Consecutive Chronic Heart Failure Patients Research Articles

Real-Life Data on Readmissions of Worsening Heart Failure Outpatients in a Heart Failure Clinic.

Introduction Recurrent hospitalizations for worsening heart failure (WHF) represent a major global public health concern, resulting in significant individual morbimortality and socioeconomic costs. This real-life study aimed to determine the rate and predictors of readmission for WHF in a cohort of outpatients with chronic heart failure (CHF) followed in a heart failure clinic (HFC) at a university hospital. Methods We conducted a longitudinal, observational, and retrospective study of all consecutive CHF patients seen at the HFC of the São Francisco Xavier Hospital, Lisbon, by a multidisciplinary team in 2019. The patients were followed for one year and were on optimized therapy. The inclusion criteria for the study were patients who had been hospitalized and subsequently discharged at least three months prior to their enrollment. Patient demographics, heart failure (HF) characterization, comorbidities, pharmacological treatment, treatments of decompensated HF in the day hospital (DH), hospitalizations for WHF, and death were recorded. We applied logistic regression analysis to assess predictors of hospital readmission for HF. Results A total of 351 patients were included: 90 patients (26%) had WHF requiring treatment with intravenous diuretics in the DH; 45 patients (mean age: 79.1 ± 9.0 years) were readmitted for decompensated HF within one year (12.8%) with no gender difference, while 87.2% of the patients (mean age: 74.9 ± 12.1 years) were never readmitted. Readmitted patients were significantly older than those who were not (p=0.031). Additionally, they had a higher New York Heart Association (NYHA) functional classification (p<.001), were on a higher daily dose of furosemide (p=0.008) at the time of the inclusion visit, were more frequently affected by the chronic obstructive pulmonary disease (COPD) (p=0.004); had been treated more often in the DH for WHF (p<.001) and had a higher mortality rate (p<.001) at one year. Conclusions This study aimed to determine WHF patient readmission rates and predictors. According to our results, a higher NYHA class, the need for treatment in the DH for WHF, a daily dose of furosemide equal to or greater than 80 mg, and COPD were predictors of readmission for WHF. CHF patients continue to experience WHF and recurrent hospitalizations despite therapeutic advances and close follow-up in the HFC with the multidisciplinary team. Besides COPD, the HF readmission risk factors found were mainly related to advanced disease. Furthermore, the structured and multidisciplinary approach of our disease management program likely contributed to our relatively low rate of readmissions.

Abstract 10593: Resting Energy Expenditure is an Important Factor to Predict Cardiac Mortality in Chronic Heart Failure

Introduction: Parameters derived from cardiopulmonary exercise testing (CPET) with respiratory gas analyzer are important prognostic factors in patients with chronic heart failure (CHF). However, all patients with CHF cannot undergo CPET for reasons such as frailty and comorbidity. On the other hands, resting energy expenditure (REE) derived from respiratory gas analyzer can be easily measured in most patients with CHF, but clinical significance of this parameter had not been fully elucidated in patients with CHF. Aims: We aimed to determine the clinical importance including the prognostic impact of REE in patients with CHF. Methods: A total of 1185 consecutive CHF patients who underwent CPET were enrolled. REE was calculated by Weir's formula (3.941resting oxygen consumption (VO 2 )+1.106resting carbon dioxide production (VCO 2 )). The study population was divided into two groups according to median REE and we compered the clinical characteristics between two groups. Also, we examined the value of REE to predict cardiac mortality in CHF patients. Results: In all subjects, 966 were males, median age was 63 years. Median resting VO 2 was 236 ml/min, median resting VCO 2 was 222 ml/min and median REE was 1178 kcal/day. Patients with low REE (&lt;1178 kcal/day) were older and had higher prevalence of female and anemia, lower body mass index (BMI), more impaired renal function, lower parameters of nutrition such as serum total protein and albumin, higher levels of plasma type-B natriuretic peptide, lower resting VO 2 , lower resting VCO 2 and lower peak VO 2 than those with high REE (&gt;1178 kcal/day). But left ventricular ejection fraction was similar between two groups. Patients with low REE had significantly higher rates of cardiac death, all cause death and composite cardiac event (cardiac death and re-hospitalization due to worsening heart failure). Furthermore, REE was the independent predictor of cardiac death, all-cause death and composite cardiac events in the Cox proportional hazard analysis after adjusted cofounding variables including peak VO 2 . Conclusions: REE as well as peak VO 2 is important predictor of cardiac mortality in patients with CHF.

Utilization and Efficacy of Cardiac Resynchronization Therapy in Patients With Chronic Heart Failure - A Report From the CHART-2 Study.

Background: Although cardiac resynchronization therapy (CRT) is effective for patients with chronic heart failure (CHF) with reduced left ventricular ejection fraction and wide QRS (≥120 ms), data on the use of or long-term outcomes after CRT implantation in Japan are limited.Methods and Results: We examined proper CRT utilization and outcomes in 3,447 consecutive symptomatic CHF patients registered in the CHART-2 Study. We identified 167 potentially eligible patients and divided them into 4 groups according to the presence (+) or absence (−) of an indication for and implantation of CRT: Group A (reference group), (+)indication/(+)CRT; Group B, (+)indication/(−)CRT; Group C, (−)indication/(+)CRT; and Group D, (−)indication/(−)CRT. Based on the Japanese Circulation Society guidelines, 91 patients met the eligibility for CRT implantation, with 43 (47%) of them undergoing CRT implantation. After adjusting for confounders, age was significantly associated with no CRT use (odds ratio per 5-year increase 1.46; 95% confidence interval 1.11–2.05; P=0.012). Among the 4 groups, the cumulative incidence of cardiovascular death and CHF admission were highest in Group B and lowest in Group D (P=0.029).Conclusions: In this study, only half the eligible CHF patients properly received CRT. Aging was a significant risk factor for no CRT use. Patients without CRT despite having an indication could be at higher risk of mortality and CHF admission.

Abstract 9577: Resting Energy Expenditure is Important Factor to Predict Cardiac Mortality in Chronic Heart Failure

Introduction: Parameters derived from cardiopulmonary exercise testing (CPX) including peak oxygen consumption (VO 2 ) are important prognostic factors in patients with chronic heart failure (CHF). However, all patients with CHF cannot undergo CPX because of such as exercise intolerance. On the other hands, resting parameters derived from respiratory gas analyzer including resting energy expenditure (REE) could be easily measured and clinical significance of these parameters had not been fully elucidated in patients with CHF. We aimed to determine the prognostic impact of REE in patients with CHF. Methods: A total of 1185 consecutive CHF patients underwent CPX were enrolled. The subjects of this study were divided into two groups according to median REE and we compered the clinical characteristics between two groups. Also, we examined the value of REE (Weir’ formula: 3.941resting VO 2 +1.106resting VCO 2 ) to predict cardiac mortality in CHF patients. Results: In all subjects, 966 were males, median age was 63 years. Median resting VO 2 was 236 ml/min, median resting VCO 2 was 222 ml/min and median REE was 1178 kcal/day. Patients with low REE (&lt;1178 kcal/day) were older and had higher prevalence of female and anemia, lower body mass index (BMI), more impaired renal function, lower parameters of nutrition such as serum total protein and albumin, higher levels of plasma type-B natriuretic peptide, lower resting VO 2 and lower resting VCO 2 and lower peak VO 2 than those with high REE ( &gt; 1178 kcal/day). But left ventricular ejection fraction was similar between two groups. Patients with low REE had significantly higher rates of cardiac death, all cause death and composite cardiac events (cardiac death and re-hospitalization due to worsening heart failure) than those with high REE. Furthermore, REE was the independent predictor of cardiac death, all-cause death and composite cardiac events in the Cox proportional hazard analysis after adjusting for cofounding variables including peak VO 2 . Conclusions: REE as well as peak VO 2 is important predictor of cardiac mortality in patients with CHF.

“Rehospitalization Prognostic Factors In Patients with Heart Failure”

Introduction: The prognosis of chronic heart failure (CHF) is determined by the complex relationship of neurohormonal, mechanical and polyorgan pathological changes emerging in the course and progression of the disease.&#x0D; Objective: To assess the risk and rate of rehospitalisation due to decompensation of chronic heart failure (CHF) in relation to certain biologic, clinical and instrumental characteristics.&#x0D; Material and Methods: This study conducted in the Department of Cardiology, Community Based Medical College &amp; Hospital, Bangladesh. Prospective study on 228 consecutive CHF patients. The follow-up period was 12 to 24 months. The primary endpoint was rehospitalization due to HF decompensation. The risk values were calculated using the Cox regression models. &#x0D; Results: Median survival time was 8 months. The total number of rehospitalizations was 86 (37.7%). Rehospitalization risk values were insignificantly lower in women (HR 0.7, 95% CI 0.4-1.1, р &gt;0.05) and higher in older age groups (HR 1.4 95% CI 0.8-2.2, р&gt;0.05). Univariate regression analysis showed a higher rehospitalization risk in patients with survived myocardial infarction, clinical signs of CHF, high functional class and pulmonary pressure. Multivariate regression analyses revealed the leading role of functional class on rehospitalization risk. &#x0D; Conclusion: rehospitalization rates due to decompensation of CHF are high. Age and gender are insignificant predictors for rehospitalization in our study. Functional class is the prognostic factor with an independent effect on rehospitalization risk over the defined follow-up period among the examined group of patients.

Long-term post-LVAD surgery outcome in patients with and without pre-operative hemodynamic guided optimization

Abstract Background/Introduction Despite improved surgical techniques and pump designs, LVAD therapy remains associated with high mortality and morbidity. CardioMEMS guided hemodynamic optimization shortly pre-LVAD surgery could improve the long-term post-surgery outcomes. Purpose The aim of this analysis was to investigate the feasibility of pre-operative optimization using the hemodynamic monitoring provided by the CardioMEMS in patients with an LVAD surgery, to improve the long-term outcome compared to a cohort of historical controls. Methods Ten consecutive chronic heart failure patients, with an INTERMACS Class 2–5, scheduled for (semi-) elective HeartMate 3 (HM3) LVAD surgery were enrolled in the HEMO-VAD pilot study. All patients received a CardioMEMS device prior to LVAD surgery. The daily hemodynamic readings were used to guide the patient optimization process pre- and post-operatively. Aims of hemodynamic optimization were the normalization of the mean pulmonary artery pressure (mPAP), decongesting of the right ventricle (RV) and optimization of the renal function. Patients were categorized into optimized patients (mPAP ≤25mmHg) and non-optimized mPAP (mPAP &amp;gt;25mmHg). Additionally, a historical cohort, consisting of 24 (semi-) elective HM3 LVAD recipients were included in this analysis. The outcome of this analysis was the event-free survival of the combined endpoint of all-cause mortality, RV failure, acute kidney injury (AKI) and/or renal replacement therapy (RRT) during the first 12 months post-LVAD surgery (time to first event analysis). Results The median age was 60.3 [51.6–66.3], 58.7 [53.4–61.9] and 60.1 [53.5–65.2] years in the optimized patients, non-optimized patients and historical controls, respectively (p=0.90). Of the optimized patients, 66.7% were men, compared to 75.0% and 100.0% of the non-optimized patients and historical controls, respectively (p=0.02). During the first year post-LVAD surgery, the combined endpoint occurred in 19 patients, five (83%) events occurred in the non-optimized patients, and 14 (58%) events in the historical controls, while no (0%) events occurred in the optimized patients (p=0.018) (Figure). Conclusion(s) This analysis demonstrated the feasibility of hemodynamic guided optimization pre-LVAD surgery using the CardioMEMS. The hemodynamic optimized patients were at very low risk for all-cause mortality, right-sided HF, and AKI/RRT compared to non-optimized patients or historical controls. Figure 1. Event-free survival for the combined endpoint (all-cause mortality, right ventricular failure, and acute kidney injury and/or renal replacement therapy). Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): This work was supported by Abbott with an independent research grant, partially covering personnel costs. This study was investigator-initiated and was designed, conducted, interpreted and reported independently of the funder

Release of mitochondrial DNA is associated with mortality in severe acute heart failure.

Inflammation is regarded as an important trigger for disease progression in heart failure. Particularly in severe acute heart failure, tissue hypoxia may lead to cellular damage and the release of intracellular mitochondrial DNA, which acts as an activator of the immune system due to its resemblance to bacterial DNA. It may therefore serve as a mediator of disease progression. The aim of this study was to determine circulating levels of mitochondrial DNA and its association with mortality in patients with heart failure in different presentations. Plasma levels of circulating mitochondrial DNA were measured in 90 consecutive patients with severe acute heart failure admitted to our medical intensive care unit as well as 109 consecutive chronic heart failure patients. In patients admitted to our medical intensive care unit (median age 64 (49-74) years, median NT-pro-brain natriuretic peptide 4986 (1525-23,842) pg/mL, 30-day survival 64.4%), mitochondrial DNA levels were significantly higher in patients who died within 30 days after intensive care unit admission, and patients with plasma levels of mitochondrial DNA in the highest quartile had a 3.4-fold increased risk (P=0.002) of dying independent of renal function, vasopressor use and NT-pro-brain natriuretic peptide, troponin T, lactate levels or CardShock and acute physiology and chronic health evaluation II score. However, mitochondrial DNA did not provide incremental prognostic accuracy on top of the current gold standard acute physiology and chronic health evaluation II. Patients with severe acute heart failure showed significantly higher mitochondrial DNA levels (P<0.005) as compared to patients with chronic heart failure. In these patients, mitochondrial DNA levels were associated with the New York Heart Association functional class but were not associated with outcome. The release of mitochondrial DNA into the circulation is associated with mortality in patients with severe acute heart failure but not in patients with chronic heart failure. The release of mitochondrial DNA may therefore play a role within the pathophysiology of acute heart failure, which warrants further research. However, the use of mitochondrial DNA as a biomarker for risk stratification in these patients is of limited utility.

Improved Quality of Life and Functional Performance Post-LVAD Surgery Using Hemodynamic Guided Optimization Pre-LVAD Surgery

We assessed the effect of pre-operative hemodynamically optimization by CardioMEMS on the outcome of LVAD patients in relation to the quality of life (QoL) and functional performance. Ten consecutive chronic heart failure patients, with an INTERMACS Class 2-5, scheduled for (semi-) elective LVAD surgery were enrolled in the HEMO-VAD pilot study. The median age was 59.7 [52.4-63.0] years and 70.0% of patients were men. All patients received before LVAD surgery a CardioMEMS device on a median of 13.5 (range 3-23) days before surgery. The daily hemodynamic readings were used to guide the patient's optimization process. Aims of hemodynamically optimization were normalization of the mean pulmonary artery pressure (mPAP) and decongesting of the right ventricle and optimization of the renal function. In this analysis, we investigated the change in the quality of life (QoL) (according to the EQ-5D-5L, KCCQ, and PHQ-9 questionnaires) and 6-minute walking distance between baseline and 3 months of follow-up. The QoL improved in both groups between baseline and 3 months of follow-up, measured in all three questionnaires. Also the 6-minute walking distance improved significantly in both groups between baseline and 3 months of follow-up. Interestingly, the improvement in the EQ-5D-5L (+38.8±15.1 vs. +16.6±4.9) and 6-minute walking distance (+395.9±43.6 vs. +147.9±102.7) was bigger in patients who were hemodynamically optimized pre-LVAD surgery. QoL and functional performance improved in the first 3 months post-LVAD surgery. Patients who were hemodynamically optimized pre-LVAD surgery using the CardioMEMS seem to improve more in QoL and functional performance compared to those not hemodynamically optimized.

Pre-Operative Hemodynamic Guidance by Cardiomems to Improve LVAD Outcome

LVAD therapy remains a complex treatment, associated with high mortality and morbidity. Optimizing patients shortly before LVAD surgery can improve post-surgery outcomes. Therefore, we aimed to investigate the feasibility of pre-LVAD surgery optimization using the hemodynamic monitoring provided by the CardioMEMS to improve post-LVAD surgery outcome. Ten consecutive chronic heart failure patients, with an INTERMACS Class 2-5, scheduled for (semi-) elective LVAD surgery where enrolled in the HEMO-VAD pilot study. The median age was 59.7 [52.4-63.0] years, and 70.0% of patients were men. All patients received before LVAD surgery a CardioMEMS device. The daily hemodynamic readings were used to guide the patient optimization process pre and post-operative. Aims of hemodynamically optimization were normalization of the mean pulmonary artery pressure (mPAP) and decongesting of the right ventricle and optimization of the renal function. In this analysis, we investigated the occurrence of a combined endpoint of all-cause mortality, right-sided HF or renal replacement therapy (RRT) during the first 3 months of follow-up (time to first event analysis). During the optimization period, the mean cumulative reduction of mPAP was larger in the hemodynamic optimized patients (-58.8±82.9mmHg day) compared with those not hemodynamically optimized (0.8±29.3mmHg day). During the first three months post-LVAD surgery, the combined endpoint occurred in four out of six not hemodynamically optimized patient, compared to none off the hemodynamically optimized patients (p=0.05) (Figure). A trend towards better event-free survival of right-sided HF and RRT was observed in hemodynamically optimized patients. This pilot study demonstrates the feasibility of hemodynamic guided optimization using the CardioMEMS before LVAD surgery, which identified a group of patients at increased risk of all-cause mortality, right-sided HF, and RRT if not hemodynamically optimized pre-operatively.

P4514Agreement and prognostic significance of 6 frailty tools in patients with chronic heart failure

Abstract Background Frailty is common in patients with chronic heart failure (CHF) and is associated with adverse outcome. Many frailty tools are available, however, there is no standard way of evaluating frailty in patients with CHF. Purpose To report the prevalence of frailty, agreement and prognostic significance amongst 3 frailty assessment tools and 3 screening tools in CHF patients. Methods We comprehensively studied frailty using 6 frailty tools. Frailty screening tools include: Clinical frailty scale (CFS); Derby frailty index &amp; Acute frailty network frailty criteria. Frailty assessment tools include: Fried criteria; Edmonton frailty score &amp; Deficit index. Since there is no gold standard in evaluating frailty in CHF patients, for each of the frailty tools, we used the results of the other 5 tools to produce a combined frailty index which we used as a “standard” frailty tool. Subjects were defined as frail if so identified by at least 3 out of 5 tools. Results 467 consecutive ambulatory CHF patients (67% male, median age 76 (IQR: 69–82) years, median NTproBNP 1156 (IQR: 469–2463) ng/L) and 87 controls (79% male, median age 73 (IQR: 69–77 years) were studied. Prevalence of frailty was much higher in CHF patients than in controls (30–52% vs 2–15%, respectively). Amongst the frailty screening tools, DFI scored the greatest proportion of patients as frail (48%) while CFS scored the lowest proportion as frail (44%). Amongst the assessment tools, Fried criteria scored the greatest proportion of patients as frail (52%) while EFS scored the lowest proportion as frail (30%). Frail patients were older, have worse symptoms, higher NTproBNP and more co-morbidities compared to non-frail patients. Of the screening tools, CFS had the strongest agreement with assessment tools (kappa coefficient: 0.65–0.72, all p&lt;0.001). CFS had the highest sensitivity (87%) and specificity (89%) amongst screening tools and the lowest misclassification rate (12%) amongst all 6 frailty tools in identifying frailty according to the combined frailty index. During a median follow-up of 559 days (IQR 512–629 days), 82 (18%) patients died. 55% (N=45) of frail patients died of non-cardiovascular causes. Worsening frailty as detected by all 6 frailty tools was associated with worse outcome. A base model for mortality prediction including sex, NYHA class (III/IV vs I/II), BMI, log NTproBNP and haemoglobin had a C-statistics of 0.78. Amongst frailty tools: CFS and Fried criteria increased model performance most compared with base model (c-statistics: 0.80 for both). Patients who were frail according to CFS had a 9 times greater mortality risk than non-frail patients (Figure). Conclusion Frailty is common in CHF patients and is associated with worse outcome. CFS is a simple screening tool which identifies a similar group as lengthy assessment tools and has similar prognostic significance. Frailty screening should be incorporated into routine care of patients with CHF. Acknowledgement/Funding None

N-terminal pro brain natriuretic peptide eliminates the prognostic effect of atrial fibrillation in patients with chronic heart failure.

AimsCo‐morbid atrial fibrillation (AF) increases both mortality and N‐terminal pro brain natriuretic peptide (NT‐proBNP) concentrations in patients with chronic heart failure (CHF). It is unclear whether AF worsens prognosis independently from NT‐proBNP concentrations. If AF was an independent risk factor, NT‐proBNP levels for outcome prediction would need to be adjusted in patients with AF. We aimed to analyse the influence of AF on the prognostic value of NT‐proBNP in patients with CHF.Methods and resultsA total of 2541 consecutive CHF patients with sinus rhythm (SR) or AF were identified in the outpatients' CHF registry of the University of Heidelberg, Germany. Of these, 250 patients with SR were individually matched to 250 patients with AF with respect to NT‐proBNP, New York Heart Association functional class, sex, age, and aetiology of CHF. In the general sample, both AF and NT‐proBNP were associated with all‐cause mortality [hazard ratio (HR) = 1.96, 95% confidence interval (CI) 1.61–2.39, P < 0.001; and HR = 1.03 per 1000 ng/L increase, 95% CI 1.02 to 1.04, P < 0.001, respectively]. After matching, NT‐proBNP retained its prognostic power (HR = 1.13 per 1000 ng/L increase, 95% CI 1.10 to 1.16, P < 0.001), but AF did not (HR = 0.91, 95% CI 0.66 to 1.25, P = 0.56). Despite similar prognosis, matched patients with SR were in more advanced CHF than were AF patients as indicated by a lower left ventricular ejection fraction (30 ± 13% vs. 34 ± 14%, P < 0.001).ConclusionsThe prognostic value of NT‐proBNP in CHF is not influenced by concomitant AF. AF, in return, might be a surrogate of a worse cardiac condition rather than an independent risk factor.

Identification of Frailty in Chronic Heart Failure

ObjectivesThis study sought to report the prevalence of frailty, classification performance, and agreement among 3 frailty assessment tools and 3 screening tools in chronic heart failure (CHF) patients. BackgroundFrailty is common in patients with CHF. There are many available frailty tools, but no standard method for evaluating frailty. MethodsWe used the following frailty screening tools: the clinical frailty scale (CFS); the Derby frailty index; and the acute frailty network frailty criteria. We used the following frailty assessment tools: the Fried criteria; the Edmonton frailty score; and the Deficit Index. ResultsA total of 467 consecutive ambulatory CHF patients (67% male; median age: 76 years; interquartile range [IQR]: 69 to 82 years; median N-terminal pro–B-type natriuretic peptide: 1,156 ng/l [IQR: 469 to 2,463 ng/l]) and 87 control patients (79% male; median age: 73 years; IQR: 69 to 77 years) were studied. The prevalence of frailty using the different tools was higher in CHF patients than in control patients (30% to 52% vs. 2% to 15%, respectively). Frail patients tended to be older, have worse symptoms, higher N-terminal pro–B-type natriuretic peptide levels, and more comorbidities. Of the screening tools, CFS had the strongest correlation and agreement with the assessment tools (correlation coefficient: 0.86 to 0.89, kappa coefficient: 0.65 to 0.72, depending on the frailty assessment tools, all p < 0.001). CFS had the highest sensitivity (87%) and specificity (89%) among screening tools and the lowest misclassification rate (12%) among all 6 frailty tools in identifying frailty according to the standard combined frailty index. ConclusionsFrailty is common in CHF patients and is associated with increasing age, comorbidities, and severity of heart failure. CFS is a simple screening tool that identifies a similar group using more lengthy assessment tools.

Reduced levels of vasopressin, an independent mechanism in the obesity paradox in patients with chronic heart failure: Insights from the DAMOCLES study

BackgroundAn “obesity paradox” has been described in patients with chronic heart failure (CHF), obese patients having a better survival. Vasopressin is elevated in patients with CHF, and higher levels are associated with worsening severity of the disease. We aimed at evaluating the relationship between body mass index (BMI), obesity (BMI ≥30 kg/m2), and vasopressin in patients with CHF, as well as the prognostic implications of vasopressin across the full spectrum of BMI values. MethodsWe included 1132 consecutive CHF patients referred to a multidisciplinary CHF unit. BMI and vasopressin levels were measured at baseline, and their association was evaluated using multivariable linear and logistic regression models. Death was evaluated after a median follow-up of 2.93 years and using Cox regression analyses. ResultsMean age was 73 years, 43% women, mean BMI 28 kg/m2. Vasopressin levels were independently associated with all-cause death across the whole spectrum of BMI values, and were significantly lower in obese as compared to non-obese patients (median adjusted estimated levels of log-vasopressin in obese patients 2.57 [95% CI 1.5–3.67], in non-obese patients 3.16 [95% CI 2.11–4.23]; p < 0.001). Also, the higher the BMI, the lower the vasopressin levels, at least for patients with BMI <35 kg/m2. Subgroup analyses stratifying by left ventricle ejection fraction and sensitivity analyses further adjusting for norepinephrin levels yielded similar findings. ConclusionsReduced levels of vasopressin may represent an independent mechanism in the survival paradox in obese patients with CHF. Studies including larger samples of patients BMI ≥35 kg/m2 are needed.

Effects of ivabradine on endothelial function, aortic properties and ventricular-arterial coupling in chronic systolic heart failure patients.

Heart rate (HR) is an important prognostic factor in patients affected by chronic heart failure (CHF); ivabradine has been demonstrated to significantly reduce nonfatal myocardial infarction and hospitalization rate for acute heart failure and to improve left ventricular (LV) reverse remodeling, quality of life, exercise capacity, and arterial elastance (Ea) in these patients. We aimed at evaluating the short-term effects of ivabradine on ventricular-arterial coupling (VAC), aortic stiffness, and endothelial function in stable patients with CHF. We evaluated 30 consecutive CHF patients (LVEF≤ 35%, NYHA class II) with sinus rhythm and HR ≥ 70bpm on optimized pharmacological therapy. All of them underwent both transthoracic echocardiogram to assess aortic elastic properties (aortic distensibility, AD; aortic stiffness index, ASI; systolic aortic strain, SAS) and VAC, and peripheral arterial tonometry to measure endothelial function. Therapy with ivabradine 5mg bid was added and each patient was evaluated with the same examinations after 4months. At the baseline, 73% of patients had impaired VAC and 63% endothelial dysfunction. After 4months, there was a significant improvement in the VAC value (ΔVAC -0.10±0.18, P=.021), mainly linked to Ea (ΔEa -0.40±0.23mm Hg/mL; P=.003). All the parameters of aortic elasticity underwent significant improvement (ΔAD 1.82±1.43cm² × dyn- ¹, P=.004; ΔASI -4.73±6.07, P=.033; ΔSAS -7.98±4.37%, P=.003). Lastly, we also noted a significant improvement of endothelial function (Δ RHI 0.35±0.35; P<.001). At follow-up 40% of patients had impaired VAC (P=.018) and 33% endothelial dysfunction (P=.038). In patients with CHF adding ivabradine on top to the standard optimized medical therapy, when indicated, seems to improve endothelial function, aortic properties, and VAC.

Serum corin is associated with the risk of chronic heart failure.

It has been well documented that corin is a critical protease involved in the regulation of blood pressure and cardiac function. We performed a case-control study to determine whether serum corin is associated with the risk of chronic heart failure (CHF). We included 484 consecutive CHF patients and 484 control subjects to investigate the potential relationship between serum corin and CHF using logistic regression analysis. Compared with healthy controls, the CHF patients were more likely to have histories of hypertension and diabetes, and had higher levels of N-terminal pro-brain natriuretic peptide and lower levels of corin. The odds ratios of ischemic and non-ischemic HF were significantly reduced with the growing levels of serum corin after multivariate adjustment. Moreover, the decrease in serum corin levels seemed to be associated with the severity of CHF. In conclusion, our study suggested that serum corin levels were reduced in CHF patients and inversely correlated with the incidence of ischemic and non-ischemic HF.

P2-4 - Clinical Background in Patients With Pulmonary Hypertension Due to Left Heart Disease

Background: Pulmonary hypertension (PH) is a relevant complication of left heart disease (LHD). The 2015 ESC/ERS PH guidelines report two different hemodynamic phenotypes of PH due to LHD (PH-LHD) based on pulmonary vascular resistance (PVR) and diastolic pressure gradient (DPG): isolated post-capillary PH (Ipc-PH) and combined post- and pre-capillary PH (Cpc-PH). The objective of this study is to reveal the clinical characterics of Ipc-PH and Cpc-PH. Methods and Results: Among 184 consecutive chronic heart failure patients (averaged age: 64 y.o) who underwent right heart catheterization in our hospital, 62 patients (34%) were identified as PH-LHD. According to the guidelines, Ipc-PH is defined by DPG <7 mmHg and/or PVR ≦ 3 WU and Cpc-PH by DPG ≧ 7 mmHg and/or PVR > 3 WU. Using this definition, we identified three patient groups: Ipc-PH with both normal PVR and DPG (34 pts); Cpc-PH with both increased PVR and DPG (6 pts); and an intermediate group with either increased PVR or DPG (22 pts). Patients with Cpc-PH and the intermediate group had significantly higher mean PA pressure (40 ± 9 vs 31 ± 5 mmHg, P < .001) and lower SvO2 (60 ± 5 vs 69 ± 7%, P < .001) and lower cardiac output compared with the group of patients with Ipc-PH. LVEF in Cpc-PH and the intermediate group tend to be lower than Ipc-PH. Conclusion: Patients with Cpc-PH and the intermediate group have severe clinical background than those with Ipc-PH.

Association of serum albumin level and clinical outcomes among heart failure patients receiving cardiac resynchronization therapy

Objective: To assess the relationship between serum albumin level and clinical outcome in heart failure (HF) patients receiving cardiac resynchronization therapy (CRT). Methods: In this retrospective cohort study, 357 consecutive chronic heart failure patients receiving CRT between January 2010 and December 2015 were enrolled and divided into two groups based on pre-CRT serum albumin (albumin≥40 g/L, n=244; albumin<40 g/L, n=113). Clinical outcomes were defined as all-cause mortality (including heart transplantation) and rehospitalization due to worsening HF.Baseline characteristics were compared and all-cause mortality (including heart transplantation) and rehospitalization due to worsening heart failure (HF) were analyzed using Kaplan-Meier curves.Prognostic value of albumin level was evaluated in Cox proportional-hazards regression models. Results: Over a median follow-up time of 21 months, 45 patients (12.6%) died, 4 patients (1.1%) underwent heart transplantation and 100 patients (28.0%) were rehospitalized due to worsening HF. HF patients with pre-CRT albumin<40 g/L were related with worse NYHA function class, lower HDL-C level and ACEI/ARB use compared to HF patients with pre-CRT albumin≥40 g/L. Kaplan-Meier analyses evidenced lower survival rate in HF patients (log-rank test: P=0.000 4, χ(2)=12.60) and higher rehospitalization rate due to worsening HF (log-rank test: P=0.009, χ(2)=6.82) in HF patients with pre-CRT albumin<40 g/L.Multivariate Cox analyses indicated that serum pre-CRT albumin <40 g/L was an independent risk factor for all-cause mortality (HR=2.019, 95%CI 1.125-3.622, P=0.018) and HF rehospitalization (HR=1.517, 95%CI 1.014-2.270, P=0.043). Conclusion: Pre-CRT serum albumin level is associated with the severity of heart failure in CRT recipients.Patients with lower pre-CRT albumin level face increased risk of all-cause mortality and HF rehospitalization in chronic heart failure patients receiving cardiac resynchronization.

Clinical value of bendopnea in chronic heart failure patients with reduced left ventricular ejection fraction

Objective: To explore the clinical value of bendopnea in chronic heart failure patients with reduced ejection fraction (HFrEF). Methods: According to the existence of bendopnea or not, a total of 192 consecutive chronic heart failure patients with HFrEF admitted to our department from January 2014 to January 2016 were divided into the bendopnea group and non-bendopnea group. Subgroup analysis was performed in the subgroups with various bendopnea symptoms appearance time (0-10 s, 11-20 s and 21-30 s). The relationship between bendopnea and left ventricular ejection fraction (LVEF), 6-minute walking distance (6-MWD), NT-proBNP and NYHA classification were analyzed. Results: Bendopnea was confirmed in 74 out of 192 (38.54%) cases with HFrEF, and the average time of symptoms appearance was (8.62±2.29) s. LVEF and 6-MWD values were significantly lower in the bendopnea group than those in the non-bendopnea group (both P<0.05). The NT-proBNP level and the prevalence of patients with NYHA grade Ⅳ were significantly higher in the bendopnea group than those in the non-bendopnea group (both P<0.05). There were significant difference on LVEF, 6-MWD, NT-proBNP and patients with NYHA grade Ⅳ in bendopnea patients with various bendopnea symptoms appearance time (all P<0.05) and shorter bendopnea symptoms appearance time was related to severe symptoms and signs of chronic heart failure. Conclusion: The incidence rate of bendopnea is high in patients with HFrEF, and which is related closely to the cardiac function and shorter bendopnea symptoms appearance time is related to severe symptoms and signs of chronic heart failure in HFrEF patients.

Echocardiographic Determinants of One-Year All-Cause Mortality in Patients With Chronic Heart Failure Complicated by Significant Functional Tricuspid Regurgitation

BackgroundRight ventricular (RV) dysfunction plays an important role in chronic heart failure (CHF). We evaluated the echocardiographic determinants of 1-year all-cause mortality in CHF patients with clinically relevant functional tricuspid regurgitation (TR). Methods and ResultsA total of 101 consecutive CHF patients (mean age 74 ± 10 years, 53% male) with moderate or severe functional TR were enrolled. Each patient underwent at least 2 echocardiography examinations in an interval of >6 months. Clinical follow-up was made after a median of 305 (interquartile range 164–365) days after the last echocardiography. The primary end point was all-cause mortality. Forty-two patients (42%) died during follow-up. Baseline right atrial (RA) area, TR volume increase and RV enlargement over time were significantly higher in nonsurvivors than survivors (all P < .05). Compared to baseline levels, systolic pulmonary artery pressure (sPAP) was significantly reduced in nonsurvivors during follow-up echocardiography (54 ± 19 vs 49 ± 21 mm Hg; P = .010), but significantly increased in survivors (48 ± 17 vs 54 ± 17 mm Hg; P = .001). Multivariable survival analysis suggested that baseline RA area ≥27 cm2 (hazard ratio [HR] 2.41, 95% confidence interval [CI] 1.21–4.80; P = .013), follow-up TR proximal isovelocity surface area regurgitant volume increase ≥15 mL (HR 2.27, 95% CI 1.20–4.31; P = .012), RV middle diameter increase ≥10 mm (HR 2.38, 95% CI 1.10–5.11; P = .027), and sPAP reduction ≥10 mm Hg (HR 3.04, 95% CI 1.51–6.13; P = .002) were determinants of 1-year all-cause mortality after the last echocardiography. Patients with 2 or 3 of these determinants were faced with significantly increased 1-year mortality (88% or 100%). ConclusionsDynamic RV morphologic and functional changes during serial echocardiography are associated with significantly increased mortality risk in CHF patients with moderate or severe functional TR.

Reasons why patients suffering from chronic heart failure at very low risk for mortality die

BackgroundA proper prognostic stratification is crucial for organizing an effective clinical management and treatment decision-making in patients with chronic heart failure (CHF). In this study, we selected and characterized a sub-group of CHF patients at very low risk for death aiming to assess predictors of death in subjects with an expected probability of 1-year mortality near to 5%. MethodsWe used the Cardiac and Comorbid Conditions HF (3C-HF) Score to identify CHF patients with the best mid-term prognosis. We selected patients belonging to the lowest quartile of 3C-HF score (≤9 points). ResultsWe recruited 1777 consecutive CHF patients at 3 Italian Cardiology Units (age 76±10years, 43% female, 32% with preserved ejection fraction). Subjects belonging to the lowest quartile of 3C-HF score were 609. During a median follow-up of 21 [12–40] months, 48 of these patients (8%) died, and 561 (92%) survived. The variables that contributed to death prediction by Cox regression multivariate analysis were older age (HR 1.03[CI 1.00–1.07]; p=0.04), male gender (HR 2.93[CI 1.50–5.51]; p=0.002) and a higher degree of renal dysfunction (HR 0.96[CI 0.94–0.98]; p<0.001). ConclusionsThe prognostic stratification of CHF patients by 3C-HF score allows one to select patients at different outcome and to identify the factors associated with death in outliers with a very low mortality risk at mid-term follow-up. The reasons why these patients do not outlive the matching part of subjects who expectedly survive are related to a declined renal function and unmodifiable conditions including older age and male gender.