Coexistent Heart Failure Research Articles

Abstract 4125533: Demographic Trends and Disparities in Mortality Related to Coexisting Heart Failure and Diabetes Mellitus Among Older Adults in the United States: A Large Database Analysis from 1999 to 2020

Background: In the United States, over 38 million people have diabetes mellitus (DM) and more than 6 million have heart failure (HF). DM and HF often coexist, and each condition independently increases the likelihood of developing the other. Approximately 40% of individuals with HF also have DM, and this prevalence is even higher among older adults and hospitalized patients. While there has been concern regarding the increasing burden of disease for both conditions individually over the last decade, a comprehensive examination of mortality trends associated with their coexistence has not been thoroughly explored. Methods: This study analyzed death certificates from the CDC WONDER database, specifically focusing on mortality caused by the simultaneous presence of HF and DM among individuals aged 75 years and older. The data covers the period from 1999 to 2020. Age-adjusted mortality rates (AAMRs) per 100,000 individuals and annual percent change (APC) were computed and categorized based on year, gender, and race/ethnicity. Results: Between 1999 and 2020, a total of 663,016 deaths were reported in patients with coexisting HF and DM. Overall, AAMR increased from 154.1 to 186.1 per 100,000 population between 1999 and 2020, with an initial increase from 1999 to 2005 (APC: 0.80; 95% CI: -0.17 to 2.94), a significant decline from 2005 to 2011 (APC: -2.82; 95% confidence interval (CI): -5.47 to – 1.71), a subsequent increase from 2011 to 2018 (APC: 0.61; 95% CI: -0.59 to 2.18), and finally a steep increase from 2018 to 2020 (APC: 11.30; 95% CI: 6.98 to 14.11). Gender-based analysis revealed that older men had consistently higher AAMRs than older women (Men: 185; 95% CI: 184.3 to 185.6; vs Women: 135.4; 95% CI: 135 to 135.8). Furthermore, we found that AAMRs were the highest among non-Hispanic American Indian or Alaska natives (214.4; 95% CI: 207.5 to 221.4) followed by non-Hispanic African Americans (179.9; 95% CI: 178.5 to 181.4), Hispanics (159.5; 95% CI: 158 to 161.1), non-Hispanic White (152.9; 95% CI: 152.5 to 153.3), and non-Hispanic Asian or Pacific Islander populations (104.1; 95% CI 102.4 to 105.8) (Figure 1). Conclusion: The mortality rate due to coexisting HF and DM has increased in the elderly population over the past decade. Males and non-Hispanic American Indians or Alaskan Natives had the highest AAMRs in our study.

Canagliflozin reduces oral loop diuretic intensification in patients with type 2 diabetes: a participant level pooled analysis of CREDENCE and CANVAS

Abstract Background Patients with type 2 diabetes often have coexistent heart failure or chronic kidney disease (CKD) that require treatment with loop diuretics; however, the prognostic implications of oral loop diuretic intensification are not well characterized. The sodium glucose cotransporter-2 inhibitor canagliflozin reduces the risk of hospitalization for heart failure or cardiovascular death and CKD progression among patients with type 2 diabetes at high cardiovascular risk or with concomitant CKD. Purpose To assess the prognostic implications of oral loop diuretic intensification and the treatment effects of canagliflozin versus placebo on loop diuretic use in high-risk patients with type 2 diabetes. Methods This was a post-hoc participant-level pooled analysis of the CANVAS Program and CREDENCE trial which enrolled patients with type 2 diabetes at high cardiovascular risk or with CKD. Oral loop diuretic intensification was defined as a composite of new loop diuretic initiation (among patients not receiving loop diuretics at baseline) or loop diuretic dose increase (among patients receiving loop diuretics at baseline). We assessed the association between the requirement for loop diuretic intensification and the incidence of subsequent all-cause death. The effect of canagliflozin versus placebo on the composite of loop diuretic intensification as well as its components were evaluated. We further examined the effect of canagliflozin on an expanded post hoc composite of cardiovascular death, hospitalization for heart failure or loop diuretic intensification. Results 2,263 (15.6%) of 14,543 patients were treated with loop diuretics at baseline. Over a median follow-up of 2.2 years, 1,264 patients (9.4%) required oral loop diuretic intensification, of which 981 (77.6%) patients required initiation of oral loop diuretics and 283 (22.4%) required oral loop diuretic dose increase. Patients requiring oral loop diuretic intensification experienced rates of subsequent mortality that were 3.5-fold higher (5.9[5.4-6.5] per 100 patient-years) than those not requiring oral loop diuretic intensification (1.7[1.6-1.9] per 100 patient-years). Treatment with canagliflozin reduced the need for oral loop diuretic intensification by 41% (HR 0.59; 95%CI: 0.53-0.66) including both new diuretic initiation (HR 0.65; 95%CI: 0.57-0.74) and diuretic dose increase (HR 0.42; 95%CI: 0.33-0.54); Figure 1. Treatment with canagliflozin similarly reduced an expanded composite of worsening heart failure inclusive of cardiovascular death, heart failure hospitalization or diuretic intensification (HR 0.64; 95%CI: 0.58-0.70). Conclusion Among high-risk patients with T2D, new oral loop diuretic intensification was frequent and associated with an increased risk of subsequent mortality. Treatment with canagliflozin significantly reduced the need for loop diuretic intensification.

Demographic trends and disparities in mortality related to coexisting heart failure and diabetes mellitus among older adults in the United States between 1999 and 2020: A retrospective population-based cohort study from the CDC WONDER database

BackgroundHeart Failure (HF) and Diabetes Mellitus (DM) often coexist, and each condition independently increases the likelihood of developing the other. While there has been concern regarding the increasing burden of disease for both conditions individually over the last decade, a comprehensive examination of mortality trends and demographic and regional disparities needs to be thoroughly explored in the United States (US). MethodsThis study analyzed death certificates from the CDC WONDER database, focusing on mortality caused by the co-occurrence of HF and DM in adults aged 75 and older from 1999 to 2020. Age-adjusted mortality rates (AAMRs) and annual percent changes (APCs) were computed and categorized by year, gender, race, census region, state, and metropolitan status. ResultsA total of 663,016 deaths were reported in patients with coexisting HF and DM. Overall, AAMR increased from 154.1 to 186.1 per 100,000 population between 1999 and 2020, with a notable significant increase from 2018 to 2020 (APC: 11.30). Older men had consistently higher AAMRs than older women (185 vs. 135.4). Furthermore, we found that AAMRs were highest among non-Hispanic (NH) American Indian or Alaskan natives and lowest in NH Asian or Pacific Islanders (214.4 vs. 104.1). Similarly, AAMRs were highest in the Midwestern region and among those dwelling in non-metropolitan areas. ConclusionsMortality from HF and DM has risen significantly in recent years, especially among older men, NH American Indian or Alaska Natives, and those in non-metropolitan areas. Urgent policies need to be developed to address these disparities and promote equitable healthcare access.

Short- and Long-Term Outcomes After Transfemoral Aortic Valve Replacement in Patients with Co-Existent Chronic Right Heart Failure

Short- and Long-Term Outcomes After Transfemoral Aortic Valve Replacement in Patients with Co-Existent Chronic Right Heart Failure

Discontinuation of afterload-reducing drugs decreases left ventricular outflow tract obstruction in hypertrophic obstructive cardiomyopathy.

Hypertrophic cardiomyopathy (HCM), the most common genetic heart disease, is classified into hypertrophic non-obstructive and hypertrophic obstructive cardiomyopathy (HOCM). Patients with HOCM and coexisting heart failure or arterial hypertension are often prescribed afterload-reducing drugs. Although recommended in current guidelines, data on the direct effect of discontinuing afterload-reducing medication are scarce. This study aims to demonstrate the benefit of discontinuing afterload-reducing medication in HOCM patients. This monocentric retrospective analysis included 24 patients with HOCM with afterload-reducing medication, including angiotensin-converting enzyme inhibitors, angiotensin-1 receptor blocker and dihydropyridine-calcium channel blocker, at their first outpatient visit. Effects of discontinuing this medication on LVOTO were examined compared to patients with persistent use despite medical advice. 16 patients discontinued their afterload-reducing drugs, resulting in a significant decrease in median LVOT gradient from 86.5 [60.5-109.3] mmHg to 61.5 [28.3-97.50] mmHg (p = 0.0004). In 6 patients, beta-blocker therapy was initiated simultaneously, or the dose was increased. Regardless, LVOT gradient reduction was also significant in the remaining 10 patients (p = 0.001). The gradient was not changed significantly in the 8 patients continuing their afterload-reducing medication. Discontinuation of afterload-reducing drugs significantly decreases LVOTO. Our study underscores the significance of abstaining from afterload-reducing drugs in HOCM patients, particularly in patients with concomitant hypertension or heart failure. According to recently published European guidelines, HOCM patients should preferably be treated with beta-blockers or non-dihydropyridine-calcium channel blockers.

In-hospital outcomes of autologous stem cell transplantation in patients with multiple myeloma with versus without heart failure.

e19511 Background: Autologous stem cell transplantation (ASCT) in patients with multiple myeloma (MM) is known to improve progression-free survival. However, the outcomes in patients with heart failure (HF) are uncertain. This study aims to compare hospital outcomes in patients with MM undergoing ASCT with and without HF. Methods: The National Inpatient Sample database was used to identify patients with MM undergoing ASCT during hospitalizations between 2016 and 2020. Under IRB exemption, data was extracted using ICD-10 codes. Data were stratified between patient with and without HF. A multivariate regression model was used to estimate the association of HF with ASCT in hospital outcomes, adjusting for statistically significant comorbidities. Results: A total of 30,375 hospitalizations with a diagnosis of MM undergoing ASCT were included, of which 1,535 had HF. On multivariant analysis compared to hospitalization without HF, those with HF had significantly higher risk of in-hospital mortality (adjusted odds ratio [aOR]: 2.20, 95% confidence interval [CI]: 1.49-3.24), graft-versus-host disease (GvHD) (aOR: 4.02, 95% [CI]: 2.48-6.52), transplant complications (aOR: 2.03, 95% [CI]: 1.62-2.56), sepsis (aOR: 2.279, 95% [CI]: 1.95- 2.65), septic shock (aOR: 3.49, 95% [CI]: 2.71-4.48), cardiogenic shock (aOR: 5.33, 95% [CI]: 2.61- 10.9), cardiac arrest (aOR: 3.78, 95% [CI]: 2.24- 6.35) and ventricular arrhythmia (aOR: 2.81, 95% [CI]: 2.08- 3.78). All p-values were <0.001. Additionally, patients with HF had a longer average length of stay (20.48 vs 16.38 days, p< 0.001) and a higher total cost of hospital stay ($245,831 vs $198,732, p<0.001) compared to those without HF. Conclusions: Our findings demonstrated that patients with multiple myeloma undergoing autologous stem cell transplantation, while also having coexisting heart failure (HF), experienced worse outcomes compared to patients without HF. These patients had a higher risk of transplant complications, GvHD, sepsis, septic shock, cardiogenic shock, cardiac arrest, ventricular arrhythmias and mortality. Additionally, these patients experienced a longer hospital stay with higher healthcare costs. Further interventions and research are warranted to improve outcomes in this group of patients.

E-12 | In-Hospital Outcomes of Transcatheter Aortic Valve Implantation in Patients with Coexisting Heart Failure

E-12 | In-Hospital Outcomes of Transcatheter Aortic Valve Implantation in Patients with Coexisting Heart Failure

Elevated Soluble ST2 Blood Levels in Patients with Depression and Comorbid Heart Failure: A Correlative Study

IntroductionDepressive disorders frequently coexist with chronic medical conditions like heart failure (HF), significantly impacting patients’ overall health and quality of life. This study aims to explore the correlation between soluble ST2 molecule levels and the presence of depressive disorders in patients with heart failure.ObjectivesA total of 200 patients, all diagnosed with heart failure, were included in this study. Among them, 30 patients were mentally healthy, and the remaining 170 exhibited medium-level depressive disorders. Blood samples were collected and analyzed for soluble ST2 levels to assess the potential correlation between depressive disorders and soluble ST2 levels in patients with heart failure.MethodsA total of 200 patients, all diagnosed with heart failure, were included in this study. Among them, 30 patients were mentally healthy, and the remaining 170 exhibited medium-level depressive disorders. Blood samples were collected and analyzed for soluble ST2 levels to assess the potential correlation between depressive disorders and soluble ST2 levels in patients with heart failure.ResultsThe study demonstrated a statistically significant finding, indicating that the levels of soluble ST2 were 1.6 times higher in patients with depression and comorbid heart failure compared to mentally healthy individuals with heart failure.ConclusionsThis study elucidates a statistically significant correlation between medium-level depressive disorders and elevated soluble ST2 levels in patients with coexisting heart failure, shedding light on the potential role of soluble ST2 as a biomarker in identifying and managing depressive disorders in heart failure patients. The observed 1.6-fold increase in soluble ST2 levels in heart failure patients with depression emphasizes the importance of mental health assessment and intervention in individuals with chronic medical conditions, particularly heart failure, to enhance overall care and outcomes.Disclosure of InterestNone Declared

Efficacy of cardiopulmonary rehabilitation nursing in enhancing pulmonary function, sleep quality, and living ability in COVID-19 patients.

The purpose of this study was to elucidate the impact of cardiopulmonary rehabilitation nursing on the pulmonary function, sleep quality, and living ability of patients afflicted with Coronavirus Disease 2019 (COVID-19). A total of 98 patients with COVID-19 treated at The People's Hospital of Guang'an between September 2021 and January 2023 were retrospectively collected as the research subjects. Among them, 48 patients who received standard nursing care from September 2021 to September 2022 were set as the control group, and 50 patients who underwent cardiopulmonary rehabilitation nursing from October 2022 to January 2023 were set as the research group. The pulmonary function indicators [including Forced Expiratory Volume in 1 second (FEV1) and Left Ventricular Ejection Fraction (LVEF)], sleep quality [evaluated using the Pittsburgh Sleep Quality Index (PSQI)], and living ability [assessed by the 36-Item Short Form Survey (SF-36) scale] pre- and post-intervention were compared between the two groups. Pre-intervention, FEV1, LVEF, PSQI scores, inflammatory factor levels [C-reactive protein (CRP), procalcitonin (PCT)], and SF-36 scores showed no significant differences between the two groups (P>0.05). Post-intervention, the research group exhibited notably enhanced FEV1 and LVEF, lower PSQI scores, lower CRP and PCT, and higher SF-36 scores compared with the control group, with statistical significance (P<0.05). Multifactorial logistic regression analysis showed that non-receipt of cardiopulmonary rehabilitation, age ≥60 years, concurrent respiratory failure, coexistent heart failure, and acid-base imbalance were independent risk factors of adverse outcomes in COVID-19 patients (P<0.05). Application of cardiopulmonary rehabilitation nursing in COVID-19 patients can significantly improve pulmonary function, sleep quality, and overall quality of life, and relieve the inflammatory state of the patients, thereby enhancing prognosis. This approach has certain value of popularization and application.

Evaluation of Clinical, Echocardiographic, and Therapeutic Characteristics, and Prognostic Outcomes of Coexisting Heart Failure among Patients with Atrial Fibrillation: The Jordan Atrial Fibrillation (JoFib) Study.

Atrial fibrillation (AF) is the most commonly encountered cardiac arrhythmia in clinical practice. Heart failure (HF) can occur concurrently with AF. We compared different demographic, clinical, and echocardiographic characteristics between patients with AF+HF and patients with AF only. Furthermore, we explored whether concurrent HF independently predicts several outcomes (all-cause mortality, cardiovascular mortality, ischemic stroke/systemic embolism (IS/SE), major bleeding, and clinically relevant non-major bleeding (CRNMB)). Comparisons between the AF+HF and the AF-only group were carried out. Multivariable Cox proportional hazard models were constructed for each outcome to assess whether HF was predictive of any of them while controlling for possible confounding factors. A total of 2020 patients were included in this study: 481 had AF+HF; 1539 had AF only. AF+HF patients were older, more commonly males, and had a higher prevalence of diabetes mellitus, dyslipidemia, coronary artery disease, and chronic kidney disease (p≤0.05). Furthermore, AF+HF patients more commonly had pulmonary hypertension and low ejection fraction (p≤0.001). Finally, HF was independently predictive of all-cause mortality (adjusted HR 2.17, 95% CI (1.66-2.85) and cardiovascular mortality (adjusted HR 2.37, 95% CI (1.68-3.36). Coexisting AF+HF was associated with a more labile and higher-risk population among Jordanian patients. Furthermore, coexisting HF independently predicted higher all-cause mortality and cardiovascular mortality. Efforts should be made to efficiently identify such cases early and treat them aggressively.

Abstract 18513: Causes and Predictors of 30-day Readmissions Following Covid-19 Hospitalizations and Co-Existing Acute Heart Failure: Insights From National Readmission Database 2020

Introduction: COVID-19 infection notably impacts the cardiovascular system, with evidence of higher in-hospital mortality in patients with acute heart failure (AHF) and COVID-19 infection. However, less is known about short-term outcomes following discharge. Therefore, we sought to analyze readmission data in COVID-19 hospitalizations with AHF from the National Readmission Database (NRD). Methods: NRD (2020) was queried to identify all COVID-19 hospitalizations and co-existing AHF using ICD-10 CM codes. The group was then stratified into heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). The outcomes were 30-day readmission rate, length of stay (LOS), total hospital charge (THC), and predictors of readmission. Multivariate/univariate logistic and linear regression analyses were used to analyze the outcomes and adjust for possible confounders. Results: A total of 53,337 COVID-19 admissions with co-existing AHF were identified, of which 38,401 were discharged alive. Within 30 days from discharge, 8,159 (21.26%) were readmitted. Upon stratification, 51% belonged to the HFrEF group and were found to have scarcely higher 30 days readmission rates than encounters with HFpEF (21.46% vs. 21.14%). Readmissions lead to an additional mean THC of $85,687 and a mean LOS of 7.8 days. The top five all-causes of readmissions were COVID-19 infection (24.8%), heart failure (16.2%), sepsis (15.4%), acute kidney injury (2.2%), and pneumonia (1.2%). Figure-1 shows a multivariate analysis of independent factors associated with readmissions. Conclusions: Our analysis showed a 21.26% 30-days readmission rate following acute heart failure during COVID-19 infection. Cirrhosis, anemia, diabetes mellitus, chronic lung diseases, and discharge against medical advice were significant readmission predictors. Optimizing these co-morbidities during index admission may reduce readmissions and overall financial burden.

Enhanced Levels of Adiposity, Stretch and Fibrosis Markers in Patients with Coexistent Heart Failure and Atrial Fibrillation.

The coexistence of heart failure (HF) and atrial fibrillation (AF) worsens the prognosis of patients. We aimed to study the inflammation, metabolism, adiposity, and fibrosis markers on epicardial and subcutaneous fat and blood, and their relationship with HF and AF. Samples from 185 patients undergoing cardiac surgery were collected. Levels of multi-markers on fat biopsies and plasma were analyzed. Patients were grouped by HF or AF presence. Plasma adiposity markers were increased in AF patients, while increased stretch markers correlated with HF. Patients with both AF and HF had higher ANP and GDF-15 levels. After excluding AF patients, plasma FABP4 was identified as the main HF predictor. Fat biopsies from AF patients showed an enhanced inflammatory profile. Higher levels of adiposity markers are associated with AF or HF, and higher stretch and fibrosis markers with combined AF and HF, suggesting a role of adiposity-fibrosis pathway in HF and AF coexistence.

Therapies for patients with coexisting heart failure with reduced ejection fraction and non-alcoholic fatty liver disease.

Heart failure with reduced ejection fraction (HFrEF) and nonalcoholic fatty liver disease (NAFLD) are two common comorbidities that share similar pathophysiological mechanisms. There is a growing interest in the potential of targeted therapies to improve outcomes in patients with coexisting HFrEF and NAFLD. This manuscript reviews current and potential therapies for patients with coexisting HFrEF and NAFLD. Pharmacological therapies, including angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, mineralocorticoids receptor antagonist, and sodium-glucose cotransporter-2 inhibitors, have been shown to reduce fibrosis and fat deposits in the liver. However, there are currently no data showing the beneficial effects of sacubitril/valsartan, ivabradine, hydralazine, isosorbide nitrates, digoxin, or beta blockers on NAFLD in patients with HFrEF. This study highlights the importance of considering HFrEF and NAFLD when developing treatment plans for patients with these comorbidities. Further research is needed in patients with coexisting HFrEF and NAFLD, with an emphasis on novel therapies and the importance of a multidisciplinary approach for managing these complex comorbidities.

#2976 CHRONIC KIDNEY DISEASE WITH COMORBIDITY IN PRIMARY CARE: CARDIORENAL TREATMENT, QUALITY OF CARE AND PROGNOSIS

Abstract Background and Aims Diabetes, heart failure, hypertension and cardiovascular disease are common in primary care, and frequently coexist with impaired kidney function (CKD), further increasing risk of cardiovascular- and renal events as well as premature death. These comorbidities therefore call for more complex treatment regimens and monitoring. Our aim was to describe the prevalence, management, and prognosis of individuals with CKD and additional comorbidity in a large primary care cohort. Method Individuals were included from the Copenhagen Primary Care Laboratory (CopLab) Database, which contains 112 million biochemistry results from persons followed in primary care between 2000 and 2015 and divided into three groups based on (CKD-EPI) eGFR (&amp;gt;60 ml/min, 30-59 ml/min and &amp;lt;30 ml/min) with or without comorbidity in the form of diabetes or heart failure. We included all individuals with at least two measurements of creatinine. The date of the second measurement of creatinine was considered index date (baseline). The database has been combined with pharmacological data (The Danish National Prescription Registry), outpatient clinic visits and hospitalizations (The Danish National Patient Registry - NPR), and mortality information (The Danish Civil Registration System). Heart Failure was defined by ICD-codes in NPR from outpatient clinic visits and hospitalizations and we calculated crude event rates for a range of outcomes according to comorbidity. Diabetes was defined as at least one measurement of plasma or serum glucose ≥11 mmol/l or HbA1c ≥48 mmol/mol in CopLab. We evaluated monitoring of eGFR, albuminuria (UACR) and use of guideline-recommended pharmacological therapy (i.e. RAS-blockers and statins) in each group. Results In the total primary care population of 171,134 individuals of which 63.8% were female, 8.3% had impaired kidney function (eGFR&amp;lt;60ml/min). The median follow-up for the three eGFR groups was 8.4, 4.7 and 2.0 years, respectively. Overall, event rates were higher in individuals with impaired kidney function and comorbidity, i.e. mortality in the group with eGFR&amp;lt;30 ml/min with concurrent heart failure; 42.8 per 100 patient-years (PY). Event rates for ESKD were low in general (0.03 to 0.51 per 100 PY) except for individuals with eGFR&amp;lt;30 ml/min (2.1 to 3.5 per 100 PY). Annual monitoring of eGFR was high in all groups (&amp;gt;90%) with increasing frequency in individuals with impaired kidney function, and measurement of UACR was low in groups with non-diabetic CKD (10-30%). Antihypertensive treatment was frequently prescribed in eGFR &amp;lt;30 ml/min; overall 87.6% and 94.8% with coexisting diabetes and 92.8% with coexisting heart failure. The use of RAS inhibition was more used in diabetes and in heart failure (&amp;gt;50%) but less with low eGFR. Statin therapy was used in approximately 50% of individuals with diabetes, regardless of CKD group, but was used to a much less extent in non-diabetic CKD (20-24%). Conclusion Our data from a large primary care cohort demonstrate a high prevalence of coexisting diabetes and/or heart failure with CKD, increasing the risk for adverse outcomes. The quality of CKD care in general practice may be improved, especially in the non-diabetic population.

HEART FAILURE AS AN IN-HOSPITAL MORTALITY PREDICTING FACTOR IN COPD PATIENTS: AN OBSERVATIONAL STUDY

INRODUCTION: Chronic obstructive pulmonary disease (COPD) and heart failure are two major causes of mortality, globally. Coexistence of both conditions cause diagnostic difficulties because of similarities in symptoms and signs. Most patients with both conditions are characterized by high mortality.Age,sex and comorbidities are considered to be the major predictors of mortality in patients with COPD and heart failure alone.Undiagnosed heart failure in patients of COPD has catastrophic consequences.AIM OF STUDY:To describe prevalence of heart failure in COPD patients and its impact on in hospital mortality.MATERIAL AND METHODS:An observational study was conducted on 100 diagnosed cases of COPD for a period of 6 months,admitted in medicine ward and medical intensive care unit at Jhalawar Medical College.RESULTS: Out of the 100 patients studied,72 (72%) were males and 28 (28%) were females.23 patients (23%) were diagnosed with coexisting heart failure. In hospital mortality was 12%, mortality among coexisting heart failure patients was higher (30.43%) in comparison to patients with only COPD (6.49%)- odd ratio 6.3 (95% CI 1.77-22.41). CONCLUSION: Heart failure has an important impact on in hospital mortality in patients with COPD. Heart failure and other comorbidities should be recognized early and properly treated in order to improve survival in patients with COPD

Coexistent Chronic Obstructive Pulmonary Disease-Heart Failure: Mechanisms, Diagnostic and Therapeutic Dilemmas

Mortality in chronic obstructive pulmonary disease (COPD) is more often due to cardiac rather than respiratory causes. The coexistence of heart failure (HF) and COPD is frequent but remains under-diagnosed. Both conditions share several similarities including the age of the population affected, a common risk factor in smoking and symptoms of exertional dyspnoea. There is also a strong possibility of COPD promoting atherosclerotic vascular disease through systemic inflammation. Both the conditions are punctuated by episodes of acute exacerbations of symptoms from time to time where differentiation between these two can be especially challenging. Although coexistence of the two is common, more often, only one of the two is diagnosed resulting in under-treatment and unsatisfactory response. Awareness of co-occurrence is essential among both pulmonologists and cardiologists and a high index of suspicion should be maintained. The coexistence of the COPD and HF also poses several challenges in management. Active search for the second disease using clinical examination supplemented with specialised investigations including plasma natriuretic peptides, lung function testing and echocardiography should be carried out followed by appropriate management. Issues such as adverse effects of drugs on cardiac or pulmonary function need to be sorted out by studies in coexistent COPD-HF patients. Caution is advised with use of beta2-agonists in COPD when HF is also present, more so in acute exacerbations. On current evidence, the beneficial effects of selective beta1-blockers should not be denied in stable patients who have coexistent COPD-HF. The prognosis of coexistent COPD and HF is poorer than that in either disease alone. A favourable response in the patient with coexistent COPD and HF depends on proper evaluation of the severity of each of the two and appropriate management with judicious use of medication.

Rhythm control versus rate control in patients with atrial fibrillation and heart failure across the left ventricular ejection fraction spectrum

BackgroundRhythm control and rate control are both employed commonly in patients with atrial fibrillation (AF) and heart failure (HF), but limited real-world data exist on them. We aimed to compare outcomes between these two strategies across the left ventricular ejection fraction (LVEF) spectrum. Materials and methodsThis retrospective cohort study used data from the randomized MISOAC-AF trial, including from patients with AF and coexistent HF who were hospitalized and followed up after discharge. At baseline, the patients were classified into pharmaceutical (or electrical cardioversion) rhythm control strategy or rate control treatment (b-blocker, digoxin, calcium channel blockers) groups. The primary outcome was all-cause mortality. Kaplan-Meier curves and multivariable-adjusted Cox regression were utilized to compare the two strategies. Spline curve models were used to demonstrate the results across the LVEF stratified spectrum. ResultsIn total, 199 AF patients with HF were studied (mean age, 77 years). At discharge, 73 (36.7%) patients received rhythm control and 126 (63.3%) rate control treatment. After a median follow-up period of 31 months, 26 (35.6%) patients in the rhythm-control group died, as compared to 43 (33.3%) in the rate-control group (aHR: 1.29; 95% CI: 0.78-2.14; p = 0.31). The spline curves also revealed no difference in all-cause mortality favoring either strategy in any HF subtype across the nominally classified LVEF. ConclusionThe use of a pharmacological rhythm-control strategy was not associated with a survival advantage compared to the rate control strategy in recently hospitalized patients with AF and comorbid HF. More randomized trials and large studies are needed in the future to explore these results in each subgroup of HF patients.

Heart failure in patients with COPD exacerbations: Looking below the tip of the iceberg

BackgroundPatients surviving hospitalization for exacerbations of chronic obstructive pulmonary disease (ECOPD) are at heightened risk of cardiovascular events. Heart failure is often underdiagnosed and undertreated in COPD; better care could improve outcome. We aimed to capture contemporary investigation and management of heart failure (HF) in patients hospitalized with ECOPD. MethodsIn two UK hospitals, patients admitted with ECOPD between 2017 and 2020 were retrospectively identified. Baseline characteristics between known, newly diagnosed and no HF were compared using analysis of variance and chi-squared test. Impact of HF on mortality was assessed by Kaplan-Meier analysis and Cox proportional-hazards regression. Sensitivity and specificity of NT-proBNP for diagnosing HF at recognized thresholds were reported. ResultsOn admission, 94/476 (19.7%) patients had known HF. Among remaining patients, 89/382 (23.3%) were investigated within 100 days of admission, confirming HF in 38. Of 33 patients with heart failure with reduced ejection fraction (HFrEF), 18 (54.5%) were prescribed ACE-inhibitor and B-blocker. 77/132 patients (58.3%) with HF and 108/344 patients (31.4%) without HF died (adjusted HR 2.03, 95% CI 1.46–2.82, p < 0.001) during follow up (median 11.7 months). At ≥400 pg/mL, NPV and PPV of NT-proBNP for the diagnosis of HF were 77.8% and 82.8%. ConclusionsA new diagnosis of HF was made in over 40% investigated. In patients with coexistent HF, undertreatment was common and 1-year mortality exceeded 50%. NT-proBNP may help identify patients who need cardiovascular functional imaging. Research to improve HF diagnosis and treatment in hospitalized ECOPD is urgently needed.

Outcomes of digoxin vs. beta blocker in atrial fibrillation: report from ESC-EHRA EORP AF Long-Term General Registry.

The safety of digoxin therapy in atrial fibrillation (AF) remains ill-defined. We aimed to evaluate the effects of digoxin over beta-blocker therapy in AF. Patients with AF who were treated with either digoxin or a beta blocker from the ESC-EHRA EORP AF (European Society of Cardiology-European Heart Rhythm Association EURObservational Research Programme Atrial Fibrillation) General Long-Term Registry were included. Outcomes of interest were all-cause mortality, cardiovascular (CV) mortality, non-CV mortality, quality of life, and number of patients with unplanned hospitalizations. Of 6377 patients, 549 (8.6%) were treated with digoxin. Over 24months, there were 550 (8.6%) all-cause mortality events and 1304 (23.6%) patients with unplanned emergency hospitalizations. Compared to beta blocker, digoxin therapy was associated with increased all-cause mortality [hazard ratio (HR) 1.90 (95% confidence interval, CI, 1.48-2.44)], CV mortality [HR 2.18 (95% CI 1.47-3.21)], and non-CV mortality [HR 1.68 (95% CI 1.02-2.75)] with reduced quality of life [health utility score 0.555 (±0.406) vs. 0.705 (±0.346), P<0.001] but no differences in emergency hospitalizations [HR 1.00 (95% CI 0.56-1.80)] or AF-related hospitalizations [HR 0.95 (95% CI 0.60-1.52)]. On multivariable analysis, there were no differences in any of the outcomes between both groups, after accounting for potential confounders. Similar results were obtained in the subgroups of patients with permanent AF and coexisting heart failure. There were no differences in outcomes between AF patients receiving digoxin with and without chronic kidney disease. Poor outcomes related to the use of digoxin over beta-blocker therapy in terms of excess mortality and reduced quality of life are associated with the presence of other risk factors rather than digoxin per se. The choice of digoxin or beta-blocker therapy had no influence on the incidence of unplanned hospitalizations.

Are the results of the RATE-AF trial reproducible in daily practice? Clinical outcomes with digoxin vs beta-blocker for heart rate control in permanent atrial fibrillation

Abstract Background There is little evidence to support selection of heart rate control therapy in patients with permanent atrial fibrillation (AF), in particular those with coexisting heart failure. In the recent RATE-AF trial that included patients with permanent AF and symptoms of heart failure, treatment with low-dose digoxin or bisoprolol did not result in statistically significant difference in quality of life at 6 months. The purpose of the study was to analyse whether the clinical outcomes may differ among unselected patients with permanent AF treated with digoxin or beta-blocker seen in daily practice. Methods All patients with atrial fibrillation (AF) seen in an academic institution were identified in a database. We examined the clinical course of 8962 consecutive patients with AF seen over a 10-year period. The adverse outcomes were investigated during follow-up and we identified the causes of death. Among them 1,787 patients had the RATE-AF criteria of inclusion (permanent AF, age ≥60 and NYHA ≥2), of whom 512 patients (29%) were treated with beta-blocker alone, 425 (24%) were treated with digoxin alone and 237 (13%) were treated with both a beta-blocker and digoxin. Outcomes in patients treated with beta-blocker alone or digoxin alone were compared after 1:1 propensity-score matching. Results After propensity score matching, 270 patients treated with beta-blocker were matched 1:1 with 270 patients treated with digoxin. In these patients (age 79±8 years, CHA2DS2VASc score 4.0±1.3), 125 deaths were recorded during a follow-up of 2.2±2.7 years (median 1.1, interquartile 0.1–3.5 years, yearly rate of death 10.4%) including 72 cardiovascular deaths (yearly rate 6.0%). Major clinical events (all-cause death, myocardial infarction, ischemic stroke or major bleeding) were recorded in 192 patients (yearly rate 19.1%). In this matched analysis, risk was not statistically significant in the 2 groups for all-cause death (HR 0.95, 95% CI 0.67–1.35 for beta-blocker use vs digoxin use), cardiovascular death (HR 1.23, 95% CI 0.77–1.96 for beta-blocker use vs digoxin use) or major clinical events (HR 0.98, 95% CI 0.74–1.31 for beta-blocker use vs digoxin use). Conclusion Our analysis included more patients and had a longer follow-up than in the RATE-AF trial, resulting in a 10-fold higher number of clinical events. We found that among patients with permanent AF and symptoms of HF, there was no statistically significant difference in the risk of all-cause death, cardiovascular mortality and major clinical events between those treated with digoxin or beta-blocker. Concerns regarding the use of digoxin, such as the narrow therapeutic window and drug interactions, were not issues resulting in worse clinically relevant cardiovascular outcomes with the approach used in the current study. Funding Acknowledgement Type of funding sources: None.