Heart Failure Specialists Research Articles

Implementation of sodium-glucose co-transporter 2 inhibitors in patients with heart failure through a new digital strategy (EMAIL-HF): a randomised clinical trial study design

Abstract Introduction Delayed implementation of new medical discoveries remains a global healthcare challenge and is mainly due to the complexity of cross-institutional patient care. Sodium-glucose co-transporter-2 (SGLT-2) inhibitors is the latest medical discovery in heart failure (HF) and have recently been added to clinical guidelines as they have proven to reduce the risk of adverse cardiovascular outcomes in patients with HF across the ejection fraction spectrum. Whether a new digital strategy can optimise and accelerate the implementation of SGLT2 inhibitors in patients living with HF is of great importance for public health. Purpose To evaluate whether a new and streamlined digital strategy can optimise and accelerate the implementation of SGLT2 inhibitors in patients with HF. Design and methods: The trial is a multicentre, parallel group, register-based randomised clinical study, evaluating the effect and potential of a new digital strategy to implement new guideline therapies to patients living with a chronic disease, specifically SGLT2 inhibitors to patients with HF (figure 1). The setup employs data from nationwide health registers and official digital letters to inform patients about the new therapy option and invite them to have their eligibility evaluated by a HF specialist and start therapy. A total of ~10,000 patients with HF across the ejection fraction spectrum (with and without diabetes), who have not yet been started on SGLT2 inhibitors, are identified through Danish nationwide health registers, and randomised 1:1 to receive the digital letter (figure 2). The primary outcome is the proportion of patients redeeming a prescription of a SGLT2 inhibitor within six months. Secondary outcome is a composite HF endpoint consisting of all-cause death or HF hospitalisation. Other outcome measures are renal failure, stroke and myocardial infarction, safety outcomes, adherence to therapy and proportion of vulnerable patient groups initiating therapy including immigrants, elderly, frail patients, patients with lower socioeconomic level and lower educational level. A total of 4689 patients have been randomised (February 2024) and data will be presented in 2025. Conclusions The trial will determine the efficacy and safety of a new and streamlined digital strategy to implement SGLT2 inhibitors to patients with chronic HF. The setup has the potential to be used in a broad spectrum of patients living with chronic diseases and is expected to be highly cost-effective.Figure 1.Study hypothesisFigure 2.Study design

Point-of-care screening for heart failure with reduced ejection fraction using simple pulse oximetry

Abstract Background More than 64 million patients with heart failure (HF) are burdened with poor quality of life, frequent hospitalizations, and high readmission rates. While HF with reduced ejection fraction (HFrEF) accounts for approximately half of these patients, there is currently no effective tool for performing cost-effective and reliable early-stage screening. For this purpose, we derived and cross-validated a machine learning (ML) based system capable of identifying HFrEF based on analysis of the photoplethysmographic (PPG) signal recorded by a simple pulse-oximeter. Methods Patients attending a routine ambulatory check-up at an outpatient clinic were included in the study. Left ventricular ejection fraction was determined by standard transthoracic echocardiography. Diagnosis of HF was based on the latest ESC recommendations for HF. PPG was measured using a standard oximeter modified to record raw PPG signal. Before processing, the quality of the measured PPG signal was assessed by signal quality indices to determine whether the quality of signal was sufficient for further analysis. In brief, the signal processing involved noise removal, filtering for specific frequencies, automatic artifact detection and identification of individual heartbeats, on which specific parts of the signal and signal characteristics, necessary for further analysis, were identified. Four different ML processing pipelines with different approaches to feature selection and class balancing were deployed, validated using the K-fold cross-validation and compared. Results A total of 371 patients were included in the study: 54 patients with HFrEF (mean age 66.87 ± 14.35, 74.07% male) and 317 patients with HFmrEF (4), HFpEF (42) or no history of HF (271) (mean age 54.12 ± 17.79, 51.73% male). From the 4 ML pipelines, LightGBM with SMOTE + Edited Nearest Neighbors balancing had the highest cross-validated predictive performance for detection of HFrEF (c-statistics 0.8, CI 0.69 – 0.89). Conclusions Our results suggest that HFrEF can be effectively screened using a simple pulse oximeter, thanks to ML signal analysis. This solution could be adapted to a simple, non-invasive, readily available, time-saving, and inexpensive point-of-care diagnostic tool for primary care. Early disease detection and referral to a cardiologist (or HF specialist) would have a positive impact on patient morbidity and mortality.Receiver Operating Characteristics CurveModel Performance Metrics

Impact on healthcare costs of adding telemedicine to a multidisciplinary disease management program for heart failure: a sub-analysis of the iCOR trial

Abstract Background Impact of telemedicine on heart failure outcomes has shown conflicting results. Little is known about the effect of these programs on mid-term healthcare costs. Purpose To evaluate the cost-efficacy of a comprehensive telemonitoring program within the vulnerable post-discharge period after an acute heart failure admission. Methods The insuficiència cardiaca Optimizació Remota (iCOR) trial was a single-centre, randomized, open-label study designed to evaluate the efficacy of the addition of telemonitoring and teleintervention to a specialized multidisciplinary nurse-led heart failure (HF) program. Adult patients with a recent hospital admission for acute HF and an acceptable social support and cognitive ability were recruited. This sub-analysis evaluates the effect of telemedicine on mid-term healthcare costs, including clinical events, drugs and devices, technology purchase and maintenance, outpatient care, days of hospitalization, procedures and complementary tests. t-test via bootstrap estimation is used to compare differences between the telemedicine (TM) and the usual care (UC) groups. Results 81 patients were assigned to the TM group and 97 patients to the UC group. Mean age was 74 years, more than 50% had HF with preserved ejection fraction and 25% were frail. Baseline characteristics were well-balanced between groups. Among the TM subgroup, adherence was very high (< 1% of missed biometric daily transmissions). During 6 months of follow-up, mean total healthcare cost per patient was 7949 euros (€) in the UC cohort and 4383 € in the TM cohort (relative risk reduction [RRR] of 45%; between-group differences 3546 €, 95% confidence interval 627-6464 €, bootstrap achieved significance level 0.022). This result was consistent across several subgroups (age, sex, frailty, left ventricular ejection fraction, educational level) and mainly driven by a 63% RRR in costs of hospitalization (which accounted for two-thirds of the total costs) in the TM cohort. 20 patients required HF admissions in the TM group, compared to 51 patients in the TM group (p < 0.001). This was associated with a 59% RRR in the need for diagnostic procedures. Total number of days of hospitalization per patient decreased from 12.2 in the UC group to 4.2 days in the TM group (p = 0.003), impelled by a reduction in HF and cardiovascular days of hospital stay. On the contrary, ambulatory care costs increase two-fold in the TM group compared to UC group. Nevertheless, these costs only accounted for a 19% of the total costs. Cost of devices needed to implement TM supposed 698 € per patient. Use of TM was associated with a 355 € increase in the cost of ambulatory neurohormonal treatment for HF. Conclusions TM implementation during the vulnerable phase after an acute HF admission was associated to a 45% RR reduction in mean total healthcare cost per patient. This result was driven by an almost two-thirds decrease in costs of hospitalization.UC and TM total healthcare costs

Acute kidney injury stage 2/3 during acute heart failure admission - clinical contributors and outcomes

Abstract Introduction Acute Heart failure (AHF) may be complicated by acute kidney injury (AKI) as a result of cardiorenal syndrome.(1) However other factors may contribute to AKI. AKI stage 2 or 3 predicts negative inpatient outcomes in the general population.(2) We have reported data in a contemporary cohort on AKI in AHF. This study looks at a larger cohort in 5 previous years to test whether those findings were consistent. Better understanding of this clinical scenario may lead to improvements in care. Aim To assess the clinical factors associated with AKI 2/3 in AHF inpatients. Methods This study used retrospective data from a single teaching hospital collected for inclusion in the UK National Heart Failure National Audit. All AHF admissions over a 5-year period, from April 2017 – April 2022 inclusive, were analysed. Renal function on admission and discharge/death were assessed. AKI stage was defined according to KDIGO guidelines based on serum creatinine levels. Electronic patient records were reviewed and the clinical course leading up to and following AKI 2/3 was reviewed. Reported mode of death was also collected. Results 3219 AHF admissions (2360 unique patients) were assessed. 257 patients died during admission (8% admission mortality, 10.9% patients). 157 (4.9%) admissions had AKI 2/3 on admission/discharge. 85 (54.1%) AKI 2/3 died during their hospital admission vs 6.1% mortality in admissions without AKI 2/3. Baseline population characteristics are summarised in Table 1. Admissions with AKI 2/3 who died were older (77.6±11.5 vs 71.5 ±15.8) and had higher rates of atrial fibrillation (48.2% vs 39.9%), diabetes (40% vs 36%), ischaemic cardiomyopathy (56.5% vs 41.7%) and LVEF <35% (38.8% vs 27.7%). The most frequent contributors to AKI 2/3 were sepsis (55, 64.7%) and congestive cardiac failure/cardiorenal syndrome (48, 56.6%). Hypotension (25, 29.4%), over-diuresis (17, 20%), radioiodine contrast (10, 11.8%) and aminoglycosides (8, 9.4%) were less common factors in development of AKI 2/3. ≥2 contributors were present in 49, 57.6%. The dominant contributor for AKI 2/3 was adjudicated to be sepsis in 33 (38.8%) of admissions, followed by cardiorenal syndrome (congestive heart failure with AKI) in 29 (34.1%), and cardiogenic shock in 7 (8.2%). AKI 2/3 contributors are summarised in Table 2. In AKI 2/3 cases who died, 35 (41.2%) involved renal specialist input; 60 (70%) involved heart failure specialist review. Conclusion AKI in AHF is associated with high inpatient mortality. Despite this, specialist renal input was uncommon. AKI 2/3 was usually multifactorial. Cardiorenal syndrome accounted for one third of cases and may not be preventable. In keeping with our findings from a smaller contemporary cohort, sepsis was the most common dominant cause of severe AKI. Prevention, early identification, and treatment of infection could reduce this risk. Awareness of the high mortality of AKI in AHF and specialist review may improve outcomes in AHF.

Clinical characteristics of patients with raised BNP referred from primary care to an outpatient heart failure with potential heart failure using NICE guidelines

Abstract Introduction UK NICE guidelines (1) mandate the referral of patients with potential heart failure (signs, symptoms and raised BNP) for specialist opinion including diagnostic echocardiography. We have analysed the demographic and clinical characteristics of 233 consecutive referrals over a nine month period of such patients from primary care to our outpatient cardiology service. Purpose To identify any differences between those who are subsequently identified as having reduced LV systolic function (HFrEF) and those with preserved LV systolic function. We have further explored any potential differences between those with moderately raised (>440 <2000ng/L) and those with grossly raised levels (>2000ng/L) of BNP as NICE guidance proposes a difference in urgency of assessment for these two patient cohorts. Methods All patients had diagnostic echocardiography following the British Society of Echocardiography guidelines (2) and were clinically assessed by a consultant cardiologist and specialist heart failure nurse. Results Of the 233 patients, 64 (27%) were identified as having HFrEF with the remaining 169 having preserved LV systolic function. In patients with HFrEF the majority had grossly raised BNP (62.5%) whereas with preserved LV systolic function the majority had moderately raised BNP (70.5%); Table 1. Within the referred population, demographics and clinical characteristics were broadly similar for patients with HFrEF and those with preserved LV systolic function for age and cardiovascular comorbidities (IHD, diabetes mellitus, hypertension) but were different for gender and heart rhythm. Patients with HFrEF and moderately raised BNP were twice as likely to be in sinus rhythm (75%) than those with grossly raised BNP (37.5%). In patients with moderately raised BNP those with preserved LV systolic function were more likely to be in AF than those with HFrEF (41% v. 25%). No gender difference was seen in patients with preserved LV systolic function whereas patients with HFrEF were twice as likely to be male; Table 2. Conclusions 1. The majority of patients with raised BNP and potential heart failure referred from primary care do not have HFrEF (72.5%) 2. Regardless of their LV systolic function those patients with the highest BNP levels are more likely to be in AF 3. Of patients with a raised BNP and HFrEF twice as many are male whereas no gender difference is seen in those with a raised BNP and preserved LV systolic 4. Whilst the mean age of both groups (preserved and reduced LV systolic function) is the same, in both groups those with grossly raised BNP are on average 5 years older than those with moderately raised BNP.

Implementation and evaluation of specialist heart failure pharmacist prescribing clinics.

Medications form the basis of treatment for heart failure (HF) and adherence is crucial as untreated HF has a mortality of greater than 30%. As such, specialist HF pharmacists with expertise in prescribing and promoting adherence have become an integral part of the wider HF multidisciplinary team (MDT). To implement specialist HF pharmacist prescribing clinics and evaluate their impact. An integrated HF team at a tertiary London hospital. The clinic was initially developed to facilitate the introduction of sacubitril-valsartan evolving to 6 dedicated clinics/week. A dedicated electronic referral pathway was created to channel referrals to the specialist clinic, and referral criteria expanded to all patients requiring optimisation of medical therapy. Data were retrospectively collected for patients with heart failure with reduced ejection fraction seen in the HF pharmacist clinic between September 2021 and July 2022. Overall, 114 patients were seen (mean age 66years, 78 male). The mean time to medication optimisation was 3months (averaging 1 appointment/month). The number on optimised doses of guideline-directed medical therapy, increased significantly from 8% at first appointment to 76% on discharge (p < 0.001). The HF pharmacists reviewed all medications and optimised non-HF medications for 17.5% (n = 20) of patients. HF pharmacists can optimise patients' HF and non-HF medical therapy typically within 3months. By reviewing all prescribed medications, HF pharmacists provide a holistic review of all medications. They can play a vital role in addressing the underutilisation of HF medical therapy and thereby improving patient outcomes.

Translating the 2021 ESC heart failure guideline recommendations in daily practice: Results from a heart failure survey. A scientific statement of the ESC Council for Cardiology Practice and the Heart Failure Association of the ESC.

Real-world data show that guidelines are insufficiently implemented, and particularly guideline-directed medical therapies (GDMT) are underused in patients with heart failure and reduced ejection fraction (HFrEF) in clinical practice. The Council for Cardiology Practice and the Heart Failure Association of the European Society of Cardiology (ESC) developed a survey aiming to (i) evaluate the perspectives of the cardiology community on the 2021 ESC heart failure (HF) guidelines, (ii) pinpoint disparities in disease management, and (iii) propose strategies to enhance adherence to HF guidelines. A 22-question survey regarding the diagnosis and treatment of HFrEF was delivered between March and June 2022. Of 457 physicians, 54% were general cardiologists, 19.4% were HF specialists, 18.9% other cardiac specialists, and 7.7% non-cardiac specialists. For diagnosis, 52.1% employed echocardiography and natriuretic peptides (NPs), 33.2% primarily used echocardiography, and 14.7% predominantly relied on NPs. The first drug class initiated in HFrEF was angiotensin-converting enzyme inhibitors/angiotensin receptor-neprilysin inhibitor (ACEi/ARNi) (91.2%), beta-blockers (BB) (73.8%), mineralocorticoid receptor antagonists (MRAs) (53.4%), and sodium-glucose cotransporter 2 (SGLT2) inhibitors (48.1%). The combination ACEi/ARNi + MRA+ BB was preferred by 39.3% of physicians, ACEi/ARNi + SGLT2 inhibitors + BB by 33.3%, and ACEi/ARNi + BB by 22.2%. The time required to initiate and optimize GDMT was estimated to be <1 month by 8.3%, 1-3 months by 52%, 3-6 months by 31.8%, and >6 months by 7.9%. Compared to general cardiologists, HF specialists/academic cardiologists reported lower estimated time-to-initiation, and more commonly preferred a parallel initiation of GDMT rather than a sequential approach. Participants generally followed diagnostic and treatment guidelines, but variations in HFrEF management across care settings or HF specialties were noted. The survey may raise awareness and promote standardized HF care.

Echocardiographic screening for heart failure and optimization of the care pathway for individuals with pacemakers: a randomized controlled trial

AbstractIndividuals with pacemakers are at increased risk of left ventricular systolic dysfunction (LVSD). Whether screening for and optimizing the medical management of LVSD in these individuals can improve clinical outcomes is unknown. In the present study, in a multicenter controlled trial (OPT-PACE), we randomized 1,201 patients (717 men) with a pacemaker to echocardiography screening or usual care. In the screening arm, LVSD was detected in 201 of 600 (34%) patients, who then received management in either primary care or a specialist heart failure (HF) and devices clinic. The primary outcome of the trial was the difference in a composite of time to first HF hospitalization or death. Over 31 months (interquartile range = 30–40 months), the primary outcome occurred in 106 of 600 (18%) patients receiving echocardiography screening, which was not significantly different compared with the occurrence of the primary outcome in 115 of 601 (19%) patients receiving the usual care (hazard ratio = 0.89; 95% confidence interval = 0.69, 1.17). In a prespecified, nonrandomized, exploratory analysis, patients with LVSD managed by the specialist clinic experienced the primary outcome event less frequently than those managed in primary care. The results of this trial indicate that echocardiography screening commonly identifies LVSD in individuals with pacemakers but alone does not alter outcomes. ClinicalTrials.gov registration: NCT01819662.

Heart failure in Europe: Guideline-directed medical therapy use and decision making in chronic and acute, pre-existing and de novo, heart failure with reduced, mildly reduced, and preserved ejection fraction-the ESC EORP Heart Failure III Registry.

We analysed baseline characteristics and guideline-directed medical therapy (GDMT) use and decisions in the European Society of Cardiology (ESC) Heart Failure (HF) III Registry. Between 1 November 2018 and 31 December 2020, 10 162 patients with acute HF (AHF, 39%, age 70 [62-79], 36% women) or outpatient visit for HF (61%, age 66 [58-75], 33% women), with HF with reduced (HFrEF, 57%), mildly reduced (HFmrEF, 17%) or preserved (HFpEF, 26%) ejection fraction were enrolled from 220 centres in 41 European or ESC-affiliated countries. With AHF, 97% were hospitalized, 2.2% received intravenous treatment in the emergency department, and 0.9% received intravenous treatment in an outpatient clinic. AHF was seen by most by a general cardiologist (51%) and outpatient HF most by a HF specialist (48%). A majority had been hospitalized for HF before, but 26% of AHF and 6.1% of outpatient HF had de novo HF. Baseline use, initiation and discontinuation of GDMT varied according to AHF versus outpatient HF, de novo versus pre-existing HF, and by ejection fraction. After the AHF event or outpatient HF visit, use of any renin-angiotensin system inhibitor, angiotensin receptor-neprilysin inhibitor, beta-blocker, mineralocorticoid receptor antagonist and loop diuretics was 89%, 29%, 92%, 78%, and 85% in HFrEF; 89%, 9.7%, 90%, 64%, and 81% in HFmrEF; and 77%, 3.1%, 80%, 48%, and 80% in HFpEF. Use and initiation of GDMT was high in cardiology centres in Europe, compared to previous reports from cohorts and registries including more primary care and general medicine and regions more local or outside of Europe and ESC-affiliated countries.

What services are currently provided to people with HFpEF in the UK and what are their components? A protocol for a scoping literature review.

Heart failure with preserved ejection fraction (HFpEF) is increasing in incidence and is increasingly the most common heart failure (HF) diagnosis. Patients with HFpEF are often excluded from specialist HF services which has negative impacts on their healthcare experiences and health-related outcomes. As emerging evidence-based treatments are being incorporated into clinical guidelines, it is timely to focus on the management of this phenotype. This review aims to explore literature around care provision for HFpEF in the United Kingdom; to characterise and assess HFpEF care pathways against current standards, and to generate evidence to create an optimised framework of care. A scoping review of the evidence from six databases will be performed, alongside a search of grey literature search and consultation with relevant experts. Given expected heterogeneity, multiple lines of synthesis are anticipated. Data analysis will follow best practice guidelines for the synthesising methodologies selected. Patient and public representatives will assist with analysis and in identifying priority components for HFpEF clinical services. This scoping literature review will enable an in-depth examination of the current health service provision for those with HFpEF in the UK. Synthesis of key components of services and illumination of challenges and barriers will inform current and future practice. There is a long history of specialist HF care in the UK, including seminal work on nurse-led care. Therefore, evidence derived from this review will likely be useful to HF services across Europe. The proposed combination of the search across both peer-reviewed literature and grey literature, combined with patient and public involvement will identify the key components of a framework of care for those with HFpEF. This scoping review protocol was published on the public Open Science Framework platform (no registration reference provided) and can be accessed at: https://osf.io/5gufq/.

Differences in heart failure with preserved ejection fraction management between care providers: an international survey.

Heart failure (HF) with preserved ejection fraction (HFpEF) is characterized by growing incidence and poor outcomes. A large majority of HFpEF patients are cared by non-cardiologists. The availability of sodium-glucose cotransporter 2 inhibitors (SGLT2i) as recommended therapy raises the importance of prompt and accurate identification and treatment of HFpEF across diverse healthcare settings. We evaluated HFpEF management across specialties through a survey targeting cardiologists, HF specialists, and non-cardiologists. An independent web-based survey was distributed globally between May and July 2023. We performed a post-hoc analysis, comparing cardiologists, HF specialists, and non-cardiologists. A total of 1460 physicians (61% male, median age 41[34-49]) from 95 countries completed the survey; 20% were HF specialists, 65% cardiologists, and 15% non-cardiologists. Compared with HF specialists, non-cardiologists and cardiologists were less likely to use natriuretic peptides (p = 0.003) and HFpEF scores (p = 0.004) for diagnosis, and were also less likely to have access to or consider specific echocardiographic parameters (p < 0.001) for identifying HFpEF. Diastolic stress tests were used in less than 30% of the cases, regardless of the specialty (p = 1.12). Multidrug treatment strategies were similar across different specialties. While SGLT2i and diuretics were the preferred drugs, angiotensin receptor blockers and angiotensin receptor-neprilysin inhibitors were the least frequently prescribed in all three groups. However, when constrained to choose one drug, the proportion of physicians favoring SGLT2i varied significantly among specialties (66% HF specialists, 52% cardiologists, 51% non-cardiologists). Additionally, 10% of non-cardiologists and 8% of cardiologists considered beta blocker the drug of choice for HFpEF. Significant differences among specialty groups were observed in HFpEF management, particularly in the diagnostic work-up. Our results highlight a substantial risk of underdiagnosis and undertreatment of HFpEF patients, especially among non-HF specialists.

HeartFailure Specialist Care and Long-Term Outcomes for Patients Admitted With Acute HeartFailure.

For patients with acute heart failure (HF), specialist HF care during admission improves diagnosis and treatments. The authors aimed to investigate the association of HF specialist care with in-hospital and longer term prognosis. The authors used data from the National HeartFailure Audit from January 1, 2018, to December 31, 2022, linked to electronic records for hospitalization and deaths. All-cause mortality was the primary outcome measure and in-hospital mortality the secondary outcome measure. Data for 227,170 patients admitted to hospital with HF (median age: 81 years; IQR: 72-88 years), were analyzed. Approximately 80% of acute HF admissions received support from HF specialists. Thirty-nine percent of patients (n=70,720) were seen by a multidisciplinary team (HF physicians and HF specialist nurses [HFSNd]), 22% (n=40,330) were seen by HFSNs alone, and the remaining 39% (n=71,700) were seen exclusively by specialist HF physicians. At discharge, more patients who received HF specialist care were prescribed medical therapy for HF and had specialized follow-up. Conversely, diuretic agents were prescribed to fewer patients. HF specialist care was independently associated with a higher rate of prescribing HF therapies at discharge and a lower likelihood of receiving diuretic therapy (OR: 0.90 [95%CI: 0.86-0.95]; P< 0.001). HF specialist care was associated with better long-term survival (HR: 0.89 [95%CI: 0.87-0.90]; P< 0.001) and lower in-hospital mortality (OR: 0.92 [95%CI: 0.0.88-0.97]; P<0.001). Receiving HF specialist care during admission for HF is associated with a higher rate of implementation of medical therapy, fewer discharges on diuretic therapy, and lower in-hospital and long-term mortality across the left ventricular ejection fraction spectrum, especially for patients with heart failure with reduced ejection fraction.

Cardiomyopathies matter: a multistakeholder european initiative to improve patient outcomes through effective health policies

Abstract Background/Introduction Cardiomyopathies are common and affect up to 1:250 of the population. Despite conferring a risk for sudden cardiac death and substantial disease burdens that could be reduced through better awareness, detection and care, cardiomyopathy care is rarely incorporated in European and national health policies. New European Society of Cardiology cardiomyopathy guidelines (1) could substantially benefit care but need to be supported by effective policies. Cardiomyopathies Matter is a Europe-wide, multistakeholder initiative aiming to raise awareness about cardiomyopathies and to ensure they receive the policy attention they warrant from EU and national decision-makers. Methods Cardiomyopathies Matters participants include experts from the fields of cardiology, cardiac nursing, economics, and patient advocacy, coordinated by a Secretariat, representing 36 countries and 6 patient advocacy groups (PAGs). A Policy Roadmap and other publications were co-created based on i) reviews of published and grey literature, and ii) input from topic experts and PAGs through 2 group workshops, individual consultation meetings, and a modified nominal group technique reviewing successive drafts toward consensus approval. Results The Roadmap (2) identifies unmet needs and challenges throughout the patient care pathway and offers holistic EU and national policy recommendations to address these and improve patient outcomes (Figure 1). These include policy measures to support early and accurate diagnosis, access to expert multidisciplinary care, guidelines-informed disease investigation and management, holistic support and empowerment of patients and carers, and research and innovation. Key aspects for nurses and allied health professionals include the need for 1)improved knowledge and awareness to promote early diagnosis; 2)rapid referral systems to multidisciplinary care and access to specialist cardiomyopathy or heart failure nurses care coordination, 3)genetic counselling (index cases and cascade/family screening), and 4)support of patients and families. Building on existing examples of good practice at national expert centre networks (e.g. France, Spain, UK),Cardiomyopathies Matter published updated policy recommendations for the European Union mandate (3), which are now being adopted more widely. National initiatives are underway or in development in Belgium, Hungary, Italy, Netherlands, Poland, and Spain. Local actions include multistakeholder roundtables and events, national Roadmap publications, events, educational activities, and media outreach. Conclusions EU and national Cardiovascular Health Action Plans are needed, with specific attention to cardiomyopathies and other inherited CVDs. Cardiomyopathies Matter fosters collaboration between healthcare professionals, PAGs and policymakers to promote policies that ensure all patients and families have access to guidelines-informed care.Figure 1Cardiomyopathy Priorities

Implementation of a cardiogenic shock team in a tertiary academic center

ObjectiveObservational studies have shown that the management of patients with cardiogenic shock (CS) by dedicated multidisciplinary teams improves clinical outcomes. Nevertheless, these studies reflect a specific organizational setting with most patients being transferred from referring hospitals, hospitalized in cardiac intensive care units (ICU), or treated with mechanical circulatory support (MCS) devices. The purpose of this study was to document the organization and outcomes of a CS team offering acute care in an all-comer population. MethodsA CS team was developed in a large academic tertiary institution. The team consisted of emergency care physicians, critical care cardiologists, interventional cardiologists, cardiac surgeons, ICU physicians, and heart failure specialists and was supported by a predefined operating protocol, a dedicated communication platform, and regular team meetings. ResultsOver 12 months, 70 CS patients (69 ± 13 years old, 67% males) were included. Acute myocardial infarction (AMI-CS) was the most common cause (64%); 31% of the patients presented post-resuscitated cardiac arrest and 56% needed invasive mechanical ventilation (IMV). Coronary angiography was performed in 70% and 53% had percutaneous coronary intervention. MCS was used in 10% and 6% were referred for urgent cardiac surgery. The in-hospital mortality in our center was 40% with 39% of the patients dying within 24 h from presentation. Overall, 76% of the live patients were discharged home. ConclusionAcross an all-comer population, AMI was the most common cause of CS. A significant number of patients presented post-cardiac arrest, and the majority required IMV. Mortality was high with a significant number dying within hours of presentation.

Cancer Screening in Patients with Heart Failure with Mildly Reduced and Reduced Ejection Fraction

Background: Heart failure with mildly reduced and reduced ejection fraction are associated with incident cancer. However, cancer screening is not routinely discussed in this population. This study aimed to describe the uptake and perception of cancer screening among patients with heart failure attending a specialised heart failure clinic in Australia. Methods: A prospective survey of consecutive ambulatory patients attending the clinic from 2022–2023 was performed. Included patients were eligible for recommended breast, cervical and/or bowel cancer screening according to Australian guidelines, had an ejection fraction of &lt;50% and no prior history of cancer. The primary endpoint was adherence to recommended cancer screening according to Australian guidelines. Perceptions towards cancer screening were also assessed and cancer screening rates were compared with those of the general Australian population. Results: Among the 200 included patients, there was low uptake of recommended breast, bowel and cervical cancer screening despite the availability of free national cancer screening programmes. Cancer screening rates among heart failure patients were lower than observed in the general Australian population. Patients were unaware of the association between cancer and heart failure and expressed interest in cancer screening participation. Conclusion: Future efforts should be targeted at improving education on cancer screening among patients and cardiovascular healthcare providers to improve overall health outcomes in heart failure.

Optimizing heart failure pathways to enhance patient care: the Program to Optimize Heart Failure Patient Pathways (PRO-HF).

Many European healthcare providers struggle to adopt multidisciplinary, integrated care pathways for people with heart failure (HF) as recommended by the European Society of Cardiology. PRO-HF (Program to Optimize Heart Failure Patient Pathways) was developed to help clinicians identify strengths, gaps, and shortcomings in their HF pathways and support tailored interventions to optimize pathways and enhance patient care. We report initial findings from baseline assessments of HF pathway characteristics and challenges from 10 hospitals in six European countries (France, Ireland, Portugal, Spain, The Netherlands, and United Kingdom). Baseline assessments were holistic appraisals of full HF services to calibrate current status and development needs and assist management teams in prioritizing improvement projects. Assessments were performed using a comprehensive checklist of measures covering the HF patient journey from diagnosis to ongoing follow-up. These included a digital survey sent to full HF care teams and one-to-one interviews. The digital survey focused on four key areas (HF outpatient clinic; remote patient management; efficient device implantation and inpatient pathways; and network maximization) and 16 dimensions of excellence. Priority areas and themes for action identified in baseline assessments were (i) provision of HF specialist care; (ii) data capture and analysis; (iii) institutional care protocols; (iv) hospital-wide strategies; and (v) multidisciplinary teams (MDTs). Suboptimal specialist care of emergency inpatients was an issue at all hospitals and prioritized at 8/10. Availability and accessibility of data on patients, activities, and outcomes was an issue at all hospitals and prioritized by 4/10. A lack of clear protocols, templates, and tools for some HF activities created variability in patient care (e.g., HF specialist consultations, diagnostic testing, follow-up appointments, medications, and device eligibility) and inefficient use of clinician time. This made it difficult to initiate new technologies (e.g., remote patient monitoring) due to the risk of overburdening staff. MDTs were frequently understaffed. Multiple interventions were identified to address gaps and shortcomings that could be tailored to specific needs of individual hospitals (e.g., inpatient pathway optimization, creation/optimization of HF outpatient clinics, development of an HF performance dashboard, enhancement of protocol adherence, streamlining cardiac resynchronisation therapy pathways, and MDT coordination). PRO-HF provides a valuable opportunity to identify gaps and significant shortcomings in HF pathways in European hospitals. Preliminary findings from hospitals that have initiated suggested changes to address these challenges are encouraging, though longer-term follow-up from more hospitals is needed to confirm the impact of PRO-HF on HF pathway optimization and patient care.

Uptake of SGLT2i and Outcomes in Patients with Diabetes and Heart Failure: A Population-Based Cohort and a Specialized Clinic Cohort

BackgroundSodium/glucose cotransporter 2 inhibitors (SGLT2i) are effective in adults with diabetes mellitus (DM) and heart failure (HF) based on randomized clinical trials. We compared SGLT2i uptake and outcomes in two cohorts: a population-based cohort of all adults with DM and HF in Alberta, Canada and a specialized heart failure clinic (HFC) cohort. MethodsThe population-based cohort was derived from linked provincial healthcare datasets. The specialized clinic cohort was created by chart review of consecutive patients prospectively enrolled in the HFC between February 2018 and August 2022. We examined the association between SGLT2i use (modeled as a time-varying covariate) and all-cause mortality or deaths/cardiovascular hospitalizations. ResultsOf the 4,885 individuals from the population-based cohort, 64.2% met the eligibility criteria of the trials proving the effectiveness of SGLT2i. Utilization of SGLT2i increased from 1.2% in 2017 to 26.4% by January 2022. In comparison, of the 530 patients followed in the HFC, SGLT2i use increased from 9.8% in 2019 to 49.1 % by March 2022. SGLT2i use in the population-based cohort was associated with fewer all-cause mortality (aHR 0.51, 95% CI 0.41–0.63) and deaths/cardiovascular hospitalizations (aHR 0.65, 95% CI 0.54–0.77). However, SGLT2i usage rates were far lower in HF patients without DM (3.5% by March 2022 in the HFC cohort). ConclusionsDespite robust randomized trial evidence of clinical benefit, the uptake of SGLT2i in patients with HF and DM remains low, even in the specialized HFC. Clinical care strategies are needed to enhance the use of SGLT2i and improve implementation.

Catheter-based and surgical treatment of mitral valve diseases

There is abroad spectrum of mitral valve diseases ranging from young patients with rheumatic mitral valve stenosis up to older patients with secondary mitral valve regurgitation and numerous comorbidities. Aprofound understanding of the etiology, anatomical characteristics of mitral valve diseases and current treatment options is necessary to be able to prepare apatient-centered treatment approach. The interdisciplinary collaboration of referring physicians, interventional cardiologists, cardiac surgeons, heart failure and imaging specialists as well as anesthesiologists is acornerstone of optimal patient treatment.

The findings of a service evaluation on the practice of assessment and treatment of iron deficiency in people admitted to a UK hospital with decompensated Heart Failure

BackgroundIron Deficiency (ID) is common in Heart Failure (HF) and associated with poor outcomes. Replacement with intravenous (IV) iron can improve functional status, quality of life and risk of unplanned admission. In 2015/16 a local service evaluation was performed which found that of people admitted with HF, only 27.5 % had assessment of iron status, and when identified, replacement occurred in fewer than half. Education strategies were employed to increase awareness of the importance of assessment and correction. ObjectivesTo assess if practice had improved following education strategies. MethodsA review of 220 patient records for people admitted with HF in 2020/21 to establish if iron status assessed, presence of ID, and whether if ID identified it was treated, and by which route. Trends in 2020/21 data were explored in sub-groups by age, sex, type of HF, anaemia status, input from HF specialists and type of ID. ResultsCompared to 2015/16, more assessments of iron status were performed (45% vs 27.5 %), ID was corrected more frequently (57% vs 46 %) and increased use of the IV route for replacement (83% vs 58 %) ConclusionsDespite the impact of COVID-19 on usual care in 2020/21, improvement was seen in proportion of assessment and treatment of ID following simple education strategies for key stakeholders. There may be scope to improve practice further if the findings remain similar post pandemic. If so, a formal Quality Improvement approach may be helpful.

Performance of risk models to predict mortality risk for patients with heart failure: evaluation in an integrated health system.

Referral of patients with heart failure (HF) who are at high mortality risk for specialist evaluation is recommended. Yet, most tools for identifying such patients are difficult to implement in electronic health record (EHR) systems. To assess the performance and ease of implementation of Machine learning Assessment of RisK and EaRly mortality in Heart Failure (MARKER-HF), a machine-learning model that uses structured data that is readily available in the EHR, and compare it with two commonly used risk scores: the Seattle Heart Failure Model (SHFM) and Meta-Analysis Global Group in Chronic (MAGGIC) Heart Failure Risk Score. Retrospective, cohort study. Data from 6764 adults with HF were abstracted from EHRs at a large integrated health system from 1/1/10 to 12/31/19. One-year survival from time of first cardiology or primary care visit was estimated using MARKER-HF, SHFM, and MAGGIC. Discrimination was measured by the area under the receiver operating curve (AUC). Calibration was assessed graphically. Compared to MARKER-HF, both SHFM and MAGGIC required a considerably larger amount of data engineering and imputation to generate risk score estimates. MARKER-HF, SHFM, and MAGGIC exhibited similar discriminations with AUCs of 0.70 (0.69-0.73), 0.71 (0.69-0.72), and 0.71 (95% CI 0.70-0.73), respectively. All three scores showed good calibration across the full risk spectrum. These findings suggest that MARKER-HF, which uses readily available clinical and lab measurements in the EHR and required less imputation and data engineering than SHFM and MAGGIC, is an easier tool to identify high-risk patients in ambulatory clinics who could benefit from referral to a HF specialist.