Cardiovascular Rehospitalization Research Articles

Abstract 4138815: Prognostic Implications of Glycemic Variability Assessed by Continuous Glucose Monitoring-derived Coefficient of Variation among Patients Hospitalized for Acute Heart Failure

Background: Recent findings indicate that high glycemic variability (GV) could increase the risk of adverse outcomes in patients with cardiovascular disease. With the advances in technology, the utility of continuous glucose monitoring (CGM) has grown during recent years, which can provide valuable information that is not captured by HbA1c. We used the glucose coefficient of variation (CV, calculated as the ratio of standard deviation divided by the mean glucose level) of the obtained CGM data to analyze GV. Aims: We aimed to analyze CGM-derived CV as an indicator of GV and to evaluate prognostic implications of CGM-derived CV in patients hospitalized for acute heart failure (HF). Methods: Patients hospitalized for HF who had not been diagnosed diabetes were performed 75g-oral glucose tolerance test (OGTT). CV was evaluated using CGM system for at least 72 consecutive hours after being able to have meals stably during hospitalization. The primary outcome was a composite of cardiovascular death or re-hospitalization for HF. Patients were divided into two groups based on the median value of CV. Results: We prospectively analyzed 130 patients (mean age: 76±10 years, male 56%) admitted for acute HF. Following the 75g-OGTT, only 21% of the entire cohort exhibited normal glucose tolerance. During the median follow up period of 905 days, Kaplan–Meier curve analysis revealed that the cumulative incidence of the primary outcome event was significantly higher in patients with CV above median than in those with CV less than median (51.7% versus 24.4%, Log-rank P=0.01)(Figure). Multivariate Cox proportional analysis demonstrated that the risk of CV per 1% increment for the primary outcome was significant adjusted for history of diabetes, CGM-derived mean glucose level, and HbA1c level (hazard ratio: 1.06, 95% confidence interval 1.03–1.09). Conclusions: CGM-derived CV was associated with long term prognosis of patients hospitalized for HF with or without diabetes.

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

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

Strategy Optimization for a Combined Procedure in Patients With Atrial Fibrillation: The COMBINATION Randomized Clinical Trial.

The optimal strategy of combining left atrial appendage occlusion (LAAO) with catheter ablation (CA) in patients with atrial fibrillation (AF) during a single procedure remains unclear. To determine the effects of ablation-first vs occlusion-first strategies on long-term clinical outcomes among patients with atrial fibrillation undergoing a combined LAAO and CA procedure. The prospective, multicenter COMBINATION randomized clinical trial was conducted in 14 high-volume centers in China. Enrollment of patients with nonvalvular AF referred for the combined procedure began on July 24, 2020, and concluded on January 20, 2022. Patients were randomly assigned to either the ablation-first group or the occlusion-first group. Outcomes of LAAO using an occlusion device and CA using a contact force-sensing catheter following different combination strategies during long-term follow-up were evaluated. The primary end point was a composite of thromboembolic events including stroke or transient ischemic attack, device-related thrombus (DRT), clinically relevant bleeding, and cardiovascular rehospitalization or death. Freedom from AF or atrial tachyarrhythmia (ATA) after a single procedure without antiarrhythmic drugs, at both 1 year and long-term follow-up, was also evaluated. Of the 202 patients enrolled, 194 (96.0%) completed the trial (97 in the ablation-first group and 97 in the occlusion-first group). The mean (SD) age of the cohort was 67.3 (9.2) years, and 110 patients (56.7%) were male. All procedures achieved acute successful LAAO and restoration of sinus rhythm, with similar incidences of periprocedural complications. Compared with the ablation-first group, the occlusion-first group exhibited significantly higher event-free survival of the primary end point (83.5% vs 71.1%; hazard ratio [HR], 0.53 [95% CI, 0.29-0.95]; log-rank P = .04) during the median 2.5 (IQR, 2.3-2.8) years of follow-up. Subgroup analysis indicated that male patients and those with higher CHA2DS2-VASc scores (a composite of factors associated with stroke risk; higher scores indicate higher risk) were at lower risk of thromboembolic events. Rates of long-term freedom from AF (77.3% vs 63.5%; HR, 0.58 [95% CI, 0.34-0.97]; log-rank P = .04) and from ATA (70.1% vs 55.7%; HR, 0.62 [95% CI, 0.39-0.99]; log-rank P = .04) were higher in the occlusion-first group vs the ablation-first group. Additionally, a higher incidence of chronic peridevice leak (15 [15.5%] vs 5 [5.2%]; P = .03) and DRT (8 [8.2%] vs 1 [1.0%]; P = .04) was observed in the ablation-first group vs the occlusion-first group. In this randomized clinical trial, the occlusion-first approach was superior due to its higher event-free survival of the primary end point and long-term freedom from ATA. These findings suggest that the occlusion-first approach should be recommended for combined procedures with plug-like device implantation. Chinese Clinical Trial Registry Identifier: ChiCTR2000031486.

In-hospital bioimpedance-derived total body water predicts short-term cardiovascular mortality and re-hospitalizations in acute decompensated heart failure patients.

Hospital re-admissions in heart failure (HF) patients are mostly caused by an acute exacerbation of their chronic congestion. Bioimpedance analysis (BIA) has emerged as a promising non-invasive method to assess the volume status in HF. However, its correlation with clinically assessed volume status and its prognostic value in the acute intra-hospital setting remains uncertain. In this single-center observational study, patients (n = 49) admitted to the cardiology ward for acute decompensated HF (ADHF) underwent a daily BIA-derived volume status assessment. Median hospital stay was 7 (4-10) days. Twenty patients (40%) reached the composite endpoint of cardiovascular mortality or re-hospitalization for HF over 6months. Patients at discharge displayed improved NYHA class, lower body weight, plasma and blood volume, as well as lower NT-proBNP levels compared to the admission. Compared to patients with total body water (TBW) less than or equal to that predicted by body weight, those with higher relative TBW levels had elevated NT-proBNP and E/e´ (both p < 0.05) at discharge. In the Cox multivariate regression analysis, the BIA-derived delta TBW between admission and discharge showed a 23% risk reduction for each unit increase (HR = 0.776; CI 0.67-0.89; p = 0.0006). In line with this finding, TBW at admission had the highest prediction importance of the combined endpoint for a subgroup of high-risk HF patients (n = 35) in a neural network analysis. In ADHF patients, BIA-derived TBW is associated with the increased risk of HF hospitalization or cardiovascular death over 6months. The role of BIA for prognostic stratification merits further investigation.

The in-hospital administration of sacubitril/valsartan in acute myocardial infarction: A meta-analysis.

There is a need to address the evidence gap regarding the in-hospital administration of sacubitril/valsartan in acute myocardial infarction patients. After searching MEDLINE, Google Scholars and Scopus, a random-effects meta-analysis of randomized controlled trials comparing the in-hospital administration of the angiotensin receptor-neprilysin inhibitors (ARNis) versus the standard therapy in patients with reduced heart failure due to myocardial infarction was performed. The primary outcome was major adverse cardiovascular events. All-cause mortality, cardiac death, rehospitalization for heart failure, non-fatal myocardial infarction (MI), changes in left ventricular ejection fraction, left ventricular volumes, N terminal pro brain natriuretic peptide and adverse events were the secondary endpoints. Nine studies (eight randomized controlled trials and one echo-substudy) with a total 6597 individuals (angiotensin-converting enzyme inhibitor/angiotensin receptor blocker: 3300 patients vs. ARNis: 3297 patients) were included for quantitative analysis. Median follow-up was 6months. Patients receiving an in-hospital coadministration of ARNi had a lower risk of major cardiovascular event [odds ratio (OR) 0.45, 95% confidence interval (CI) 0.32-0.63, P<0.0001] and lower rate of repeat rehospitalization for heart failure (OR 0.40, 95% CI 0.26-0.62, P<0.0001), compared with a standard regimen. Additionally, left ventricle volumes were significantly lower in the ARNi group [left ventricular end-diastolic volume, mean difference (MD) 11.48mL, 95% CI 6.10-16.85, P<0.0001; left ventricular end-systolic volume, MD 7.09mL, 95% CI 2.89-11.29, P=0.0009] with a significant change in left ventricular ejection fraction (MD 3.07, 95% CI 1.61-4.53, P<0.0001), compared with standard therapy. No significant differences were observed in terms of cardiac death, all cause of mortality, non-fatal myocardial infarction and N terminal pro brain natriuretic peptide. Higher rates of iatrogenic hypotensive events were observed in the ARNi group compared with the standard therapy (OR 1.42, 95% CI 1.26-1.60, P value<0.00001). In patients with acute myocardial infarction related heart failure, the in-hospital administration of ARNis was associated with a reduced risk of major cardiovascular events and re-hospitalization for heart failure, as well as cardiac remodelling, but higher rates of hypotensive events compared with standard therapy.

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

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

Early repeat catheter ablation in patients with early recurrent arrhythmia

Abstract Background Repeat catheter ablation reduces adverse cardiovascular endpoints in patients with recurrent atrial tachyarrhythmia after index ablation. However, when to proceed with re-ablation in patients with early recurrent arrhythmia is unknow. Objective In this study, we aim to access the effectiveness of early repeat ablation on cardiovascular outcomes in early recurrent atrial tachycardia patients. Methods A total of 502 post-ablation patients, who experienced early atrial tachyarrhythmia recurrence within 6 months outside the blank period post index ablation and had undergone a repeat ablation, were consecutively enrolled from China AF registry from January 2012 to December 2018. Early repeated ablation (ERA) was defined as patients underwent a subsequent catheter ablation procedure within early recurrent period, then late repeated ablation (LRA) referred to a redo procedure that performed after 6 months since the de novel ablation. Cox proportional hazard models were used to estimate the effect of early re-ablation on primary endpoint (a composite of cardiovascular death, stroke and cardiovascular rehospitalization) and secondary endpoint (each component of primary outcome and AF/AT recurrence). Results The median follow-up time was 26 months after the redo-AF/AT ablation. First primary composite outcome occurred in 39 of the patients received early re-ablation (24.38 per 100 person-years) and in 136 of the patients performed with late re-ablation (39.77 per 100 person-years) (HR = 0.55, 95% CI = 0.38-0.79; P0.001). Cardiovascular re-hospitalization (hazard ratio 0.52 95% confidence interval [0.36; 0.73]) and AF recurrence occurred less often (hazard ratio 0.76, 95% confidence interval [0.58; 0.98]) in the ERA group. No significant difference between the two groups was found in terms of cardiovascular death, stroke and major bleeding events. Conclusion Early initiation of redo-ablation conveys better clinical benefit in patients with early arrhythmia recurrence.

Real-life impact of complete revascularization of non-ST elevation myocardial infarction during index hospitalization

Abstract Introduction patients with non-ST elevation acute myocardial infarction (NSTEMI) frequently present multivessel disease (MVD) with significant stenosis in non-infarct-related arteries (non-IRA). Unlike for ST elevation acute myocardial infarction, there is a paucity of studies evaluating the prognostic impact of complete revascularization in these patients. In fact, recommendation for complete revascularization is based in observational and non-randomized studies suggesting a possible benefit regarding mortality and major cardiovascular events. Purpose to evaluate the prognostic impact of complete revascularization during the index hospitalization in the Portuguese patients with NSTEMI and MVD. Methods patients hospitalized for NSTEMI with MVD included in a national multicentre retrospective study between October 2010 and December 2022 were divided into two groups: group 1 was submitted to complete percutaneous revascularization during the index hospitalization (IRA and non-IRA with diameter stenosis ≥50% on angiography), and group 2 performed IRA-only revascularization. The impact of complete revascularization on the probability of cardiovascular re-hospitalization, as well as on in-hospital and one-year mortality rates was evaluated. Results a total of 3084 patients was included, 74.8% were males, with a mean age of 67.8±11.9 years. Most patients were submitted to IRA-only revascularization (72.9%). From the remaining, 81.4% performed complete revascularization during the index procedure and 18.6% staged during index hospitalization. Group 1 patients were younger (65.5±11.8 vs. 68.6±11.8 years, p&amp;lt;0.001), with fewer comorbidities and slightly higher left ventricular ejection fraction (55±11 vs. 51±11%, p&amp;lt;0.001). On the other hand, group 2 patients revealed a significantly higher percentage of previous, revascularization (14.8% vs. 1.6%), mostly surgical. Besides overall similar incidence of in-hospital complications, including recurrence of acute myocardial infarction, patients submitted to complete revascularization showed a non-significant trend to an inferior in-hospital mortality rate (0.7 vs. 1.6%, p=0.06). Also, 1-year mortality rate was similar between groups (4.2 vs. 5.0%, p=0.54). However, complete revascularization appeared to result in a long-term prognostic benefit, halving the incidence of unplanned cardiovascular re-hospitalizations at one year of follow-up (9.3 vs. 18.8%, p&amp;lt;0.001). Conclusion complete revascularization led to an overall long-term benefit, mainly due to a reduction in cardiovascular re-hospitalizations, without a significant impact on 1-year mortality rate.

Long-term outcomes in hospitalized heart failure patients in China: results from the China National Heart Failure (CN-HF) registry study

Abstract Background There is a paucity of data on the long-term outcomes of heart failure (HF) patients in China. We aimed to investigate the incidence of cardiovascular (CV) death or rehospitalization due to worsening HF (WHF) and other outcomes among different subtypes of patients with chronic HF in China. Methods Data from the China National HF registry (CN-HF) during the period 1 February 2013–31 October 2015 were analyzed. Patients were categorized into three groups based on their left ventricular ejection fraction (LVEF): HF with reduced ejection fraction (HFrEF, LVEF≤40%), HF with mildly reduced ejection fraction (HFmrEF, LVEF 41%–49%), and HF with preserved ejection fraction (HFpEF, LVEF≥50%). Rates and risk of CV death or HF rehospitalization and other outcomes including all-cause mortality in each group were calculated and compared. Results In total 7171 patients (mean age 69.6 years, 59.5% male) with HF were enrolled across 45 centers in China. At discharge, ACEIs/ARBs, β-blockers and MRA were prescribed in 57.3%, 50.8% and 54.5% HF patients totally. The overall incidence of the primary outcome (CV death or HF rehospitalization) was 8.9%, 16.1%, and 23.5% at 6, 12, and 24 months post-discharge, respectively. Significantly higher rates of the primary outcome, all-cause mortality, and HF re-hospitalization were observed in patients with HFrEF and HFmrEF compared with those with HFpEF at 6, 12, and 24 months (P &amp;lt; 0.05). The incidence of CV death was similar across all LVEF subgroups. Conclusions Compared to patients with HFpEF, incidence of death or rehospitalization were higher among patients with HFrEF or HFmrEF in China. Optimal follow-up and management of HF both inside and outside of the hospital should be highlighted and put into practice.Primary outcome according to LVEFAll-cause death and rehospitalization

Left atrial reservoir strain as a prognostic indicator for cardiovascular events after mitral valvuloplasty

Abstract Background In patients after mitral valvuloplasty (MVP), assessing valve function and heart failure (HF) is crucial for prognostic predictions. Left ventricular diastolic function assessed by transthoracic echocardiography (TTE) plays an important role in the evaluation of HF in general practice. However, post-mitral valve surgery patients are excluded from the left ventricular diastolic function assessment guidelines proposed by the American Society of Echocardiography in 2016 due to their low correlation with left ventricular diastolic function indices. On the contrary, the left atrial reservoir strain (LARS) before MVP is considered as a prognostic factor, reflecting left atrial dysfunction caused by mitral regurgitation. Nevertheless, there are limited reports on the relationship between LARS and cardiovascular (CV) events after MVP. Purpose The study aims to investigate the utility of LARS in predicting CV events after MVP. Methods The study included 249 patients who underwent TTE between January 2011 and January 2023 after MVP at our hospital. Patient background data, including NYHA classification, medical history, medications, blood tests, and TTE data, were collected at the time of follow-up TTE. LARS, left ventricular global longitudinal strain (LV-GLS), and right ventricular free wall strain (RV-FWSL) analysis were performed using a vender-independent external strain analysis software for all patients in the cohort. The primary endpoints were cardiovascular death and HF rehospitalization. The predictor of cardiovascular events was assessed using the Cox proportional hazards model and Kaplan-Meier curve (KMC). Results The mean age was 61±14 years, and 159 patients (64%) were male. The median time from surgery to TTE was 4.8 (1.0-6.8) years, 32 patients (13%) had events within 8.5 (3.7-10.8) years after TTE. The event groups had higher age, NYHA classification, and NT-pro BNP compared to the non-event group. TTE parameters such as left ventricular mass index, left ventricular end-diastolic volume and end-systolic volume were larger, and LV-GLS and LARS were significantly lower in the event group. In multivariate Cox proportional hazards models showed that LARS was also a prognostic indicator even after adjustment for several variables (Table 1). The KMC showed that LARS was associated with events regardless of left atrial volume index (Log-rank p &amp;lt;0.001, chi-square:31.03) (Figure 1). Conclusion LARS was strongly associated with CV events after MVP. We consider LARS to be a useful prognostic indicator after MVP.

Association of systemic inflammatory markers with clinical adverse prognosis and outcomes in HFpEF: a systematic review and meta-analysis of cohort studies.

To evaluate the association between systemic inflammatory markers and clinical outcomes (all-cause mortality, cardiovascular mortality, and rehospitalization) in patients with heart failure with preserved ejection fraction (HFpEF). We conducted a comprehensive literature search in PubMed, Embase, and Ovid Medline databases from inception to June 27, 2024. Studies were included if they were observational clinical studies involving HFpEF patients over 18 years old, with exposure to systemic inflammatory markers and reporting on adverse prognosis outcomes. The Newcastle-Ottawa Scale (NOS) was used to assess study quality. Eight studies ultimately included in the meta-analysis which involved 9,744 participants from six countries. The meta-analysis showed that systemic inflammatory markers were significantly associated with all-cause mortality (HR 1.43, 95% CI 1.19-1.72, p < 0.05), cardiovascular mortality (HR 2.04, 95% CI 1.33-3.12, p < 0.05), and cardiovascular rehospitalization (HR 2.83, 95% CI 0.92-8.67, p < 0.05) in HFpEF patients. Low heterogeneity was observed across studies (I2 = 0.00%). Sensitivity and publication bias analyses indicated that the results were robust. Systemic inflammatory markers demonstrate significant predictive value for adverse clinical outcomes in HFpEF patients. The findings suggest that monitoring systemic inflammation may provide valuable prognostic information for clinicians managing HFpEF patients. https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=562698, identifier (CRD42024562698).

Health Care Resource Utilization Following Acute Myocardial Infarction: Findings from the RECORD-MI Registry

The contemporary health care resource utilization after an acute myocardial infarction (MI) is not well-known. All patients admitted because of MI between January 2015 and December 2021 across 28 hospitals in the Baylor Scott & White Health system were studied. Patient characteristics and outcomes, including all-cause and cardiovascular (CV) rehospitalizations, emergency department (ED) visits, and outpatient visits were evaluated. Of 6,804 patients admitted because of MI, 6,556 were discharged alive. The median age was 69 years, 60% were men, and 77% had non-ST-elevation MI; 17% (1,090) had multivessel disease. The number of patients with first all-cause readmissions within 30 days, 3 months, and 12 months of discharge were 844 (13%), 1,372 (21%), and 2,306 (35%), respectively, with a higher readmission rate in patients with non-ST-elevation MI, previous heart failure (HF), new-onset HF, and left ventricular ejection fraction ≤40%. ED visits at 12 months for any cause were 2,401 (37%), of which 1,321 (55%) were for any CV cause, with a higher incidence in patients with previous HF. Of the 6,556 patients, 4,102 (63%) had at least 1 primary care visit in the past year, 5,009 (76%) had CV specialty visits, and 3,860 (59%) had non-CV visits, with a similar distribution across subgroups. Patients hospitalized with an MI had a high risk of subsequent hospital readmissions and ED and outpatient visits, especially those with a previous HF diagnosis and those discharged with an MI and HF diagnosis.

Prognostic value of left atrial reverse remodelling in patients hospitalized with acute decompensated heart failure.

Left atrial (LA) volume index (LAVI) in chronic heart failure (HF) predicts cardiovascular outcomes. However, the association between LAVI reduction during acute decompensated HF (ADHF) and its prognostic potential is limited. We hypothesized that LA reverse remodelling (LARR) after ADHF therapy would be associated with better clinical outcomes. This retrospective study analysed clinical outcomes and the LAVI reduction rate of 363 out of 861 patients hospitalized for ADHF who underwent two-point echocardiography at admission and discharge between January 2015 and December 2019. The mean age was 74.3±13.6years, and the mean ejection fraction (EF) was 38.9±15.2%. The follow-up echocardiogram was performed 13.0 [9.5, 20] days after admission. As the median LAVI reduction rate was 7.02%, the LARR was defined as an LAVI reduction rate >7%. During the 34.0±20.2months of follow-up, 117 patients (32.2%) reached the primary endpoint defined as cardiovascular death and rehospitalization for ADHF. Kaplan-Meier survival analysis showed that patients with LARR had a better prognosis. Multivariate analysis indicated that LARR was an independent predictor of cardiovascular events. Similar findings were observed in the subgroup analyses of patients with persistent/permanent atrial fibrillation and those with non-HF with reduced EF. Among patients who were brain natriuretic peptide (BNP) responders, defined as a relative reduction of >70% in BNP from admission to discharge, non-LARR was observed in 41.6%. BNP responders without LARR experienced worse prognoses. LARR in the early vulnerable phase after hospitalization for ADHF was associated with better long-term clinical outcomes.

Prevalence, Clinical Features, Treatment, and Outcomes in Patients With Myocardial Infarction With Non-Obstructive Coronary Arteries.

To study clinical and demographic characteristics, treatment options, and clinical outcomes in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) compared with patients with myocardial infarction with obstructive coronary arteries (MIOCA). This single-center prospective observational study included 712 successive patients diagnosed with acute myocardial infarction (MI), who routinely underwent direct coronary angiography. Based on the presence of stenosing coronary atherosclerosis, the patients were divided into two groups: MIOCA (coronary stenosis ≥50%) and MINOCA (coronary stenosis &lt;50% without other, alternative causes). Clinical outcomes included in-hospital and long-term overall mortality, and cardiovascular rehospitalization. The median follow-up was 1.5 years. MINOCA was diagnosed in 73 (10.3%) patients, 37 (50%) of whom were women. The median age of patients with MINOCA was 61 years and in the MIOCA group 65 years. No significant differences in cardiovascular risk factors were found between patients with MINOCA and MIOCA. In 53.4% of cases, the cause of MINOCA was a discrepancy between the myocardial oxygen demand and supply, and in 35.6% of cases, the cause was hypertensive crisis and pulmonary edema. The factors associated with MINOCA included an age ≤58 years, female gender, absence of the ST-segment elevation, absence of areas of impaired local contractility, and presence of aortic stenosis and bronchopulmonary infection. Patients with MINOCA were less likely to be prescribed acetylsalicylic acid, P2Y12 inhibitors, dual antiplatelet therapy, beta-blockers, and statins (p&lt;0.05). Data on long-term outcomes were available for 87.5% of patients (n=623). The prognosis of patients with MIOCA was comparable for in-hospital mortality (1.5% vs. 6.2%; p=0.161) and long-term overall mortality (6.1% vs. 14.7%; p=0.059). Cardiovascular rehospitalizations were more frequent in the MINOCA group (33.3% vs. 21.5%; p=0.042). The prevalence of MINOCA in our study was 10.3% among all patients with acute MI. MINOCA patients had comparable generally recognized cardiovascular risk factors with MIOCA patients. MINOCA patients had a comparable prognosis for in-hospital and long-term mortality and more often required cardiovascular rehospitalization.

Descarga precoz y evolución clínica en pacientes con miocarditis fulminante sometidos a ECMO-VA: resultados de un estudio retrospectivo multicéntrico

Introduction and objectivesAlthough venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides effective cardiocirculatory support in patients with fulminant myocarditis, the most effective timing of venting is uncertain. We aimed to investigate the benefit of early venting among patients who underwent VA-ECMO for fulminant myocarditis. MethodsAmong 841 patients with acute myocarditis from 7 hospitals in the Republic of Korea, 217 patients with fulminant myocarditis who underwent VA-ECMO were included in this analysis. The patients were categorized into 2 groups: an early unloading group that underwent venting within 24hours of ECMO insertion, and the no or delayed unloading group. The primary outcome was a composite of death, cardiac replacement, or cardiovascular rehospitalization. ResultsAmong 217 patients, 56 underwent early venting, 54 underwent delayed venting, and 107 did not undergo venting. On spline curves in 110 patients who underwent venting, rapid deterioration was observed as the timing of venting was delayed. The incidence of the primary outcome was lower in the early venting group than in the no or delayed unloading group (37.5% vs 58.4%; HR, 0.491; 95%CI, 0.279-0.863; P=.014). Among patients not experiencing the primary outcome within 6 months, clinical outcomes were similar after 6 months (P=.375). ConclusionsEarly left heart unloading within 24hours of ECMO insertion is associated with a lower risk of a composite of death, cardiac replacement therapy, and cardiovascular rehospitalization in patients with fulminant myocarditis undergoing VA-ECMO. Registered at ClinicalTrials.gov (NCT05933902).

Vericiguat in heart failure with reduced ejection fraction: hope or solid reality?

In recent years, thanks to the advent of new classes of drugs (ARNI and SGLT2-i), the prognosis of patients suffering from heart failure with reduced ejection fraction (HFrEF) has gradually improved. Nonetheless, there is a residual risk that is not targeted by these therapies. Currently, it is recognized that vericiguat, an oral stimulator of soluble guanylate cyclase (sGC), can restore the NO-sGC-cGMP pathway, through stimulation and activation of sGC, aiming to increase cGMP levels with a reduction in heart failure-related oxidative stress and endothelial dysfunction. Even though the Victoria trial demonstrated that HFrEF patients in treatment with vericiguat showed a 10% reduction in the composite of cardiovascular mortality and rehospitalization for heart failure, statistically significantly reducing heart failure hospitalization, the international guidelines limit its use as a second-line drug for patients with worsening symptomatology despite optimized medical therapy. Furthermore, vericiguat has proved to be a valid therapeutic ally especially in those patients with comorbidities such that they cannot receive the classic four-pillar therapy of HF (in particular renal failure). In this review, the authors report on randomized clinical trials, substudies, and meta-analysis about vericiguat in HFrEF, emphasizing the strengths that would suggest the possible role of vericiguat as the fifth pillar of the HFrEF treatment, acknowledging that there are still gaps in the evidence that need to be clarified.

Recurrence of left ventricular systolic dysfunction and its risk factors in heart failure with improved ejection fraction patients receiving guideline-directed medical therapy: A trajectory analysis based on echocardiography

BackgroundDespite the better prognosis of heart failure (HF) with improved ejection fraction (HFimpEF), remnant cardiovascular risks, including cardiovascular death, rehospitalization, and future deterioration of left ventricular (LV) systolic function, remain in HFimpEF. However, for HFimpEF patients, especially for those receiving guideline-directed medical therapy (GDMT), the recurrent LV systolic dysfunction and its risk factors is still unclear. MethodsA total of 1098 HF patients under HF follow-up management system were initially screened. Echocardiography was re-evaluated at 3-, 6-, and 12-month follow-up. After exclusion, a total of 203 HFimpEF patients on GDMT were enrolled in our final analysis. Cox regression analysis was conducted to select risk factors. ResultsDuring the 1-year follow-up, a total of 28 (13.8%) patients had recurrent LV systolic dysfunction. The trajectory analysis of echocardiographic parameters illustrated that persistent decline of left ventricular ejection fraction (LVEF) and worsening LV remodeling was observed in patients with recurrent LV systolic dysfunction. Multivariable Cox regression analysis identified that ischemic cardiomyopathy, atrial fibrillation, higher left ventricular end-diastolic diameter index (LVEDDI), elevated serum potassium, and a lack of sodium-glucose co-transporter-2 inhibitors (SGLT2i) treatment were confirmed as independent risk factors for recurrent LV systolic dysfunction. Recurrent LV systolic dysfunction was associated with higher rehospitalization rate. ConclusionIn our longitudinal cohort study, almost 14% HFimpEF receiving GDMT suffered recurrent LV systolic dysfunction. Ischemic cardiomyopathy, atrial fibrillation, higher LVEDDI, higher serum potassium, and a lack of SGLT2i therapy were tightly associated with recurrence of LV systolic dysfunction. Relapse of LV systolic dysfunction correlated with poor prognosis.

The associationof quality of life and the functioning in the chronic disease among patients after myocardial infarction

Abstract Background The importance of health-relatedquality of life (HRQoL) and improving functional status in reducing risk factors of myocardial infarction (MI) has also been increasingly recognized. Purpose This study aimed to examine the level of quality of life (QoL) in patients after myocardial infarction (MI) in relation to the degree of functioning in chronic disease. Methods This was a cross-sectional, single-centre study. The study was conducted among 231 patients who were hospitalized for myocardial infarction (MI) after percutaneous coronary intervention (PCI). The WHO Quality of Life Questionnaire (WHOQOL BREF) andthe Chronic Disease Functioning Scale(FCIS) were used. Results The Spearman's correlation coefficient showed a statistically significant correlation (coefficient value 0.5 &amp;lt; |r/rho| ≤ 0.7) between general functioning in chronic disease and the average QoL (rho = 0.56;p &amp;lt; 0.001)and somatic QoL levels(rho = 0.52;p &amp;lt; 0.001), as well as a moderately strong positive correlation with the QoL level on the psychological domain (rho = 0.50;p &amp;lt; 0.001), social domain (rho = 0.48;p &amp;lt; 0.001) and environmental domain (rho = 0.43;p &amp;lt; 0.001). Conclusion Identifying the chronic disease functioning indicator in post-MI patients in relation to HRQoL allows for targeted counseling and secondary prevention of ischemic heart disease (IHD), which translates into a reduced risk of further cardiovascular events and related rehospitalization.

Long-Term Comparative Effectiveness of Transcatheter Aortic Valve Replacement (TAVR) Versus Surgical Aortic Valve Replacement (SAVR) in High-Risk Aortic Stenosis Patients: A Meta-Analysis

Transcatheter aortic valve replacement (TAVR) has become an alternative to surgical aortic valve replacement (SAVR) for high-risk patients with severe aortic stenosis (AS). This meta-analysis aims to compare the long-term outcomes of TAVR and SAVR in this population. A systematic search of PubMed, Embase, and the Cochrane Library was conducted up to December 2023. Randomized controlled trials (RCTs) and observational studies comparing TAVR and SAVR with a minimum follow-up of one year were included. The primary outcome was all-cause mortality. Secondary outcomes included cardiovascular mortality, stroke, myocardial infarction (MI), and rehospitalization. Twenty-three studies involving 15,482 patients (TAVR=7,785, SAVR=7,697) were included. The mean follow-up period was 3.2 years (range 1-5 years). There was no significant difference in all-cause mortality between TAVR and SAVR (Hazard Ratio [HR] 1.02, 95% CI 0.95-1.09, p=0.63). Similarly, there were no differences in cardiovascular mortality (HR 1.05, 95% CI 0.96-1.15, p=0.28), stroke (HR 0.98, 95% CI 0.87-1.10, p=0.75), or MI (HR 0.94, 95% CI 0.82-1.08, p=0.39). However, TAVR was associated with a lower rate of rehospitalization (HR 0.85, 95% CI 0.78-0.93, p=0.001). TAVR is a viable alternative to SAVR in high-risk patients with AS, demonstrating comparable long-term survival and safety outcomes. The reduced rehospitalization rate associated with TAVR may be an important consideration for these patients.

Triglyceride-glucose index and the prognosis of patients with heart failure: A meta-analysis.

The triglyceride-glucose index (TyGI) is a novel indicator of insulin resistance, which has been associated with an increased risk of cardiovascular diseases. The aim of this meta-analysis was to determine the association between TyGI and the prognosis of patients with heart failure (HF). Cohort studies relevant to the aim of the meta-analysis were retrieved by searching electronic databases, including PubMed, Web of Science, and Embase. A random-effects model was used to combine the data, incorporating the influence of between-study heterogeneity. Twelve studies involving 20,639 patients with HF were included. Pooled results showed that compared to patients with the lowest category of TyGI at baseline, those with the highest TyGI index were associated with a higher risk of all-cause mortality during follow-up (relative risk [RR] 1.71, 95% confidence interval [CI] 1.46 - 2.00; P < 0.001; I² = 55%). Sensitivity analyses limited to studies after adjustment for confounding factors showed similar results (RR 1.89, 95% CI 1.67 - 2.21; P < 0.001; I² = 13%). Subsequent meta-analyses also showed that a high TyGI at baseline was related to the incidence of cardiovascular death (RR 1.87, 95% CI 1.42 - 2.47; P < 0.001; I² = 57%), HF rehospitalization (RR 1.33, 95% CI 1.04 - 1.69; P < 0.02; I² = 46%), and major adverse cardiovascular events (RR 1.69, 95% CI 1.39 - 2.06; P < 0.001; I² = 17%) during follow-up. In conclusion, a high TyGI may be associated with a poor clinical prognosis for patients with HF.