Concomitant Heart Failure Research Articles

Impact of stroke volume on prognostic outcome in patients with atrial fibrillation and concomitant heart failure with preserved ejection fraction

BackgroundAtrial fibrillation (AF) can lead to a decrease in stroke volume (SV) despite a preserved left ventricular ejection fraction (LVEF). However, no previous studies have evaluated the prognostic importance of the decreased SV in patients with AF and concomitant heart failure with preserved ejection fraction (HFpEF). MethodsWe retrospectively studied the cases of 1520 consecutive patients who had undergone right heart catheterization. HFpEF (New York Heart Association functional class ≥II and LVEF ≥50%) was observed in 574 patients. We selected 47 patients with persistent AF with a heart rate of 40–110bpm and HFpEF without other underlying heart diseases. ResultsAmong a total of 47 patients, 16 (34%) had normal SV [SV index (SVI) >35ml/m2 and 31 (66%) patients had low SV (SVI≤35ml/m2)]. During the follow-up period of 1115±305 days, 14 patients (30%) met the composite endpoint defined as cardiac death and admission due to worsening heart failure. Cox proportional hazard ratio analysis showed that SVI was a predictor of the endpoint, independently of the cardiac index and other parameters. Kaplan–Meyer analysis showed that low SVI was significantly associated with a poor prognosis, with an event-free rate of 58% at the mean follow-up period of 991 days (log-rank p=0.02). In the multiple regression analysis, a high systemic vascular resistance index and a high heart rate were independent determinants of low SVI. ConclusionsOur findings suggest that low SV had a significant impact on prognosis in patients with AF despite the preserved LVEF. The SVI depended on the heart rate and SVRI.

Atrial fibrillation ablation in heart failure.

This review summarizes the rationale and current scientific evidence for catheter ablation in patients with atrial fibrillation and concomitant heart failure, puts it in context with recent practice recommendations, and discusses emerging technologies and future directions.

Bariatric surgery among patients with heart failure: a systematic review and meta-analysis

BackgroundBariatric surgery reduces cardiovascular risk in obese patients. Heart failure (HF) is associated with an increased perioperative risk following bariatric surgery. This systematic review aimed to assemble the evidence on...

Use of Oral Anticoagulation in Eligible Patients Discharged With Heart Failure and Atrial Fibrillation.

Stroke prophylaxis in patients with atrial fibrillation (AF) and heart failure (HF) in the era of direct oral anticoagulants is not well characterized. Using data from American Heart Association Get With The Guidelines-AFIB, we sought to evaluate oral anticoagulation (OAC) use at discharge among AF patients with concomitant HF. AF patients with a diagnosis of HF hospitalized from January 2013 to March 2017 were included. We compared patient characteristics and use of OAC at discharge among patients with reduced (redundant ejection fraction [EF], EF≤40%), borderline (40%<EF<50%), and preserved (EF≥50%) EF using multivariable mixed logistic regression models. Among 10 883 patients with AF and HF, 1790 (16.4%) had a reported contraindication to anticoagulation and were excluded from further analysis. Among 9093 patients eligible for OAC, 3499 (38.5%) had HF with reduced EF, 1062 (11.7%) had HF with borderline EF, and 4532 (49.8%) had HF with preserved EF. The median CHA2DS2-VASc score was 5 (Q1, Q3; 3, 6) among all patients and higher among those with HF with preserved EF than HF with reduced EF (5 [4, 6] versus 4 [3, 5]; P<0.0001). The proportion of eligible patients discharged on OAC was 94.9%, with 43.6% discharged on warfarin and 50.7% discharged on direct oral anticoagulants. A higher proportion of patients with HF with reduced EF and HF with borderline EF were discharged on direct oral anticoagulants than with HF with preserved EF, but the difference was small (52.8%, 53.1% versus 48.5%, respectively; P=0.0002). EF group was not significantly associated with a patient's OAC use at discharge. In the context of American Heart Association Get With The Guidelines-AFIB, a quality improvement program, the rate of use of OAC at discharge in eligible AF patients with HF was almost 95%. To our knowledge, these rates represent some of the highest use of appropriate anticoagulation for patients in a national registry to date.

Abstract 371: Cardiac Endocrinology: Biology of a Heart-derived Hormone That Regulates Body Growth

The endocrine system is crucial for maintaining whole-body homeostasis. Little is known regarding endocrine hormones secreted by the heart other than ANP and BNP discovered over 30 years ago. We recently identified growth differentiation factor 15 (GDF15) as a heart-derived hormone that regulates body growth. Pediatric heart disease induces GDF15 synthesis and secretion by cardiomyocytes. Circulating GDF15 in turn acts on the liver to inhibit growth hormone (GH) signaling and body growth. Blocking cardiomyocyte production of GDF15 normalizes circulating GDF15 level and restores liver GH signaling, establishing GDF15 as a bona fide heart-derived hormone that regulates pediatric body growth. Importantly, plasma GDF15 is further increased in children with concomitant heart disease and failure to thrive. In addition, we used massively parallel single-nucleus RNA-Seq to decipher cardiac cell type specific gene regulatory network that induces GDF15 transcription in heart disease condition. We further determined how GDF15 precursor is processed into mature hormone. Together these studies reveal a new endocrine mechanism (cardiac endocrinology) by which the heart coordinates cardiac function and body growth.

Practical management of concomitant acute heart failure and worsening renal function in the emergency department.

Worsening renal function (i.e. any increase in creatinine or decrease in the estimated glomerular filtration rate) is common in patients admitted for acute heart failure in the emergency department. Although worsening renal function (WRF) has been associated with the occurrence of dismal outcomes, this only appears to be the case when associated with clinical deterioration. However, if the clinical status of the patient is improving, a certain increase in serum creatinine may be acceptable. This WRF, which is not associated with clinical deterioration or adverse outcomes (e.g. during treatment up-titration), has been referred to as 'pseudo-WRF' and should not detract clinicians from targeting 'guideline-recommended' therapies. This is an important message for emergency physicians to pursue diuretics as long as signs of pulmonary congestion persist to improve the clinical status of the patient. In the present review, we aim to provide clinicians in acute settings with an integrative and comprehensive approach to cardiorenal interactions in acute heart failure.

Outcomes of Angiotensin Receptor-Neprilysin Inhibitor Prescriptions for Patients with Heart Failure and Reduced Ejection Fraction in Real World Clinical Practice

Introduction While guidelines now recommend the use of Angiotensin Receptor-Neprilysin Inhibitors (ARNI) in place of ACE inhibitors and angiotensin receptor blockers for select patients with heart failure and reduced ejection fraction, the utilization of ARNI among eligible patients in clinical practice remains low. Access, cost, and tolerability are perceived barriers to use. Hypothesis We hypothesized that financial barriers to prescriptions are an important factor contributing to underutilization of ARNI among eligible patients in clinical practice. Methods We conducted a single-center, retrospective analysis of all new ARNI prescriptions at our center written from June 2015 to May 2017. For all prescriptions, we tracked the subsequent success with prior insurance authorization (PA), patient initiation of medication, dose titration, as well as adaptations to concomitant heart failure medications. Results Of 167 prescriptions written, 139 reflected new starts of sacubitril/valsartan, 26 reflected continuations, and 2 had insufficient data for analysis. Of the new prescriptions, PAs were requested in 81 (58% of new starts), and granted in 75 patients (92.6% of requests). Prescriptions were successfully filled in 123 (88.5% of new starts), and subsequently discontinued in 17 patients (13.8%). Of subjects filling prescriptions, 33.3% of patients were titrated to the high dose (97/103 mg sacubitril/valsartan twice daily), 34.2% were titrated to the middle dose (49/51 mg twice daily) and 18.7% were titrated to the low dose (24/26 mg twice daily) [Figure 1] . Limiting factors to titration and continuation of therapy included hypotension (37%) and renal function (5.7%). During titration, dose reductions in beta-blockers and loop diuretics were made in 6.5% and 14% of patients respectively. Minimal changes were noted in dosing of aldosterone antagonists or other vasodilators. Conclusions Most patients prescribed ARNI therapy are successfully initiated in practice without significant cost or insurance barriers. As in the trials which led to approval, dose titration of ARNI was frequently limited by hypotension and renal dysfunction, and often facilitated reduction in loop diuretics. These ‘real-world’ data suggest that financial/insurance factors do not account for most underutilization of ARNI

An Analysis on Clinical Outcomes and Diuretic Requirements Following Initiation of Sacubitril/Valsartan in Patients with Chronic Heart Failure with Reduced Ejection Fraction

Background A post-hoc analysis of the PARADIGM-HF clinical trial demonstrated treatment with sacubitril/valsartan resulted in a significant reduction in patients with worsening NYHA functional class, as compared to enalapril. Additional post-hoc analyses have revealed a reduction in intensification in outpatient diuretics, as well as a reduction in overall daily diuretic requirements, for patients treated with sacubitril/valsartan verses enalapril. Real world evidence is limited in analyzing patient experiences surrounding improvement in HF symptoms and diuretic usage. Methods This analysis was a retrospective chart review of patients consecutively prescribed sacubitril/valsartan at the Jefferson Heart Institute from January 1, 2016 until January 31, 2017. Patient clinical outcomes and diuretic requirements were analyzed for 3 months following maintenance on any dose of sacubitril/valsartan for four weeks. Chart examinations reviewed documentation for improvements in heart failure (HF) symptoms, NYHA functional class, and LVEF, as well as changes in concomitant HF medications. Safety endpoints included symptomatic hypotension and an elevation in serum creatinine and/or potassium. Results A total of 42 patients were included in the analysis. Thirty-six patients (85.7%) were titrated from their initial starting dose, although only 28 patients (66.7%) reached the targeted dose of 97/103mg twice daily. Fifty-seven percent of the patients (24/42) reported improvements in their HF-related symptoms, while 38.1% (16/42) of the patients demonstrated improvement NYHA functional classification. Thirty-six patients were concomitantly receiving loop diuretics during the initiation of sacubitril/valsartan, of whom 6 (16.7%) and 14 patients (38.9%) required discontinuation and dose reductions of loop diuretics, respectively. Twenty-two patients had a repeat ECHO after sacubitril/valsartan was initiated, fourteen of whom (63.6%) showed improvements in their LVEF. Two patients required discontinuation of therapy due to an adverse reaction; however, no other discontinuations were required from symptomatic hypotension, hyperkalemia or renal impairment. Sixteen patients (38%) experienced symptomatic hypotension, and 50% of those patients were not titrated to the target dose. Conclusion Treatment with sacubitril/valsartan resulted in an improvement in patient-reported HF symptoms, NYHA functional class and LVEF. Although the majority of patients were maintained on diuretics post initiation of sacubitril/valsartan, daily dose reductions were observed. Patients did not require discontinuation of therapy as a result of symptomatic hypotension, hyperkalemia and/or renal impairment. Despite a small sample size, this retrospective analysis serves as an example of real world experience with initiating sacubitril/valsartan in patients with chronic HFrEF.

Diagnostic and prognostic properties of procalcitonin in patients with acute dyspnea: Data from the ACE 2 Study

BackgroundProcalcitonin (PCT) concentrations increase during bacterial infections and could improve diagnosis of pneumonia and risk stratification in patients with acute dyspnea. MethodsPCT concentrations were measured <24 h of admission in 310 patients with acute dyspnea and compared to C-reactive protein (CRP) and white blood cells (WBC) in the total cohort and the subset of patients with concomitant acute heart failure (HF). ResultsWe diagnosed pneumonia in 16 out of 140 patients with acute HF (11%) and in 45 out of 170 patients with non-HF-related dyspnea (27%). PCT concentrations were higher in patients with pneumonia vs. patients without pneumonia, both among acute HF patients (median 2.79 [Q1–3 0.18–5.80] vs. 0.10 [0.07–0.14] ng/mL, p < .001) and non-HF patients (0.22 [Q1–3 0.13–0.77] vs. 0.07 [0.05–0.10] ng/mL, p < .001). CRP and WBC were also higher in patients with pneumonia in both groups, but among acute HF patients, only PCT concentrations were associated with pneumonia in multivariate analysis. In patients with acute HF, receiver-operating statistics area under the curve (ROC-AUC) to diagnose pneumonia was 0.90 (95% CI 0.81–0.98) for PCT, 0.84 (0.73–0.94) for CRP, and 0.72 (0.57–0.87) for WBC. The corresponding ROC-AUCs among patients with non-HF-related dyspnea were 0.88 (0.82–0.93), 0.94 (0.90–0.98), and 0.79 (0.72–0.87), respectively. During a median follow-up of 823 days (Q1–3 471–998) 114 patients died, and PCT and CRP, but not WBC concentrations were associated with all-cause mortality. ConclusionIn acute HF patients, PCT concentrations were superior to CRP and WBC to diagnose concurrent pneumonia.

Double trouble: managing diabetic emergencies in patients with heart failure

Double trouble: managing diabetic emergencies in patients with heart failure

Diabetes mellitus and heart failure: insights from a toxic relationship

Diabetes mellitus and heart failure: insights from a toxic relationship

Operative Techniques and Pitfalls in Donor Heart-Lung Procurement

BackgroundHeart-lung transplantation is a well-established therapeutic modality for concomitant end-stage heart and lung failure. With growing organ scarcity, the rates of these transplants are declining, and center experience is waning. MethodsWith over 35 years of experience performing heart-lung transplantation, we describe our procurement protocol herein, as well as offer suggestions to avoid potential pitfalls in order to ensure technical excellence in harvesting these valuable grafts. ResultsProcurement issues most commonly arise with organ preservation and inadvertent damage to structures that are difficult to fully visualize. ConclusionsEn-bloc heart-lung procurement can be taught effectively and safely to trainees with an emphasis on avoiding common pitfalls that may compromise graft function.

Patterns of glucose-lowering medication use in patients with type 2 diabetes and heart failure. Insights from the Diabetes Collaborative Registry (DCR)

BackgroundOptimal glucose-lowering strategies in patients with both heart failure (HF) and type 2 diabetes mellitus (T2D) are not well defined, particularly as novel medication classes emerge.We sought to evaluate current patterns of glucose-lowering medication use in adults with T2D with and without HF. MethodsThe DCR is a US-based outpatient registry of adults with diabetes; currently includes 3074 providers in 203 practices. We used hierarchical, modified Poisson regression models to examine the relationship between concomitant HF with use of each glucose-lowering medication class, adjusting for other factors that could impact selection of one medication class over another: age, chronic kidney disease (CKD), coronary artery disease (CAD), number of glucose-lowering medications, and insurance. ResultsAmong 456,106 adults with T2D, 125,161 (27%) had a diagnosis of HF (30% HFrEF, 15%HFmrEF, 55% HFpEF). Patients with T2D and HF were more likely to be older and male, and to have CAD, atrial fibrillation, and CKD. In the multivariable models, HF was associated with a greater use of insulin (RR 1.39, 95% CI 1.36–1.42) and lower use of thiazolidinediones (RR 0.79, 95% CI 0.74–0.83), SGLT2 inhibitors (RR 0.83, 95% CI 0.79–0.89), and metformin (RR 0.84, 95% CI 0.82–0.86). Among the subgroup of patients with HF, thiazolidinediones, GLP-1 receptor agonists, and SGLT2 inhibitors were used even less often in patients with lower ejection fraction, indicating that both the diagnosis of clinical HF and ejection fraction may influence the choice of glucose-lowering medications. ConclusionIn a large US-based outpatient registry, we found that a quarter of adults with T2D had a diagnosis of HF, which was predominantly HFpEF. Although certain T2D medication use in patients with HF appeared consistent with evidence (less use of thiazolidinediones), others appeared contrary to evidence (less use of metformin and SGLT2 inhibitors).

Rhythm Versus Rate Control for Atrial Fibrillation: A Meta-analysis of Randomized Controlled Trials

Atrial fibrillation (AF) is a common, sustained tachyarrhythmia, associated with an increased risk of mortality and thromboembolic events. We performed this meta-analysis to compare the clinical efficacy of rate and rhythm control strategies in patients with AF in a meta-analysis framework. A comprehensive search of PubMed, OVID, Cochrane-CENTRAL, EMBASE, Scopus, and Web of Science was conducted, using relevant keywords. Dichotomous data on mortality and other clinical events were extracted and pooled as risk ratios (RRs), with their 95% confidence-interval (CI), using RevMan software (version 5.3). Twelve studies (8451 patients) were pooled in the final analysis. The overall effect-estimate did not favor rate or rhythm control strategies in terms of all-cause mortality (RR= 1.13, 95% CI [0.88, 1.45]), stroke (RR= 0.97, 95% CI [0.79, 1.20]), thromboembolism (RR= 1.06, 95% CI [0.64, 1.76]), and major bleeding (RR= 1.10, 95% CI [0.90, 1.35]) rates. These findings were consistent in AF patients with concomitant heart failure (HF). The rate of rehospitalization was significantly higher (RR= 0.72, 95% CI [0.57, 0.92]) in the rhythm control group, compared to the rate control group. In younger patients (&lt;65 years), rhythm control was superior to rate control in terms of lowering the risk of all-cause mortality (p=0.0003), HF (p=0.003) and major bleeding (p=0.02). In older AF patients and those with concomitant HF, both rate and rhythm control strategies have similar rates of mortality and major clinical outcomes; therefore, choosing an appropriate strategy should consider individual variations, such as patient preferences, comorbidities, and treatment cost.

Sustained atrial fibrillation increases the risk of anticoagulation-related bleeding in heart failure.

Oral anticoagulation therapy in individuals with atrial fibrillation (AF) reduces the risk of thromboembolic events at cost of an increased bleeding risk. Whether anticoagulation-related outcomes differ between patients with paroxysmal and sustained AF receiving anticoagulation is controversially discussed. In the present analysis of the prospective multi-center cohort study thrombEVAL, the incidence of anticoagulation-related adverse events was analyzed according to the AF phenotype. Information on outcome was centrally recorded over 3years, validated via medical records and adjudicated by an independent review panel. Study monitoring was provided by an independent institution. Overall, the sample comprised 1089 AF individuals, of whom n = 398 had paroxysmal AF and n = 691 experienced sustained AF. In Cox regression analysis with adjustment for potential confounders, sustained AF indicated an independently elevated risk of clinically relevant bleeding compared to paroxysmal AF [hazard ratio (HR) 1.40 (1.02; 1.93); P = 0.038]. For clinically relevant bleeding, a significant interaction of the pattern of AF type with concomitant heart failure (HF) was detected: HRHF 2.45 (1.51, 3.98) vs. HRno HF 0.85 (0.55, 1.34); Pinteraction = 0.003. In HF patients, sustained AF indicated also an elevated risk of major bleeding [HR 2.25 (1.26, 4.20); P = 0.006]. A simplified HAS-BLED score incorporating only information on age (> 65years), bleeding history, and HF with sustained AF demonstrated better discriminative performance for clinically relevant bleeding than the original version: AUCHAS-BLED: 0.583 vs. AUCsimplifiedHAS-BLED: 0.642 (P = 0.004). In HF patients receiving oral anticoagulation, sustained AF indicates a substantially elevated risk of bleeding. https://clinicaltrials.gov , identifier: NCT01809015.

Usefulness of Oral Ferric Citrate in Patients With Iron-Deficiency Anemia and Chronic Kidney Disease With or Without Heart Failure

Patients with chronic inflammatory conditions including chronic kidney disease (CKD) and heart failure (HF) are undertreated with iron-deficiency anemia (IDA). Progressive inflammation and reduced iron transport associated with CKD and HF may reduce the efficacy of oral iron therapy. Oral ferric citrate improves anemia markers in CKD, but its effects in patients with CKD and concomitant HF have not been described. Patients with CKD not on dialysis and IDA from a phase 2 and 3 trial were treated with ferric citrate (n = 190) or placebo (n = 188); patients with HF were identified from medical histories. Hemoglobin response was defined as a ≥10.0-g/L increase in hemoglobin. Changes in hemoglobin, transferrin saturation, ferritin, and serum phosphate from baseline to week 12 and the incidence of adverse events potentially related to HF were evaluated. HF was reported in 22% (n = 81) of patients. The proportion of patients with hemoglobin response to ferric citrate treatment did not significantly differ in patients with and without HF (43% vs 49%, respectively; p = 0.47); changes from baseline in hemoglobin, iron parameters, and serum phosphate were similar. Adverse events potentially related to HF were noted more frequently in patients with HF (ferric citrate, 23%; placebo, 17%) versus those without HF (ferric citrate, 12%; placebo, 11%). In conclusion, these results indicate a potential role for ferric citrate in the treatment of IDA in patients with CKD not on dialysis and concomitant HF.

Do the SGLT-2 Inhibitors Offer More than Hypoglycemic Activity?

Type 2 diabetes mellitus (T2DM) is one of the most common chronic health conditions in the USA; it affects approximately 10% of adults with up to one-quarter being undiagnosed. T2DM is associated with substantial cardiovascular (CV) morbidity and mortality. T2DM is a pathological condition characterized by elevated levels of glucose and associated with high CV risk. Traditional hypoglycemic drugs have demonstrated their capability for effective and maintained management of high glucose levels, but they have not significantly impacted on the incidence of CV events. Recently, a new class of hypoglycemic agents, SGLT-2 receptor inhibitors, has been developed. The EMPA-OUTCOME trial involving empagliflozin (a SGLT-2 receptor inhibitor) has shown significant reductions in major adverse cardiac events (MACEs), cardiovascular mortality, and hospitalization for heart failure (HF) when administered on top of standard-of-care therapy for T2DM patients at high CV risk. The dramatic change driving the superiority of the primary composite outcome (major adverse CV events) was a significantly lower CV death rate (38% relative risk reduction). In addition, there were also an impressive 35 and 32% relative risk reductions in hospitalization for heart failure (HF) and death from any cause, respectively. These effects are even more important given the difficulties for treating concomitant HF in T2DM patients. These surprising results have been also corroborated by another agent of this class, canagliflozin, and the CANVAS trial. The magnitude of these somehow surprising cardiac benefits attained in the absence of major differences in glycemic, lipid, or blood pressure (BP) control has led to several groups to suggest that these benefits may be independent of its hypoglycemic activity and whether this new class could be considered a "cardiac" drug. The objective of this review has been to review the different hypotheses proposed to explain the cardiac benefits of this new class of antidiabetic drugs.

Anticoagulation in atrial fibrillation with heart failure.

Heart failure (HF) and atrial fibrillation (AF) frequently coexist, and they can beget one another due to similar factors and shared pathophysiology. These pathophysiologic changes promote the episodes of AF, while they in turn predispose to the exacerbation of HF. In this review, we will discuss pathophysiological mechanisms shared by AF and HF. Patients with concomitant HF and AF are at a particularly high risk of thromboembolism, which contribute to even worse symptoms and poorer prognosis. Vitamin K antagonists (VKA) (warfarin) were the traditional medication in AF patients for the prevention of stroke, whereas the advance of novel non-VKA oral anticoagulants (NOACs) (dabigatran, apixaban, rivaroxaban, and edoxaban) is challenging these standard prescriptions. NOACs' potential advantages over warfarin, including fixed dosing regimens, wide therapeutic window, and more sustained anticoagulant response, promote clinicians to consider these novel agents in the first place. However, some data suggested patients with AF and HF may receive different therapeutic response than those with AF alone in anticoagulant treatment. Accordingly, we aim to assess the potential role of oral anticoagulants, especially NOACs, in the management of patients with concomitant AF and HF.

Multimorbidity and survival for patients with acute myocardial infarction in England and Wales: Latent class analysis of a nationwide population-based cohort.

BackgroundThere is limited knowledge of the scale and impact of multimorbidity for patients who have had an acute myocardial infarction (AMI). Therefore, this study aimed to determine the extent to which multimorbidity is associated with long-term survival following AMI.Methods and findingsThis national observational study included 693,388 patients (median age 70.7 years, 452,896 [65.5%] male) from the Myocardial Ischaemia National Audit Project (England and Wales) who were admitted with AMI between 1 January 2003 and 30 June 2013. There were 412,809 (59.5%) patients with multimorbidity at the time of admission with AMI, i.e., having at least 1 of the following long-term health conditions: diabetes, chronic obstructive pulmonary disease or asthma, heart failure, renal failure, cerebrovascular disease, peripheral vascular disease, or hypertension. Those with heart failure, renal failure, or cerebrovascular disease had the worst outcomes (39.5 [95% CI 39.0–40.0], 38.2 [27.7–26.8], and 26.6 [25.2–26.4] deaths per 100 person-years, respectively). Latent class analysis revealed 3 multimorbidity phenotype clusters: (1) a high multimorbidity class, with concomitant heart failure, peripheral vascular disease, and hypertension, (2) a medium multimorbidity class, with peripheral vascular disease and hypertension, and (3) a low multimorbidity class. Patients in class 1 were less likely to receive pharmacological therapies compared with class 2 and 3 patients (including aspirin, 83.8% versus 87.3% and 87.2%, respectively; β-blockers, 74.0% versus 80.9% and 81.4%; and statins, 80.6% versus 85.9% and 85.2%). Flexible parametric survival modelling indicated that patients in class 1 and class 2 had a 2.4-fold (95% CI 2.3–2.5) and 1.5-fold (95% CI 1.4–1.5) increased risk of death and a loss in life expectancy of 2.89 and 1.52 years, respectively, compared with those in class 3 over the 8.4-year follow-up period. The study was limited to all-cause mortality due to the lack of available cause-specific mortality data. However, we isolated the disease-specific association with mortality by providing the loss in life expectancy following AMI according to multimorbidity phenotype cluster compared with the general age-, sex-, and year-matched population.ConclusionsMultimorbidity among patients with AMI was common, and conferred an accumulative increased risk of death. Three multimorbidity phenotype clusters that were significantly associated with loss in life expectancy were identified and should be a concomitant treatment target to improve cardiovascular outcomes.Trial registrationClinicalTrials.gov NCT03037255.

Clinical correlates and pharmacological management of Asian patients with concomitant diabetes mellitus and heart failure.

Asia is the center of convergence of the twin epidemics of diabetes mellitus (DM) and heart failure (HF). The regional and ethnic diversity across Asia, along with a high prevalence of a young, lean diabetic phenotype, emphasizes the importance of targeted public health strategies that address the unique needs of Asian patients with DM and HF. This review discusses the epidemiology, clinical correlates, pharmacological management, and outcomes of Asian patients with concomitant DM and HF.