Outpatient Heart Failure Clinic Research Articles

Guideline-Directed Medical Therapy in Patients With Heart Failure With Reduced Ejection Fraction and Incident Cancer

It has been postulated that cancer hampers the delivery of guideline-directed medical therapy (GDMT) for heart failure (HF). However, few data are available in this regard. We performed a retrospective analysis from the HF Outpatient Clinic of the IRCCS Ospedale Policlinico San Martino in Genova, Italy. All HF patients evaluated between 2010 and 2019, with a left ventricular ejection fraction <50% and at least two visits ≥3 months apart with complete information about GDMT were included in the study. We assessed the prescription of GDMT-in particular, beta-blockers (BB), renin-angiotensin system inhibitors (RASi), and mineralocorticoid antagonists (MRA)-at the time of the last HF evaluation and compared it between patients with and without incidental cancer. For those with incidental cancer, we also evaluated modifications of GDMT comparing the HF evaluations before and after cancer diagnosis. Of 464 HF patients, 39 (8%) had incidental cancer. There were no statistical differences in GDMT between patients with and without incidental cancer at last evaluation. In the year following cancer diagnosis, of 33 patients with incidental cancer on BB, none stopped therapy, but two had a down-titration to a dosage <50%; of 27 patients on RASi, two patients stopped therapy and three had a down-titration to a dosage <50%; of 19 patients on MRA, four stopped therapy. Although HF patients with incidental cancer may need to have GDMT down-titrated at the time of cancer diagnosis, this does not appear to significantly hinder the delivery of HF therapies during follow-up.

A novel referral strategy to enhance the enrollment of patients with heart failure in cardiac rehabilitation: A feasibility study.

Rehabilitation targeting patients with cardiac conditions are evident and acknowledged in clinical guidelines. However, participation rates remain suboptimal, with only 50% of all patients with cardiac conditions participating in these programs across Europe. Considering the well-documented effects of rehabilitation, increasing the referral rate to cardiac rehabilitation would be desirable. This study aimed to evaluate the feasibility of a novel referral strategy that could potentially enhance enrollment in cardiac rehabilitation for patients with heart failure. This prospective feasibility study incorporating both quantitative and qualitative methods was conducted in an outpatient heart failure clinic and a municipal health care center. 106 patients with heart failure were referred to the heart failure clinic from September 2021 through July 2022. A 15-20 min face-to-face physiotherapy consultation was incorporated into usual care, evaluating patients' habitual and actual level of functioning, disability, and physical activity and assessing their potential need and motivation for cardiac rehabilitation. Three predefined quantitative feasibility outcomes: reach, referral rate, and data completeness were assessed. Additionally, semi-structured interviews explored acceptability among patients and health care professionals at the municipal health care center and the hospital. Finally, the potential effect was assessed based on the enrollment rate. Physiotherapy consultations were offered to 86% of eligible patients; of these, 52% were referred to cardiac rehabilitation. Ninety-one percent data completeness was achieved. The intervention was well-accepted by patients and health care professionals. The enrollment rate reached 79%. The novel referral strategy proved feasible concerning reach and data completeness, although the referral rate suggested that further refinements are required before a full-scale trial. The novel referral strategy was well-accepted, and enrollment rate approached an acceptable level.

Rates of Reproductive Counseling and Contraception Use in Patients with Heart Failure at a Tertiary Care Center

BackgroundIncreasing numbers of women of childbearing age have cardiac disease including heart failure. In these women, pregnancy can cause significant morbidity and mortality. Contraceptive use and pregnancy counseling in women with heart failure is an essential part of their medical care. Here, we assess contraceptive use and pregnancy counseling of patients with heart failure at a single tertiary care center. MethodsThis was a retrospective, single-center cohort study of female patients with heart failure with reduced ejection fraction, LVADs, and heart transplants who were seen in the adult Advanced Heart Failure outpatient clinics. Patients were identified in the electronic health-care record system, and records were reviewed to assess for documentation of contraception and pregnancy counseling. ResultsWe identified 156 women of childbearing age, age >18 to <45, seen in the heart failure clinics between 2018-2023. Patients were sub-divided by their most recent diagnosis/therapy: heart failure with reduced ejection fraction (83, 53.2%), LVAD (18, 11.5%), and heart transplant (55, 35.3%). Contraception was documented for 74% of women with heart failure, 56% of women with LVAD, and 85% of women with heart transplants. Pregnancy counseling was documented for 18% of women with heart failure, 0.06% of women with LVAD, and 29% of women with heart transplants. ConclusionsIn our study, many women with heart failure, LVAD, or transplant have documented contraceptive therapy, however pregnancy counseling appears to be limited. This vital aspect of medical care should be available for all patients given potential pregnancy-associated risks.

Secretoneurin levels are higher in dilated cardiomyopathy than in ischaemic cardiomyopathy: preliminary results.

Secretoneurin (SN) is a neuropeptide with potential utility as a biomarker of cardiovascular episodes. The main effect of SN is mediated through its inhibition of calmodulin-dependent kinase II (CaMKII), which influences calcium handling. We aimed to associate the levels of SN in plasma with different causes of heart failure. We prospectively enrolled consecutive patients with ischaemic (ICM) and dilated (DCM) cardiomyopathy from the outpatient heart failure clinic and healthy individuals. SN was analysed from venous blood by use of the ELISA method. SN plasma levels were compared in DCM, ICM and healthy individuals with non-parametric tests. A total of 53 patients (81.1% male, 18.9% female; mean age 67.9 ± 12.6 years) and 34 healthy individuals (38% male, 62% female) were included in the analysis. Plasma SN levels were significantly higher in the dilated cardiomyopathy (38.8 ± 27 pmol/L) as compared with the ischaemic cardiomyopathy (19.7 ± 22.6 pmol/L) group (P = 0.006). There was no significant difference between females vs. males (27.1 ± 23 vs. 25.5 ± 26.2 pmol/L, P = NS). Plasma SN levels allowed DCM and ICM to be differentiated with 88% sensitivity and 61% specificity (P = 0.007), the cut of value is 13.3 pmol/L. Plasma SN levels differed significantly between healthy volunteers and both ICM (P < 0.0001) and DCM (P = 0.049). Plasma SN levels did not differ according to age and were not associated with comorbidities, left ventricular ejection fraction, heart failure medication, troponin, creatinine, or natriuretic peptide plasma levels. Plasma secretoneurin levels differed significantly in DCM vs. ICM, being higher in the former. Based on plasma SN levels, discrimination between DCM and ICM might be possible. Healthy individuals produce higher SN plasma levels than stable HFrEF patients.

The Relationship between the Presence of Cardiohepatic Syndrome and Mortality in Heart Failure with Reduced Ejection Fraction.

Heart failure (HF) is a major health burden that commonly affects liver function. Therefore, cardiohepatic syndrome (CHS) has been defined to describe the relationship between the heart and the liver. In this study, we aimed to evaluate the effect of CHS on long-term mortality in HF with reduced ejection fraction (HFrEF). Patients followed at the outpatient HF clinic of our hospital with HFrEF between 2010 and 2018 were retrospectively analyzed. CHS was defined as elevation of at least two of three cholestasis parameters (total bilirubin, alkaline phosphatase, and gamma-glutamyl transferase) above the upper limit of normal. Patients were divided into two groups according to the presence of CHS. The endpoint was all-cause mortality. Patients were followed up for a median of 4.4 (3.3-5.9) years. A total of 469 patients were included in the study. The mean age of the group was 52.2 ± 11.9 years and 75.5% of the patients were males. About 22.4% (n = 105) of the patients had CHS. Patients with CHS were older and had more comorbidities than patients without CHS. Furthermore, significantly worse left and right ventricular functions were observed in CHS (+) group. All-cause mortality was significantly higher in CHS (+) group (61.9% vs. 19.5%, P < 0.001). Multivariate analysis revealed the presence of CHS (HR: 2.92, 95% CI: 2.09-4.07, P < 0.001) as an independent predictor of long-term mortality. The presence of CHS is associated with increased long-term mortality in outpatients with HFrEF. As an easy parameter to assess from routine laboratory parameters, CHS should be used to evaluate the long-term prognosis of patients with HFrEF.

Incidence and predictors of heart failure with improved ejection fraction category in a HFrEF patient population.

The aim of the study was to assess the incidence and predictive factors of the development of heart failure with improved ejection fraction (HFimpEF) category during a 1year follow-up period in a heart failure with reduced ejection fraction (HFrEF) patient population managed in a heart failure outpatient clinic. The study evaluated data from patients enrolled in the Hungarian Heart Failure Registry (HHFR). The incidence and predictive factors of the development of the HFimpEF category after 1year follow-up were assessed in the group of patients who had HFrEF at baseline. We evaluated the incidence and predictors of the development of HFimpEF after a 1year follow-up in relation to time since diagnosis of HFrEF in patients diagnosed within 3months, between 3months and 1year, and beyond 1year. The predictive factors of the development of HFimpEF were analysed using univariate and multivariate logistic regression analysis. Of the 833 HFrEF patients enrolled in the HHFR, the development of HFimpEF was observed in 162 patients (19.5%) during 1year follow-up. In the whole patient population, independent predictors of the development of HFimpEF were female gender [odds ratio (OR): 1.73; 95% confidence interval (CI): 1.01-2.96; P<0.05], non-ischaemic aetiology (OR: 1.95; 95% CI: 1.15-3.30; P<0.05), and left ventricular end-diastolic diameter (LVEDD) <60mm (OR: 2.04; 95% CI: 1.18-3.51; P<0.05). The 1year incidence of HFimpEF decreased in relation to time since diagnosis of HFrEF. The incidence of HFimpEF was 27.1% in patients diagnosed within 3months, 18.4% in patients diagnosed between 3months and 1year, and 12.2% in patients diagnosed beyond 1year. Non-ischaemic aetiology (OR: 4.76; 95% CI: 1.83-12.4; P<0.01) and QRS width (OR: 0.81; 95% CI: 0.71-0.94; P<0.01) for patients diagnosed within 3months, LVEDD (OR: 0.54; 95% CI: 0.32-0.90; P<0.05) and left atrial diameter ≤45mm (OR: 5.44; 95% CI: 1.45-20.4; P<0.05) for patients diagnosed between 3months and 1year, and LVEDD<67mm (OR: 2.71; 95% CI: 1.07-6.88; P<0.05) for patients diagnosed beyond 1year were found to be independent predictive factors. In our study, in this HFrEF patient population managed in a heart failure outpatient clinic, the 1year incidence of HFimpEF was found to be ~20%. The 1year incidence of HFimpEF decreased in relation to time since diagnosis of HFrEF. The most important predictors of the development of HFimpEF were female sex, non-ischaemic aetiology, narrower QRS width, and smaller diameter of the left ventricle and left atrium.

Is the obesity paradox in outpatients with heart failure reduced ejection fraction real?

The obesity occurrence has achieved epidemic levels worldwide and several studies indicate a paradoxical similarity among obesity and the prognosis in heart failure (HF). The primary objective was to understand the association between body mass index (BMI) and heart failure with reduced ejection fraction (HFREF) of ischemic etiology in outpatients, using mortality as a parameter. The secondary objectives were to determine the differences in HF functional class, pharmacological therapy and evaluate the prognostic value of MAGGIC Score in this population. We analyzed 1,556 medical records from the HF outpatient clinic of a quaternary hospital and 242 were selected according to the criteria. Most were male, average age 62.6 (56-70), BMI 18.5-24.9 = 35.1%, 25-29.9 = 37.2%, 30-34.9 = 17.8%, 35-39.9 = 7%; BMI <18.5 and >40 groups were eliminated from the central analyzes because of scarce testing. BMI 30-34.9 and BMI 18.5-24.9 had the best prognosis, BMI 25-29.9 had an average performance, and BMI -39.9 group provided the worst outcome (p = 0.123). In the subcategory analysis, BMI 30-34.9 group had a better prognosis compared to the BMI 35-39.9 group (p = 0.033). In the multivariate analysis The MAGGIC score was not able to foretell mortality in this population according to BMI. In not hospitalized patients with HFREF of ischemic etiology, obesity was not a protective factor.

Candidacy and predicted efficacy of vericiguat in contemporary heart failure outpatient clinics

Abstract Background Vericiguat is a novel drug class (soluble guanylate cyclase stimulator) approved for the treatment of symptomatic heart failure with reduced ejection fraction (HFrEF) patients who are stable after recent decompensation. Its safety and efficacy in high-risk HFrEF patients (ejection fraction &amp;lt;45%) with recent hospitalisation was demonstrated in the VICTORIA trial, along with advantages: lesser impact on blood pressure, sustained efficacy up to eGFR 15 mL/min/1.73m2. Subgroup analyses have shown variability in heart failure hospitalisation (HFH) and cardiovascular death (CVD) reduction according to NT-proBNP levels. While real-world candidacy for Vericiguat have been described in hospitalised patients, data on Vericiguat eligibility within contemporary heart failure outpatient (HF OPD) clinics is limited. Purpose We describe the proportion of HFrEF patients reviewed in HF OPD clinics eligible for vericiguat (according to the VICTORIA trial criteria) and likely to benefit from therapy based on NT-proBNP levels. Methods A retrospective review was performed on HFrEF patients reviewed in HF OPD services in 2022. Hospital records were assessed to identify community managed HFrEF patients experiencing HFH in 2022 and the VICTORIA trial's selection criteria was applied to determine Vericiguat eligibility. Predicted efficacy (reduction in HFH and/or CVD) in Vericiguat eligible patients was based on NT-proBNP level cut-off: &amp;gt;8000 ng/L: no benefit; ≤8000 ng/L: net benefit; ≤5314 ng/L: strong benefit. Stable NT-proBNP value was taken as the peak value within 30 days of discharge of the HFH event. Results 333 HFrEF patients were reviewed in HF OPD services in 2022. 94 (28.2%) patients experienced HFH in 2022, of which 33 (9.9%) occurred after guideline directed medical therapy (GDMT) was optimized in HF OPD review. Pharmacotherapy patterns of patients with HFH were identified at HF OPD review: 24 (33.8%) quadruple GDMT, 18 (25.4%) triple GDMT, 21 (40.8%) dual or single GDMT. 71 (21.3%) patients with HFH met the VICTORIA trial criteria and were eligible for Vericiguat. When subdivided according to NT-proBNP level cut-off, the following predicted efficacy were identified: 52 (15.6%) net benefit, 42 (12.6%) strong benefit, and 19 (5.7%) no benefit. Conclusions In HF OPD services, 28.2% of HFrEF patients may experience HFH within 1 year with 9.9% occurring despite GDMT optimization. 40.8% of community managed HFrEF patients were still only on dual or single GDMT. The proportion of community managed HFrEF patients eligible for Vericiguat is 21.3%. Based on NT-proBNP levels, the proportion likely to experience net and strong beneficial effects from Vericiguat were 15.6% and 12.6% respectively. Considering Vericiguat has advantages over the traditional barriers (hypotension, renal function) of conventional HFrEF pharmacotherapy agents, our findings provide insight into the potential real-world use of Vericiguat within contemporary HF OPD clinics.Figure 1Table 1

The prognostic value of aortic stenosis and aortic sclerosis in patients with heart failure with reduced ejection fraction

Abstract Background Aortic stenosis (AS) and aortic valve sclerosis (AVS) as assessed by Doppler echocardiography have been associated with adverse clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF). However, further clarification of the role of AV and AVS in the HFrEF population is warranted. Methods A total of 873 patients with stable HFrEF were included in this retrospective cohort study. At referral, the patients had a left ventricular ejection fraction (LVEF) of 45% or lower Baseline clinical and echocardiographic data were retrieved from the heart failure outpatient clinic's database, and the patients were followed through a nationwide register for the outcome of all-cause mortality. The presence of AS and AVS was assessed using Doppler-derived pressure gradients of the aortic valve (AV) from the echocardiogram. Cox-regression models were used to determine the association between AV peak gradient and mortality. Multivariable models were adjusted for demographic, clinical, and echocardiographic parameters (age, sex, diabetes (DM), ischemic heart disease (IHD), BMI, heart rate, mean arterial pressure, total cholesterol and atrial fibrillation (AF), LVEF, left atrial volume index (LAVi), left ventricular mass index (LVMi), E/e’). Results Seventy-four percent of patients were male, and mean age was 66.8 ± 11.4 years. In total, 13% had DM, 57% had IHD, 38% had NYHA III-IV, 8% had implantable cardiac device (including pacemaker, ICD, and CRT), and 15.9% had AF. Mean LVEF was 27.3 ± 9.4% with a mean LVMi of 120.2 g/m2 ± 38.2. Mean AV peak velocity was 1.4 m/s ± 0.5 and median AV peak gradient was 6.3 mmHg (IQR 4.7; 8.9). During a median follow-up of 3.3 years (IQR 1.9 – 4.7 years), 143 patients (16.4 %) reached the outcome. In univariable analysis, AV peak gradient was associated with all-cause mortality (HR 1.23 per 10 mmHg increase, 95% CI 1.05-1.44, p = 0.012). LVEF modified the prognostic value of AV peak gradient (p = 0.026 for interaction). After stratifying the population by the median value of LVEF (cut-off = 28%), AV peak gradient remained prognostic only in patients with LVEF above the median (HR 1.58 per 10 mmHg increase, 95% CI 1.30-1.91, p &amp;lt; 0.001), whereas AV peak gradient was not significantly associated with mortality amongst the patients with LVEF below the median level (HR 1.03 per 10 mmHg increase, 95% CI 0.83-1.37, p = 0.827). After multivariable adjustment, AV peak gradient remained an independent predictor of the outcome in patients in the higher median of LVEF (HR 1.32 per 10 mmHg increase, 95% CI 1.02-1.70, p = 0.035) (Figure 1). Conclusion Presence of AS and AVS (derived by AV peak gradient Doppler echocardiography) is an independent predictor of all-cause mortality amongst HFrEF patients. However, presence of AS and AVS only entails prognostic information amongst the HFrEF patients without severely reduced LVEF.Incidence rates of all-cause mortality

Ventricular arrhythmia outcomes in hypertrophic cardiomyopathy from a high level myectomy centre

Abstract Background The presence of ≥15% late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (MRI) is used as a prognostic indicator for sudden cardiac death in patients with hypertrophic cardiomyopathy (HCM). [1] According to the European Society of Cardiology clinical practice guidelines (2014), septal myectomy is only indicated for symptomatic relief from left ventricular outflow tract obstruction (LVOTO) that is refractory to medical therapy, provided LVOTO gradient ≥ 50 mmHg. [2] At present, there is scarce data correlating the burden of ventricular arrhythmia and sudden cardiac death with LGE percentage or showing benefit of myectomy in reducing the burden of the same. Purpose We aimed to compare the burden of ventricular arrhythmia burden in patients with HCM who underwent septal myectomy compared with those who did not. Methods Adult patients with HCM followed in the advanced heart failure outpatient clinic at Allegheny General Hospital were included in this study. All included patients had cardiac MRI with LGE quantification and data related to cardiac events through devices placed for various indications (such as evaluation of reported palpitations, established supraventricular tachycardia, implantable cardioverter-defibrillator for primary or secondary prevention). Patients were divided into 2 groups: those undergoing myectomy (post myectomy group) and those that did not undergo myectomy (non-myectomy group). Chi square test was used to calculate incidence of premature ventricular contractions (PVCs), non-sustained ventricular tachycardia (NSVT) and sustained ventricular tachycardia (SVT) in the non-myectomy and post myectomy group. Results 76 patients with HCM (interventricular septal thickness ≥1.5 cm and LGE positive) longitudinally followed in the Allegheny General Hospital advanced heart failure outpatient clinic from 2016 to 2022 were included. 37 patients underwent septal myectomy. Baseline characteristics of post myectomy and non-myectomy group were matched and are listed in table 1. Left ventricular mass index was expectedly higher in patients undergoing myectomy. LGE was quantified on cardiac MRI prior to myectomy (mean 16.4% in myectomy group, 14.6% in non-myectomy group). Burden of ventricular arrhythmia (PVCs, NSVT and SVT) was found to be significantly lower in the post myectomy group (n=13, 44.83%) compared to the non-myectomy group (n=36, 92.31%). None of the patients included were noted to have ventricular fibrillation or sudden cardiac death. Conclusion Septal myectomy may reduce the incidence of ventricular arrhythmia and thus impact outcomes related to sudden cardiac death. This is likely a consequence of removal of arrhythmogenic scar tissue. Larger studies are required to further evaluate the burden and correlation of ventricular arrhythmia with scar tissue volume measured on cardiac MRI.

Improved heart failure screening and prevention in type 2 diabetes mellitus by cardiologist in rural areas

Abstract Purpose Guidelines recommend screening in type 2 diabetes mellitus (T2DM) for unrecognised asymptomatic left ventricular systolic dysfunction (LVSD), reduced (HFrEF), mid-range (HFmrEF) or preserved (HFpEF) heart failure (HF) with periodic evaluation of natriuretic peptides (NTproBNP) or echocardiography (echo). Tissue doppler and speckle-tracking echo may be needed to facilitate HF diagnosis at earlier, more treatable stage. Methods 2185 consecutive asymptomatic T2DM (age 62 ±4 years, 62% women) patients (pts) were referred from January 2015 by rural diabetologists (dia) to echolab with elevated NTproBNP (&amp;gt;125 pg/mL) or 5-year HF risk score WATCH-DM ≥14 points. After exclusion of abnormal electrocardiogram or chest x-ray and significant valvular heart disease was compared continued usual care by diabetologist with randomly assigned prospective follow-up by regional cardiologist. Results At referral in both groups were similar baseline characteristics, 20% pts were treated with ACE-inhibitor (ACEi), 2% beta-blockers (BB). After cardiologist consultation ACEi and BB use increased significantly to 96% and 84% in both groups (all p &amp;lt;0.001). Global LVSD (EF≤50%) was detected in 8% at baseline and 29% pts after 5 years in diabetologist group, respectively 9% at baseline and 13% after 5 years in cardiologist group (p &amp;lt;0.001). Systolic dysfunction (S’≤6.0 cm/s) occured in 20% at baseline and 41% pts after 5 years in dia group, respectively 19% at baseline and 24% after 5 years in cardiologist group (p &amp;lt;0.001). Reduced global longitudinal (GLS&amp;lt;16%) observed in 26% at baseline and 59% pts after 5 years in dia group, respectively 26% at baseline and 36% after 5 years in cardiologist group (p &amp;lt;0.001). At baseline we found 1% pts with new-onset HF in both groups (only HFmrEF). After mean follow-up of 54 ±7 months in cardiologist group developed new HF in 4% pts (2% HFmrEF, 2% HFpEF) compared with 25% pts (3% HFrEF, 7% HFmrEF, 15% HFpEF) in diabetologist group (p &amp;lt;0.001). Significant (p &amp;lt;0.001) predictors of incident HFmrEF were systolic dysfunction (S’≤6.0 cm/s), hazard ratio (HR) 3.6, 95% CI 2.96-4.2) and reduced GLS (HR 4.6, 95% CI 3.8-5.2), all p &amp;lt;0.01. The strongest (p &amp;lt;0.001) predictors of incident HFpEF were new-onset atrial fibrillation (HR 2.5, 95% CI 1.2-3.7) and echo-detected left ventricular hypertrophy (septal and posterior wall thickness ≥13 mm, HR 1.7, 95% CI 1.2-2.1), all p &amp;lt;0.01. Conclusions For preventing HF progression is required additional research focused on cooperative care between diabetologists and specialised HF outpatient clinic.

Use of loop diuretics in patients with chronic heart failure: an observational overview

IntroductionThis study aimed to evaluate the use and dose of loop diuretics (LDs) across the entire ejection fraction (EF) spectrum in a large, ‘real-world’ cohort of chronic heart failure (HF)...

The Relationship Between Atrial Fibrillation and Parathyroid Hormone in Heart Failure Outpatients.

Background Atrial fibrillation (AF) is a common arrhythmia in heart failure (HF). Plasma concentrations of para-thyroid hormone (PTH) have been shown to increase in HF. The relationship between PTH concentrations and the presence of AF in HF is, however, unknown. This study analyzed the relationship between plasma PHT concentrations and AF in patients with systolic HF.Material and methods 131 consecutive, stable HF patients, who were admitted to the HF outpatient clinic, were included in this prospective, observational study. Patients were classified as those with AF (n = 36) and those in sinus rhythm (SR, n = 95).Results PTH concentrations were markedly higher in patients with AF compared to the patients in SR [85 (15-320) vs. 112 (30-326) U / ml, p=0.007]. PTH, creatinine clearance, hemoglobin, creatinine, age, and left ventricular ejection fraction were found to be related to AF by univariate analysis; though, multivariate logistic regression analysis showed that only PTH concentration was independently related to AF.Conclusion PTH concentrations can be used to indicate AF in patients with systolic HF.

[Telemonitoring patients with chronic heart failure. Results from a pilot study in the Veneto Region, Italy].

Remote monitoring of patients with chronic heart failure (HF) can prevent acute episodes of HF, optimize treatment, reduce emergency room (ER) visits and hospitalizations, and improve quality of life of patients and caregivers. In current clinical practice, however, the most appropriate model is still under debate. We aimed to evaluate the impact of a new remote telemonitoring (TM) system in the clinical management of HF patients on the reduction of hospitalizations and ER admissions and on possible related-economic benefits. A working group participated by primary care and family practitioners, cardiologists, home care nurses of the 8th Local Health Unit of the Veneto Region, Italy, has established a new operating procedure for TM chronic HF patients, identifying the clinical profiles and the inclusion/exclusion criteria of enrollment, the clinical parameters to be monitored, the input/output modalities of the information to/from the call center, the alarm criteria and the response procedures. Patients were profiled into three risk categories based on age, clinical characteristics, prognosis assessment, and social needs and provided with appropriate devices for remote measurement and transmission of blood pressure, heart rate, peripheral oxygen saturation (SpO2) and body weight. Clinical data, self-measured at home according to a predetermined schedule based on the patient's risk profile, were automatically transmitted to the operating center, generating, if above the threshold, a grading of alarms (green/cyan, yellow, red) and the consequent activation of the most appropriate response (returned phone calls to check patient's status, reporting to primary physician/family practitioner for clinical evaluation, notification to the HF outpatient clinic for an early follow-up visit, alerting medical emergency services). The number of hospitalizations and ER visits during the TM period was compared with the pre-TM equivalent for each individual patient. Overall, 22 patients with chronic HF were enrolled (mean age 82.3 ± 8.6 years, 17 males). The average duration of TM was 18.7 ± 8.8 months. Overall, 62 108 home measurements were performed and transmitted. The alarms received by the operating center were 4120 (6.6% of all measurements): 62% cyan, 30% yellow, 8% red. Most of the data above the threshold concerned weight gain (42.0%) and SpO2 variations (28.0%). During the observation period (TM period and pre-TM equivalent interval calculated for each individual patient), a total of 127 hospitalizations and 181 ED visits were recorded. Compared to the pre-TM period, there was a 66% reduction in hospitalizations for all causes (95 vs 32, p<0.001) and a 68% decrease in ED visits (137 vs 44, p<0.001). Similarly, hospitalizations and ED visits due to HF were reduced by 82% (p<0.001) and 66% (p<0.001), respectively, with a decrease in days of HF-related hospitalization from 211 to 48. Despite a higher cost for TM of € 6911.15, a total saving of € 64 103.87 was obtained for the reduction of expenses from € 8665.45 to € 2664.00 for ED visits and from € 71 627.93 to € 13 525.51 for HF hospitalizations. This pilot experience on remote monitoring HF patients proved to be effective in determining a significant reduction in ED visits and hospitalizations with a consequent significant economic benefit. Larger studies are needed to confirm this favorable outcome.

Long-Term Trajectories of Biomarkers, Functional, and Echocardiographic Parameters in Patients with Chronic Heart Failure from Dilated or Ischaemic Cardiomyopathy

Introduction: The long-term evolution of clinical, echocardiographic, and laboratory parameters of cardiac function in patients with chronic heart failure (HF) with either reduced (HFrEF) or mildly reduced (HFmrEF) left ventricular ejection fraction (LVEF) is incompletely characterised. Methods: We identified patients with chronic stable HF who presented at least twice to a university HF outpatient clinic between 1995 and 2021. Trajectories of NYHA functional class, LVEF, left ventricular internal end-diastolic diameter (LVIDD), NT-proBNP concentrations, and HF treatment over 10 years of follow-up were analysed using fractional polynomials. Analyses were repeated after stratifying patients according to aetiology (ischaemic vs. dilated) or HF category (HFrEF vs. HFmrEF). Results: A total of 2,132 patients were included, of whom 51% had ischaemic and 49% had dilated HF. Eighty six percent and 14% were classified as HFrEF and HFmrEF, respectively. Mean LVEF was 28 ± 10%, and median NT-proBNP and estimated glomerular filtration rate values were 1,170 (385–3,176) pmol/L and 81 (62–100) mL/min/1.73 m², respectively. Median follow-up was 5.2 (2.6–9.2) years. Overall, NYHA functional class and LVIDD trajectories were U-shaped, whereas LVEF and NT-proBNP concentrations markedly improved during the first year and remained stable thereafter. However, the evolution of HF parameters significantly differed with respect to HF category and aetiology, with greater improvements seen in patients with HFrEF of non-ischaemic origin. Improvements in HF variables were associated with optimization of HF therapy, notably with initiation and up-titration of renin-angiotensin-system blockers. Conclusion: This study provides insights into the natural history of HF in a large cohort of well-treated chronic HF outpatients with respect to subgroups of HF and different aetiologists.

Women with heart failure and their experiences of sexuality and intimacy: A qualitative content analysis.

This study aimed to explore how women with heart failure experience intimacy and sexual activity. Knowledge about women diagnosed with heart failure and their sexual activity is scarce. By investigating the experience of sexual activity and intimacy of women diagnosed with heart failure, an alignment between current practice and patients' expectations and needs within this area might be obtained. A qualitative design was used. Fifteen women diagnosed with heart failure were recruited from a heart failure outpatient clinic at a university hospital. The study was carried out from January to September 2018. The inclusion criteria were women >18 years, with estimated New York Heart Association Class II or III living together with a partner. Face-to-face semi-structured interviews were undertaken at the hospital. The interviews were organised around a set of predetermined open-ended questions, transcribed verbatim and analysed using a qualitative content analysis. COREQ guidelines were used. The analysis revealed one overarching theme characterises how living with heart failure has an impact on women's sexual relationship. Furthermore, three sub-themes were identified: (1) redefining sexual activity, (2) reducing sexual activity and (3) maintaining sexual activity. Women need information about sexual activity and heart failure in order to prevent fear and anxiety. It is important to include partners in patient consultations at heart failure outpatient clinics and in sexual counselling. It is furthermore essential to educate patients about sexual activity in relation to medication and comorbidities. Findings from this study support that information about sexuality and intimacy is a central part of the consultation in a heart failure outpatient clinic, and highlights the importance of not making assumptions about aging, frailty and interest in sexual expression. Data were collected through face-to-face semi-structured interviews.

Diagnostic yield and predictive value on left ventricular remodelling of genetic testing in dilated cardiomyopathy.

We assessed the diagnostic yield of genetic testing and the relationship of left ventricular (LV) reverse remodelling (LVRR) with the presence of DNA pathogenic (P) or likely pathogenic (LP) variants in patients with dilated cardiomyopathy (DCM). From 680 outpatients followed at the Heart Failure Outpatient Clinic of our institution, we selected subjects with a diagnosis of DCM as defined by LV ejection fraction (LVEF) ≤40% and LV dilatation not explained by coronary artery disease or other causes. All patients were offered genetic investigation of 42 disease-associated DCM genes with next-generation sequencing. Seventy patients fulfilled the definition of DCM and 66 underwent genetic investigation. We identified 18 P/LP variants in 16 patients, with a diagnostic yield of 24%. The most common variants were truncating TTN variants (n=7), followed by LMNA (n=3), cytoskeleton Z-disc (n=3), ion channel (n=2), motor sarcomeric (n=2), and desmosomal (n=1) genes. After a median follow-up of 53months (inter-quartile range 20-111), patients without P/LP variants exhibited higher systolic and diastolic blood pressure, lower plasma brain natriuretic peptide levels, and a larger extent of LVRR, as reflected by the increase in LVEF (+14% vs. +1%, P=0.0008) and decrease in indexed LV end-diastolic diameter (-6.5 vs. -2mm/m2 , P=0.03) compared with patients with P/LP variants. Our results confirm the high diagnostic yield of genetic testing in selected DCM patients and suggest that identification of P/LP variants in DCM portends poorer LVRR in response to guideline-directed medical therapy.

How to fill the gap in the symptomatic HF patient journey between optimal medical therapy and advanced heart failure treatment: two Italian surveys

Abstract Funding Acknowledgements Type of funding sources: None. Background Heart failure (HF) is the pandemic of our century and an estimated 64.3 million people are living with HF worldwide. New therapies alongside the old ones have been recently introduced in clinical practice with good results but the prognosis for a high percentage of patients remains poor with a high mortality rate and markedly reduced functional status. Purpose This study aims to investigate through two surveys what physicians think are the current needs in HF management to gain insight into the epidemiology and characteristics of patients followed by Italian HF outpatient clinics. In particular, we evaluated the gap that Cardiac Contractility Modulation (CCM) could fill in HF management in a real-world scenario. Methods a 20-question survey on HF management in different scenarios addressed to all physicians operating in Italian centers involved in HF care was published on the website Cardioinfo. A second survey was sent to Italian high-volume referral outpatient HF clinics. The participating centers were asked to collect the number of patients admitted during 4 weeks and to fill out a 19 items survey regarding some characteristics of these patients. Results A total of 105 physicians (77% cardiologists) and 14 high-volume referral outpatient HF clinics took part in the surveys. Despite regular clinical follow-up at 3-6 months in 94% of cases, the currently available medical therapy is considered insufficient in stabilizing HF patients in 30% of cases. 23% of physicians perceive to have a lack of treatment options in symptomatic patients with reduced ejection fraction and this percentage rises to 66% in patients without reduced ejection fraction (Figure 1). Cardiac contractility modulation is considered a valid option by 15% of physicians. According to Food and Drug Administration criteria, in the cohort of patients referred to HF clinics around 3% of patients are suitable for CCM implantation (2 patients a month per heart failure outpatient clinic), but considering additional selection criteria the percentage of patients eligible may increase to 5-6%. Conclusions The surveys confirm the significant attention paid to HF in Italian hospitals, however the lack of therapeutic options for a non-negligible number of patients, who are clinically evaluated regularly, but without associated substantial changes in therapy, leads to frustration for the patient and the physician, and an increase in costs for the health care system. A relatively small percentage of the total HF population fulfills the indication for immediate CCM treatment. Nevertheless, considering the size of the HF population, CCM, reducing hospitalizations, improving functional capacity and QoL may be of key importance for many HF patients, especially the elderly.

P332 A CASE OF METABOLIC ACIDOSIS AFTER INITIATION OF SGLT2–I THERAPY IN HEART FAILURE WITH REDUCED EJECTION FRACTION

Abstract In July 2022 C.M., a 58–year–old woman, was admitted to our Heart Failure Outpatient Clinic. Patient with permanent AF undergoing DOAC therapy, previous double mitral and tricuspid valve replacement with bioprosthesis. As comorbidities she had stage IIIb CKD, previous ischemic stroke without outcome, multifactorial anaemia, asthma, ulcerative rectocolitis non–responsive to biological therapy. Since April 2022 progressive reduction in exercise tolerance with dyspnoea for previously well–tolerated exertion, with finding of severe left ventricular systolic dysfunction (FE 25%) due to widespread hypokinesia previously unknown. In September angiographic control confirmed the absence of coronary artery disease. Amiodarone therapy was started for frequent runs of VT. Cardiac MRI confirmed FE 27% with fibrosis of the interventricular septum and lower basal wall of non–ischemic appearance. In view of the clinical–instrumental findings, a single–chamber ICD pacemaker was implanted and the therapy for heart failure with reduced FE was optimised with the introduction of Sacubitril/Valsartan (later discontinued due to hypotension), MRA and SGLT2–I (Empagliflozin). Due to the persistence of labile haemodynamic compensation, an indication was given to perform three cycles of Levosimendan infusion at our Day Hospital. The routine EGA taken during the first infusion cycle showed metabolic acidosis in the absence of significant worsening of renal function (Fig. 1) with mild hypobicarbonatemia and electrolytes in the normal range. On the assumption that the acidosis was secondary to the introduction of SGLT2–I (about two months earlier), Empagliflozin was discontinued. One week after discontinuation, the control EGA (Fig. 1) showed resolution of the acidosis, with a substantially stable glomerular filtrate, so that discontinuation of the drug was confirmed. Conclusions In the literature there are reviews and case reports of euglycaemic diabetic ketoacidosis (euDKA) in DM2 patients on SGLT2–I therapy although there are currently only hypotheses regarding the pathophysiological mechanism. The possibility of inducing acidosis with hypobicarbonatemia in the absence of worsening renal function is unclear. A ‘Fanconi–like‘ mechanism could be hypothesised with induction of type 2 tubular acidosis with bicarbonate loss due to glycosuria.

P69 SHORT–TERM EFFECT OF DAPAGLIFLOZIN ON LEFT VENTRICULAR LONGITUDINAL FUNCTION IN PATIENTS WITH HEART FAILURE WITH REDUCED LEFT VENTRICULAR EJECTION FRACTION

Abstract Background It is known that sodium–glucose cotransporter 2 (SGLT2) inhibitors have been shown to confer important clinical benefits in patients with congestive heart failure (HF). Several evidences show SGLT2 influence the longitudinal systolic function of the left ventricle after medium and long term follow–up (FUP) in patients with HF. The aim of this study is to demonstrate how dapagliflozin can modify the global longitudinal strain (GLS) in a population of patients with systolic congestive heart failure (HFrEF) evaluating possible correlations with the basal functional capacity. Methods Clinical and echocardiographic data were retrospectively analyzed in 60 HFrEF patients treated with dapagliflozin, within a dedicated outpatient HF clinic. Pre–treatment data were correlated with to clinical and instrumental FUP date that was generally performed after two months of treatment. The clinical and instrumental data consisted of the NYHA functional class, the left ventricular ejection fraction (LVEF) and the GLS. Results There was no significant change between baseline and FUP date on LVEF (25.2 ± 9.9% vs 25.6 ± 9.6% p.s.), while GLS showed significant improvement (13.1 ± 3.7% vs 14.3 ± 3.1% p &amp;lt; 0.03). GLS improvement in HFrEF patients with more impaired functional class (NYHA III/IV) was more significant from 10.9 ± 3.4% to 13.1 ± 2.2% (p &amp;lt; 0.01), compared to that in HFeEF patients with less compromised functional class (NYHA I–II) from 13.6 ± 2.4% to 14.1 ± 2.1% (p 0.07). Conclusions Dapagliflozin was associated with short term improvement in longitudinal left ventricular myocardial function in patients with chronic congestive systolic heart failure. This improvement is more evident in patients who start from a more impaired functional capacity than in clinically more stable patients.