Heart Failure Specialists Research Articles

Abstract 13531: Uptake of SGLT2i and Outcomes in Patients With Diabetes and Chronic Heart Failure: A Community-Based Cohort and a Specialized Clinic Cohort

Introduction: Sodium/glucose cotransporter 2 inhibitors (SGLT2i) have an established benefit in people with diabetes mellitus (DM) and chronic heart failure (HF). We aimed to evaluate the uptake and impact of these agents in two cohorts: a community-based cohort of all adults with DM and HF in Alberta who had an echocardiogram and a cohort of people with DM and HF being cared for in a specialized heart failure clinic (HFC). Methods: We identified the community-based cohort using validated ICD code-based case definitions for DM and HF (physician claims, outpatient, hospitalization databases) with an echocardiogram study (available from two major centres) from 2015 (when SGLT2i were available provincially) to March 2022. In addition, we identified the HFC cohort by chart review of patients seen in the Mazankowski Alberta Heart Institute HFCconsented between February 2018 and August 2021 with HF and DM and followed them until August 2022. We examined the association between SGLT2i use and all-cause mortality and/or cardiovascular (CV)-related hospitalizations using Cox proportional hazard models adjusted for clinical covariates and time-varying SGLT2i use. Results: In 12,150 people with DM and HF in the community-based cohort, 2,321 (19.1%) were dispensed an SGLT2i compared to 208 (39.2%) of the 530 patients with DM and HF followed in the HFC. SGLT2i was associated with less CV-related hospitalization and all-cause mortality (the composite outcome) (aHR 0.65 [95%CI 0.58 - 0.73]) in the community but no difference (aHR 0.88 [95% CI 0.64 - 1.21] in the HFC. SGLT2i use was associated with less all-cause mortality (aHR 0.50 [95% CI 0.44 - 0.57]) in the community but no difference (aHR 0.81 [95% CI 0.54 - 1.20]) in the HFC. Conclusion: Despite robust randomized trial evidence of clinical benefit, the uptake of SGLT2i even in people with DM and HF remains low. Although uptake is higher in a specialized HFC overall the rate is below optimal. Multifaceted Strategies (targeted to healthcare professionals, patients, and policymakers) to guide risk identification and raise awareness on the clinical benefits of these agents are warranted.

Abstract 18190: Role of Specialised Heart Failure Unit in Optimisation of Guideline-Directed Medical Therapy With Focus on Renal Function - Real World Data

Introduction: Guideline-directed medical therapy (GDMT) has proven to significantly reduce morbidity and mortality in Heart Failure. We highlighted the differences in renal function among HF patients managed on GDMT, comparing those within a dedicated HF unit (HFU) to those under General Medical (GM) and Geriatrics (GER). Aim: The purpose of this single-centre cohort study is to highlight differences in renal function outcome between these groups. Methods: Our database consists of 540 patients with AHF admitted to HFU or GM/GER from 01/08/2021 to 31/07/2022. We divided this group as follows: Group A : 267 patients from GM/GER. Group B : 273 patients in HFU.Groups were classified by ejection fraction(HFrEF/HFmrEF/HFpEF). We analyzed eGFR, K+ and Creatinine(Cr) on admission(adm) and discharge(dc). Results: Group A(GM/GER) : HFrEF patients had average eGFR of 45.70(mL/min) on adm and 43.58 on dc. HFmrEF subgroups had eGFR of 48.60 on adm and 46.54 on dc. HFpEF subgroups had eGFR of 50.16 on adm and 47.75 on dc. Group B(HFU): Patients with HFrEF had eGFR of 53.50 on adm and 50.74 on dc. HFmrEF subgroup had adm eGFR of 49.48 and 47.01 on dc. HFpEF subgroups had eGFR of 45.95 on adm and 41.72 on dc. Group A and B comparison : We have previously demonstrated (Fig.1) that among patients with AHF managed in HFU, there is better optimisation of GDMT. Within the HFrEF cohort, eGFR decreased -2.76 in Group B, with reduction of -2.12 in Group A. Group B HFmrEF showed reduced eGFR of -2.47; Group A decreased -2.06. In HFpEF, eGFR reduced -4.23 in Group B. In Group A, eGFR decreased -2.41. An inpatient mortality of 15.73% was calculated in Group A, contrasting significantly with 6.23% among the HFU cohort. Conclusion: This study highlights differences in renal function outcome between these two groups. It demonstrates that despite optimisation and initiation of GDMT in Group B - which may lead to concern for its impact on renal function - eGFR, Cr and K+ levels were not markedly different between both cohorts.

O038 Obstructive Sleep Apnoea Prevalence and Severity in a Specialist Heart Failure with Preserved Ejection Fraction (HFpEF) Clinic

Abstract Heart Failure with Preserved Ejection Fraction (HFpEF) is a debilitating, incurable form of HF associated with a normal left ventricular ejection fraction and elevated ventricular filling pressures. While Obstructive Sleep Apnoea (OSA) is common in HFpEF and OSA treatment may be associated with improved outcomes, the causal role of OSA in the pathophysiology of HFpEF remains unclear. Accordingly, accurate diagnosis and tracking of OSA in HFpEF patients is emerging as a potentially important approach for impacting prognosis. This study sought to identify the prevalence and severity of OSA in consecutive patients referred to a recently established tertiary hospital HFpEF clinic. All patients were confirmed to have HFpEF using standard clinical approaches and completed the Epworth Sleepiness Scale (ESS) to screen for sleep-disordered breathing and a level 2 polysomnogram to confirm OSA presence and severity. To date 28 patients have been assessed for OSA (9M/27F; Age 67±2y; BMI 35.0±1.6kg/m2; BNP 214±64ng/L). All 28 patients (100%) were diagnosed with OSA (AHI≥5 events/h), while 16 (57%) had moderate-severe OSA (AHI≥15 events/h). Average ESS was 7±1, with only 6 patients (21%) identified at risk for sleep-disordered breathing (ESS>9). These preliminary data confirm a very high prevalence of OSA in HFpEF patients when assessed via polysomnography. Furthermore, these patients appear asymptomatic in terms of sleepiness, as measured by the ESS. The nature of the association between OSA and HFpEF and the potential benefit of OSA treatment warrant study. Given that the ESS did not effectively identify OSA risk in HFpEF, alternative screening tools warrant consideration.

Diagnostic yield of a heart failure referral pathway using N-terminal pro-brain natriuretic peptide

ObjectiveTo determine the diagnostic yield of a ‘high’ N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with suspected heart failure (HF) referred from primary to secondary care.MethodsIn this retrospective study, cardiac...

Webtool to enhance the accuracy of diagnostic algorithms for HFpEF: a prospective cross-over study.

Diagnosis of heart failure with preserved ejection fraction (HFpEF) can be challenging. This study aimed to evaluate the potential of a webtool to enhance the scoring accuracy when applying the complex HFA-PEFF and H2 FPEF algorithms, which are commonly used for diagnosing HFpEF. We developed an online tool, the HFpEF calculator, that enables the automatic calculation of current HFpEF algorithms. We assessed the accuracy of manual vs. automatic scoring, defined as the percentage of correct scores, in a cohort of cardiologists with varying clinical experience. Cardiologists scored eight online clinical cases using a triple cross-over design (i.e. two manual-two automatic-two manual-two automatic). Data were analysed in study completers (n=55, 29% heart failure specialists, 42% general cardiologists, and 29% cardiology residents). Manually calculated scores were correct in 50% (HFA-PEFF: 50% [50-75]; H2 FPEF: 50% [38-50]). Correct scoring improved to 100% using the HFpEF calculator (HFA-PEFF: 100% [88-100], P<0.001; H2 FPEF: 100% [75-100], P<0.001). Time spent on clinical cases was similar between scoring methods (±4min). When corrections for faulty algorithm scores were displayed, cardiologists changed their diagnostic decision in up to 67% of cases. At least 67% of cardiologists preferred using the online tool for future cases in clinical practice. Manual calculation of HFpEF diagnostic algorithms is often inaccurate. Using an automated webtool to calculate HFpEF algorithms significantly improved correct scoring. This new approach may impact the eventual diagnostic decision in up to two-thirds of cases, supporting its routine use in clinical practice.

Missed opportunities in the diagnosis of heart failure: a real-world assessment.

Heart failure (HF) is a leading cause of hospitalization worldwide. An early HF diagnosis is key to reducing hospitalizations. We used electronic health records (EHRs) to characterize HF pathways at the primary care physician (PCP) level prior to a first HF hospitalization (hHF). This study aimed to identify missed opportunities for HF diagnosis and management at the PCP level before a first hHF. This cohort study used EHRs of a large health care organization in Portugal. Patients with incident hHF between 2017 and 2020 were identified. Missed opportunities were defined by the absence of any of the following work-up in the 6months after signs or symptoms had been recorded: lab results and electrocardiogram, natriuretic peptides, echocardiogram, referral to HF specialist, or HF medication initiation. A total of 2436 patients with a first hHF were identified. The median (interquartile range) age at the time of hospitalization was 81 (14) years, and 1361 (56%) were women. Most patients were treated with cardiovascular drugs prior or at index event. A total of 720 (30%) patients had records of HF signs or symptoms, 94% (n=674) within 6months prior to hHF. Among patients with recorded HF signs or symptoms, 410 (57%) had clinical management considered adequate before signs and symptoms were recorded. Of the 310 remaining patients, 155 (50%) had a follow-up that was considered inadequate. Relatively few patients with a first hHF had primary care records of signs or symptoms prior to admission. Of these, nearly half had inadequate management considering diagnosis and treatment. These data suggest the need to improve PCP HF awareness.

Differences between heart failure specialists and non-specialists regarding heart failure drug implementation and up-titration.

Differences between heart failure specialists and non-specialists regarding heart failure drug implementation and up-titration.

Clonal Hematopoiesis of Indeterminate Potential From a Heart Failure Specialist's Point of View.

Clonal hematopoiesis of indeterminate potential (CHIP) is a common bone marrow abnormality induced by age-related DNA mutations, which give rise to proinflammatory immune cells. These immune cells exacerbate atherosclerotic cardiovascular disease and may induce or accelerate heart failure. The mechanisms involved are complex but point toward a central role for proinflammatory macrophages and an inflammasome-dependent immune response (IL-1 [interleukin-1] and IL-6 [interleukin-6]) in the atherosclerotic plaque or directly in the myocardium. Intracardiac inflammation may decrease cardiac function and induce cardiac fibrosis, even in the absence of atherosclerotic cardiovascular disease. The pathophysiology and consequences of CHIP may differ among implicated genes as well as subgroups of patients with heart failure, based on cause (ischemic versus nonischemic) and ejection fraction (reduced ejection fraction versus preserved ejection fraction). Evidence is accumulating that CHIP is associated with cardiovascular mortality in ischemic and nonischemic heart failure with reduced ejection fraction and involved in the development of heart failure with preserved ejection fraction. CHIP and corresponding inflammatory pathways provide a highly potent therapeutic target. Randomized controlled trials in patients with well-phenotyped heart failure, where readily available anti-inflammatory therapies are used to intervene with clonal hematopoiesis, may pave the way for a new area of heart failure treatment. The first clinical trials that target CHIP are already registered.

Impact of Specialised Heart Failure Care at Home on Readmissions: Challenges and Opportunities

Impact of Specialised Heart Failure Care at Home on Readmissions: Challenges and Opportunities

Providing Specialised Heart Failure Care at Home: Challenges in Reducing Readmission

Providing Specialised Heart Failure Care at Home: Challenges in Reducing Readmission

Variation in Hemodynamic Assessment and Interpretation: A Call to Standardize the Right Heart Catheterization

BackgroundInvasive hemodynamic measurement via right heart catheterization has shown divergent data in its role in the treatment of patients with heart failure (HF) and cardiogenic shock. We hypothesized that variation in data acquisition technique and interpretation might contribute to these observations. We sought to assess differences in hemodynamic acquisition and interpretation by operator subspecialty as well as level of experience. Methods and ResultsIndividual-level responses to how physicians both collect and interpret hemodynamic data at the time of right heart catheterization was solicited via a survey distributed to international professional societies in HF and interventional cardiology. Data were stratified both by operator subspecialty (HF specialists or interventional cardiologists [IC]) and operator experience (early career [≤10 years from training] or late career [>10 years from training]) to determine variations in clinical practice. For the sensitivity analysis, we also look at differences in each subgroup. A total of 261 responses were received. There were 141 clinicians (52%) who self-identified as HF specialists, 99 (38%) identified as IC, and 20 (8%) identified as other. There were 142 early career providers (54%) and late career providers (119 [46%]). When recording hemodynamic values, there was considerable variation in practice patterns, regardless of subspecialty or level of experience for the majority of the intracardiac variables. There was no agreement or mild agreement among HF and IC as to when to record right atrial pressures or pulmonary capillary wedge pressures. HF cardiologists were more likely to routinely measure both Fick and thermodilution cardiac output compared with IC (51% vs 29%, P < .001), something mirrored in early career vs later career cardiologists. ConclusionsSignificant variation exists between the acquisition and interpretation of right heart catheterization measurements between HF and IC, as well as those early and late in their careers. With the growth of the heart team approach to management of patients in cardiogenic shock, standardization of both assessment and management practices is needed.

Perspective on AHFTC Specialty by Women in Heart Transplant and MCS (WiTMCS)

BackgroundThe advanced heart failure (HF) and transplant cardiology specialty has seen a decrease in applicants seeking training in the field. Data are needed to identify principal reform areas to generate and maintain interest in the field for sustainability. MethodsWomen in Transplant and Mechanical Circulatory support conducted a survey across their membership group investigating the barriers to attracting new talent and areas that need reform to improve the status of the specialty. A Likert scale was used to assess various perceived barriers to attracting new trainees and reform needed to improve the specialty. ResultsA total of 131 women physicians in transplant and mechanical circulatory support responded to the survey. Five principal areas in need of reform were identified: need for practice model variety (86.9%), inadequate compensation for non–revenue value unit activities and total compensation (86.4% and 79.1%, respectively), challenging work–life balance (78.5%), need for curriculum reform and specialized pathways (73.1% and 65.4%, respectively), and exposure during general cardiology fellowship (65.1%). ConclusionGiven the increasing number of patients with HF and the increased demand for more HF specialists, reform is needed to restructure the 5 areas identified in our survey to increase interest in the field of advanced HF and transplant cardiology and maintain the current talent.

Smartphone-Based Remote Monitoring for Chronic Heart Failure: Mixed Methods Analysis of User Experience From Patient and Nurse Perspectives.

Community-based management by heart failure specialist nurses (HFSNs) is key to improving self-care in heart failure with reduced ejection fraction. Remote monitoring (RM) can aid nurse-led management, but in the literature, user feedback evaluation is skewed in favor of the patient rather than nursing user experience. Furthermore, the ways in which different groups use the same RM platform at the same time are rarely directly compared in the literature. We present a balanced semantic analysis of user feedback from patient and nurse perspectives of Luscii, a smartphone-based RM strategy combining self-measurement of vital signs, instant messaging, and e-learning. This study aims to (1) evaluate how patients and nurses use this type of RM (usage type), (2) evaluate patients' and nurses' user feedback on this type of RM (user experience), and (3) directly compare the usage type and user experience of patients and nurses using the same type of RM platform at the same time. We performed a retrospective usage type and user experience evaluation of the RM platform from the perspective of both patients with heart failure with reduced ejection fraction and the HFSNs using the platform to manage them. We conducted semantic analysis of written patient feedback provided via the platform and a focus group of 6 HFSNs. Additionally, as an indirect measure of tablet adherence, self-measured vital signs (blood pressure, heart rate, and body mass) were extracted from the RM platform at onboarding and 3 months later. Paired 2-tailed t tests were used to evaluate differences between mean scores across the 2 timepoints. A total of 79 patients (mean age 62 years; 35%, 28/79 female) were included. Semantic analysis of usage type revealed extensive, bidirectional information exchange between patients and HFSNs using the platform. Semantic analysis of user experience demonstrates a range of positive and negative perspectives. Positive impacts included increased patient engagement, convenience for both user groups, and continuity of care. Negative impacts included information overload for patients and increased workload for nurses. After the patients used the platform for 3 months, they showed significant reductions in heart rate (P=.004) and blood pressure (P=.008) but not body mass (P=.97) compared with onboarding. Smartphone-based RM with messaging and e-learning facilitates bilateral information sharing between patients and nurses on a range of topics. Patient and nurse user experience is largely positive and symmetrical, but there are possible negative impacts on patient attention and nurse workload. We recommend RM providers involve patient and nurse users in platform development, including recognition of RM usage in nursing job plans.

Practice patterns in extracorporeal life support in tertiary cardiac intensive care units in north america: a survey-based analysis from the critical care cardiology trials network

Abstract Funding Acknowledgements Type of funding sources: None. Background The use of veno-arterial (VA) and veno-venous (VV) extracorporeal membrane oxygenation (ECMO) has significantly increased in the last decade. However, there is substantial variability in practice patterns between institutions. To date, the optimal ECMO program model is unclear and possible differences between ECMO centers in staffing, organization and team structure have been poorly characterized. Purpose Our aim was to describe contemporary practices of care for patients undergoing ECMO in tertiary cardiac centers in North America. Methods An 11-question anonymous survey was sent to all participating sites in the Critical Care Cardiology Trials Network (CCCTN), a prospective registry of advanced cardiac intensive care units (CICUs) in North America, coordinated by the TIMI Study Group. The survey evaluated ECMO staffing models, decision-making processes, cannulation and longitudinal care. Results The response rate was 100% (39/39) across CCCTN centers. The decision to proceed with VA ECMO was made as a team in 79% of the cases and in 58.3% of the VV ECMO cases, rather than by an individual specialty. An ECMO consult service was used in 67% of the centers, and integrated with the cardiogenic shock team in 58%. The most common specialty participating in the ECMO service was cardiothoracic surgery (CTS) (73.1%), followed by heart failure specialists (38.5%), with critical care cardiology (CCC) in only 23.1% of the centers (Figure 1A). In the majority of centers, VA ECMO cannulation was performed by CTS alone (46.2%), Interventional cardiology (IC) and CTS (38.5%), and IC alone (7.7%, Figure 1B). Cannulation for VA ECMO was not performed by intensivists at any center. VV ECMO cannulations were performed by CTS in 51.3%, intensivists in 17.9% and IC in 2.6% of the centers. VA ECMO patients were admitted to the cardiovascular surgical intensive care unit in 64.1% of centers, with 20.5 % admitted to the CICU (Figure 1C). VV ECMO patients were admitted to the cardiovascular surgical intensive care unit in 36.8% of sites, and the medical intensive care unit in 34.2%. The most common ECMO specialist model was having a perfusionist at the bedside, followed by nurse specialist (Figure 1D). Specialty services consulted within 24-48 hours of cannulation included physical therapy in 48.7%, palliative care in 30.8%, and bioethics in only 2.6% of centers. Simulation-based ECMO training is performed in 59% of the centers. Half (51.3%) of the centers perform ECPR, while 17.9% reported plans of developing a program. Conclusions Although there is significant variability in ECMO cannulation, location of care, staffing practices in advanced CICUs in North America, a multidisciplinary team approach is common in ECMO centers, with early involvement of physical therapy and palliative care specialists. Further research to establish the optimal model for ECMO programs is of high importance.

Guideline-Directed Medical Therapy Tolerability in Patients With Heart Failure and Mitral Regurgitation: The COAPT Trial

BackgroundIn the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial, a central committee of heart failure (HF) specialists optimized guideline-directed medical therapies (GDMT) and documented medication and goal dose intolerances before patient enrollment. ObjectivesThe authors sought to assess the rates, reasons, and predictors of GDMT intolerance in the COAPT trial. MethodsBaseline use, dose, and intolerances of angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), angiotensin receptor neprilysin inhibitors (ARNIs), beta-blockers, and mineralocorticoid receptor antagonists (MRAs) were analyzed in patients with left ventricular ejection fraction (LVEF) ≤40%, in whom maximally tolerated doses of these agents as assessed by an independent HF specialist were required before enrollment. ResultsA total of 464 patients had LVEF ≤40% and complete medication information. At baseline, 38.8%, 39.4%, and 19.8% of patients tolerated 3, 2, and 1 GDMT classes, respectively (any dose); only 1.9% could not tolerate any GDMT. Beta-blockers were the most frequently tolerated GDMT (93.1%), followed by ACEIs/ARBs/ARNIs (68.5%), and then MRAs (55.0%). Intolerances differed by GDMT class, but hypotension and kidney dysfunction were most common. Goal doses were uncommonly achieved for beta-blockers (32.3%) and ACEIs/ARBs/ARNIs (10.2%) due to intolerances limiting titration. Only 2.2% of patients tolerated goal doses of all 3 GDMT classes. ConclusionsIn a contemporary trial population with HF, severe mitral regurgitation, and systematic HF specialist-directed GDMT optimization, most patients had medical intolerances prohibiting 1 or more GDMT classes and achieving goal doses. The specific intolerances noted and methods used for GDMT optimization provide important lessons for the implementation of GDMT optimization in future clinical trials. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [The COAPT Trial] [COAPT]; NCT01626079)

Successful Deployment Of A Novel Intermittent SVC Occlusion System For Acute Decompensated Heart Failure By A Heart Failure Specialist

Successful Deployment Of A Novel Intermittent SVC Occlusion System For Acute Decompensated Heart Failure By A Heart Failure Specialist

Clinical course and therapy optimization of patients after discharge from a specialized heart failure clinic.

Aim: We aimed to describe the clinical course of patients with heart failure with reduced ejection fraction (HFrEF) after discharge from the heart failure clinics (HFC). Patients & methods: We reviewed the hospital's records of 610 patients that were discharged between 2013 and 2018 from the HFC at a single centre. Patients with no recurrent contact to ambulatory cardiac care were invited to an echocardiographic assessment. Results: Of the survivors, 72% were re-referred after discharge. Nearly 30% of the patients with no recurrent contact with ambulatory cardiac care had persistent HFrEF and further therapeutical optimizations were indicated in half of them. Conclusion: This highlights the importance to identify high-risk patients that would benefit from extended management in the HFC.

Primary care Adherence To Heart Failure guidelines IN Diagnosis, Evaluation and Routine management (PATHFINDER): a randomised controlled trial protocol

IntroductionGeneral practitioners (GPs) routinely provide care for patients with heart failure (HF); however, adherence to management guidelines, including titrating medication to optimal dose, can be challenging in this setting. This...

Considerations for Advanced Heart Failure Consultation in Individuals With Fontan Circulation: Recommendations From ACTION.

Individuals with Fontan circulation are at risk of late mortality from both cardiac and noncardiac causes. Despite the known risk of mortality, referral indications for advanced heart failure care vary between centers, and many individuals die from Fontan circulation-related complications either after late consideration for advanced heart failure therapies or having never seen a heart failure specialist. There is a critical need for guidelines to direct appropriately timed referral for advanced heart failure consultation. The Advanced Cardiac Therapies Improving Outcomes Network (ACTION) Fontan Committee has developed recommended thresholds for advanced heart failure referral to guide primary cardiologists. These recommendations are divided into 4 categories of clinical Fontan circulatory dysfunction including (1) cardiac/systemic ventricular dysfunction, (2) Fontan pathway dysfunction, (3) lymphatic dysfunction, and (4) extracardiac dysfunction.

Emerging concepts in heart failure management and treatment: circulatory support with extracorporeal membrane oxygenation (ECMO).

Circulatory support with extracorporeal membrane oxygenation (ECMO) is being increasingly used in several critical situations but evidence of its impact on outcomes is inconsistent. Understanding of the specific indications and appropriate timing of implantation of this technology might lead to improved results. Indeed, the line between success and futility may be sometimes very thin when facing a patient in critical condition. New techniques with lighter, simpler and effective devices are being developed. Hence, ECMO has become an accessible technology that is being increasingly used outside of the operating room by heart failure specialists, critical care cardiologists and intensivists. Proper timing of utilization and choice of device may lead to better outcomes. We herein aim to improve this knowledge gap by conducting a literature review to provide simple information, evidence-based indications and a practical approach for cardiologists who may encounter acutely ill adult patients that may be ECMO candidates. This article is part of the Emerging concepts in heart failure management and treatment Special Issue: https://www.drugsincontext.com/special_issues/emerging-concepts-in-heart-failure-management-and-treatment.