Clinical Outcomes In Heart Failure Patients Research Articles

P189 HYPERTENSION AND OBSTRUCTIVE SLEEP APNOEA SYNDROME IN ADULTS WITH HEART FAILURE IN NIGERIA: CLINICAL CORRELATES AND ASSOCIATION WITH CLINICAL OUTCOMES

Rationale: Heart failure (HF) is a common endpoint for cardiovascular diseases. It is a major cause of morbidity and mortality worldwide. Hypertension is a leading cause of HF; a significant proportion of HF patients also have obstructive sleep apnea syndrome (OSAS) which is known to impact clinical outcomes adversely. The diagnosis of OSAS is often missed due to inadequate clinical diagnosis and diagnostic backup. This study aims to add to the body of evidence thereby improving outcomes in HF patients. Methods: This cross-sectional descriptive study involved 200 consenting adults with HF at Jos University Teaching Hospital, Nigeria. Each participant had relevant medical history, physical examination (including a six-minute walk test distance) and relevant investigations. OSAS was diagnosed using high-risk scores obtained using Berlin and STOP-Bang questionnaires, daytime somnolence was assessed by Epworth questionnaire and quality of life by Minnesota living with HF questionnaire. Comorbidities were assessed using Charlson comorbidity index (CCI)) and hospitalizations in the preceding 12 months documented. Data was analyzed using Stata version 13. Results: Hypertension was the aetiology of HF in 41% of the study population and 62.8% of the subset with OSAS (p=0.001). OSAS was identified in 47% and 45.5% by high-risk scores obtained using Berlin and STOP-Bang questionnaires respectively. Significant daytime somnolence was identified in 56.0% of the study population and 93.6% of those with OSAS, (p<0.001). Those with OSAS had a significant association with hypertension (p=0.001), atrial fibrillation (p<0.001), obesity (p=0.002), higher comorbidity index (p=0.001), HF with preserved ejection pattern (p=0.001) and NYHA ≥3 (p<0.001). OSAS was significantly associated with six-minute WTD ≤ 300m, hospitalizations (p<0.001) and sub-optimal quality of life (p=0.003). Conclusion: Hypertension and OSAS are significantly associated and are common in HF. It is recommended to routinely screen HF patients for OSAS as the diagnosis is often missed with consequent adverse clinical outcomes. This will facilitate prompt diagnosis, enhance management and favourable clinical outcomes in HF patients.

Comparative effectiveness of mesenchymal stem cell versus bone-marrow mononuclear cell transplantation in heart failure: a meta-analysis of randomized controlled trials

BackgroundThere is no clear evidence on the comparative effectiveness of bone-marrow mononuclear cell (BMMNC) vs. mesenchymal stromal cell (MSC) stem cell therapy in patients with chronic heart failure (HF).MethodsUsing a systematic approach, eligible randomized controlled trials (RCTs) of stem cell therapy (BMMNCs or MSCs) in patients with HF were retrieved to perform a meta-analysis on clinical outcomes (major adverse cardiovascular events (MACE), hospitalization for HF, and mortality) and echocardiographic indices (including left ventricular ejection fraction (LVEF)) were performed using the random-effects model. A risk ratio (RR) or mean difference (MD) with corresponding 95% confidence interval (CI) were pooled based on the type of the outcome and subgroup analysis was performed to evaluate the potential differences between the types of cells.ResultsThe analysis included a total of 36 RCTs (1549 HF patients receiving stem cells and 1252 patients in the control group). Transplantation of both types of cells in patients with HF resulted in a significant improvement in LVEF (BMMNCs: MD (95% CI) = 3.05 (1.11; 4.99) and MSCs: MD (95% CI) = 2.82 (1.19; 4.45), between-subgroup p = 0.86). Stem cell therapy did not lead to a significant change in the risk of MACE (MD (95% CI) = 0.83 (0.67; 1.06), BMMNCs: RR (95% CI) = 0.59 (0.31; 1.13) and MSCs: RR (95% CI) = 0.91 (0.70; 1.19), between-subgroup p = 0.12). There was a marginally decreased risk of all-cause death (MD (95% CI) = 0.82 (0.68; 0.99)) and rehospitalization (MD (95% CI) = 0.77 (0.61; 0.98)) with no difference among the cell types (p > 0.05).ConclusionBoth types of stem cells are effective in improving LVEF in patients with heart failure without any noticeable difference between the cells. Transplantation of the stem cells could not decrease the risk of major adverse cardiovascular events compared with controls. Future trials should primarily focus on the impact of stem cell transplantation on clinical outcomes of HF patients to verify or refute the findings of this study.

Intravenous iron therapy for heart failure and iron deficiency: An updated meta-analysis of randomized clinical trials.

Heart failure (HF) patients frequently exhibit iron deficiency, which is associated with a poor prognosis. Although various trials have been conducted, it is uncertain if intravenous (IV) iron replenishment improves clinical outcomes in HF patients with iron deficiency. A comprehensive literature search was conducted using PubMed/MEDLINE, Embase, and the Cochrane Library from inception till 15 September 2023 to retrieve randomized controlled trials (RCTs) that compared IV iron therapy with placebo or standard of care in patients with HF and iron deficiency. Clinical outcomes were assessed by generating forest plots using the random-effects model and pooling odds ratios (ORs) or weighted mean differences (WMDs). Fourteen RCTs with 6651 patients were included. IV iron therapy showed a significantly reduced incidence of the composite of first heart failure hospitalization (HHF) or cardiovascular (CV) mortality as compared with the control group (OR=0.73, 95% CI: 0.58 to 0.92). The IV iron therapy resulted in a trend towards lower CV mortality (OR=0.88, 95% CI: 0.76 to 1.01), 1-year all-cause mortality (OR=0.85, 95% CI: 0.71 to 1.02), and first HHF (OR=0.73, 95% CI: 0.51 to 1.05), and an improved left ventricular ejection fraction (LVEF) (MD=4.54, 95% CI: -0.13 to 9.21). Meta-regression showed a significant inverse moderating effect of baseline LVEF on the first HHF or CV death. In patients with HF and iron deficiency, IV iron therapy reduced the incidence of composite of first HHF or CV mortality. There was a trend of lower overall CV and 1-year all-cause mortality, first HHF, and improved LVEF with IV iron therapy.

Prognostic Implications of Insulin Resistance in Heart Failure in Japan.

Diabetes mellitus (DM) is a major risk and prognostic factor for heart failure (HF). Insulin resistance (IR) is an important component of DM, but the relationship between IR and HF prognosis has not yet been established across a wide variety of HF populations. We retrospectively evaluated the relationship between IR and clinical outcomes of HF patients at our hospital between 2017 and 2021. IR was defined as a homeostatic model assessment of IR (HOMA-IR) index ≥ 2.5, calculated from fasting blood glucose and insulin concentrations. The primary outcome was a composite of all-cause death and hospitalisation for HF (HHF). Among 682 patients included in the analyses, 337 (49.4%) had IR. The median age was 70 [interquartile range (IQR): 59-77] years old, and 66% of the patients were men. Among the patients, 41% had a left ventricular ejection fraction below 40%, and 32% had DM. The median follow-up period was 16.5 [IQR: 4.4-37.3] months. IR was independently associated with the primary outcome (HR: 1.91, 95% CI: 1.39-2.62, p < 0.0001), death (hazard ratio [HR]: 1.86, 95% confidence interval [CI]: 1.28-2.83, p < 0.01), and HHF (HR: 1.91, 95% CI: 1.28-2.83, p < 0.01). HOMA-IR is an independent prognostic factor of HF in a wide variety of HF populations.

Left bundle branch pacing and cardiac remodeling in HF patients with type 2 diabetes mellitus: epigenetic pathways and clinical outcomes.

Left bundle branch (LBB) pacing could achieve cardiac resynchronization therapy (CRT) in patients who cannot be resynchronized via the placement of the left ventricle (LV) lead into the coronary sinus. LBB pacing could improve cardiovascular outcomes in heart failure (HF) patients with LBB block who are affected by type 2 diabetes mellitus (T2DM). LBB pacing could increase the number of CRT responders and lead to the best clinical outcomes in HF patients with T2DM, inducing cardiac remodeling and improving left ventricle ejection fraction (LVEF) via microRNA (miR) modulation. In a multicenter observational study, we enrolled 334 HF patients with LBB block and an indication to receive LBB pacing for CRT. In these patients, we evaluated the CRT responder rate, clinical outcomes, and miR expression at 1 year of follow-up. At 1 year of follow-up, we had 223 responders (66.8%), 132 hospitalizations for HF (39.5%), 24 cardiac deaths (7.2%), and 37 all-cause deaths (11.1%), with a higher rate of HF hospitalizations (77 (69.4%) vs 55 (24.7%), p < 0.05), and cardiac deaths (13 (11.7% vs 11 (4.9%), p < 0.05) in non-responders vs responders. At the end of follow-up, we found the lowest expression of miR-26, miR-29, miR-30, miR-92, and miR-145 in LBB-pacing non-responders vs responders (p < 0.05), and a direct correlation between miR-30 (0.340, [0.833-1.915]; p 0.001), the 6-minute-walking test (6MWT; 0.168, [0.008-0.060]; p 0.011), angiotensin-receptor-neprilysin inhibitors (ARNI; 0.157, [0.183-4.877]; p 0.035), sodium-glucose-transporter-2 inhibitors (0.245, [2.242-7.283]; p 0.001), and LVEF improvements. C reactive protein (CRP) inversely correlated with LVEF improvement (-0.220, [-(0.066-0.263)]; p 0.001). ARNI (1.373, CI 95% [1.007-1.872], p 0.045), miR-30 (2.713, CI 95% [1.543-4.769], p 0.001), and 6MWT (1.288, CI 95% [1.084-1.998], p 0.001) were predictors of LBB pacing responders at 1 year of follow-up. LBB-pacing responders evidenced miR modulation, which was linked to significant improvement of the cardiac pump. Specifically, miR-30 was linked to cardiac pump improvement and predicted responders at 1 year of follow-up in patients with T2DM.

Machine Learning-Based Mortality Prediction in Chronic Kidney Disease among Heart Failure Patients: Insights and Outcomes from the Jordanian Heart Failure Registry

Background and Objectives: Heart failure (HF) is a prevalent and debilitating condition that imposes a significant burden on healthcare systems and adversely affects the quality of life of patients worldwide. Comorbidities such as chronic kidney disease (CKD), arterial hypertension, and diabetes mellitus (DM) are common among HF patients, as they share similar risk factors. This study aimed to identify the prognostic significance of multiple factors and their correlation with disease prognosis and outcomes in a Jordanian cohort. Materials and Methods: Data from the Jordanian Heart Failure Registry (JoHFR) were analyzed, encompassing medical records from acute and chronic HF patients attending public and private cardiology clinics and hospitals across Jordan. An online form was utilized for data collection, focusing on three kidney function tests, estimated glomerular filtration rate (eGFR), blood urea nitrogen (BUN), and creatinine levels, with the eGFR calculated using the Cockcroft–Gault formula. We also built six machine learning models to predict mortality in our cohort. Results: From the JoHFR, 2151 HF patients were included, with 644, 1799, and 1927 records analyzed for eGFR, BUN, and creatinine levels, respectively. Age negatively impacted all measures (p ≤ 0.001), while smokers surprisingly showed better results than non-smokers (p ≤ 0.001). Males had more normal eGFR levels compared to females (p = 0.002). Comorbidities such as hypertension, diabetes, arrhythmias, and implanted devices were inversely related to eGFR (all with p-values &lt;0.05). Higher BUN levels were associated with chronic HF, dyslipidemia, and ASCVD (p ≤ 0.001). Higher creatinine levels were linked to hypertension, diabetes, dyslipidemia, arrhythmias, and previous HF history (all with p-values &lt;0.05). Low eGFR levels were associated with increased mechanical ventilation needs (p = 0.049) and mortality (p ≤ 0.001), while BUN levels did not significantly affect these outcomes. Machine learning analysis employing the Random Forest Classifier revealed that length of hospital stay and creatinine &gt;115 were the most significant predictors of mortality. The classifier achieved an accuracy of 90.02% with an AUC of 80.51%, indicating its efficacy in predictive modeling. Conclusions: This study reveals the intricate relationship among kidney function tests, comorbidities, and clinical outcomes in HF patients in Jordan, highlighting the importance of kidney function as a predictive tool. Integrating machine learning models into clinical practice may enhance the predictive accuracy of patient outcomes, thereby supporting a more personalized approach to managing HF and related kidney dysfunction. Further research is necessary to validate these findings and to develop innovative treatment strategies for the CKD population within the HF cohort.

Abstract P272: Association of Depression and Handgrip Strength With Morbidity and Mortality in Patients With Heart Failure: A Secondary Analysis From a Randomized Controlled Trial

Introduction: Depression is associated with increased morbidity and mortality in patients with heart failure (HF). Handgrip strength (HGS) is a measure of sarcopenia and lower HGS has been associated with adverse HF outcomes. We hypothesized that relationships between HGS and morbidity and mortality would be moderated by depression in HF patients. Methods: We conducted a secondary analysis of patients hospitalized with HF categorized by depression status. We calculated HGS adjusted for body weight and categorized the values into tertiles, from lowest to highest. We fitted Cox proportional hazards models to estimate hazard ratios (HRs) comparing HGS tertiles in relation to 5-year mortality and 1-year readmissions among depressed and non-depressed and tested whether relationships differ by depression status. Models included HGS tertile, depression status, tertile-by-depression interaction, age, sex, race, medical comorbidities, educational attainment, employment, and HF severity. Results: A total of 494 patients were included in the analysis (mean age 63.4 ± 13.4 years, 44% female, 26% non-white race). A total of 83% of patients had depression and the mean LVEF (SD) was 27.8% (9.2). At 12-months following the index hospitalization the readmission rate was 56% (275 of 494), and the 5-year mortality rate was 41% (204 of 494). Individuals with higher HGS (tertile 2) were less likely to be readmitted compared to tertile 1 (46% vs. 63%; P=0.013). Depression status significantly moderated the relationship between HGS and readmission such that strong handgrip strength predicted readmission among depressed (adjusted HR of 0.35 (95% CI; 0.16, 0.81) comparing tertile 2 to tertile 1) but not among non-depressed patients (0.77 (0.55, 1.06)). However, the HGS-mortality relationship was not moderated by depression. Conclusion: HGS is a predictor of hospital readmission among HFrEF patients, and depression is a moderator of the HGS-readmission relationship. We recommend routinely assessing hospitalized HFrEF patients’ HGS and mood symptoms prior to discharge home, and further research is needed to assess the effects of depression on sarcopenia in its relation to clinical outcomes in HF patients.

Predictors of mortality in heart failure patients with reduced or mildly reduced Ejection Fraction: The CASABLANCA HF Study.

Heart failure(HF) poses a significant public health challenge throughout the world and Morocco. Our objective was to delineate the epidemiological characteristics of Moroccan patients living with chronic heart failure and to identify prognostic factors correlated with CHF mortality. A total of 1344 patients participated in this study, with survival rates at 3, 6, and 10years recorded at 75.2%, 60%, and 34%, respectively. During the follow-up, 886 patients succumbed, representing a mortality rate of 65.9%. A Cox regression model, utilizing baseline candidate variables, was developed to predict cardiovascular (CV) mortality. Predictors all of which had a P value less than 0.05 included age, left ventricular ejection fraction (EF) at commencement (< 35%), hypertension, male sex, anemia, creatinine levels, and the number of hospitalizations due to HF decompensation. Notably, the frequency of hospitalizations emerged as the most potent predictor of mortality, with an HR of 2.5 (95% CI [2-2.9]). Almost 90% of patients with three or more readmissions for HF decompensation experienced mortality by the follow-up's conclusion. This study offers valuable insights into risk factors and clinical outcomes in HF patients in Morocco. Factors such as male gender, advanced age, a history of hypertension, lower systolic blood pressure, rehospitalizations for HF decompensation, low left ventricular ejection fraction, anemia, and elevated creatinine levels were associated with increased mortality. Medical and health services managers should be aware of the substantial burden and future challenges posed by HF in Morocco, prompting the adoption of multidisciplinary strategies for its management and care.

COVID-19 among heart failure patients: A retrospective study of 294 patients at a referral cardiac center in northern Iran

Cardiovascular disease, especially heart failure (HF), is the most important comorbidity that increases the risk of death in COVID-19 patients. This study aimed to assess and compare demographic characteristics, clinical features, and clinical outcomes in HF patients with and without COVID-19. Using a retrospective research, 294 patients with HF referred to a cardiac center in Guilan province, northern Iran were enrolled. Data were collected using census sampling from August 2020 to 2021. In this study, the medical records of all patients with HF were assessed. In this research, 294 HF patients were enrolled. Also, 26.53% of HF patients had COVID-19. Mean EF, blood pressure, and HF duration in HF patients with COVID-19 were 25.83 (SD=12.31), 126.65 (SD=24.67) mmHg, and 3.79 (SD=2.10) years, respectively. The most common symptoms in HF patients with COVID-19 were cough (52.56%), headache (44.87%), and gastrointestinal problems (43.59%), respectively. Finally, 55.13% of HF patients with COVID-19 died. The mean age of HF patients with COVID-19 was higher than in HF patients without COVID-19 (66.02 vs. 62.79 years; P=0.031). Hyperlipidemia was higher in HF patients with COVID-19 than in HF patients without COVID-19 (25.64% vs. 13.89%; P=0.018). Also, in-hospital mortality was higher in HF patients with COVID-19 than in HF patients without COVID-19 (55.13% vs. 16.20%; P&lt;0.001). Overall, HF patients with COVID-19 are at particular risk for severe complications and high mortality. Therefore, it is recommended to pay special attention to HF patients with COVID-19.

A Narrative Review on the Efficacy and Safety of Loop Diuretics in Patients With Heart Failure With Reduced Ejection Fraction and Preserved Ejection Fraction.

To date, loop diuretics are the mainstay treatment for decongestion in patients with acute decompensated heart failure (HF). In clinical practice, loop diuretics have also been utilized for patients with chronic HF with reduced and preserved ejection fractions. There is a paucity of quality evidence of the effect of loop diuretics use and dosing on clinical outcomes in HF patients beyond symptomatic relief. In this review, we aimed to summarize recently published data on the use of loop diuretics in patients with HF, focusing on efficacy and safety outcomes in patients with HF with reduced and preserved ejection fraction. We searched EMBASE, PubMed, CINAHL, and the "Web of Science" databases. Cohort studies and randomized controlled trials published after 2018 and written in English were included in this review. Case reports, case series, cross-sectional studies, review articles, commentaries, articles published more than five years ago, and studies involving children were excluded. Results were divided into the efficacy and safety of loop diuretics in HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). Aregistry-based study included in our reviewobserveda reduced 30-day all-cause mortality in patients with HFrEF receiving loop diuretics compared to those not receiving loop diuretics (HR=0.73; 95% CI=0.57-0.94; p=0.016), but there was no statistically significant association at the 60-day follow-up of the same group of patients. Most studies reviewed showed that the choice of loop diuretics did not influence clinical outcomes such as mortality and HF rehospitalization in patients with HF with reduced and preserved ejection fraction despite differences in oral bioavailability and half-life. Studies have consistently shown that patients with HF who receive a higher dose of loop diuretics are likely to experience a decline in renal function and hypotension, regardless of their type of HF. Discontinuation or reduction of the dose of loop diuretics should be considered in patients with HF after decongestion.

Efficacy of ivabradine in heart failure patients with a high-risk profile (analysis from the SHIFT trial).

Early start and patient profile-oriented heart failure (HF) management has been recommended. In this post hoc analysis from the SHIFT trial, we analysed the treatment effects of ivabradine in HF patients with systolic blood pressure (SBP)<110mmHg, resting heart rate (RHR)≥75b.p.m., left ventricular ejection fraction (LVEF)≤25%, New York Heart Association (NYHA) Class III/IV, and their combination. The SHIFT trial enrolled 6505 patients (LVEF≤35% and RHR≥70b.p.m.), randomized to ivabradine or placebo on the background of guideline-defined standard care. Compared with placebo, ivabradine was associated with a similar relative risk reduction of the primary endpoint (cardiovascular death or HF hospitalization) in patients with SBP<110 and ≥110mmHg [hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.74-1.08 vs. HR 0.80, 95% CI 0.72-0.89, P interaction=0.34], LVEF≤25% and >25% (HR 0.85, 95% CI 0.72-1.01 vs. HR 0.80, 95% CI 0.71-0.90, P interaction=0.53), and NYHA III-IV and II (HR 0.83, 95% CI 0.74-0.94 vs. HR 0.81, 95% CI 0.69-0.94, P interaction=0.79). The effect was more pronounced in patients with RHR≥75 compared with <75 (HR 0.76, 95% CI 0.68-0.85 vs. HR 0.97, 95% CI 0.81-0.1.16, P interaction=0.02). When combining these profiling parameters, treatment with ivabradine was also associated with risk reductions comparable with patients with low-risk profiles for the primary endpoint (relative risk reduction 29%), cardiovascular death (11%), HF death (49%), and HF hospitalization (38%; all P values for interaction: 0.40). No safety concerns were observed between study groups. Our analysis shows that RHR reduction with ivabradine is effective and improves clinical outcomes in HF patients across various risk indicators such as low SBP, high RHR, low LVEF, and high NYHA class to a similar extent and without safety concern.

HbA1c variability is associated with adverse outcomes in heart failure patients with and without diabetes

Abstract Funding Acknowledgements Type of funding sources: None. Background Glycemic control is an important clinical issue in the management of patients with heart failure (HF). Variability of Glycated hemoglobin A1c (HbA1c) has been proven to be a predictor of cardiovascular events. However, previous studies mainly focused on general population and patients with coronary artery disease, while less is known about the effect of long-term HbA1c variability on clinical outcomes in HF patients. Purpose To evaluate the association of HbA1c variability and the risk of all-cause mortality and rehospitalization in patients with HF irrespective of their diabetic status. Methods By using the data from the well-validated Clinical Data Analysis Reporting System (CDARS), HF patients from 2003-2020 who had more than 3 times HbA1c measurements after the diagnosis of HF were included (N=65950, mean age was 66.5±12.0 years and 39409 (52.9%) were male). Average successive variability (ASV) ( average absolute difference between successive values), standard deviation (SD) of HbA1c were calculated. Hazard ratio (HR) of all-cause mortality and HF rehospitalization were estimated using competing risk regression with Cox proportional-hazard model. Results During a median follow-up of 7.2 years, 52446 (79.5%) patients developed HF rehospitalization and 34508 (52.3%) died. After adjusting for confounders, each unit change of HbA1c ASV or SD was significantly associated with higher risk of all-cause mortality, as well as higher risk of HF-rehospitalization (Figure 1). Among the study population, 48673 (73.8%) was diabetic while the remaining 17277 (26.2%) were non-diabetic. Interestingly, HbA1c variability had a stronger impact to non-diabetic compared to diabetic patients (P for interaction &amp;lt;0.001) in predicting all-cause mortality and HF rehospitalization (Table 1). Conclusion In patients with HF, a greater HbA1c variability was associated with an increased risk of HF rehospitalization and all-cause mortality. Such effect was stronger in non-diabetic compared with diabetic. HbA1c variability, irrespective of baseline diabetic status, should be evaluated in HF patients for better risk-stratification.

A conversion CRT strategy combined with AVJA may be a perspective alternative for heart failure patients with persistent atrial fibrillation.

Heart failure (HF) combined with persistent atrial fibrillation (AF) often coexist and may promote the pathological conditions of cardiac dysfunction, leading to poor prognosis. Cardiac resynchronization therapy (CRT) combined with atrioventricular junction ablation (AVJA) is a highly effective treatment for HF patients with underlying AF who either have failed or are not suitable for catheter ablation. The CRT-AVJA combination therapy can improve clinical outcomes in HF patients. Currently, clinical CRT methods are categorized into biventricular pacing (BVP) - based and conduction system pacing (CSP) - based methods. These procedures have inherent advantages and disadvantages, in addition to their considerable differences in clinical applications. This article aims to review the clinical progress of AVJA combined with different CRT strategies for treating HF patients with persistent AF and propose that conversion CRT strategy (BVP/CSP-CRT) combined with AVJA may be a perspective alternative. Meanwhile, we generalize that 7 categories of HF patients with persistent AF may need to consider the CRT-AVJA combination therapy.

Nurses’ Beliefs and Barriers of Delivering Cardiopulmonary Rehabilitation for Heart Failure Patients in Saudi Arabia: A Cross-Sectional Study

Background: Patients with heart failure (HF) may benefit greatly from cardiopulmonary rehabilitation (CR), which is provided by a team of healthcare professionals that often includes nurses. There has been no research on how nurses perceive providing CR or the hurdles that may affect referrals. Methods: All registered nurses in Saudi Arabia’s Eastern Province were given access to a cross-sectional online survey consisting of nine multiple-choice questions that address attitudes, beliefs, and barriers to CR for HF patients in Saudi Arabia. Descriptive statistics were used to characterize the respondents. Results: Altogether, 439 registered nurses participated in the online survey, with men making up 194 (44%) and women 245 (56%). The mean and SD of years of clinical experience in caring for patients with HF were 6 ± 5 years. Out of 439 nurses, 107 (24%) strongly agree, and 255 (58%) agree that CR will enhance the physical fitness of patients. However, 94 (21.1%) strongly agree, and 248 (56.4%) agree that CR might alleviate dyspnea in HF patients. The vast majority of the nurses either strongly agree (90 (20.5%)) or agree (240 (55%)), that CR would help reduce palpitations and fatigue in HF patients. Indeed, 87 (19.81%) strongly agree, and 262 (59.68%) agree that CR would help improve HF patients’ ability to perform daily activities, while 51 (11.6%) strongly agree and 223 (51%) agree that CR would help in reducing hospital readmission. It was shown that 360 (82%) of the 439 nurses favored the delivery of CR programs in hospital-supervised programs, while 368 (83.8%) ranked information on HF disease as the most important aspect of the CR program, followed by information about medications at 305 (69.4%). The availability of CR facilities (36%), the cost of therapy (35%), and the absence of an established standardized referring strategy (34%) were identified as the most significant barriers affecting the referral of patients with HF for CR by nurses. Conclusion: Generally, nurses believed CR helped improve desired clinical outcomes in HF patients. Although a hospital-based program with close supervision is optimal for administering CR, few such options exist. Referrals of patients with HF were hampered by the lack of CR facilities, the cost of intervention, and the lack of a systematic approach to referrals.

Association of malnutrition with renal dysfunction and clinical outcome in patients with heart failure

Malnutrition, glomerular damage (GD), and renal tubular damage (RTD) are common morbidities associated with poor clinical outcomes in heart failure (HF) patients. However, the association between malnutrition and renal dysfunction and its impact on clinical outcomes in HF patients have not yet been fully elucidated. We assessed the nutritional status and renal function of 1061 consecutive HF patients. Malnutrition, GD, and RTD were defined as a controlling nutritional status (CONUT) score of ≥ 5, reduced eGFR or microalbuminuria, and levels of N-acetyl-beta-d-glucosamidase of > 14.2 U/gCr according to previous reports, respectively. Patients with RTD had a higher CONUT score and a lower prognostic nutritional index and geriatric nutritional risk index than those without. Multivariate logistic analysis demonstrated that RTD, but not GD, was significantly associated with malnutrition. There were 360 cardiac events during the median follow-up period of 688 days. Multivariate Cox proportional hazard regression analysis demonstrated that comorbid malnutrition and renal dysfunction, rather than simple malnutrition, were significantly associated with cardiac events in HF patients. We found a close relationship between malnutrition and renal dysfunction in HF patients. Comorbid malnutrition and renal dysfunction were risk factors for cardiac events in HF patients, suggesting the importance of managing and treating these.

Physical activity and heart failure: a forgotten indicator

Abstract Introduction Low physical activity may be associated with comorbidities, sedentary lifestyle or clinical worsening in heart failure (HF) patients. Cardiovascular implantable electronic devices (CIEDs) detect and analyse physical activity data that is often integrated in multifactorial algorithms for predicting HF decompensations, but its potential is probably underestimated. Purpose We hypothesized that low physical-activity levels, obtained from remote monitoring of CIEDs, help predict clinical outcomes in HF patients, independently from multifactorial algorithms. Methods We retrospectively evaluated consecutive patients with HF and CIEDs through clinical assessments and remote monitoring (two monitoring systems were used). Low activity was defined as &amp;lt;1 hour/day of physical activity and two groups of patients were defined: patients with low activity alerts (group 1) and patients without low activity alerts (group 2). Primary outcome was defined as death by all causes and secondary outcome as HF hospitalizations and sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) episodes. Results From 121 patients with RPM, physical activity data was obtained in 104 (85,9%). Mean age was 63,98±12,44 years, 70,2% were males and follow-up was 59,19±38,491 months. Fifty-four (51,9%) had implantable cardiac resynchronization therapy (CRT) defibrillator (CRT-D), 46 (44,2%) transvenous implantable cardioverter defibrillator (ICD), and 4 (3,8%) CRT pacemaker (CRT-P). The aetiology was idiopathic in 42,5% and ischemic in 40,2%. Mean left ventricular ejection fraction was 34,08±11,40% and mean physical activity duration was 2,25±1,84 hours/day. Forty-eight (53,7%) had low activity alerts (group 1) and 56 (46,3%) had no low activity alerts (group 2). In group 1 mean period of low activity was 52,978±15,75 days/year. Patients from group 1 were older (p=0,001), had more oncological disease (p=0,041) and peripheral artery disease (p=0,028). Three deaths occurred in total, all in group 1 (p=0,039) and HF hospitalizations were more frequent in group 1 (1,68±2,59 vs 0,69±1,32, p=0,005). Low activity burden was also associated with atrial fibrillation burden (r=0,473, p&amp;lt;0,05) and number of episodes of VT or VF (r=0,267, p=0,007). A decrease of 50% or more in mean duration of physical activity, but above 1 hour/day, was associated with increase HF hospitalizations (1,83±2,13 vs 1,05±1,95, p=0,006). Conclusion Low physical activity data obtained from CIEDs was associated with HF hospitalizations, arrhythmic events and death by all causes, independently of multifactorial algorithms. A decrease in basal activity even above alert threshold, was associated with HF hospitalizations and may be an even earlier sign of HF decompensations. Funding Acknowledgement Type of funding sources: None.

Comorbidities complicating heart failure: changes over the last 15 years

AimsManagement of comorbidities represents a critical step in optimal treatment of heart failure (HF) patients. However, minimal attention has been paid whether comorbidity burden and their prognostic value changes over time. Therefore, we examined the association between comorbidities and clinical outcomes in HF patients between 2002 and 2017.Methods and resultsThe 2002-HF cohort consisted of patients from The Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH) trial (n = 1,032). The 2017-HF cohort were outpatient HF patients enrolled after hospitalization for HF in a tertiary referral academic hospital (n = 382). Kaplan meier and cox regression analyses were used to assess the association of comorbidities with HF hospitalization and all-cause mortality.Patients from the 2017-cohort were more likely to be classified as HF with preserved ejection fraction (24 vs 15%, p < 0.001), compared to patients from the 2002-cohort. Comorbidity burden was comparable between both cohorts (mean of 3.9 comorbidities per patient) and substantially increased with age. Higher comorbidity burden was significantly associated with a comparable increased risk for HF hospitalization and all-cause mortality (HR 1.12 [1.02–1.22] and HR 1.18 [1.05–1.32]), in the 2002- and 2017-cohort respectively. When assessing individual comorbidities, obesity yielded a statistically higher prognostic effect on outcome in the 2017-cohort compared to the 2002-HF cohort (p for interaction 0.026).ConclusionDespite major advances in HF treatment over the past decades, comorbidity burden remains high in HF and influences outcome to a large extent. Obesity emerges as a prominent comorbidity, and efforts should be made for prevention and treatment.Graphical abstractCreated with BioRender.com.

Biventricular versus Conduction System Pacing after Atrioventricular Node Ablation in Heart Failure Patients with Atrial Fibrillation.

Conduction system pacing (CSP) modalities, including His-bundle pacing (HBP) and left bundle branch pacing (LBBP), are increasingly used as alternatives to biventricular (BiV) pacing in heart failure (HF) patients scheduled for pace and ablate strategy. The aim of the study was to compare clinical outcomes of HF patients with refractory AF who received either BiV pacing or CSP in conjunction with atrio-ventricular node ablation (AVNA). Fifty consecutive patients (male 48%, age 70 years (IQR 9), left ventricular ejection fraction (LVEF) 39% (IQR 12)) were retrospectively analysed. Thirteen patients (26%) received BiV pacing, 27 patients (54%) HBP and 10 patients (20%) LBBP. All groups had similar baseline characteristics and acute success rate. While New York Heart. Association (NYHA) class improved in both HBP (p < 0.001) and LBBP (p = 0.008), it did not improve in BiV group (p = 0.096). At follow-up, LVEF increased in HBP (form 39% (IQR 15) to 49% (IQR 16), p < 0.001) and LBBP (from 28% (IQR 13) to 40% (IQR 13), p = 0.041), but did not change in BiV group (p = 0.916). Conduction system pacing modalities showed superior symptomatic and echocardiographic improvement compared to BiV pacing after AVNA. With more stable pacing parameters, LBBP could present a more feasible pacing option compared to HBP.

Multivariable prognostic model for heart failure in Chinese Han population-based setting.

AimsThe prognosis of heart failure (HF) depends on genetic predisposition, and recent studies have shown that impaired autophagy is involved in HF. This study was aimed to construct a prognostic model combining polygenetic background based on the autophagy pathway and other traditional risk factors (TRF) of HF prognosis.Methods and resultsVia re‐analysing the transcriptomic data of 50 failing and 14 non‐failing donors, differentially expressed autophagy‐related genes (ARGs) were chosen for further comparison and analysis with whole exome sequencing and follow‐up data of 1000 HF patients. By searching from reported articles, prognosis‐related polymorphisms were identified. ARGs and prognosis‐related polymorphisms were used to develop genetic risk score (GRS) and genetic risk factor (GRF), respectively. We compared the predictive power of five models [Model 1, GRS; Model 2, composite of TRF and N‐terminal B‐type natriuretic peptide (NT‐proBNP); Model 3, composite of TRF, NT‐proBNP, and GRS; Model 4, composite of TRF, NT‐proBNP, and GRF; and Model 5, composite of TRF, NT‐proBNP, GRF, and GRS] by applying receiver operating characteristic curves. Twenty‐four prognosis‐related polymorphisms were used to construct GRF and 11 variants among 48 differentially expressed ARGs associated with clinical outcomes of HF patients were applied for GRS. GRS was strongly associated with cardiac mortality of HF patients, independent of TRF and GRF (95% confidence interval 1.273–1.739, P = 5.78 × 10−7). Comparing with patients with lowest GRS tertile, those with highest tertile had higher risks of developing worse clinical outcomes (hazard ratio = 1.866; 95% confidence interval 1.352–2.575, P = 1.47 × 10−4). The discrimination power of the model including GRS, TRF, GRF, and NT‐proBNP is most considerable (area under curve = 0.777), especially in men, patients over 60, patients with hypertension, patients without diabetes or hyperlipidaemia.ConclusionsThe model combining autophagy‐related GRS, TRF, GRF, and NT‐proBNP performs well in distinguishing between worse‐prognosis and better‐prognosis HF patients, leading a promising strategy for HF treatment and HF prevention.

Prognostic value of the MELD-XI score in patients undergoing cardiac resynchronization therapy.

AimsMulti‐organ dysfunction was recently reported to be a common condition in patients with heart failure (HF). The Model for End‐stage Liver Disease eXcluding International normalized ratio (MELD‐XI) score reflects liver and kidney function. The prognostic relevance of this score has been reported in patients with a variety of cardiovascular diseases who are undergoing interventional therapies. However, the relationship between the severity of hepatorenal dysfunction assessed by the MELD‐XI score and the long‐term clinical outcomes of HF patients receiving cardiac resynchronization therapy (CRT) has not been evaluated.Methods and resultsClinical records of 283 patients who underwent CRT implantation between March 2003 and October 2020 were retrospectively evaluated (mean age 67 ± 12, 22.6% female). Blood samples were collected before CRT implantation. Patients were divided into three groups based on tertiles of the MELD‐XI score: first tertile (MELD‐XI = 9.44, n = 95), second tertile (9.44 < MELD‐XI < 13.4, n = 94), and third tertile (MELD‐XI ≥ 13.4, n = 94). The primary endpoint was all‐cause mortality. Compared with the other groups, the third tertile group exhibited significantly older age, higher prevalence of diabetes mellitus and hypertension, lower haemoglobin level, and higher N‐terminal pro‐brain natriuretic peptide level (all P < 0.05). The functional CRT response rate was also significantly lower in the third tertile group (P = 0.011). During a median follow‐up of 30 months (inter‐quartile range, 9–67), 105 patients (37.1%) died. Kaplan–Meier analysis revealed that patients with a higher MELD‐XI score had a greater risk of all‐cause mortality (log‐rank test: P < 0.001). Even after adjustment for clinically relevant factors and a conventional risk score, the MELD‐XI score was still associated with mortality (adjusted hazard ratio: 1.04, 95% confidence interval: 1.00–1.07, P = 0.014, and adjusted hazard ratio: 1.04, 95% confidence interval: 1.01–1.09, P = 0.005, respectively). A higher MELD‐XI score was associated with a greater risk of all‐cause mortality than a lower MELD‐XI score regardless of whether a pacemaker or defibrillator was implanted (log‐rank test: P = 0.010 and P < 0.001, respectively).ConclusionsImpaired hepatorenal function assessed by the MELD‐XI score was associated with older age, higher prevalence of multiple co‐morbidities, severity of HF, lower CRT response rates, and subsequent all‐cause mortality in HF patients undergoing CRT implantation. These results suggest that the MELD‐XI score can provide additional prognostic information and may be useful for improving risk stratification in this population.