Cohort Of Heart Failure Patients Research Articles

Prognostic value of myocardial work and global longitudinal strain in patients with heart failure and functional mitral regurgitation.

In patients with heart failure and functional mitral regurgitation (FMR), the assessment of left ventricular (LV) function is important for risk stratification and decision making. As LV ejection fraction (LVEF) might not be an optimal metric for LV systolic performance in this population, alternatives such as global longitudinal strain (GLS) and global myocardial work index (GWI) have been proposed. In the present study, we investigated the prognostic value of GLS and GWI and compared these measures to other LV systolic performance parameters. A prospective and consecutive cohort of 181 patients (median age 72years, 76% male) with LVEF < 50% and FMR underwent comprehensive echocardiographic examination including speckle tracking echocardiography and grading of FMR severity. During a median follow-up of 42months, 72 cardiovascular (CV) events occurred. In univariate analysis, LVEF, GLS, GWI, mitral S', LV outflow tract time velocity integral, forward LVEF and LV ejection time were associated with CV events. After multivariate adjustment only GLS (hazard ratio (HR) = 0.884, p = 0.015) and GWI (HR = 0.927, p = 0.034) remained independently associated with CV events. There was no difference in the incremental prognostic value of GWI compared to GLS (delta -2 log likelihood = 0.8; p = 0.37). In this cohort of heart failure patients with FMR, GLS and GWI were independently associated with cardiovascular events, whereas other systolic performance parameters were not. However, GWI did not outperform GLS, and further research is required to determine the value of these strain-based measures in clinical practice.

Abstract 13584: Outcomes and Associated Costs With Temporary Mechanical Circulatory Support Devices in Patients With Cardiogenic Shock

Objective: Clinical outcomes and costs associated with different temporary mechanical circulatory support (tMCS) devices has not been previously described. We describe outcomes and costs among heart failure (HF) patients who received tMCS i.e. Impella, intra-aortic balloon pump (IABP) or extra-corporeal membrane oxygenator (ECMO). Methods: This was a retrospective study of a large administrative claims dataset between 01/01/10 and 12/31/19. We included patients with HF or cardiogenic shock who received tMCS i.e. Impella, IABP or ECMO in the absence of an acute myocardial infarction (AMI) or coronary revascularization. Outcomes studied included 30-day mortality, in-hospital stroke and bleeding. We used logistic regression techniques to evaluate association between tMCS device, outcomes and cost. Results: We included 2205 HF unique patients receiving tMCS in the study: 1503 (68%) with ischemic cardiomyopathy (ICM) and 702 (32%) with non-ischemic cardiomyopathy (NICM). Rate of 30-day mortality was higher with ECMO compared to IABP or Impella respectively (22% vs. 15% vs. 17%) with higher stroke (21% vs. 12% vs. 16%) and bleeding rates (42% vs. 25% vs. 33%). This association persisted with multivariable adjustment for all adverse events. ECMO has higher odds of all adverse events vs IABP. Impella has higher odds than IABP for bleeding only. Median standardized cost was highest with ECMO $210383.0 (IQR: $165,760-$239,373), followed by Impella $142,518 (IQR: $126,845-$179938) and IABP $132,059.7 (IQR: $113,794-$160,243.7). Overall, we noted a decrease in cost with ECMO and IABP device types during the study period per year (Figure1). Conclusion: In a cohort of HF patients without AMI or coronary revascularization, use of ECMO was associated with higher rates of 30-day mortality, in-hospital stroke and bleeding compared to IABP and Impella. Associated costs with tMCS use are rising with an increase in survival over time.

Abstract 13432: Pulmonary Artery Pressure-Guided Therapy in Patients With Heart Failure Using the CardioMEMS Device and HF Readmissions: Analysis of the National Readmissions Database

Introduction: Pulmonary artery pressure (PAP)-guided therapy in patients with heart failure (HF) using the CardioMEMS device (CMM), an implantable PAP sensor, has shown to reduce hospitalizations in prior studies. Hypothesis: We sought to evaluate the clinical benefit of the CMM device in regard to readmission rates using the National Readmission Database (NRD). Methods: We queried the NRD to identify patients who underwent CMM implantation (CPT code 33289) between years 2014 to 2018 and studied their HF readmissions. We compared CMM patients and their readmissions with a matched cohort of patients with HF without CMM. Multivariate Cox regression analysis was performed to adjust for other predictors of readmissions. Results: Prior to matching we identified 3,965,188 weighted HF patients without CMM and 1528 patients with CMM. After propensity score matching for several patient and hospital related characteristics, the cohort consisted of 1528 patients with CMM and 1528 with HF without CMM. Before matching CMM patients were younger, more frequently males, with higher rates of prior myocardial infarction and chronic kidney disease. Readmission rates at 30-days were 17.6% vs. 21% for patients with vs. without CMM respectively and remained statistically significant after matching (17.5% vs. 22.7%, p=0.01). The rates of 90-day (29.1% vs 36.5%, p=0.002) and 180-day (40.1% vs. 46.6%, p=0.03) readmissions were lower in the CMM group (Figure). In multivariable regression models, CMM was associated with lower risk of readmissions (HR, 0.78, 95% CI 0.64-0.94, p=0.01). Conclusions: The CardioMEMS device was associated with reduced HF rehospitalization rates in a nationally representative cohort of HF patients

Abstract 10226: Bioactive Adrenomedullin for Assessment of Venous Congestion in Heart Failure

Introduction: Bioactive adrenomedullin (bio-ADM) is a vascular-derived peptide hormone that has emerged as a promising biomarker for assessment of congestion in decompensated heart failure (HF). Hypothesis: We aimed to evaluate diagnostic and prognostic performance of bio-ADM for HF in comparison to amino-terminal pro-B-type natriuretic peptide (NT-proBNP), with decision thresholds derived from invasive hemodynamic and population-based studies. Methods and Results: Normal reference ranges (95% prediction interval) for bio-ADM were derived from a community-based cohort (n=5060): 8-39 pg/mL. In a cohort of HF patients undergoing right heart catheterization (n=346), bio-ADM was correlated with mean right atrial pressure (mRAP, r=0.55) and followed a concordant trajectory to mRAP after heart transplantation. In contrast, NT-proBNP was correlated with pulmonary arterial wedge pressure (PAWP). The area under the receiver operating characteristic curve (AUROC) for discrimination of elevated mRAP and PAWP was 0.74 (95%CI=0.67-0.79) and 0.70 (95%CI=0.64-0.75), respectively, with optimal bio-ADM decision cutoff of 39 pg/mL, concordant with cubic spline analyses. NT-proBNP discriminated PAWP slightly better than mRAP (AUROC 0.73 [95%CI=0.68-0.79] and 0.68 [95%CI=0.61-0.75]). In a cohort of patients presenting with acute dyspnea (n=1534), including patients with decompensated HF (n=570), a bio-ADM decision cutoff of 39 pg/mL was associated with 30- and 90-day mortality and conferred a 2-fold increased odds of HF diagnosis, independently from NT-proBNP. Conclusions: Bio-ADM tracks with mRAP and associates with measures of systemic congestion and with mortality in decompensated HF independently from NT-proBNP. Our findings support utility of bio-ADM as a biomarker of systemic venous congestion in HF and nominate a decision threshold.

Abstract 11566: Use of Temporary Mechanical Circulatory Support Devices in Heart Failure Patients with Cardiogenic Shock

Objective: Contemporary use of temporary mechanical circulatory support devices (tMCS) for heart failure (HF) without acute myocardial infarction (AMI) is not well described. Accordingly, we evaluated use patterns for tMCS in HF patients. Methods: This was a retrospective study of a large administrative claims dataset between 01/01/06 and 12/31/19. We included patients with HF or cardiogenic shock who received tMCS i.e. Impella, intra-aortic balloon pump (IABP) or extra-corporeal membrane oxygenator (ECMO) in the absence of AMI or coronary revascularization. Multinomial logistic regression model was used to identify predictors for type of tMCS device. Temporal trends in use of tMCS was also evaluated. Results: We included 2722 HF patients receiving tMCS: 1836 (68%) with ischemic cardiomyopathy (ICM) and 886 (32%) with non-ischemic cardiomyopathy (NICM). There were no gender or racial differences in device use. Table shows adjusted odds ratio for predictors associated with receipt of ECMO or Impella compared to IABP. After multivariable adjustment, patients with ICM or NICM placed on ECMO compared to IABP, had a higher comorbidity burden. For both groups, patients with valvular disease were more likely to receive IABP and patients with peripheral vascular disease an Impella. Over time, there was an increase in Impella and ECMO use with a decrease in IABP use (p &lt;0.05; Figure). Conclusions: In a real world cohort of HF patients with cardiogenic shock without AMI, use of Impella and ECMO has increased over the last decade and IABP has decreased. Patients receiving ECMO have a higher co-morbidity burden, whereas patients receiving IABP are more likely to have valvular heart disease.

Abstract 11699: Angiographic Coronary Artery Disease (CAD) and Outcomes in Acute Heart Failure (HF)

Introduction: The association between CAD severity and long-term outcomes in patients admitted with acute HF has not been determined. We characterized the angiographic burden of CAD in patients with acute HF and determined the association between CAD severity and mortality and readmission outcomes. Methods: In a multicenter registry of 70 hospitals in Ontario, Canada, we identified acute HF patients who underwent coronary angiography within 14 days of hospitalization (April 2010-March 2013) using stratified random sampling. We selected a cohort of HF patients with a higher a priori risk of CAD, defined inclusively as those with at least one of the following features: previous myocardial infarction (MI), troponin elevation, or angina on presentation. Using angiographic data, we defined obstructive CAD as the presence of &gt; 70% stenosis in at least one epicardial vessel or &gt; 50% left main (LM) stenosis. Multivessel disease (MVD) was defined as the presence of obstructive disease in 2 or more vessels. We determined adjusted associations between coronary anatomy and the rate of cardiovascular (CV) death and readmissions over two years. Results: Of 1772 patients undergoing angiography who met inclusion criteria (median age 71 [IQR 62-79] years; 38.5% women), 1039 patients had CAD and 683 had MVD. Increasing CAD burden was associated with higher CV death (Figure). CV death was significantly increased in those with any CAD and HFpEF (HR 2.27, 95%CI; 1.12, 4.59, p=0.023). The rate of CV death was increased in MVD (HR 1.91, 95% CI; 1.32, 2.75, p&lt;0.001) but not single-vessel disease (HR 1.15, 95%CI; 0.75, 1.77, p=0.516), compared to no obstructive CAD. There was no interaction between MVD and HFpEF or HFrEF status for the outcome of CV death (p=0.690). CV readmission was also significantly higher only in MVD (HR 1.28, 95%CI; 1.07, 1.54, p=0.008). Conclusion: In patients presenting with acute HF, angiographic MVD is associated with an increased rate of CV death and readmissions over 2 years.

Abstract 11426: Signs of Depression Predict Mortality Among Swedish Heart Failure Patients

Introduction: Anxiety and depression are common comorbid conditions in heart failure (HF), and there is growing evidence that they increase the risk of adverse outcomes, including rehospitalization and functional decline. Hypothesis: We aimed to determine if symptoms of anxiety and depression would predict mortality and rehospitalization in a Swedish prospective HF patient cohort. Methods: 387 patients hospitalized for HF (mean age 75 years; 32% women) were assessed using the Hospital Anxiety and Depression Scale (HADS) to measure symptoms of anxiety (HADS Anxiety) and depression (HADS Depression). The median follow-up time to death and rehospitalization was 665 (range,1737; interquartile range, 811) and 316 (range, 2069; interquartile range, 348) days, respectively. Relations between baseline HADS scores, mortality and rehospitalization risk were analyzed using multivariable Cox regression analysis adjusted for age, sex, body- mass index, smoking, prevalent atrial fibrillation, educational level, prevalent diabetes, NYHA-class at hospitalization and systolic blood pressure. Results: A total of 30 patients (8%) had signs of depression according to HADS Depression score &gt;11 points. In the fully adjusted Cox regression model using continuous standardized values per 1 SD change, higher score on HADS Depression scale (HR,1.42; CI, 1.16-1.75; p=0.001) yielded significant associations with increased mortality whereas no associations were found for HADS Anxiety scale (HR, 1.04; CI, 0.86-1.26; p=0.719). Rehospitalization risk (n = 246; 64%) was not significantly associated with higher scores on HADS Depression scale (HR, 1.08; CI, 0.94-1.25; p=0.274) or HADS Anxiety scale (HR, 0.95; CI, 0.82-1.09; p=0.449). Conclusions: Higher scores on HADS Depression scale indicated increased mortality risk in hospitalized HF patients, independently of traditional risk factors. However, higher scores on HADS Anxiety scale did not herald increased risk of mortality or rehospitalization.

Evaluation of functional mitral regurgitation profile in a real-world cohort of heart failure patients and the referral rate of these patients

Abstract Introduction Patients with heart failure and reduced ejection fraction (HFrEF) frequently have significant functional mitral regurgitation (FMR), which carries important prognostic impact. Randomized clinical trials on transcatheter mitral-valve repair have shown conflicting results, and their representativeness in real-world populations are unclear. Purpose This real-world study sought to identify the proportion of patients who would be eligible for mitral valve intervention and describe the current referral patterns at an academic center. Methods We conducted a single center cross-sectional study enrolling consecutive patients with HFrEF and FMR under guideline directed medical therapy from January 2010 to December 2018. Moderate FMR was defined as the presence of an effective regurgitant orifice area (EROA) of ≥20mm2 or a regurgitant volume (Regvol) of ≥30mL/beat, according to American Society of Echocardiography guidelines. Demographic, clinical, echocardiographic and treatment data were assessed. Main MITRA-FR and COAPT Trial eligibility criteria (NYHA class, left ventricular ejection fraction (LVEF), left ventricle end-systolic diameter, pulmonary artery systolic pressure, and right ventricle dysfunction) were applied according to trial protocols. Patterns of referral for mitral valve intervention were assessed by pre-procedural transesophageal echocardiography for mitral regurgitation evaluation. Results A total of 175 patients with at least moderate FMR were included in the analysis (mean age 70±12 years, 80% male, mean LVEF 32% ±9). After applying the main eligibility criteria for each study, 73.7% (n=129) of patients would have been enrolled in MITRA-FR trial, whereas only 27.4% (n=48) patients would have met criteria for COAPT trial (Figure 1). Patients with MITRA-FR profile had a mean EROA 25±8 mm2; mean Regvol 36±9 mL/beat; mean LVEDV 205±72 mL; EROA/LVEDV ratio 0.13±0.04. “COAPT-like” patients had a mean EROA 33±10 mm2; mean Regvol 48±13 mL/beat; mean LVEDV 203±65 mL; mean EROA/LVEDV ratio 0.17±0.05. Only 13.1% (n=23) were referred for transesophageal echocardiography in order to establish the criteria of feasibility for mitral intervention. A total of 16 patients (9.1%) were submitted to mitral valve intervention during follow-up. Conclusion In a real-world population of HFrEF patients with significant FMR, more than one fourth of patients had a “COAPT-like” profile and could have benefited from percutaneous mitral valve intervention. The referral rate for evaluation for a potential intervention was low, which precludes patients from benefiting from this type of treatment. Funding Acknowledgement Type of funding sources: None.

Long-term evolution of estimated glomerular filtration rate in heart failure

Abstract Background Limited data are available on the very long-term trajectory of glomerular filtration rate (GFR) in patients with chronic heart failure (HF). Purpose To assess the GFR dynamics estimated by CKD-EPI in a real-life cohort of HF patients over a 14-year follow-up. Methods In a prospective observational registry of real-life HF outpatients, estimated GFR (eGFR) was calculated by CKD-EPI at baseline and on a structured schedule every 3 months up to 14 years. We included in the analysis only eGFR values that were assessed at scheduled visits, discarding urgent renal function assessments. Loess (locally weighted error sum of squares) curves were plotted for the whole cohort and subgroups according to vital status up to 14 years of follow-up. Loess curves are useful to observe a trend or relationship on nonlinear data observed over time. Results 2423 patients were consecutively included from August 2001 to December 2018. Mean age was 67.0±12.7 years, 28,8% were women and 71.1% had HF with reduced ejection fraction (EF&amp;lt;40%). Out of 37360 eGFR values, 25458 were included in the analysis with a median of 8 values per patient [IQR 4–15] and a range between 1 and 47. Significant changes occurred along the whole trajectory. An initial decline in eGFR was observed during the first three years of follow-up. Subsequently, there was an upward trend during the following five years and after that period a progressive decline was seen until the end of follow-up (Figure 1). In the sub-group of patients who died during follow-up the eGFR slope showed a persistent decline over time of ∼1ml/min/1.73m2 per year. On the contrary, patients who survived to follow-up maintained a stable eGFR (Figure 2). Conclusions The eGFR long-term trajectory in patients with chronic HF showed a snaky pattern with an early decrease, mid-term improvement and late progressive decline. Patients who died during follow-up presented a progressive decline from the beginning. Funding Acknowledgement Type of funding sources: None. Figure 1. Long-term evolution of eGFRFigure 2. eGFR evolution according to vital status

Peripheral artery disease is associated with adverse outcome among hospitalized patients with decompensated heart failure

Abstract Patients with heart failure (HF) and peripheral artery disease (PAD) share common high co-morbidities and outcomes. Management of HF patients has changed dramatically in the last decade. Our purpose in this analysis was to describe the prognostic significance of PAD in a large contemporary cohort of HF patients. Methods Analysis included consecutive patients who were hospitalized with decompensated HF between 2008–2020 at our Center. All patients' records were reviewed for the presence of PAD. Patients with cancer or chronic obstructive pulmonary disease were excluded from the analysis. Study outcomes were all-cause mortality and HF hospitalizations. Cox regression and propensity score matching models were applied. Results Final study population included 8,216 patients of whom 548 (7%) had PAD. Patients with PAD had higher rates of co-morbidities. Median follow-up was 3 (IQR 1–7) years. PAD was associated with a significant 35% increased risk of re-admission and mortality in univariate analysis (p&amp;lt;.001 for both). Propensity score matching analysis has demonstrated that PAD patients had similar mortality rates, but higher re-hospitalization rates during follow up. Finally, sensitivity analysis of the matching model (n=474), after excluding patients with RV dysfunction or severe pulmonary hypertension, successfully showed that HF patients with PAD were 50% more likely to be re-admitted and 30% more likely to die during follow-up (p=0.02 and 0.006 respectively; Figure 1) Funding Acknowledgement Type of funding sources: None. Figure 1

Effectiveness of telemedicine in patients with heart failure according to frailty phenotypes: insights from the iCOR randomised controlled trial

Abstract Background/Introduction The potential impact of telemedicine (TM) in the monitoring of heart failure (HF) patients is still uncertain, largely due to the heterogeneity of the studies published to date. A subgroup of patients in which its key role is particularly uncertain is that of the frailest patients mainly due to TM-based strategies have been often discouraged on the basis of a foreseeable limited benefit in them. Purpose The aim of this study was to define the efficacy of a TM-based managed care solution across different HF patient frailty phenotypes in a cohort of HF patients recruited in a randomized clinical trial (The Insuficiència Cardíaca Optimitzaciό Remota [iCOR] study) evaluating the efficacy of a TM-based management compared to usual care (UC) in the early post-discharge period. Methods Five previously described frailty clusters were analysed. Cox proportional-hazards regression models were used to evaluate the effect of each cluster and group of treatment (and its interaction) on a series of endpoints (the incidence of non-fatal HF events as primary endpoint and all-cause hospitalization, all-cause death and the composite endpoint combining of all-cause death or non-fatal HF events as secondary endpoints). The incidence proportion of the first occurrence of each of the study endpoints was calculated for each study arm and for cluster, and these compared using χ2 tests. Additionally, a survival analysis was conducted using Cox regression to describe the event-free survival experience of the combination of the clusters with each of the 2 treatment groups for the study endpoints evaluated, and p-value was used to compare the different curves. Results The positive effect of TM compared to UC strategy was consistent across all frailty phenotypes (p-value for interaction 0.711). The risk of experiencing a primary event was significantly lower in patients that underwent allocation to the TM arm compared to UC (p-value=0.016). As shown for the primary endpoint, the positive effect of TM compared to UC strategy was consistent across all frailty phenotypes also for the secondary endpoints (all p-value for interaction &amp;gt;0.05). Likewise, the risk of all-cause hospitalization or the composite end-point of all-cause death or non-fatal HF event was significantly lower in patients that underwent allocation to the TM arm compared to UC (p-value=0.030 and 0.016 respectively). However, the risk of all-cause death did not differ across subgroup strata (p-value&amp;gt;0.05). Conclusion(s) This study showed that non-invasive TM-based follow-up tools are effective compared to UC in preventing fatal and non-fatal adverse events in the early post-discharge period, regardless of the 5 different frailty phenotypes. Importantly, when comparing TM-based follow-up with UC management in patients belonging to equal frailty cluster, those who were followed-up by eHealth had a considerably lower risk of non-fatal HF events, hospitalization or death. Funding Acknowledgement Type of funding sources: None. Cox regression non-fatal HF eventsCox regression all-cause hospitalization

Primary care heart failure service identifies a missed cohort of heart failure patients with reduced ejection fraction.

AimsWe explored whether a missed cohort of patients in the community with heart failure (HF) and left ventricular systolic dysfunction (LVSD) could be identified and receive treatment optimization through a primary care heart failure (PCHF) service.Methods and resultsPCHF is a partnership between Inspira Health, National Health Service Cardiologists and Medtronic. The PCHF service uses retrospective clinical audit to identify patients requiring a prospective face-to-face consultation with a consultant cardiologist for clinical review of their HF management within primary care. The service is delivered via five phases: (i) system interrogation of general practitioner (GP) systems; (ii) clinical audit of medical records; (iii) patient invitation; (iv) consultant reviews; and (v) follow-up. A total of 78 GP practices (864 194 population) have participated. In total, 19 393 patients’ records were audited. HF register was 9668 (prevalence 1.1%) with 6162 patients coded with LVSD (prevalence 0.7%). HF case finder identified 9725 additional patients to be audited of whom 2916 patients required LVSD codes adding to the patient medical record (47% increase in LVSD). Prevalence of HF with LVSD increased from 0.7% to 1.05%. A total of 662 patients were invited for consultant cardiologist review at their local GP practice. The service found that within primary care, 27% of HF patients identified for a cardiologist consultation were eligible for complex device therapy, 45% required medicines optimization, and 47% of patients audited required diagnosis codes adding to their GP record.ConclusionA PCHF service can identify a missed cohort of patients with HF and LVSD, enabling the optimization of prognostic medication and an increase in device prescription.

Angiopoietin 1 release from human neutrophils is independent from neutrophil extracellular traps (NETs)

BackgroundNeutrophils induce the synthesis and release of angiopoietin 1 (Ang1), a cytosolic growth factor involved in angiogenesis and capable of inducing several pro-inflammatory activities in neutrophils. Neutrophils also synthesize and release neutrophil extracellular traps (NETs), comprised from decondensed nuclear DNA filaments carrying proteins such as neutrophil elastase (NE), myeloperoxidase (MPO), proteinase 3 (PR3) and calprotectin (S100A8/S100A9), which together, contribute to the innate immune response against pathogens (e.g., bacteria). NETs are involved in various pathological conditions through pro-inflammatory, pro-thrombotic and endothelial dysfunction effects and have recently been found in heart failure (HF) and type 2 diabetes (T2DM) patients. The aim of the present study was to investigate the role of NETs on the synthesis and release of Ang1 by the neutrophils in patients with T2DM and HF with preserved ejection fraction (HFpEF) (stable or acute decompensated; ADHFpEF) with or without T2DM.ResultsOur data show that at basal level (PBS) and upon treatment with LPS, levels of NETs are slightly increased in patients suffering from T2DM, HFpEF ± T2DM and ADHF without (w/o) T2DM, whereas this increase was significant in ADHFpEF + T2DM patients compared to healthy control (HC) volunteers and ADHFpEF w/o T2DM. We also observed that treatments with PMA or A23187 increase the synthesis of Ang1 (from 150 to 250%) in HC and this effect is amplified in T2DM and in all cohorts of HF patients. Ang1 is completely released (100%) by neutrophils of all groups and does not bind to NETs as opposed to calprotectin.ConclusionsOur study suggests that severely ill patients with HFpEF and diabetes synthesize and release a greater abundance of NETs while Ang1 exocytosis is independent of NETs synthesis.

Characteristics of patients with acute heart failure in North Central Nigeria

Objectives: Heart failure (HF) is an important cause of hospital admission in Nigeria. HF is increasingly prevalent because the population is aging and HF epidemiology is changing. We aimed at profiling the socio-demographic, clinical and echocardiographic (Echo) characteristics of patients admitted for acute HF. This is one of the largest cohorts of HF patients profiled in Nigeria so far.&#x0D; Methods: Cross sectional design. Socio-demographic, clinical and Echo data were collected from 455 patients admitted for AHF at University of Ilorin Teaching Hospital, North central, Nigeria.&#x0D; Results: Mean age of patients was 58.9± 15.7years, (men were older than women, P= 0.006). 265(58.2%) were males, most patients were aged &gt;60 years, 4.8% had pre-existing Type2 Diabetes mellitus. 53.2% of patients presented in New York Heart Association Stages III and IV. Median duration of admission was 11days (IQR, 6-17), intrahospital mortality- 11.6%. Hypertension was the commonest aetiological factor (62.4%), followed by dilated cardiomyopathy 17.6%, rheumatic heart disease (6.6%), Peripartum cardiomyopathy (5.3%), and others.&#x0D; Conclusion: AHF patients in our study are older than those in previous studies in Nigeria and sub-Saharan Africa. Hypertension is main driver of AHF, and patients largely present with clinically advanced disease necessitating stronger public health education about risk factors and early presentation.&#x0D;

Assessing post-exercise respiratory gas kinetics in clinical sample - a pilot study

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiopulmonary exercise testing (CPX) is established in the evaluation of patients with cardiac and pulmonary diseases, and its clinical utility seems to be expanding. Currently the most important diagnostic and prognostic ventilatory metrics of CPX rely on the exercise phase. Nevertheless, a consistent body of evidence suggests that important information can be derived from the recovery phase, especially in the first few minutes after exercise. In this context, patients with heart failure (HF) demonstrate a slower recovery of the oxygen consumption (VO2) compared with healthy individuals. Purpose: To comprehensively investigate the behavior of respiratory gases during recovery from CPX in a diverse cohort of HF patients. Methods: All individuals who performed CPX at the department of cardiology of Stanford University Hospital were eligible for the study. Patients were included in the experimental group if they (i) were recorded for five minutes after the exercise phase of CPX and (ii) had documented heart failure. They were excluded if they had other clinical diagnoses which may be responsible for exercise intolerance or symptoms or were unable to give informed consent. Healthy controls were recruited from the local community and were included if they did not have documented or suspected disease. Respiratory gases were collected on a breath-by-breath basis and analysed after applying a 30 second rolling average filter. Metrics were analyzed as absolute values, percentage change from peak and the half-time of recovery (T ½; i.e. the duration until a metric had returned to ½ of its value at peak). Data was analyzed over time within patients and averages between groups using parametric statistical methods. In accordance with previous studies, the amount of change in a metric after exercise is presented as the "magnitude" of overshoot. Results: 32 patients with HF (11 Female, 47 ± 13 yrs) and 30 healthy subjects (14 Female, 43 ± 12 yrs) were included. A comparison of ventilatory metrics during recovery between HF and controls is depicted in Figure 1. Peak VO2 was 1135 ± 419 mL/min (13.5 ± 3.8 mL/Kg/min) vs 2408 ± 787 mL/min (32.5 ± 9.0 mL/Kg/min); P &amp;lt;0.01. A significant difference between patients with HF and healthy subjects was found in T ½ of VO2 (111.3 ± 51.0s vs 58.0 ± 13.2s, p &amp;lt; 0.01) and VCO2 (132.0 ± 38.8s vs 74.3 ± 21.1s, p &amp;lt; 0.01). The magnitude of the overshoot was also found to be significantly reduced in patients with HF for VE/VO2 (41.9 ± 29.1% vs 62.1 ± 17.7%, P &amp;lt; 0.01), RQ (25.0 ± 13.6% vs 38.7 ± 15.1%, p &amp;lt; 0.01) and PETO2 (7.2 ± 3.3% vs 10.1 ± 4.6%, p &amp;lt; 0.01). Finally, the magnitude of the RQ overshoot showed a moderate correlation with peak VO2 (ϱ=0.58, p &amp;lt; 0.01). Conclusions: We observed that ventilatory kinetics measured in early recovery after CPX differ significantly between healthy subjects and patients with HF. The assessment of post exercise respiratory gases in a clinical setting may add to the prognostic and diagnostic value of CPX in heart failure. Abstract Figure.

Chagas disease is an independent predictor of stroke and death in a cohort of heart failure patients.

Chagas disease is a common cause of heart failure (HF) and death in developing countries. Although stroke is known to occur in these patients, an accurate estimate of stroke incidence is lacking. We aimed to determine the incidence of stroke and death in patients with HF, comparing Chagas and non-Chagas etiologies. Cohort of stroke-free patients with HF (Framingham criteria) followed in a university-based outpatient clinic in Brazil. Baseline characteristics included sociodemographic, risk factor assessment, echocardiographic and electrocardiographic findings. Chagas disease was defined by appropriate serologic tests. Cause-specific Cox regression was used to search for predictors of stroke or death as separate outcomes. We studied 565 patients with HF between January 2003 and December 2018, mean age 54.3 ± 12.9 years, 305 (54.0%) females, 271/535 (50.7%) with Chagas disease. Chagas patients were older (55.5 vs. 53.1 years), more frequently women (60.5% vs. 47.3%), less frequently harbored coronary artery disease (14.5% vs. 34.1%) when compared to non-Chagas patients. Echocardiography showed more severe disease among non-Chagas patients [median left ventricle ejection fraction (LVEF) 37.3% vs. 47.0%]. Over a mean 42.9 (±34.4) months, we followed 404 (71.5%) patients, completing 1442 patient-years of follow-up. Stroke incidence was higher in Chagas when compared to non-Chagas patients (20.2 vs. 13.9 events per 1000 patient-years), while death rate was similar (41.6 vs. 43.1 deaths per 1000 patient-years). In the multivariable analysis for stroke outcome adjusted for LVEF and arrhythmias, cause-specific hazard ratio (CSHR) for Chagas was 2.54 (95% confidence interval 1.01-6.42, p = 0.048). Chagas disease was also associated with increased risk of death (CSHR 1.83; 95% confidence interval 1.04-3.24, p = 0.037). Chagas disease is associated with increased risk of stroke and death when compared to other etiologies of HF, independently of HF severity or cardiac arrhythmias, suggesting other factors contribute to increased stroke risk and mortality in Chagas disease. Early prevention and treatment of Chagas disease is imperative to reduce a later risk of stroke in endemic areas.

Long-term outcomes of index cryoballoon ablation or point-by-point radiofrequency ablation in patients with atrial fibrillation and systolic heart failure.

Catheter ablation is an establishedeffective approach for the treatment of atrial fibrillation (AF) in patients with heart failure, however, the role of cryoablation in this setting is unclear. Procedural success and left ventricular systolic dysfunction (LVEF) improvement in patients with LVEF ≤ 45% undergoing index catheter ablation with cryoablation were evaluated. Freedom from AF recurrence was seen in 43% rising to 59% following repeat procedure. There were significant improvements in LVEF and functional status at long-term follow-up. Results were comparable to a contemporaneous cohort of heart failure patients undergoing index ablation with radiofrequency ablation. Cryoablation is an effective first-line AF ablation approach in the setting of heart failure.

A systematic approach towards implementing value-based health care in heart failure: Understandings from retrospective analysis methods in South London.

BackgroundValue-Based Health Care (VBHC) is an evolving model of healthcare delivery aimed at achieving better patient outcomes at lower costs to the healthcare provider. The practise of VBHC requires efficient information systems with good reporting capability and subsequent outcome measuring. Information systems within the National Health Service (NHS) are often multiple and not necessarily integrated to one another. We therefore developed a systematic approach to collecting, validating and analysing data from multiple sources and information systems, with the aim of designing and endorsing an automatic system to capture health outcomes data in heart failure to support future VBHC models.MethodsA retrospective cohort of heart failure patients with reduced ejection fraction undergoing Implantable Cardioverter Defibrillator (ICD) or Cardiac Resynchronization Therapy (CRT) procedures within a limited geographical area in South London were evaluated. A purpose built database was created to integrate, transform and validate health care data from multiple information systems.ResultsValidation analysis shows that our implemented methodology has produced a robust dataset. Our limited cohort of 134 patients does not allow for any complex statistical analysis however has identified some important themes related to outcomes and costs.ConclusionWe have created a validated database specific to our Trust that can be upscaled locally with ease and transferred to other health diseases. Due to variations in local procedure from one Trust to another, this methodology now requires implementation across multiple sites to understand differences in transformation of data and outcome measuring.

Abstract 14882: Outcomes of Heart Failure in Hypoplastic Left Heart Syndrome and the Impact of Recovery

Introduction: Survival for children with hypoplastic left heart syndrome (HLHS) and right ventricular (RV) dysfunction (dysfxn) remain poor. We describe outcomes of HLHS patients with RV dysfxn and the long-term impact of interval normalization. Methods: The SickKids Heart Failure (HF) Database is a retrospective cohort of HF patients from 2001 to 2017. We included patients with HLHS and at least mild RV dysfxn on echocardiogram lasting &gt;30 days, or death or transplant within 30 days of onset of dysfxn. We defined normalization as normal RV function (fxn) lasting &gt; 30 days after dysfxn onset. The primary endpoint was death or transplant. Descriptive statistics and time to event analysis were used. Results: We identified 99 patients with a median (IQR) age at onset of dysfxn of 2.6 (1 - 5.3) months. Of these, 51 (52%) had normalization of RV fxn for a median (IQR) duration of 3.5 (0.8 - 9.1) years and 28 (55%) had multiple periods of normal fxn. Of those who normalized, 4 (8%) normalized within a few months post Glenn procedure and 6 (13%) had normal fxn at last follow up. Patients with and without normalization had similar frequency of severe dysfxn (41 vs 52%, p=0.6). Normalization of RV fxn correlated with improved transplant free survival (78 % vs. 14 %, p&lt;0.001, Figure 1C) independent of surgical stage (p=0.03, figure 1D). Table 1 shows risk factors independently associated with transplant-free survival, including angiotensin converting enzyme inhibition. Conclusions: HLHS patients with RV dysfxn have poor transplant-free survival, especially those at interstage, but outcomes improve in those with persistent normalization of fxn. Factors predicting normalization need further study

Cardiac rehabilitation effectively reduces the number of deaths in the heart failure population (propensity score matched analysis)

Abstract Background Numerous cardiac rehabilitation (CR) studies have demonstrated functional benefits, improvement in quality of life and clinical outcomes from exercise training in patients with heart failure (HF), so CR is consistently recommend for HF patients. However its influence on survival in HF population is unknown. Purpose To assess the influence of CR on survival rate in HF patients. Methods It is a retrospective analysis of 1 620 686 HF patients in Poland in years 2013–2018, based on nationwide Polish Ministry of Health registry, that provides public universal healthcare coverage to all residents and collects detailed information for the entire Polish population (38,495,659 in 2013) since 2009. Within registry, we identified the experimental group of 11 512 HF patients ≥18 years old who underwent CR in 2013–2018. From entire HF population we identified a 1:1 propensity score matched cohort of HF patients, who did not get CR. Results After propensity-score matching, we identified 11,512 patient pairs who underwent/not CR. Average age was approximately 66 years (18–39: 2.1 vs 2.0%; 40–49: 491 – 4.3 vs 4.2%; 50–59: 17.0 vs 17.1%; 60–69: 34.9 vs 35.2%; 70–79: 31.3 vs 31.4%; 80+: 10.4 vs 10.3% respectively), 61% of the participants were males, mainly urban residence nearly 70%, with HF diagnose put during hospitalization 74.5%. Both groups were similar also by comorbidities evaluated by Charlson Comorbidity Index. Patients subjected to CR compared CR negative significantly increased survival risk at 1st, 2nd, 3rd, 4th and 5th year (CR vs CR negative 97.4% vs. 84.9%; 93.9% vs. 77.9%; 89.9% vs. 71.9%; 85.2% vs 66.0%; 81.8% vs 62.1% respectively) – Figure 1. Conclusion Our analysis showed that in heart failure patients, CR was associated with an increased survival rate among HF patients as treated in routine health care system. Figure1 Funding Acknowledgement Type of funding source: Other. Main funding source(s): European Union from the European Social Fund