Severe Heart Failure Symptoms Research Articles

Cardiomyopathy Management and In-Hospital Outcomes in a Tertiary Care Center: Clinical Components and Venues of Advanced Care.

BackgroundThere are few reports on the prevalence of different types of cardiomyopathy, clinical presentation, severity, short-term outcomes, and implementation of advanced heart failure treatment. This study aimed to assess the prevalence, clinical background of different types of cardiomyopathy and to identify the candidate for advanced treatment in a tertiary care cardiac center with many advantages MethodA single-center retrospective cohort study included 1069 patients admitted to our center and diagnosed with cardiomyopathy during 2019 and 2020 ResultsOut of 1069 cardiomyopathy patients admitted and diagnosed at our center between 2019 and 2020, 62% had ischemic cardiomyopathy (ICM), 36% had dilated cardiomyopathy (DCM), and 2% had hypertrophic cardiomyopathy (HOCM). ICM patients were older, showed a higher prevalence of both male gender and pilgrims, and they had more frequent cardiovascular risk factors compared to dilated cardiomyopathy group of patients. However, DCM patients with more severe heart failure symptoms (NYHA class III/IV), much worse LVEF, were subsequently considered deemed for aggressive diuretic therapy, and further advanced therapy (Sacubitril-Valsartan and device therapy) compared to ICM patients. ICM patients showed poor in-hospital outcomes compared to DCM group of patients (0.05 and <0.001) for an indication for mechanical ventilation and in-hospital mortality, respectively). Increased age, presence of renal dysfunction and lower LVEF were found the independent predictors of in-hospital mortality among our studied patients ConclusionThere are discrepancies between DCM and ICM patients. Although DCM patients were younger at age and had fewer cardiovascular risk factors, they presented with severe symptoms and dysfunction, hence more eligible candidates for advanced heart failure treatment, and finally showed a lower mortality rate. Increased age, presence of renal dysfunction and lower LVEF were found the independent predictors of in-hospital mortality.

Protocolo diagnóstico de la pericarditis constrictiva

Constrictive pericarditis is a rare pericardial disease in which a rigid, inelastic, non-distensible pericardium leads to severe diastolic dysfunction and symptoms of heart failure that is mainly right-sided. It has a significant repercussion on functional capacity and quality of life in patients who suffer from it. Although cardiac catheterization has traditionally been considered the gold standard hemodynamic evaluation for this disease, advances in cardiac imaging techniques—and in the use of multimodal imaging in particular—now allow for conducting a suitable, noninvasive diagnostic approach. A radical pericardiectomy is the treatment of choice for chronic forms of the disease. Anti-inflammatory agents can be tried in patients who are in the early stages of the disease and have signs of active pericardial inflammation on imaging tests. Prognosis following surgery varies. A series of factors of poor prognosis have been identified, which include advanced age, poor preoperative functional class, or radiology as the etiology.

Pericarditis constrictiva

Constrictive pericarditis is a rare pericardial disease in which a rigid, inelastic, non-distensible pericardium leads to severe diastolic dysfunction and symptoms of heart failure that is mainly right-sided. It has a significant repercussion on functional capacity and quality of life in patients who suffer from it. Although cardiac catheterization has traditionally been considered the gold standard hemodynamic evaluation for this disease, advances in cardiac imaging techniques—and in the use of multimodal imaging in particular—now allow for conducting a suitable, noninvasive diagnostic approach. A radical pericardiectomy is the treatment of choice for chronic forms of the disease. Anti-inflammatory agents can be tried in patients who are in the early stages of the disease and have signs of active pericardial inflammation on imaging tests. Prognosis following surgery varies. A series of factors of poor prognosis have been identified, which include advanced age, poor preoperative functional class, or radiology as the etiology.

Haemodynamic-guided management of heart failure (GUIDE-HF): a randomised controlled trial

Previous studies have suggested that haemodynamic-guided management using an implantable pulmonary artery pressure monitor reduces heart failure hospitalisations in patients with moderately symptomatic (New York Heart Association [NYHA] functional class III) chronic heart failure and a hospitalisation in the past year, irrespective of ejection fraction. It is unclear if these benefits extend to patients with mild (NYHA functional class II) or severe (NYHA functional class IV) symptoms of heart failure or to patients with elevated natriuretic peptides without a recent heart failure hospitalisation. This trial was designed to evaluate whether haemodynamic-guided management using remote pulmonary artery pressure monitoring could reduce heart failure events and mortality in patients with heart failure across the spectrum of symptom severity (NYHA funational class II-IV), including those with elevated natriuretic peptides but without a recent heart failure hospitalisation. The randomised arm of the haemodynamic-GUIDEed management of Heart Failure (GUIDE-HF) trial was a multicentre, single-blind study at 118 centres in the USA and Canada. Following successful implantation of a pulmonary artery pressure monitor, patients with all ejection fractions, NYHA functional class II-IV chronic heart failure, and either a recent heart failure hospitalisation or elevated natriuretic peptides (based on a-priori thresholds) were randomly assigned (1:1) to either haemodynamic-guided heart failure management based on pulmonary artery pressure or a usual care control group. Patients were masked to their study group assignment. Investigators were aware of treatment assignment but did not have access to pulmonary artery pressure data for control patients. The primary endpoint was a composite of all-cause mortality and total heart failure events (heart failure hospitalisations and urgent heart failure hospital visits) at 12 months assessed in all randomly assigned patients. Safety was assessed in all patients. A pre-COVID-19 impact analysis for the primary and secondary outcomes was prespecified. This study is registered with ClinicalTrials.gov, NCT03387813. Between March 15, 2018, and Dec 20, 2019, 1022 patients were enrolled, with 1000 patients implanted successfully, and follow-up was completed on Jan 8, 2021. There were 253 primary endpoint events (0·563 per patient-year) among 497 patients in the haemodynamic-guided management group (treatment group) and 289 (0·640 per patient-year) in 503 patients in the control group (hazard ratio [HR] 0·88, 95% CI 0·74-1·05; p=0·16). A prespecified COVID-19 sensitivity analysis using a time-dependent variable to compare events before COVID-19 and during the pandemic suggested a treatment interaction (pinteraction=0·11) due to a change in the primary endpoint event rate during the pandemic phase of the trial, warranting a pre-COVID-19 impact analysis. In the pre-COVID-19 impact analysis, there were 177 primary events (0·553 per patient-year) in the intervention group and 224 events (0·682 per patient-year) in the control group (HR 0·81, 95% CI 0·66-1·00; p=0·049). This difference in primary events almost disappeared during COVID-19, with a 21% decrease in the control group (0·536 per patient-year) relative to pre-COVID-19, virtually no change in the treatment group (0·597 per patient-year), and no difference between groups (HR 1·11, 95% CI 0·80-1·55; p=0·53). The cumulative incidence of heart failure events was not reduced by haemodynamic-guided management (0·85, 0·70-1·03; p=0·096) in the overall study analysis but was significantly decreased in the pre-COVID-19 impact analysis (0·76, 0·61-0·95; p=0·014). 1014 (99%) of 1022 patients had freedom from device or system-related complications. Haemodynamic-guided management of heart failure did not result in a lower composite endpoint rate of mortality and total heart failure events compared with the control group in the overall study analysis. However, a pre-COVID-19 impact analysis indicated a possible benefit of haemodynamic-guided management on the primary outcome in the pre-COVID-19 period, primarily driven by a lower heart failure hospitalisation rate compared with the control group. Abbott.

Surgical versus transcatheter repair for secondary mitral regurgitation: A propensity score–matched cohorts comparison

ObjectivesTo compare the efficacy and clinical outcomes of transcatheter edge-to-edge mitral valve repair (TMVr) and surgical mitral valve repair (SMVr) among patients with secondary mitral regurgitation (SMR). MethodsConsecutive patients with SMR treated using either TMVr (n = 199) or SMVr (n = 222) at 2 centers were included and retrospectively analyzed. To account for differences in patient demographic characteristics, 1:1 propensity score matching was performed. The primary endpoint was all-cause death within 2 years after the procedure. ResultsThe study population consisted of 202 matched patients. At 2 years, all-cause mortality was 24.3% for TMVr and 23.0% for SMVr (hazard ratio, 0.97; 95% confidence interval, 0.55-1.71; P = .909). Severe heart failure symptoms at 2 years were less prevalent after SMVr (New York Heart Association functional class III or IV: 13.5% vs 29.5%; P = .032) than after TMVr. A higher proportion of the SMVr patients had SMR reduction to none or mild at discharge (90.8% vs 72.0%; P < .001) and 2 years (86.5% vs 59.6%; P < .001). Among patients who achieved none or mild MR at discharge, 7 patients (10.1%) in the SMVr group and 15 (34.9%) in the TMVr group had progression to moderate or greater MR at 2 years (P = .003). Left ventricular ejection fraction (LVEF) significantly improved (+10.1% ± 11.1%; P < .001) after SMVr (LVEF at 2 years: 45.7% ± 12.8%), whereas it remained unchanged (–1.3% ± 8.9%; P = .260) after TMVr (LVEF at 2 years: 34.0% ± 13.2%). ConclusionsIn this propensity score-matched analysis, there was no significant difference in 2-year survival between TMVr and SMVr, despite greater and more durable SMR reduction, as well as LVEF improvement in the surgical group.

Magnetic resonance imaging of dilated cardiomyopathy: prognostic benefit of identifying late gadolinium enhancement in Asian patients.

Risk stratification in dilated cardiomyopathy (DCM) is imprecise, relying largely on echocardiographic left ventricular ejection fraction (LVEF) and severity of heart failure symptoms. Adverse cardiovascular events are increased by the presence of myocardial scarring. Late gadolinium enhancement (LGE) on cardiovascular magnetic resonance (CMR) imaging is the gold standard for identifying myocardial scars. We examined the association between LGE on CMR imaging and adverse clinical outcomes during long-term follow-up of Asian patients with DCM. Consecutive patients with DCM undergoing CMR imaging at a single Asian academic medical centre between 2005 and 2015 were recruited. Clinical outcomes were tracked using comprehensive electronic medical records and mortality was determined by cross-linkages with national registries. Presence and distribution of LGE on CMR imaging were determined by investigators blinded to patient outcomes. Primary endpoint was a composite of heart failure hospitalisations, appropriate implantable cardioverter-defibrillator shocks and cardiovascular mortality. Of 86 patients, 64.0% had LGE (80.2% male; mean LVEF 30.1% ± 12.7%). Mid-wall fibrosis (71.7%) was the most common pattern of LGE distribution. Over a mean follow-up period of 4.9 ± 3.2 years, 19 (34.5%) patients with LGE reached the composite endpoint compared to 4 (12.9%) patients without LGE (p = 0.01). Presence of LGE, but not echocardiographic LVEF, independently predicted the primary endpoint (hazard ratio 4.15 [95% confidence interval 1.28-13.50]; p = 0.02). LGE presence independently predicted adverse clinical events in Asian patients with DCM. Routine use of CMR imaging to characterise the myocardial substrate is recommended for enhanced risk stratification and should strongly influence clinical management.

Dosing of losartan in men versus women with heart failure with reduced ejection fraction: the HEAAL trial.

In heart failure with reduced ejection fraction (HFrEF), guidelines recommend up-titration of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptors blockers (ARBs) to the maximum tolerated dose. However, some studies suggest that women might need lower doses of ACEi/ARBs than men to achieve similar treatment benefit. The HEAAL trial compared low vs. high dose of losartan. We reassessed the efficacy and safety of high- vs. low-dose in men vs. women using Cox models and machine learning algorithms. The mean age was 66 years and 30% of patients were women. Men appeared to have benefited more from high-dose than from low-dose losartan, whereas women appeared to have responded similarly to low and high doses [hazard ratio (95% confidence interval) comparing high- vs. low-dose losartan for the composite outcome of all-cause death or all-cause hospitalization: 0.89 (0.81-0.98) in men and 1.10 (0.95-1.28) in women; interaction P= 0.018]. Female sex clustered along with older age, ischaemic heart failure, New York Heart Association class III/IV, and estimated glomerular filtration rate <60 mL/min. Patients with these features had a poorer response to high-dose losartan. Subgroup analyses supported no benefit from high-dose losartan in patients with poorer kidney function and severe heart failure symptoms. Compared with men, women might need lower doses of losartan to achieve similar treatment benefit. However, beyond sex, other factors (e.g. kidney function, age, and symptoms) may influence the response to high-dose losartan, suggesting that sex-based subgroup findings may be biased by other confounders.

Perceptions of Need for Palliative Care in Recently Hospitalized Patients With Systolic Heart Failure

ContextThe symptom burden associated with heart failure (HF) remains high despite improvements in therapy and calls for the integration of palliative care into traditional HF care. Little is also known about how patients with HF perceive palliative care and patient-level characteristics associated with the need for palliative care, which could influence the utilization of palliative care in HF management. ObjectivesTo identify characteristics of HF patients associated with perceived need for palliative care. MethodsWe analyzed data from the Hopeful Heart Trial, which studied the efficacy of a collaborative care intervention for treating both systolic HF and depression. Palliative care preferences were collected during routine study follow-up. We assessed the association of perceived need for palliative care during study follow-up and baseline data on sociodemographics, clinical measures, and patient-centered outcomes. We then used descriptive statistics and logistic regression to analyze our data. ResultsParticipants were on average 64 years old, male, and reported severe HF symptoms and poor to below average quality of life (. Most had unfavorable impressions of palliative care, but many still perceived a need for palliative care. Factors associated with perceived need for palliative care included depression, non-white race, more severe HF symptoms, and lower mental & physical health-related quality of life. ConclusionHF patients’ beliefs about palliative care may affect utilization of palliative care. Specific characteristics can help identify patients with HF who may benefit from palliative care involvement. Education targeted towards patients with selected attributes may help incorporate palliative care into HF management.

Health-Related Quality of Life and Mortality in Heart Failure: The Global Congestive Heart Failure Study of 23 000 Patients From 40 Countries.

Poor health-related quality of life (HRQL) is common in heart failure (HF), but there are few data on HRQL in HF and the association between HRQL and mortality outside Western countries. We used the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) to record HRQL in 23 291 patients with HF from 40 countries in 8 different world regions in the G-CHF study (Global Congestive Heart Failure). We compared standardized KCCQ-12 summary scores (adjusted for age, sex, and markers of HF severity) among regions (scores range from 0 to 100, with higher score indicating better HRQL). We used multivariable Cox regression with adjustment for 15 variables to assess the association between KCCQ-12 summary scores and the composite of all-cause death, HF hospitalization, and each component over a median follow-up of 1.6 years. The mean age of participants was 65 years; 61% were men; 40% had New York Heart Association class III or IV symptoms; and 46% had left ventricular ejection fraction ≥40%. Average HRQL differed between regions (lowest in Africa [mean± SE, 39.5±0.3], highest in Western Europe [62.5±0.4]). There were 4460 (19%) deaths, 3885 (17%) HF hospitalizations, and 6949 (30%) instances of either event. Lower KCCQ-12 summary score was associated with higher risk of all outcomes; the adjusted hazard ratio (HR) for each 10-unit KCCQ-12 summary score decrement was 1.18 (95% CI, 1.17-1.20) for death. Although this association was observed in all regions, it was less marked in South Asia, South America, and Africa (weakest association in South Asia: HR, 1.08 [95% CI, 1.03-1.14]; strongest association in Eastern Europe: HR, 1.31 [95% CI, 1.21-1.42]; interaction P<0.0001). Lower HRQL predicted death in patients with New York Heart Association class I or II and III or IV symptoms (HR, 1.17 [95% CI, 1.14-1.19] and HR, 1.14 [95% CI, 1.12-1.17]; interaction P=0.13) and was a stronger predictor for the composite outcome in New York Heart Association class I or II versus class III or IV (HR 1.15 [95% CI, 1.13-1.17] versus 1.09 [95% CI, [1.07-1.11]; interaction P<0.0001). HR for death was greater in ejection fraction ≥40 versus <40% (HR, 1.23 [95% CI, 1.20-1.26] and HR, 1.15 [95% CI, 1.13-1.17]; interaction P<0.0001). HRQL is a strong and independent predictor of all-cause death and HF hospitalization across all geographic regions, in mildly and severe symptomatic HF, and among patients with preserved and reduced ejection fraction. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03078166.

Not all fluid overloads are the same: some practical considerations for better decongestion

Not all fluid overloads are the same: some practical considerations for better decongestion

Recurrence of Gerbode Defect despite Surgical Repair in a Patient with Bacterial Endocarditis

Gerbode defect refers to an abnormal communication of the left ventricle (LV) with the right atrium (RA), causing a severe left-to-right shunt. Symptoms of gerbode defect depend on the degree of communication between LV and RA. This defect can be congenital or acquired. Some etiologies of acquired gerbode defect include cardiac trauma, myocardial ischemia, a complication of prior cardiac surgery, or bacterial endocarditis. Regardless of the etiology, surgical intervention involving the closure of the defect is the definitive treatment of this rare anatomical anomaly. We present the case of a young man with an acquired gerbode defect as a complication of bacterial endocarditis for which he underwent surgical correction. He later had a recurrence and worsening of left-to-right shunt via the gerbode defect a few days after the first surgery, requiring another surgical intervention. To our knowledge, recurrence of this defect after a surgical repair has so far not been reported in the literature. Therefore, we conclude that patients presenting with symptoms of severe right heart failure in whom prior surgical repair of the gerbode defect is performed should prompt clinicians to rule out recurrence of this defect.

Recurrent Granulomatous Myocarditis after Heart Transplant

<h3>Introduction</h3> Recurrent granulomatous myocarditis is an uncommon phenomenon after heart transplantation. We present a case of late recurrent granulomatous myocarditis after heart transplant. <h3>Case Report</h3> A previously healthy gentleman presented with complete heart block requiring placement of a permanent pacemaker. He subsequently developed reduced left ventricular function and progressive heart failure, prompting an endomyocardial biopsy which revealed granulomatous myocarditis. He was treated with steroids but his symptoms progressed and ultimately underwent orthotopic heart transplant. Pathologic examination of the explanted heart revealed "Florid granulomatous inflammation throughout the myocardium, with dense scar that is patchy and irregularly distributed." 7 Years after transplant he developed severe rapid onset heart failure symptoms. Transthoracic echocardiography revealed a newly reduced left ventricular ejection fraction of 35 %. Urgent catheterization and endomyocardial biopsy was performed revealing mild single vessel allograft vasculopathy, mildly elevated filling pressures and a cardiac index of 2 liters per minute per meter squared. Pathologic examination of the biopsy revealed myocardium with significant inflammation including numerous eosinophils and scattered multinucleated giant cells with myocyte damage. Cardiac magnetic resonance imaging (CMR) was performed revealing late gadolinium enhancement in the apical lateral, and basal anteroseptal walls [Figure] with prolonged T2 time suggestive of edema. He was treated with high dose steroids, intravenous diuretics were administered, and he clinically recovered symptomatically and continues to follow in clinic. <h3>Summary</h3> Granulomatous myocarditis caused by giant cell myocarditis or cardiac sarcoidosis can lead to end stage heart failure and necessity for heart transplant. Recurrence of the granulomatous inflammation can lead to graft dysfunction and can be identified by endomyocardial biopsy as well as noninvasive imaging with CMR.

12-Month outcomes of transcatheter tricuspid valve repair with the PASCAL system for severe tricuspid regurgitation.

We investigated the durability of tricuspid regurgitation (TR) reduction and the clinical outcomes through 12 months after transcatheter tricuspid valve repair (TTVr) with the PASCAL Transcatheter Valve Repair System. TTVr has rapidly developed and demonstrated favorable acute outcomes, but longer follow-up data are needed. Overall, 30 patients (age 77 ± 6 years; 57% female) received PASCAL implantation from September 2017 to May 2019 and completed a clinical follow-up at 12 months. The TR etiology was functional in 25 patients (83%), degenerative in three (10%), and mixed in two (7%). All patients had TR severe or greater (massive or torrential in 80%) and heart failure symptoms (90% in NYHA III or IV) under optimal medical treatment. Single-leaflet device attachment occurred in two patients. Moderate or less TR was achieved in 23/28 patients (82%) at 30 days, which was sustained at 12 months (86%). Two patients underwent repeat TTVr due to residual torrential TR (day 173) and recurrence of severe TR (day 280), respectively. One-year survival rate was 93%; 6 patients required rehospitalization due to acute heart failure. NYHA functional class I or II was achieved in 90% and 6-minute walk distance improved from 275 ± 122 m at baseline to 347 ± 112 m at 12-month (+72 ± 82 m, p < .01). There was no stroke, endocarditis, or device embolization during the follow-up. Twelve-month outcomes from this multicenter compassionate use experience with the PASCAL System demonstrated high procedural success, acceptable safety, and significant clinical improvement.

Indications and outcomes of TAVI (transcatheter aortic valve implantation) in Iceland

Surgical aortic valve replacement (SAVR) has been the standard of treatment for aortic stenosis but transcatheter aortic valve implantation (TAVI) is increasingly used as treatment in Iceland and elsewhere. Our objective was to assess the outcome of TAVI in Iceland, focusing on indications, complications and survival. This retrospective study included all TAVI-procedures performed in Iceland between January 2012 and June 2020. Patient characteristics, outcome and complications were registered, and overall estimated survival compared to an age and sex matched Icelandic reference-population. The mean follow-up was 2.4 years. Altogether 189 TAVI procedures (mean age 83±6 years, 41.8% females), were performed, all with a self-expanding biological valve. Most patients (81.5%) had symptoms of severe heart failure (NYHA-class III-IV) and median EuroSCORE-II was 4.9 (range: 0.9-32). Echocardiography pre-TAVI showed a mean aortic-valve area of 0.67 cm2 and a max aortic-valve gradient of 78 mmHg. One out of four patients (26.5%) needed permanent pacemaker implantation following TAVI. Other complications were mostly vascular-related (13.8%) but cardiac cardiac temponade and stroke occurred in 3.2 and 2.6% of cases, respectively and severe paravalvular aortic valve regurgitation in 0.5% cases. Thirty-day mortality was 1.6% (n=3) with one-year survival of 93.5% (95% CI: 89.8-97.3). Finally long-term survival survival of TAVI-patients was similar to the matched reference population (p=0.23). The outcome of TAVI-procedures in Iceland is good, especially regarding 30-day mortality and long-term survival that was comparable to a reference population. Incidence of major complications was also low.

Risk factors of severe heart failure in HIV-positive patients

Aim . To study the relationship of N-terminal pro-brain natriuretic peptide (NT-proBNP) with clinical symptoms, structural and functional cardiac abnormalities in human immunodeficiency virus (HIV)-positive patients with heart failure (HF), as well as to identify risk factors for severe HF. Material and methods . During the year, 150 HIV-positive patients with typical symptoms and signs of stable HF were examined in the hospital. Among them, HF, confirmed by structural and functional cardiac changes and NT-proBNP increase above 125 pg/ml, was identified in 83 (55,3%) patients. These patients were divided into 3 groups depending on the blood concentration of NT-proBNP: group 1 (n=54) — patients with NT-proBNP of 125-700 pg/ml; group 2 (n=12) — patients with NT-proBNP of 701-1500 pg/ml; group 3 (n=17) — patients with NT-proBNP &gt;1500 pg/ml. Results . As NT-proBNP increased in HIV-positive patients with HF, the left ventricular (LV) ejection fraction (EF) significantly decreased (p=0,005). Also, the increase in the severity of HF symptoms (p&lt;0,001), prevalence of chronic kidney disease (CKD) (p&lt;0,001), chronic hepatitis B and/or C (p=0,011), prior infective endocarditis (p=0,002), thromboembolic events (p=0,007), chronic obstructive pulmonary disease (p=0,016), pneumonia (p=0,002) and inflammatory diseases during hospitalization (p=0,002), severe thrombocytopenia (p=0,032). We revealed significant differences between the groups in the frequency of decreased cluster of differentiation antigen 4 (CD4) &lt;200 cells/pl (p=0,013). Conclusion. In HIV-positive patients with clinical symptoms of HF, the prevalence of its verification in accordance with Russian guidelines (2020) was 55,3%. In 62,7% of HIV-positive patients with HF, preserved EF was detected. Among the comorbidities, 9 risk factors of severe HF in HIV-positive patients with NT-proBNP &gt;1500 pg/ml were identified. With CKD and inflammatory diseases during hospitalization, the relative risk of severe HF in patients with HIV infection is increased by more than 6 times, while with thromboembolic events — 5,3 times, infective endocarditis — 4,4 times, pneumonia during hospitalization and severe thrombocytopenia — more than 3,5 times, chronic obstructive pulmonary disease — 2,1 times, chronic hepatitis B and/or C — 1,7 times. As HIV infection progresses (CD4 &lt;200 cells/pL), the risk of severe HF increases 1,6 times.

Associations Between Female Sex, Sarcomere Variants, and Clinical Outcomes in Hypertrophic Cardiomyopathy.

The impact of sex on phenotypic expression in hypertrophic cardiomyopathy (HCM) has not been well characterized in genotyped cohorts. Retrospective cohort study from an international registry of patients receiving care at experienced HCM centers. Sex-based differences in baseline characteristics and clinical outcomes were assessed. Of 5873 patients (3788 genotyped), 2226 (37.9%) were women. At baseline, women were older (49.0±19.9 versus 42.9±18.4 years, P<0.001) and more likely to have pathogenic/likely pathogenic sarcomeric variants (HCM patients with a sarcomere mutation; 51% versus 43%, P<0.001) despite equivalent utilization of genetic testing. Age at diagnosis varied by sex and genotype despite similar distribution of causal genes. Women were 3.6 to 7.1 years older at diagnosis (P<0.02) except for patients with MYH7 variants where age at diagnosis was comparable for women and men (n=492; 34.8±19.2 versus 33.3±16.8 years, P=0.39). Over 7.7 median years of follow-up, New York Heart Association III-IV heart failure was more common in women (hazard ratio, 1.87 [CI, 1.48-2.36], P<0.001), after controlling for their higher burden of symptoms and outflow tract obstruction at baseline, reduced ejection fraction, HCM patients with a sarcomere mutation, age, and hypertension. All-cause mortality was increased in women (hazard ratio, 1.50 [CI, 1.13-1.99], P<0.01) but neither implantable cardioverter-defibrillator utilization nor ventricular arrhythmia varied by sex. In HCM, women are older at diagnosis, partly modified by genetic substrate. Regardless of genotype, women were at higher risk of mortality and developing severe heart failure symptoms. This points to a sex-effect on long-term myocardial performance in HCM, which should be investigated further.

Relation of Neighborhood Disadvantage to Heart Failure Symptoms and Hospitalizations

Residence in socioeconomically deprived neighborhoods may influence patient's health-related behaviors and overall health. We evaluated the association of neighborhood disadvantage on heart failure (HF) symptom burden and hospitalization rates. We characterized neighborhood deprivation in 359 HF subjects (age 56 ± 13 years, 52% black) in metropolitan Atlanta using the Area Deprivation Index (ADI). ANOVA was used to compare HF symptoms measured using the Kansas City Cardiomyopathy Questionnaire, and HF Self-Care Index across ADI tertiles. Zero-inflated Poisson regression was used to compare rates of recurrent HF hospitalization (HFH) across ADI tertiles. Subjects living in more deprived neighborhoods were more likely to be black, have Medicare or Medicaid insurance, and have a lower ejection fraction than those living in less deprived neighborhoods (all p ≤ 0.005). Subjects in more deprived neighborhoods had more severe HF symptoms (p < 0.001), but there was no difference in HF Self-Care Index scores across ADI tertiles. Subjects living in more deprived neighborhoods had a higher odds of being hospitalized for HF than subjects in less deprived neighborhoods. Once subjects had experienced a HFH, however, the association between ADI and the risk of recurrent HFH varied by racial group. In whites, increasing ADI was associated with a marginally decreased risk of recurrent HFH, while there was no association between ADI and recurrent HFH in blacks. In conclusion, patients with HF living in more deprived neighborhoods have greater symptom burden and are more likely to experience a HFH than those living in less deprived neighborhoods.

National healthcare expenditure influences CRT implantations- results from CRT Survey II with 11088 patients

Abstract Background Cardiac Resynchronization Therapy (CRT) reduces morbidity and mortality in selected patients with heart failure (HF) and electrical dyssynchrony. This treatment receives level I recommendations in ESC guidelines from both HFA and EHRA. However, despite these strong recommendations, CRT implantation practice varies greatly in ESC member states. Purpose To describe how countries' healthcare expenditure affects CRT implantation practice. Methods Between 2015 and 2017, two ESC associations, EHRA and HFA, conducted the CRT Survey II, a survey of CRT implantations in 11,088 patients in 42 ESC member states. We divided these countries into three groups according to their current health expenditure per capita. Results The countries with the lowest health care expenditure were more likely to implant CRT in patients who had strong guideline recommendations for implantation such as symptomatic heart failure, LVEF≤35%, sinus rhythm, QRS duration ≥150 ms and LBBB. These countries were also less likely to implant patients with weaker recommendation level such as those with atrial fibrillation, and were more likely to implant CRT in patients hospitalized for HF in the past year or with NYHA functional class III or IV HF. Conclusions CRT Survey II has demonstrated a non-uniform delivery of healthcare. Countries with low health care expenditure appear to be reserving CRT therapy for younger patients, those with guideline recommendation level I indications and patients with more severe symptoms of heart failure. Funding Acknowledgement Type of funding source: Other. Main funding source(s): The work was supported by the European Heart Rhythm Association; the Heart Failure Association; Biotronik; Boston Scientific; Medtronic; Sorin; St. Jude; Abbott; Bayer; Bristol-Myers Squibb and Servier.

Incidence, Source, Determinants, And Prognostic Impact Of Major Bleeding In Outpatients With Chronic Heart Failure: Insights From The CARDIONOR Registry

Risk, correlates, and consequences of major bleeding as well as the frequency of antithrombotic use in heart failure (HF) patients are largely unknown. We analyzed incident major bleeding during a 3-year follow-up in 2910 HF outpatients included in the prospective multicenter CARDIONOR registry. Major bleeding was defined as a type ≥ 3 bleed using the Bleeding Academic Research Consortium (BARC) definition and adjudicated by a blinded committee. Most patients were male (62%) with a mean age of 71.6 ± 12.8 years. The mean LVEF was 48 ± 13% with proportions being 50% for preserved, 24% for mid-range, and 26% for reduced LVEF. Altogether, 45% of the patients had a history of CAD. The NYHA class was ≥ 3 in 22.8% of the cases. There was a high prevalence of AF at inclusion (57.3%). At inclusion, most patients (89%) received at least one antithrombotic: anticoagulation (54%) and/or antiplatelet therapy (46%). Major bleeding occurred in 111 patients (3-year cumulative incidence: 3.6% [95%CI: 3.0-4.3]). Most events were BARC 3a (32.5%) or 3b (31.5%). Most frequent sites of bleeding were gastrointestinal (40.6%) and intracranial (27.9%). Anticoagulation was used in 82% of the patients at time of major bleeding. Variables associated with major bleeding were atrial fibrillation (P < 0.0001), diabetes (P = 0.012), and older age (P = 0.049). The incidence of bleeding was similar in HF patients with preserved, mid-range or reduced left ventricle ejection fraction (LVEF), with mild or severe HF symptoms, and with ischemic or non-ischemic HF. Major bleeding was strongly associated with mortality (adjusted hazard ratio: 5.63; 95% CI 4.37–7.24; P < 0.0001). In HF outpatients, major bleeding occurs at a stable rate of 1.2% annually and is associated with a dramatic increase in mortality. Most events occur in patients receiving anticoagulation. The risk of bleeding is similar in patients with preserved, mid-range, or reduced LVEF.

Correction to: Patients' Willingness to Accept Mitral Valve Procedure-Associated Risks Varies Across Severity of Heart Failure Symptoms.

Correction to: Patients' Willingness to Accept Mitral Valve Procedure-Associated Risks Varies Across Severity of Heart Failure Symptoms.