Cases Of Congestive Heart Failure Research Articles

Verification about the usefulness of early cardiac rehabilitation initiation in patients with congestive heart failure requiring hospitalization

Abstract Background It is a well-known fact that for patients with decompensated congestive heart failure (CHF) who require hospitalization, starting cardiac rehabilitation (CR) early after hospitalization has a positive impact on their clinical course. To maintain their activity and nutritional status through the early mobilization by efficient medical care, we have introduced our own clinical pathway(PATH) for CHF since August 2015. In PATH, the initiation of CR early after admission was stipulated. With PATH introduction, starting time of CR was significantly earlier and the average hospitalization period for CHF cases was also significantly reduced. However, there are still some cases applied PATH who are unable to start CR early after admission for various reasons. Purpose We examined whether the clinical course after admission differs depending on the timing of CR initiation even in CHF cases applied PATH. Methods We enrolled 933 patients admitted with CHF for the first time from August 2015 to July 2023, applied PATH, started physical therapy (PT) as CR, and discharged alive. We divided them into two groups based on when they started PT, Early-group (649 cases: Starting time is within the 3rd hospital day) and the Late-group (284 cases: Starting time is after the 4th hospital day). And we investigated patient background, clinical data at admission, and clinical course after admission for all cases, and examined the differences in each item between the two groups. Results There were no differences in patient characteristics or clinical data at admission between the two groups (Table 1). On the other hand, although there was no difference in the performance rate of each acute treatment between the two groups, the performance duration of each treatment in cases introduced was significantly shorter in Early-group. Furthermore, the average meal (side dish) intake rate on the 2nd to 4th hospital days after admission was significantly higher in Early-group, and the average length of hospitalization was significantly shorter in the Early-group (Figure 1). Conclusions For 8 years, we have strived to begin cardiac rehabilitation interventions early after hospitalization with introduction of our own clinical pathway. However, we found that even with the introduction of the clinical pathway, cardiac rehabilitation was started on or after the 4th hospital day in 30% of all cases. And we found that in these cases, each treatment during the acute phase was prolonged, nutritional intake was inadequate, and the length of hospitalization tended to be prolonged. The delay in initiation of rehabilitation was thought to be related to factors such as the timing of hospitalization (admission on holidays or public holidays) or the location of hospital management (ICU management in severe cases). It seemed necessary to create a system that would allow cardiac rehabilitation to be started flexibly even in such situations.Table1Figure 1

A machine learning tool for identifying newly diagnosed heart failure in individuals with known diabetes in primary care.

We aimed to create a predictive model utilizing machine learning (ML) to identify new cases of congestive heart failure (CHF) in individuals with diabetes in primary health care (PHC) through the analysis of diagnostic data. We used a sex- and age-matched case-control design. Cases of new CHF were identified across all outpatient care settings 2015-2022 (n=9098). We included individuals 30years and above, by sex and age groups of 30-65years and >65years. The controls (five per case) were sampled from the individuals in 2015-2022 without CHF at any time between 2010 and 2022, in total 45 490. From the stochastic gradient boosting (SGB) technique model, we obtained a rank of the 10 most important factors related to newly diagnosed CHF in individuals with diabetes, with the normalized relative influence (NRI) score and a corresponding odds ratio of marginal effects (ORME). Area under curve (AUC) was calculated. For women 30-65years and >65years, we identified 488 and 3240 new cases of CHF, respectively, and men 30-65years and >65years 1196 and 4174 new cases. Among the 10 most important factors in the four groups (divided by sex and lower and higher age) for newly diagnosed CHF, we found the number of visits 12months before diagnosis (NRI 44.3%-55.9%), coronary artery disease (NRI 2.9%-7.8%), atrial fibrillation and flutter (NRI 6.6%-12.2%) and 'abnormalities of breathing' (ICD-10 code R06) (NRI 2.6%-4.4%) were predictive in all groups. For younger women, a diagnosis of COPD (NRI 2.7%) contributed to the predictive effect, while for older women, oedema (NRI 3.1%) and number of years with diabetes (NRI 3.5%) contributed to the predictive effect. For men in both age groups, chronic renal disease had predictive effect (NRI 3.9%-5.1%) The model prediction of CHF among patients with diabetes was high, AUC around 0.85 for the four groups, and with sensitivity over 0.783 and specificity over 0.708 for all four groups. An SGB model using routinely collected data about diagnoses and number of visits in primary care, can accurately predict risk for diagnosis of heart failure in individuals with diabetes. Age and sex difference in predictive factors warrant further examination.

6724 A Broken Heart Due to Excess Thyroid

Abstract Disclosure: R. Subramani: None. R. Subramani: None. V. Zeykan: None. Introduction: Tachycardia-induced cardiomyopathy related to thyrotoxicosis is an uncommon yet serious complication affecting fewer than 1% of individuals with hyperthyroidism. Restoring a euthyroid state can potentially reverse the abnormal cardiac structure and function. Here we report a case of tachycardia-induced cardiomyopathy secondary to thyrotoxicosis Case Summary: A 52-year-old woman with a history of hypertension presented with recent-onset exertional dyspnea, a nonproductive cough, and paroxysmal nocturnal dyspnea. On examination, she exhibited tachycardia (heart rate: 150/min), tachypnea, hypertension, and was afebrile. Physical findings included a mildly enlarged, firm, non-tender thyroid gland bilaterally, without exophthalmos or tremors. Auscultation revealed bilateral crackles in the left lower lung fields. Laboratory analysis revealed undetectable TSH (<0.02 uIU/mL), elevated free T4 (5.3 ng/dL), free T3 (16.30 pg/mL), thyroid stimulating immunoglobulin (TSI) at 216%, and NT proBNP at 8528 pg/mL. Neck ultrasound and CT confirmed diffuse enlargement of the thyroid gland. Transthoracic echocardiography (TTE) displayed severely depressed left ventricular systolic function, estimating an ejection fraction (EF) of 25-30%. Initial management involved intravenous beta-blockers for heart rate control, IV Lasix, and IV hydrocortisone. Subsequently, the patient received propylthiouracil, propranolol, and prednisone, resulting in symptomatic improvement. A follow-up TTE after 6 months revealed an improved EF of 50%. Discussion: The pathophysiologic mechanisms underlying thyrotoxic cardiomyopathy encompass several factors, including tachycardia-induced cardiomyopathy, direct myopathic effects induced by the T3 hormone, and concurrent autoimmune myocarditis associated with Graves' disease. Thyroid hormone exerts a comprehensive impact on nearly all tissue and organ systems, heightening basal metabolic rate and subsequently increasing preload, myocardial contractility, and cardiac output. While thyrotoxicosis-related congestive heart failure (CHF) is relatively uncommon among patients hospitalized for acute CHF, addressing hyperthyroidism and CHF through definitive treatment yields a more favorable prognosis compared to cases of acute CHF stemming from other etiologies. The intricate interplay of these mechanisms highlights the importance of a comprehensive approach in managing thyrotoxic cardiomyopathy, emphasizing the need for targeted interventions to address both the underlying thyroid dysfunction and associated cardiac manifestations. Presentation: 6/3/2024

Heart failure in first- and second-generation immigrants aged 18-54years in Sweden: A national study.

We aimed at analysing the risk of congestive heart failure (CHF) among first- and second-generation immigrants in younger age groups. All individuals aged 18-54years, n=3973454 in the first-generation study and n=3817560 in the second-generation study, were included. CHF was defined as at least one registered diagnosis in the National Patient Register between 1 January 1998 and 31 December 2018. Cox regression analysis was used to estimate the relative risk [hazard ratios (HRs) with 99% confidence intervals (CIs)] of incident CHF with adjustments for age, co-morbidities and socio-demographics. In the first-generation study, a total of 85719 cases of CHF were registered, 54369 men and 31350 women, where fully adjusted models showed HRs for all foreign-born men of 1.12 (99% CI 1.06-1.17) and for women of 0.99 (0.92-1.05). Groups with higher risk included men from Eastern Europe, Central Europe, Africa and Asia and women from Africa and Asia, and a lower risk was found among Latin American women. In the second-generation study, a total of 88999 cases of CHF were registered, 58403 men and 30596 women, where fully adjusted models showed HRs for second-generation men of 1.04 (0.99-1.09) and women of 0.97 (0.90-1.04). The higher risk in some foreign-born groups needs to be paid attention to in clinical practice. The fact that almost all increased risks were attenuated and absent in second-generation immigrants suggests that lifestyle and environmental factors are more important than genetic differences in the risk of CHF.

Relationship between N-terminal pro-brain natriuretic peptide concentration and heart-type fatty acid-binding protein in postmortem urine

The clinical use of N-terminal pro-brain natriuretic peptide (NT-proBNP) and blood concentrations of heart-type fatty acid-binding protein (HFABP) is well-established in diagnosing heart conditions. However, their applicability in forensics is controversial due to postmortem changes. NT-proBNP and HFABP are excreted in the urine due to their small molecular weights and may be found in postmortem urine samples; however, their correlation has not been evaluated. In this study, we compared the concentrations of urinary NT-proBNP and HFABP in 386 forensic autopsy cases. The urinary NT-proBNP levels were significantly higher in acute myocardial infarction (AMI), congestive heart failure (CHF), sepsis, and hyperthermia cases, with the highest levels in CHF cases. Similarly, HFABP concentration was significantly higher in CHF, sepsis, and hyperthermia cases, with the highest level observed in hyperthermia cases. However, the difference in urinary HFABP levels between the AMI and control cases was not significant. Our analysis revealed a correlation between postmortem urine NT-proBNP and HFABP levels, and the NT-proBNP/HFABP ratio was high in patients with CHF and sepsis cases and low in those with hyperthermia. The difference between the ratios was possibly due to the combined release of ventricular myocardial cells in response to ventricular wall stress and myocardial injury for NT-proBNP, as well as myocardial and skeletal muscle injuries for HFABP. This study, for the first time, demonstrates the utility of postmortem measurements of urinary NT-proBNP and HFABP levels, offering valuable insights for improving the accuracy of postmortem diagnosis in forensic medicine.

Abstract 14347: Albuminuria, N-Terminal Pro-Brain Natriuretic Peptide and Incident Congestive Heart Failure in High-Risk Adults With Hypertension: A Post Hoc Analysis of the Systolic Blood Pressure Intervention Trial

Introduction: Abnormal levels of urinary albumin concentration (UAC) and N-terminal pro-Brain Natriuretic Peptide (NT-proBNP) have each been independently associated with an increased risk of congestive heart failure (CHF). It remains unknown whether the concomitant presence of abnormal UAC and NT-proBNP increases an individual’s risk for future CHF beyond that contributed by each biomarker. Objective: To examine the joint association between abnormal UAC and NT-ProBNP with incident CHF in participants from the SPRINT (Systolic Blood Pressure Intervention Trial) study. Methods: This analysis included 8,176 participants from SPRINT with available data on baseline UAC and NT-proBNP. UAC was measured by urine albumin-creatinine ratio (UACR). Albuminuria was defined as UACR ≥30 mg/g. Abnormal NT-proBNP was defined as levels ≥125 pg/ml. Cox proportional hazard models were used to examine the association of UAC and NT-proBNP, as well as albuminuria and abnormal NT-proBNP, with incident CHF. Results: Over a median follow-up of 3.2 years, 179 incident cases of CHF were observed. In adjusted models, the risk of incident CHF (HR 95% CI) associated with each 1 (one) unit standard deviation increase in the levels of UAC and NT-proBNP was 1.10 (1.04-1.16; p <0.001) and 1.13 (1.10-1.16; p <0.0001), respectively. A statistically significant multiplicative interaction between UAC*NT-proBNP was observed in the fully adjusted model (p <0.0001). The risk associated with the presence of abnormal UAC +/- abnormal NT-proBNP in the SPRINT cohort is depicted in the figure. Conclusions: Among SPRINT participants, we found a significant multiplicative interaction between UAC and NT-proBNP as predictors of incident CHF. Also, the risk of future CHF was over six times higher in individuals with abnormal UAC and NT-proBNP, compared with those with normal levels of both biomarkers. More studies are needed to further explore this interaction and the implications on CHF prevention.

Examination of the acute efficacy and safety about aggressive use of tolvaptan for early rising after admission in super-elder patients with congestive heart failure

Abstract Background From August 2015, for shortening of hospitalization period through efficient medical care in acute phase, we had introduced a unique clinical pathway (PATH) for congestive heart failure (CHF) cases. In PATH, since immediate taking of Tolvaptan, which is an strong oral diuretic and approver for use in the treatment of CHF cases since 2010 in Japan, after admission is specified, early diuresis makes it possible to achieve early rising from bed and streamline each medical care such as oxygen inhalation, continuous infusion, and urethral catheterization. Early rising from bed is particularly important for super-elder CHF patients who merge often frail. On the other hand, for super-elder CHF patients, it is feared that aggressive use of Tolvaptan may frequently cause dehydration, renal damage caused by it, or hypernatremia, which is a peculiar side effect about the drug. Purpose In this study, we examined the usefulness and safety of active use of Tolvaptan by introducing PATH in patients with super-elder CHF patients. Methods We set up three groups, NE group consist of 37 CHF cases (90 years old or over) who admitted in our hospital before (without) introduction of PATH between April 2014 and July 2015, PE group consist of 130 CHF cases (90 years old or over) and PY group consist of 466 CHF cases (under 90 years old) who ware admitted with introduction of PATH between August 2015 and July 2020. And in each group, we investigated various medical conditions in their acute phase after admission and the incidence of adverse events related to oral administration of tolvaptan, and examined the differences between three groups. Results Between NE group and PE group, there were no significant differences in mean age, pre-hospital living status, or clinical status at admission (Figure 1). But due to lean and efficient CHF care, the average length of hospitalization period was significantly shorter in PE group. And, in PE group, each medical care was performed as efficiently as in PY group, but the progression of renal damage or hypernatremia that required unscheduled discontinuation of tolvaptan use occurred more frequently in PE group (Figure 2). Conclusions Aggressive Tolvaptan use through our unique clinical pathway for congestive heart failure cases seemed to be useful even in super-elder patients. Although we thought that the safety of active use of tolvaptan for super-elder patients was well tolerated considering the results of this study, the incidence of adverse events such as hypernatremia was clearly higher in super-elder patients than in non-super-elder patients. It seemed that we should pay close attention to the clinical data of super-elder patients after introduction of tolvaptan. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Examination about more realistic prognosis evaluation method, how long the patients with congestive heart failure can spend at home

Abstract Background From August 2015, for efficient medical care in congestive heart failure (CHF) cases, we had introduced a unique clinical pathway (PATH) provided the immediate use of Tolvaptan and comprehensive education by multi-disciplinary staff after admission. And by introduction of PATH, we confirmed the shortening effect of hospitalization period with CHF and the suppressive effect of readmission with CHF after discharge. But since almost CHF patients repeat hospitalization and discharge due to change of their medical condition, the investigation for only first readmission rate after discharge is not enough to assess the entire long clinical course of CHF. Recently we found one report about evaluation method for CHF clinical prognosis, how long CHF patients can stay healthy at their own home after discharge within a certain period. This evaluation method is considered to take into account the long clinical course of CHF. Purpose We investigated whether the CHF patients introduced PATH on admission could stay longer at their home than CHF patients without PATH. Methods Between April 2014 and July 2019, 471 CHF cases, who ware admitted in our hospital at first and could be followed up for at least 1 month after discharge, ware enrolled. We divided them to two groups, PATH- group before introducing PATH (until July 2015, 142 cases), and PATH+ group applied PATH (after August 2015, 329 cases). Between both groups, we investigated the readmission rate (RR) with CHF and the total period (TP) that patients could spend at home within1, 3, 6 and 12month after discharge. Results There were no significant differences in mean age, pre-hospital living status, or clinical status at admission between the two groups. On the other hand, due to efficient CHF care, the average length of hospital stay was significantly shorter (figure1). RR within 1, 3, 6 and 12 months after discharge ware all lower in PATH+ group. And TP within 1, 3, 6 and 12 months after discharge ware all longer in PATH+ group (figure2). Conclusion By introducing our unique clinical pathway for congestive heart failure cases requiring hospitalization, we could confirm not only the improvement of their conventional clinical prognosis index but also the improvement of their new and more realistic clinical prognosis index after discharge. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Clinico-Etiological profile of congestive heart failure (CHF) in children

Congestive heart failure (CHF) occurs when the heart doesn’t pump blood to meet the oxygen demand of the various organs. Usually congenital heart disease (CHD) like VSD, PDA, CoA, TGA physiology, ECD, Ebstein anomaly present with CHF before U5 age. In India most common cause of CHF from 5 to 15 yrs. age is due to Rheumatic Fever / RHD. We also get cases like pericardial effusion, constrictive pericarditis, DCM, AR in rheumatic disease, iron overload causing myocardial failure in Thalassemia and anemia presenting as CHF as in more than 5-year children. CHF cases contribute to about 10% of mortality in children.We conducted a Hospital based descriptive and cross-sectional study from November 2018 to October 2020 at Pediatric department of M.K.C.G Medical College Hospital, Berhampur. All pediatric patients with signs and symptoms of CHF as per clinical diagnosis in the age group of 1 month to 14 year were included in our study. The study population was 136. Out of the total cardiac cases, 57% were CHD, 43% were acquired. Among the total 105 cardiac cases of CHF, CHD were 60(57.2%). Out of the total CHD, acyanotic heart diseases were 46.7% and acquired heart diseases constituted 42.8%. Out of total 136 cases 87(63.2%) were discharged, 23(17.6%) died, 19 cases (14%) were referred to higher centre. After data collection detail analysis was made by SPSS software. An initiative regarding addressing the problematic Congestive heart failure along with its clinical management will definitely help the future generation and researchers.

Presentation of SARS-CoV-2 (COVID-19 in patients with congestive heart failure. A Retrospective study

Background and Aims: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of COVID-19, has infected 86,468,659 people around the globe until 6/1/2021, with 1,869,808 mortalities. It is estimated that people with congestiveheart failure (CHF) are in a high risk category for mortality. Furthermore, persons with obesity who become ill and require intensive care present challenges in patient management as it is more difficult to intubate these persond, and this is especially true in Saudi Arabia and the region of Hail, where morbid obesity is at 33.6% of the population. Our aim is to establish an epidimiological link for our population between diabetes, obesity and percentage of intubated patients as we measured mortalities and readmissions in 30 days. Methods: A retrospective cohort study of 751 patients admitted as positive COVID 19 patients, from April 1, 2020 to July 31, 2020, covering a period of 4 months. We then categorised the patient in cohorts accordind to the existence of CHF or not, and categorised them according to their BMI index. We then correlated using statistical tool analysis - SPSS statistics tool - intubation, mortality,readmitance in 30 days in thes groups of patients Results: Around 12% of our cases were CHF. 16% of these cases intubated, instead of 5% of non CHF cases. Mortalities were higher in the CHF group as percentage ( 72% to 7%), and readmissions. Significant correlation between BMI and days of ICU stay in the CHF group Conclusions: There is significantly elevated morbidity and mortality at obese CHF cases with COVID 19

Sleep Timing May Predict Congestive Heart Failure: A Community-Based Cohort Study.

BackgroundPrevious studies have suggested that sleep timing is associated with cardiovascular risk factors. However, there is no evidence on the relationship between sleep timing and congestive heart failure (CHF). We aimed to examine this relationship in this study.Methods and ResultsWe recruited 4765 participants (2207 men; mean age, 63.6±11.0 years) from the SHHS (Sleep Heart Health Study) database in this multicenter prospective cohort study. Follow‐up was conducted until the first CHF diagnosis between baseline and the final censoring date. Sleep timing (bedtimes and wake‐up times on weekdays and weekends) was based on a self‐reported questionnaire. Cox proportional hazard models were constructed to investigate the association between sleep timing and CHF. During the mean follow‐up period of 11 years, 519 cases of CHF (10.9%) were reported. The multivariable Cox proportional hazards models revealed that participants with weekday bedtimes >12:00 am (hazard ratio [HR], 1.56; 95% CI, 1.15–2.11; P=0.004) and from 11:01 pm to 12:00 am (HR, 1.25; 95% CI, 1.00–1.56; P=0.047) had an increased risk of CHF compared with those with bedtimes from 10:01 pm to 11:00 pm. After stratified analysis, the association was intensified in participants with a self‐reported sleep duration of 6 to 8 hours. Furthermore, wake‐up times >8:00 am on weekdays (HR, 1.53; 95% CI, 1.07–2.17; P=0.018) were associated with a higher risk of incident CHF than wake‐up times ≤6:00 am.ConclusionsDelayed bedtimes (>11:00 pm) and wake‐up times (>8:00 am) on weekdays were associated with an increased risk of CHF.

Integration of Lung Point-of-care Ultrasound into Clinical Decision Making for Medical Students in Simulated Cases.

BackgroundPoint-of-care ultrasound (POCUS) has an emerging presence in medical student education; however, there is limited evidence that this translates into appropriate clinical care. We aimed to evaluate the ability of medical students to integrate newly obtained POCUS knowledge into simulated clinical cases.MethodsWe conducted an observational study of medical students participating in a mandatory rotation during their clinical years. Students in small groups underwent formalized lung POCUS lectures and hands-on training. Students participated in simulated “dyspnea” cases focused on either congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD). They were observed for critical actions including elements related to medical decision-making and ultrasound use and interpretation. Ultrasound-specific written knowledge was gauged with a short assessment after the first lecture and at week 4.ResultsA total of 62 students participated and were observed during simulations. All groups correctly identified and treated CHF in the simulated case. Most groups (7 out of 9) attempted to use ultrasound in the CHF case; five groups correctly recognized B-lines; and four groups correctly interpreted B-lines as pulmonary edema. No groups used ultrasound in the COPD case.ConclusionMost students attempted to use ultrasound during simulated CHF cases after a brief didactic intervention; however, many students struggled with clinical application. Interestingly, no students recognized the need to apply ultrasound for diagnosis and management of COPD. Future studies are needed to better understand how to optimize teaching for medical students to improve translation into POCUS skills and improved clinical practice.

Prevalence and Patterns of Obstructive Sleep Apnea in Asian Indians With Congestive Heart Failure.

BackgroundSleep-disordered breathing (SDB) has a potential association with the pathogenesis of congestive heart failure (CHF). We assessed the prevalence and patterns of obstructive sleep apnea (OSA) in patients presenting with CHF.MethodThis was a prospective, observational, all-comers study of consecutive 77 confirmed cases of CHF. All these patients were clinically assessed and evaluated for OSA with sleep study after routine blood testing, electrocardiogram (ECG), chest X-ray, and echocardiography.ResultsOf 77 patients with CHF 38 (49.4%) had apnea-hypopnea index (AHI) <5 while 39 (50.6%) had AHI >5. Of these 39, 37 (94.8%) patients showed the clinical features of OSA. The majority (64.9%) of them were males. The majority of OSA (64.9%) had coronary artery disease (CAD) (p<0.05) as the etiology of CHF, followed by dilated cardiomyopathy (32.4%) and valvular heart disease (2.7%). The prevalence of OSA was higher amongst New York Heart Association (NYHA) class 2 (51.4%) as compared to NYHA class 3 (37.8%) and NYHA class 4 (10.8%). There were 12 (32.8%) patients, each having OSA with a heart rate between 71 and 80 bpm and 81 and 90 bpm. Twenty-two (59.5%) had systolic blood pressure (BP) more than 120 mmHg and 20 (54.1%) had diastolic BP more than 80 mmHg. The majority (64.9%) patients had the lowest O2 saturation between 80% and 90%. A significantly large number of patients (62.2%) had ejection fraction 21%-30% (p<0.05). The majority (62.16%) of patients with OSA had AHI between 5 and 15. With 5-15 AHI, 20 (87%) patients with OSA had a snoring, tiredness, observed apnea, high BP, BMI, age, neck circumference, and male gender (STOP-Bang) score between 3 and 7 with AHI 5-15 (p<0.05).ConclusionsIn our cohort, the prevalence of OSA in CHF was 50.6%. Predictors of OSA in CHF were left ventricular ejection fraction (LVEF) 20%-30% and NYHA class 2. The majority had AHI between 5 and 15. Sleep apnea screening should be routinely implemented in the evaluation and follow-up of heart failure patients.

Our unique clinical pathway for congestive heart failure cases required admission achieved a dramatic reduction of their hospitalization period and a significant reduction of readmission with heart fa

Abstract Background In recent years, the number of elderly congestive heart failure (CHF) cases has been increasing in Japan with the aging of the population. This tendency is particularly remarkable in rural areas where our facilities are located. After admission with CHF, the hospitalization period (PE) was prolonged due to various complications unique to the elderly, and re-exacerbation of CHF occurred shortly after discharge. Approximately 30% of them were readmitted within one year. From August 2015, for shortening of PE and reduction of CHF readmission through the efficiency of CHF treatment and comprehensive patient education, we had introduced a unique clinical pathway (PATH) that provided the immediate use of Tolvaptan and comprehensive education by multi-disciplinary staff after admission. Purpose In this study, we verified whether the improvement of clinical prognosis were achieved by introduction of PATH. Methods Between April 2014 and July 2019, 635 CHF cases (764 admissions) ware enrolled. We divided them to two groups, N-group before introducing PATH (198 cases, 262 admissions) and P-group applied PATH (437 cases, 502 admission). Between both groups, we compared the various acute care situation, PE and readmission rate with CHF within 1 year after discharge. Results There were no differences between P and N-group in mean age, distribution of underlying illness or daily activity level before admission. There ware not also differences about left ventricle function by echocardiography and various blood test data at admission. The enforcement rate of continuous infusion and the rate of urinary catheter placement were significantly lower in the P-group (71 vs 88%; p&amp;lt;0.0001, 52 vs 63%; p&amp;lt;0.01, respectively). And their enforcement duration was significantly shorter in P-group (4.6±5.3 vs 10.5±9.6 days; p&amp;lt;0.0001, 6.3±7.9 vs 12.8±13.1 days; p&amp;lt;0.0001 respectively). The enforcement rate of cardiac rehabilitation was significantly higher in group P (94 vs 84%; p&amp;lt;0.0001), and the starting time of rehabilitation was significantly earlier (2.9±1.5 vs 6.3±4.8th illness day; p&amp;lt;0.0001). As a result, the average HP was significantly shorter in group P (16.5±13.4 vs 28.6±24.1 days, p&amp;lt;0.0001). The readmission rate with CHF within one year after discharge was significantly lower in group P (23 vs 36%; p&amp;lt;0.001). Conclusion By the introduction of our original clinical pathway for congestive heart failure, the efficiency of medical care was achieved and the mean hospitalization period was widely shortened. In addition, by the through comprehensive patient education by multi-disciplinary staff involved in the pathway, the self-restraint life style after discharge seemed to be maintained and the readmission with worsening of heart failure was significantly suppressed. Funding Acknowledgement Type of funding source: None

Use of cardiovascular drugs and risk of incident heart failure in patients with atrial fibrillation.

Congestive heart failure (CHF) is the most important cause of death in patients with atrial fibrillation (AF). We aimed to study the association between cardiovascular drugs in AF patients and incident CHF. The study population included all adults (n=120756) aged ≥45years diagnosed with AF in Sweden diagnosed for the period 1998-2006. Outcome was incident congestive heart failure (follow-up 2007-2015) in AF patients. Associations between treatment with cardiovascular pharmacotherapies and CHF were evaluated using Cox regression to estimate hazard ratios (HRs) with 95% CIs, after adjustment for age, sociodemographic variables, and comorbidities. During a mean 5.3years (SD 3.0) of follow-up, there were 28257 (23.4%) incident cases of CHF. Treatment with beta-1-selective and non-selective beta-blockers and statins was associated with lower risks of incident CHF in men, HR, (95% CI); 0.90, (0.87-0.94); 0.90, (0.84-0.97), and 0.94, (0.90-0.99), respectively. Only beta-1-selective beta-blockers were protective in women 0.94 (0.91-0.98). Treatment with loop diuretics, potassium-saving agents, ACE inhibitors, and angiotensin receptor blockers was associated with a higher risk of CHF. For men, treatment with heart-active calcium channel blockers also led to a higher risk of CHF. In conclusion, we found that beta-blockers, in particular, but also statins were associated with lower risk of incident CHF in patients with AF.

Postmortem urine concentration of N-terminal pro-brain natriuretic peptide in relation to the cause of death

The utility of biochemical marker analysis in forensic autopsy cases is still uncertain due to the postmortem changes which they undergo. Thus, research is required to elucidate alternative samples and biochemical markers which are less affected by postmortem changes. Levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) are known to be elevated in congestive heart failure (CHF), acute myocardial infarction (AMI), and sepsis patients. Although NT-proBNP is reportedly excreted into the urine, no study has previously evaluated the diagnostic efficacy of urinary concentrations in a forensic setting. The aim of this study was to evaluate the diagnostic efficacy of NT-proBNP concentration in urine obtained postmortem in a series of forensic autopsy cases. Methods: Urinary NT-proBNP was measured in 36 AMI, 10 CHF, and 19 sepsis cases, and in 124 control cases (all with postmortem interval [PMI]<72h). Results: Urinary NT-proBNP was significantly higher in AMI, CHF, and sepsis cases than in control cases. Cut-off values for diagnosing AMI, CHF, and sepsis-related fatalities were 98 (sensitivity, 55.6 %; specificity, 73.4 %), 1050 (sensitivity, 80.0 %; specificity, 94.4 %), and 363pg/mL (sensitivity, 84.2 %; specificity, 85.5 %), respectively. Furthermore, we subdivided the control cases according to the death process as either acute death (87 cases) or prolonged death cases (37 cases). Although urine NT-proBNP of CHF and sepsis cases were significantly higher compared with both cases, the concentration in the AMI cases were significantly high only when compared with the acute death cases. Conclusion: This study is the first to elucidate the diagnostic utility of NT-proBNP measurement in urine obtained postmortem in a series of causes of death. This study suggests the diagnostic efficacy for AMI, CHF, and sepsis-related fatality in cases in which the PMI was within 72h.

P6352The antimicrobial protein Azurocidin-1 is associated with prevalent diastolic dysfunction and incident congestive heart failure in a Swedish population cohort

Abstract Background Although Azurocidin-1 (Azu-1), also known as heparin binding protein, has been associated with myocardial infarction, possible associations of Azu-1 with congestive heart failure (CHF) remains unknown. Here we tested the possible association of Azu-1 with prevalent diastolic dysfunction and/or incident CHF in a large Swedish prospective population based cohort. Methods Azu-1 was analyzed using the Proseek Multiplex CVD III panel in 1737 participants from a subsample of the population (mean age 67 years, 29% women) who underwent a complete echocardiographic examination. All biomarkers were logarithmized and standardized prior to statistical analysis. Logistic and linear regression were adjusted for age, sex, BMI, diabetes, systolic and diastolic blood, anti-hypertensive treatment and subjects with an ejection fraction below 50% were excluded for the analysis of prevalent diastolic dysfunction and Azu-1. For the linear regression model, we used E/é ratio as a key functional variable in assessing diastolic function according to ESC 2016 Guidelines for Acute and Chronic Heart Failure. Furthermore, we dichotomized the E/é ratio at &gt;13 in another logistic regression model. Finally, in line with ESC Guidelines 2016, we combined the key functional (E/é &gt;13) and key structural (left ventricular mass index (LVMI) ≥115 g/m2 for males and ≥95 g/m2 for females) alterations for diastolic dysfunction and used this variable in both logistic regression for association with Azu-1 and for Cox regression analysis of incident CHF. 1439 subjects (938 cases with some degree of diastolic dysfunction and 501 controls) remained for the analysis. For the analysis of incident CHF, Cox regression was used excluding subjects with ejection fraction below 50% and prevalent CHF and further adjusted for prevalent coronary disease on top of age, sex, BMI, diabetes, systolic and diastolic blood and anti-hypertensive treatment. 1,511 subjects (64 incident cases of CHF vs 1447 controls; median follow up time 8.9 years) remained. Results After adjustment for above mentioned risk factors, each 1 standard deviation (SD) of increase in Azu-1 was associated with any degree of prevalent diastolic dysfunction (odds ratio (OR) 1.13, p=0.048), E/é &gt;13 OR 1.21, p=0.028 and for combined LVMI and E/é OR 1.17, p=0.015. In fully adjusted linear regression Azu-1 was associated with E/é with a β-coefficient of 0.056, p=0.018. In a fully adjusted Cox regression models Azu-1 was associated with incident CHF (hazard ratio (HR) 1.32, p=0.025). As expected and as proof of concept E/é &gt;13 and combined LVMI with E/é were also associated with incident CHF; HR 2.84, p&lt;0.001 and HR 2.12, p=0.006, respectively. Conclusion An inflammatory mediator, Azurocidin-1, is associated with prevalent diastolic dysfunction, E/é, E/é combined with LVMI as well as incident congestive heart failure in a population-based cohort.

Three-year follow-up from a phase 3 study of SB3 (a trastuzumab biosimilar) versus reference trastuzumab in the neoadjuvant setting for human epidermal growth factor receptor 2–positive breast cancer

BackgroundWe assessed long-term cardiac safety and efficacy in patients with human epidermal growth factor receptor 2–positive early breast cancer treated with a trastuzumab biosimilar (SB3) or its reference product, trastuzumab (TRZ), in a phase 3 study. MethodsPatients who completed the phase 3 study could be enrolled in this extension study. The outcomes included the incidence of symptomatic congestive heart failure (CHF), asymptomatic significant left ventricular ejection fraction (LVEF) decrease, incidence of other cardiac events, event-free survival (EFS), and overall survival. In post hoc analysis, the Cox proportional hazards regression model was used to assess factors associated with EFS. ResultsA total of 367 patients were enrolled in the study (SB3, n = 186; TRZ, n = 181). The median follow-up duration from the main study enrolment was 40.8 and 40.5 months for SB3 and TRZ, respectively. During the two-year follow-up after adjuvant therapy, incidence of asymptomatic significant LVEF decrease was rare (SB3, n = 1; TRZ, n = 2), with all patients recovering with LVEF ≥ 50%, and no cases of symptomatic CHF or other cardiac events were reported. At 3 years, the EFS was 91.9% with SB3 and 85.2% with TRZ. The number of patients with events was 17 (9.1%) with SB3 and 31 (17.1%) with TRZ [hazard ratio: 0.47, 95% confidence interval: 0.26–0.87]. Antibody-dependent cell-mediated cytotoxicity (ADCC) activity and the breast pathologic complete response rate were the factors associated with EFS. ConclusionCardiotoxicity was rare in this extension study. EFS was higher with SB3 versus TRZ, with post hoc analysis suggesting that a downward drift in ADCC activity was a contributing factor. Clinical trial registration numbersNCT02771795 (EudraCT 2015-005663-17).

Exposure to ambient air pollution and the incidence of congestive heart failure and acute myocardial infarction: A population-based study of 5.1 million Canadian adults living in Ontario

Long-term exposure to ambient air pollution has been linked to cardiovascular mortality, but the associations with incidence of major cardiovascular diseases are not fully understood, especially at low concentrations. We aimed to investigate the associations between exposure to fine particulate matter (PM2.5), nitrogen dioxide (NO2), ozone (O3), redox-weighted average of NO2 and O3 (Ox) and incidence of congestive heart failure (CHF) and acute myocardial infarction (AMI). Our study population included all long-term residents aged 35–85 years who lived in Ontario, Canada, from 2001 to 2015 (~5.1 million). Incidence of CHF and AMI were ascertained from validated registries. We assigned estimates of annual concentrations of pollutants to the residential postal codes of subjects for each year during follow-up. We estimated hazard ratios (HRs) and 95% CIs for each pollutant separately using Cox proportional hazards models. We examined the shape of concentration-response associations using shape-constrained health impact functions. From 2001 to 2015, there were 422,625 and 197,628 incident cases of CHF and AMI, respectively. In the fully adjusted analyses, the HRs of CHF corresponding to each interquartile range increase in exposure were 1.05 (95% CI: 1.04–1.05) for PM2.5, 1.02 (95% CI: 1.01–1.04) for NO2, 1.03 (95% CI: 1.02–1.03) for O3, and 1.02 (95% CI: 1.02–1.03) for Ox, respectively. Similarly, exposure to PM2.5, O3, and Ox were positively associated with AMI. The concentration-response relationships were different for individual pollutant and outcome combinations (e.g., for PM2.5 the relationship was supralinear with CHF, and linear with AMI).

Exposure to Ambient Ultrafine Particles and Nitrogen Dioxide and Incident Acute Myocardial Infarction and Congestive Heart Failure: A Population-Based Cohort Study

Background. Although long-term exposure to traffic-related air pollutants such as nitrogen dioxide (NO2) has been linked to cardiovascular mortality and morbidity, little is known about the effect of ultrafine particles (&amp;#8804;0.1um in diameter; UFPs) on the incidence of major cardiovascular events. We conducted a population-based cohort study to assess the associations of chronic exposure to UFPs and NO2 with the incidence of acute myocardial infarction (AMI) and congestive heart failure (CHF). Methods. We used the Ontario Population Health and Environment Cohort (ONPHEC) to assemble our study cohorts which comprised all long-term Ontario residents who were aged 30 to 100 years and free of respective study outcomes, and lived in the City of Toronto, Canada on January 1st, 1996. Subjects were followed until December 31st, 2012. Outcomes were ascertained using validated province-wide databases. We estimated annual concentrations of UFPs and NO2 using land-use regression models and assigned these estimates to participants&amp;#8217; annual postal-code addresses during the follow-up period. Using random-effects Cox proportional hazards models, we calculated hazard ratios (HRs) and 95% confidence intervals (CIs) for UFPs and NO2, adjusted for individual- and neighborhood-level covariates. We considered both single- and multi-pollutant models. Results. Between 1996 and 2012, we identified 106,644 and 43,745 incident cases of AMI and CHF, respectively. Each interquartile change in exposure to UFPs (~10,000 count/cm3) was associated with increased risk of incident AMI (HR&amp;#61;1.05; 1.02-1.07) and CHF (HR&amp;#61;1.03; 1.02-1.05) after adjusting for all covariates. These results remained unaltered with further control for fine particulate matter (PM2.5) and NO2. Exposure to NO2 was also independently associated with higher incidence of CHF.Conclusion. Exposure to traffic-related air pollution including UFPs and NO2 may increase the risk of incident cardiovascular events.