Heart Failure Pts Research Articles

Effects of Cycle Ergometer Training on Heart Rate Recovery and Mind Fullness in NYHA class I, II Heart Failure Patients

Aim: To determine effect of Cycle ergometer on heart rate recovery and mindfulness in NYHA Class I and II heart failure pts. Study design: The study was a randomized controlled trial. Place and duration: Total study duration was 6 months, carried out at Rawal general and dental hospital Islamabad. Methodology: 38 patients were divided into the Control and experimental group. The control group received only conventional Therapy at home and the hospital on the third and 6th weeks for a supervised conventional therapy session. The experimental group received conventional therapy and cycle ergometer training thrice weekly for six weeks. Baseline demographic data, Vitals, HRR1, HRR2, and MAAS scores were gathered from both groups and compared after six weeks. Results: The mean age of the control group was (46.37±4.43) and of the experimental group (was 50.47±9.22). The MAAS score was significant with a p-value (< 0.05). HRR1 and HRR2 were also significant, with a p-value (<0.05). Conclusion: This study showed that cycle ergometer exercise training significantly improved heart rate recovery in NYHA Class I and II heart failure patients and improved mindfulness. Keywords: Heart failure, Heart Rate Recovery 1(HRR1), Heart Rate Recovery 2 (HRR2), Mindful Attention Aware Scale

Abstract 10590: Detection of Cardiac Attr Amyloidosis in a Real-World Hf Population by Natural Language Processing Guided Automated Data Extraction From Electronic Health Records

Background: As cardiac aTTR amyloidosis(aTTR-CM) is frequently underdiagnosed and missed, improved screening to enhance earlier diagnosis of the disease is essential. Recent observations have demonstrated that clinical clues related to the presence of aTTR-CM and additional predisposing or associated medical conditions derived from machine learning(ML) models may provide a systematic framework to increase the suspicion of aTTR-CM in heart failure(HF) pts. Objectives: The present study was set up to explore the use of a systematic framework to diagnose aTTR-CM in a real-world HF population. Methods: Between 2014 and 2018, 3035 HF pts (Age:74 ± 12 years; EF: 45 ± 19 %, male: 50 %) consecutively referred to a community HF clinic were assessed. Using targeted disease-specific electronic health record (EHR) models (Natural language processing/ LynxCare Inc., Leuven, Be) the prevalence and odds ratios for cardiac, non-cardiac, and combinations of both cardiac and non-cardiac phenotypes predictive for aTTR-CM were assessed. Results: 101 pts((Age: 78.57 ± 9.17 years; EF 46 ±15 %, male: 40% ) were diagnosed with aTTR-CM. Besides HF and cardiomyopathy-related phenotypes, atrial fibrillation was the strongest cardiac predictor for aTTR-CM(prevalence:76 %, OR 2.95, 95% CI= 2.10, 4.14) whereas the strongest non-cardiac predictor was carpal tunnel syndrome(prevalence :21 %, OR 6.55, 95% CI= 7.21, 5.90). The combination of heart block, joint disorders, and combined systolic and diastolic HF was the highest combined phenotype in aTTR-CM(prevalence:16 %, ORR 2.63, 95% CI = 0.96, 3.28). Conclusion: On top of well-known diagnoses and phenotypes unique combinations of cardiac and non-cardiac phenotypes predict aTTR-CM In a real-world HF population. Therefore, if successfully employed in the EHR this strategy may identify aTTR-CM pts and lead to earlier detection of it by raising the suspicion of the diagnosis in HF pts.

Legacy effects of infection in patients with heart failure: a national cohort study of 31,318 patients in Taiwan

Abstract Background Although infection is a common cause of hospitalization in patients (pts) with heart failure (HF), the long-term cardiovascular (CV) prognosis in HF after infection is not well studied. Methods and results From 2009 to 2015, 310,485 pts with their first HF admissions and survival to discharge were identified from the National Health Insurance Research Database. Among the pts, 103,505 (33.3%) were readmitted within 1 year after HF discharge for infection, including pneumonia (44.2%), urinary tract infection (UTI) (37.9%), skin and soft tissue infections (9.7%), and others (8.1%). Those without admission for any infection were controls. We compared the primary composite endpoint, including all-cause death, acute myocardial infarction (AMI), stroke, and hospitalization for HF (HHF) between the 2 groups after the infection episode. After propensity score matching, the clinical characteristics (age 71.7±13.9 years, male 52.0%) and treatment were similar between the groups (n=15,659 in each group). In a mean follow-up time of 4.3±2.9 years, 86.2% pts with a history of infection admission and 63.6% pts in the control group met the primary endpoint. Multivariate Cox proportional hazards analysis showed the infection group had a higher risk of the primary composite endpoint (HR 1.760, 95% CI 1.714–1.807), including all-cause death (HR 1.587, 95% CI: 1.540–1.636), HHF (HR 1.993, 95% CI 1.922–2.066), AMI (HR 1.332, 95% CI 1.224–1.450), and stroke (HR 1.769, 95% CI 1.664–1.882). In infection group, HHF was the earliest outcome event with a mean time of 17.5 months and mortality is the second early event with a mean time of 23 months after discharge from the infection episode. Pneumonia carried a higher risk than UTI for the primary composite endpoint (HR 1.140, 95% CI 1.104–1.178). Conclusions One-third of HF pts discharged from the hospital experienced acute infection that required readmission. The pts had worse CV prognosis after readmission for infectious disease compared to those without infection Funding Acknowledgement Type of funding sources: Private hospital(s). Main funding source(s): This study is supported by National Cheng Kung University Hospital and Tainan Hospital, Ministry of Health and Welfare, Taiwan.

A new cardiopulmonary exercise testing score for predicting heart failure events

Abstract Background Cardiopulmonary exercise test (CPET) provides several variables (V) that are strong predictors of events in patients (pts) with heart failure (HF). Purpose Our aim was to develop and evaluate the predictive power (PP) of a CPET-based score, comparing to that of the Heart Failure Survival Score – HFSS. Methods Retrospective evaluation of adult pts with HF submitted to CPET in a tertiary center. Pts were followed up for at least 1 year for the primary endpoint of cardiac death and urgent heart transplantation/ ventricular assist device implantation (MTV). The PP of several CPET V's was assessed using ROC curve analysis, which was used to define optimal threshold values for each V. A multiple regression analysis was performed to identify independent prognostic predictors and to determine the regression coefficient (β) for the Vs included in the model, each expressed dichotomously using the threshold value. According to β, a weight was assigned to each V and summed to calculate the composite score. ROC curves were compared using the Hanley and McNeil test. Results CPET was performed in 487 HF pts, with a mean age of 56±13 years, 79% were male. 46% of pts were of ischemic etiology, with a mean LVEF of 30±8%, a mean HFSS of 8.6±1.1 and a mean BNP value of 509±668pg/ml. The mortality rate during a mean follow-up of 21 months, was 19% (93pts) with 23 pts (5%) undergoing HT. The primary endpoint was reached by 55 (11%) pts. The variables with higher predictive power were OUES (AUC 0.796), ventilatory power (AUC 0.790), the partial pressure of end-tidal CO2 at the anaerobic threshold (PETCO2L – AUC of 0.787), the pVO2 (AUC 0.767) and heart rhythm (HR) during the test (AUC – 0.640). LVEF also presented a high predictive power with AUC of 0.755. The multivariate analysis revealed that pVO2, PETCO2L, AF, and LVEF were independent prognostic predictors. According to the β of these Vs, the equation was calculated as follows: (pVO2 × 2.194) + (PETCO2L × 1.545) + (LVEF × 1.134) + (HR × 1.055; 0 if AF, 1 if sinus rhythm). The score presented a high PP with an AUC of 0.866. A cut-off of 120 had an 83.6% sensitivity and a 75% specificity for MTV, and pts with a score value of <120 had a markedly lower rate of MTV (log-rank p<0.001). When compared to HFSS, our score presented a higher PP (0.866 vs 0.774, p=0.011). Conclusion A multivariable score based on readily available CPET Vs provides a simple, integrated and powerful method to predict HF events. Funding Acknowledgement Type of funding sources: None.

HEART SOUNDS CHARACTERISTICS FROM A 3D ACCELEROMETER IN HEART FAILURE PATIENTS

HEART SOUNDS CHARACTERISTICS FROM A 3D ACCELEROMETER IN HEART FAILURE PATIENTS

Impact of recurrent acute heart failure hospitalizations on prognosis of heart failure patients

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Hospitalizations for acute heart failure (AHF) are significant events for heart failure (HF) patients (pts) with each hospitalization portending a poor prognosis. Our aim was to compare pts with recurrent AHF admissions to those without and to study the impact of recurrent admissions on overall mortality. Methods Single centre retrospective study that included all pts followed at the HF Clinic of the Cardiology Department that had at least one visit during 2018. All data since their initial follow-up on HF Clinic was considered. Recurrent admissions were defined as 2 or more admissions for AHF in the same year, during the follow-up. Results A total of 138 pts were included (83% male, mean age 61±11years). Dilated cardiomyopathy (65;47%) and ischemic cardiomyopathy (62;45%) were the most frequent aetiologies and most pts had HF with reduced ejection fraction (131;95%). Mean left ventricular ejection fraction (LVEF) was 26±9% and right ventricular dysfunction was present in 27% of the cases. The majority of patients was on NYHA class II (80, 58%). A total of 84 (61%) pts was medicated with inhibitors of the renin-angiotensin system (iRAS), 45 (33%) with angiotensin receptor-neprilysin inhibitor (ARNI), 127 (92%) with beta-blockers (BB) and 116 (84%) with mineralocorticoid receptor antagonists (MRA). Ninety-seven (70%) pts had a cardiac electronic device implanted (47 CRT, 50 ICD). During a median follow-up of 40 months (IQR 32-58), 41 (30%) pts had hospitalizations for AHF and 21 (15%) had recurrent admissions. The median time to the first hospitalization was 16 months (IQR 6-29). Pts with recurrent admissions had a similar comorbidity profile and HF aetiology in comparison to pts with one or none admissions. Considering baseline echocardiographic parameters on first visit, they had a higher mean E/E’ ratio (22±8 vs 14±6, p= .012) and pulmonary systolic artery pressures (52±20 vs 38±14 mmHg, p= .026). No differences were found in LVEF, left ventricular volumes, presence of right ventricular dysfunction or mitral regurgitation. They were less frequently medicated with iRAS or ARNI (81% vs 96%, p=.012) and BB (81% vs 94%, p= .043) and had a higher mean diuretic dosage (87±47 vs 63±43 mg). During the follow-up a total of 31 (22%) pts died, 14 (10%) for cardiovascular reasons. Pts with recurrent AHF admissions were more likely to die from any cause (log rank =.01). On a multivariate analysis, recurrent AHF hospitalizations were an independent predictor of all-cause death (HR 2.4, IC95% 1.1-5.2, p=.03). Conclusion Recurrent AHF hospitalizations are associated with a worse long-term outcome of HF pts. Efforts should be made for an earlier identification of these pts. A higher baseline pulmonary systolic artery pressure and mean E/E’ ratio may identify a higher risk group who benefits from a closer follow-up.

Association Between Oral Microbiome, Inflammation, Endotoxemia, and Heart Failure Severity

<h3>Purpose</h3> Gut microbial imbalance may contribute to endotoxemia and inflammation in heart failure (HF). Changes occurring in the oral microbiota and inflammatory milieu during HF progression are unknown. <h3>Methods</h3> We prospectively collected oral and blood samples in HF pts. Biomarkers of endotoxemia (LPS, sCD14) and inflammation (CRP, IL6, TNF-α) were measured in 150 blood samples. 167 oral samples were analyzed using 16S rRNA sequencing. Alpha diversity was assessed via Shannon Index (SI) and regressed on NYHA Class and biomarker levels with linear models. Association between NYHA Class and Beta diversity (Bray-Curtis dissimilarity) was assessed with PERMANOVA. DESeq2 regressed taxa abundance on NYHA Class and below vs. above median biomarker levels; multiple comparisons were controlled with false discovery rate. Models were adjusted for age, sex, race/ethnicity, and smoking status. <h3>Results</h3> 167 HF pts (59±14yo, 85% M, 47% White, LVEF 20±9%, 49% smokers) were included. Mean Sl±SD across NYHA class I/II (N=50), III (N=65), and IV (N=52) was 3.28±0.47, 3.42±0.49, 3.20±0.78. NYHA class was associated with both Alpha (p<.01) and Beta diversity (p<.05). Decreased Alpha diversity was associated with ischemic etiology (p<.05), but not with sex, smoking, age, race/ethnicity, or clinical variables, including antibiotics. In unadjusted models, increased Alpha Diversity was associated with decreased inflammation: IL6 (r=-0.16), TNF-α (r=-0.18), CRP (r=-0.21); all p<.05. Statistical significance was lost after adjustment. Several taxa differed by NYHA class, levels of inflammation, and endotoxemia in multivariable models (<b>Figure</b>). <h3>Conclusion</h3> HF severity, inflammation, and endotoxemia were associated with oral microbial diversity and bacteria linked to poor oral health <i>(Treponema denticola</i> and <i>Porphyromonas gingivalis</i>). Future prospective studies are warranted to establish the relationship between oral microbiota and HF progression as this may represent potential therapeutic targets.

Utilizing The Electronic Medical Record To Assess Optimal Medical Therapy In Heart Failure Patients

<h3>Intro</h3> As healthcare payment models continue to shift from fee-for-service to pay-for-performance, adequate tools to measure & manage population health will be critical. Heart failure (HF) remains a prevalent & costly chronic condition that has been difficult to manage on a population basis. Guideline-directed optimal medical therapy (OMT) improves HF outcomes, but significant limitations exist in assessing & improving physician/patient compliance with guideline-directed therapy in real world clinical practice. <h3>Hypothesis</h3> Creating an objective scoring system for HF OMT & integrating it into the EMR can benchmark current medical therapy in HF patients & identify gaps in guideline-directed care. <h3>Methods</h3> A small committee within a 100-physician cardiology practice worked to adapt a proposed HF OMT score published in a JACC:HF editorial to meet updated guidelines & specific practice goals. The different guideline-directed HF medications were assigned scores to be combined to a total HF OMT score for a specific patient. The score was integrated into EMR to calculate prospectively for all patient encounters in which there was a history of LVEF less than or equal to 40% or diagnosis of systolic heart failure without LVEF. The treating physician/APP was not alerted to the calculated score in order to truly assess the baseline use of OMT in HF pts. Results: The HF OMT score was calculated for 1,201 pts at the time of a physician/APP encounter over a one-month period. The average score for all visits was 2.8. Evaluation by medication class & dose reveals significant underutilization of MRA and SGLT2i in HF patients in our practice. <h3>Conclusion</h3> Active management & optimization of guideline driven OMT in HF pts across a population will be critical to improving outcomes & succeeding in the evolving pay-for-performance environment. Long term use of a standardized HF OMT score can identify gaps in care for specific medications, by specific physician/APPs, or related to specific patient factors (race/ethnicity, insurance status, gender). Additionally this score can be used to measure the success of future interventions targeting improved compliance with guideline-directed therapy.

The Impact Of Race And Ethnicity On Clinical Outcomes In Patients With Heart Failure(On Behalf Of The Guide-IT Steering Committee)

Introduction Black and Hispanic patients (pts) with heart failure (HF) are under-represented in clinical trials. Thus, it has been challenging to understand the impact of race and/or ethnicity on clinical outcomes and responsiveness to treatment in pts with HF. Hypothesis The data in the GUIDE-IT (Guiding Evidence-Based Therapy Using Biomarker-Intensified Treatment in HF) trial was used to explore racial and ethnic differences in clinical outcomes. Pts were included who were event-free at 90 days and had data on attainment of guideline-directed triple therapy (GDMT, defined as greater than 50% target dose of beta-blocker, ACEI or ARB, and any MRA dose) or target NT-proBNP ≤ 1000 pg/mL. We postulated that Black pts would have worse clinical outcomes than non-Black pts, and that Hispanic pts would have worse outcomes than non-Hispanic pts. Methods Cox proportional hazards models were used to estimate the impact of race and ethnicity on mortality and HF hospitalization. These models accounted for 3-month achievement of GDMT or target NT-proBNP, as well as previously identified prognostic characteristics. Results Of the 733 patients included, 35% were Black and 6% were Hispanic. Black pts were younger, had more co-morbidities, lower EF, and higher NYHA class vs. non-Black pts. After accounting for GDMT attainment, Black pts were at a higher risk than non-Black pts for HF hospitalization (HR=1.97, 95% CI = 1.41-2.77, p < 0.0001), but not mortality (HR = 0.70, 95% CI = 0.39-1.26, p = 0.23) (Figures 1A-1B). Hispanic pts trended towards a higher risk than non-Hispanic pts for HF hospitalization (HR=1.83, 95% CI = 0.82-4.08, p = 0.14), but not for death (HR = 0.61, 95% CI = 0.18-2.09, p = 0.43) (Figures 1C-1D). Similar patterns were observed when accounting for target NT-proBNP. Estimated effects on mortality were limited by the low mortality rate (14%). Conclusion After adjusting for GDMT or target NT-proBNP attainment, as well as prognostic characteristics, Black HF pts had a higher risk of HF hospitalization than non-Black pts. There was also a trend for higher HF hospitalization risk for Hispanic pts compared to non-Hispanic pts . Mortality results were indeterminate, but point estimates did not support an excess mortality risk for Black or Hispanic pts. Black and Hispanic patients (pts) with heart failure (HF) are under-represented in clinical trials. Thus, it has been challenging to understand the impact of race and/or ethnicity on clinical outcomes and responsiveness to treatment in pts with HF. The data in the GUIDE-IT (Guiding Evidence-Based Therapy Using Biomarker-Intensified Treatment in HF) trial was used to explore racial and ethnic differences in clinical outcomes. Pts were included who were event-free at 90 days and had data on attainment of guideline-directed triple therapy (GDMT, defined as greater than 50% target dose of beta-blocker, ACEI or ARB, and any MRA dose) or target NT-proBNP ≤ 1000 pg/mL. We postulated that Black pts would have worse clinical outcomes than non-Black pts, and that Hispanic pts would have worse outcomes than non-Hispanic pts. Cox proportional hazards models were used to estimate the impact of race and ethnicity on mortality and HF hospitalization. These models accounted for 3-month achievement of GDMT or target NT-proBNP, as well as previously identified prognostic characteristics. Of the 733 patients included, 35% were Black and 6% were Hispanic. Black pts were younger, had more co-morbidities, lower EF, and higher NYHA class vs. non-Black pts. After accounting for GDMT attainment, Black pts were at a higher risk than non-Black pts for HF hospitalization (HR=1.97, 95% CI = 1.41-2.77, p < 0.0001), but not mortality (HR = 0.70, 95% CI = 0.39-1.26, p = 0.23) (Figures 1A-1B). Hispanic pts trended towards a higher risk than non-Hispanic pts for HF hospitalization (HR=1.83, 95% CI = 0.82-4.08, p = 0.14), but not for death (HR = 0.61, 95% CI = 0.18-2.09, p = 0.43) (Figures 1C-1D). Similar patterns were observed when accounting for target NT-proBNP. Estimated effects on mortality were limited by the low mortality rate (14%). After adjusting for GDMT or target NT-proBNP attainment, as well as prognostic characteristics, Black HF pts had a higher risk of HF hospitalization than non-Black pts. There was also a trend for higher HF hospitalization risk for Hispanic pts compared to non-Hispanic pts . Mortality results were indeterminate, but point estimates did not support an excess mortality risk for Black or Hispanic pts.

Factors Associated with Change in Health-Related Quality of Life from Before to 24 Months After Surgery

<h3>Purpose</h3> We sought to identify factors associated with long-term changes in health-related quality of life (HRQOL) among 3 groups of older patients (pts) with advanced heart failure (HF) undergoing heart transplantation (HT), with or without pre-transplant mechanical circulatory support (MCS), or long-term MCS, if ineligible for HT. <h3>Methods</h3> From 10/1/15-12/31/18, 393 pts (60-80 years) were enrolled from 13 U.S. sites, including 239 pts awaiting HT (118 with and 121 without MCS) and 154 long-term MCS pts. Of these, 151 pts (95 HT pts [34 with MCS and 61 without MCS before HT] and 56 long-term MCS pts) had 24-month follow-up data. The EQ-5D Visual Analog Scale (VAS; 0-100 [worst-best health state]) and KCCQ-12 overall summary score (OSS; 0-100 [poor-excellent health status]) were collected at baseline (closest to surgery) and 24-months. Analyses included ANOVA, paired t-tests, and multivariable linear regression. <h3>Results</h3> Average age at HT or long-term MCS implant (n=151) was 66.8 ±4.5 years, 80% were male, and 81% were white. At baseline, long-term MCS pts, compared with HT pts awaiting HT with MCS and those awaiting HT on medical therapy, had the lowest VAS scores (48.7±20.8 vs 65.9±21.0 vs 51.6±25.4, p=0.002) and KCCQ-12 OSS (37.1±20.9 vs 56.5±25.6 vs 46.4±20.5, p<0.001). HRQOL improved significantly in all 3 groups by 24 months (p<0.001); however, long-term MCS pts, compared with HT pts awaiting HT with MCS and those awaiting HT on medical therapy, still had the lowest VAS scores (70.9±19.7 vs 81.8±14.6 vs 86.2±12.1, p<0.001) and KCCQ-12 OSS (63.3±24.1 vs 85.3±16.0 vs 90.0±14.3, p<0.001). Multivariable models (Table) indicate that baseline HRQOL and undergoing HT, with or without MCS, are the strongest predictors of improvement in HRQOL. <h3>Conclusion</h3> Among pts with advanced HF requiring HT or MCS, improvement in HRQOL was greatest in those undergoing HT with or without MCS pre-HT and those with worse baseline HRQOL. These findings may inform advanced HF pts of anticipated HRQOL outcomes with alternative therapies.

Abstracts for the 40th emergencies in medicine conference

Abstracts for the 40^th emergencies in medicine conference

Hemodynamic impact of percutaneous left atrial appendage closure

Percutaneous left atrial appendage closure (LAAC) has emerged as an alternative to reduce the risk of stroke for patients with non-valvular atrial fibrillation. It still remains however unclear whether LAAC can cause a potential hemodynamic impairment or not. Our retrospective monocentric study included 62 patients who underwent LAAC between 2015 and 2019. Patients were put into two groups based on new onset or worsening of heart failure (HF) signs within 12 months after LAAC procedure: HF patients ( n = 19) and no HF patients ( n = 49). In comparison with no HF patients, those who experienced new onset heart failure or worsening HF had lower left ventricular ejection fraction (LVEF) at presentation (no HF pts 60.7 ± 9% vs. HF pts 49.1 ± 12.5%, P < 0.001), higher left atrial diameter (3.6 ± 0.6 cm vs. 4.2 ± 0.5 cm, P < 0.001), higher left atrial area (26.5 ± 8 cm 2 vs. 32.1+/6.4 cm 2 , P < 0.01) and tended to have a higher left atrial volume index (52.8 ± 28 mL/m 2 vs. 62.4 ± 22 mL/m 2 , P = 0.07). 12 weeks after LAAC procedure, a B-type natriuretic peptide (BNP or NT-proBNP) increase > 30% was more frequently observed in HF patients (30.8% vs. 80%, P < 0.001) without significant difference in left atrial remodeling. Device-related thrombus was observed in 3 patients with HF (2,3% vs. 15,8%, P = 0,05) and residual peridevice leak in 4 patients (15,4% vs. 20%, P = 0,4). After 2 years of follow-up, Kaplan–Meier estimated that survival was not significantly different among these two groups. Our results suggested that monitoring possible occurrence of heart failure should be tested after LAAC, especially in the patients with previous HF. Further investigations concerning biological and imaging data predictive factors of heart failure in a large population are needed.

Abstract 10010: Long-Term Prognostic Value of the Combination of Ahead Score and a Systemic Inflammation-Nutrition Index in Patients Admitted for Acute Decompensated Heart Failure

Backgrounds: Comorbidities are strongly associated with poor clinical outcome in heart failure patients (pts). AHEAD (A: atrial fibrillation; H: hemoglobin; E: elderly; A: abnormal renal parameters; D: diabetes mellitus) score has been related to clinical outcomes in acute decompensated heart failure (ADHF) pts. On the other hand, systemic inflammation plays a critical role in the outcomes of heart failure and malnutrition is also associated with poor outcome in heart failure pts. It has been recently reported that advanced lung cancer inflammation index (ALI), which is calculated as body mass index х serum albumin / neutrophil to lymphocyte ratio (NLR), is an independent prognostic marker in several types of cancer. We sought to investigate the prognostic value of the combination of AHEAD score and ALI in pts admitted for ADHF. Methods and Results: We studied 260 pts admitted for ADHF and discharged with survival. At the discharge, we evaluated AHEAD score (range 0-5, atrial fibrillation, hemoglobin &lt;13 mg/dL for men and 12 mg/dL for women, age &gt;70 years, creatinine &gt;130 μmol/L, and diabetes mellitus) and measured ALI. The study endpoint was cardiovascular-renal poor outcome (CVR), defined as cardiovascular death and the development of end-stage renal disease requiring renal replacement therapy. During a follow-up period of 5.1±4.2 years, 77 pts had CVR. At multivariate Cox analysis, AHEAD score and ALI were significantly associated with CVR, independently of prior heart failure hospitalization, systolic blood pressure and serum sodium level. Pts with both high AHEAD score (≥3 determined by ROC analysis: AUC 0.651[0.582-0.719]) and low ALI (&lt;35.8: AUC 0.7171[0.648-0.786]) had a higher risk of mortality than those with either and none of them (59% vs 28% vs 15%, p&lt;0.0001, respectively). Conclusion: The combination of AHEAD score and ALI would be useful for stratifying patients at risk for cardiovascular-renal poor outcome in ADHF pts.

Abstract 10356: Impact of Statin Therapy in Heart Failure Patients: Results of a Large Real-World Experience

Introduction: The use of statins in patients (pts) with heart failure (HF) is controversial. In patients without HF, statins reduce the risk of atherosclerotic cardiovascular disease (ASCVD), including HF-related events. In contrast, no benefit was observed in statin-treated HF pts in the CORONA and GISSI-HF trials. However, issues with generalizability may limit the applicability of these trial results in clinical practice. Therefore, we analyzed the impact of statin therapy in systolic HF pts in a large real-world experience. Methods: We searched Intermountain Healthcare medical records for pts with a diagnosis of HF and a reported ejection fraction of &lt;=40%. We compared outcomes (MACE=death, MI, stroke) at a median of 4.5 years follow-up in those who were and were not prescribed a statin. Statin use was defined as use at or after a HF diagnosis but prior to 60-days before MACE or end of follow-up. Cox hazard regression analysis was used to determine hazard ratios. Results: A total of 15,010 pts were studied. Baseline demographics and outcomes are shown in the Table. Statin use was associated with more frequent ASCVD risk factors yet a lower MACE risk during follow-up. Benefit was similar for primary and secondary prevention pts and for prior and new statin prescriptions. By time-varying hazard ratio (HR) analysis, the longer the pt was on a statin, the greater the reduction in risk of MACE (p&lt;0.0001). Conclusion: These results suggest a potential benefit of selective statin use in the real-world management of HF pts with ASCVD or at high-ASCVD risk. These novel observations deserve validation in additional real-world experiences.

Abstract 11746: Prior Heart Failure Hospitalization and Effects of a Nurse-Led Disease Management Program to Reduce Readmission in Heart Failure

Background: Hospitalization due to heart failure (HF) is a strong predictor of adverse outcomes. This study sought to what extent previous HF admissions impacted on the success of a disease management program (DMP) to reduce readmission. Methods: We prospectively enrolled 1363 consecutive HF pts, who were followed for 3 months after discharge. Of these, 431 (31%) received a DMP (1-month duration, including post-discharge home visits, medication reconciliation, exercise guidance and early clinical review). Study outcomes were all-cause readmission or death at 30- and 90-day post-discharge. Previous HF admissions were collected from medical records. Results: Of the 1363 HF patients, death or readmission occurred in 386 (28%) at 30 days and 556 (41%) at 90-days post-discharge. Compared to 765 patients without any previous HF admission ever, the 143 patients with a previous HF admission &gt;12 months before the current admission had no higher risks of readmission or death at 30 days (relative risk) and 23% higher risks of readmission or death at 90 days. The 420 patients who had a previous HF admission ≤12 months from the current admission had higher risks of the composite outcome at both 30 and 90 days (Table). DMP was not associated with any reductions in risks of adverse outcomes at both 30 and 90 days among patients with a previous HF admission in ≤12 months, but was significantly associated with a reduction in risks at 30 and 90 days (Table) among those without any previous HF admission in ≤12 months. These findings were independent of HF severity, systolic and diastolic function, comorbidities, cognitive function and any demographic or socioeconomic factors. Conclusion: Higher levels of attention should be focused on HF patients with a recent prior HF admission who have higher risks of post-discharge adverse outcomes and appear to be non-responsive to a DMP to reduce readmission.

Effects of aerobic physical rehabilitation on muscle fiber metabolism in patients with severe heart failure

Abstract Purpose To evaluate changes of functional state and metabolism of skeletal muscle fiber (MF) after aerobic physical rehabilitation (PR), based on original method; to study relationship between clinical data dynamics and indicators of skeletal muscle metabolism after PR. Methods 100 patients; heart failure (HF) with reduced ejection fraction (HFrEF), NYHA III, mean age 52±5,2 years, ejection fraction (EF) 27,3±4,2%, BMI 23,5±2,8 kg/m2. Before inclusion in PR program cardiopulmonary exercising test (CPET), echocardiography (EchoCG), quality of life (QOL), exercise tolerance (ET) were estimated. Physical training intensity was based on lactate threshold achievement during CPET. PR efficiency was estimated on the basis of peak oxygen uptake (VO2peak), EF, QOL and ET dynamics after 6 months PR. Shin muscle biopsy was performed at baseline and after 3–6 months PR. In muscle samples activity of alkaline phosphatase (AP), lactate dehydrogenase (LDH) and succinate dehydrogenase (SDG) was evaluated with plag-method. Data were statistically processed using software package “Statistika, 9.0”. Results After 6 months of training EF increased by 10,5±2,3%, ET increased by 9,7±0,5 points (p1,2 &amp;lt;0,05), QOL changed by 24,8±3,5 points (significant regression of symptoms), VO2peak increased by 5,2±0,5 ml/min/kg (p3,4 &amp;lt;0,05). MF diameter (dMF) after PR slightly decreased in 6 patients, in 2 patients it did not change. After 3–6 months of training AP activity increased by 24,2% (p&amp;lt;0,05); LDH activity in glycolytic MF decreased by 24,4%, in oxidative MF it decreased by 6,0% only (p1 &amp;lt;0,05, p2&amp;gt;0,05). SDG activity in glycolytic MF increased by 20%, in oxidative MF it increased by 30% (p1 &amp;lt;0,05, p2&amp;lt;0,05). There was a positive relationship between heart failure functional class dynamics and dMF (r=0,4, p=0,05), increase in CPET parameters was associated with AP activity (r=0,5, p=0,05). Conclusion Aerobic physical rehabilitation in stable HF pts, selected on the basis of LT achievement, was effective in improving values of EF, QOL, VO2peak and ET. After 3–6 months PR dMF slightly decreased; Participating in the PR program decreased LDH activity in both oxidative and glycolytic muscle fibers; it also increased AP and SDG activity significantly. This may indicate an increase in oxidative metabolism activity and decrease in MF edema, improvement in skeletal muscles microcirculation. Funding Acknowledgement Type of funding sources: None.

Assessment of ECG during hybrid comprehensive telerehabilitation in heart failure patients – subanalysis of the TELEREHabilitation in heart failure patients – TELEREH-HF randomized clinical trial

Abstract Background Exercise training in heart failure (HF) patients (pts) should be monitored to ensure patients safety. That is why we use ECG telemonitoring during hybrid comprehensive telerehabilitation (HCTR). Purpose Assessment of frequency of cardiac arrhythmias during telerehabilitation in HF patients. Methods The present analysis formed part of TELEREH-HF multicenter, randomized (1:1), controlled trial that enrolled 850 HF pts with New York Heart Association class I, II, or III and left ventricular ejection fraction (LVEF) of 40% or less. Patients were randomized 1:1 to 9 week HCTR plus usual care or usual care only. This subanalysis focuses on 386 pts (aged 62±11 years, LVEF 31±7%) randomized to HCTR based on Nordic walking training 5 times/week. HCTR was tele-monitored with an EHO mini device adjusted to record 16-second fragments of ECG (from three precordial leads) and to transmit the data via mobile phone network to the monitoring center. The timing of automatic ECG recording were pre-set and coordinated with exercise training. Results In all, 16622 HCTR sessions were registered and 66488 ECGs transmitted fragments were evaluated (four 16-second recording per patient per one session were recorded). A sinus rhythm was present in 320 (83%) pts, permanent atrial fibrillation in 66 (17%) pts. Assessment of ECG during HCTR procedure is presented in Table 1. Conclusions Telerehabilitation in heart failure patients is safe without evidence for symptomatic cardiac arrhythmias requiring discontinuation of training. Non-sustained ventricular tachycardia and paroxysmal atrial fibrillation episodes were rare but have required adjustment of the telerehabilitation regimen. The most common arrhythmias were ventricular and supraventricular premature beats. These arrhythmias did not result in any changes in rehabilitation and therapy regimens. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): The National Centre for Research and Development, Warsaw, Poland.

Optimizing Autologous Stem Cell Transplant for High-Risk Patients with Plasma Cell Dyscrasias

Autologous hematopoietic stem cell transplantation (ASCT) is recommended for transplant-eligible pts (pts) with newly diagnosed multiple myeloma (MM) as well as AL Amyloidosis (AA). However, melphalan-associated gastrointestinal (GI) and cardiac toxicities may limit its applicability. GI toxicity is a main limitation to ASCT in the elderly population which constitute a significant proportion of MM pts, where the median age at diagnosis is 68 years. There is an unmet need for measures to minimize non-hematological toxicities without compromising the melphalan (MEL) anti-tumor efficacy; this could lead to expansion of transplant eligibility to older pts as wells pts with high-risk cardiac AA. Also, minimizing treatment-related morbidity may allow dose-escalation or the addition of novel anti-myeloma agents to MEL conditioning; such may improve the depth of response and remission duration after ASCT. Here, we report outcomes of an integrated ASCT program for high-risk MM and AA pts.We incorporated a series of measures to decrease GI toxicity, infections and cardiac failure to our ASCT program. All pts receive amifostine 740 mg/m2 as a bolus infusion before MEL. In addition, stem cell collection is performed inpatient if pts are on hemodialysis (HD) and/or have high-risk AA. Peripheral blood stem cell (PBSC) mobilization uses plerixafor and Neupogen. The CardioMEMS HF System is used for high-risk AA with cardiac involvement to achieve more accurate fluid balance throughout the ASCT process. This device is FDA-approved for wirelessly measuring and monitoring pulmonary artery pressure and heart rate in New York Heart Association Class III heart failure pts who have been hospitalized for heart failure in the previous year. HD was done on the day before and the day of transplant and three times weekly thereafter. DMSO used for PBSC cryopreservation is washed from the infused stem cell product prior to infusion. High-risk pts are those older than age 65 years, on HD, or with high-risk AA (Mayo stage III, Kumar et al. JCO 30.9 (2012): 989-995). All pts fulfilling these criteria treated from January 2013 to Dec 2016 were retrospectively analyzed. Survival outcomes were measured from the date of ASCT until disease relapse or progression, Survival distribution was estimated using Kaplan-Meier methods.Thirty seven pts were analyzed (median age=66.6 years; range: 45-77). Thirty-five pts (95%) were older > 65. Fourteen pts were female (37%). Five pts were on HD (14%); two had AA with cardiac involvement. Six pts had light chain disease (16%), 21 IgG (56%) and eight had IgA (21%) MM, and two had AL AA. Five pts were ISS stage I (14%), 16 stage II (46%) and 14 stage III (40%). Five MM pts (14%) had extramedullary disease. Thirty pts (85%) were considered standard-risk and 5 had high-risk cytogenetics (14%). Median time from diagnosis to ASCT was 8.7 months (range: 3.2-169.4). Median number of therapy lines was 1 (range 1-7). Thirty pts (85%) had at least partial response (PR) at the time of transplant. Nine pts (24%) were collected with filgrastim only and 28 (75%) with filgrastim and Plerixafor (including all pts on HD and AA). Median number of CD34 cells collected was 6.36 x10E6/Kg (range: 2.34-23.99 x10E6/Kg). Median number of CD34 cells infused was 3.25 x10E6/Kg (range: 1.88-10.8). Fourteen pts (37%) received conditioning with MEL 140 mg/m2, and 63% received 200 mg/m2. Median length of hospital stay for ASCT was 15 days (range: 13-25). Grade II-III toxicity was seen in 13 pts (35%), with only 2 grade III and no grade IV GI toxicity. There was no difference in toxicity between MEL 140 vs. 200 (P=0.210). Median length of mucositis was 6.5 days (range: 2-18). One pt used PCA dilaudid. No pt needed total parenteral nutrition. Median time to neutrophil and platelet engraftment was 11 (range: 9-15) and 12 days (range: 8- 19), respectively. Transplant-related mortality was zero. Day 100 response rate (at least PR) occurred in 34 pts (97%), with 18 (51%) achieving near complete remission or better. Twenty eight (75%) received maintenance therapy. Median follow-up time for survivors was 38 months. At the end of follow up period, only 4 pts (10%) had died. Median PFS was not reached, 3-year PFS: 70% (Figure-1.A and B).Taken together, our results indicate the safety of the sequential approach described here. Prospective studies to examine the use of CardioMEMs and amifostine to improve clinical outcome of high-risk autologous transplant are warranted. [Display omitted] DisclosuresCooper:Novartis: Research Funding. Caimi:Abbvie: Equity Ownership; Incyte: Equity Ownership; Seattle Genetics: Equity Ownership; Celgene: Speakers Bureau. de Lima:Pfizer: Membership on an entity's Board of Directors or advisory committees; Celgene Corporation: Research Funding. Malek:Sanofi: Membership on an entity's Board of Directors or advisory committees; Celgene: Speakers Bureau; Takeda: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

P005. Patient Satisfaction with Virtual Heart Failure Care in the Bronx During the Initial COVID-19 Surge

BackgroundAt the epicenter of the COVID-19 pandemic, there was an urgent need to limit the exposure of patients (pts) to SARS-CoV-2, including areas within outpatient medical offices. Nevertheless, high risk heart failure (HF) pts continued to require close management. To overcome this predicament, at our institution pts were asked to stay at home and engage in virtual HF visits (VHFVs) via telephone or video, in lieu of in-office visits (IOVs).ObjectiveThe purpose of this abstract is to report patient satisfaction with VHFVs during the initial 30 day surge of COVID 19, compared to their satisfaction with IOVs over the preceding 3 months.MethodsThe Montefiore- Einstein Heart Failure service cares for over 4,000 pts who predominantly reside within the Bronx borough, and represent a vulnerable, urban, low socioeconomic population. Our team includes 12 providers consisting of both NPs and MDs. On 3/17/20 all non-urgent IOVs were stopped, and as a work around a virtual platform was created within our electronic medical record system (EPIC) to facilitate VHFVs. As of April 1st, all IOVs were converted to VHFVs, with few exceptions.We retrospectively identified all HF pts (N=502) who engaged in VHFVs (N=609) during the month of April, 2020. Those pts who also had IOVs within the preceding 90 days made up the survey cohort (N=283). A patient satisfaction survey was created in English and Spanish, using a 5 point Likert Scale. The survey was administered by phone, in the subjects' native language.ResultsThe survey was completed by 117 of the 283 eligible subjects (41%), with clinical characteristics as described (Table 1). In 5 of 8 categories of patient satisfaction, pts indicated that they preferred IOVs to VHFVs (Figure 1). IOVs and VHFV were equally ranked in regard to the scheduled appointment time, and also how well pts were listened to and understood by the clinician. Only the convenience of VHFVs was favored more. Nevertheless, 90% of pts were willing to have another VHFV if necessary.ConclusionEven in the setting of a pandemic and despite the convenience (of time, cost and travel), pts overall tended to prefer IOVs to VHFVs, yet remained open to engaging in future VHFV if necessary. Given the unique situation of the COVID-19 surge during the conduct of this survey, the results may not reflect patient satisfaction during ordinary times.

Malnutrition is Associated with Gut Dysbiosis and Perioperative Infections in LVAD Patients

<h3>Purpose</h3> Malnutrition is common in heart failure (HF) and contributes to poor outcomes. Nutrient metabolism might be influenced by the complex interplay between HF progression, venous congestion, inflammation and gut dysbiosis. We investigated the association between nutritional status and: i) biomarkers of congestion and inflammation; ii) gut microbial diversity; and iii) perioperative infections among HF pts undergoing LVAD. <h3>Methods</h3> From 8/2016 to 8/2018, hospitalized pts with prospectively collected stool and blood samples prior to LVAD and a nutritional assessment were retrospectively reviewed. Nutritional status was assessed according to current guidelines. Pts were divided into 2 groups: no malnutrition vs malnutrition (≥moderate). Calorie and fiber consumption over 7-day period pre-LVAD was averaged. Serum biomarkers of congestion (NT-proBNP) and inflammation (CRP) were measured. Stool samples were analyzed using 16S rRNA sequencing and summarized both at the taxa level, and overall using the Shannon index (a composite metric of gut alpha-diversity). Regression analyses explored differences in Shannon index and individual taxa (via DESeq) by nutritional status. <h3>Results</h3> 37 pts (56 ±12.6 y, 92% M) were included. 10 (27%) had malnutrition. Malnourished pts had significantly lower Shannon Index (Fig 1A). A positive correlation was found between Shannon index and calorie (r =.36, <i>p</i>=.027) and fiber intake (r= .32, <i>p</i>=.05). We observed n=3 taxa, all with anti-inflammatory properties, to be significantly enriched in pts without malnutrition (Fig 1B). Pre-LVAD levels of NT-proBNP and CRP were similar between groups. Perioperative infections were more prevalent in pts with malnutrition (Fig 1C); specifically, pre-LVAD 50% vs 18% and post-LVAD infections 60% vs 26%, both <i>p</i>=.05. <h3>Conclusion</h3> Malnutrition is associated with gut dysbiosis and perioperative infections in HF pts undergoing LVAD. Proof of principle trials to increase fiber intake and reduce gut dysbiosis and infection are justified.