Cardiovascular Rehospitalization Research Articles

Cognitive disorders in takotsubo syndrome: incidence, short and long-term outcome. Results from a prospective multi-center registry

Abstract Background Takotsubo syndrome (TTS) is an acute and reversible left ventricular dysfunction, whose pathophysiological mechanisms are not completely known. There are evidence suggesting a possible link between neurological disease and TTS. Aim of the study was to evaluate incidence and prognostic value of cognitive neurological disorders among TTS patients. Methods 379 consecutive patients were enrolled in a prospective multicenter registry. History, clinical features, echocardiographic parameters, in-hospital complications and long-term follow up events of all patients were recorded. Cognitive neurological disorders included Alzheimer disease, old age dementia and cognitive impairment for other causes. Results Prevalence of cognitive neurological disorders among TTS patients was 5.5% (num=21). Among this subset of patients 48% (num=10) had Alzheimer syndrome, 24% (num=5) old age dementia and 28% (num=6) cognitive impairment for other causes. Compared to the control group, these patients were older (81±5 vs 71±12, p=0.01) and predominantly men (24% vs 9%, p=0.01). No differences in term of cardiovascular risk factors and left ventricular ejection fraction at admission and discharge were found among the two groups. TTS patients with cognitive neurological disorders experienced higher rate of in-hospital complications (62% vs 28% p=0.01), that were mainly driven by higher rate of pulmonary edema (14% vs 9% p=0.01), cardiogenic shock (29% vs 8%, p=0.01), death (24% vs 4% p=0.01), ischemic stroke (10% vs 4% p=0.01) and left ventricular thrombi (10% vs 3%, p=0.01). At long term follow up patients with cognitive neurological disorders when compared to those without, experienced higher rate of mayor cardiovascular events (48% vs 16%, p=0.01), cardiovascular re-hospitalization (14% vs 10%, p=0.01) and death (43% vs 9%, p=0.01). Conclusion TTS patients with cognitive neurological disorders had an increased risk of in and out of hospital mayor cardiac adverse events and mortality at short and long-term follow-up. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Ospedali Riuniti di Foggia-Università di Foggia

Transcatheter paravalvular leak closure is an effective alternative to surgical repair with respect to 5-year outcomes

Abstract Introduction Paravalvular leakage (PVL) is a relatively common complication of heart valve replacement, associated with heart failure and increased mortality. Transcatheter PVL closure may be a promising alternative to surgical repair, especially in high-risk patients. Purpose Assessment of safety and efficacy of transcatheter PVL closure compared to surgical repair. Methods This is a retrospective single-centre study including all consecutive patients who underwent either transcatheter PVL closure between January 2013 and December 2020, or surgical repair between March 2015 and December 2020. Primary endpoints were 5-year all-cause mortality and the composite of 5-year cardiovascular mortality and rehospitalization for the underlying condition. Secondary endpoints were technical success and individual patient success at one year according to the PVL Academic Research Consortium. Results Of the 129 patients included, 85 went for transcatheter repair and 44 went for surgical repair. As compared to surgical repair, patients undergoing transcatheter PVL closure were older (71 years vs. 64,5 years; p≤0,01) and more symptomatic (NYHA class III & IV; 76,5% vs. 59,1%; p=0,04). At 5 years, transcatheter PVL closure was comparable to surgery in terms of the primary composite endpoint (HR: 1,20; 95% CI: 0,68–2,13; p=0,54), all-cause mortality (HR: 1,70; 95% CI: 0,82–3,50; p=0,15) and rehospitalization for the underlying condition (HR: 1,12; 95% CI: 0,54–2,89; p=0,780). Rates of technical success (92,9% vs. 95,5%; p=0,58) and individual patient success at one year (70,6% vs. 77,3%; p=0,87) were similar between transcatheter PVL closure and surgery respectively. Transcatheter PVL closure was associated with shorter in-hospital stay (7 days vs. 14 days; p≤0,01). Conclusion These findings support the use of transcatheter closure of PVL, especially in high-risk patients. Long term survival remains temperate in these challenging patients. Funding Acknowledgement Type of funding sources: None.

Optimal timing of intervention in NSTE-ACS without pre-treatment

Abstract Introduction In patients (P) with non-ST segment elevation acute coronary syndromes (NSTE-ACS), an invasive strategy is recommended to reduce adverse outcomes. The optimal timing to perform coronary angiography (CA) remains undetermined, particularly in our era attending to the new European guidelines restricting pre-treatment (PT). Objective To evaluate the prognostic value of an early strategy (ES; <24h) versus a delayed strategy (DS; >24h) when no loading dose of a P2Y12 antagonist was given as PT in NSTE-ACS. Material and methods Retrospective analysis of P data admitted with NSTE-ACS at multicentric national registry between 2015–19. Compared demographic and clinical characteristics of P with an ES versus DS. A multivariate logistic regression was performed to evaluate predictor factors of in-hospital and 1-year endpoints. Survival was evaluated through Kaplan-Meier curve and Cox multivariate regression. Results 691P were included, mean age 64±11 years, 77.4% male. 59.2% performed CA as an ES. P proposed to a DS presented higher KK class, higher levels of creatinine and lower of hemoglobin. They also needed more frequently invasive (1.1 vs 0.7%, p=0.692) or non-invasive ventilation (1.8 vs 0.7%, p=282). A higher proportion of DS patients used the transfemoral access (5.5 vs 9.3%, p=0.058). On CA, 6.2% had normal coronary arteries, 49.2% 1-vessel disease and 45.1% multivessel disease. Revascularization was performed in 88.2%: PCI in 86.2%, CABG in 1.7% and both in 0.3%, with no significant differences. Pending CA, 98.4% were medicated with aspirin, 64.8% ticagrelor and 44% clopidogrel, with no differences. P proposed to an ES were more medicated with glycoprotein inhibitor (36.3 vs 26.4%, p=0.015) and non-fractioned heparin (6.4 vs 2.1%, p=0.01) and less with fondaparinux (56.2 vs 65.2%, p=0.017). A higher percentage of calcium-channel blockers (25.2 vs 11.7%, p<0.001) and nitrates (74.1 vs 53.3%, p<0.001) was observed in the DS. No difference was observed in beta-blockers (p=0.581). Discharge medication followed these tendencies. There was a trend to worse in-hospital outcomes in the DS regarding heart failure, shock, ventricular arrhythmias, cardiac arrest and death, although not significatively different, except for major bleeding (1.8 vs 0.2%, p=0.044). 1-year composite endpoint of mortality and cardiovascular rehospitalization occurred in 9.9%, with no difference between groups (p=0.181). Predictor factors, evaluated through Cox multivariate regression, were ejection fraction <50% (p=0.001), KK class >I (p=0.002) and nitrate prescription at discharge (p=0.001). A DS was not a predictor factor (p=0.812). Conclusion Our results are in accordance with available data. In P with higher-risk NSTE-ACS in the absence of P2Y12 antagonist PT, an ES was not associated with a reduction in the composite of global mortality and rehospitalization for cardiovascular causes. Funding Acknowledgement Type of funding sources: None.

Rapid Risk Stratification of Acute Ischemic Stroke Patients in the Emergency Department: The Incremental Prognostic Role of Left Atrial Reservoir Strain

ObjectivesTo determine the prognostic value of positive global left atrial strain (LA-GSA+), measured by two-dimensional speckle tracking echocardiography (2D-STE) in a population of acute ischemic stroke (AIS) patients without atrial fibrillation (AF), in the setting of Emergency Department (ED). MethodsAll consecutive AIS patients with sinus rhythm on ECG and without AF history entered this prospective study. All patients underwent complete blood tests and transthoracic echocardiography implemented with 2D-STE analysis of LA strain parameters within 6–12 h after symptoms onset. At 6-months follow-up, we evaluated the composite endpoint of all-cause mortality plus cardiovascular re-hospitalizations. ResultsA total of 102 AIS patients (76.4 ± 10.8 yrs, 47% males) were prospectively included. LA-GSA+ was markedly reduced in AIS patients (20.8 ± 7.7%), without any statistically significant difference between the stroke subtypes. At 6-months follow-up, 7 deaths and 27 re-hospitalizations occurred. On multivariate Cox regression analysis, variables independently associated with outcome were: LA-GSA+ (per unit) (HR 0.29, 95% CI 0.19–0.39) and C-reactive protein (CRP) (per 0.1 mg/dl) (HR 1.45, 95% CI 1.15–1.75) as continuous variables; statin therapy (HR 0.45, 95%CI 0.28–0.62), and type 2 diabetes (HR 1.65, 95% CI 1.15–2.35) as categorical variables. A LA-GSA+ ≤20.0% predicted the occurrence of the above-mentioned outcome at 6-months follow-up with 94% sensitivity and 81% specificity (AUC=0.84). Interestingly, GSA+ showed a strong inverse correlation with CRP levels (r = -0.86). ConclusionsA LA-GSA+ ≤20% reflects a more advanced atrial cardiomyopathy and might provide a rapid and reliable prognostic risk stratification of AIS patients without AF history in the setting of ED.

Health Status Predicts Short- and Long-Term Risk of Composite Clinical Outcomes in Acute Heart Failure

ObjectivesThis study aims to examine the association between the Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 score and the 30-day and 1-year rates of composite events of cardiovascular death and heart failure (HF) rehospitalization in patients with acute HF. BackgroundFew studies reported the prognostic effects of KCCQ in acute HF. MethodsThis study prospectively enrolled adult patients hospitalized for HF from 52 hospitals in China and collected the KCCQ-12 score within 48 hour of index admission. The study used multivariable Cox regression to examine the association between KCCQ-12 score and 30-day and 1-year composite events and was further stratified by new-onset HF and acutely decompensated chronic heart failure (ADCHF). Subgroup analyses were performed to explore the potential heterogeneity. The study evaluated the incremental prognostic value of KCCQ-12 score over N-terminal pro−B-type natriuretic peptide (NT-proBNP) levels and established risk scores by C-statistics, net reclassification improvement, and integrated discrimination improvement. ResultsAmong 4,898 patients, 29.4% had new-onset HF. After adjustment, each 10-point decrease in the KCCQ-12 score was associated with a 13% increase in 30-day risk and a 7% increase in 1-year risk. The associations were consistent regardless of new-onset HF or ADCHF, age, sex, left ventricular ejection fraction, New York Heart Association functional class, NT-proBNP level, comorbidities, and renal function. Adding KCCQ-12 score to NT-proBNP and established risk scores significantly improved prognostic capabilities measured by C-statistics, net reclassification improvement, and integrated discrimination improvement. ConclusionsIn acute HF, a poor KCCQ-12 score predicted short- and long-term risks of cardiovascular death and HF rehospitalization. KCCQ-12 could serve as a convenient tool for rapid initial risk stratification and provide additional prognostic value over NT-proBNP and established risk scores.

The Prognosis of Baseline Mitral Regurgitation in Patients with Transcatheter Aortic Valve Implantation.

Mitral regurgitation (MR) is the most common valvular lesion in transcatheter aortic valve implantation (TAVI) recipients. This study aims to assess the long-term prognostic impact of baseline MR in TAVI patients. Methods: Adult patients who underwent TAVI were identified in the French National Hospital Discharge Database. All-cause and cardiovascular mortality, stroke, and rehospitalization with heart failure (HF) were compared in TAVI patients with and without baseline MR and tricuspid regurgitation (TR), respectively; the associations of MR and TR with the outcomes were assessed by Cox regression. Results: Baseline MR was identified in 8240 TAVI patients. Patients with baseline MR have higher yearly incidence of all-cause mortality (HR: 1.192, 95% confidence interval CI: 1.125–1.263), cardiovascular mortality (HR: 1.313, 95%CI: 1.210–1.425), and rehospitalization for heart failure (HF) (HR: 1.411, 95%CI: 1.340–1.486) compared to those without, except for stroke rate (HR: 0.988, 95%CI: 0.868–1.124). Neither baseline MR nor TR was an independent risk predictor for all-cause mortality or cardiovascular mortality in TAVI patients. Baseline MR was independently associated with rehospitalization for HF in TAVI patients. Conclusions: Baseline MR and TR were associated with increased all-cause and cardiovascular mortality post-TAVI, however, neither of them was independent predictor for all-cause or cardiovascular mortality.

Relationship Between the Eosinophil/Monocyte Ratio and Prognosis in Decompensated Heart Failure: A Retrospective Study.

PurposeThe aim of this study was to assess the value of the eosinophil/monocyte ratio (EMR) for predicting the prognosis of decompensated heart failure (HF).Patients and MethodsThis was a retrospective cohort study. We included adults (≥18 years old) diagnosed with decompensated HF for whom EMR data were available. The patients were divided into three groups according to EMR tertiles (T1 [EMR≤0.15], T2 [0.15<EMR≤0.32], and T3 [EMR>0.32]). The primary endpoint was the composite outcome of cardiovascular death or HF rehospitalization.ResultsInitially, the records of 2264 patients with decompensated HF were screened; 1883 of these patients had EMR data and were therefore included in the study. There were 627 patients in the T1 group, 628 in the T2 group, and 628 in the T3 group. The risk of cardiovascular death or HF rehospitalization was significantly different among the three groups (Log rank test, P=0.007). Compared with the T3 group, both the T1 group (hazard ratio [HR]: 1.50, 95% confidence interval [CI]: 1.16–1.94, P=0.002) and the T2 group (HR: 1.34, 95% CI: 1.03–1.74, P=0.030) had significantly higher rates of cardiovascular death or HF rehospitalization. A Cochran-Armitage test for trend showed a positive correlation between the EMR and the composite outcome of cardiovascular death or HF. There was a significant difference between the three groups in terms of cardiovascular death (Log rank test, P<0.001) and HF rehospitalization (Log rank test, P=0.03).ConclusionThe EMR is positively correlated with the risk of cardiovascular death or HF rehospitalization in patients with decompensated HF. Specifically, the lower the EMR, the higher the risk of cardiovascular death or HF rehospitalization.

Biomarkers of Systemic Versus Local Inflammation During the Acute Phase of Myocardial Infarction, as Predictors of Post-infarction Heart Failure

Abstract Background: The aim of this study was to investigate the correlation between serum biomarkers of left ventricular dysfunction and systemic inflammation in the first days after the acute episode, and to investigate their role for early identification of patients at high risk for post-infarction heart failure. Materials and methods: In total, 123 subjects admitted to the Intensive Cardiovascular Care Unit of the Cardiology Clinic of the Târgu Mureș County Clinical Emergency Hospital, Romania, with acute myocardial infarction were retrospectively analyzed in this study. Based on the level of NT-proBNP, the study population was divided into 2 groups: Group 1 (n = 92), with NT-proBNP &lt;3,000 pg/mL, and Group 2 (n = 31), with NT-proBNP &gt;3,000 pg/mL. Results: Biomarkers reflecting systemic inflammation presented significantly higher values in patients with elevated NT-proBNP (hs-CRP – 12.3 ± 8.9 mg/L vs. 3.6 ± 6.7 mg/L, p &lt;0.0001, and interleukin 6 – 27.6 ± 30.7 pg/mL vs. 8.6 ± 6.2 pg/mL, p &lt;0.0001). However, cell adhesion molecules VCAM and ICAM were not significantly different between the groups. Patients in Group 2 presented significantly higher rates of major cardiovascular events and rehospitalizations in the first year after the acute coronary event, with 13.33% event rate for patients in Group 2 compared to 8.7% in Group 1 (p &lt;0.05). Conclusions: Serum biomarkers of ventricular dysfunction are strongly associated with systemic inflammation and ventricular impairment in the immediate phase after an acute myocardial infarction. Systemic inflammation has a higher impact on the clinical outcomes and progression to heart failure than the local coronary inflammation expressed by cell adhesion molecules.

Clinical Characteristics and Outcomes of Hospitalized Patients With Heart Failure From the Large-Scale Japanese Registry Of Acute Decompensated Heart Failure (JROADHF).

With aging population, the prevalence and incidence of heart failure (HF) have been increasing worldwide. However, the characteristics and outcomes of patients with HF in an era of aging are not well established in Japan. The Japanese Registry Of Acute Decompensated Heart Failure (JROADHF), a retrospective, multicenter, nationwide registry, was designed to study the clinical characteristics and outcomes of patients hospitalized with HF throughout Japan in 2013. One hundred and twenty-eight hospitals were selected by cluster random sampling and 13,238 hospitalized patients with HF were identified by medical record review. Demographics, medical history, severity, treatment, and in-hospital and long-term outcome data were collected from the Diagnostic Procedure Combination and medical charts. Data were analyzed using univariate and multivariate logistic regression or Cox regression analysis. The mean age of registered patients was 78.0±12.5 years and 52.8% were male. Elderly patients (age >75 years) accounted for 68.9%, and HF with preserved ejection fraction (HFpEF) accounted for 45.1%. Median length of hospital stay was 18 days and in-hospital mortality was 7.7%. The median follow-up period was 4.3 years, and the incidence rates for cardiovascular death and rehospitalization for HF were 7.1 and 21.1 per 100 person-years, respectively. A contemporary nationwide registry demonstrated that hospitalized HF patients were very elderly, HFpEF was common, and their prognosis was still poor in Japan.

Increased ratio of sST2/LVMI predicted cardiovascular mortality and heart failure rehospitalization in heart failure with reduced ejection fraction patients: a prospective cohort study

BackgroundInflammation is one of the principal triggering mechanisms for left ventricular fibrosis and remodeling in heart failure, leading to adverse clinical outcomes. Soluble suppression of tumorigenicity 2 (sST2), a member of the interleukin-1 receptor family, is assumed to play a significant role in the fibrotic response to inflammation. Left ventricular mass index (LVMI) is a parameter of the prefibrotic inflammatory phase of heart failure preceding remodeling. The present study aimed to investigate the prognostic value of the sST2/LVMI ratio in heart failure with reduced ejection fraction.MethodsThis was a prospective cohort study. A total of 45 consecutive patients with heart failure with reduced ejection fraction, treated between September 2015 and December 2016, were enrolled. The sST2/LVMI ratio was measured at baseline. The primary endpoint was a composite of cardiovascular mortality and readmission for heart failure. The prognostic impact of the sST2/LVMI ratio was evaluated using a multivariable Cox proportional hazards regression model.ResultsForty-five patients were enrolled in this study. Their average age was 48 ± 14 years, and approximately 20% of them were men. Patients were followed for 9 months, during which the primary outcome occurred in 15 patients. Kaplan–Meier analysis showed that patients with a high sST2/LVMI ratio (≥ 0.39) had shorter event-free survival than those with intermediate (between 0.39 and 0.24) and low ratios (< 0.24) (log-rank, P = 0.022). The fully adjusted multivariable Cox regression analysis showed that the sST2/LVMI ratio was positively associated with the composite outcome in patients with heart failure with reduced ejection fraction after adjusting for confounders (hazard ratio 1.64, 95% confidence interval 1.06 to 2.54). By subgroup analysis, a stronger association was found with age between 40 and 55 years, systolic blood pressure < 115 or ≥ 129 mmHg, diastolic blood pressure < 74 mmHg, hematocrit < 44.5%, and interventricular septum thickness ≥ 8.5 mm.ConclusionIn patients with heart failure with reduced ejection fraction, the relationship between the sST2/LVMI ratio and the composite outcome was linear. A higher baseline ratio of sST2/LVMI was associated with an increased risk of cardiovascular mortality and heart failure rehospitalization in the short-term follow-up.

In-hospital Heart Rate Reduction With Beta Blockers and Ivabradine Early After Recovery in Patients With Acute Decompensated Heart Failure Reduces Short-Term Mortality and Rehospitalization.

Objective: In the past years, heart rate (HR) has emerged as a highly relevant modifiable risk factor for heart failure (HF) patients. However, most of the clinical trials so far evaluated the role of HR in stable chronic HF cohorts. The aim of this multi-center, prospective observational study was to assess the association between HR and therapy with HR modulators (beta blockers, ivabradine, or a combination of ivabradine and beta blockers) at hospital discharge with patients' cardiovascular mortality and re-hospitalization at 6 months in acutely decompensated HF patients.Materials and Methods: We recruited 289 HF patients discharged alive after admission for HF decompensation from 10 centers in northern Italy over 9 months (from April 2017 to January 2018). The primary endpoint was the combination of cardiovascular mortality or re-hospitalizations for HF at 6 months.Results: At 6 months after discharge, 64 patients were readmitted (32%), and 39 patients died (16%). Multivariate analysis showed that HR at discharge ≥ 90 bpm (OR = 8.47; p = 0.016) independently predicted cardiovascular mortality, while therapy with beta blockers at discharge was found to reduce the risk of the composite endpoint. In patients receiving HR modulators the event rates for the composite endpoint, all-cause mortality, and cardiovascular mortality were lower than in patients not receiving HR modulators.Conclusions: Heart rate at discharge ≥90 bpm predicts cardiovascular mortality, while therapy with beta blockers is negatively associated with the composite endpoint of cardiovascular mortality and hospitalization at 6 months in acutely decompensated HF patients. Patients receiving a HR modulation therapy at hospital discharge showed the lowest rate of cardiovascular mortality and re-hospitalization.

The association between ivabradine and adverse cardiovascular events in acute decompensated HFrEF patients.

AimsIvabradine has been used in patients who have chronic heart failure (HF) with reduced ejection fraction (HFrEF) and concomitant sinus heart rate ≥70 bpm. This administration for acute HFrEF remains a concern. This study used a real‐world multicentre database to investigate the effects of ivabradine among patients with acute decompensated HFrEF before discharge.Methods and resultsThis study retrospectively identified patients with acute decompensated HFrEF who were administered ivabradine at discharge from two multicentre HF databases. Propensity score matching was performed to adjust for confounders. Cardiovascular mortality, all‐cause mortality, and recurrent HF rehospitalization risks were then compared between those with and without ivabradine treatment. After 1:2 propensity score matching, 876 patients (age, 60.7 ± 14.6 years; female, 23.2%; left ventricular ejection fraction, 28.2% ± 7.8%; and heart rate at discharge, 84.3 ± 13.8 bpm) were included in the final analysis, including 292 and 584 patients with and without ivabradine treatment at discharge, respectively. No significant differences were observed in baseline characteristics between the two groups. At 1 year follow‐up, patients in the ivabradine group had significantly lower heart rates (77.6 ± 14.7 vs. 81.1 ± 16.3 bpm; P = 0.005) and lower HF severity symptoms (New York Heart Association Functional class, 2.1 ± 0.7 vs. 2.3 ± 0.9; P < 0.001) than those from the non‐ivabradine group. Ivabradine users had significantly lower risks of 1 year cardiovascular mortality (5.8 vs. 12.2 per 100‐person year; P = 0.003), all‐cause mortality (7.2 vs. 14.0 per 100‐person year; P = 0.003), and total HF rehospitalization (42.3 vs. 72.6 per 100‐person year; P < 0.001) than non‐ivabradine users. Following multivariate analysis, the predischarge prescription of ivabradine remained independently associated with lower 1 year all‐cause mortality (hazard ratio, 0.45; 95% confidence interval, 0.28–0.74; P = 0.002) and cardiovascular mortality (hazard ratio, 0.41; 95% confidence interval, 0.24–0.72; P = 0.002).ConclusionsThe current study findings suggest that ivabradine treatment is associated with reduced risks of cardiovascular mortality, all‐cause mortality, and HF rehospitalization within 1 year among patients with acute decompensated HFrEF in real‐world populations.

Prognostic implications of peak early diastolic strain rate (PEDSR) by feature-tracking cardiac magnetic resonance in patients with st-elevation myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): the National Key Research and Development Program of China OnBehalf Renji Hospital Affiliated to Medical College of Shanghai Jiaotong University Background：The prognostic value of Peak Early Diastolic Strain Rate (PEDSR) measured by Cardiac Magnetic Resonance (CMR) in ST-Elevation Myocardial Infarction (STEMI) is not clear. Methods：420 first-STEMI patients from the EARLY Assessment of MYOcardial Tissue Characteristics by CMR in STEMI (EARLY-MYO-CMR) registry (NCT03768453) and 40 normal people were enrolled and followed up. The patients received timely percutaneous coronary intervention (PCI) within 12h and CMR within 1 week (median,5 days; range, 2-7 days) after infarction. LV circumferential, radial, longitudinal PEDSR and other routine CMR parameters were measured. Clinical end point was a composite major adverse cardiovascular events (MACEs) including cardiovascular death, re-infarction and re-hospitalization for heart failure. Results：During follow-up (median: 52 months, inter-quartile range: 29–78 months), 73 (17.4%) patients experienced a MACE event. Compared with normal people, STEMI patients had lower PEDSR (circumf. PEDSR 0.77 vs. 1.27%/s, P &amp;lt; 0.001). Patients who developed MACEs also had lower PEDSR than patients who didn’t (circumf. PEDSR 0.64 vs. 0.78%/s, P &amp;lt; 0.001). Circumf. PEDSR can significantly predict MACEs with an AUC of 0.659 (95%CI 0.587-0.731, P &amp;lt; 0.001) which is not inferior to LVEF (0.659 vs. 0.651, P = 0.843), LVIS (0.659 vs. 0.661, P = 0.678) and LVMVO (0.659 vs. 0.666, P = 0.600). Circumf. PEDSR ≤ 0.665%/s is the independent predictive factor of MACEs in clinical (HR 2.099 [95%CI 1.273-3.461], P = 0.004) and CMR models (HR 1.795 [95%CI 1.065-3.026], P = 0.028). In Kaplan-Meier curve, patients with impaired PEDSR are more likely to experience MACEs (P &amp;lt; 0.001). When subdivided by LVEF, PEDSR still makes a significant difference to MACEs in patients with LVEF &amp;gt; 50.28% (P = 0.003) but not in reduced LVEF patients (P = 0.204). PEDSR is also incremental to LVEF (Continuous NRI 0.515 [95%CI 0.268-0.763], P &amp;lt; 0.001), LVIS (Continuous NRI 0.576 [95%CI 0.330-0.822], P &amp;lt; 0.001), and LVMVO (Continuous NRI 0.576 [95%CI 0.330-0.822], P &amp;lt; 0.001). Finally, worse TIMI flow post-PCI (HR 3.353 [95%CI 1.603-7.016], P = 0.001) and LVEF (HR 0.920 [95%CI 0.900, 0.940], P &amp;lt; 0.001) are the risk factors for PEDSR impairment. Conclusions：CMR-derived PEDSR can significantly predict MACEs with the discriminative power not inferior to LVEF, LVIS and LVMVO. Circumf. PEDSR ≤ 0.665%/s is an independent predictive factor of MACEs and is incremental in the prognostic risk stratification of STEMI.

MID TERM OUTCOMES IN WELLENS SYNDROME

Background. Wellens syndrome (WS) has been described as a clinical and electrocardiographic (ECG) complex that identifies a subset of patients with unstable angina (UA) at an impending risk of myocardial infarction (MI) and death in studies published almost 4 decades ago, before the wide use of cardiac biomarkers such as troponins. The mid and long term outcomes of patients with Wellens syndrome have never been compared with a contemporary cohort of patients with non-ST elevation acute coronary syndromes (NSTEACS). Objectives. The primary endpoints of our study were the rate of cardiovascular rehospitalizations, the rate of ischaemic reccurences, the rate of subsequent or reccurent revascularization and the rate of mortality at six months from the index event. Materials and methods. We performed a prospective analysis of 64 consecutive patients with WS who underwent coronary angiography and we compared them with an age and sex matched cohort of patients with NSTEACS who underwent coronary angiography. The study took place at Bagsadar-Arseni Emergency Clinical Hospital and included a total of 127 patients recruited within 2 years (from January 2018 until December 2019), who were followed for a period of 6 months. Results. Within 6 months of follow-up, patients in the control group had a significantly higher rate of cardiovascular rehospitalizations (41.9% vs. 21.9%, p = 0.016), although the rate of ischaemic recurrences was similar between the 2 groups. Other interventional end-points, such as subsequent interventional revascularization, repeat interventional revascularization and repeat target vessel revascularization (TVR) were comparable between the 2 groups at 6 months follow-up. There was no significantly difference with respect to global mortality (6.3% in WS group vs. 7.9% in the control group, p = 0.74). Discussions. To our knowledge, this is the first prospective study with mid term follow up that compared a consecutive cohort of patients with WS who underwent coronary angiography with an age and sex matched cohort of patients with NSTEACS. Patients with WS had similar event rates with respect to ischaemic recurrences, subsequent or repeat interventional revascularization and repeat target vessel revascularization (TVR) and mortality rate at 6 months, although significantly more patients in WS group were considered at low risk. Conclusions. Wellens sign is frequently overlooked in the emergency department and risk assessment based on risk scores is frequently misleading. Prompt recognition of subtle ECG ischaemic changes, such as WS, in patients with chest pain is crucial, as it reflects a large area of myocardium at risk and identifies a subgroup of patients who can benefit from early invasive management.

Incidence, Predictors, and Prognostic Impact of Immediate Improvement in Left Ventricular Systolic Function After Transcatheter Aortic Valve Implantation

Immediate improvement in left ventricular ejection fraction (LVEF) following transcatheter aortic valve implantation (TAVI) is common; however, data on the pattern and prognostic value of this improvement are limited. To evaluate the incidence, predictors, and clinical impact of immediate improvement in LVEF, we studied 694 consecutive patient who had underwent successful TAVI for severe aortic stenosis (AS) between March 2010 and December 2019. We defined immediate improvement of LVEF as an absolute increase of ≥5% in LVEF at post-procedure echocardiogram. The primary outcome was major adverse cardiac or cerebrovascular event (MACCE), defined as a composite of death from cardiovascular cause, myocardial infarction, stroke, or rehospitalization from cardiovascular cause. Among them, 160 patients showed immediate improvement in LVEF. The independent predictors of immediate LVEF improvement were absence of hypertension and baseline significant aortic regurgitation, and greater baseline LV mass index. Immediate improvement in LVEF was significantly associated with a lower risk of MACCE (adjusted hazard ratio, 0.48; 95% confidence interval, 0.28-0.81; p=0.01). In conclusion, approximately one-fourth of patients with severe AS who underwent TAVI showed immediate improvement in LVEF during index hospitalization. Immediate LVEF recovery was associated with a lower risk of MACCE during follow-up.

Efficacy and safety of left bundle branch area pacing versus right ventricular apex pacing in patients with atrioventricular block: study protocol for a randomised controlled trial

IntroductionLeft bundle branch area pacing (LBBaP) is a relatively new approach for physiologic pacing. A limited number of retrospective clinical studies, featuring small sample sizes, have shown that compared with...

Early diuretic strategies and the association with In-hospital and Post-discharge outcomes in acute heart failure

Decongestion is a primary goal during hospitalizations for decompensated heart failure (HF). However, data surrounding the preferred route and strategy of diuretic administration are limited with varying results in prior studies. This is a retrospective analysis using patients from ASCEND-HF with a stable diuretic strategy in the first 24 hours following randomization. Patients were divided into three groups: intravenous (IV) continuous, IV bolus and oral strategy. Baseline characteristics, in-hospital outcomes, 30-day composite cardiovascular mortality or HF rehospitalization and 180-day all-cause mortality were compared across groups. Inverse propensity weighted modeling was used for adjustment. Among 5,738 patients with a stable diuretic regimen in the first 24 hours (80% of overall ASCEND trial), 3,944 (68.7%) patients received IV intermittent bolus administration of diuretics, 799 (13.9%) patients received IV continuous therapy and 995 (17.3%) patients with oral administration. Patients in the IV continuous group had a higher baseline creatinine (IV continuous 1.4 [1.1-1.7]; intermittent bolus 1.2 [1.0-1.6]; oral 1.2 [1.0-1.4] mg/dL; P <0.001) and high NTproBNP (IV continuous 5,216 [2,599-11,603]; intermittent bolus 4,944 [2,339-9,970]; oral 3,344 [1,570-7,077] pg/mL; P <0.001). There was no difference between IV continuous and intermittent bolus group in weight change, total urine output and change in renal function till 10 days/discharge (adjusted P >0.05 for all). There was no difference in 30 day mortality and HF readmission (adjusted OR 1.08 [95%CI: 0.74, 1.57]; P=0.701) and 180 days mortality (adjusted OR 1.04 [95%CI: 0.75, 1.43]; P=0.832). In a large cohort of patients with decompensated HF, there were no significant differences in diuretic-related in-hospital, or post-discharge outcomes between IV continuous and intermittent bolus administration. Tailoring appropriate diuretic strategy to different states of acute HF and congestion phenotypes needs to be further investigated.

MMMELD-XI Score Is Associated With Short-Term Adverse Events in Patients With Heart Failure With Preserved Ejection Fraction.

Aim: Accumulating evidence suggests that MELD-XI score holds the ability to predict the prognosis of congestive heart failure. However, most of the evidence is based on the end-stage heart failure population; thus, we aim to explore the association between the MELD-XI score and the prognosis in heart failure with preserved ejection fraction (HFpEF).Methods: A total of 30,096 patients hospitalized for HFpEF in Fujian Provincial Hospital between January 1, 2014 and July 17, 2020 with available measures of creatinine and liver function were enrolled. The primary endpoint was 60-day in-hospital all-cause mortality. Secondary endpoints were 60-day in-hospital cardiovascular mortality and 30-day rehospitalization for heart failure.Results: A total of 222 patients died within 60 days after admission, among which 75 deaths were considered cardiogenic. And 73 patients were readmitted for heart failure within 30 days after discharge. Generally, patients with an elevated MELD-XI score tended to have more comorbidities, higher NYHA class, and higher inflammatory biomarkers levels. Meanwhile, the MELD-XI score was positively correlated with NT-pro BNP, left atrial diameter, E/e' and negatively correlated with LVEF. After adjusting for conventional risk factors, the MELD-XI score was independently associated with 60-day in-hospital all-cause mortality [hazard ratio(HR) = 1.052, 95% confidential interval (CI) 1.022–1.083, P = 0.001], 60-day in-hospital cardiovascular mortality (HR = 1.064, 95% CI 1.013–1.118, P = 0.014), and 30-day readmission for heart failure (HR = 1.061, 95% CI 1.015–1.108, P = 0.009). Furthermore, the MELD-XI score added an incremental discriminatory capacity to risk stratification models developed based on this cohort.Conclusion: The MELD-XI score was associated with short-term adverse events and provided additional discriminatory capacity to risk stratification models in patients hospitalized for HFpEF.

Healthcare utilization after cryoballoon ablation for treatment of atrial fibrillation in patients with heart failure: real-world results from the Cryo AF Global Registry

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Medtronic, Inc. OnBehalf Cryo AF Global Registry Investigators Background Heart failure (HF) concomitant to atrial fibrillation (AF) can exacerbate the risk of hospitalization, morbidity, mortality, and impairment in quality of life posed by each condition alone. While the reciprocal relationship between HF and AF challenges effective treatment for these patients, catheter ablation for treatment of AF is reasonable for select patients with AF and HF according to guidelines. Purpose: Assess real-world usage and healthcare utilization outcomes of cryoablation for patients with AF and HF. Methods: The Cryo AF Global Registry (NCT02752737) is an ongoing, prospective, multicenter registry. Patients with AF were enrolled and treated with cryoballoon ablation (Arctic Front Advance, Medtronic) according to clinical practice at 56 sites in 26 countries world-wide. Subjects with NYHA class I-III at baseline comprised the HF cohort and were compared to patients without HF (No-HF). Freedom from atrial arrhythmia recurrence ≥30 sec, adverse events associated with the AF ablation procedure, repeat ablations, AAD usage, and cardiovascular rehospitalization over a 12-month follow-up were compared between cohorts. Results: A total of 1,303 patients (318 HF, 985 No-HF) were included. The HF cohort included patients with NYHA Class I (56.3%) and II/III (43.7%) with either preserved (81.6%) or mid/reduced (18.4%) left ventricular ejection fraction. HF patients were more often female (45.6% vs 33.6%) with persistent AF (25.8% vs 14.3%), larger left atrial diameter (4.4 ± 0.9 vs 4.0 ± 0.7 cm), and higher rates of hypertension (67.9% vs 49.1%) and prior myocardial infarction (3.8% vs 1.7%; all, P &amp;lt; 0.05). The rate of serious procedure-related complications was 5.3% in HF and 3.0% in No-HF (P = 0.08). Freedom from atrial arrhythmia recurrence at 12-months was not different between HF and No-HF patients with either paroxysmal (84.2% (95% CI:78.6-88.4) vs 86.8% (95% CI: 84.2 – 89.0)) or persistent AF (69.6% (95% CI: 58.1 – 78.5) vs 71.8% (95% CI: 63.2-78.7)), respectively (p = 0.32, HF vs No-HF). AF-related symptoms and antiarrhythmic drug use were significantly reduced after cryoablation in the HF and No-HF cohorts (P &amp;lt; 0.05). Freedom from repeat ablation at 12-months was similar between HF and No-HF patients. Of patients who had a cardiovascular rehospitalization after cryoablation, 78% presented with a supraventricular tachyarrhythmia. Persistent AF and HF at baseline both increased the risk of cardiovascular rehospitalization after cryoballoon ablation (P &amp;lt; 0.05). Conclusion: Cryoablation is used to treat patients with AF and concomitant HF in real-world practice and is similarly safe and effective at 12-months in patients with and without HF.

Clinical phenogroups are more effective than left ventricular ejection fraction categories in stratifying heart failure outcomes.

AimsHeart failure (HF) guidelines place patients into 3 discrete groups according to left ventricular ejection fraction (LVEF): reduced (<40%), mid‐range (40–49%), and preserved LVEF (≥50%). We assessed whether clinical phenogroups offer better prognostication than LVEF.Methods and resultsThis was a sub‐study of the Patient‐Centered Care Transitions in HF trial. We analysed baseline characteristics of hospitalized patients in whom LVEF was recorded. We used unsupervised machine learning to identify clinical phenogroups and, thereafter, determined associations between phenogroups and outcomes. Primary outcome was the composite of all‐cause death or rehospitalization at 6 and 12 months. Secondary outcome was the composite cardiovascular death or HF rehospitalization at 6 and 12 months. Cluster analysis of 1693 patients revealed six discrete phenogroups, each characterized by a predominant comorbidity: coronary heart disease, valvular heart disease, atrial fibrillation (AF), sleep apnoea, chronic obstructive pulmonary disease (COPD), or few comorbidities. Phenogroups were LVEF independent, with each phenogroup encompassing a wide range of LVEFs. For the primary composite outcome at 6 months, the hazard ratios (HRs) for phenogroups ranged from 1.25 [95% confidence interval (CI) 1.00–1.58 for AF] to 2.04 (95% CI 1.62–2.57 for COPD) (log‐rank P < 0.001); and at 12 months, the HRs for phenogroups ranged from 1.15 (95% CI 0.94–1.41 for AF) to 1.87 (95% 1.52–3.20 for COPD) (P < 0.002). LVEF‐based classifications did not separate patients into different risk categories for the primary outcomes at 6 months (P = 0.69) and 12 months (P = 0.30). Phenogroups also stratified risk of the secondary composite outcome at 6 and 12 months more effectively than LVEF.ConclusionAmong patients hospitalized for HF, clinical phenotypes generated by unsupervised machine learning provided greater prognostic information for a composite of clinical endpoints at 6 and 12 months compared with LVEF‐based categories.Trial Registration: ClinicalTrials.gov Identifier: NCT02112227