Hospitalization For Acute Heart Failure Research Articles

Prognostic determinants in patients with heart failure with reduced ejection fraction after a first hospitalisation for acute heart failure. COMFE registry

Abstract Introduction The clinical characteristics and determinants for prognosis of patients with a first hospitalisation for heart failure (HF) with reduced left ventricular ejection fraction (LVEF <40%) are poor described and show heterogeneous results that need major investigation. Purpose The aim of our study was to identify the clinical characteristics, prognosis and their main determinants in a prospective registry of patients with HF and reduced LVEF with a first hospital admission for acute heart failure, prognosis and their main determinants in a prospective registry in these patients. Methods We carried out a prospective registry in 2 University Hospitals of patients admitted to cardiology department due to first-time HF hospitalisation with reduced LVEF. 231 admitted consecutively between March 2021 and September 2022 were included, with a mean follow-up of 381 days. Continuous variables were represented as median (interquartile range) and categorical variables as percentage %. A multivariate logistic regression was performed in which age, sex, comorbidities, treatment, rhythm at discharge and improvement in LVEF were included; and using the Wald method, the predictors of rehospitalization and/or death were identified. Data were analysed using SPSS v. 25.0. Results The main baseline characteristics are shown in Table 1. The population had a median age of 71 years, 75% were men, with a high prevalence of arterial hypertension (HBP) (69%) and hyperlipidemia (57%). Quadruple therapy (Na-Glucose cotransporter 2 inhibitor [SGLT2i], Beta-Blocker, mineralocorticoid receptor antagonist [MRA] and angiotensin receptor-neprilysin inhibitor [ARNI], angiotensin converting enzyme inhibitor [ACEi] or Angiotensin-II receptor blocker [ARB]) was achieved in 57% at discharge. The dynamics of NTproBNP was studied from admission to completed up-titration, observing an average reduction of 37% and 32% met the criteria for improved LVEF after. The etiology is described in Figure 1a, with ischemic heart disease being the most represented (31%). Multivariate Cox regression for the combined event of readmission/death from any cause showed that treatment with SGLT2i (OR 0,48 [CI 95%: 0,23-0,98 p:0,04]) and Beta-Blocker (OR 0,35 [CI 95%: 0,14-0,87 p:0,02]) at discharge and improved LVEF (OR 0,33 [CI 95%: 0,15-0,72 p:0,006]) were protective predictors against the event; but diabetes mellitus (DM) was a predictor of a worse prognosis (OR 2,9 [CI 95%: 1,52-5,5 p:0,001]) Fig. 1b. Conclusions Patients with a first admission for HF with reduced LVEF constitute a heterogeneous clinical group. Improvement in LVEF after drug up-titration and treatment with SGLT2i and Beta-blocker are independently associated with a better prognosis. Our findings may have implications for their clinical management.Table 1Figure 1

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<0.001). Also, right ventricular dysfunction evaluated at discharge, defined by tricuspid annular plane systolic excursion <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<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<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.

Changes and prognostic impact of right ventricular-to-pulmonary artery coupling after transcatheter aortic valve replacement

Abstract Background The ratio of tricuspid annular plane systolic excursion to systolic pulmonary artery pressure (TAPSE/sPAP), a good noninvasive approach for right ventricular to pulmonary artery (RV/PA) coupling, is of prognostic significance in many cardiovascular diseases. Yet, data regarding RV/PA coupling in transcatheter aortic valve replacement (TAVR) remain sparse. Aims: To assess the change in TAPSE/sPAP between pre- and post-TAVR as well as its long-term prognostic value. Methods: All patients who underwent TAVR for severe aortic stenosis between 2002 and 2022 at a university hospital, with an available TAPSE/sPAP assessed by echocardiography before and after procedure were included in this study. When available, TAPSE/sPAP was correlated with invasive right heart catheterization data. The primary endpoint was 5-years all-cause death or hospitalization for acute heart failure. C-tree analysis was used to find the best TAPSE/sPAP cut-off to be associated with the primary outcome. Results: Two hundred and sixty-nine patients were included in this analysis (median age 85 years, 57% women, 63% NYHA III-IV). Balloon expandable valves was implanted in 90% of cases. TAPSE/sPAP was significantly improved by TAVR (0.52 vs 0.58 mm/mmHg, p=0.02). The lower the TAPSE/sPAP, the higher the NYHA functional class (p=0.0017), the higher the NTproBNP level (p <0.001) and the higher the logistic EuroSCORE (p<0.001). TAPSE/sPAP had a good correlation with pulmonary artery elastance (r=-0.61, p<0.001). Using C-tree analysis, TAPSE/sPAP ≤0.55 mm/mmHg was the best cut-off associated with the primary outcome (p=0.002). In multivariable Cox regression analysis, TAPSE/sPAP remained independently associated with the primary outcome even after adjustment with echocardiography, comorbidities or logistic EuroSCORE (Table 1). Both from baseline and follow-up assessment, patients with TAPSE/sPAP ≤0.55 mm/mmHg had worse event-free survival (Figure 1A-B). Interestingly, change in TAPSE/sPAP provided important prognostic value (Figure 1C). Conclusion: This study emphasizes the prognostic value of TAPSE/sPAP in the field of TAVR and suggest considering RV/PA coupling assessment not only before or after procedure but also the change in TAPSE/sPAP to identify patients at higher risk of worse outcome.Table1.Multivariable Cox analysisFig1.Kaplan meier curves

Right ventricular pulmonary artery uncoupling independently associated with 5 year outcome following AHF hospitalisation

Abstract Background Right ventricular pulmonary artery (RV-PA) uncoupling is associated with poor outcome across a range of conditions, but its role in acute heart failure (AHF) remains incompletely investigated. Purpose To investigate if RV-PA uncoupling is independently associated with mortality following hospitalisation for AHF. Methods 418 patients were recruited. 391/418 (93.5%) had measurable TAPSE and SPAP and were followed up for 5 years to assess for all-cause mortality. Patients were recruited if they displayed signs and symptoms of AHF, had point-of-care brain-natriuretic peptide >100pg/ml and had evidence of HF on TTE. We identified a study-specific cut-off for TAPSE/SPAP of 0.24mm/mmHg on ROC analysis and performed univariate analysis to assess for an association with outcome. 30 covariates encompassing comorbidities, medications, echo parameters and observations were assessed and logistic regression analysis performed including variables associated with outcome. Results Patient average age at presentation was 79 years, 53.3% were male, 55.5% had hypertension, 30.7% had diabetes and 36.8% had CAD with a mean LVEF of 42.6% and BNP of 1363pg/ml. The mean TAPSE was 15.6mm and SPAP of 52.5mmHg. The average TAPSE/SPAP was 0.34mm/mmHg. 252/391 (64.5%) presented with TAPSE/SPAP <0.24mm/mmHg. These individuals were at higher risk of 5-year mortality compared to >0.24mm/mmHg: HR 1.94 (95% CI 1.49-2.54 [p<0.0001]), which persisted when adjusted for significant covariates – HR 1.35 (95% CI 1.02-1.80 [p<0.0395]). Conclusion TAPSE/SPAP ratio is an independent predictor of mortality in patients admitted with AHF. Our cut-off, a lower value than others have suggested in the literature for chronic conditions such as pulmonary hypertension, could identify those at risk of poor outcome in the acute setting. This may offer an exciting therapeutic target and help risk stratify patients. These results should focus the attention of those managing AHF patients onto the RV, pulmonary pressures and their interrelationship. It is time we moved beyond the LVEF.

Effect of nutritional guidance on mortality and composite endpoints in patients with acute myocardial infarction: a single center retrospective cohort study

Abstract Background/Introduction Acute myocardial infarction (AMI) stands as a major global cause of mortality. Various intervention strategies, such as pre-hospital care, reperfusion therapies, pharmacological interventions, dietary modifications, and exercise therapies, have been researched to improve patient prognosis (1,2). While reports suggest the efficacy of the Mediterranean diet, there remains a lack of evidence regarding the impact of nutritionist-led dietary guidance on the prognosis of AMI patients. Purpose This study aimed to elucidate whether nutritional guidance by nutritionists who have national qualifications would improve the mortality and the primary composite endpoint (including acute decompensated heart failure, stroke, and acute coronary syndrome) of patients following an acute myocardial infarction. Methods A retrospective cohort study was conducted, enrolling 446 consecutive AMI patients who underwent emergency coronary angiography and percutaneous coronary interventions between September 1, 2015, and October 31, 2023. Patients meeting the universal definition of myocardial infarction were included (3). After excluding 37 in-hospital deaths, evaluations for all-cause mortality, cardiovascular mortality, and composite endpoints were performed during follow-up in 409 patients. Nutritionists guided 223 patients (54.5%) during hospitalization in this study. The nutritional guidance used in our study was also based on the definition of adequate caloric intake of 25–30 kcal per ideal body weight (kg). Under an appropriate total energy intake, a fat energy ratio of 20–25% and a carbohydrate energy ratio of 50–60% are recommended, with protein and lipid restrictions depending on the disease state. Results During a median follow-up of 39 months, 24 cases of all-cause mortality (5.9%) and 6 cases of cardiovascular mortality (1.5%) were recorded. Additionally, 15 cases of nonfatal stroke (3.7%), 17 cases of nonfatal acute coronary syndrome (4.2%), and 20 cases of hospitalizations for acute decompensated heart failure (4.9%) were observed. Kaplan–Meier curves demonstrated significantly higher incidence rates of death and primary composite endpoints among patients without nutritional guidance. The multivariate Cox regression model incorporated all variables exhibiting statistically significant associations with long-term mortality, and the primary composite endpoints. The multivariate Cox regression model revealed nutritional guidance as a significant predictor for long-term mortality but not for primary composite endpoints. Conclusion Nutritional guidance for AMI patients may improve overall mortality. Further research is warranted to explore the physiological impacts of improved diets resulting from such guidance and their effects on enhancing prognosis.

Role of pericoronary adipose tissue inflammation at CCTA after heart transplantation as non-invasive diagnostic tool of cardiac rejection and predictor of major adverse cardiovascular events

Abstract Background Long-term survival of heart transplanted (HT) patients is challenged by cardiac rejection and cardiac allograft vasculopathy (CAV). Until now, there are no established biomarkers for graft dysfunction, and the conventional approach for cardiac rejection surveillance is through the endomyocardial biopsy (EMB), an invasive and costly procedure. Purpose This study investigates the prognostic value of the pericoronary Fat Attenuation Index (FAI) and its role as a marker of inflammation and rejection in HT recipients. Methods A double-center observational retrospective study was conducted on a cohort of HT patients who underwent coronary computed tomography angiography (CCTA) between January 2016 and December 2022. FAI was measured with dedicated software and using the cut-off described in literature, we considered each coronary as "inflamed" if FAI was ≥ - 70,1 HU and "not inflamed" if FAI was < - 70,1 HU. Then, based on the number of inflamed coronary arteries for each patient, we divided the population into two comparison groups: high inflammatory (high INF) phenotype (alle three coronary arteries inflamed) and low inflammatory (low INF) phenotype (at least one coronary artery not inflamed). The primary endpoint was a composite of all-cause mortality, acute myocardial infarction, urgent revascularization and heart failure hospitalization. Furthermore, we investigated the correlation between FAI and cardiac rejection by looking for T cell-mediated rejection (TCMR) and antibody-mediated rejection (AMR) through EMB performed no more than six months before or after CCTA. Results A total of 101 HT patients were included; of this group 58 patients underwent EMBs within six months after or before the CCTA. The median duration of follow-up was 28 months. The composite endpoint occurred in 17 patients (16.8%). We documented 26 significative cardiac rejection episodes, 14 TCMR ≥ 2R and 12 AMR. The composite endpoint was achieved in 37.9% of patients with high INF phenotype compared to 8.3% with low INF phenotype (p < 0.001). In the multivariate analysis, the high INF phenotype remained an independent predictor of the composite endpoint in our population (HR: 10.5; 95% CI: 1.88-58.71; p = 0.007). Patients with TCMR and AMR had significantly higher FAI values. High INF phenotype correlated with the presence of ACR ≥ 2R (55.0% vs 7.9%, p < 0.001) and AMR (55.0% vs 2.6%, p < 0.001). Conclusion In HT patients, FAI is an independent predictor of major cardiovascular events. It is also associated with TCMR and AMR within six months from CCTA. FAI, therefore, may offer a non-invasive approach to stratify the prognosis of HT patients and serve as a valuable inflammatory biomarker for early diagnosis of cardiac rejection, supporting the use of CCTA in this setting of patients.Correlation FAI and MACECorrelation FAI and cardiac rejection

Increased frailty is associated with risk of hospital-acquired infections and death during heart failure hospital admissions

Abstract Background Frailty is common in patients admitted with acute decompensation of heart failure (ADHF) and it is unclear how the frailty syndrome affects heart failure (HF) patients during their acute hospital admission. Understanding the interplay between frailty, impaired renal function, hospital-acquired infections (HAI), and death may be useful in optimising patient care and prognosis. Purpose The aim of this analysis was to explore the relationship between admission frailty levels and the incidence of HAI, acute kidney injury (AKI), and mortality in acute HF hospital admissions. Methods This is a retrospective analysis of data submitted from a single centre to the National HF audit between January and June 2023. Additional frailty and baseline renal function data was retrospectively collected from electronic patient health records. Patients were categorised into three groups according to their Rockwood Clinical Frailty Scale (CSF) (1): no/mild frailty (CFS 1-3), moderate frailty (CFS 4-6) and severe frailty (CFS 7-9). AKI was defined based on baseline and admission creatinine, as per KDIGO guidelines (2). Chi-squared and t-tests were used to compare baseline characteristics between frailty groups. Chi-squared tests were used to compare frailty groups in terms of: HAI, AKI, mortality. Results Between 1st January and 22nd June 2023, there were 344 acute HF hospital admissions in our centre. Most patients had moderate frailty on admission (n=256, 74.4%). Frail patients were significantly older, had a lower admission mean haemoglobin and more were female, compared to non-frail patients (Figure 1A). Patients who were more frail were more likely to experience HAI during their admission; p=0.035 (figure 1B). Furthermore, patients with HAI had a greater risk of mortality, at a median follow-up of 171 (IQR 100.25) days after admission, compared to those without HAI (p>0.001). 41.9% of acute HF admissions were associated with an AKI, and although numerically more frail patients had an AKI, this did not achieve statistical significance (p=0.084). Patients who were more frail were more likely to die, both during hospital admission and at 3 months following discharge; p<0.001 (Figure 1B). Furthermore, this trend persisted after follow-up; p<0.001 (Figure 2). Conclusions Patients with moderate or severe frailty are at greater risk of adverse events (HAI, death) during an acute HF hospital admission, than patients with no or mild frailty. It is imperative to consider the frailty status of all patients with ADHF, to be aware of the frailty-associated risks, and act proactively with targeted interventions (screen for infections, daily bloods, early conversations with patients and their families about treatment escalation plans and patient priorities) to improve outcomes and enhance the quality of care for this vulnerable patient population. Further research is warranted to explore potential interventions to address frailty-related risks in HF management.

Characteristics and outcomes of patients with cancer hospitalized with new onset acute heart failure.

Limited evidence exists regarding the outcomes of cancer patients hospitalized with new onset acute heart failure (AHF). We assessed the in-hospital mortality and 1year outcomes of cancer patients admitted for new onset AHF, taking into account both past and active cancer status as well as cancer site. We examined administrative data of adult patients hospitalized with a first episode of AHF from 2003 to 2018 in Lombardy, Italy. Patients were categorized based on their cancer history. The primary endpoint was in-hospital mortality with secondary endpoints including 1year all-cause mortality and 1year re-hospitalization for AHF. Among 283144 patients AHF hospitalizations, 55145 (19%) involved patients with a history of cancer (60% past cancer, 40% active cancer). Both in-hospital and 1year mortality rates were higher among cancer patients compared with those without (9.3% vs. 6.4% and 34.9% vs. 22.3%, respectively; P<0.0001). After adjustment, cancer patients exhibited increased risk of in-hospital mortality [odds ratio (OR) 1.40; 99% confidence interval (CI) 1.34-1.46] and 1year mortality (HR 1.35; 99% CI 1.32-1.39), particularly among those with lung cancer. Patients with active and past cancer had a similar in-hospital mortality risk (OR 0.99; 99% CI 0.91-1.07) while 1year mortality risk was higher among those with active cancer (HR 1.26; 99% CI 1.21-1.31). Cancer is a prevalent comorbidity in patients hospitalized with new onset AHF, and it is associated with a poorer prognosis. Mortality risk appears to vary based on cancer status and type.

Évaluation préliminaire de l'intérêt d'une cellule d'optimisation thérapeutique sur la titration des traitements de l'insuffisance cardiaque à fraction d’éjection ventriculaire gauche réduite et la qualité de vie des patients

IntroductionA multidisciplinary therapeutic optimization unit (COT) was created in January 2023 at Versailles Hospital, aimed at therapeutic optimisation of patients with chronic heart failure with reduced left ventricular ejection fraction. The objective of the study was to assess the impact of the first year of COT activity on the sequential implementation and titration of heart failure treatments, the clinical evolution, and improvement of patients’ quality of life. MethodsThis prospective study included consecutive patients treated by the COT after hospitalisation for acute heart failure, from January to December 2023. Clinical, biological, titration, and tolerance data were analysed. Quality of life was assessed at baseline and at the end of the follow-up by COT, using standardized SF-12 and EQ-5D questionnaires. ResultsWe included 90 patients (men 73%, mean age 67 years). The mean left ventricular ejection fraction was 34 ± 10 %. At final visit (median number of visits 4 ; median follow-up duration 156 days), 76.7% of patients achieved optimisation with respect to maximum individually tolerated doses, but only 13.3% with respect to theoretical maximum doses for the four therapeutic classes. At 1-year follow up, total mortality was 4.4% (4/90), and 9 patients (10%) were rehospitalised unplanned for acute heart failure. COT monitoring was associated with significant improvement in NYHA class, left ventricular ejection fraction, and SF-12 and EQ-5D-5L quality of life scores. ConclusionAlthough titration of heart failure treatments remained suboptimal, significant improvement was observed for NYHA class, left ventricular ejection fraction, and patient quality of life parameters.

Quantitative aortic Na[18F]F positron emission tomography computed tomography as a tool to associate vascular calcification with major adverse cardiovascular events

Abstract Purpose Sodium[18F]fluoride (Na[18F]F) used in positron emission tomography (PET) binds to active calcification and correlates consistently with higher cardiovascular risk. This study aims to investigate the feasibility of aortic Na[18F]F-PET in hybrid combination with low-dose computed tomography (CT) as a risk model for major adverse cardiovascular events (MACE). Methods Patient data and Na[18F]F-PET/CT scans from January 2019 to February 2022 were retrospectively collected at the University Medical Center Groningen (UMCG), the Netherlands. MACE-outcome was a composite of time to first documented myocardial infarction, cerebral vascular accident (CVA), acute heart failure hospitalization, and aortic aneurysms. MACE dates were recorded from the day of the scan until follow-up in December 2023. The aorta was manually segmented in all low-dose CT scans. To minimize spill-over effects from the vertebrae, the vertebrae were automatically segmented using an open-source model, dilated with 10 mm, and subtracted from the aortic mask. The total aortic Na[18F]F corrected maximum standardized uptake value (cSUVmax) and total aortic Agatston score were automatically calculated using SEQUOIA. Kaplan–Meier and Cox regression survival analysis were performed, stratifying patients into high, medium, and low cSUVmax and Agatston categories. Cox regression models were adjusted for age. Results Out of 280 identified scans, 216 scans of unique patients were included. During a median follow-up of 3.9 years, 12 MACE occurred. Kaplan–Meier survival analysis demonstrated a significant difference in MACE-free survival among the high cSUVmax group compared to the medium and low groups (p = 0.03 and p &lt; 0.01, respectively). Similarly, patients with high Agatston scores had a significantly lower MACE-free survival probability compared to those with medium and low scores (both p &lt; 0.01). Conclusion This study highlights the potential clinical utility of Na[18F]F-PET/CT as an imaging tool to predict the risk of MACE. Clinical validation of this novel proof-of-concept method is needed to confirm these results and expand the clinical context.

Significance of an Early Repeat Troponin Measurement Upon Presentation to the Hospital for Acute Heart Failure.

Higher cardiac troponin is associated with worse outcomes in patients with acute heart failure. The significance of repeat measurements over hours remains unclear. We assessed whether a repeat measurement and the Δ between measurements of high-sensitivity cardiac troponin I (hs-cTnI) were associated with outcomes in hypervolemic patients with acute heart failure without acute coronary syndrome. We analyzed 582 individuals from AKINESIS (Acute Kidney Injury Neutrophil Gelatinase-Associated Lipocalin Evaluation of Symptomatic Heart Failure Study) with hs-cTnI measured ≤12 hours from admission and repeated ≤6 hours thereafter. Associations between hs-cTnI levels and their Δ with short-term (death, intensive care unit admission, receipt of inotropes, or positive pressure ventilation during hospitalization) and long-term (death or heart failure readmission within 1 year) outcomes were assessed. The average age was 69±13 years, 62% were men, 65% were White, 46% had coronary artery disease, and 22% had chest pain. Median hs-cTnI levels were 27 (interquartile range [IQR], 13-62) ng/L initially and 28 (IQR, 14-68) ng/L subsequently, with a Δ of 0 [IQR, -2 to 4] ng/L over 3.4±1 hours. Only the second measurement was associated with short-term outcomes (odds ratio, 1.14 per 2-fold higher [95% CI, 1.02-1.28]). Both individual measurements and the Δ were associated with long-term outcomes (hazard ratios, 1.09, 1.12, and 1.16 for first, second, and Δ, respectively). Associated risk for the first and second measurements were not constant over the year but highest early after being measured and decreased over 1 year. Repeat measurements of hs-cTnI over hours can identify individuals with acute heart failure without acute coronary syndrome at risk for short- and long-term outcomes.

Clonal Hematopoiesis Is Associated With Long-Term Adverse Outcomes Following Cardiac Surgery.

Cardiac surgery triggers sterile innate immune responses leading to postoperative complications. Clonal hematopoiesis (CH) is associated with short-term inflammation-mediated outcomes after cardiac surgery. The impact of CH on long-term postoperative outcomes remains unknown. In this cohort study, patients undergoing elective cardiac surgery were included from January 2017 to September 2019. Patients were screened for CH using a predefined gene panel of 19 genes. Recorded clinical events were all-cause death, major adverse cardiac and cerebral events including cardiovascular death, myocardial infarction or nonscheduled coronary revascularization, stroke, and hospitalization for acute heart failure. The primary study outcome was time to a composite criterion including all-cause mortality and major adverse cardiac and cerebral events. Among 314 genotyped patients (median age: 67 years; interquartile range 59-74 years), 139 (44%) presented with CH, based on a variant allelic frequency ≥1%. Carriers of CH had a higher proportion of patients with a history of atrial fibrillation (26% for CH versus 17% for non-CH carriers, P=0.022). The most frequently mutated genes were DNMT3A, TET2, and ASXL1. After a median follow-up of 1203 [813-1435] days, the primary outcome occurred in 50 patients. After multivariable adjustment, CH was independently associated with a higher risk for the primary outcome (hazard ratio, 1.88 [95% CI, 1.05-3.41], P=0.035). Most adverse events occurred in patients carrying TET2 variants. In patients undergoing cardiac surgery, CH is frequent and associated with a 2-fold increased long-term risk for major adverse clinical outcomes. CH is a novel risk factor for long-term postcardiac surgery complications and might be useful to personalize management decisions. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03376165.

Inpatient Use of Guideline-Directed Medical Therapy During HeartFailure Hospitalizations Among Community-Based Health Systems.

Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) remains underused. Acute heart failure (HF) hospitalization represents a critical opportunity for rapid initiation of evidence-based medications. However, data on GDMT use at discharge are mostly derived from national quality improvement registries. This study aimed to describe contemporary GDMT use patterns across HF hospitalizations at community-based health systems. The authors identified HF hospitalizations from 2016 to 2022 in a U.S. database aggregating deidentified electronic health record data from more than 30 health systems. In-hospital and discharge rates of GDMT use were reported for eligible HFrEF patients. Factors associated with inpatient GDMT use and predischarge discontinuation were evaluated with the use of multivariable models. A total of 20,387 HF hospitalizations among 13,729 HFrEF patients were identified. Renin-angiotensin system inhibitors, beta-blockers, and mineralocorticoid receptor antagonists were administered during 70%, 86%, and 37% of eligible hospitalizations, respectively. Angiotensin receptor-neprilysin inhibitors and sodium-glucose cotransporter 2 inhibitors were used in 17% and 8% of eligible hospitalizations, respectively. Discharge GDMT rates were low. Triple/quadruple therapy was administered in 26% of hospitalizations, falling to 14% on discharge. Predischarge GDMT discontinuations were associated with inpatient hypotension, hyperkalemia, and worsening renal function, but 43%-57% had no medical contraindications. In adjusted analyses, use of 3 or more GDMT classes was associated with fewer 90-day all-cause deaths and HF readmissions compared with less comprehensive GDMT. Inpatient GDMT use in a national analysis of HF hospitalizations was lower than reported in quality improvement registries. High discontinuation rates emphasize an unmet need for inpatient and postdischarge strategies to optimize GDMT use.

Digoxin initiation after an acute heart failure episode and its association with post-discharge outcomes: an international multicenter analysis.

Digoxin is commonly used to treat acute heart failure (AHF), especially in patients with concurrent atrial fibrillation (AF). Nonetheless, there is little consensus about in which patients digoxin should be given, the proper time for digoxin initiation, and whether digoxin initiation is associated with improved outcomes. We investigated factors related to digoxin initiation after an episode of AHF and whether patients receiving digoxin presented better short-term outcomes. We analyzed digoxin-naïve AHF patients from a Spanish and Swiss database, who were dichotomized into cohorts based on their receipt of digoxin treatment at discharge. The relationship between digoxin initiation and 23 additional patient covariates, including chronic treatment, was investigated, as well as its association with 90-day combined adverse events (defined as all-cause death or AHF hospitalization). Of 13,105 patients (10,600/2505 from the Spanish/Swiss cohorts, respectively), the median (interquartile range) age was 83 (74.87) years, and 51% were women. Of these, 484 (3.7%) received digoxin at discharge, which was associated with AF, female sex, left ventricular ejection fraction (LVEF) < 50%, and coming from the Spanish cohort. Parameters inversely associated with receiving digoxin at discharge included some chronic treatments, diabetes mellitus (DM), and chronic kidney disease (CKD). Digoxin initiation was not association with 90-day adverse events, adjusted hazard ratio (aHR) = 0.939 (0.769-1.146), but there was an interaction for CKD, aHR = 1.390 (0.831-2.325) vs. 0.854 (0.682-1.183), p = 0.039, and for cohort pertinence, with higher risk in the Swiss cohort; aHR = 1.405 (0.827-2.386) vs. 0.862 (0.689-1.077), p = 0.046. Digoxin initiation after an AHF episode was more frequent in the Spanish cohort and was associated with certain patient characteristics (AF, female sex, reduced LVEF, no DM, no CKD), but had no effect on 90-day outcomes.

Prognostic Factors of Adverse Events in Acute Heart Failure in Older Adults

Objective: Acute heart failure (AHF) is a severe and prevalent disease, especially in older adults. The primary objective of our study was to identify the impact of geriatric factors on adverse events (increased length of hospitalization, death during hospitalization, or transfer to another acute unit) during hospitalization for AHF. The second objective was to identify the impact of geriatric factors on not returning home after hospitalization. Methods: In this retrospective multicenter study in France, older adults ≥ 75 years old hospitalized in 4 different acute geriatric units in Marseille for AHF from January 2018 to December 2019 were included. All the included patients were identified according to the Program for Medicalization of Information Systems (PMSI) coding, with the main diagnosis of AHF being referred to as the “principal diagnosis”. Results: A total of 187 patients with AHF were included. The mean age was 88.2 years (± 5.5), and 69.5% were women. The death rate was 9.6%, and the length of stay was increased for 41.7% of patients. In multivariate analysis, adverse events significantly increased in patients with functional impairment and bedsores. The odds of an unfavorable follow-up after hospitalization significantly increased in patients with mood disorders and functional impairment. Conclusion: Our study highlighted functional impairment, mood disorders, and bedsores as factors that impacted adverse events and unfavorable follow-up after hospitalization in patients managed for AHF. These geriatric domains should be considered in the management of AHF to improve survival, functional status, and the number of older patients who return home after hospitalization.

PRADOC: A Multicenter Randomized Controlled Trial to Assess the Efficiency of PRADO-IC, a Nationwide Pragmatic Transition Care Management Plan for Hospitalized Patients With Heart Failure in France.

The PRADO-IC (Programme de Retour à Domicile après une Insuffisance Cardiaque) is a transition care program designed to improve the coordination of care between hospital and home that was generalized in France in 2014. The PRADO-IC consists of an administrative assistant who visits patients during hospitalization to schedule follow-up visits. The aim of the present study was to evaluate the PRADO-IC program based on the hypotheses provided by health authorities. The PRADOC study is a multicenter, controlled, randomized, open-label, mixed-method trial of the transition program PRADO-IC versus usual management in patients hospitalized with heart failure (standard of care group; NCT03396081). A total of 404 patients were recruited between April 2018 and May 2021. The mean patient age was 75 years (±12 years) in both groups. The 2 groups were well balanced regarding severity indices. At discharge, patients homogeneously received the recommended drugs. There was no difference between groups regarding hospitalizations for acute heart failure at 1 year, with 24.60% in the standard of care group and 25.40% in the PRADO-IC group during the year following the index hospitalization (hazard ratio, 1.04 [95% CI, 0.69-1.56]; P=0.85) or cardiovascular mortality (hazard ratio, 0.67 [95% CI, 0.34-1.31]; P=0.24). The PRADO-IC has not significantly improved clinical outcomes, though a trend toward reduced cardiovascular mortality is evident. These results will help in understanding how transitional care programs remain to be integrated in pathways of current patients, including telemonitoring, and to better tailor individualized approaches. URL: https://www.clinicaltrials.gov; Unique Identifier: NCT03396081.

Trends and Disparities in Ambulatory Follow-Up After Cardiovascular Hospitalizations : A Retrospective Cohort Study.

Timely follow-up after cardiovascular hospitalization is recommended to monitor recovery, titrate medications, and coordinate care. To describe trends and disparities in follow-up after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations. Retrospective cohort study. Medicare. Medicare fee-for-service beneficiaries hospitalized between 2010 and 2019. Receipt of a cardiology visit within 30 days of discharge. Multivariable logistic regression models were used to estimate changes over time overall and across 5 sociodemographic characteristics on the basis of known disparities in cardiovascular outcomes. The cohort included 1 678 088 AMI and 4 245 665 HF hospitalizations. Between 2010 and 2019, the rate of cardiology follow-up increased from 48.3% to 61.4% for AMI hospitalizations and from 35.2% to 48.3% for HF hospitalizations. For both conditions, follow-up rates increased for all subgroups, yet disparities worsened for Hispanic patients with AMI and patients with HF who were Asian, Black, Hispanic, Medicaid dual eligible, and residents of counties with higher levels of social deprivation. By 2019, the largest disparities were between Black and White patients (AMI, 51.9% vs. 59.8%, difference, 7.9 percentage points [pp] [95% CI, 6.8 to 9.0 pp]; HF, 39.8% vs. 48.7%, difference, 8.9 pp [CI, 8.2 to 9.7 pp]) and Medicaid dual-eligible and non-dual-eligible patients (AMI, 52.8% vs. 60.4%, difference, 7.6 pp [CI, 6.9 to 8.4 pp]; HF, 39.7% vs. 49.4%, difference, 9.6 pp [CI, 9.2 to 10.1 pp]). Differences between hospitals explained 7.3 pp [CI, 6.7 to 7.9 pp] of the variation in follow-up for AMI and 7.7 pp [CI, 7.2 to 8.1 pp]) for HF. Generalizability to other payers. Equity-informed policy and health system strategies are needed to further reduce gaps in follow-up care for patients with AMI and patients with HF. National Institute on Aging.

Protocol-driven approach to guideline-directed medical therapy optimization for heart failure: A real-world application to recovery

The objective of our study was to evaluate the real-world effects of an aggressive, personalized protocol for guideline-directed medical therapy (GDMT) titration in patients with heart failure (HF) with reduced ejection fraction (HFrEF). We conducted a two-center retrospective cohort study. Patients with HFrEF who presented to a HF clinic from January 2020 to December 2022 were placed on a GDMT protocol. 180 patients were included in the study. Mean GDMT score significantly increased from 4.7 to 5.9 (p < 0.001) between initial and final visits. Mean left ventricular ejection fraction (LVEF) significantly increased from 28 % to 33 % (+5 %, p < 0.001). 27 (15.7 %) of the 172 patients with complete New York Heart Association (NYHA) classification data had improvement by at least 1 class, while 2 (1.2 %) patients had worsening NYHA classification. 140 (77.8 %) patients had no unplanned hospitalizations between visits. 21 (11.7 %) patients had an unplanned hospitalization for acute HF during the study period with a mean time from first clinic visit to hospitalization of 183 days (range: 13–821 days). 2 (1.1 %) patients were hospitalized due to GDMT-associated adverse drug events (i.e. hypotension, hyperkalemia). 7 (3.9 %) patients died during the study period, which was lower than the predicted 1-year death rate for our cohort (12.3 %) using the MAGGIC score. In conclusion, an aggressive, personalized protocol for GDMT titration in patients with HFrEF led to significant improvements in LVEF, NYHA classification, hospitalization, and mortality in a real-world setting. This protocol may help serve as a road map to lessen the gap between clinical knowledge and practice surrounding optimization of GDMT and move HFrEF patients toward a path to recovery.

Characteristics and Factors of 30-Day Readmissions after Hospitalization for Acute Heart Failure in China.

Patients with acute heart failure (HF) are at high risk of 30-day readmission. Little is known about the characteristics and associated factors of 30-day readmissions among patients with acute HF in China. We enrolled consecutive patients hospitalized for acute HF and discharged from 52 hospitals in China from August 2016 to May 2018. We describe the rate of 30-day readmission, the time interval from discharge to readmission, and the causes of readmission. We also analyzed the factors associated with readmission risk by fitting multivariate Cox proportional hazards models. We included 4875 patients with a median age of 67 years (interquartile range, 57-75), 3045 (62.5%) of whom were male. Within 30 days after discharge, 613 (12.6%) patients were readmitted for all causes, with a median from discharge to readmission of 12 (6-21) days. Most readmissions were attributed to cardiovascular causes (71.1%) and 60.0% to HF-related causes. Readmission occurred within 14 days of discharge in more than half of the patients (56.4%). Diabetes (hazard ratio [HR]: 1.25, 95% confidence interval [95% CI]: 1.06-1.50), anemia (HR: 1.26, 95% CI: 1.03-1.53), high New York Heart Association classification (HR: 1.48, 95% CI: 1.08-2.01), elevated N-terminal pro-B type natriuretic peptide (HR: 1.67, 95% CI: 1.24-2.25), and high-sensitivity cardiac troponin T (HR: 1.26, 95% CI: 1.01-1.58) were associated with increased risks of readmission. High systolic blood pressure (HR: 0.56, 95% CI: 0.38-0.81) and Kansas City Cardiomyopathy Questionnaire-12 scores (HR: 0.64, 95% CI: 0.44-0.94) were associated with decreased risk of readmission. In China, almost one in eight patients with acute HF were readmitted within 30 days after discharge, mainly due to cardiovascular reasons, and approximately three-fifths of the readmissions occurred in the first 14 days. Both clinical and patient-centered characteristics were associated with readmission.

Early vs. late transcatheter aortic valve replacement in acute heart failure hospitalizations: A comparative nationwide analysis

BackgroundSevere aortic stenosis (AS) is the most common valvular disease in the USA. Patients undergoing urgent or emergent transcatheter aortic valve replacement (TAVR) have worse clinical outcomes than those undergoing non-urgent procedures. No studies have examined the impact of procedural TAVR timing on outcomes in AS complicated by acute heart failure (AHF). AimsWe aimed to evaluate differences in in-hospital mortality and clinical outcomes between early (<48 h) vs. late (≥48 h) TAVR in patients hospitalized with AHF using a real-world US database. MethodsWe queried the National Inpatient Sample database to identify hospitalizations with a diagnosis of AHF, aortic valve disease, and a TAVR procedure (2015–2020). The associations between TAVR timing and clinical outcomes were examined using logistic regression model. ResultsA total of 25,290 weighted AHF hospitalizations were identified, of which 6855 patients (27.1 %) underwent early TAVR, and 18,435 (72.9 %) late TAVR. Late TAVR patients had higher in-hospital mortality rate (2.2 % vs. 2.8 %, p < 0.01) on unadjusted analysis but no significant difference following adjustment for demographic, clinical, and hospital characteristics [aOR 1.00 (0.82–1.23)]. Late TAVR was associated with higher odds of cardiac arrest (aOR 1.50, 95 % CI: 1.18–1.90) and use of mechanical circulatory support (aOR 2.05, 95 % CI: 1.68–2.51). Late TAVR was associated with longer hospital stay (11 days vs. 4 days, p < 0.01) and higher costs ($72,851 vs. $53,209, p < 0.01). ConclusionEarly TAVR was conducted in approximately 25 % of the AS patients admitted with AHF, showing improved in-hospital outcomes before adjustment, with no significant differences observed after adjustment.