Clinical Diagnosis Of Heart Failure Research Articles

Echocardiography in the Assessment of Heart Failure Patients.

Doppler echocardiography is the corner-stone of non-invasive investigation of patients with a clinical diagnosis of heart failure. It provides an accurate and quantitative assessment of cardiac structure and function. Furthermore, spectral Doppler measurement is an invaluable technique for estimating intracardiac pressures with their crucial value in the optimum management of heart failure patients, irrespective of ejection fraction. Speckle tracking echocardiography stretches the unique application of echocardiography to analyze the myocardial deformation function which has proved very accurate in detecting ischemia, dyssynchrony, subclinical dysfunction and also in estimating pulmonary capillary wedge pressures. The role of longitudinal myocardial left atrial deformation dynamics has recently emerged as a valuable tool for assessing left ventricular diastolic dysfunction in patients with cardiac diseases regardless of their ejection fraction. Finally, the extent of myocardial deformation has been shown to correlate with the severity of myocardial fibrosis, a common finding in patients with heart failure.

Individual heart failure patient variability in nocturnal hypoxia and arrhythmias.

Traditional heart failure research often uses daytime population parameter estimates to assess hypoxia and arrhythmias. This approach might not accurately represent heart failure patients as nighttime cardiac behaviors offer crucial insights into their health, especially regarding oxygen levels and heart rhythms. We conducted a prospective study on nocturnal oxygen saturation and heart rate in home-dwelling heart failure patients over 6 nights. Patients were recruited from the Walter Reed National Military Medical Center heart failure clinic. Criteria included a clinical diagnosis of heart failure, a New York Heart Association (NYHA) classification of I to III, ages between 21 to 90, cognitive intactness, capability to use the wearable device, and willingness to use the device for 6 consecutive nights. Average oxygen saturation was 92% with individual readings ranging from 40% to 100%. The mean heart rate was 72 beats per minute (bpm), but individual rates ranged from 18 bpm to a high of 296 bpm. A significant drop in oxygen levels and sleep arrhythmias were consistently observed among participants. Heart failure patients demonstrate notable and variable desaturations and arrhythmias across multiple nights. A single-night sleep study or a 24-hour heart rate monitor may not comprehensively depict patients' oxygenation and heart rate irregularities. Our research highlights wearable devices' potency in medical research for capturing essential nocturnal data. In only 6 nights, we gleaned invaluable clinical insights for optimizing patient care. This study is pioneering, being the first to intensively examine nighttime oxygen levels and heart rates in home-based heart failure patients.

Characterization of Non-Ischemic Dilated Cardiomyopathy in a Native Tanzanian Cohort: MOYO Study.

Non-ischemic dilated cardiomyopathy (NIDCM) is a common cause of heart failure with progressive tendency. The disease occurs in one in every 2,500 individuals in the developed world, with high morbidity and mortality. However, detailed data on the role of NIDCM in heart failure in Tanzania is lacking. To characterize NIDCM in a Tanzanian cohort with respect to demographics, clinical profile, imaging findings and management. Characterization of non-ischemic dilated cardioMyOpathY in a native Tanzanian cOhort (MOYO) is a prospective cohort study of NIDCM patients seen at the Jakaya Kikwete Cardiac Institute. Patients aged ≥18 years with a clinical diagnosis of heart failure, an ejection fraction of ≤45% on echocardiography and no evidence of ischemia were enrolled. Clinical data, echocardiography, electrocardiography (ECG), coronary angiography and stress ECG information were collected from February 2020 to March 2022. Of 402 patients, n = 220 (54.7%) were males with a median (IQR) age of 55.0 (41.0, 66.0) years. Causes of NIDCM were presumably hypertensive n = 218 (54.2%), idiopathic n = 116 (28.9%), PPCM n = 45 (11.2%), alcoholic n = 10 (2.5%) and other causes n = 13 (3.2%). The most common presenting symptoms were dyspnea n = 342 (85.1%), with the majority of patients presenting with New York Heart Association (NYHA) Class III n = 195 (48.5%). The mean (SD) left ventricular ejection fraction (LVEF) was 29.4% (±7.7), and severe systolic dysfunction (LVEF <30%) was common n = 208 (51.7%). Compared with other forms of DCM, idiopathic DCM patients were significantly younger, had more advanced NYHA class (p < 0.001) and presented more often with left bundle branch block on ECG (p = 0.0042). There was suboptimal use of novel guidelines recommended medications ARNI n = 10 (2.5%) and SGLT2 2-inhibitors n = 2 (0.5%). In our Tanzanian cohort, the majority of patients with NIDCM have an identified underlying cause, and they present at late stages of the disease. Patients with idiopathic DCM are younger with more severe disease compared to other forms of NIDCM.

Artificial intelligence methods for improved detection of undiagnosed heart failure with preserved ejection fraction.

Heart failure with preserved ejection fraction (HFpEF) remains under-diagnosed in clinical practice despite accounting for nearly half of all heart failure (HF) cases. Accurate and timely diagnosis of HFpEF is crucial for proper patient management and treatment. In this study, we explored the potential of natural language processing (NLP) to improve the detection and diagnosis of HFpEF according to the European Society of Cardiology (ESC) diagnostic criteria. In a retrospective cohort study, we used an NLP pipeline applied to the electronic health record (EHR) to identify patients with a clinical diagnosis of HF between 2010 and 2022. We collected demographic, clinical, echocardiographic and outcome data from the EHR. Patients were categorized according to the left ventricular ejection fraction (LVEF). Those with LVEF ≥50% were further categorized based on whether they had a clinician-assigned diagnosis of HFpEF and if not, whether they met the ESC diagnostic criteria. Results were validated in a second, independent centre. We identified 8606 patients with HF. Of 3727 consecutive patients with HF and LVEF ≥50% on echocardiogram, only 8.3% had a clinician-assigned diagnosis of HFpEF, while 75.4% met ESC criteria but did not have a formal diagnosis of HFpEF. Patients with confirmed HFpEF were hospitalized more frequently; however the ESC criteria group had a higher 5-year mortality, despite being less comorbid and experiencing fewer acute cardiovascular events. This study demonstrates that patients with undiagnosed HFpEF are an at-risk group with high mortality. It is possible to use NLP methods to identify likely HFpEF patients from EHR data who would likely then benefit from expert clinical review and complement the use of diagnostic algorithms.

Which Diastolic Pressure Should Be Used to Assess Diastolic Function?

Although high left ventricular filling pressures [left ventricular (LV) end-diastolic pressure or pulmonary capillary wedge pressure (PCWP)] are widely taken as surrogates for LV diastolic dysfunction, the actual distending pressure that governs LV diastolic stretch is transmural pressure difference (∆PTM). Clinically, preferring ∆PTM over PCWP may improve diagnostic and therapeutic decision-making. We aimed to compare the clinical implications of diastolic function characterization based on PCWP or ∆PTM. We retrospectively screened our hospital database for adult patients with a clinical diagnosis of heart failure who underwent right heart catheterization. Echocardiographic diastolic dysfunction was graded according to the current guidelines. LV end-diastolic properties were assessed with construction of complete end-diastolic pressure-volume relationship (EDPVR) curves using the single-beat method. Survival status was checked via the electronic national health-care system. A total of 693 cases were identified in our database; the final study population comprised 621 cases. ∆PTM-based, but not PCWP-based, EDPVR diastolic stiffness constants were significantly predictive of advanced diastolic dysfunction. PCWP-based diastolic stiffness constants were not able to predict 5-year mortality, whereas ∆PTM-based EDPVR stiffness constants and volumes all turned out to have significant predictive power for 5-year mortality. Left ventricular diastolic function assessment can be improved using ∆PTM instead of PCWP. As ∆PTM ultimately linked to right-sided functions, this approach emphasizes the limitations of taking LV diastolic function as an isolated phenomenon and underlines the need for a complete hemodynamic assessment involving the right heart in therapeutic and prognostic decision-making processes.

Abstract 17497: Natural History of the Left Ventricular Ejection Fraction in Heart Failure and Sudden Cardiac Death

Background: A clinical diagnosis of heart failure (HF) is associated with increased risk of sudden cardiac death (SCD), but only HF with severely reduced LV ejection fraction (HFrEF, EF ≤35%) is utilized for risk stratification. Guideline-directed medical therapy and heart disease processes may improve or reduce the LVEF. Hypothesis: There is significant variation of LVEF over time among HF patients with SCD. Methods: From a large, prospective population-based study of SCD in the Northwest US (catchment population 1 million, 2002-2018), we identified all consecutive patients with a diagnosis of HF and prior assessment of LVEF. The sub-group of patients with at least 2 prior LVEF evaluations (earliest and latest in relation to SCD) was determined. Results: A total of 1622 individuals suffered SCD with a known diagnosis of HF (65% male, age 72±14) of which 434 had 2 LVEF evaluations at least 1 yr apart prior to their SCD. At earliest evaluation, 100 (23%) had HFrEF (73% male, age 67±13), 88 (20%) had HF with moderately reduced EF (HFmrEF, 35&lt;ef&amp;lt;50) (71% male, age 72±12), and 246 (57%) had hf with preserved ef (hfpef, ef≥50) (57% 72±12). comparing the earliest latest assessment of lvef, mean lvef in hfref increased by 9±14 percentage points (p&amp;lt;0.001) from 27±6 to 36±14; hfmref decreased over time -4±14 (p="0.003)" 43±4 39±14; hfpef -8±13, 62±7 54±14. each subtype changed substantially (mean 2.9±1.5 yrs), sizeable proportions re-classified into different subtypes (Figure). Overall, the HF LVEF subtype was unchanged in 58% and altered in 42% (p&amp;lt;0.001). Conclusions: Based on the LVEF, at least 40% of HF sub-types were re-classified prior to SCD and risk assessment would be variable depending on when LVEF was measured. These findings highlight the limitations of using the LVEF as the only risk predictor of SCD.

Evaluation the value of H2FPEF score and HFA-PEFF step E score in the diagnosis of heart failure with preserved ejection fraction

Background Clinical diagnosis of heart failure with preserved ejection fraction (HFpEF) remains challenging. The aim of the study is to evaluate the value of the H2FPEF score and HFA-PEFF step E score in the diagnosis of HFpEF. Methods 319 hospitalised patients with ‘shortness of breath’ or ‘dyspnoea’ were retrospectively collected and scored with the above two scores, respectively. They were divided into HFpEF group and non-HFpEF group in the study. Results Both the negative and positive predictive value of H2FPEF score and HFA-PEFF Step E score were 95.52%, 96.83% and 98.28%, 93.63%, respectively. However, there were 189 (59.25%) and 104 (32.60%) cases could not be diagnosed or excluded in the H2FPEF score and the HFA-PEFF step E score, respectively. Conclusions Both scores of the H2FPEF and the HFA-PEFF step E may be used to effectively rule out or confirm HFpEF according to the score point. However, there are three fifths and one third patients in the H2FPEF score and the HFA-PEFF step E score, respectively, in the intermediate scores who are needed further invasive catheterisation or exercise stress tests.

Preoperative clinical diagnostic accuracy of heart failure among patients undergoing major noncardiac surgery: a single-centre prospective observational analysis.

Reliable diagnosis of heart failure during preoperative evaluation is important for perioperative management and long-term care. We aimed to quantify preoperative heart failure diagnostic accuracy and explore characteristics of patients with heart failure misdiagnoses. We performed an observational cohort study of adults undergoing major noncardiac surgery at an academic hospital between 2015 and 2019. A preoperative clinical diagnosis of heart failure was defined using keywords from the history and clinical examination or administrative documentation. Across stratified subsamples of cases with and without clinically diagnosed heart failure, health records were intensively reviewed by an expert panel to develop an adjudicated heart failure reference standard using diagnostic criteria congruent with consensus guidelines. We calculated agreement among experts, and analysed performance of clinically diagnosed heart failure compared with the adjudicated reference standard. Across 40 555 major noncardiac procedures, a stratified subsample of 511 patients was reviewed by the expert panel. The prevalence of heart failure was 9.1% based on clinically diagnosed compared with 13.3% (95% confidence interval [CI], 10.3-16.2%) estimated by the expert panel. Overall agreement and inter-rater reliability (kappa) among heart failure experts were 95% and 0.79, respectively. Based upon expert adjudication, heart failure was clinically diagnosed with an accuracy of 92.8% (90.6-95.1%), sensitivity 57.4% (53.1-61.7%), specificity 98.3% (97.1-99.4%), positive predictive value 83.5% (80.3-86.8%), and negative predictive value 93.8% (91.7-95.9%). Limitations exist to the preoperative clinical diagnosis of heart failure, with nearly half of cases undiagnosed preoperatively. Considering the risks of undiagnosed heart failure, efforts to improve preoperative heart failure diagnoses are warranted.

Abstract 9899: Effects of Ambient Air Pollutants on Progression of Cardiac Structure and Function in the Echocardiographic Study of Latinos (Echo-SOL)

Background: Air pollutants may affect cardiac function; effects preceding clinical diagnosis of heart failure are not understood. We assessed longitudinal associations between fine particulate matter (PM 2.5 ), nitrogen dioxide (NO 2 ) and cardiac structure and function among 1,660 participants in the Echocardiographic Study of Latinos, in the Hispanic Community Health Study/Study of Latinos. Hypothesis: Air pollution is associated with longitudinal changes in subclinical structure/function. Methods: Left ventricular (LV) mass index, relative wall thickness, average global longitudinal strain (GLS), LV ejection fraction, e’, left atrial (LA) volume index, E/e’ ratio, and diastolic function grades were assessed by echocardiogram. Air pollution concentrations were estimated from validated spatio-temporal models at home locations, as mean concentrations of PM 2.5 and NO 2 for the year prior to clinical visit 1 (V1, 2008-2011) and 2 (V2, 2015-2018). A mixed effects model was used to jointly model cross-sectional and longitudinal relationships between time-varying air pollution and continuous measures of CF, adjusted for baseline physical activity, gender, education, age, BMI, SBP, DBP, statin use, diabetes, and hypertension status and time-varying smoking and alcohol use, with random intercepts for clinical center and primary sampling unit. Results: Participants’ mean age was 56.4 years at V1; mean follow-up was 6.52 years. Mean PM 2.5 was 10.3 μg/m 3 at V1 and 8.8 μg/m 3 at V2. Mean NO 2 was 17.4 ppb at V1 and 14.3 at V2. Per interquartile range of pollutant, higher PM 2.5 and NO 2 were associated with a 0.52% (95% CI -0.16, 1.11) and 0.98% (95% CI 0.13, 1.23) increase in GLS, respectively. NO 2 was associated with -1.07% (95% CI -2.24, 0.10) decrease in LV ejection fraction. PM 2.5 was associated with a 0.75 (95% CI 0.39, 1.12) increase in e’ and a 1.25 (95% -1.95, -0.56) decrease in E/e’ ratio. No other associations with air pollution and echo measures were found. Conclusion: These findings suggest that air pollution is associated with longitudinal changes in GLS, LV ejection fraction, e’, and E/e’ ratio in a US Hispanic/Latino cohort, an important understudied population. Air pollution may represent a modifiable risk factor in the development of clinical heart failure.

Cardiovascular magnetic resonance phenotyping of heart failure with mildly reduced ejection fraction.

The 2016 European Society of Cardiology Heart Failure Guidelines defined a new category: heart failure with mid-range ejection fraction (HFmrEF) of 40-49%. This new category was highlighted as having limited evidence and research was advocated into underlying characteristics, pathophysiology, and diagnosis. We used multi-parametric cardiovascular magnetic resonance (CMR) to define the cardiac phenotype of presumed non-ischaemic HFmrEF. Patients (N = 300, 62.7 ± 13 years, 63% males) with a clinical diagnosis of heart failure with no angina symptoms, history of myocardial infarction, or coronary intervention were prospectively recruited. Patients underwent clinical assessment and CMR including T1 mapping, extracellular volume (ECV) mapping, late gadolinium enhancement, and measurement of myocardial blood flow at rest and maximal hyperaemia. Of 273 patients in the final analysis, 93 (34%) patients were categorized as HFmrEF, 46 (17%) as heart failure with preserved ejection fraction (HFpEF), and 134 (49%) as heart failure with reduced ejection fraction (HFrEF). Nineteen (20%) patients with HFmrEF had evidence of occult ischaemic heart disease. Diffuse fibrosis and hyperaemic myocardial blood flow were similar in HFmrEF and HFpEF, but HFmrEF showed significantly lower native T1 (1311 ± 32 vs. 1340 ± 45 ms, P < 0.001), ECV (24.6 ± 3.2 vs. 26.3 ± 3.1%, P < 0.001), and higher myocardial perfusion reserve (2.75 ± 0.84 vs. 2.28 ± 0.84, P < 0.001) compared with HFrEF. Patients with HFmrEF share most phenotypic characteristics with HFpEF, including the degree of microvascular impairment and fibrosis, but have a high prevalence of occult ischaemic heart disease similar to HFrEF. Further work is needed to confirm how the phenotype of HFmrEF responds to medical therapy.

Post-mortem examination of high mortality in patients with heart failure and atrial fibrillation

BackgroundThe prevalence of combined heart failure (HF) and atrial fibrillation (AF) is rising, and these patients suffer from high rates of mortality. This study aims to provide robust data on factors associated with death, uniquely supported by post-mortem examination.MethodsA retrospective cohort study of hospitalized adults with a clinical diagnosis of HF and AF at a tertiary centre in Romania between 2014 and 2017. A standardized post-mortem examination was performed where death occurred within 24 h of admission, when the cause of death was not clear or by physician request. National records were used to collect mortality data, subsequently categorized and analysed as HF-related death, vascular death and non-cardiovascular death using Cox proportional hazards regression.ResultsA total of 1009 consecutive patients with a mean age of 73 ± 11 years, 47% women, NYHA class 3.0 ± 0.9, left ventricular ejection fraction (LVEF) 40.1 ± 11.0% and 100% anticoagulated were followed up for 1.5 ± 0.9 years. A total of 291 (29%) died, with post-mortems performed on 186 (64%). Baseline factors associated with mortality were dependent on the cause of death. HF-related death in 136 (47%) was associated with higher NYHA class (hazard ratio [HR] 2.45 per one class increase, 95% CI 1.73–3.46; p < 0.001) and lower LVEF (0.95 per 1% increase, 0.93–0.97; p < 0.001). Vascular death occurred in 75 (26%) and was associated with hypertension (HR 2.83, 1.36–5.90; p = 0.005) and higher LVEF (1.08 per 1% increase, 1.05–1.11; p < 0.001). Non-cardiovascular death in 80 (28%) was associated with clinical obesity (HR 2.20, 1.21–4.00; p = 0.010) and higher LVEF (1.10 per 1% increase, 1.06–1.13; p < 0.001). Across all causes, there was no relationship between mortality and AF type (p = 0.77), HF type (p = 0.85) or LVEF (p = 0.58).ConclusionsSupported by post-mortem data, the cause of death in HF and AF patients is heterogeneous, and the relationships with typical markers of mortality are critically dependent on the mode of death. The poor prognosis in this group demands further attention to improve management beyond anticoagulation.Graphical

Digoxina para fibrilação atrial: boa, mas não muito: relato de caso

Digoxin is a cardiotonic glycoside that is traditionally used for the treatment of heart failure and atrial fibrillation in humans and animals. However, the use of digoxin is still a challenge in clinical practice due to its narrow therapeutic range and its potential interaction with several drugs, which could facilitate the development of toxicity. A 12-year-old Labrador retriever was referred with a clinical diagnosis of heart failure and atrial fibrillation, anorexia, vomiting, and diarrhea. He had been medicated with digoxin, furosemide, lisinopril, and amiodarone. The patient also showed clinical signs of hip osteoarthritis and received firocoxib for four days. He additionally received drugs for gastrointeritis. The electrocardiogram demonstrated atrial fibrillation and signs of digitalis toxicity. Laboratory examination showed a high concentration of plasma digoxin, and 5 days after withdrawal of the drugs, the symptoms disappeared, as did the digitalis effects seen in the previous electrocardiogram.

Development of Advanced Heart Failure: A Population-Based Study.

Some patients with heart failure (HF) will go on to develop advanced HF, characterized by severe HF symptoms despite attempts to optimize medical therapy. The goals of this study were to examine the risk of developing advanced HF in patients with newly diagnosed HF, identify risk factors for developing advanced HF, and evaluate the impact of advanced HF on outcomes. This was a population-based, retrospective cohort study of Olmsted County, Minnesota, residents with a new clinical diagnosis of HF between 2007 and 2017. Risk factors for the development of advanced HF (2018 European Society of Cardiology criteria) were examined using cause-specific Cox proportional hazard regression models. The associations of development of advanced HF with risks of hospitalization and mortality were examined using the Andersen-Gill and Cox models, respectively. There were 4597 residents with incident HF from 2007 to 2017. The cumulative incidence of advanced HF was 11.5% (95% CI, 10.5%-12.5%) at 6 years after incident HF diagnosis overall and was 14.4% (95% CI, 12.3%-16.9%), 11.4% (95% CI, 8.9%-14.6%), and 11.7% (95% CI, 10.3%-13.2%) in patients with incident HF with reduced, mildly reduced, and preserved ejection fraction, respectively. Key demographics, comorbidities, and echocardiographic characteristics were independently associated with the development of advanced HF. Development of advanced HF was associated with increased risks of all-cause hospitalization (adjusted hazard ratio, 3.0 [95% CI, 2.7-3.4]; P<0.001), HF hospitalization (hazard ratio, 10.2 [95% CI, 8.7-12.1]), all-cause mortality (hazard ratio, 5.0 [95% CI, 4.5-5.6]; P<0.001), and cardiovascular mortality (hazard ratio, 7.8 [95% CI, 6.7-9.1]). In this population-based study, development of advanced HF was common and was associated with markedly increased morbidity and mortality.

Left ventricular diastolic dysfunction, including an impaired myocardial relaxation pattern, predicts long-term cardiovascular and non-cardiovascular mortality in the community

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction Prior studies have demonstrated abnormalities of diastolic function are independent predictors of heart failure and all-cause mortality. The optimal way to classify diastolic function has continued to evolve over time, particularly in those with preserved left ventricular ejection fraction. A notable change in the 2016 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) guidelines is that individuals with impaired myocardial relaxation and normal filling pressure can be classified as normal diastolic function. Purpose To determine whether the association of diastolic dysfunction with increased risk of all-cause mortality is driven by cardiovascular or non-cardiovascular death. Second, to evaluate if the presence of an impaired myocardial relaxation inflow pattern without other diastolic abnormalities conveys a marker of increased risk. Methods This study utilized the Olmsted County Heart Function Study (OCHFS), a well characterized prospective adult community cohort with comprehensive echocardiography between 2001 and 2004 and long-term follow-up. Only individuals with measurable diastolic function were included (n = 1,104). Those with reduced left ventricular ejection fraction, more than moderate valve disease, or a clinical diagnosis of heart failure (n = 52); or indeterminate diastolic function (n = 47) were excluded. Diastolic function was assessed by the current Mayo Clinic diagnostic algorithm (Figure). Results A total of 695 individuals were classified as normal, 265 with impaired myocardial relaxation or grade 1 diastolic dysfunction, and 45 with grade 2-3 diastolic dysfunction. Those with diastolic dysfunction were older and had more comorbidities including diabetes, hypertension and coronary disease (Table). There were 264 deaths in the median follow up period of 15.2 years (IQR 14.4 – 18.0), including 173 non-cardiovascular and 81 cardiovascular deaths. Both cardiovascular and non-cardiovascular mortality were associated with the presence and grade of diastolic dysfunction (Table 1). Individuals classified as normal by 2016 ASE/EACVI criteria, but grade 1 by the Mayo algorithm had an increased risk of all-cause mortality after univariate analysis (HR 4.35, 95% CI (3.35, 5.65), p &amp;lt; 0.0001) compared to normal subjects and remained associated after adjustment for age (HR 1.55, 95% CI (1.15, 2.09), p &amp;lt; 0.0001. Subjects with a grade 1 pattern had a higher rate of cardiovascular mortality (ꭕ2 70.1, p &amp;lt; 0.0001). Conclusions Individuals with diastolic dysfunction, including those with an impaired relaxation mitral inflow, were at increased risk of mortality, particularly cardiovascular mortality. This study highlights the importance of separating grade 1 diastolic dysfunction from normal in the assessment of diastolic function as it represents a clinically significant risk marker of myocardial disease. Abstract Figure. Abstract Figure.

Abstract 12125: Baseline Analysis of National Malaysian Heart Failure Registry Indicates Hospitalization as a Key Opportunity to Initiate GDMT in HF Patients

Introduction: There is scarcity of big data on Heart Failure (HF) in the Asean region in the current era of guideline directed medical therapy (GDMT). Malaysia Heart Failure (MYHF) Registry was set up in 2019 to advance fundamental understanding of the burden, morbidity and mortality among Malaysian patients with HF Objective: This analysis is to determine baseline characteristics, diagnostic work up and treatment pattern of patients admitted with the diagnosis of HF to address the unmet and growing clinical needs of HF patients in Malaysia. Methods: The first ever National HF Registry is planned as a prospective, observational study of HF patients (NYHA II-IV) across 18 tertiary care centers in Malaysia over a period of 3 years starting in 2019. This Registry recruited all patients admitted with a clinical diagnosis of HF by the attending physician with a minimum hospital stay of 24 hours for stabilisation prior to discharge. Primary endpoint is all cause mortality and hospital readmission for acute decompensated heart failure (ADHF) at one year. This paper summarizes baseline and clinical characteristics of patients along with treatment pattern and outcomes of index hospitalization. Results: We evaluated 2673 patients with mean age of 60 years (SD 13.8). De novo HF constituted one third of hospitalizations. Mean left ventricular ejection fraction (LVEF) was 36.4% (SD 15.3) stratified into 65% of HFrEF (LVEF ≤ 40%), 21% of HFpEF (LVEF ≥ 50%); and 11% of HFmrEF (LVEF 41-49%). Prior to index HF hospitalization, proportion of patients on BB, ACEi, ARBs, ARNI, MRA and ivabradine were 57%, 32%, 8%, 6%, 24% &amp; 6% respectively changing to 79%, 36%, 8%, 15%, 43% &amp; 12% at discharge of the patient. Mean length of hospital stay was 7.3 days (SD 8.9). In-hospital mortality was 3% attributed largely to cardiac causes (68%). Conclusions: The registry identifies at-risk patient populations with HF and highlights lesser prevalence of HFpEF compared to other HF registries. The analysis shows increased usage of GDMT post HF hospitalization event remarkably for BB, MRA, ivabradine and ARNI indicating hospitalization as a key opportunity to initiate GDMT in HF patients.

Abstract 10603: Risk Factors for Development of Advanced Heart Failure: A Population-Based Study

Introduction: Some patients with heart failure (HF) will go on to develop advanced HF, characterized by severe HF symptoms despite attempts to optimize medical therapy. Our understanding of advanced HF at a population level remains limited. The goals of this study were to determine the risk of developing advanced HF in patients with newly diagnosed HF, identify risk factors for developing advanced HF, and evaluate the impact of advanced HF on outcomes. Methods: This was a population-based, retrospective cohort study of Olmsted County, Minnesota residents with a new clinical diagnosis of HF between 2007-2017. The primary outcome was development of advanced HF, defined using the 2018 European Society of Cardiology Criteria. Risk factors for development of advanced HF from the time of incident HF diagnosis were examined using cause-specific Cox proportional hazard regression models. The associations of development of advanced HF with risks of hospitalization and mortality were examined using Andersen-Gill and Cox models, respectively, with advanced HF treated as a time dependent covariate. Results: There were 4597 residents with incident HF from 2007 to 2017. The cumulative incidence of advanced HF was 6.0%, 9.1%, and 11.5% at 2, 4, and 6 years after incident HF diagnosis. Characteristics independently associated with development of advanced HF included older age, male sex, diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, lower serum sodium, worse right ventricular function, left atrial enlargement, higher estimated filling pressures, and higher right ventricular systolic pressure (p&lt;0.05 for each). Development of advanced HF was associated with increased risks of all-cause hospitalization (adjusted HR 3.00; 95% CI 2.65-3.41, p&lt;0.001), HF hospitalization (HR 10.24, 95% CI 8.67-12.10), all-cause mortality (HR 5.00, 95% CI 4.46-5.59, p&lt;0.001), and cardiovascular mortality (HR 7.84, 95% CI 6.74-9.12). Conclusions: In this population-based study, clinical, laboratory and echocardiographic characteristics at the time of incident HF diagnosis were associated with future risk of advanced HF. Development of advanced HF was associated with markedly increased morbidity and mortality.

Heart failure care and outcomes in a Tanzanian emergency department: A prospective observational study.

BackgroundThe burden of heart failure is growing in sub-Saharan Africa, but there is a dearth of data characterizing care and outcomes of heart failure patients in the region, particularly in emergency department settings.MethodsIn a prospective observational study, adult patients presenting with shortness of breath or chest pain to an emergency department in northern Tanzania were consecutively enrolled. Participants with a physician-documented clinical diagnosis of heart failure were included in the present analysis. Standardized questionnaires regarding medical history and medication use were administered at enrollment, and treatments given in the emergency department were recorded. Thirty days after enrollment, a follow-up questionnaire was administered to assess mortality and medication use. Multivariate logistic regression was performed to identify baseline predictors of thirty-day mortality.ResultsOf 1020 enrolled participants enrolled from August 2018 through October 2019, 267 patients (26.2%) were diagnosed with heart failure. Of these, 139 (52.1%) reported a prior history of heart failure, 168 (62.9%) had self-reported history of hypertension, and 186 (69.7%) had NYHA Class III or IV heart failure. At baseline, 40 (15.0%) reported taking a diuretic and 67 (25.1%) reported taking any antihypertensive. Thirty days following presentation, 63 (25.4%) participants diagnosed with heart failure had died. Of 185 surviving participants, 16 (8.6%) reported taking a diuretic, 24 (13.0%) reported taking an antihypertensive, and 26 (14.1%) were rehospitalized. Multivariate predictors of thirty-day mortality included self-reported hypertension (OR = 0.42, 95% CI: 0.21–0.86], p = 0.017) and symptomatic leg swelling at presentation (OR = 2.69, 95% CI: 1.35–5.56, p = 0.006).ConclusionIn a northern Tanzanian emergency department, heart failure is a common clinical diagnosis, but uptake of evidence-based outpatient therapies is poor and thirty-day mortality is high. Interventions are needed to improve care and outcomes for heart failure patients in the emergency department setting.

Heart failure documentation in outpatients with diabetes and volume overload: an observational cohort study from the Diabetes Collaborative Registry

BackgroundHeart failure is a common and devastating complication of type 2 diabetes (T2D). Prompt recognition of heart failure may avert hospitalization, facilitate use of guideline-directed therapies, and impact choice of T2D medications. We sought to determine the rate and factors associated with heart failure documentation in T2D patients with evidence of volume overload requiring loop diuretics.MethodsDCR is an on-going, prospective US registry of outpatient T2D patients from > 5000 cardiology, endocrinology, and primary care clinicians (current analysis used data from 2013–2019). Among T2D patients receiving loop diuretics, we examined the rate of chart documentation of heart failure. We used a 3-level hierarchical logistic regression model (patients nested within physician within practice) to examine factors associated with heart failure diagnosis.ResultsAmong 1,322,640 adults with T2D, 225,125 (17.0%) were receiving a loop diuretic, of whom 91,969 (40.9%) had documentation of heart failure. Male sex, lower body mass index, atrial fibrillation, chronic kidney disease, and coronary artery disease were associated with greater odds of heart failure diagnosis. After accounting for patient factors, patients seen by cardiologists were the most likely to have HF documented followed by PCPs and then endocrinologists.ConclusionsAmong US outpatients with T2D, 17% of patients had evidence of volume overload—defined by loop diuretic prescription—of whom fewer than half had a clinical diagnosis of heart failure. While there may be non-heart failure indications for loop diuretics, our data suggest that a substantial proportion of T2D patients may have unrecognized heart failure and therefore could be missing opportunities for targeted therapies that could alter the clinical course of heart failure.

Ultrasound imaging of congestion in heart failure: examinations beyond the heart.

Congestion, related to pressure and/or fluid overload, plays a central role in the pathophysiology, presentation and prognosis of heart failure and is an important therapeutic target. While symptoms and physical signs of fluid overload are required to make a clinical diagnosis of heart failure, they lack both sensitivity and specificity, which might lead to diagnostic delay and uncertainty. Over the last decades, new ultrasound methods for the detection of elevated intracardiac pressures and/or fluid overload have been developed that are more sensitive and specific, thereby enabling earlier and more accurate diagnosis and facilitating treatment strategies. Accordingly, we considered that a state-of-the-art review of ultrasound methods for the detection and quantification of congestion was timely, including imaging of the heart, lungs (B-lines), kidneys (intrarenal venous flow), and venous system (inferior vena cava and internal jugular vein diameter).

Abstract 15970: Risk of Heart Failure Preserved Ejection Fraction in Obstructive Sleep Apnea: A Single Center Retrospective Analysis

Background: Inherent characteristics of patients with Obstructive Sleep Apnea (OSA), such as age, obesity, diabetes and hypertension increase the risk for cardiovascular diseases including heart failure (HF). Herein, we sought to elucidate if there is an increased likelihood of having heart failure with preserved ejection fraction (HFpEF) as OSA severity increases. Furthermore, we correlated a validated H2FpEF score system in this cohort with clinical and imaging findings for HFpEF. Results: Out of 585 charts reviewed from patients diagnosed with OSA, a total of 108 patients with a concomitant transthoracic echocardiogram (TTE) and electrocardiogram performed were identified. The median age was 59 years old with 55.6% being males and Hispanic predominance 64.5%. The comorbidities found in our cohort involved hypertension (63.9%), diabetes mellitus (30.6%), coronary artery disease (15.7%), HF (13%), atrial fibrillation (8.3%), and stroke (7.4%). Mean BMI was 32.48 kg/m 2 and average neck size 16.02 inches. TTE findings demonstrated an average ejection fraction of 58±7% and mean pulmonary artery systolic pressure of 24±10 mmHg. OSA severity distribution is shown in Table 1. No significant association was found between grade of severity of OSA with clinical diagnosis of HF, nor with diastolic dysfunction by TTE. The average probability of HFpEF by validated score was 50%, and the distribution of the score was the same across severity of OSA (p=0.260). Pearson’s correlation showed a significant positive relationship between age, BMI and PASP, and H2FpEF score (p&lt;0.01 for all), however, no relation was found when correlating with neck size, apnea-hypopnea index and mean oxygen saturation. Conclusion: Although patients with OSA might have a higher H2FpEF score due to inherent characteristics, the clinical diagnosis of HFpEF in our population was lower than expected by H2FpEF score, in which the degree of severity was not associated with a higher H2FpEF score.