Clinical History Of Heart Failure Research Articles

Metabolic abnormalities and reprogramming in cats with naturally occurring hypertrophic cardiomyopathy.

The heart is a metabolic organ rich in mitochondria. The failing heart reprograms to utilize different energy substrates, which increase its oxygen consumption. These adaptive changes contribute to increased oxidative stress. Hypertrophic cardiomyopathy (HCM) is a common heart condition, affecting approximately 15% of the general cat population. Feline HCM shares phenotypical and genotypical similarities with human HCM, but the disease mechanisms for both species are incompletely understood. Our goal was to characterize global changes in metabolome between healthy control cats and cats with different stages of HCM. Serum samples from 83 cats, the majority (70/83) of which were domestic shorthair and included 23 healthy control cats, 31 and 12 preclinical cats with American College of Veterinary Internal Medicine (ACVIM) stages B1 and B2, respectively, and 17 cats with history of clinical heart failure or arterial thromboembolism (ACVIM stage C), were collected for untargeted metabolomic analysis. Multiple linear regression adjusted for age, sex and body weight was applied to compare between control and across HCM groups. Our study identified 1253 metabolites, of which 983 metabolites had known identities. Statistical analysis identified 167 metabolites that were significantly different among groups (adjusted P<0.1). About half of the differentially identified metabolites were lipids, including glycerophospholipids, sphingolipids and cholesterol. Serum concentrations of free fatty acids, 3-hydroxy fatty acids and acylcarnitines were increased in HCM groups compared with control group. The levels of creatine phosphate and multiple Krebs cycle intermediates, including succinate, aconitate and α-ketoglutarate, also accumulated in the circulation of HCM cats. In addition, serum levels of nicotinamide and tryptophan, precursors for de novo NAD+ biosynthesis, were reduced in HCM groups versus control group. Glutathione metabolism was altered. Serum levels of cystine, the oxidized form of cysteine and cysteine-glutathione disulfide, were elevated in the HCM groups, indicative of heightened oxidative stress. Further, the level of ophthalmate, an endogenous glutathione analog and competitive inhibitor, was increased by more than twofold in HCM groups versus control group. Finally, several uremic toxins, including guanidino compounds and protein bound putrescine, accumulated in the circulation of HCM cats. Our study provided evidence of deranged energy metabolism, altered glutathione homeostasis and impaired renal uremic toxin excretion. Altered lipid metabolism suggested perturbed structure and function of cardiac sarcolemma membrane and lipid signalling.

Prevalence and outcomes of American Heart Association stages of heart failure in an adult brazilian population of the ELSA-Brasil study

Abstract Aims Heart failure (HF) has a major impact on public health, affecting up to 2% of adult population. HF staging is helpful in capturing pre-clinical disease and its progression to advanced stages. We aimed to determine the prevalence and mortality of HF stages in the participants of a Brazilian adult cohort. Methods The ELSA-Brasil cohort comprises 15,105 adult public servants from 6 Brazilian capitals. In the initial evaluation of the study (2008-2010), ELSA carried out interviews and clinical, laboratory, and cardiovascular ancillary tests. In this analysis, we included participants who had electrocardiogram and echocardiogram performed at baseline visit, and additional information regarding risk factors and functional capacity. The HF stages were defined based on AHA guidelines criteria as follow: Stage 0 was defined as a healthy individual with no risk factors for heart failure. Stage A (at risk for HF) included those without cardiac structural or functional abnormality but with any of the following conditions: systemic hypertension; diabetes mellitus, obesity, history of myocardial revascularization, history of rheumatic fever, and seropositivity for Chagas’ disease. Stage B (pre-HF) was defined as asymptomatic participants with history of myocardial infarction or any major abnormalities on ECG or echocardiogram. Stage C (symptomatic HF) included participants with a clinical history of HF, or HF symptoms in the presence of structural heart disease (defined as in Pre-HF stage). Considering the community-dwelling profile of the sample, we did not expect to have advanced heart failure patients in our sample. Results We included the 3,267 participants (61±9 years; 53% women) with baseline data. Prevalences of HF stages were stage 0: 938 (29%) A: 1,385 (42%), B: 651 (28%) and C: 293 (9%), with different distribution between sexes (p&amp;lt;0.001). Older participants had higher prevalences of stages B and C (p&amp;lt;0.001), with the prevalence of stage C increasing from 1.8% at 35-44 years to 12.2% at 65-74 years. After 12 years of follow-up, total mortality rates of HF stages were Stage 0: 4%; A:10%. B: 16%, and C: 26%, and respective Cox proportional hazard ratios [95% CI] adjusted for age and sex were A: 1.94 [1.3-2.8], B:2.78 [1.9-4.1], and C: 5.39 [3.6-8.1] compared to stage 0. Conclusions The prevalence of HF in Brazilians reflects what is described in international literature, with a large proportion of individuals in pre-symptomatic stages. A notable shift in the sample toward pre-symptomatic and symptomatic HF occurred gradually and persistently across the age span studied. Mortality rates increase incrementally across the HF stages. This information is important for understanding and planning health policies for this syndrome.

Incidence of atrial fibrillation detected by an insertable cardiac monitor in a large real-world cohort of heart failure patients with reduced and preserved ejection fraction

Abstract Background Subcutaneous implantable cardiac monitors (ICM) have the capability to detect atrial fibrillation (AF) episodes with high degree of accuracy [1]. Objective We investigated the incidence of AF in patients implanted with an ICM and a clinical history of heart failure (HF) with reduced or preserved left ventricular ejection fraction (LVEF). Methods Patients with history of HF admissions who were implanted with an ICM were identified from the aggregated and de-identified electronic health record (EHR) database during 2007-2021. The device collected data were merged with the EHR data to create a de-identified database of real-world patients. Patients were included if they had ≥180 days of device follow-up. ICMs detect AF based on incoherence of RR intervals and absence of single p-wave between two R-waves [1]. All ICM detected AF episodes stored with at least 30 seconds of ECG at onset were adjudicated using an artificial intelligence (AI) model. The AI model was previously trained and validated using over 60K manually adjudicated episodes and was shown to have an accuracy of over 97% [2]. ICM detected AF episodes with AI model based true probability of AF ≥ 0.9 was analyzed. The Kaplan-Meier incidence curves for AF incidence as a function of episode duration, clinical history of AF, and LVEF are reported. Results A total of 1020 LINQ ICM patients with history of HF admission prior to implant were identified from the deidentified real-world dataset. LVEF was available in 889 (87%) patients, of whom 394 (44%) had EF &amp;lt;50%, and 495 (56%) had EF≥50%. NYHA class was available in 296 (29%) patients, of whom 39 (13%) were class I, 126 (43%) were class II, 112 (38%) were class III, and 19 (6%) were class IV. Patients had an average age of 68±13 years with 52% being males and had clinical history of hypertension in 95%, diabetes in 56%, coronary artery disease in 75%, AF in 57%, stroke/TIA in 51%, and renal dysfunction in 53%. A total of 911 patients with ≥180 days of follow-up (average follow-up of 25.8 months) were included. A total of 8407 episodes from 358 patients were classified by the AI model as true AF. The incidence of AF as a function of episode duration, clinical history of AF and reduced vs preserved LVEF are shown in Figures A, B, and C respectively. Incidence of AF, as detected by an ICM over 42 months of follow-up, was estimated to be 38% to 46% depending on AF episode duration. Estimated 42-month AF incidence was 23% in patients with no clinical history of AF. The 42-month AF incidence was 44% vs 47% in HF patients with reduced versus preserved LVEF. Conclusion Incidence of AF, as detected by an ICM over 3 years of follow-up, was estimated to be in close to half of ICM patients with history of HF events. Close to one fourth of the patients with no prior clinical history of AF had newly detected AF. AF incidence was similar in HF patients with preserved versus reduced LVEF in this real-world cohort.

HYPERTENSIVE EMERGENCIES AND URGENCIES: ADHERENCE TO GUIDELINES AND RELATIONSHIP BETWEEN BLOOD PRESSURE MANAGEMENT AND IN–HOSPITAL MORTALITY

Abstract Introduction Data regarding prevalence and clinical management of hypertensive emergencies and urgencies are lacking and heterogeneous. Our goal is to characterize patients with hypertensive emergencies and urgencies admitted to the Emergency Department (ED) of Niguarda hospital and Pio XI Hospital of Desio. In this population we also want to evaluate factors associated with organ damage, adherence to guidelines and the impact of Blood Pressure (BP) management on in–hospital mortality. Method We performed a multi–centre retrospective study collecting data about all adult patients with systolic BP ≥ 180 mmHg and/or diastolic BP ≥120 mmHg admitted to our hospitals‘ ED during 2017 and 2019. Results Admission to ED for BP elevation were 1838 (0.95% of total admission to ED), of whom 38% were hypertensive emergencies and 62% were hypertensive urgencies. Patients with hypertensive emergencies were older, mainly male, with more comorbidities and more symptomatic at ED admission. In the emergencies group, we observe a SBP mean reduction of 39.50 mmHg (±26.35) and a DBP mean lowering of 16.28 mmHg (±17.57); the most used drugs were furosemide, nitroglycerin and parenteral labetalol. In the urgencies group, the mean reduction was 39.09 mmHg (±22.46) for SBP and 15.34 mmHg (±16.07) for DBP. The most used drug was short–acting nifedipine benzodiazepine and amlodipine in this group. Age, sex, clinical history of heart failure and chronic obstructive pulmonary disease, symptoms at ED admission ad eGFR have been recognised as factors associated with organ damage. Instead, BP at ED admission and its management didn’t appear to have a significant impact on outcomes. Conclusions Our study demonstrated better adherence to guidelines in the treatment of hypertensive emergency than of hypertensive urgencies. Furthermore, no significant association were found between the BP management in the ED and in–hospital mortality.

A SHORT SURVEY ABOUT AWARENESS OF INFLUENZA VACCINATION AMONG PATIENTS WITH HEART FAILURE IN A TERTIARY CARE HOSPITAL OF PAKISTAN

Objectives: The objective of this survey was to highlight whether influenza vaccination was advised or not in patients with heart failure. Whether heart failure patients are aware of its significance or not, and more importantly they are getting vaccinated or not. Methodology: This descriptive short survey was conducted at heart failure clinic of a tertiary care cardiac center. Consecutive patients of heart failure with reduced ejection fraction (HFrEF) were interviewed regarding awareness and significance of influenza vaccination. Survey was conducted using a structured questionnaire with specific sections pertinent to the demographic details of the participants, clinical history of heart failure and hospitalizations, co-morbid conditions, and awareness and adherence to the influenza vaccination. Results: A total of 60 patients with HFrEF participated in this survey, 71.7% (43) of which were male, overall mean age was 56.82 ± 11.78 years, and mean duration since diagnosis of HFrEF was 3.88 ± 3.66 years. Only 15% (9) of the participants were aware of influenza vaccination, 18.3% (11) recall being advised by the medical officer, and 11.7% (7) received these vaccinations. Conclusion: Influenza vaccination rate in patients with heart failure in Pakistan population is very low. The primary reason is inadequate prescription practice by physicians and lack of adequate awareness. Need of time is to emphasis health care provider to prescribe and encourage their patients with heart failure to receive influenza vaccine and to make it accessible.

Left Ventricular Diastolic Indices and Their Impact on Outcomes in Patients with Recently Diagnosed Atrial Fibrillation.

Background: Early identification of atrial fibrillation (AF) patients at risk for heart failure (HF) remains critical for improving their outcomes. We aimed to investigate whether indices of left ventricular diastolic dysfunction (LVDD) can stratify AF patients without clinical history of HF. Methods: We extracted 1775 patients’ data from a prospective cohort that consecutively recruited recently recognized AF patients with ejection fraction ≥50%. We categorized patients as LVDD grade 0 (none) to 3 (severe) based on mitral deceleration time and E/e’ per the American Society of Echocardiography recommendation. The primary outcome was a composite of all-cause death, stroke, and HF hospitalization during the 2-year follow-up. We also investigated the Atrial Fibrillation Effects on QualiTy-of-Life (AFEQT) scores. Results: Overall, 857 (48.3%) had mild or higher LVDD. Incidence of primary outcomes increased in parallel with LVDD grading (1.8%, 2.8%, 6.5%, and 8.1% for grades 0–3, respectively, p < 0.001), and the presence of grade 3 LVDD was an independent predictor of the primary outcome (adjusted HR 2.28 (vs. grade 0), 95%CI 1.13–4.60). Furthermore, patients with LVDD had lower AFEQT scores at the enrollment and 1-year follow-up. Conclusions: LVDD indices were associated with adverse clinical outcomes and patients’ perceived health status in a recently diagnosed AF cohort without HF.

Implantable cardioverter defibrillator and cardiac resynchronization therapy use in New Zealand (ANZACS-QI 33).

BackgroundThe ANZACS‐QI Cardiac Implanted Device Registry (ANZACS‐QI DEVICE) collects nationwide data on cardiac implantable electronic devices in New Zealand (NZ). We used the registry to describe contemporary NZ use of implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT).MethodsAll ICD and CRT Pacemaker implants recorded in ANZACS‐QI DEVICE between 1 January 2014 and 31 December 2017 were analyzed.ResultsOf 1579 ICD implants, 1152 (73.0%) were new implants, including 49.0% for primary prevention and 51.0% for secondary prevention. In both groups, median age was 62 years and patients were predominantly male (81.4% and 79.2%, respectively). Most patients receiving a primary prevention ICD had a history of clinical heart failure (80.4%), NYHA class II‐III symptoms (77.1%) and LVEF ≤35% (96.9%). In the secondary prevention ICD cohort, 88.4% were for sustained ventricular tachycardia or survived cardiac arrest from ventricular arrhythmia. Compared to primary prevention CRT Defibrillators (n = 155), those receiving CRT Pacemakers (n = 175) were older (median age 74 vs 66 years) and more likely to be female (38.3% vs 19.4%). Of the 427 (27.0%) ICD replacements (mean duration 6.3 years), 46.6% had received appropriate device therapy while 17.8% received inappropriate therapy. The ICD implant rate was 119 per million population with regional variation in implant rates, ratio of primary prevention ICD implants, and selection of CRT modality.ConclusionIn contemporary NZ practice three‐quarters of ICD implants were new implants, of which half were for primary prevention. The majority met current guideline indications. Patients receiving CRT pacemaker were older and more likely to be female.

Micro-RNA and mRNA myocardial tissue expression in biopsy specimen from patients with heart failure

AimsThere is increasing evidence that changes in microRNA (miRNA) expression occur in chronic heart failure and these may be involved in the pathogenesis. In this study we have explored the expression of selected myocyte and fibroblast-related microRNAs and messenger RNAs (mRNAs) that are associated with hypertrophy, apoptosis and fibrosis in biopsy specimens from patients with relatively new onset heart failure compared to a group of patients without heart failure. Methods and ResultsMyocardial biopsy specimens taken from Chinese patients presenting with recent heart failure were compared with a group of patients without heart failure undergoing routine cardiac surgery (n=34). miRNAs (miR-1, -21, -23, -29, -30, -130, -133, -195, -199, -208, and -320) and corresponding mRNA expression were measured by real-time quantitative-PCR method. miR-1, -21, -23, -29, -130, -195 and -199 were significantly up-regulated in the heart failure group when compared to those without heart failure (all p<0.01). However, miR-30, -133, -208 and -320 were not significantly different. Related mRNAs (casp3, coll I, coll III and TGF) were also significantly up-regulated (all p<0.05) in the heart failure group. ConclusionCertain selected microRNAs involved in apoptosis, hypertrophy and fibrosis are up-regulated in the myocardium of patients with a clinical history of heart failure compared to those without. These specific miRNAs may be the most suitable for circulating biomarkers in the early stages of chronic heart failure and possibly future therapeutic targets.

Values of high sensitive troponin T in long-term survivors of childhood cancer treated with anthracyclines

BackgroundCardiac biomarkers can play an important role in the early detection of subclinical heart failure. Our aims are to 1) obtain values of high sensitive cardiac troponin T (hs-cTnT) in long-term survivors of childhood cancer and 2) investigate the potential role of hs-cTnT in the detection of subclinical late-onset cardiotoxicity. MethodsHs-cTnT and N-terminal-pro-brain natriuretic peptide (NT-pro-BNP) were measured in 64 survivors. Electrocardiography and echocardiography were performed to evaluate cardiac function. ResultsMean follow-up period was 8.3years (range of 4.5 to 34.1). All survivors were clinically asymptomatic and had no history of clinical heart failure during or immediately after anthracycline treatment. Electrocardiography (available in 59 of 64 survivors) showed no signs of myocardial injury related to ischemia or abnormal QTc. Echocardiography was performed in all survivors. Mean left ventricular shortening fraction (SF) was 34% (range of 28 to 43%); mean ejection fraction (EF) was 61% (range of 48 to 74%). Seven survivors had a mildly decreased EF between 48% and 55%. Normal hs-cTnT levels were found in all 64 survivors (range of 3 to 13ng/L) and did not differ among different anthracycline dosage groups: ≤120, 120–300 and ≥300mg/m2. Yet, 5/64 survivors had elevated NT-pro-BNP levels (range of 7 to 25pg/ml) with normal SF and ECG findings and only one mildly abnormal EF of 51%. ConclusionsHs-cTnT concentrations are normal in long-term survivors of childhood cancer, even in the subpopulations with elevated NT-pro-BNP and/or a mildly decreased EF, indicating that it is not a sensitive marker for late onset subclinical anthracycline induced cardiotoxicity.

Abstract 14990: Sudden Death in Patients with Heart Failure and Preserved Ejection Fraction

Introduction: Severely reduced left ventricular ejection fraction (EF) is an established risk factor for sudden cardiac death (SCD), but has limited sensitivity and specificity. We evaluated the contribution of heart failure (HF) with preserved ejection fraction toward risk of SCD in the general population. Hypothesis: We hypothesized that HF would predict risk of SCD, even among patients with preserved EF. Methods: Subjects from an ongoing community-based study of SCD in the northwest US (pop. approx. one million) were included if age ≥18 (2002 - 2012) with clinical history and assessment of EF. Clinical history of heart failure (HF) was determined by physician report. Ejection fraction (EF) was determined from echocardiogram, angiogram, or multigated acquisition scan, and categorized as EF &lt;20%, 20-34%, 35-44%, 45-54%, and ≥55%. Laboratory values of brain natriuretic peptide (BNP) were obtained from routine clinical laboratory testing for a subset of patients. Results: Cases (n=628, mean age 69.9, 65% male) were more likely than controls (n = 580, mean age 66.8, 66% male) to have a history of clinically-recognized HF (58% vs. 24%, p&lt;0.0001) and to have an EF ≤ 35% (27% vs. 12%, p&lt;0.0001). At each EF level above 20%, HF was approximately twice as prevalent in cases compared to controls (Figure, p≤0.002). Median BNP levels were significantly higher for patients with HF vs. those without, across EF categories. Adjusting for age and sex, each category of decreasing EF was associated with an increased risk of SCD (OR 1.4, 95% CI 1.3 - 1.6, p&lt;0.0001), but the association was diminished by adjustment for HF, and for BNP. Odds of SCD were 4-fold higher (p&lt;0.0001) in the presence HF, adjusting for age and sex, across all categories of EF. Conclusions: In this population, the significant role of HF with preserved EF in SCD was confirmed by BNP level trends. Improvements in SCD prevention will require focused investigation of high risk SCD markers in patients with heart failure and preserved EF.

Relationship of Heart Rate Variability to Sleepiness in Patients with Obstructive Sleep Apnea with and without Heart Failure

Many patients with severe obstructive sleep apnea (OSA) do not complain of excessive daytime sleepiness (EDS), possibly due to increased sympathetic nervous activity (SNA) and accompanying heightened alertness. We hypothesized that in patients with OSA, those without subjective EDS (Epworth Sleepiness Scale, ESS score < 11) would have higher very low frequency (VLF) heart rate variability (HRV) during sleep, reflecting greater sympathetic heart rate modulation than patients with an ESS score ≥ 11. Patients with severe OSA (AHI ≥ 30: 26 with and 65 without heart failure) were divided into those with and without EDS. Heart rate (HR) signals were acquired in stage 2 sleep during periods of recurrent apneas and hypopneas and submitted to coarse graining spectral analysis, which extracts harmonic, neurally mediated contributions to HRV from total spectral power. Because the apnea-hyperpnea cycle entrains muscle SNA at VLF (0 to 0.04 Hz), VLF power was our principal between-group comparison. Subjects without EDS had higher harmonic VLF power (944 ± 839 vs 447 ± 461 msec(2), p = 0.003) than those with EDS, irrespective of the presence or absence of heart failure (1218 ± 944 vs 426 ± 299 msec(2), p = 0.043, and 1029 ± 873 vs 503 ± 533 msec(2), p = 0.003, respectively). ESS scores correlated inversely with VLF power in all (r = -0.294, p = 0.005) and in heart failure subjects (r = -0.468, p = 0.016). Patients with severe OSA but without EDS have higher VLF-HRV than those with EDS. This finding suggests that patients with severe OSA but without EDS have greater sympathetic modulation of HRV than those with EDS that may reflect elevated adrenergically mediated alertness. Taranto Montemurro L; Floras JS; Picton P; Kasai T; Alshaer H; Gabriel JM; Bradley TD. Relationship of heart rate variability to sleepiness in patients with obstructive sleep apnea with and without heart failure.

Inferior vena cava parameters predict re‐admission in ischaemic heart failure

The clinical history of heart failure (HF) is usually characterized by frequent hospitalizations for decompensation. Therefore, several markers of subclinical hemodynamic congestion are under investigation for predicting early rehospitalization. In this field, the potential of ultrasound inferior vena cava (IVC) assessment has been recently investigated in HF but not yet assessed in the different aetiological categories. Forty-eight patients admitted for decompensated HF (n = 25 with ischaemic heart disease [IHD] and n = 23 non-IHD) underwent biochemical examination (including NT-proBNP), echocardiography and IVC assessment by hand-carried ultrasound (HCU). During 60-day follow-up after discharge, the re-hospitalization rate for HF was recorded to investigate the predictive power of NT-proBNP and IVC assessment among the two study groups. IHD and non-IHD patients with HF were similar except for gender distribution. During follow-up, 16·7% of patients were rehospitalized for decompensated HF, with higher prevalence in IHD group (28% vs. 4·3% P = 0·031). IVC assessment at discharge significantly predicted re-admission in the overall population and in IHD group, whereas NT-proBNP failed to predict rehospitalization in IHD group. In adjusted hazard ratio, only IVC min and the changes of IVC from admission significantly predicted re-admission. ROC analysis confirmed the change in IVC min as the best predictor of rehospitalization in patients with IHD. This pilot study showed a higher early re-admission rate in patients with HF due to IHD. In addition, the change in IVC min diameter from admission to discharge was the best predictor of re-admission in patients with IHD.

Determinants of hemodialysis-induced segmental wall motion abnormalities

Patients who demonstrate worsening of cardiac wall motion (WM) during hemodialysis have higher 1-year mortality. We sought to identify risk factors for dialysis-induced WM abnormalities. Additionally, we examined the effects of hemodialysis on other parameters of cardiac function. Forty patients underwent echocardiography directly before dialysis and during the last hour of dialysis (79 dialysis sessions). Candidate predictors for intradialytic worsening of WM included age, a history of heart failure (HF) or coronary artery disease, changes in blood pressure or heart rate, high sensitivity cardiac troponin T and N-terminal brain natriuretic peptide. Among 40 patients, WM worsened segmentally in eight patients (20%), worsened globally in one patient (3%), and improved segmentally in four patients (10%). Diastolic function worsened in 44% of patients, and left ventricular ejection fraction was largely unchanged during dialysis. The case of globally worsened WM occurred in the setting of intradialytic hypertension in a patient without HF. Surprisingly, history of coronary artery disease, hemodynamics, and serologic factors were not associated with worsened segmental WM during dialysis. After adjustment for history of coronary artery disease and other cardiac risk factors, patients with a history of HF had a threefold higher risk of worsening segmental WM during dialysis (RR 3.1, 95% CI [1.1, 9], p = 0.04). In conclusion, patients with a history of clinical HF were at higher risk of intradialytic worsening of segmental WM. Further studies are needed to determine the mechanism of this association and whether cardioprotective medications could ameliorate this adverse cardiac effect of hemodialysis.

Heart Failure With Preserved or Reduced Ejection Fraction in Patients Treated With Peritoneal Dialysis

Heart failure is one of the most frequent complications in dialysis patients. However, little is known of the significance of the entity "heart failure with preserved ejection fraction" (HFPEF) in this population. This study aimed to determine the prevalence, clinical profiles, and long-term outcomes of peritoneal dialysis patients with HFPEF. Prospective cohort study. 220 patients treated with peritoneal dialysis were recruited from a university teaching hospital in Hong Kong. Heart failure was defined clinically based on the presence of: (1) symptoms and signs, including dyspnea, increased jugular venous pressure, and basal crepitations; (2) radiographic evidence of pulmonary venous congestion or interstitial edema; and (3) resolution of symptoms, signs, and radiographic changes with hypertonic peritoneal dialysis exchanges. Based on a combination of clinical history of heart failure and echocardiography-derived ejection fraction, patients were classified as having no heart failure, HFPEF, and heart failure with reduced ejection fraction (HFREF). All-cause mortality, cardiac death, heart failure, and fatal or nonfatal cardiovascular events. All patients underwent 2-dimensional echocardiography and tissue Doppler imaging at baseline and were followed up prospectively for clinical events for 4 years. 86 (39%) patients had heart failure, of whom 54.7% had preserved ejection fraction ≥50% and 45.3% had reduced ejection fraction <50%. Patients with HFPEF were intermediate between those with no heart failure and those with HFREF in terms of blood pressure, prevalence of coronary artery disease, diabetes, cardiac biomarkers, left ventricular mass, volume, and ratio of early mitral inflow velocity to peak mitral annulus velocity. In the multivariable Cox regression analysis, patients with HFPEF showed an increased adjusted HR for cardiac death (2.57; 95% CI, 1.20-5.50), heart failure (HR, 2.25; 95% CI, 1.28-3.96), and fatal or nonfatal cardiovascular event (HR, 2.01; 95% CI, 1.26-3.21) compared with those with no heart failure, but the risk was lower compared with those with HFREF. The study included prevalent peritoneal dialysis patients and may introduce survival bias. HFPEF is common in peritoneal dialysis patients (∼55% of all heart failure) and is associated with increased risk of mortality and adverse cardiovascular outcomes compared with those with no heart failure, although the risk was lower than in patients with HFREF. This entity needs to be more recognized in peritoneal dialysis patients.

Venous Thromboembolism in Heart Failure: Preventable Deaths During and After Hospitalization

Objective Our aim was to compare the clinical characteristics, prophylaxis, treatment, and outcomes of patients with venous thromboembolism with and without heart failure. Methods We studied patients with heart failure in the population-based Worcester Venous Thromboembolism Study of 1822 consecutive patients with validated venous thromboembolism. Results Of the 1822 patients with venous thromboembolism, 319 (17.5%) had a history of clinical heart failure and 1503 (82.5%) did not. Patients with heart failure were older (mean age 75 vs 62 years, P < .0001) and more likely to have been immobilized (65.2% vs 46.1%, P < .0001). Thromboprophylaxis was omitted in approximately one third of patients with heart failure who had been hospitalized for non-venous thromboembolism-related illness or had undergone major surgery within the 3 months before diagnosis. Patients with heart failure had a higher frequency of in-hospital death (9.7% vs 3.3%, P < .0001) and death within 30 days of venous thromboembolism diagnosis (15.6% vs 6.4%, P < .0001). Heart failure (adjusted odds ratio [OR] 2.04; 95% confidence interval [CI], 1.15-3.62) and immobility (adjusted OR 4.37; 95% CI, 2.42-7.9) were associated with an increased risk of in-hospital death. Heart failure (adjusted OR 1.57; 95% CI, 1.01-2.43) and immobility (adjusted OR 3.05; 95% CI, 2.01-4.62) also were independent predictors of death within 30 days of venous thromboembolism diagnosis. Conclusion High mortality was observed among patients with heart failure and venous thromboembolism both during and after hospitalization. Heart failure and immobility are potent risk factors for in-hospital death and death within 30 days in patients with venous thromboembolism.

238 Comparison of the clinical profiles of hypertensive patients with a history of heart failure and reduced versus preserved left ventricular ejection fraction – the O-PREDICT 2 study

While the links between high blood pressure and heart failure (HF) are well known, the clinical profiles of hypertensive patients (pts) according to measure of left ventricular (LV) ejection fraction (EF) remain poorly investigated. O-PREDICT 2 was a multicentre observational study conducted among 1537 general practitioners who classified 4427 hypertensive outpatients (pts) (mean age 72±9 years; 66% males) according to the presence (Group 1, 2969 Pts) or absence (Group 2, age > 65 years) of a history of clinical HF. The study cohort included 2052 (46.4%) pts with an available measure of LVEF, 1713 (58%) from group 1 and 350 from group 2. In group 1, 677 (39.5%) pts had a reduced EF ≤ 40% (1A) and 1036 (60.5%) had a preserved EF > 40% (1B), while, in group 2, 330 (94.3%) had a preserved EF. When comparing groups 1A, 1B and 2, a significant difference (p<.05) was found for history of hospitalization for HF (70.3%, 59.2% and 0%, respectively), SBP ≥ 140 mmHg (35%, 47.7% and 53.6%), coronary artery disease (52.2%, 40.4% and 15.2%), and myocardial infarction (69.2%, 52.3% and 46.8%). Incidence of atrial fibrillation (AF) was 11% in group 2 while in groups 1A and 1B it differed according to the NYHA functional class, reaching respectively 50.1% and 62.9% of the pts in class II, and 39.5% and 24.6% of the pts in class III. Reduced EF was more frequent in male (74% in group 1A vs. 64.2% in group 1B and 63.6% in group 2) than in female (26% vs. 35.8% and 36.4%, respectively). LV hypertrophy, cardiovascular disease, renal failure or arteriopathy, were evenly distributed in groups 1A and 1B. Among hypertensive pts with a clinical history of HF, pts with preserved HF are more often female and presented with AF, while pts with systolic HF are more often hospitalized or presented with a history of coronary artery disease. However, even in case of preserved EF, the rates of hospitalizations and myocardial infarction remain markedly elevated (> 50%)

069 Main risk factors leading from arterial hypertension to heart failure – The O-PREDICT 2 study

While the major role played by hypertension (HT) in the genesis of chronic heart failure (HF) is well known, the main risk factors leading to HF in hypertensive patients remain poorly investigated. O-PREDICT 2 was a multicentre, observational study conducted with 1537 general practitioners who recruited 4427 consecutive hypertensive outpatients (pts) (mean age 72±9 years; 66% males). We compared pts with a clinical history of HF (group 1, n=2969) and without HF (group 2, n=1458, age > 65 yrs). Sex ratio and age were similar between groups. Duration of HT was higher (P<.05) in group 1 (14± 8 vs. 11± 8 years in group 2). Blood pressure was lower in group 1, with 49.4% pts having SBP ≥ 140 mmHg vs. 60.9% in group 2. The number of cardiovascular risk factors ranged from 0 to 11 with a median of 4 in group 1, and from 0 to 10 with a median of 2 in group 2; 74.3% of pts in group 1 vs. 45.6% in group 2 had more than 3 risks factors (P<.05). Using multivariate analysis, left ventricular hypertrophy (LVH) was the strongest risk factor of HF (OR= 25.4, 95%CI=21-31), followed by the presence of heart valve disease (OR=4.1, 95%CI=2.7-6.3), paroxystic or permanent atrial fibrillation (OR=4.05, 95%CI=3.1-5.3), renal dysfunction, history of myocardial infarction and coronary artery disease (OR<3 for each of them). As suspected, LVH is the strongest risk factor for HF in hypertension, while a majority of pts presented with > 3 risk factors for HF. This study highlights the need for an early management of HF risk factors in hypertensive pts.

Clinical Usefulness of Electrophysiologic Study (EPS)-Guided Risk Stratification for Life-Threatening Arrhythmia in Patients With Heart Failure

Ventricular tachyarrhythmia is one of the most important factors determining the prognosis of patients with heart failure and sudden death can be observed even during stable therapy controlling clinical heart failure. In this study, the usefulness of electrophysiologic study (EPS) for the prediction of a future arrhythmic event was evaluated in patients with heart failure. The patient population consisted of 474 patients with a history of clinical heart failure but without an episode of spontaneous sustained ventricular tachycardia or fibrillation (VT/VF). A Holter ECG was performed in all patients, and 177 of the 474 patients underwent EPS because of a recording of nonsustained VT (NSVT, > 5 beats). When sustained VT/VF was inducible in EPS, the patient was assigned to implantation of a defibrillation device. The patients were divided into 3 groups, ie, 1) no NSVT (n = 297), 2) NSVT + no inducible VT/VF (n = 134), and 3) NSVT + inducible VT/VF (n = 43), and were followed-up for > 12 months. All patients were followed-up under standard therapy for heart failure. There were no significant differences in basic clinical characteristics and therapies among the 3 groups. During the follow-up period of 32 +/- 18 months, 56/474 patients suffered a VT/VF episode, ie, 21/297 in no NSVT, 14/134 in NSVT + no inducible VT/VF, and 21/43 in NSVT + inducible VT/VF patients (P = 0.032). All patients were rescued from sudden death among patients with an implanted defibrillator, but 11 patients without a defibrillator died. In patients with heart failure, future arrhythmic events could be predicted by EPS and Holter ECG. EPS-guided risk stratification seems to be useful in managing patients with heart failure.

Left Main Coronary Revascularization at the Crossroads

Percutaneous revascularization of left main coronary artery (LMCA) disease has remained controversial for more than 25 years, since LMCA balloon angioplasty was first performed by Andreas Gruentzig in 1978. Summarizing his experience, Gruentzig concluded, “We have not been too successful with dilating left main stems…although the procedure is relatively simple, the potential complications are both sudden and serious.”1 Following the evolution of percutaneous catheter-based therapies to include both bare metal stent and, more recently, drug-eluting stent (DES) platforms in conjunction with advances in periprocedural and postprocedural adjunctive pharmacotherapies, interest in percutaneous LMCA revascularization, particularly unprotected left main, has been renewed. Although studies performed with bare metal stents demonstrated a low rate of in-hospital mortality, the incidence of late coronary restenosis remained high.2–6 In the Unprotected Left Main Trunk Intervention Multi-Center Assessment (ULTIMA) registry, which enrolled 279 patients with unprotected LMCA disease who had percutaneous coronary revascularization (69% bare metal stent), mortality at a 1-year follow-up was proportional to clinical risk stratification (40% in high-risk versus 3.5% in low-risk patient cohorts), and repeated revascularization was required in 34% of cases.6 The experience gleaned from these studies continued to support the American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations that in reasonable surgical candidates with LMCA disease, coronary bypass surgery is the preferred therapeutic option.7 After the introduction of DES, several small clinical series demonstrated the feasibility and short-term safety of LMCA stenting, while late clinical/angiographic outcomes appeared favorable as compared with historical (nonrandomized) patient cohorts treated with bare metal stents.3,8–11 The cumulative experience with DES treatment for LMCA demonstrated an apparent marked reduction in major adverse cardiovascular events, including target vessel revascularization, during 6 to 12 months of follow-up as compared with the precedent experience after bare metal stent deployment. Article p 2542 The clinical …

Long term prognosis of heart failure after acute coronary syndromes without ST elevation

Background: Information about long term outcomes of patients with acute coronary syndromes (ACS) who have clinically diagnosed heart failure is scarce. Methods: In a UK registry, this study evaluated patients...