Chronic Diastolic Heart Failure Research Articles

Impact of congestive heart failure on patients undergoing lumbar spine fusion for adult spine deformity.

With the increasing amount of elective spine fusion patients presenting with cardiac disease and congestive heart failure, it is becoming difficult to assess when it is safe to proceed with surgery. Assessing the severity of heart failure (HF) through ejection fraction may provide insight into patients' short- and long-term risks. The purpose of this study was to assess the severity of HF on perioperative outcomes of spine fusion surgery patients. This was a retrospective cohort study of the PearlDiver database. We enrolled 670,526 patients undergoing spine fusion surgery. Thirty-day and 90-day complication rates, discharge destination, length of stay (LOS), physician reimbursement, and hospital costs. Patients undergoing elective spine fusion surgery were isolated and stratified by preoperative HF with preserved ejection fraction (P-EF) or reduced ejection fraction (R-EF) (International Classification of Diseases-9: 428.32 [chronic diastolic HF] and 428.22 [chronic systolic HF]). Means comparison tests (Chi-squared and independent samples t-tests, as appropriate) compared differences in demographics, diagnoses, comorbidities, procedural characteristics, LOS, 30-day and 90-day complication outcomes, and total hospital charges between those diagnosed with P-EF and those not R-EF. Binary logistic regression assessed the odds of complication associated with HF, controlling for levels fused (odds ratio [OR] [95% confidence interval]). Statistical significance was set at P < 0.05. Totally 670,526 elective spine fusion patients were included. Four thousand and seventy-seven were diagnosed with P-EF and 2758 R-EF. Overall, P-EF patients presented with higher rates of morbid obesity, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus, and hypertension (all P < 0.001). In relation to No-HF, P-EF patients had higher rates of 30-day major complications including pulmonary embolism, pneumonia, cerebrovascular accident (CVA), myocardial infarctions (MI), sepsis, and death (all P < 0.001). Furthermore, P-EF was associated significantly with increased odds of pneumonia (OR: 2.07 [1.64-2.56], P < 0.001) and sepsis (OR: 2.09 [1.62-2.66], P < 0.001). Relative to No-HF, R-EF was associated with significantly higher odds of MI (OR: 3.66 [2.34-5.47]), CVA (OR: 2.70 [1.67-4.15]), and pneumonia (OR: 1.85 [1.40-2.40]) (all P < 0.001) postoperative within 30 days. Adjusting for prior history of MI, CAD, and the presence of a pacemaker R-EF was a significant predictor of an MI 30 days postoperatively (OR: 2.2 [1.14-4.32], P = 0.021). Further adjusting for history of CABG or stent placement, R-EF was associated with higher odds of CVA (OR: 2.11 [1.09-4.19], P = 0.028) and MI (OR: 2.27 [1.20-4.43], P = 0.013). When evaluating the severity of HF before spine surgery, R-EF was associated with a higher risk of major complications, especially the occurrence of a myocardial infarction 30 days postoperatively. During preoperative risk assessment, congestive HF should be considered thoroughly when thinking of postoperative outcomes with emphasis on R-EF.

Endovascular Management of External Iliac “Snowplowing” Using “Reverse Snowplow” Technique During Transcatheter Aortic Valve Replacement

This case describes an 84-year-old female with chronic diastolic heart failure, coronary artery disease status post coronary artery bypass and percutaneous coronary intervention, hypertension, diabetes mellitus and chronic kidney disease stage III, who presented with progressive dyspnea found to have severe aortic stenosis demonstrated by echocardiogram (aortic valve area, .06 ^cm2; mean gradient, 42 mm Hg). She was evaluated by the Heart Team and deemed to be a candidate for a transfemoral transcatheter aortic valve replacement (TAVR) after computed tomography angiography (CTA) evaluation. During insertion of the valve sheath through the external iliac, intimal “snowplowing” occurred resulting in complete occlusion of the iliac artery. The intima was successfully milked back into anatomical position using a “reverse snowplow” technique. Extravasation was managed with covered stents. The patient recovered over several days and was discharged home on post-procedure day 7. When appropriate, Endovascular management of vascular complications avoids the morbidity associated with open repair. Pre-operative evaluation is imperative in identifying anatomical features that pose a risk to vascular complications. This patient had an increased risk with an elevated iliofemoral tortuosity score, however, had minimal calcification and no acute angulation in the iliofemoral arterial system. This case highlights the complexity of vascular complication management and difficulty faced in identifying patients who are at risk for these types of complications.

Influence of bisoprolol and nebivolol on the regulatory-adaptive status of patients with diastolic chronic heart failure

Background. Chronic heart failure (CHF) is the most common outcome of cardiovascular disease, of hypertension disease (HD). Beta-blockers contribute to the correction of hypertension, reduce heart remodeling, slow the progression of CHF. At the same time, bisoprolol and nebivolol differing pharmacochemical properties can have a multidirectional effect on the regulatory-adaptive status (RAS).&#x0D; Aim. To determine the effect of bisoprolol or nebivolol therapy on the RAS of patients with diastolic CHF on the background of HD III stage.&#x0D; Material and methods. The study involved 68 patients with diastolic CHF who were randomized into two groups for treatment with bisoprolol or nebivolol. As part of the combination therapy, patients were administered quinapril was prescribed (13.52.5 mg/day, n=34 and 12.82.8 mg/day, n=34), and if indicated, acetylsalicylic acid, atorvastatin. Initially and after 24 weeks of therapy were carried out: quantitative assessment of RAS, echocardiography, treadmill test, six-minute walking test, subjective assessment of quality of life, determination of the level of N-terminal propeptide of brain natriuretic hormone in blood plasma, daily monitoring of blood pressure.&#x0D; Results. Both schemes of combined therapy comparably improved the structural and functional state of the heart, controlled arterial hypertension. In comparison with bisoprolol, nebivolol differed positive impact on RAS, more increased tolerance to physical activity and improved quality of life.&#x0D; Conclusion. In patients with diastolic CHF and HD III stage, the use of nebivolol in combination therapy may be preferable due to the positive effect on RAS, in comparison with bisoprolol.

In-hospital mortality rate and predictors of 30-day readmission in patients with iron deficiency anemia and diastolic heart failure: A cross-sectional study

Introduction: There is currently strong evidence of the adverse effects of anemia on the prognosis of heart failure with reduced ejection fraction. Unfortunately, the data on the effects of anemia on a large sample of patients with diastolic heart failure (DHF) is lacking. In this study, we aimed to evaluate the effect of iron deficiency anemia on DHF readmission rates and its corresponding causes and burdens on the healthcare system. Methods: We utilized 2018 Nationwide readmission data and included patients aged ≥18 years with ICD-10 CM code indicating acute or acute chronic diastolic heart failure and iron deficiency anemia was included in the study. The primary outcome is 30-day readmission rates. Secondary outcomes were mortality rates, common causes of readmission, and healthcare utilization. Independent predictors for readmission were identified using cox regression analysis. Results: The total number of admissions in our study was 795,777. The mean age was 74.4 years (SD=13.7), and 63.54% were females. The 30-day readmission rate in patients with diastolic heart failure and iron deficiency anemia was 18.32 % vs. 16.01% in patients without anemia. The mortality rate at index admission and readmission was 3.62 % (2601) and 5.82 % (737), respectively. The most common cause of readmission was hypertensive heart and kidney disease with heart failure (17.74%). The independent predictors of readmission were age&lt;85 years, household income &lt;59000$/per year, Medicare and Medicaid insurance, higher Elixhauser comorbidities score, longer Length of stay during the index admission, discharge to a nursing home, hospital located in a large metropolitan area. The financial burden on healthcare for all the readmission was $837 million for 2018. Conclusion: The 30-day readmission rate in patients with diastolic heart failure and iron deficiency anemia is 18.32% in the year 2018. The mortality rate increased from 3.62 % to 5.82 % with readmission. The financial burden for readmission during that year was $837 million. Future studies are warranted to treat iron deficiency anemia to prevent readmissions in diastolic heart failure.

Thirty-day readmission in patients with heart failure with preserved ejection fraction: Insights from the nationwide readmission database.

BACKGROUNDThere are rising numbers of patients who have heart failure with preserved ejection fraction (HFpEF). Poorly understood pathophysiology of heart failure with preserved and reduced ejection fraction and due to a sparsity of studies, the management of HFpEF is challenging.AIMTo determine the hospital readmission rate within 30 d of acute or acute on chronic heart failure with preserved ejection fraction and its effect on mortality and burden on health care in the United States.METHODSWe performed a retrospective study using the Agency for Health-care Research and Quality Health-care Cost and Utilization Project, Nationwide Readmissions Database for the year 2017. We collected data on hospital readmissions of 60514 adults hospitalized for acute or acute on chronic HFpEF. The primary outcome was the rate of all-cause readmission within 30 d of discharge. Secondary outcomes were cause of readmission, mortality rate in readmitted and index patients, length of stay, total hospitalization costs and charges. Independent risk factors for readmission were identified using Cox regression analysis. RESULTSThe thirty day readmission rate was 21%. Approximately 9.17% of readmissions were in the setting of acute on chronic diastolic heart failure. Hypertensive chronic kidney disease with heart failure (1245; 9.7%) was the most common readmission diagnosis. Readmitted patients had higher in-hospital mortality (7.9% vs 2.9%, P = 0.000). Our study showed that Medicaid insurance, higher Charlson co-morbidity score, patient admitted to a teaching hospital and longer hospital stay were significant variables associated with higher readmission rates. Lower readmission rate was found in residents of small metropolitan or micropolitan areas, older age, female gender, and private insurance or no insurance were associated with lower risk of readmission.CONCLUSIONWe found that patients hospitalized for acute or acute on chronic HFpEF, the thirty day readmission rate was 21%. Readmission cases had a higher mortality rate and increased healthcare resource utilization. The most common cause of readmission was cardio-renal syndrome.

PO-712-03 RATE OF 30-DAY READMISSION AND ECONOMIC BURDEN IN PATIENTS WITH SICK SINUS SYNDROME WITH COEXISTING CHRONIC DIASTOLIC HEART FAILURE WHO UNDERWENT PACEMAKER INSERTION

Patients with Chronic Diastolic Heart Failure (cDHF) have multiple risk factors & can develop conduction disturbances that necessitate pacemaker insertion (PMI). Heart failure outcomes after PMI are poorly understood. We sought to determine the 30-Day Readmission rate (30-DRr) & outcomes of patients with Sick Sinus Syndrome (SSS) with co-existing cDHF who underwent PMI. Using the 2017 & 2018 National Readmission Database, we conducted a retrospective analysis of patient discharges with SSS who underwent pacemaker insertion as a principal diagnosis and cDHF as a secondary diagnosis. Readmission was defined as the first admission to any hospital within 30 days of the index admission. Same-day admissions and discharges excluded. The primary outcome was 30DRr, while secondary outcomes were readmission mortality rate, most common diagnoses for readmission, and resource utilization defined by length of stay (average and total), patient charge (average and total), and total hospital cost (average and total). There was a total of 9,441 index hospitalization for SSS with coexisting cDHF who underwent pacemaker insertion &; the mean age was 79.7 yrs. & 62.9% of patients were females. In-hospital mortality rate for index admission was 1.05%, while 30-DRr was 10.8% (Figure 1). Among this group of readmitted patients, In-hospital mortality rate was 4.4%, compared to index admission(4.4% vs. 1.05%, adjusted p=0.004, OR; 3.4, CI; 1.5-7.8). The total hospital days associated with readmission were 5,368 days, with a total hospital cost of $12,100,000 & a total patient's economic burden of $49,100,000. Patients admitted for SSS with coexisting cDHF who underwent PMI showed a high readmission rate with increased mortality. In addition, coexisting chronic kidney disease (CKD), atrial fibrillation, chronic right ventricular pacing, valvular disease, cardiac amyloid, ischemic heart disease may contribute to a greater risk of DHF. Risk factor modification & SGLT2i may lower the risk of HF & readmission.

Reverse Septal Contour On Cardiac Magnetic Resonance Imaging- A Mimicker Of Hypertrophic Cardiomyopathy In Transthyretin Cardiac Amyloidosis

Introduction Transthyretin cardiac amyloidosis (ATTR) causes cardiomyopathy secondary to extracellular deposition of transthyretin protein in the heart muscle. Clinical Presentation An 86-year-old man with chronic diastolic heart failure and a recent transcatheter aortic valve replacement (TAVR) (26 mm Edwards Sapien 3 Bioprosthesis) for severe symptomatic aortic stenosis was seen in the TAVR clinic for a follow-up visit. The examination was consistent with mild volume overload. EKG showed an irregular rhythm with left axis deviation. A previous transthoracic echocardiogram showed biventricular hypertrophy with normal biventricular size and ejection fraction. For concerns of restrictive cardiomyopathy, a cardiac MRI (C-MRI) was performed which showed biventricular systolic dysfunction and right ventricular (RV) hypertrophy confirmed via RV mass index. Furthermore, tau inversion recovery imaging was normal (no intramyocardial edema). In addition, reverse septal hypertrophy of the interventricular septum (IVS) (wall thickness of 22 mm) and LV end-diastolic volume 175.61 ml, classically seen in hypertrophic cardiomyopathy patients was observed (Image 1A). Discussion The patient was diagnosed with cardiac amyloidosis based on a diminished longitudinal excursion of the basal segments, marked biventricular transmural homogenous and global amorphous Late Gadolinium Enhancement (LGE), and rapid LGE washout (Image 1 (B-C)). The diagnosis was supported by a positive via 99mTc-PYP scan and normal immunofixation electrophoresis. The patient was started on tafamidis. Transthyretin cardiac amyloidosis (ATTR) causes cardiomyopathy secondary to extracellular deposition of transthyretin protein. CMRI is used for tissue characterization and phenotyping of cardiomyopathies. CMRI methodologies such as T1 mapping, LGE, and basal-apical contractile gradient/longitudinal strain can differentiate HCM phenocopies such as ATTR amyloidosis from a typical HCM phenotype showing reverse septal contour and help in decision making and guide management Conclusion Newer imaging techniques in Cardiac MRI have helped increase diagnostic accuracy in patients with suspected cardiac amyloidosis. This has led to an increase in noninvasive diagnosis of the disease at an earlier stage which helps with prompt management. Transthyretin cardiac amyloidosis (ATTR) causes cardiomyopathy secondary to extracellular deposition of transthyretin protein in the heart muscle. An 86-year-old man with chronic diastolic heart failure and a recent transcatheter aortic valve replacement (TAVR) (26 mm Edwards Sapien 3 Bioprosthesis) for severe symptomatic aortic stenosis was seen in the TAVR clinic for a follow-up visit. The examination was consistent with mild volume overload. EKG showed an irregular rhythm with left axis deviation. A previous transthoracic echocardiogram showed biventricular hypertrophy with normal biventricular size and ejection fraction. For concerns of restrictive cardiomyopathy, a cardiac MRI (C-MRI) was performed which showed biventricular systolic dysfunction and right ventricular (RV) hypertrophy confirmed via RV mass index. Furthermore, tau inversion recovery imaging was normal (no intramyocardial edema). In addition, reverse septal hypertrophy of the interventricular septum (IVS) (wall thickness of 22 mm) and LV end-diastolic volume 175.61 ml, classically seen in hypertrophic cardiomyopathy patients was observed (Image 1A). The patient was diagnosed with cardiac amyloidosis based on a diminished longitudinal excursion of the basal segments, marked biventricular transmural homogenous and global amorphous Late Gadolinium Enhancement (LGE), and rapid LGE washout (Image 1 (B-C)). The diagnosis was supported by a positive via 99mTc-PYP scan and normal immunofixation electrophoresis. The patient was started on tafamidis. Transthyretin cardiac amyloidosis (ATTR) causes cardiomyopathy secondary to extracellular deposition of transthyretin protein. CMRI is used for tissue characterization and phenotyping of cardiomyopathies. CMRI methodologies such as T1 mapping, LGE, and basal-apical contractile gradient/longitudinal strain can differentiate HCM phenocopies such as ATTR amyloidosis from a typical HCM phenotype showing reverse septal contour and help in decision making and guide management Newer imaging techniques in Cardiac MRI have helped increase diagnostic accuracy in patients with suspected cardiac amyloidosis. This has led to an increase in noninvasive diagnosis of the disease at an earlier stage which helps with prompt management.

Pulmonary Hypertension and Diastolic Heart Failure in an Adolescent African-American Cantú Syndrome Patient

<h3>Introduction</h3> Cantú syndrome is a rare congenital condition characterized by hypertrichosis, coarse facial features, cardiomegaly, skeletal abnormalities, and tortuous vasculature. While progress has been made in the understanding of the molecular basis of this disease, there is still much to be uncovered regarding its natural history. Here, we present the clinical course of an African-American male with Cantú syndrome. <h3>Case Report</h3> A 4-month-old African-American male presented to the hospital with respiratory distress. A large pericardial effusion was identified, which required a pericardial window. Cardiac catheterization revealed pulmonary hypertension. At age 4, a diagnosis of Cantú syndrome was made on the basis of developmental delay, cardiomegaly, history of pericardial effusion, pulmonary hypertension, coarse facial features, hypertrichosis, wide/thickened ribs, and osteopenia. He developed chronic diastolic heart failure secondary to cardiomegaly and chronic hypercarbic respiratory failure requiring home oxygen and nocturnal bi-level positive airway pressure (BiPAP) therapy. Pulmonary hypertension treatment was initiated with sildenafil at age 13, resulting in significant improvement in exercise tolerance. Cardiac catheterization at 17 years of age demonstrated worsening pulmonary hypertension with baseline RV pressures of 85/18 mmHg and pulmonary artery (PA) pressures of 85/40 mmHg. Baseline pulmonary vascular resistance (PVR) was 15.7 Woods Units/m2. Vasoreactivity to O2 and inhaled nitric oxide was demonstrated with PVR decreasing to 6.6 and 5.5 Woods Units/m2 respectively. Carvedilol and cardiac rehabilitation therapy were initiated at age 19. On a recent admission, he required milrinone support due to worsening right ventricular (RV) dysfunction which was weaned prior to discharge. <h3>Summary</h3> Cantú syndrome is a rare genetic condition and its prevalence and prognosis are still unknown. Interestingly, nearly all patients in the International Cantú Syndrome Registry are Caucasian while our patient is African-American. Additionally, with no family history of the disease, it is possible that his case represents a sporadic mutation. Unfortunately, our patient exhibited progressive heart failure, pulmonary hypertension, and hypercarbic respiratory failure during his adolescent years.

Abstract 8889: Predictors of 30-Day Readmission in Nonagenarians Presenting With Acute Diastolic Heart Failure: Nationwide Analysis

Background: Acute diastolic heart failure (DHF) is a common but poorly studied diagnosis in hospitalized nonagenarians. Objective: To identify predictors of 30-day readmission in nonagenarians hospitalized with acute DHF. Methods: We queried National Readmission Database (NRD) of years 2016-2018 for patients aged 90 or above admitted with acute or acute on chronic DHF. ICD-10 was used to identify diagnoses. We excluded patients discharged in December and those who died in index admission. Univariate regression was performed on each variable. Variables with p value of &lt; 0.2 were included in our multivariate regression model (figure 1). Results: From a total of 45393 index admissions, 43646 (96.2%) survived to discharge. A total of 7437 (16.4%) patients had a 30-day readmission. Mean cost of readmission was 43265 USD per patient. Significant predictors of 30-day readmission were chronic ischemic heart disease (OR=1.11, 95%CI [1.01-1.22], P=0.023), chronic kidney disease stage 3 or above (OR=1.19, 95%CI [1.07-1.34], P=0.002), complicated diabetes (OR=1.22, 95%CI [1.07-1.38], P=0.003), and length of stay (LOS) &gt; 2 days (OR=1.20, 95% CI [1.09-1.32], P=0.000). Female sex (OR=0.90, 95% CI [0.83-0.99], P=0.030) and palliative care visit (OR=0.27, 95% CI [0.21-0.34], P=0.000) were associated with lower odds of readmission. Conclusion: In nonagenarians hospitalized with acute DHF, 30-day readmission is common and costly. Chronic comorbidities and LOS &gt;2 days were predictors of readmission. Palliative care visit was strongly associated with lower risk of readmission. Further strategies need to be developed to improve the quality of care and prevent readmission in this age group.

In hospital mortality and outcomes of patients with acute decompensated diastolic heart failure with and without amyloidosis

Abstract Introduction The incidence of heart failure has exponentially increased over the last few decades and acute decompensated diastolic heart failure is one of the leading causes of hospitalization and readmission. Cardiac amyloidosis is one of the rapidly progressing heart conditions. It occurs due to amorphous proteinaceous material called amyloid into the extracellular space of the heart. The infiltration of the heart from amyloid protein has a broad spectrum of presentation, including diastolic heart failure. Purpose Heart failure due to amyloidosis is characterized by diastolic dysfunction resulting from restrictive cardiomyopathy. The outcomes of hospitalized patient with acute decompensated diastolic heart failure in amyloidosis patients compared to those without amyloidosis is not well defined. Methods We conducted a retrospective cohort study by utilizing the National Inpatient sample database from 2017. Using International Classification of disease (ICD)-10 codes, patients with the diagnosis of acute and acute on chronic diastolic heart failure were enrolled in the study. They were further stratified based on the presence of amyloidosis. The primary outcome was to measure in-hospital mortality, while secondary outcomes included development of acute kidney injury (AKI), Acute respiratory failure (ARF), shock and arrhythmias. Results Out of the 915,694 patients with Acute Decompensated diastolic heart failure, about 2270 had amyloidosis as secondary diagnosis. 6.1% of ADHF and amyloidosis died in hospital, compared to 4.2% in those without amyloidosis (aOR=1.35 CI=0.89–2.05, p=0.197). On multivariate analysis, patients with Amyloidosis had increased odds of developing AKI (aOR=1.40 CI 1.13–1.72, p=0.001), Cardiogenic shock (aOR=2.67 CI 1.56–4.55, p&amp;lt;0.001) and arrhythmias (aOR=1.34, CI 1.10–1.64, p=0.004). The incidence of ARF was however lower in patients without amyloidosis compared to those with it (aOR=0.60, CI 0.47–0.75, p&amp;lt;0.001). Conclusion Amyloidosis is one of the underappreciated and underdiagnosed causes of heart failure. Our study shows an increased risk of complications in acute decompensated heart failure with the presence of amyloidosis. Thus, physicians must be aware of this clinical entity for early diagnosis as patients with advanced disease are likely to have poor prognoses. Funding Acknowledgement Type of funding sources: None.

COVID-19 INFECTION IN A PATIENT WITH HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: As we navigate through the Covid pandemic, there is emerging evidence of cardiac injury related to Covid-19 infection such as myocardial ischemia, arrhythmia and pericardial effusion. Studies have associated Covid-19 related cardiac injury with a 5-fold increase in the risk of mechanical ventilation and 14 times higher mortality rate(1). In the presence of cardiac co-morbidities, Covid-19 related all-cause mortality rate increases. We present a case of Covid-19 infection in a patient with Hypertrophic Obstructive Cardiomyopathy (HCM) intending to discuss its sequelae. CASE PRESENTATION: A 72-year old male presented to ER with 2 days history of non-productive cough and dyspnea. Six months ago, he was hospitalized for 8 days with respiratory failure secondary to Covid-19 pneumonia. He was treated with remdesivir, ceftriaxone, azithromycin and dexamethasone. His past history was significant for HCM status post AICD placement, chronic diastolic heart failure with ejection fraction of 55% and hypertension.On presentation, he was hypotensive at 83/50, with a heart rate of 58 and saturation of 94% on room air. His WBC count was elevated at 12.2. Chest x-ray revealed right basal infiltrate with bilateral small pleural effusions. His presentation ECG revealed new onset atrial fibrillation (AF). Covid PCR test was negative. He was admitted to intensive care unit for vasopressor support for management of septic shock secondary to pneumonia.Therapeutic dose of enoxaparin was initiated in view of AF with CHA2DS2VASC score of 3. Echocardiogram showed mild concentric left ventricular hypertrophy with ejection fraction of 55-60%. Significant left ventricular outflow tract gradient consistent with HCM was noted. Due to worsening of bilateral pleural effusions, bilateral thoracocentesis was performed separately draining 650ml of hemorrhagic fluid on the left and 800ml of hemorrhagic fluid on the right. Pleural fluid (PF) analysis was exudative and cytology was negative. Re-accumulation of PF warranted bilateral chest drain placement. PF culture remained negative. Unfortunately, patient had recurrent hypovolemic shock and he opted for comfort care measures. DISCUSSION: ACE2 receptor in the respiratory epithelium serves as the entry portal for the SARS-CoV-2 virus. In patients with HCM, there is up-regulation of ACE2 expression causing a 5-fold increase in ACE2 protein in sarcomeres, thereby increasing susceptibility to cardiac complications (2). Our patient in discussion had new onset AF, on the background of HCM. CONCLUSIONS: Reports indicate an increased incidence of cardiac complications in HCM patients with Covid-19 infection such as arrhythmia, as in our patient. AF in the setting of underlying HCM, can be explained by ACE2 protein up-regulation. Physicians managing HCM patients should well be aware of increased risk of such complications. REFERENCE #1: Toloui A, Moshrefiaraghi D, Madani Neishaboori A, Yousefifard M, Haji Aghajani M. Cardiac Complications and Pertaining Mortality Rate in COVID-19 Patients;a Systematic Review and Meta-Analysis. Arch Acad Emerg Med. 2021 Feb 13;9(1):e18. doi: 10.22037/aaem.v9i1.1071. PMID: 33870205;PMCID: PMC8035700. REFERENCE #2: Bos JM, Hebl VB, Oberg AL, Sun Z, Herman DS, Teekakirikul P, Seidman JG, Seidman CE, Dos Remedios CG, Maleszewski JJ, Schaff HV, Dearani JA, Noseworthy PA, Friedman PA, Ommen SR, Brozovich FV, Ackerman MJ. Marked Up-Regulation of ACE2 in Hearts of Patients With Obstructive Hypertrophic Cardiomyopathy: Implications for SARS-CoV-2-Mediated COVID-19. Mayo Clin Proc. 2020 Jul;95(7):1354-1368. doi: 10.1016/j.mayocp.2020.04.028. Epub 2020 Apr 28. PMID: 32448590;PMCID: PMC7186205. DISCLOSURES: No relevant relationships by Khushdeep Chahal, source=Web Response No relevant relationships by Sangeetha Isaac, source=Web Response No relevant relationships by Kavitha Juvvala, source=Web Response No relevant relationships by Eileen Montalvan, source=Web Response No relevant relationships by Utibe Ndebbio, source=Web Response No relevant relationships by Mohammed Afraz Pasha, source=Web Response

Eff ect of nebivolol and carvedilol on the functional state of patients with chronic heart failure and preserved left ventricular ejection fraction

Objective. Compare the eff ect of combination therapy with nebivolol or carvedilol on the functional state of patients with chronic heart failure (CHF) and preserved ejection fraction (pEF) of the left ventricle (LV). Material and methods. The study involved 80 patients with diastolic CHF, who were randomized into two groups. In group I was appointed of nebivolol (7.7 ± 2.4 mg/day, n = 40), in group II — carvedilol (30.5 ± 8.7 mg/day, n = 40). As part of the combination therapy, quinapril was prescribed (13.7 ± 2.7 mg/day, n = 40 and 13.5 ± 2.6 mg/day, n = 40), and if indicated — atorvastatin (15.3 ± 4.6 mg/day, n = 17 and 16.2 ± 5.2 mg/day, n = 17) and acetylsalicylic acid in the intestinal soluble shell (96.4 ± 13.4 mg/day, n = 14 and 93.8 ± 13.3 mg/day, n = 13), respectively. Initially and after 6 months of therapy were carried out: quantitative assessment of regulatory-adaptive status (RAS) (by means of a sample of cardiac-respiratory synchronism), echocardioscopy, treadmill test, test with a six-minute walk, subjective assessment of quality of life, determination of the level of the N-terminal fragment of the brain natriuretic peptide in blood plasma, daily monitoring of blood pressure. Results. Both schemes of combined therapy comparably improved the structural and functional state of the heart, controlled arterial hypertension. In comparison with carvedilol, nebivolol diff ered positive eff ect on the RAS, more increased tolerance to physical activity and improved quality of life. Conclusion. In patients with CHF pEF LV in combination therapy, the use of nebivolol, in comparison with carvedilol, may be preferable due to the more pronounced positive eff ect on the functional state.

Serum levels of cardiotrophin-1 in patients with obstructive hypertrophic cardiomyopathy and in patients with severe left ventricular dysfunction

Relevance. Cardiotrophin-1 (CT-1) is a member of interleukin-6 (IL-6) superfamily and is associated with cardiovascular pathology. The production of CT-1 increases in response to myocardial wall stretching and increase in its rigidity and is also modulated by a wide range of neurohormones and peptides, which allows to monitor CT-1 as a marker of biomechanical stress. However, the prognostic significance of CT-1 in patients with diastolic heart failure with hypertrophic cardiomyopathy (HCM) remains poorly understood.Objective. To study the blood serum cardiotrophin-1 contents and their relationships with NT-proBNP in patients with obstructive hypertrophic cardiomyopathy and in patients with severe left ventricular (LV) dysfunction.Material and Methods. The study comprised a total of 76 patients with obstructive HCM and 31 patients with severe LV dysfunction. The group of patients with HCM comprised patients with obstructive form; the group of patients with severe LV dysfunction included patients with the third type of post-infarction LV remodeling and ejection fraction (EF) of less than 30%. The determination of cardiotrophin-1 and highly sensitive C-reactive protein was carried out by the enzyme immunoassay. The study of NT-proBNP content in blood serum was performed by multiplex immunoassay using the FLEXMAP 3D Luminex Corporation system.Results. The content of cardiotrophin-1 in the blood serum of patients with obstructive HCM was higher than in the group of patients with severe LV dysfunction. The study of NT-proBNP concentrations in the blood serum showed increases in the content in both groups of patients. The median concentrations of NT-proBNP and C-reactive protein in patients with severe LV dysfunction were increased compared to the median concentration in patients with obstructive HCM.Conclusion. The study showed an increase in cardiotrophin-1 content in the blood serum in patients with obstructive HCM with chronic diastolic heart failure. The increase in cardiotrophin-1 content was directly associated with the increase in NTproBNP level in patients with obstructive HCM with chronic diastolic heart failure.

Assessment of the effect of nebivolol and сarvedilol on the functional state of patients with diastolic chronic heart failure

Aim. To determine the effect of combined therapy with nebivolol or carvedilol on the functional state of patients with diastolic chronic heart failure (CHF).&#x0D; Material and methods. The study involved 68 patients with CHF and preserved left ventricular ejection fraction, who were randomized into two groups for treatment with bisoprolol or carvedilol. As part of the combination therapy was prescribed quinapril, and if indicated atorvastatin, acetylsalicylic acid in the intestinal soluble shell. Initially and after 24 weeks of therapy were carried out: quantitative assessment of regulatory-adaptive status (RAS), echocardioscopy, treadmill test, six-minute walking test, subjective assessment of quality of life, determination of level of N-terminal fragment of the brain natriuretic peptide precursor in blood plasma.&#x0D; Results. Both schemes of combined therapy comparably improved the morpho-functional parameters of the heart and quality of life. In comparison with carvedilol, nebivolol more pronouncedly increased RAS and tolerance to physical activity.&#x0D; Conclusion. In patients with diastolic CHF in combination therapy, the use of nebivolol, in comparison with carvedilol, may be preferable due to the positive effect on the functional state.

Systemic Action of Inflammatory Mediators in Patients with Essential Hypertension and Diastolic Chronic Heart Failure: A Clinical Pathophysiological Study.

The aim of this research was to correlate indicators of proinflammatory status and the structural/functional characteristics of the cardiovascular system comparatively in male and female patients with essential hypertension (EH) complicated by diastolic chronic heart failure (CHF) with preserved left ventricular ejection fraction (LVEF). The study included 104 middle-aged patients (55 males (M) and 49 females (F)) with first- or second-degree EH complicated by CHF with preserved LVEF. They all belonged to the low functional class of CHF, with LVEF ≥50%, first- or second-degree of LV diastolic dysfunction (LVDD), LV hypertrophy (LVH), and dilatation of the left atrium (LA) with a sinus rhythm and N-terminal brain natriuretic peptide >125 pg/mL. Serum levels of C-reactive protein (CRP), tumor necrosis factor alpha (TNF-α), and interleukin-6 (IL-6) were measured. To identify the relationship between the proinflammatory pattern and cardiovascular parameters, Spearman’s rank correlation coefficients were determined. M had markedly higher levels of CRP, TNF-α, and IL-6 compared to F. However, all the mean values corresponded to the reference range. Significant direct associations of CRP level with the LV mass index (LVMI), relative wall thickness (RWT), LA volume index (LAVI), E/e’ ratio, and systolic and diastolic blood pressure (SBP, DBP) existed in both M and F, as well as negative correlations of CRP with LVDD parameter e’ and distance covered in a 6 min walk test. M and F had a positive association between IL-6 and LVMI, LAVI, E/e’ ratio, SBP, RWT, and DBP, as well as strong negative associations between IL-6 and e’ and distance passed in 6 min in each group. Significant direct correlations existed between serum TNF-α level and LVMI, RWT, LAVI, E/e’, SBP, and DBP both in M and F. Furthermore, there were negative relationships of TNF-α level with e’ and the distance covered for the 6 min walk. This study demonstrated a close relationship between the blood levels of proinflammatory autacoids and indicators of EH, exercise tolerance, LVH, LVDD, and LA enlargement, regardless of the patient’s sex. Compared to female patients, male patients had stronger correlations of CRP, TNF-α, and IL-6 levels with indicators of LVDD degree.

Outcomes, resource utilization and predictors of thirty day readmission in patients with heart failure with preserved ejection fraction (HFpEF): insights from the Nationwide Readmissions Database 2017

Abstract Background and aims Nearly half of all heart failure patients have heart failure with preserved ejection fraction (HFpEF). Due to differences in pathophysiology of heart failure with preserved and reduced ejection fraction, as well as a paucity of studies, the treatment of hHFpEF remains a challenge. We aimed to determine the rate of hospital readmission within 30 days of acute or acute on chronic HFpEF and its impact on mortality and health care utilization in the United States. We also focused on patient demographics as well as independent variables affecting readmission. Methods We performed a retrospective study using the Agency for Health-care Research and Quality's Health-care Cost and Utilization Project (HCUP), Nationwide Readmission Database (NRD) for the year of 2017 (data on approximately 18 million hospital stays at 2,454 hospitals in the United States). We collected data on hospital readmissions of 60,514 adults who were hospitalized for acute or acute on chronic diastolic heart failure and discharged. The primary outcome was the rate of all-cause readmission within 30 days of discharge. Secondary outcomes were reasons for readmission, readmission mortality rate, and resource use (length of stay, total hospitalization costs and charges). Independent risk factors for readmission were identified using Cox regression analysis. Results The 30-day rate of readmission was 21%. Only 1,175 (9.17%) of readmissions were associated with an admitting diagnosis of acute on chronic diastolic heart failure. The most common readmission diagnosis was hypertensive chronic kidney disease with heart failure (1,245; 9.7%). Readmission cases were associated with increased in-hospital mortality compared to index admission (7.9% vs 2.9%, p=0.000). Readmission was associated with a total of 81,997 hospital days. Total health care in-hospital economic burden was $206 million (in costs) and $779 million (in charges). Significant predictors of increased thirty-day readmission were Medicaid insurance (1.15, 1.05–1.27, p=0.004), higher Charlson co-morbidity score (1.08, 1.06–1.09, p=0.000), patient admitted to teaching hospital (1.09, 1.04–1.15, p=0.001) and longer stays in the hospital (1.01, 1.01–1.02, p=0.000). Residence in a small metropolitan (0.91, 0.86–0.97, p=0.003) or micropolitan area (0.83, 0.77–0.90, p=0.000), older age (0.99, 0.993–0.997, p=0.000), female sex (0.91, 0.86–0.95, p=0.000), private (0.85, 0.77–0.93, p=0.000) or no insurance (0.70, 0.53–0.93, p=0.015) were associated with lower odds of readmission. Interestingly discharges to rehabilitation had no effect on re-admission (0.67, 0.28–1.6, p=0.381). Conclusions In conclusion patients hospitalized for acute or acute on chronic HFpEF, we found that 21% of patients were readmitted to the hospital within 30 days of discharge. Readmissions were associated with higher mortality and resource utilization. Most readmissions were due to cardiorenal syndrome. Funding Acknowledgement Type of funding source: None

HEART FAILURE OR MALIGNANT MESOTHELIOMA? A RARE PRESENTATION OF A RARE DISEASE

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Malignant pleural mesothelioma is a rare asbestos-related neoplasm that typically presents with nonspecific symptoms such as dyspnea, cough, and chest pain. Imaging usually reveals unilateral pleural disease. Here we present a case of a man who presented with bilateral disease and initial suspicion for cardiogenic etiology. CASE PRESENTATION: A 88-year-old man presented with 2 months of progressive dyspnea on exertion, orthopnea, and unintentional weight loss of 30 pounds. Past medical history included nonobstructive coronary artery disease, chronic diastolic heart failure, diabetes, hypertension, and alcohol abuse. Social history was notable for asbestos exposure through building construction. Physical exam revealed a new oxygen requirement and decreased breath sounds on auscultation bilaterally without other signs of hypervolemia. Troponin-T and NT-proBNP were normal. Chest X-ray showed mild cardiomegaly with bilateral pleural effusions and prominence of the pulmonary vasculature. Cardiac stress test showed a partial inferior reversible perfusion defect, which led to plans for catheterization and echocardiogram. Thoracentesis revealed an exudative effusion (protein 4.3, LDH 271) with negative cytology. Pulmonary function testing showed restrictive lung disease with DLCO 48%. A chest CT scan revealed diffuse interstitial thickening with bilateral bronchial wall and pleural thickening, and a medial right lower lobe mass-like consolidation. PET/CT showed FDG-avid pleural thickening bilaterally with multiple FDG-avid lymph nodes. Ultrasound-guided core biopsy of the right pleura revealed epithelioid malignant mesothelioma. DISCUSSION: Malignant pleural mesothelioma can cause exudative pleural effusions and requires a tissue biopsy for definitive diagnosis. Studies suggest the disease is bilateral in only 10% of cases. As seen in this patient, bilateral pleural effusions in the setting of a recent positive stress test with known CHF history may lead providers to initially attribute the effusions to CHF and possibly defer thoracentesis. Rare presentations of rare diseases are likely low on a provider’s initial differential diagnosis, but thoracentesis should be considered for new effusions especially if there is clinical suspicion for an alternative etiology to CHF. Further diagnostic evaluation may be required if thoracentesis does not yield a definitive diagnosis. Had pulmonary work-up not been pursued for this patient, the diagnosis of malignant mesothelioma may have been delayed. CONCLUSIONS: Malignant pleural mesothelioma should be considered when evaluating new pleural effusions in patients with respiratory symptoms and known asbestos exposure. This case also highlights the importance of maintaining a broad differential diagnosis for a patient with new nonspecific respiratory symptoms. Reference #1: Neumann, V.; Löseke, S.; Nowak, D.; Herth, F.J.; Tannapfel, A. Malignant pleural mesothelioma: Incidence, etiology, diagnosis, treatment, and occupational health. Dtsch. Arztebl. Int. 2013;110:319–326. Reference #2: Gill RR. Imaging of mesothelioma. Recent Results Cancer Res. 2011;189:27-43. Reference #3: Karkhanis VS, and Joshi JM. Pleural effusion: diagnosis, treatment, and management. Open Access Emerg. Med. 2012;4:31–52. DISCLOSURES: No relevant relationships by Sydney Bowmaster, source=Web Response No relevant relationships by Matthew Gosse, source=Web Response No relevant relationships by Jeff Wilson, source=Web Response

Influence of metabolic and proinflammatory factors on diastolic heart failure formation in females with essential hypertension

Relevance.Diastolic chronic heart failure (CHF) is a characteristic complication of essential hypertension (EH).&#x0D; Materials and methods.62 females with EH were examined. The first group (n=47, mean age 51.56.2 years) persons with EH complicated by diastolic CHF, the second group (n=15, 49.86.7 years) persons with uncomplicated EH. The diagnosis of CHF in females of the first group is confirmed by the data of the test with 6-minute walking, increased blood content of the N-terminal precursor of the brain natriuretic peptide, the presence of left atrial dilatation, hypertrophy and disturbed left ventricle (LV) relaxation. The levels of indices of lipid, carbohydrate, purine metabolism, mediators of systemic inflammation (С-reactive protein), tumor necrosis factor alpha (TNF-a), interleukin-6 (IL-6) were studied and a correlation analysis of the whole set of laboratory data with 6-minute walking test results and an integral index of diastolic LV dysfunction (E/e).&#x0D; Results. Females with EH complicated initial manifestations of diastolic heart failure, characterized by significantly higher, but the corresponding values of the reference range, the content in blood TNF-a, IL-6 compared with females with uncomplicated EH. In females with hypertension complicated initial manifestations of diastolic heart failure is established significant correlation between blood levels of atherogenic lipids and lipoproteins, glucose, uric acid, CRP, TNF-a, IL-6 on the one hand and indices characterizing reduced tolerance to physical load, diastolic LV dysfunction.&#x0D; Conclusion.Formation of diastolic heart failure clinical syndrome as well as disturbances of LV relax function in hypertensive females allows participation of metabolic factors and pro-inflammatory pattern.

A STROKE OF BAD LUCK: NEW-ONSET MANIA IN ELDERLY PATIENT FOLLOWING UNDETECTED STROKE, A CASE REPORT

A STROKE OF BAD LUCK: NEW-ONSET MANIA IN ELDERLY PATIENT FOLLOWING UNDETECTED STROKE, A CASE REPORT

Варианты течения хронической сердечной недостаточности у больных с сердечно-сосудистой патологией. Фокус на паци-ентов с сохраненной фракцией выброса левого желудочка

Aim: to assess the application of leading scientific communities’ recommendations for the patient management with chronic heart failure (CHF) in practical medicine.Patients and Methods: a retrospective analysis of 274 case records of patients (both sexes, over 18 years of age) with cardiovascular pathology, arterial hypertension and/or CHD, hospitalized in a Moscow hospital in 2019, was performed. 89 cases were selected for the study. The incidence and patterns of CHF course were analyzed; the scope of methods usage for diagnosing CHF and the treatment compliance of CHF with the principles reflected in the current recommendations for CHF was evaluated.Results: the study included 89 patients, 28 men and 61 women, with an average age of 59±16 and 70±10 years, respectively. CHF was diagnosed in 62 (70%) patients. At the same time, CHF in combination with a low left ventricular ejection fraction (LVEF) was observed in 7 (11%), with intermediate LVEF indicators — in 3 (5%), and with preserved LVEF — in 52 (84%). The main method for confirming CHF was two-dimensional echocardiography with Doppler ultrasound. Comorbidity was observed in 89% of patients with CHF. It was not possible to conduct the complete analysis of treatment compliance, prescribed in accordance with approved national clinical guidelines due to the small number of patients with CHF.Conclusion: at present, it is necessary to expand the scope of diagnostic measures reflected in current national guidelines, as well as to further study the disease and determine treatment tactics for patients with CHF to verify both systolic and diastolic CHF. KEYWORDS: chronic heart failure, arterial hypertension, coronary heart disease, ejection fraction, comorbidity, recommendations.FOR CITATION: Eremina Yu.N., Fedulayev Yu.N., Lomaichikov V.V. et al. Variants of chronic heart failure course in patients with cardiovascular pathology. Focus on patients with preserved left ventricular ejection fraction. Russian Medical Inquiry. 2020;4(7):406–411. DOI: 10.32364/2587-6821-2020-4-7-406-411.