Goal-directed Medical Therapy Research Articles

Nanotechnology: The Future for Diagnostic and Therapeutic Intervention in Cardiovascular Diseases is Here.

With advances in technology and medicine over the last 3 decades, cardiovascular medicine has evolved tremendously. Nanotechnology provides a promising future in personalized precision medicine. In this review, we delve into the current and prospective applications of nanotechnology and nanoparticles in cardiology. Nanotechnology has allowed for point-of-care testing such as high-sensitivity troponins, as well as more precise cardiac imaging. This review is focused on 3 diseases within cardiology: coronary artery disease, heart failure, and valvular heart disease. The use of nanoparticles in coronary stents has shown success in preventing in-stent thrombosis, as well as using nanosized drug delivery medications to prevent neointimal proliferation in a way that spares systemic toxicity. In addition, by using nanoparticles as drug delivery systems, nanotechnology can be utilized in the delivery of goal-directed medical therapy in heart failure patients. It has also been shown to improve cell therapy in this patient population by helping in cell retention of grafts. Finally, the use of nanoparticles in the manufacturing of bioprosthetic valves provides a promising future for the longevity and success of cardiac valve repair and replacement.

Is patiromer a safe and effective treatment for hyperkalemia in patients with heart failure (HF) on goal-directed medical therapy?

Is patiromer a safe and effective treatment for hyperkalemia in patients with heart failure (HF) on goal-directed medical therapy?

Sacubitril-valsartan vs ACE/ARB in pediatric heart failure: A retrospective cohort study

The first angiotensin receptor/neprilysin inhibitor on the market, sacubitril-valsartan, has shown marked improvements in death and hospitalization for heart failure among adults, and is now approved for use in pediatric heart failure. While the ongoing PANORAMA-HF trial is evaluating the effectiveness of sacubitril-valsartan for pediatric patients with a failing systemic left ventricle, the enrollment criteria do not include the majority of pediatric heart failure patients. Additional studies are needed. Using the TriNetX database, we performed a propensity score matched, retrospective cohort study to assess the incidence of a composite of all-cause mortality or heart transplant within 1year. The 519 patients who received sacubitril-valsartan were compared to 519 matched controls who received an angiotensin converting enzyme inhibitor (ACE) or angiotensin II receptor blocker (ARB). There was no significant difference in the incidence of the composite outcome with sacubitril-valsartan over an ACE/ARB (13.3% vs 13.2%, p=0.95), or among the components of mortality (5.0% vs 5.8%, p=0.58) or heart transplantation (8.7% vs 7.5%, p=0.50). Patients who were receiving full goal-directed medical therapy (14.4% vs 16.0%, p=0.55) also showed no difference in the composite outcome. We observed a significantly increased incidence of hypotension (10% vs 5.2%, p=0.006) and a trend toward reduced number of hospitalizations per year (mean (SD) 1.3 (4.4) vs 2.0 (9.1), p=0.09). Sacubitril-valsartan is not associated with a decrease in the composite of all-cause mortality or heart transplantation within 1year. Future studies should evaluate the possible reduction in hospitalizations and optimal dosing to minimize hypotension.

Olanzapine-induced cardiomyopathy: A mimicker of obesity cardiomyopathy?

Olanzapine, an atypical antipsychotic medication, has gained prominence in the treatment of schizophrenia and related psychotic disorders due to its effectiveness and perceived safety profile. However, emerging evidence suggests a potential link between olanzapine use and adverse cardiovascular effects, including cardiomyopathy. This narrative review explores the mechanisms, clinical implications, and management strategies associated with olanzapine-induced cardiomyopathy. A comprehensive review of the literature was conducted to investigate the relationship between olanzapine and cardiomyopathy. The search included epidemiological studies, clinical case reports, and mechanistic research focusing on the pathophysiology of olanzapine-induced cardiomyopathy. The review also examined treatment strategies for managing this potential complication. Olanzapine-induced cardiomyopathy is hypothesized to be associated with metabolic disturbances and receptor antagonism. The metabolic effects of olanzapine, such as weight gain, insulin resistance, and dyslipidemia, share similarities with obesity-related cardiomyopathy. Additionally, olanzapine's antagonism of certain receptors may contribute to cardiovascular stress. The review highlighted that patients with new-onset heart failure and significant weight gain while on olanzapine should be closely monitored for signs of cardiomyopathy. Early detection and prompt withdrawal of olanzapine, along with initiation of goal-directed medical therapy, are crucial for mitigating this potentially life-threatening condition. The relationship between olanzapine and cardiomyopathy is complex and not yet fully understood. However, the potential for significant cardiovascular risk necessitates vigilance among healthcare providers. Early identification and management of olanzapine-induced cardiomyopathy can improve patient outcomes. Further research is needed to elucidate the precise mechanisms behind this adverse effect and to develop optimized treatment strategies for patients requiring antipsychotic therapy.

Early experience with baroreflex activation therapy from a vascular surgery perspective

Baroreflex activation therapy (BAT) is an emerging device-based treatment for patients with heart failure with a reduced ejection fraction refractory to maximally tolerated goal-directed medical therapy. Currently, there is sparse literature on the critical role that vascular surgeons serve in the delivery of this novel therapy. This single-institution series describes the creation of a BAT program and elaborates on the function of vascular surgeons in the multidisciplinary heart failure team. The preoperative evaluation, perioperative care, and postoperative course of patients receiving BAT from March 2022 to August 2023 were retrospectively analyzed. Eleven patients were evaluated by a dedicated heart failure cardiologist for medical eligibility and assessed by a vascular surgeon for technical feasibility. Of the 11 patients, 7 were men (63.6%). The median age was 60.5 years (range, 44-73 years). No patient (0.00%) had existing carotid artery disease, and one patient (9.1%) had undergone previous neck radiation therapy. All 11 patients (100%) had an existing cardiac implantable electronic device, and BAT implantation was performed on the same side as the cardiac implantable electronic device in two patients (18.1%). Four patients (36.4%) required preoperative hospital admission for medical optimization before surgery. The median length of surgery was 82 minutes (range, 58-113 minutes), and the median length of stay in the hospital after surgery was 1 day (range, 0-6 days). No major adverse neurologic or cardiovascular events, cranial nerve injuries, device complications requiring reintervention, or heart failure-related mortality at 6 months occurred. Three patients (27.3%) experienced extraneous stimulations, which affected BAT tolerability. Within 6 months after BAT implantation, no significant improvements were observed for several heart failure disease burden markers compared with 6 months before BAT implantation. Our early results demonstrate that BAT implantation is a safe procedure with rare complications. Vascular surgeons play an important role in the multidisciplinary delivery of this novel device-based therapy. More data are needed to understand whether BAT is beneficial in the treatment of heart failure with a reduced ejection fraction refractory to maximally tolerated goal-directed medical therapy.

Pulmonary Vein Flow Morphology After Transcatheter Mitral Valve Edge-to-Edge Repair as Predictor of Survival

Data on the prognostic factors after mitral valve (MV) transcatheter edge-to-edge repair (TEER;MV-TEER) are limited. Pulsed-wave Doppler interrogation of pulmonary vein flow (PVF) is a convenient method to assess the hemodynamic burden of residual mitral regurgitation (MR), which could be of utility as a predictor of outcomes. Patients that underwent MV-TEER between May 2014 and December 2021 at our institution were evaluated. Pulmonary vein flow patterns post-MV-TEER were reviewed on the procedural transesophageal echocardiogram and classified as normal (systolic dominant or codominant) or abnormal (systolic blunting or reversal). The PVF pattern was correlated with all-cause mortality at follow-up. Two-hundred sixty-five patients had diagnostic PVF post-MV-TEER, with 73 (27.5%) categorized as normal and 192 (72.5%) categorized as abnormal. Patients with abnormal PVF morphology were more likely to have atrial fibrillation (70% vs 42%, P<.001) and greater than moderate residual MR (16% vs 3%, P=.01) and had higher mean left atrial pressure (18.1±5.0 vs 15.9±4.2mm Hg, P=.002) and left atrial V wave (26.6±8.5 vs 21.4±7.3mm Hg, P<.001) postprocedure. In multivariable analysis, abnormal PVF morphology post-MV-TEER was independently associated with mortality at follow-up (hazard ratio= 1.70; 95% CI, 1.06-2.74; P=.03) after correction for end-stage renal disease, atrial fibrillation, and residual MR. Results were similar in subgroups of patients with moderate or less and those with mild or less residual MR. Pulmonary vein flow morphology is a simple and objective tool to assess MR severity immediately post-MV-TEER and offers important prognostic information to optimize procedural results. Additional studies are needed to determine whether patients with abnormal PVF pattern post-MV-TEER would benefit from more intensive goal-directed medical therapy postprocedure.

Home hospital heart failure admissions are an opportunity to initiate goal directed medical therapy - a retrospective analysis

Abstract Background There is growing recognition of the importance of goal directed medical therapy (GDMT) initiation for heart failure (HF) during hospitalization. Home hospital provides traditional inpatient hospital care in the patient’s home. Data describing GDMT initiation in home hospital is lacking. Purpose We described the rate of GDMT prescription on admission to and on discharge from home hospital for HF exacerbations, and compared the rate of sodium/glucose cotransporter-2 inhibitors (SGLT2i) prescription before and after home hospitalization. Methods This retrospective cohort is derived from all HF hospitalizations in two home hospital programs in the US between February 2020 and October 2022. Patients with heart failure with reduced ejection fraction (HFrEF; EF &amp;lt;50%) and patients with heart failure with preserved ejection fraction (HFpEF) who were hospitalized after February 2022 (when the FDA approved SGLT2i for HFpEF) were included. Exclusion criteria were if care was escalated to the traditional hospital setting, if patient goals of care were comfort care only, or if patients were receiving palliative inotropes. We report the rate of GDMT prescription immediately prior to home hospital admission and at discharge. GDMT for HFrEF was defined as beta-blocker, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB), angiotensin receptor-neprilysin inhibitor (ARNI), mineralocorticoid receptor antagonists (MRA), and SGLT2i; for HFpEF, only SGLT2i were considered. For the entire cohort, McNemar’s chi-squared test was performed to compare the rate of SGLT2i prescription before and after admission. Other GDMT therapies were not compared due to insufficient power. Reasons for not initiating GDMT are reported. Data were collected through manual chart review. Results We studied 173 hospitalizations; 95 patients had HFrEF and 78 had HFpEF. Mean age was 77.3 years; 65% had atrial fibrillation, 57% had diabetes mellitus, and 51% had chronic kidney disease. For patients with HFrEF, rates of beta-blocker, ACEi/ARB, ARNI, MRA, and SGLT2i prescription on admission were 88%, 56%, 16%, 34%, and 14% and on discharge were 85%, 49%, 17%, 35%, and 23% respectively; Figure 1. For the entire cohort – patients with HFrEF or HFpEF, the difference between the rate of SGLT2i prescription before and after the admission was statistically significant (12.1% vs 20.8%, p-value &amp;lt; 0.001); Figure 2. In 89% of hospitalizations GDMT was not initiated; the three most common reasons were no reason cited (68%), deferral to outpatient follow-up (14%), and kidney dysfunction (10%). Conclusion Home hospital admission for HF represents a feasible opportunity to initiate GDMT. Patients admitted to home hospital for HF had a statistically significant increase in the rate of SGLT2i prescription, although the overall rate remained low. Future study will investigate if GDMT prescription rates are improved with cardiology e-consultation in home hospitalizations.GDMT Prescription Rate - Reduced EFSGLT2i Prescription Rate

Abstract 18376: Social Vulnerability Indices as a Measure for the Impact of Social Determinants of Health on SGLT2-i Prescriptions in Patients With HFrEF

Introduction: Sodium-glucose cotransporter-2 inhibitors (SGLT2-i) are an important member of the 5 pillars of goal directed medical therapy (GDMT) in patients with heart failure with reduced ejection fraction (HFrEF) that was introduced in the 2022 AHA/ACC/HFSA heart failure guidelines. Despite the role of GDMT in reducing cardiovascular mortality and heart failure outcomes, medication accessibility remains limited among more socially vulnerable populations. Social Determinants of Health (SDoH) play a vital role in how patients receive and engage with health care. Goals/Aims: Our study aims to utilize the social vulnerability indices (SVI), an underutilized tool used to quantify social vulnerability, to determine associations between SDoH with SGLT2-i prescriptions. Methods/Approach: A retrospective review of SVI in 864 patients with a diagnosis of HFrEF in two urban Internal Medicine outpatient clinics between April 2022 and June 2023 was performed. Composite social vulnerability, as well as subgroups of individual data points utilized in the Centers for Disease Control and Prevention SVI were compared between those prescribed and not prescribed a SGLT2-i. Patients with a diagnosis of HFrEF were assigned SVI scores based on geocoded census tract level data. Chi-square analysis was performed to compare groups. A p-value less than &lt;0.05 was considered significant. Results: A total of 864 patients were evaluated. 78 of these patients were prescribed a SGLT2-i, while 786 were not prescribed a SGLT2-i. Those with a SVI overall percentile of 74-100% (less social vulnerability) were significantly more likely to be on a SGLT2-i (19.23% vs 10.02%, p = 0.022). Descriptively, patients with SVI Est &lt;24% below poverty were less often prescribed SGLT2-i (92.05% vs 7.95%). Similarly, those without a vehicle as defined by SVI Est &lt;24% households with no vehicle available were on less frequently prescribed SGLT2-i (93.24% vs 6.76%). Conclusion: Use of SVI data may help identify barriers to SGLT-2 prescribing in patients with HFrEF when analyzed on a population level. Further studies and investigations to target these barriers may be beneficial in increasing the amount of patients on indicated GDMT. Keywords: social determinants of health, SGLT-2i, GDMT, HFrEF

Abstract 19124: Systemic Sclerosis Masquerading as Heart Failure

Cardiac disease occurs in 80% of patients with systemic sclerosis (SS). Patients may present with various symptoms, including dyspnea, palpitations, chest pain, and heart failure. Of these, systolic heart failure has the rarest prevalence, estimated between 1-5% of patients. The mechanism behind myocardial damage is still unclear. Current literature supports a fibrotic process due to ischemic necrosis and reperfusion damage. There is a lack of representation of SS-related cardiac disease, but it is crucial to recognize it early for prompt intervention. A 62-year-old male with a history of diastolic dysfunction presented with acute hypoxic respiratory failure. A transthoracic echocardiogram demonstrated a new severely reduced systolic function at 20%. Angiogram demonstrated non-obstructive coronary artery disease. Further autoimmune workup revealed a significantly elevated ANA and highly positive RNA polymerase III antibody. The patient underwent a cardiac magnetic resonance imaging (MRI) scan, which showed evidence of inflammation with diffuse myocardial fibrosis concerning an infiltrative process. Subsequent cardiac positron emission tomography (PET) showed increased uptake in the basal portions of the septum and anterior wall for myocarditis. Given his autoimmune workup results and imaging, the patient was subsequently diagnosed with rapidly progressive cutaneous systemic sclerosis and associated non-ischemic cardiomyopathy. The patient was started on goal-directed medical therapy, including losartan, spironolactone, metoprolol, and empagliflozin. Additionally, he started on mycophenolate mofetil for immunosuppression. Roughly six months after discharge, his pulmonary function tests remain stable. His ejection fraction improved to 62%. Roughly one-third of systemic sclerosis-related deaths are due to cardiac involvement. Yet, most patients are asymptomatic during the early stages, with a variable phenotype later in disease progression. We report a case of a patient who developed systemic sclerosis-related myocarditis with an initial presentation of acute systolic heart failure. His cardiac dysfunction recovered from optimal goal-directed therapy and immunosuppression.

Abstract 16927: The Mother of All Pseudoaneurysms - A Rare Case

Introduction: Femoral artery pseudoaneurysms (FAP) are typically caused by percutaneous access during coronary and peripheral angiography. It occurs in 0.1 to 0.2% of diagnostic catheterization procedures and in 3.5% to 5.5% of interventional procedures. Cases of “Giant” femoral artery pseudoaneurysms have seldom documented in the past, however, our case is unique for two reasons:- Pseudoaneurysm presented 6 months after femoral arterial access, which is unusual.- This size of pseudo-aneurysm has yet to be documented. Case Description: 74-year-old male with history of diabetes mellitus type II and tobacco abuse presented with chest pain. He underwent cardiac catheterization via radial access, which confirmed severe multi-vessel disease with ejection fraction of 30%. Patient was started on goal-directed medical therapy with planned elective IABP-assisted coronary artery bypass grafting (CABG). On the day of surgery in anticipation of IABP, right femoral artery was accessed, however, intra-operative transesophageal echocardiography showed improvement of ejection fraction to 55%, which led to removal of the femoral sheath and application of a closure device. Six months later, patient presented with a large right groin mass. Computed tomography angiography confirmed a pseudoaneurysm anterior to the right common femoral artery, measuring 9.6 cm x 9.8 cm causing moderate stenosis of the superficial femoral artery. Peripheral arterial duplex ascertained the neck of pseudoaneurysm measuring 1.3 cm. Patient underwent emergent repair of the right femoral pseudoaneurysm, with thrombus removal. No further recurrence of pseudoaneurysm was noted. Discussion: Pseudoaneurysms may arise months after femoral arterial access. Any groin symptoms in patients who underwent percutaneous femoral arterial access warrant additional investigation. Further studies are needed to elucidate the factors that increase the risk of formation and rupture of pseudoaneurysms

Osimertinib-induced biventricular cardiomyopathy with abnormal cardiac MRI findings: a case report

BackgroundOsimertinib is a third-generation epidermal growth factor receptor (EGFR) inhibitor that is currently the first-line treatment for metastatic EGFR-mutated non-small-cell lung cancer (NSCLC) due to its favorable efficacy and tolerability profile compared to previous generations of EGFR inhibitors. However, it can cause uncommon, yet serious, cardiovascular adverse effects.Case PresentationWe present the case of a 63-year-old man with EGFR-mutated NSCLC treated with osimertinib who developed new-onset non-ischemic cardiomyopathy with biventricular dysfunction and heart failure in the context of an enlarging pericardial effusion. For the first time, we demonstrate cardiac MR imaging findings associated with osimertinib-associated cardiomyopathy, including focal late gadolinium enhancement and myocardial edema. The patient’s biventricular function normalized after initiation of goal-directed medical therapy for heart failure and holding osimertinib. The patient was subsequently started on afatinib, a second-generation epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI), without recurrence of cardiomyopathy.ConclusionsThis case highlights the need to better understand osimertinib-induced cardiotoxicity and strategies to optimize oncologic care in patients who develop severe cardiac toxicities from cancer therapy. It further underlines the importance of specialized multidisciplinary care of cancer patients who develop cardiotoxicities to optimize their oncologic outcomes.

Diagnostic Criteria of Takotsubo Cardiomyopathy in the Clinical Setting: A Case Report

Introduction Takotsubo cardiomyopathy (TTS) is a rare condition related to stress featuring apical hypokinesis. Current guidelines suggest that the exclusion of other causal factors like myocarditis is required to diagnose TTS. However, we propose that the existing diagnostic criteria for TTS, particularly, required exclusion of myocarditis, adds to the challenge of making this diagnosis in the clinical setting. Hereby, we present a case with basal hypokinesis that could have been attributed to a conjunction of reverse Takotsubo syndrome (rTTS) with viral or toxic myocarditis. Case Presentation: A 29-year-old female complained of acute persistent chest pain, palpitations, and vomiting after smoking marijuana. She was tachycardic without hemodynamic instability or hypoxia. Electrocardiogram showed sinus tachycardia. Troponin peaked at 16.1 ng/ml. Urine drug screen was positive for amphetamines. Echocardiogram and catheterization showed left ventricular reduced ejection fraction (25-30%) with basal hypokinesia and apical hyperkinesis, suggestive of reversed Takotsubo cardiomyopathy. Cardiac magnetic resonance (CMR) also showed delayed contrast enhancement suggestive of myocarditis. Viral panel noted positive Coxsackie B titer on day 7 of hospitalization. She was treated with goal-directed medical therapy and repeat echocardiogram 6 days after showed normalized left ventricular systolic function. Discussion: Guidelines recommend the use of clinical history, inflammatory markers, and CMR to exclude infectious myocarditis before diagnosing rTTS. The clinical scenario in this case presented evidence of a catecholamine-related substance exposure known to trigger takotsubo cardiomyopathy and of an elevated Coxsackie B titer. The CMR showed features explainable by myocarditis and partially by rTTS. This case highlights the complexity of diagnosing TTS or rTTS with infective myocarditis as exclusion criteria. While imaging, history, and labs play a vital role, a lack of complete understanding about the pathophysiology of this disease as well as existing diagnostic criteria complicate the ability to make this diagnosis in the clinical setting.

Heart Failure: Recent Advances and Breakthroughs

Heart failure (HF) is a common clinical condition encountered in various healthcare settings with a vast socioeconomic impact. Recent advancements in pharmacotherapy have led to the evolution of novel therapeutic agents with a decrease in hospitalization and mortality rates in HF with reduced left ventricular ejection fraction (HFrEF). Lately, the introduction of artificial intelligence (AI) to construct decision-making models for the early detection of HF has played a vital role in optimizing cardiovascular disease outcomes. In this review, we examine the newer therapies and evidence behind goal-directed medical therapy (GDMT) for managing HF. We also explore the application of AI and machine learning (ML) in HF, including early diagnosis and risk stratification for HFrEF.

Predictors of Revascularization in Lower-Extremity Peripheral Artery Disease: Insights From the PORTRAIT Study.

Peripheral artery disease (PAD) guidelines recommend revascularization only for patients with lifestyle-limiting claudication that is refractory to goal-directed medical therapy (class IIA, level of evidence A). However, real-world invasive treatment patterns and predictors of revascularization in patients with symptomatic lower-extremity PAD are still largely unknown. We aimed to examine rates, patient-level predictors, and site variability of early revascularization in patients with new or worsening PAD symptoms. Among patients with new-onset or recent exacerbation of PAD in the 10-center Patient-centered Outcomes Related to TReatment practices in peripheral Arterial disease: Investigating Trajectories (PORTRAIT) study enrolled between June 2011 and September 2015, we classified early revascularization (endovascular or surgical) as procedures being performed within 3 months of presentation. Hierarchical logistic regression was used to identify patient characteristics associated with early revascularization. Variability across sites was estimated using the median odds ratio (OR). Among 797 participants, early revascularization procedures were performed in 224 (28.1%). Rutherford class 3 (vs Rutherford class 1; OR=1.86, 95% confidence interval [CI] 1.04-3.33) and having lesions in both iliofemoral and below-the-knee arterial segments (vs below the knee only; OR=1.75, 95% CI: 1.15-2.67) were associated with a higher odds of revascularization. Longer PAD duration >12 months (vs 1-6 months; OR=0.50, 95% CI: 0.32-0.77), higher ankle-brachial index scores (per 0.1 unit increase; OR=0.86, 95% CI: 0.78-0.96), and higher Peripheral Artery Questionnaire Summary scores (per 10 unit increase; OR=0.89, 95% CI: 0.80-0.99) were associated with a lower odds of revascularization. The raw rates for revascularization in different sites ranged from 6.25% to 66.28%, and the median OR was 1.88, 95% CI: 1.38-3.57. About 1 in 3 patients with symptomatic PAD received early revascularization. A more extensive disease and symptom burden were the main predictors of receiving early revascularization in PAD. There was significant site variability in revascularization patterns, and further studies will better understand the source of this variability and optimal selection criteria for early revascularization. Real world patterns and predictors of early revascularization in peripheral artery disease are not well understood. In this retrospective analysis of the POTRAIT study, about 1 out of 3 patients with PAD symptoms received early revascularization, with significant site variability. A more extensive disease and symptom burden were the main predictors of receiving early revascularization in PAD.

Evaluation of cardiac failure and recovery in acute myelogenous leukemia.

7038 Background: Cardiac failure causes significant comorbidity and death in acute myeloid leukemia (AML) patients, with incidence estimated at 10-15% (Neuendorff N Blood Adv. 2020). We sought to describe the post-treatment cardiac experience in AML survivors including factors associated with onset, persistence, and outcome of cardiac dysfunction during and following treatment. Methods: 86 patients with AML or other high-grade myeloid neoplasms treated with induction chemotherapy with or without allogeneic hematopoietic cell transplant were identified at the University of Washington/Fred Hutchinson Cancer Center from 1/2000-1/2022. All patients sustained cardiac dysfunction, defined as left ventricular ejection function (LVEF) decline of 10% with absolute LVEF below 50% during chemotherapy. A multivariable analysis was performed to compare those who recovered (LVEF recovery) and those who did not (LVEF non-recovery), examining baseline health factors, disease risk (ELN 2017), time to dysfunction and recovery, most probable cause of cardiac dysfunction based on cardiologist evaluation, and goal-directed medical therapy (GDMT) use and dosage. Results: 48% (41 out of 86) failed to recover following LVEF decline. This cohort tended to be older, male, and had more ASCVD risk factors ( p &lt; 0.05). Neither the choice of chemotherapy regimen ( p= 0.43) nor the cumulative anthracycline dose ( p= 0.44) was significantly different between the LVEF recovery and non-recovery groups. Onset of cardiac dysfunction tended to occur later in the LVEF recovery cohort (median 72 vs. 48.5 days, p= 0.660). In subjects who recovered, the median time to recovery was 87 days (range 2-268 days). When chemotherapy was identified as the probable cause, it was associated with greater likelihood of eventual recovery ( p= 0.014), whereas ischemic coronary etiology was associated with non-recovery ( p= 0.005). Failing to recover from cardiac dysfunction correlated with shorter survival (median 229 vs 650 days, p = 0.005). Multivariable analysis is shown in the Table below. Importantly, the use of GDMT with higher doses of renin-angiotensin inhibitor medications (RAASi) were associated with higher probability of recovery (not shown, p &lt; 0.05). Conclusions: The present study demonstrates recovery occurring in over half of AML patients who experienced cardiac dysfunction during their chemotherapy. Recovery was more common in patients whose cardiac dysfunction is precipitated by chemotherapy and in patients who received GDMT with aggressive use of RAASi. Since cardiac recovery was associated with improved survival, next steps include establishing a cardiac monitoring algorithm to initiate early and aggressive GDMT. [Table: see text]

Evaluation of Goal-Directed Medical Therapy and Follow-Up Practice in Patients With Chronic Heart Failure: A Single-Centre Experience

Guideline-directed medical therapy (GDMT) and device therapy are proven to reduce mortality and morbidity for patients with heart failure (HF). This study aimed to evaluate prescribing practice of GDMT and follow-up for patients who reside in the Te Whatu Ora – Waikato region. Heart failure up-titration clinics are run by six HF nurses and details of patients are entered into an Excel database. Four registrars and two house officers extracted clinical details and outcomes from Clinical Workstation (CWS), Te Whatu Ora’s enterprise health system and NZEPS (NZ electronic prescribing system). Data were then analysed with JASP. A total of 642 patients were referred between 1 November 2021 to 31 July 2022. Of 642 referred patients, 69 were non-engaging with the service. A total of 495 (77.1%), 78 (12.2%), and 69 (10.7%) patients had heart failure with reduced ejection fraction, heart failure with mid-range ejection fraction, and heart failure with preserved ejection fraction, respectively. Prescription of beta blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, Entresto, spironolactone, and empagliflozin accounted for 89%, 31%, 58%, 46%, and 7%, respectively. Sixty-five (10%) patients had a left bundle branch morphology. Thirty-six (5.6%) patients had a cardiac resynchronisation therapy device implanted and six (0.9%) had an implantable cardioverter defibrillator implanted. Of the 642 patients, 187 (29%) had post-GDMT echocardiogram performed, of which 76 patients (40.6%) had improvement in their ejection fraction post-GDMT. Spironolactone and device therapy were underutilised in this cohort. A total of 71% of patients had no post-GDMT echocardiogram and 60% of patients who had their echocardiogram done after titration had no improvement in their EF. Further research must be conducted to evaluate reasons for prescribing practice, and follow-up practices to ensure that patients receive adequate follow-up.

Congestive Heart Failure and the Goal-Directed Medical Therapy

Heart failure is one of the top causes of death around worldwide. Heart failure affects approximately 26 million people worldwide today. Considering that obesity, hypertension, diabetes, and smoking all significantly increase the likelihood of heart failure, lifestyle modifications can significantly improve the health of the population. In addition, with an aging population and rising rates of diseases like diabetes and coronary heart disease, it is predicted that the condition’s prevalence and costs would increase. As a condition that threatens life, heart failure must consequently be a worldwide health priority. Heart failure is primarily a treatable medical illness. ACE inhibitors and beta-blockers have been found to lower mortality and hospitalization in the treatment of heart failure. The therapy of heart failure seeks to both prolong life by decreasing the progression of the disease and enhance the quality of life of patients by reducing symptoms. Patient education, diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, beta-blockers, aldosterone antagonists, sodium-glucose cotransporter-2 inhibitors, neprilysin inhibitors, sinus node inhibitors, specialized implantable pacemakers/defibrillators and other devices, and correction of the cause(s) of the HF syndrome are all included in the treatment of heart failure

Novel and emerging therapies in pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH), defined as a mean pulmonary artery pressure exceeding 20 mmHg with a pulmonary vascular resistance of 3 or more Wood units, is an incurable and progressive condition. The cornerstone of PAH treatment is pulmonary vasodilators, which act on the pulmonary vasculature to reduce pulmonary pressures and pulmonary vascular resistance and prevent progression to right heart failure. The number of available pulmonary vasodilator therapies has grown markedly in the last 10 years, alongside a rapidly expanding body of literature establishing strategies for their use. Up-front combination therapy, typically with two pulmonary vasodilator medications, has become the standard of care based on landmark trials showing superior outcomes over single therapies alone. Complex risk stratification matrices have begun to see widespread use as tools with which to guide changes in PAH therapies for individual patients. Strategies for using the pulmonary vasodilators in common use continue to be evaluated in trials exploring concepts such as up-front triple combination therapy and substitution of vasodilators for patients not meeting therapeutic goals. Alongside established pulmonary vasodilator therapies for PAH, there is a broad spectrum of experimental therapies that are being studied for the disease. These include both more conventional medications that act on pathways targeted by existing vasodilator therapies as well as non-vasodilator treatments with novel methods of action, that may act both to vasodilate and to address the detrimental changes of pulmonary arterial and right ventricular remodeling. Many of these emerging medications are the focus of active phase 2 and 3 trials. Finally, there has been significant interest in therapeutic pathways that are well established in left heart failure, with the hope of adapting strategies that may be efficacious in PAH and right heart failure as well. These include explorations of pathways treated by goal-directed medical therapy as well as device therapies such as pacing, resynchronization therapy, and cardiac monitoring devices. Many of these options show promise and may represent a complementary approach to treatment of PAH, allowing for multimodal therapy alongside pulmonary vasodilators to improve patient outcomes.

Abstract 14366: Young, Healthy Female With Myocarditis and Cardiogenic Shock After Mild COVID-19 Infection

Background: We present a case of a young female with no pre-existent conditions, who presented to the hospital one month after a mild COVID-19 infection with severe myocarditis complicated by cardiogenic shock. Case: A 40-year-old female with no prior medical history and a regular, vigorous exercise program developed a mild COVID-19 infection with symptoms of mild fatigue, myalgias, chills, fever, and loss of taste, which resolved within a week. A month later, she presented to the hospital with exertional dyspnea, weakness, chest pressure, abdominal pain, and fatigue. A transthoracic echocardiogram revealed a left ventricular ejection fraction of 15% with a severely dilated left ventricle, global hypokinesis and severe mitral regurgitation. Right heart catheterization demonstrated cardiogenic shock with a cardiac index of 1.4 liters per minute by Fick equation, and she was admitted to the cardiac intensive care unit. Cardiac magnetic resonance revealed subepicardial delayed enhancement along the lateral and inferolateral walls and elevated T1 mapping consistent with myocarditis. A right ventricle biopsy revealed myocyte hypertrophy and patchy interstitial fibrosis without evidence of inflammatory tissue. She was diuresed, supported with inotropic therapy, and empirically treated with high doses of glucocorticoids. She clinically improved with weaning of inotropes and was discharged in stable condition on goal-directed medical therapy after 2.5 weeks. Conclusion: This patient represents a case of severe cardiogenic shock, after initial infection and in the absence of previously identified risk factors for development of COVID myocarditis. The absence of inflammatory tissue on pathology raises questions regarding the centrality of inflammatory processes in COVID-19-related myocardial injury leading to “long COVID” syndrome. These findings indicate the need for ongoing investigation of the long-term cardiovascular consequences of COVID-19.

Abstract 14028: Predictors of Atrial Fibrillation Free Survival in Patients With Implantable Cardiac Devices

Introduction: Improvement of atrial fibrillation (AF) burden can be occasionally observed after pacemaker (PM) implant in patients with tachy-brady syndrome. On the other hand, patients may develop AF after the implant, even without prior history. We studied whether pre-implant parameters affect the risk of death or AF after device implant. Methods Data from 200 consecutive patients who underwent Medtronic dual (DDD) or triple chamber/cardiac resynchronization therapy (CRT) PM or ICD implants were analyzed. Pre-implant data included demographics, vitals, medications, comorbidities, labs, EKG, characteristics of any prior AF, echocardiographic parameters, and planned device type. Follow-up duration was planned as 12 months; survival and AF data (episodes &gt;5 minutes) were collected from device follow-up data. Survival analysis was performed for death and first AF occurrence. Results Average age was 75±10 years, 37% were female. Comorbidities included history of AF (26% paroxysmal, 13.5% persistent), coronary artery disease 48.5%, hypertension 83.5%, diabetes 37.5%, sleep apnea 26%, drug or alcohol abuse 12.5%, heart failure 43%, prior cerebrovascular event 9.5%. PM was implanted in 70%, ICD in 30% of patients; DDD devices in 83.5%, CRT in 16.5%.Follow-up duration was 338±111 days, mortality was 13%, 38.5% of patients had new onset or recurrent AF. There was no difference in mortality between the PM vs. ICD group (11.4% vs. 16.7%, p=0.597) and the DDD vs. CRT group (12.6% vs. 15.2%, p=0.781). The cumulative AF incidence was higher in the PM vs. ICD group (46.7% vs. 21.7%, p=0.037) and in the DDD vs. CRT group (41.9% vs. 21.2%, p=0.039). Conclusion: The type of implanted device, guided by pre-implant clinical parameters affects post-implant AF occurrence. Although ICDs and CRT are utilized in sicker patients, these groups had better AF outcomes - beneficial effects of cardiac resynchronization and routine use of goal-directed medical therapy in these patients prior to and after the implant may play a role.