carboxymaltose for iron deficiency following acute heart failure (AHF) in patients with previously diagnosed HF: a subgroup analysis of AFFIRM-AHF

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Vifor Pharma OnBehalf The AFFIRM-AHF Investigators Introduction AFFIRM-AHF is the first randomised clinical trial to evaluate the effect of intravenous ferric carboxymaltose (IV FCM) (vs placebo) on morbidity and mortality in patients with an episode of acute heart failure (HF) and concomitant iron deficiency. Purpose To determine the effect of FCM versus placebo on efficacy outcomes in the subgroup of the AFFIRM-AHF cohort with a documented history of HF. Methods This subgroup analysis evaluated patients previously diagnosed with HF. Primary outcome was a composite of total HF hospitalisations and CV death. Secondary outcomes included total HF hospitalisations, CV death, time to first HF hospitalisation or CV death, composite of total CV hospitalisations and CV death, and days lost due to HF hospitalisations or CV death. All outcomes were evaluated up to 52 weeks post-randomisation. Results In AFFIRM-AHF, 73% and 70% of patients randomly assigned to FCM and placebo, respectively, had a documented history of HF. Baseline demographics and clinical characteristics were comparable between treatment groups for this subgroup. There were significantly fewer primary events in patients assigned to FCM compared to placebo: 249 vs 336, respectively (rate ratio [RR] 0.72, 95% CI: 0.55–0.95; p = 0.022). 186 total HF hospitalisations occurred in FCM group and 267 in placebo (RR 0.67, 95% CI: 0.52–0.88; p = 0.004). The composite of first HF hospitalisation or CV death occurred in 149 (37%) assigned FCM and in 179 (44%) patients assigned placebo (hazard ratio [HR] 0·76, 95% CI: 0·61–0·95; p = 0·014). Conclusion In patients with a documented history of HF and iron deficiency who were stabilised after an episode of AHF, treatment with FCM significantly reduced the risk of a composite of total HF hospitalisation and CV death. Primary and Secondary outcomesFCM (n = 405)Placebo (n = 385)RR or HR (95% CI)P valueNo. of eventsRate per 100 patient-yrNo. of eventsRate per 100 patient-yrPrimary outcomeTotal HF hospitalisations and CV death24971.85336101.3RR: 0.72 (0.55-0.95)0.022Secondary outcomesTotal CV hospitalisationsand CV death30888.87401120.57RR: 0.74 (0.58-0.95)0.020Time to CV death63346.5568332.58HR: 0.91 (0.65-1.29)0.602Total HF hospitalisations18653.6726780.28RR: 0.67 (0.52-0.88)0.004Time to first HF hospitalisation or CV death149291.76179257.93HR: 0.76 (0.61-0.95)0.014Days lost due to HF hospitalisation and CV death4.5*526.328.3*955.55RR: 0.58 (0.38-0.90)0.015*Data point is the mean number of days lost per subject.

Glucose variability predicts 6-month mortality in patients hospitalized with acute heart failure.

In diabetes mellitus (DM), glycaemic fluctuations associate with higher oxidative stress than sustained chronic hyperglycaemia and glucose variability increases the risk of chronic diabetic complications. Our hypothesis was that higher glucose variability would associate with mortality after an acute heart failure (HF) episode. We retrospectively analysed patients with DM hospitalized with acute HF between 2009 and 2010. Patients with < 2 point-of-care glucose values/day were excluded. Glucose coefficient of variation (GCV) was defined as (glucose standard deviation/mean glucose) × 100. Patients were categorized according GCV ≤ 30.0 and > 30.0%. Follow-up: 6-months. Endpoint: all-cause mortality. A Cox-regression analysis was used to study the association of glucose variability with 6-month mortality. We studied 214 diabetic patients with acute HF, 49.1% male, mean age 76years. Mean glycaemia during hospitalization was 187 ± 50mg/dL, hypoglycaemia (< 70mg/dL) was reported in 21 patients and mean GCV was 28.3 ± 7.6%. Patients with GCV > 30.0% had higher mean glycaemia, more hypoglycaemic episodes and higher HbA1c; they were also more often treated with insulin. Patients were similar concerning age, gender, comorbidities, left ventricular systolic dysfunction and ischemic heart disease. During the 6-month follow-up, 38 (17.8%) patients died. Patients with GCV > 30.0% had a HR of 6-month mortality of 2.21 (95% CI: 1.16-4.21), p = 0.02. This association with more than twofold higher short-term mortality was independent of main confounders. Elevated glycaemic variability in acute HF admissions of patients with DM predicts short-term mortality. Patients with GCV > 30.0% have an independent more than twofold higher risk of 6-month death after an acute HF hospitalization.

Long-Term Outcome of LVAD in Duchenne Population with End Stage Cardiomyopathy

Purpose The aim of this study was to report the effect of long-term use of VAD in patients affected by Duchenne Muscular Distrophy and end stage cardiomyopathy (DMD-DCM). Methods We collected data of end stage DMD-DCM patients who were implanted with LVAD in our center (group 1) and the ones in regular follow-up because not eligible for LVAD implantation (group 2). Each patient of group 1 underwent extensive pre-operative assessment, in-hospital treatment and was enrolled in a dedicated DMD heart failure (HF) clinic during the post-discharge period. Patients of group 2 were followed in a dedicated DMD HF clinic or as inpatient in case of need of inotropic support. All data during long-term follow-up were recorded including echocardiography, ECG examination, laboratory blood tests, BNP dosing and assessment of nutritional status and respiratory function. Survival of the groups was represented by Kaplan Meier analysis and compared by log rank. Results A total of eight DMD-DCM patients (group 1) were implanted with LVAD and treated at our center during the period from 2011 until 2018 (mean age at implantation was 16.9 ± 2.9 years)¸whilst 4 patients (group 2) were not eligible for LVAD implantation. At the time of the last follow-up, 4 out of 8 patients were alive and 2 out of 8 patients did not have post-operative complications. The most prominent complications were bleeding and infections with one episode of acute heart failure that was successfully treated. The principal causes of 3 deaths at the median follow-up of 22 months were sepsis, tracheal bleeding, and cerebral hemorrhage. After one year from implantation we noticed a significant decrease in heart rate (p=0.002), in LV volumes and diameters (LVEDD p=0.03, LVESD p=0.02, EDV p=0.01 and ESV p=0.02) together with a significant increase in ejection fraction (p=0.0036). However, relative wall thickness did not change over time, showing an eccentric remodeling pattern before and after LVADs. Analysis on short and long-term follow-up showed significant improvement of survival in DMD patients treated with LVAD compared to the group that was not implanted (log rank Conclusion Our data showed that cardiac atrophy is persistent in Duchenne cardiomyopathy despite the improvement of LV function. LVAD improved outcomes in patients with LVAD when compared to those without.

Temporal trends in mortality and readmission after acute heart failure: a systematic review and meta-regression in the past four decades.

Acute heart failure (AHF) is frequent and life-threatening disease. However, innovative AHF therapies have remained limited, and care is based on experts' opinion. Temporal trends and benefits of long-term oral cardiovascular medications on AHF outcomes remain uncertain. This study is registered with PROSPERO (CRD42018099885). A systematic review ranging from 1980 to 2017, searched AHF studies with more than 100 patients that reported death and/or readmission. Primary outcomes were temporal trends, assessed by meta-regression, for 30-day or 1-year all-cause death and/or readmission rates. Secondary outcomes were temporal trends of oral cardiovascular therapies and their influence on primary outcomes. Among the 45 143 studies screened, 285 were included, representing 15 million AHFs. In the past decades, though mortality and readmission remain high, there was a decline in 30-day all-cause death [odds ratio (OR) for a 10-year increment: 0.74, 95% confidence interval (CI) 0.61-0.91; P=0.004] that persisted at 1 year (OR 0.86, 95% CI 0.77-0.96; P=0.007), while 30-day and 1-year all-cause readmission rate remained roughly unchanged. Trends of primary outcomes were linear and did not differ among continents. Decline in 1-year all-cause death rate correlated with high proportions of oral or beta-blockers, especially when combined with oral renin-angiotensin-aldosterone system inhibitors, but not with diuretics while trends in readmission remained unchanged with these therapies. Although AHF outcomes remain poor, the present study revealed global favourable trends of survival after AHF episodes probably associated with greater use of oral neurohormonal antagonists. The present study urges to implement the combination of oral renin-angiotensin-aldosterone system inhibitors and beta-blockers in patients at risk of AHF.

Efficacy and Safety of Sacubitril/Valsartan in High-Risk Patients in the PIONEER-HF Trial.

In patients stabilized during hospitalization for acute decompensated heart failure (HF), initiation of sacubitril/valsartan compared with enalapril decreased the risk of cardiovascular death or rehospitalization for HF without increasing the risk of adverse events. It is unknown whether potentially high-risk subpopulations have a similar risk-benefit profile. PIONEER-HF (Comparison of Sacubitril/Valsartan Versus Enalapril on Effect on NT-proBNP [N-terminal pro-B type natriuretic peptide] in Patients Stabilized From an Acute HF Episode) was a multicenter, randomized, double-blind trial of in-hospital initiation of sacubitril/valsartan (n=440) versus enalapril (n=441) in patients stabilized during hospitalization for acute decompensated HF. The composite of cardiovascular death or rehospitalization for HF was adjudicated. Safety outcomes included worsening renal function, symptomatic hypotension, and hyperkalemia. We evaluated heterogeneity in the effect of sacubitril/valsartan on these efficacy and safety outcomes in selected subgroups of clinical concern: patients with baseline systolic blood pressure ≤118 mm Hg (median; n=448), baseline NT-proBNP >2701 pg/mL (median; n=395), estimated glomerular filtration rate <60 mL/minute per 1.73 m2 (n=455), ≥1 additional hospitalization for HF within the prior year (n=343), admission to the ICU during the index hospitalization (n=96), inotrope use during the index hospitalization (n=68), and severe congestion (n=219). The relative risk reduction in cardiovascular death or rehospitalization for HF with sacubitril/valsartan versus enalapril was consistent across all high-risk subgroups (P interaction=non-significant [NS] for each). The risks of worsening renal function, symptomatic hypotension, and hyperkalemia with sacubitril/valsartan versus enalapril were also consistent in each high- versus low-risk subgroup (P interaction=NS for each). In high-risk subpopulations admitted for acute decompensated HF, treatment with sacubitril/valsartan after initial stabilization conferred a consistent reduction in cardiovascular death or rehospitalization for HF and was well tolerated.

A Practical Risk Score for Prediction of Early Readmission after a First Episode of Acute Heart Failure with Preserved Ejection Fraction.

Background: The first admission for acute heart failure with preserved ejection fraction (HFpEF) drastically influences the short-term prognosis. Baseline characteristics may predict repeat hospitalization or death in these patients. Methods: A 103 patient-cohort, admitted for the first acute HFpEF episode, was monitored for six months. Baseline characteristics were recorded and their relation to the primary outcome of heart failure readmission (HFR) and secondary outcome of all-cause mortality was assessed. Results: We identified six independent determinants for HFR: estimated glomerular filtration rate (eGFR) (p = 0.07), hemoglobin (p = 0.04), left ventricle end-diastolic diameter (LVEDD) (p = 0.07), E/e’ ratio (p = 0.004), left ventricle outflow tract velocity-time integral (LVOT VTI) (p = 0.045), and diabetes mellitus (p = 0.06). Three of the variables were used to generate a risk score for HFR: LVEDD, E/e’, LVOT VTI -DEI Score = − 28.763 + 4.558 × log (LVEDD (mm)) + 1.961 × log (E/e’ ratio) + 1.759 × log (LVOT VTI (cm)). Our model predicts a relative amount of 20.50% of HFR during the first 6 months after the first acute hospitalization within the general population with HFpEF with a DEI Score over −0.747. Conclusions: We have identified three echocardiographic parameters (LVEDD, E/e’, and LVOT VTI) that predict HFR following an initial acute HFpEF hospitalization. The prognostic DEI score demonstrated good accuracy.