Had HF With Preserved Ejection Fraction Research Articles

Long-term Efficacy of Pulmonary Artery Desnervation Treatment in Heart Failure With Preserved Ejection Fraction: A Subgroup Analysis of 3-year Results From the PADN-5 Study

Objective: The Pulmonary Arterial Denervation in Patients With Pulmonary Hypertension Associated With the Left Heart Failure (PADN-5) study proved that pulmonary artery denervation (PADN) is associated with significant improvements in hemodynamic and clinical outcomes in patients with combined pre- and post-capillary pulmonary hypertension (CpcPH). This study aimed to assess the 3-year clinical results of PADN in patients who had heart failure with preserved ejection fraction (HFpEF) developing into CpcPH (HFpEF-CpcPH). Methods: In this post hoc analysis of the PADN-5 trial, 38 patients with HFpEF were included in screening out of 98 patients with CpcPH who were randomly assigned to treatment with sildenafil and sham PADN (sham PADN (plus sildenafil) group, abbreviated as sham group) or PADN (PADN group). HFpEF in the PADN-5 trial was defined as a left ventricular ejection fraction ≥50%, and CpcPH was defined as a mean pulmonary arterial pressure ≥25 mmHg, a pulmonary arterial wedge pressure >15 mmHg, and a pulmonary vascular resistance >3.0 WU. The changes in the 6-minute walk distance (6-MWD) and the plasma concentration of N-terminal pro-brain natriuretic peptide (NT-proBNP) at 6-month and 3-year follow-up, as well as the clinical endpoint of the occurrence of clinical worsening, defined as cardiopulmonary-related death, rehospitalization, or heart or lung transplantation at 3-year follow-up were examined. Results: Thirty-eight patients with HFpEF-CpcPH were assigned to the PADN group (n = 19) or the sham group (n = 19). At the 6-month follow-up, 6-MWD (433 (275, 580)m vs. 342 (161, 552)m), and reductions in NT-proBNP (−47% (−99%, 331%) vs. −12% (−82%, 54%)) were significantly improved in the PADN group (all P < 0.05). Over the 3-year follow-up period, PADN treatment resulted in marked increases in 6-MWD (450 (186, 510)m vs. 348 (135, 435)m) and reductions in NT-proBNP (−55% (−99%, 38%) vs. −10% (−80%, 95%)) (all P < 0.05). Clinical worsening was experienced by 12 patients (63%) in the sham group, but by only 5 patients (26%) in the PADN group (hazard ratio = 0.149, 95% confidence interval: 0.038–0.584, P = 0.006). The 6-MWD and PADN treatments were independent predictors of clinical deterioration in patients with HFpEF-CpcPH. Conclusions: PADN therapy is associated with improvements in exercise capacity and clinical outcomes. PADN therapy may have a potential role in patients with HFpEF-CpcPH for whom current treatment options are limited.

Iron deficiency in new onset heart failure: association with clinical factors and quality of life.

The prevalence of iron deficiency (ID) in newly diagnosed heart failure (HF) and the progression of ID in patients after initiation of HF therapy are unknown. We aimed to describe the natural trajectory of ID in patients with new onset HF during the first year after HF diagnosis, assessing associations between ID, clinical factors, and quality of life (QoL). A prospective cohort of patients with new onset HF in hospitals or outpatient clinics at five major hospitals in Stockholm, Sweden, during 2015-2018 were analysed with clinical assessment, electrocardiogram, blood samples including iron levels, Minnesota living with heart failure questionnaire (MLHFQ), and echocardiogram at baseline and after 12months. Of 547 patients with new-onset HF, 482 (88%) had complete iron data at baseline. Median age was 70years (interquartile range 61-77) and 311 (65%) were men; 55% of patients had ejection fraction (EF)≤40%, 19% had EF 41-49%, and 26% had HF with preserved EF (HFpEF) [Correction added on 26 June 2024, after first online publication: The 'Mean age was 70 years' has been corrected to 'Median age was 70 years' in this version.]. At baseline, 163 patients (34%) had ID defined as ferritin <100μg/L or ferritin 100-299μg/L and transferrin saturation <20%. After 12months of follow-up, 119 (32%) had ID of the 368 patients who had complete iron data both at baseline and after 12months and did not receive intravenous (i.v.) iron during follow-up. During the first year after HF diagnosis, 19% had persistent ID, 13% developed ID, 11% resolved ID, and 57% never had ID, consequently 24% changed their classification. Anaemia at baseline was the strongest independent predictor of ID 1year after diagnosis [odds ratio (OR) 3.91, 95% confidence interval (CI) 1.88-8.13, P<0.001], followed by HF hospitalization (OR 2.21, 95% CI 1.24-3.95, P<0.01), female sex (OR 2.04, 95% CI 1.25-3.32, P<0.01), HFpEF (OR 1.96, 95% CI 1.13-3.39, P<0.05), and diabetes mellitus (OR 1.92, 95% CI 1.06-3.48, P<0.05). ID was associated with low QoL at baseline (MLHFQ score mean difference 7.4 points, 95% CI 3.1-11.7, P<0.001), but not at follow-up. About one third of patients with new onset HF had ID both at the time of HF diagnosis and after 1year, though a quarter of the patients changed their ID status. Patients with anaemia, HF hospitalization, female gender, HFpEF, or diabetes mellitus at baseline were more likely to have ID after 1year implying that these should be carefully screened for ID to find those in need of i.v. iron treatment.

Epidemiology of acute heart failure admissions in Iceland: phenotype distribution and prognostic implications

Abstract Background/Introduction Contemporary data that describe underlying causes of acute heart failure (AHF) epidemiology in a nation-wide unselected real-life cohort is lacking. Advances in diagnostics, including imaging and genetics, have facilitated the identification of the underlying cause of heart failure (HF). This is the first Icelandic nation-wide study on HF epidemiology of patients hospitalised for AHF. Purpose Investigate the underlying causes of AHF in Iceland and the patients‘ prognosis according to phenotypes. Methods This study used data from the Icelandic Heart Failure Registry (IHFR) and included all hospital admissions for AHF at Landspitali University Hospital from January 2020 to June 2022 (n = 1723). Differences in survival between HF phenotypes were analysed using a multivariate log-rank test, both after diagnosis and after the first discharge. Results The study found that 39.8% of the cases had heart failure with reduced ejection fraction (HFrEF), 17.4% had HF with mildly reduced ejection fraction (HFmrEF), 40.3% had HF with preserved ejection fraction (HFpEF), 0.9% had HF with improved ejection fraction (HFimpEF), and 1.5% had unknown ejection fraction (EF). The average length of hospital admission varied by phenotype, ranging from 8.1 to 15.9 days. Women accounted for 41.15% of all admissions, with the most common phenotype amongst women being HFpEF (57.8%) and the least common being HFrEF (25.1%). The mean age at admission was 75.8 years. Roughly 79% of the whole cohort had NYHA class III-IV at admission; 33% of HFrEF, 13% of HFmrEF and 32% of HFpEF admissions. The most common underlying cause of AHF was coronary artery disease (CAD, 30.9%) followed by atrial fibrillation (15.0%), hypertension (9.8%), diastolic dysfunction (9.4%) and valvular heart disease (9.2%). Other more rare causes were dilated cardiomyopathy (4.4%), amyloidosis (3.2%), broken heart disease (1.5%), myocarditis (0.4%), postpartum cardiomyopathy (0.2%) and Fabry disease (0.1%). During the study period, 422 mortalities were recorded, with 106 in-hospital deaths. After excluding in-hospital mortalities, no significant difference in survival between phenotypes was observed after the first discharge. However, a significant difference in survival was observed with respect to the date of diagnosis (p = 0.0191). Conclusion This study provides new insights into the underlying causes of AHF and patients' prognosis according to phenotypes in Iceland. Our results demonstrate that the most common underlying cause of AHF was CAD, followed by atrial fibrillation and hypertension and that the cohort was highly symptomatic, with a large proportion of patients having NYHA class III-IV at admission. Our findings also highlight significant differences in the prevalence of HF phenotypes between genders, with women more commonly presenting with HFpEF and less commonly with HFrEF.

Abstract 12299: Sex Differences in the Outcomes of Patients With Heart Failure Undergoing Catheter Ablation for Atrial Fibrillation

Introduction: There is a lack of data on the impact of sex on the outcomes of patients with heart failure (HF) undergoing atrial fibrillation (AF) ablation. Hypothesis: We hypothesized that outcomes of patients with HF undergoing AF ablation differ between males and females and tested this hypothesis using data from a nationally representative sample of the US population. Methods: The National Readmissions Database (NRD) was analyzed from 2016-2019 to identify patients ≥ 18 years old undergoing AF ablation. Patients were then divided into two cohorts based on their sex. A multivariable logistic regression model was used to adjust for confounders. Results: A total of 21,439 patients with HF underwent AF ablation between 2016-2019, of which 8,103 had heart failure with preserved ejection fraction (HFpEF) [64.8% were females], and 13,336 had heart failure with reduced ejection fraction (HFrEF) [38.4% were females]. Crude outcomes are shown in Figure 1. After multivariate adjustment, among patients with HFrEF, females had a longer length of stay (adjusted mean difference (aMD): 0.55 (0.16-0.93) days longer, p&lt;0.01) along with lower odds of routine home discharge (adjusted odds ratio (aOR):0.62; 95% confidence interval (CI):0.55-0.70; p&lt;0.01). Females had similar odds of in-hospital mortality, procedural complications, and 30-day/ 180-day all-cause, heart failure, and arrhythmia-related readmissions as compared to males. Among patients with HFpEF, females had higher odds of 30-day (aOR: 1.91; 95% CI: 1.24-2.93; p&lt;0.01) and 180-day heart failure readmissions (aOR: 1.53; 95% CI: 1.04-2.28; p=0.03) along with lower odds of routine home discharge (aOR:0.67; 95% CI: 0.57-0.78; p&lt;0.01), as compared to males. Conclusion: In conclusion, our results show that females with HFrEF undergoing AF ablation have similar odds of in-hospital/30-day/180-day outcomes whereas females with HFpEF have higher odds of 30-day/180-day HF readmissions, as compared to males.

Abstract 13469: A Comprehensive Echocardiographic Assessment of Patients With Chronic Myeloid Leukemia on Dasatinib

Background: Dasatinib, a tyrosine kinase inhibitor used in the treatment of chronic myeloid leukemia (CML), is known to cause cardiotoxicities; however, little is known about the echocardiographic changes associated with this drug. Here we present a comprehensive echocardiographic assessment of patients with CML on dasatinib receiving care at a quaternary facility. Methods: We performed a retrospective cohort analysis on consecutive adult patients with CML receiving dasatinib between 2017-2022 who had a baseline and follow-up echocardiogram. Comprehensive clinical, laboratory and advanced echocardiographic data with speckle-tracking analyses (Tomtec Arena, Germany) were included. Results: Among 41 adult patients with CML (average age 64±16 years old, 39% female) who were prescribed with dasatinib (initial dose 100mg once daily), at baseline, 7 (17%) patients had heart failure with preserved ejection fraction (HFpEF), 11 (27%) coronary artery disease, and 3 (7%) pulmonary hypertension. There was a statistically significant increase in the indexed LV end-diastolic diameter and LV mass in pre- vs post-dasatinib echocardiograms; however, there was no significant change in ejection fraction or global longitudinal strain. There was no significant change in RV structure or function measures. There was a significant increase in LA volume index and decrease in lateral e’ velocity in pre- vs post-dasatinib echocardiograms. A trend towards declining LA reservoir strain post-dasatinib was noted. Ten (24%) patients had a progression in diastology grading after the initiation of dasatinib. Five out of 7 patients with HFpEF at baseline had progression in diastolic function post-dasatinib. Conclusions: Dasatinib was associated with significant changes in LV end-diastolic diameter, LV mass, LA volume, and diastolic parameters in patients with CML. These findings require further corroboration with a larger patient cohort and correlation with clinical outcomes.

Abstract 14276: Using Artificial Intelligence and Natural Language Processing on Electronic Health Records of Heart Failure Patients to Examine the Impact of Estimated Glomerular Filtration Rate Trend on Mortality

Introduction and Hypothesis: Heart failure (HF) often leads to an imbalance between heart and kidney function, with a poor prognosis in HF patients linked to dynamic changes in renal function as well as chronic kidney disease (CKD). This study aimed to determine the incidence of reduced renal function upon HF diagnosis and to explore the potential for dynamic changes in kidney function to predict short- and long-term outcomes in a real-world cohort of HF patients. Methods: Clinical data of patients with a diagnosis of HF (index event) were gathered retrospectively using natural language processing. Patients were classified as having CKD based on their eGFR (&lt;60 mL/min/1.73m2) and a history of CKD and/or dialysis. eGFR trajectories were analyzed using linear mixed effects models. Cox proportional hazard models were used to analyze the relationship between baseline variables and mortality. Joint modeling was employed to assess the relationship between the eGFR trend and mortality. Results: There were 1986 patients in the study population, with a mean (SD) age of 74.8 ± 11.7 years and 58% of males. At the index event, 58% (n = 1156) had CKD, and 17% (n = 339) had HF with preserved ejection fraction (HFpEF). Median follow-up was 3.16 years. After 2 years, 10% (n = 198) of the patients had passed away. The proportion of CKD at index was considerably lower in the 2-year survivors group (55% vs 76%, p &lt; 0.001) in this group. The calculated mean annual eGFR reduction was 4.2 mL/min/1.73m 2 . Age, CVA, diastolic blood pressure, hemoglobin, HDL, potassium, and NT-proBNP levels in blood serum were found to be the primary predictors of mortality in multivariate Cox PH model. Joint modeling revealed that a current eGFR value that was 10 mL/min/1.73m 2 lower between patients corresponded with a higher mortality hazard of 1.22 ± 0.05 (p &lt; 0.001). In addition, a drop in eGFR of 10 mL/min/1.73m 2 over the previous year showed an the elevated mortality hazard of 1.97 ± 0.16 (p &lt; 0.001). Conclusions: We show that the prevalence of CKD is significant in a real-world population of HF patients, and CKD is a standalone predictor of mortality. Current eGFR value and the eGFR slope from the previous year have a potential to be used for individual mortality hazard assessment in the clinical follow-up of HF patients.

Prognostic Significance of Serum Chloride Level Reduction in Patients with Chronic Heart Failure with Different Ejection Fractions.

Little is known regarding the prognostic value of serum chloride in patients with chronic heart failure (CHF) with different ejection fractions. We sought to determine the postdischarge outcomes associated with lower serum chloride between different CHF types.We reviewed the medical records of 1221 consecutive patients with CHF admitted to the First Affiliated Hospital of Kunming Medical University from January 2017 to October 2021. After excluding patients with in-hospital death, missing follow-up data, missing serum chloride level data, or chronic dialysis therapy, 791 patients were included. Of these patients, 343 had heart failure with reduced ejection fraction (HFrEF; i.e., left ventricular ejection fraction (LVEF) < 40%), and 448 had heart failure with preserved ejection fraction (HFpEF) or heart failure with median ejection fraction (HFmrEF; HFpEF plus HFmrEF; i.e., LVEF ≥40%). Over a median follow-up of 750 days, 344 patients (43.5%) had all-cause mortality. In the univariate analysis, serum sodium and chloride were strongly associated with mortality in both HF subgroups (P < 0.0001). A multivariable model including both serum sodium and chloride showed the highly significant association between serum chloride and survival (P < 0.0001), whereas the association between serum sodium and mortality was not reported (HFpEF plus HFmrEF, hazard ratio (HR) 0.975, 95% confidence interval [CI] 0.942-1.010, P = 0.158; HFrEF, HR 1.007, 95% CI 0.966-1.051, P = 0.734). Kaplan-Meier survival curve analysis revealed a significant difference in mortality risk with decreasing chloride levels in all patients with CHF. The optimal cutoff value of chloride in predicting all-cause mortality was 102.95 mmol/L with area under the curve value of 0.76 [HR 0.760, 95% CI 0.727-0.793, P < 0.0001], sensitivity of 60.2%, and specificity of 78.3%.Lower serum chloride is an independent predictor of death in CHF, regardless of heart failure subtype.

Beneficial Effects of Dipeptidyl Peptidase-4 Inhibitors on HeartFailureWith Preserved EjectionFraction and Diabetes.

Dipeptidyl peptidase-4 (DPP-4) inhibitors have been shown to exert pleiotropic effects on heart failure (HF) in animal experiments. This study sought to investigate the impact of DPP-4 inhibitors on HF patients with diabetes mellitus (DM). We analyzed hospitalized patients with HF and DM enrolled in the JROADHF (Japanese Registry Of Acute Decompensated HeartFailure) registry, a nationwide registry of acute decompensated HF. Primary exposure was the use of a DPP-4 inhibitor. The primary outcome was a composite of cardiovascular death or HF hospitalization during the median follow-up of 3.6 years according to left ventricular ejection fraction. Out of 2,999 eligible patients, 1,130 had heart failure with preserved ejection fraction (HFpEF), 572 had heart failure with midrange ejection fraction (HFmrEF), and 1,297 had heart failure with reduced ejection fraction (HFrEF). In each cohort, 444, 232, and 574 patients received a DPP-4 inhibitor, respectively. A multivariable Cox regression model showed that DPP-4 inhibitor use was associated with a lower composite of cardiovascular death or HF hospitalization in HFpEF (HR: 0.69; 95%CI: 0.55-0.87; P = 0.002) but not in HFmrEF and HFrEF. Restricted cubic spline analysis demonstrated that DPP-4 inhibitors were beneficial in patients with higher left ventricular ejection fraction. In HFpEF cohort, propensity score matching yielded 263 pairs. DPP-4 inhibitor use was associated with a lower incidence rate of the composite of cardiovascular death or HF hospitalization (19.2 vs 25.9 events per 100 patient-years; rate ratio: 0.74; 95%CI: 0.57-0.97; P = 0.027) in matched patients. DPP-4 inhibitor use was associated with better long-term outcomes in HFpEF patients with DM.

Proportion, Precipitators and Prognostic Marker of 30-Day Heart Failure Readmission at MOI Teaching and Referral Hospital, Eldoret, Kenya

Background: Heart failure (HF) affects 26 million people globally. It is associated with a high 30-day readmission rate due to multiple cardiovascular and non-cardiovascular precipitants. Readmissions are associated with high mortality, which may be predicted by pre-discharge N-terminal pro brain natriuretic peptide (NT-proBNP). There is no data on HF readmission rates, its precipitators and use of NT-proBNP as a prognostic marker at Moi Teaching and Referral Hospital (MTRH) in Western Kenya. Objective: To determine the 30-day proportion of HF readmission, the precipitators of HF and the association between NT-proBNP and 30 days’ readmission. Methods:This was a six-month prospective cohort study where we carried out a census and recruited adult participants admitted with HF at Moi Teaching and Referral Hospital. At discharge from hospital, an interviewer administered questionnaire was administered and blood samples for NT-proBNP drawn. Upon readmission, precipitators for HF were identified and compliance to therapy assessed using European heart failure Self Care Behavioral Scale. Continuous variables were summarized using median and IQR, categorical variables using frequencies and percentages. Associations were determined using Chi square, Fishers exact and Wilcoxon rank test. A p-value of &lt;0.05 was considered statistically significant. Results: From April to November 2018, 94 participants were recruited into the study; with median age 48 years (IQR 31,70), 58 (62%) were female, 35 (38%) consumed alcohol and 25(25%) smoked. Hypertension was the commonest comorbidity 20 (21%) while cardiomyopathy was the underlying etiology for HF in 58 (63%). HF with reduced Ejection Fraction (HFrEF) was present in 76% of the participants while 24% had HF with preserved Ejection Fraction (HFpEF). Sixty percent of the participants had NT-proBNP levels of &gt;4137 pg/ml, which implied poor prognosis. Of 17 readmitted patients, 12 participants (12.8%) were readmitted within 30 days at MTRH. Six (6.4%) participants were lost to follow up. Median time to readmission was 14 days, (IQR 7, 26). Pneumonia (55%) was the commonest precipitator of HF readmissions, followed by arrhythmias (atrial fibrillation) in 5 (42%), anemia 4 (33%), noncompliance 4 (33%), acute kidney injury 2 (16.6%) and no identified precipitator 1 (8.3%). There was no association between NT-proBNP and readmission (p =0.584) or NT-pro BNP and survival (p=0.773). Readmission was associated with a high mortality (p=0.008) with 50% of readmitted participants dying during the readmission period. The total mortality of both readmitted and non-readmitted participants was 16% at the end of the 6 months’ study period. Conclusions:In this cohort of participants with HF the proportion of 30 days readmission was high. Infections, mainly pneumonia was the commonest precipitator of readmission. Discharge NT-proBNP did not predict likelihood of 30 days’ readmission. Mortality was higher among participants readmitted within 30 days. Recommendations: Measures like pneumoccal vaccinations should be implemented to prevent pneumonia. Early appointments to cardiac clinic (less than 2 weeks post discharge) should be given to screen for precipitators and reduce HF readmissions. A follow up study to assess % change in NT pro BNP in relation to 30 days readmission.

24-Hour Holter Monitoring for Identification of Arrhythmias in Elderly Heart Failure Patients: A Single-Centre Study.

Introduction Chronic heart failure (CHF)is a commoncondition seen in the elderly, and unlike coronary artery disease (CAD), its prevalence increases with age. Electrocardiography (ECG) at rest is a simple, non-invasive investigation that is recommendedin the initial evaluation of patients with heart failure. The purpose of this study was to identify various ECG abnormalities in elderly patients with heart failure and to find out whether Holter monitoring increases the chances of identifying arrhythmia in them. Materials and methods The current study was a single-centre, cross-sectional observational study. The study was conducted by collecting data from patients with heart failure attending the medicine and cardiology departments of All India Institute of Medical Sciences, Rishikesh, a tertiary care facility, from May 1st, 2020, to October 31st, 2021. The goal of this study was to look for electrocardiographic abnormalities in elderly heart failure patients who had a reduced (<50%) or preserved (>=50%) left ventricular ejection fraction (LVEF). All consecutively admitted patients who fulfilled the inclusion criteria were enrolled in the study after taking informed consent. All patients underwent echocardiography, electrocardiography and Holter monitoring. Demographic parameters were collected on a pre-formed proforma, and data was entered into an Excel sheet. Results A total of 101 patients were analyzed, and abnormal ECG results were found in 98% of them. Out of 101 patients,80 (79.2%) patients hadheart failure with reduced ejection fraction (HFrEF), withLVEF < 50%,and 21 (20.8%) patients had heart failure with preserved ejection fraction (HFpEF), with LVEF >=50%. Hypertensive heart disease was the most common etiological factor attributing to heart failurein 37 (36.6%) patientsand more among heart failure with reduced EF (p=0.01) followed by ischemic heart disease. Old ischemic changes were the commonest ECG abnormality, found in 48 (47.53%) patients with heart failure and among 45 patients (56.25%) with HFrEF (p=<0.001 ). Atrial fibrillation was the most common arrhythmia, occurring in 25 (24.75%) patients with heart failure. The detection rate of arrhythmia by Holter was better than surface ECG in patients with HErEF (p=0.007). Conclusion Electrocardiogram (ECG) in elderly heart failure patients is almost always abnormal. The majority of the patients in our study had more than two ECG abnormalities. ECG is a simple non-invasive tool that can detect underlying etiological factors attributing to heart failure. Holter monitoring can be done as an additional modality to detect arrhythmias in heart patients with reduced ejection fraction for risk stratification.

Abstract 11165: Characterization of Heart Failure Patients in an Academic Home Hospital Program and Identification of Patient Factors Requiring Escalation of Care

Background: Hospital capacity concerns exacerbated by the COVID-19 pandemic have accelerated growth of hospital at home (HaH) programs. However, for HaH admissions related to heart failure, information on patient characteristics and clinical outcomes remain sparse. We aimed to better characterize heart failure admissions in a HaH model and assess characteristics of patients who later needed escalation of care to a traditional hospitalization. Methods: This retrospective, descriptive study examined HaH admissions for heart failure at an academic medical center between 2017 and 2022. We compared baseline characteristics and outcomes using the Chi-squared test for categorical variables and t-test for continuous variables for patients who required escalation of care to those who did not. Using the same methods, we also compared patients based on their location prior to admission (e.g. emergency department (ED), home). Results: Heart failure was the primary diagnosis for 32% of HaH admissions. The majority of the heart failure cohort (N=199, average age 80.6 years), 73.9%, had heart failure with preserved ejection fraction (HFpEF). Escalation of care to traditional hospitalization was required for 22.6% of patients. 9.0% of patients died within 90 days, and 20.1% and 36.2% of patients were readmitted for any reason within 30 and 90 days respectively. Patients whose care was escalated were more likely to have a history of chronic kidney disease (84.1% vs 66.9%, p=0.043), higher admission BUN (41.5 vs 31.1, p=0.004) and creatinine (1.74 vs 1.41, p=0.011), and a history of PCI (20.5% vs 5.3%, p=0.005). Patients referred directly from home compared to the ED had similar baseline characteristics and rates of 90 day inpatient readmission and mortality. Conclusions: Patients admitted to HaH for heart failure represent a high risk cohort who are commonly older with multiple comorbidities and more likely to have HFpEF. Among this cohort, patients with kidney dysfunction and/or history of percutaneous coronary intervention are more likely to require escalation of care. These results suggest that heart failure patients admitted to HaH who will later need traditional hospitalization could be identified prospectively using these characteristics.

Incident Heart Failure With Mildly Reduced Ejection Fraction: Frequency, Characteristics, and Outcomes

Heart failure (HF) with an ejection fraction (EF) of 41%-49% is recognized as HF with a mildly reduced EF (HFmrEF). However, existing knowledge of the HFmrEF phenotype is based on HF clinical trial and registry cohorts that may be limited by multiple forms of bias. In a community-based, retrospective cohort study, adult residents of Olmsted County, Minnesota, with validated (Framingham criteria) incident HF from 2007 to 2015 were categorized by echocardiographic EF at first HF diagnosis. Among 2035 adults with incident HF, 12.5% had HFmrEF, 29.9% had HF with reduced EF (HFrEF), and 57.6% had HF with preserved EF (HFpEF). Mean age and sex varied by EF group, with HFmrEF (75.6 years, 45.3% female), HFrEF (70.9 years, 36.5% female), and HFpEF (76.9 years, 59.7% female). Most comorbid conditions were more common in HFmrEF vs HFrEF, but similar in HFmrEF and HFpEF. After a mean follow-up of 4.6 ± 3.5 years, adjusting for age, sex, and comorbidities, the risks of hospitalization and cardiovascular mortality did not differ by EF category. Of patients who began as HFmrEF, 26.9% declined to an EF of 40% or less and 44.8% improved to an EF of 50% or greater. In this community cohort of incident HF, 12.5% have HFmrEF. Clinical characteristics in HFmrEF resemble HFpEF more than HFrEF. Adjusted hospitalization and mortality risks did not vary by EF group. Patients with incident HFmrEF usually transitioned to a different EF category on follow-up.

Intravenous metoprolol versus diltiazem for atrial fibrillation with concomitant heart failure

PurposeAtrial fibrillation (Afib) with rapid ventricular response (RVR) is acutely treated with intravenous push (IVP) metoprolol (MET) or diltiazem (DIL). In heart failure (HF) patients, diltiazem is not recommended due to negative inotropic effects. Studies comparing the treatment of atrial fibrillation often exclude HF. Hirschy et al. evaluated HF patients with concomitant Afib with RVR who received IVP metoprolol or diltiazem to determine their effectiveness and safety. They found similar safety and effectiveness outcomes between the two groups. MethodsThis retrospective, IRB-approved study evaluated patients presenting to the emergency center (EC) with Afib with RVR and HF from January 1, 2018 to July 31, 2021. Included patients were 18 years of age or older, received IVP metoprolol or diltiazem in the EC, and had a recorded baseline ejection fraction (EF). The primary effectiveness outcome was successful heart rate (HR) control 30 min after treatment with either IVP metoprolol or diltiazem, which was defined as HR <100 beats per minute (bpm). Secondary effectiveness outcomes included HR control 60 min post-IVP and at EC discharge or transfer and HR reduction >20% at 30 min after IVP, 60 min after IVP, and at time of discharge or transfer. Other secondary outcomes included the time to adequate HR control, the total dose of IVP metoprolol or diltiazem given, any additional rate-controlling agents given, and crossover between metoprolol and diltiazem. Safety outcomes included bradycardia, hypotension, shortness of breath, increased oxygen requirements, change in EF, acute kidney injury or renal replacement therapy. ResultsOf 2580 evaluated, 193 patients were included (134 DIL vs. 59 MET) with age 73.3 ± 12.2 years, 63% female. The average EF was 48.2 ± 14.2% and 30% of patients had heart failure with reduced ejection fraction (HFrEF) while 64% had heart failure with preserved ejection fraction (HFpEF). Effective heart rate control 30 min post-IVP was not different between the two groups (55% DIL vs. 41% MET, p = 0.063). DIL effectively controlled HR quicker than MET (13 [9, 125] DIL vs. 27 [5, 50] MET, min, p = 0.009). DIL resulted in greater HR reductions at 30 min (33.2 ± 25.4 DIL vs. 19.7 ± 19.7 MET, bpm, p < 0.001) and at 60 min (31 ± 23.5 DIL vs. 19.6 ± 19.1 MET, bpm, p = 0.002). DIL also more frequently resulted in a HR reduction of 20% or greater at 30 min (63% DIL vs. 27% MET, p < 0.001), 60 min post-IVP (59% DIL vs. 41% MET, p = 0.019), and at time of patient discharge or transfer from the EC (70% DIL vs. 49% MET, p = 0.005). No differences in safety outcomes were identified. ConclusionAcute management of patients with Afib with RVR and HF is challenging. While successful rate control at 30 min was not significantly different between diltiazem and metoprolol, IVP diltiazem reduced HR more quickly and reduced HR by 20% or greater more frequently than IVP metoprolol with no safety outcome differences. Further studies are needed to evaluate diltiazem's safety in patients with Afib and HF.

Clinical features and long-term prognosis of patients with congestive heart failure taking tolvaptan: a comparison of patients with preserved and reduced left ventricular ejection fraction

Few studies have investigated the clinical benefit of the long-term use of tolvaptan (TLV) for heart failure (HF). This study evaluated the long-term prognosis of patients administered TLV for > 1 year among patients who had HF with preserved ejection fraction (HFpEF) and those who had HF with reduced ejection fraction (HFrEF). Overall, 591 consecutive patients were admitted to our hospital and administered TLV for HF between 2011 and 2018. We retrospectively enrolled 147 patients who were administered TLV for > 1 year. We divided them into the HFpEF group (n = 77, 52.4%) and the HFrEF group (n = 70; 47.6%). Their clinical backgrounds and long-term prognosis were examined. Compared with the patients in the HFrEF group, the patients in the HFpEF group were significantly older and included more women. Moreover, the HFpEF group showed significantly lower all-cause mortality (38.6% vs. 24.7%; log-rank, P = 0.014) and cardiovascular mortality during the average 2.7-year follow-up. Univariate analysis revealed that all-cause mortality was correlated with male sex, HFpEF, and changes in serum creatinine levels from baseline. Multivariate analysis revealed that HFpEF was an independent influencing factor for all-cause mortality (hazard ratio, 0.44; 95% confidence interval, 0.23–0.86; P = 0.017). Long-term administration of TLV may be more beneficial for HFpEF than for HFrEF.

Temporal trends and outcomes in utilisation of transcatheter and surgical aortic valve therapies in aortic valve stenosis patients with heart failure.

Heart failure (HF) is a common comorbidity in patients undergoing surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). We sought to access the temporal trends and outcomes of TAVR or SAVR in HF patients. The NIS database from 2011-2014 was queried for patients that underwent TAVR or SAVR and were subsequently diagnosed with HF. Temporal trends in the utilisation of TAVR or SAVR in HF patients were analysed. Among 27982 patients who were diagnosed with HF of whom 17681 (63.2%) had heart failure with reduced ejection fraction (HFrEF) while 10301 (36.8%) had heart failure with preserved ejection fraction (HFpEF), 9049 (32.3%) underwent TAVR and 16933 (76.7%) underwent SAVR. Patients with HFrEF and HFpEF had higher utilisation of TAVR compared with SAVR over the course of the study period (P trend<.001). TAVR was associated with lower mortality [2.8% in 2012 and 1.8% in 2014 (P .013)] compared with SAVR. Similarly, multiple logistic regression showed a statistically significant lower in-hospital mortality in the TAVR group compared with SAVR (aOR 0.634; CI 0.504, 0.798, P<.001). For patients with severe aortic valve stenosis and heart failure who undergo aortic valve intervention, TAVR is associated with less odds of in-hospital mortality compared with SAVR.

Impact of catheter ablation in patients with atrial flutter and concurrent heart failure.

BackgroundNo studies assessed impact of atrial flutter (AFL) ablation on outcomes in patients with AFL and concurrent heart failure (HF).ObjectivesTo assess the effect of AFL ablation on mortality and HF readmissions in patients with AFL and HF.MethodsThis retrospective cohort study identified 15,952 patients with AFL and HF from the 2016–17 Nationwide Readmissions Database. The primary outcome was a composite of all-cause mortality and/or HF readmission at 1 year. Secondary outcomes included HF readmission, all-cause mortality, and atrial fibrillation (AF) readmission at 1 year. Propensity score match (1:2) algorithm was used to adjust for confounders. Cox proportional hazard regression was used to generate hazard ratios.ResultsOf the 15,952 patients, 9889 had heart failure with reduced ejection fraction (HFrEF) and 6063 had heart failure with preserved ejection fraction (HFpEF). In the matched HFrEF cohort (n = 5421), the primary outcome was significantly lower in patients undergoing ablation (HR 0.72, 95% CI 0.61–0.85, P < .001). HF readmission (HR 0.73, 95% CI 0.61–0.89, P = .001), all-cause mortality (HR 0.62, 95% CI 0.46–0.85, P = .003), and AF readmission (HR 0.63, 95% CI 0.48–0.82, P = .001) were also significantly reduced. In the matched HFpEF cohort (n = 2439), the primary outcome was lower in the group receiving ablation but was not statistically significant (HR 0.80, 95% CI 0.63–1.01, P = .065).ConclusionIn patients with AFL and HFrEF, AFL ablation was associated with lower mortality and HF readmissions at 1 year. Patients with AFL and HFpEF did not show a similar significant reduction in the primary outcome.

Catheter Ablation for Atrial Fibrillation in Patients With Concurrent Heart Failure

Due to limited real-world data, the aim of this study was to explore the impact of catheter ablation (CA) for atrial fibrillation (AF) in heart failure (HF). This retrospective cohort study identified 119,694 patients with AF and HF from the Nationwide Readmissions Database (NRD) from 2016 to 2017. Propensity-matching was generated using demographics, comorbidities, hospital and other characteristics through multivariate logistic regression. Greedy's propensity score match (1:15) algorithm was used to create matched data. The primary end point was a composite of HF readmission and mortality at 1 year. Secondary outcomes include HF readmission, mortality, AF readmission, and any-cause readmission at 1 year. Of the 119,694 patients, 63,299 had HF with reduced ejection fraction (HFrEF), and 56,395 had HF with preserved ejection fraction (HFpEF). In the overall HFrEF cohort, the primary outcome was similar (HR, 95% confidence interval, p-value) (1.01, 0.91 to 1.13, 0.811). AF readmission (0.41, 0.33 to 0.49, <0.001) and any readmission (0.87, 0.82 to 0.93, <0.001) were reduced with CA. In the propensity-matched HFrEF cohort, results were unchanged (primary outcome: 1.10, 0.95 to 1.27, 0.189; AF readmission: 0.46, 0.36 to 0.59, <0.001; any readmission: 0.89, 0.82 to 0.98, 0.015). In the overall HFpEF cohort, the primary outcome was similar (0.90, 0.78 to 1.04, 0.154). AF readmission was reduced with CA (0.54, 0.44 to 0.65, <0.001). In the propensity-matched HFpEF cohort, results were unchanged (primary outcome 1.10, 0.92 to 1.31, 0.289; AF readmission 0.44, 0.33 to 0.57, <0.001). CA did not reduce mortality and HF readmission at one year irrespective of the type of HF, but significantly reduce readmission due to AF.

Heart Failure With Type 2 Diabetes Mellitus: Association Between Antihyperglycemic Agents, Glycemic Control, and Ejection Fraction.

Background: Heart failure (HF) is associated with type 2 diabetes mellitus (T2DM). Antihyperglycemic drugs have interaction with heart failure among diabetic patients. To date, the data on real world use of diabetic medication in Malaysian heart failure patients with T2DM has not been elucidated.Objective: This study aims to identify the prescribing pattern of antihyperglycemic regimens in HF patients with T2DM, and to investigate the association between glycemic control and other factors such as demographic and clinical characteristics with left ventricular ejection fraction (LVEF) in these patients.Methods: This retrospective observational study involved patients diagnosed to have HF and T2DM who were seen in the outpatient clinic in a government tertiary hospital in Malaysia. Patients receiving at least one oral antidiabetic agent and/or insulin for at least 3 months prior were included. The differences and association between study outcomes were examined and analyzed using Pearson's Chi-square test, One-Way ANOVA, Binary Logistic Regression and multiple Multinomial Logistic Regression models.Results: From July to December 2019, 194 patients were included in this study. The majority (52.1%) of the patients had HF with preserved ejection fraction (HFpEF), 20.6% had HF with mid-range EF (HFmrEF), and 27.3% had HF with reduced EF (HFrEF). Overall, metformin (59.8%) was the commonest antihyperglycemic agent prescribed, followed by insulins (54.0%), and sulphonylureas (44.9%). The most prescribed agents for HFpEF, HFmrEF, and HFrEF patients were metformin (65.3%), insulins (62.5%), and sulphonylureas (60.4%), respectively. The prescribing trend of sulphonylureas was found to be significantly associated with patients' LVEF status (p = 0.033). The odds for sulphonylurea prescription among the HFrEF patients were 2.42 times higher compared to the HFpEF patients [95% confidence interval [CI], 1.23–4.79]. There was no association found between glycemic control with patients' LVEF.Conclusion: Our findings reported metformin as the most commonly prescribed antihyperglycemic agent, sodium glucose linked transporter-2 (SGLT-2) inhibitor being under-prescribed, and detected poorly controlled diabetes in majority of patients with T2DM and HF. Understanding the prescribing pattern of antihyperglycemic agents supports the implementation of evidence-based treatment in HF patients with T2DM to improve patients' outcomes.

Relationship between ECG QRS voltage and left ventricular functions in patients with heart failure attending federal Medical Centre Nguru, Northeastern Nigeria

Introduction: Heart failure (HF) is a clinical syndrome characterized by typical symptoms (e.g., breathlessness, ankle swelling, and fatigue) that may be accompanied by signs (e.g. elevated jugular venous pressure, pulmonary crackles, and peripheral edema) caused by a structural and/or functional cardiac abnormality, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress. Electrocardiogram (ECG) is a widely available tool; it is relatively inexpensive and simple to perform; and it yields an instant result. A normal ECG makes systolic dysfunction unlikely and is rare in patients with suspected heart failure. Low ECG voltage has been reported as a marker of the severity of HF and is a risk factor for adverse outcomes in patients with systolic HF at 1 year. However, the relationship between ECG QRS voltage and left ventricular function in patients with heart failure has not been evaluated. Therefore, the objective of this study is to determine the relationship between electrocardiographic QRS voltage and left ventricular function. Methodology: This was a prospective cross-sectional study conducted among inpatients with HF in the medical ward of the hospital. Results: Three hundred and sixty patients were recruited for the study, of which 19 had incomplete data and were excluded in the analysis. The remaining 341 subjects were analyzed comprising 215 female and 126 male with a mean age of 47.54 ± 18.85 years. Majority of patients with normal or high QRS voltage had HF with preserved ejection fraction (HFpEF), while those with low QRS voltage had HF with reduced ejection fraction (HFrEF). On the other hand, patients with high QRS voltage had impaired relaxation pattern of diastolic dysfunction, while those with low QRS voltage had a restrictive pattern of diastolic dysfunction. There was a positive and significant correlation between the QRS voltage and ejection fraction, fractional shortening, isovolumic left ventricular relaxation time, and left ventricular deceleration time, while a negative but not significant correlation was observed between electrocardiographic QRS voltage and transmitral E/A ratio. Majority of patients with normal QRS voltage had normal left ventricular geometry, while those with high QRS voltage predominantly had concentric left ventricular hypertrophy and those with low QRS voltage had eccentric left ventricular hypertrophy. Patients with concentric left ventricular hypertrophy had predominantly HFpEF and impaired relaxation pattern of diastolic dysfunction, while those with eccentric left ventricular hypertrophy had HFrEF and restrictive pattern of diastolic dysfunction. Conclusion: HF patients with high QRS voltage had preserved left ventricular systolic function, impaired relaxation pattern of left ventricular diastolic dysfunction, and concentric left ventricular hypertrophy. While those with low QRS voltage predominantly had reduced left ventricular systolic function, restrictive pattern of left ventricular diastolic dysfunction, and eccentric left ventricular hypertrophy.

The Role of Hand Carried Ultrasound in Guiding Management of Challenging Heart Failure Patients

Purpose Accurate assessment of volume status and estimation of central venous pressure is critical in directing management of acute heart failure (HF) patients . We evaluated the impact of hand carried ultrasound (US) in guiding therapy for HF patients with uncertain volume status on physical examination (PE) or with worsening serum creatinine (Cr). Methods We prospectively included patients admitted to the hospital with acute HF exacerbation and had uncertain volume status or worsening Cr to undergo US-guided management between January 2017 to October 2018. HF team provided initial management plan based on standard of care (PE, symptoms and lab results), then they were provided with US estimation of intravascular volume (by assessing inferior vena cava size and respiratory variation, right and left jugular veins size, respiratory variation and compressibility). Primary outcome was percent change of initial plan after providing US results. Logistic regression was used to compare the percent change in plan by HF type. Results A total of 151 (Age 64±15,46% females, 78% white) patients were included during study duration. 47(31%) patients had HF with preserved ejection fraction (HFpEF), and 104 (69%) patients had HF with reduced ejection fraction (HFrEF). A change in plan was observed in 77.5% of the patients after using ultrasound. No difference in percent change of plan between HFrEF (81%) and HFpEF patients (70%), (OR 1.7, 95% CI: 0.73, 3.9, p= 0.2). Conclusion Ultrasound management of patients with HF and uncertain volume status or worsening Cr may significantly impact management decisions regardless of HF type, Further studies are needed to explore whether these changes improve outcomes of this population.