Heart Failure Unit Research Articles

Wearable Cardioverter-Defibrillator Used as a Telemonitoring System in a Real-Life Heart Failure Unit Setting.

Background: In patients with reduced left ventricular ejection fraction (LVEF) who are at risk of sudden cardiac death, a wearable cardioverter-defibrillator (WCD) is recommended as a bridge to the recovery of LVEF or as a bridge to the implantation of a device. In addition to its function to detect and treat malignant arrhythmia, WCD can be used via an online platform as a telemonitoring system to supervise patients’ physical activity, compliance, and heart rate. Methods: We retrospectively analyzed 173 patients with regard to compliance and heart rate after discharge. Results: Mean WCD wearing time was 59.75 ± 35.6 days; the daily wearing time was 21.19 ± 4.65 h. We found significant differences concerning the patients’ compliance. Men showed less compliance than women, and younger patients showed less compliance than patients who were older. Furthermore, we analyzed the heart rate from discharge until the end of WCD prescription and found a significant decrease from discharge to 4, 8, or 12 weeks. Conclusion: WCD can be used as a telemonitoring system to help the involved heart failure unit or physicians attend to and adjust the medical therapy. Furthermore, specific patient groups should be educated more intensively with respect to compliance.

The impact of a community-based heart failure multidisciplinary team clinic on healthcare utilization and costs.

AimsMultidisciplinary team (MDT) management in heart failure (HF) is recommended to reduce mortality and HF hospitalization. We investigated whether an MDT in a community‐based HF unit (HFU) impacted patients' healthcare utilization (HCU) and costs.Methods and resultsA retrospective cohort study was conducted among HF patients who visited at least once in a regional community‐based HFU, established for ambulatory specialist care for New York Heart Association Functional Classes III and IV, between January 2012 and August 2019. HCU data were obtained from the health maintenance organization's claims data for 12 months before and after first HFU visit. Multivariable generalized estimating equation models were specified for the annual average change in total healthcare utilization and hospitalization costs. Our cohort consisted of 962 patients, of whom 843 (87.6%) completed at least 12 months of follow‐up (Group A) and 119 (12.4%) died within 12 months following their first visit (Group B). Both groups were comparable regarding sex, socio‐economic status, Charlson Comorbidity Index, ischaemic heart disease, and/or carotid artery disease. Those who died within 12 months were older and had more hypertension, diabetes, chronic renal disease, and malignancy. There was a significant reduction in the total average annual HCU costs of the entire study population 12 months after the first HFU visit [$12 675 (±17 210) after vs. $13 188 (±15 011) before, P = 0.014]. This was driven by a reduction in costs among patients who completed 12 months of follow‐up [$11 955 (±17 352) after vs. $13 112 (±15 268) before, P < 0.001], whereas an increase in these costs was observed among patients who died during follow‐up [$17 774 (±15 292) after vs. $13 728 (±13 093) before, P = 0.015]. These opposite trends stem mainly from a decrease [$3540 (±8991) after vs. $4941 (±6806) before, P < 0.001] vs. increase [$10 932 (±11 660) after vs. $6733 (±7215) before, P = 0.002] in hospitalization costs of these groups, respectively. The multivariable models revealed that patients who died within 12 months following the first visit to the HFU demonstrated a significant increase of 57% in hospitalization costs following their first visit [relative risk (RR) = 1.57, 95% confidence interval (CI): 1.20–2.05, P = 0.001], whereas there was a decrease of 34% in the hospitalization costs of patients who completed 12 months of follow‐up after their first visit (RR = 0.66, 95% CI: 0.54–0.81, P < 0.001). The entire cohort demonstrated 27% decrease in hospitalization costs following their first HFU visit (RR = 0.73, 95% CI: 0.62–0.87, P < 0.001).ConclusionsIntensification of therapy by a dedicated MDT significantly reduced healthcare utilization and costs, predominantly due to a decrease in hospitalizations.

Predictors of Acute Heart Failure Decompensation at 30 days After Discharge. Results from a Multidisciplinary Heart Failure unit

Abstract Background Unexpected readmissions are frequent among heart failure (HF) patients (pts). These are associated with high economic cost and have great clinical relevance. HF Units are cornerstones to build early intervention to prevent readmissions. Due to their natural history HF implies multiple readmissions, with high costs and clinical relevance. HF Units are cornerstones to avoid early readmission. Purpose We aimed to identify predictors of early HF decompensation (at 30 days) that could recognize high risk patients during the systematic follow-up in our Multidisciplinary Heart Failure Program (MHFP) that was launched in February 2019. Methods We carried out an analytical and observational study including all patients admitted to our University Hospital, which covers 220,000 individuals. We built a predictive multivariate model with Logistic Regression using relevant predictors (clinical and statistical) that were identified. Results A total of 235 acute HF decompensations were referred to our MHFP. The 69.8% of them were men with median age of 75 years (interquartile range, IR 71–81). Mean left ventricular ejection fraction was 41% (IR 29–54%. A total of 55% with reduced and 30% with preserved ejection fraction). The 26% of the patients had right ventricle dilatation and 35% disfunction. Left bundle branch block was present in 27% of them. Median glomerular filter was 54ml/min (IR 37–73ml/min) and median pulmonary artery systolic pressure 50mmhg (IR 42–66mmg). Mean time to readmission was 19.6 months. Among decompensations that we detected in MHFP during 30 days after discharge, just 39% (5 pts) could be detected and managed in day hospital and 61% (8 pts) as an admission. In Table 01 we show the predictors that were included in the multivariate model. We finally found that it was just the NTproBNP level in a blood test within 7–10 days after discharge (R2N 0.59) which remains significative. Risk increased 1.20 times (1.0001851000) for each 1000 units rise in blood test (Table 1. Graph 1). Conclusion According to our results, detecting high NTproBNP levels in blood test within 7–10 days after discharge might predict a higher HF decompensation risk. The final multivariate model would explain 59% of those events at one month after discharge. Funding Acknowledgement Type of funding sources: None. Graph 1

Analysis of telephone demand in a heart failure unit: something more than a simple call

Abstract Introduction Specific care programs for HF patients significantly reduce readmissions, which is why they are recommended in clinical practice guidelines with the highest level of evidence. Telephone assistance is a service offered to patients within these programs. Purpose The main objective was to evaluate the most frequent reasons for consultation and the ability to resolve them after the call. Methods This is a descriptive, retrospective study of all the telephone consultations registered between June 2020 and January 2021. The calls are attended by the HF consultation nurse, commenting with Cardiology on those that imply changes in the pharmacological treatment. Sociodemographic and clinical variables, reasons for the call and their frequency were collected. Categorical variables were expressed as percentages and quantitative variables as means ± standard deviation. Results During the analyzed period, 1.608 consultations were attended, 494 were telephone calls, which represents 31% of the overall activity of the nursing consultation. 423 consultations were analyzed, 55.7% (235) reactive, and 44.3% (187) proactive. 72.5% of the patients were under follow-up by the nurse, compared to 27.5% who had completed drug titration. The mean age was 65 (± 12.3) years, 65.6% were men, 98.4% had a caregiver, 77% of the patients had an LVEF &amp;lt;40%, Charlson modified mean 4.7 (± 3.6) and 92.3% were on treatment with beta-blockers, 89.1% with ACE inhibitors/ARBs/ARNI and 82.3% with MRA. The mean number of drugs per patient was 8.6 (± 3). Reasons for the reactive calls were in 46% of the cases the consultation of symptoms, 20% to consult doubts about the treatment or procedures, 16% for problems related to the prescription of pharmacological treatment and 14% for the appointment management. Reasons for proactive calls were 40% for symptoms control, 30.5% for appointment management, 27.3% for drug titration and 2.1% related to other causes. When the reason for consultation was the appearance of symptoms, the mean number of calls required was 1.4 (± 0.8), 77.6% of the calls were solved through the telephone, 16.4% required a face-to-face visit in the nursing consultation and 2.7% were referred to the emergency room. Queries related to doubts, problems with the prescription or appointment management were solved in a single telephone consultation. Conclusions The most common telephone request when the patient made the call was the worsening of HF symptoms. The telephone consultation is presented as an effective tool in these cases, by favoring the accessibility of patients and avoiding unnecessary trips to the health center. Funding Acknowledgement Type of funding sources: None. Table 1. Descriptive details of patientsTable 2. Call reasons

Global longitudinal strain predicts clinical disease progression in stable asymptomatic heart failure patients better than left ventricular ejection fraction

Abstract Background Previous studies have shown that left ventricular (LV) global longitudinal strain (GLS) is a feasible and reliable predictor for outcomes in heart failure (HF) patients with greater accuracy than LV ejection fraction (LVEF). However, these studies rarely included stable or asymptomatic patients. Purpose To assess the predictive value of GLS, as compared to LVEF, in asymptomatic stable HF patients. Methods This is a retrospective study, including patients with HF with reduced and mid-range ejection fraction (HFrEF: LVEF&amp;lt;40%; HFmrEF: LVEF 40–49%) in NYHA I with no history of decompensation within the previous 6 months. All patients underwent comprehensive baseline echocardiographic assessment. The primary endpoint was the composite of cardiovascular death, hospitalization and need for intensification of HF treatment within a 12 month follow-up period. Results Out of 837 patients with LVEF &amp;lt;50% that underwent follow-up in our HF unit between January 2016 and December 2017, 153 patients were included in the study. The mean age was 74 (±10.2) years and 82% were male. The cumulative incidence of HF progression was 17.8%, with a median time to event of 193 days. Death and hospitalization due to HF accounted for three-quarters of the events. The mean LVEF was 40.9% (± 6.96),without significant differences between patients with and without clinical progression (39.5% vs 43%, p=0.093). We did not find significant differences between the two groups, concerning LV and atrial dimensions, as well as mitral inflow, PSAP and tricuspid annular systolic plane excursion (TAPSE). LV GLS was significantly lower (i.e. less negative) in patients that presented clinical progression, that in patients without disease progression (−7.7 vs −12.2, p&amp;lt;0.001). Receiver operating characteristic curve and univariate Cox regression analysis identified GLS as the most accurate predictor for clinical progression among all continuous variables (AUC: 0.809, cut-off: −8.5%, sensitivity: 74.1%, specificity: 89%, HR: 14.78 (95% CI: 6.2–35.1), p&amp;lt;0.001). LVEF predicted HF progression less precisely (AUC: 0.654, cut-off: 42%, sensitivity: 70.4%, specificity: 54%, HR: 2.38 (95% CI: 1.1–5.2), p=0.03). Conclusion In asymptomatic stable HF patients (in NYHA I), LV GLS showed to be a more accurate predictor of clinical disease progression than LVEF. Funding Acknowledgement Type of funding sources: None. Global longitudinal strain (GLS)Receiver operating characteristic (ROC)

Impact of COVID-19 on heart failure hospitalizations: one year after

BackgroundCoronavirus disease 2019 (COVID-19) rapidly spread worldwide since it first emerged in December 2019, with more than 100 million cases reported to date, causing a great impact on healthcare systems. Heart failure (HF) is a major health problem. It affects about 10 million people in Europe and is the leading cause of hospitalization for patients older than 65 years. During the first wave of COVID-19 there was an important decrease in HF hospitalizations. Data regarding HF admissions during the second and third waves and inter-waves periods is scarce.PurposeTo examine the impact of COVID-19 on HF hospitalizations during the first year of the pandemic and to compare the clinical characteristics and in-hospital outcomes of patients admitted during the three pandemic waves with those admitted the previous year during the same periods.MethodsData from a tertiary Heart Failure Unit in Southern Spain between 1 March 2020 and 28 February 2021 were compared to the corresponding time period in the previous year. The impact of the pandemic on weekly hospitalizations was assessed using a Poisson Regression model, with year, season and pandemic wave as covariates. Clinical characteristics and in-hospital outcomes of patients admitted during the three waves were compared to those admitted during the same periods one year after.ResultsA significantly lower weekly number of admissions for HF was observed during the three pandemic wave periods compared to all other included periods (inter-wave periods and same periods in the previous year) (p=0.002, IRR 0.81, 0.77–0.86). Figure 1 shows monthly HF admissions between 1 March 2020 and 28 February 2021 (pandemic year) and the previous year, as well as COVID-19 hospitalized cases in our area. Clinical characteristics and in-hospital outcomes of patients admitted during the COVID-19 waves and the same periods in the previous year are shown in Figure 2. Patients admitted during the COVID-19 waves were younger, and fewer had diabetes mellitus (DM), atrial fibrillation (AF) and valvular heart disease (VHD). There were no differences in clinical outcomes (intensive care unit admission, in-hospital mortality).ConclusionThere was decline in HF hospitalization during the three waves of the pandemic year, but not during the inter-wave periods. Patients admitted during the wave periods had some clinical differences but similar in-hospital outcomes.Funding AcknowledgementType of funding sources: None. Figure 1Figure 2

Clinical and prognostic significance of the inflammatory markers GlycA and GlycB in chronic heart failure of both ischemic and non-ischemic etiologies

Abstract Background N-acetylglucosamine/galactosamine (GlycA) and sialic acid (GlycB) constitute evolving nuclear magnetic resonance (NMR) biomarkers of systemic inflammation. They have been increasingly studied and associated with cardiovascular (CV) disease and incident heart failure (HF), but little is known about its value in chronic HF population. Purpose We aimed to examine the association on long-term CV outcomes of GlycA and GlycB in chronic HF relative to aetiology. Methods We prospectively included a cohort of 429 HF patients admitted to an ambulatory HF Unit. Plasma GlycA and GlycB concentrations were determined using NMR spectroscopy. The primary endpoint was a composite of CV death and readmission due to HF. Competing risk regression models were performed with non-CV death as the competing event. Because an interaction existed between GlycA and GlycB with ischemic etiology (p&amp;lt;0.01), we examined this further. Results The mean (SD) follow-up was 4.5±2.9 years. Median concentrations (IQR) for GlycA and GlycB were 5.4 (4.9–6.2) mmol/L and 1.9 (1.7–2.2) mmol/L, respectively. A total of 92 (41.1%) and 123 (60.0%) patients from non-ischemic and ischemic etiology, respectively, the clinical endpoint. In ischaemic HF patients (47.8%; n=205) both markers were not associated with the primary endpoint. Conversely, in non-ischemic HF patients (52.2%; n=224), GlycA and GlycB exhibited association with the primary endpoint in univariable and after multivariable adjustment (HR 1.14; 95% confidence interval [CI]: 1.02–1.28, p=0.018 and HR 1.91; 95% CI: 1.27–2.88, p=0.002; respectively. Figure 1 and 2). In this subgroup, a correlation analysis with well-known biomarkers (NT-proBNP, hs-TnT and ST2) only evidenced a positively and significantly correlation of GlycB with ST2 (r=0.26, p&amp;lt;0.001). No association was found with NYHA functional class. Conclusions GlycA and GlycB represent an evolving approach of inflammation status with prognostic value of long-term CV related events in non-ischemic HF patients. Funding Acknowledgement Type of funding sources: None. Figure 1. Probability of MACE by GlycA tertilesFigure 2. Probability of MACE by GlycB tertiles

How predict right ventricular-pulmonary circulation coupling improvement in chronic heart failure

Abstract Background Right ventricular-pulmonary circulation coupling (RVPAC), which can be measured by the relation between tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (SPAP) by echocardiography, has been postulated as an independent prognostic factor of hospitalizations and mortality in heart failure (HF) patients. Purpose Our aim was to know the predictors of RVPAC improvement in a chronic HF cohort. Methods Retrospective analysis of a prospectively studied cohort of HF outpatients of different aetiologies attended in a multidisciplinary HF Unit. Prospectively scheduled echo-Doppler studies were performed at first visit and 1 year. A TAPSE/SPAP ratio &amp;lt;0.36 mm/mmHg was identified as the most deleterious. Significant RVPAC improvement at 1 year was defined as TAPSE/SPAP ratio ≥0.36 mm/mmHg together with a ≥10% improvement from baseline RVPAC. Multivariable logistic regression analysis (conditional backward stepwise) was performed to select variables independently associated with significant RVPAC improvement. A predictive model including age and the previously selected variables was created. Results From August 2001 to July 2017, 554 patients with TAPSE and SPAP data in the initial visit were included. Mean follow-up time was 4.6±3.7 years. At first visit 252 (45.5%) patients had RVPAC &amp;lt;0.36 mm/mmHg. Out of them, RVPAC at 1 year improved in 55 (21.8%). In multivariable analysis, the presence of baseline atrial fibrillation/flutter (OR 0.12 [95% CI 0.05–0.28], p&amp;lt;0.001), SPAP (OR 0.96 [95% CI 0.92–0.99], p=0.014) and female gender (OR 0.34 [95% CI 0.12–0.91], p=0.03) were related to lesser probability of RVPAC improvement at 1 year. A model with such variables, together with age, showed an AUC of 0.824 to predict significant RVPAC improvement. Conclusions Atrial fibrillation/flutter, increasing SPAP and female gender hamper RVPAC improvement at 1 year in HF patients with baseline TAPSE/SPAP ratio &amp;lt;0.36. Funding Acknowledgement Type of funding sources: None. Multivariate regression analysis

Head-to-head comparison of NT-proBNP and soluble ST2 for long-term prognosis of patients with hypertrophic cardiomyopathy

Abstract Background N-terminal pro-brain natriuretic peptide (NT-proBNP) predicts mortality and the development of heart failure (HF) in hypertrophic cardiomyopathy (HCM), however, evidence regarding soluble interleukin-1 receptor-like 1 (ST2) in this population is lacking. Purpose To assess the ST2 and NT-proBNP significance for risk stratification of patients with HCM during long-term follow-up. Methods We prospectively enrolled a cohort of consecutive patients with HCM admitted to an ambulatory HF Unit in a Tertiary University Hospital. All patients had clinical and echocardiographic evaluation and measurement of NT-proBNP and ST2 at inclusion. The primary endpoint was the composite of all-cause death or HF-related hospitalization. Results 103 patients were enrolled, 68% (n=70) males with a median (IQR) age of 60 (50–71) years. The median (IQR) of ST2 was 31.5 (IQR: 24.5 – 40.7) pg/mL. During a median follow-up of 2.5 years, 17 patients had the primary endpoint. Both, NT-proBNP and ST2 (both log-transformed) were associated with the primary endpoint in the univariable analyses (p&amp;lt;0.01). However, after adjustment by age, sex, NYHA functional class and left ventricular ejection fraction (LVEF), this association remained statistically significant only for ST2 (HR: 4.62, 95% CI 1.80–11.87, p=0.001 vs HR: 1.57, 95% CI 0.97–2.54, p=0.068 for NT-proBNP). The addition of ST2 to a clinical model (age, sex, NYHA functional class and LVEF) increased the Harrel's C statistic from 0.70 to 0.76, while the addition of NT-proBNP increase this C-statistic only to 0.73. Conclusions ST2 appears to be a valuable biomarker for the prediction of death and heart failure related hospitalization in patients with HCM, outperforming the prognostic value of NT-proBNP. Future research should delve into this association. Funding Acknowledgement Type of funding sources: None.

Palliative Care in Heart Failure: Challenging Prognostication.

Heart failure (HF) is a chronic progressive disease with high morbimortality and poor quality of life (QoL). Palliative care significantly improves clinical outcomes but few patients receive it, in part due to challenging decisions about prognosis.This retrospective study, included all patients consecutively discharged from an Acute Heart Failure Unit over a period of one year, aiming to assess the accuracy of the Meta‐Analysis Global Group in Chronic Heart Failure (MAGGIC) score in predicting mortality. Additionally, predictors of death at one and three years were explored using a multivariate regression model.The MAGGIC score was useful in predicting mortality, without significant difference between mortality observed at three-years follow-up compared with a mortality given by the score (p=0.115). Selected variables were statistically compared showing that poor functional status, high New York Heart Association (NYHA) at discharge, psychopharmacs use, and high creatininemia were associated with higher mortality (p<0.05).The multivariate regression model identified three predictors of one-year mortality: psychopharmacs baseline use (OR=4.110; p=0.014), angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (ACEI/ARB) medication at discharge (OR=0.297; p=0.033), and higher admission's creatinine (OR=2.473; p=0.028). For three-year mortality outcome, two variables were strong independent predictors: psychopharmacs (OR=3.330; p=0.022) and medication with ACEI/ARB at discharge (OR=0.285; p=0.018). Models’ adjustment was assessed through the receiver operating characteristic (ROC) curve. The best model was the one-year mortality (area under the curve, AUC 81%), corresponding to a good discrimination power.Despite prognostication, when setting goals of care an individualised patient-centred approach is imperative, based on the patient’s objectives and needs. Risk factors related to poorer outcomes should be considered, in particular, higher NYHA at discharge which also represents symptom burden. Hospitalisation is an opportunity to optimize global care for heart failure patients including palliative care.

Safety and Efficacy of the Combination of Sacubitril/Valsartan and SGLT2i in HFrEF Patients (SECSI Registry).

Recent studies have proven benefit of SGLT2i drugs in patients with heart failure with reduced ejection fraction (HFrEF), but their safety when combined with angiotensin-neprilysin inhibitor (ARNI) has not been established. The Safety and Efficacy of the Combination of Sacubitril/Valsartan and SGLT2i in HFrEF Patients registry was conducted to address this issue. SECSI registry is a consecutive, observational, retrospective, multicentre study conducted in 3 Heart Failure Units in Spain. It included 144 HFrEF patients who were treated with ARNI and iSGLT2. Data were collected at baseline, month 2, and month 6. The primary endpoint was the estimated glomerular filtration rate (eGFR), after the initiation of ARNI and sodium-glucose cotransporter-2 inhibitors (SGLT2i). Secondary endpoints included potassium levels and functional class (New York Heart Association class). There were 3 prespecified subgroup analyses: Elderly patients (≥70 years), patients with chronic kidney disease (KDIGO classification G3), and the sequence of drug initiation. Mean age was 69.9 ± 10.1 years, and 110 (76.4%) were men. Left ventricular ejection fraction was 32 ± 7.8%, and most patients were symptomatic [123 (87.2%) New York Heart Association II/III/IV]. eGFR decreased at month 2 and this trend was maintained at month 6 [eGFR baseline 68.5 ± 17.3, month 2 62 ± 19.7 and month 6 64.7 ± 8.6 mL/min/1.73 m2 (P < 0.01 for both)]. In prespecified analysis, elder patients and those who simultaneously initiate both treatments showed the steeper decrease in eGFR. To conclude, co-administration of SGLT2i and ARNI in routine care in HFrEF patients produced a slight decrease in eGFR at 6 months of follow-up. This decrease was especially significant in elder patients and those who initiate both drugs simultaneously.

Gender differences in congestive heart failure: The Ibn Rochd registry

Evidence from several observational studies suggests sex-related differences in the incidence and prognosis of CHF. The main objective of the study is to report clinical, electrical, echocardiographic, etiological and therapeutic aspects of CHF in women. It is a transversal retrospective study conducted between May 2006 and June 2019 including all patients beyond the age of 14 with congestive heart failure followed-up in the therapeutic unit of heart failure of our department. We studied clinical, electrical, echocardiographic and etiological aspects of CHF among women compared to men. Among 3412 CHF patients: 1237 were women (36.25%), women mean age was 64.96 ± 12.96 years vs. 64.89 ± 12.79 years in men ( P = 0,068). A total of 37.8% of women were diabetic vs. 26,1% of men ( P < 0.001), 49.6% were hypertensive vs. 32.7% ( P < 0.001), 4% were smokers vs. 42.5% ( P < 0.001), 12.3%vs 8.4% were dyslipidemic ( P = 0.002). 25.8% had a history of myocardial infarctionvs 32.6%. CHF in women compared to men was due to ischemic heart disease in 50.6% vs. 63.2%, dilated cardiomyopathy in 13% vs. 8.8%, valvular heart disease in 4.4%vs 3.3%, cardiac toxicity in 3.5%vs 0,8%, peripartum cardiomyopathy in 0,8% ( P < 0.001). Dyspnea in women compared to men was classified mostly class II NYHA in 59.7% vs. 57.3%, class III in 22%vs 17,9%, class IV in 1,9%vs 2%. Mean heart rate was 79.06 ± 16.65 bpm and mean blood pressure was 131.51 ± 24,89/75,27 ± 13,69 mmHg. 12,8% of women had atrial fibrillation vs. 12.5% in men ( P = 0.860). Mean LVEF was 37.43 ± 15.85% vs. 35.65 ± 10.07% in men P < 0.001. No impact of gender on hospitalization for HF was observed ( P = 0.867) Several clinical and epidemiological studies, in particular the Framingham and MILIS trials, indicate an increased long-term risk of CHF following myocardial infarction in women. This may be explained by a greater prevalence of risk factors for coronary atherosclerosis as well as by female gender.

Impact of left bundle branch block on heart failure with reduced ejection fraction symptoms and outcomes: Experience of a Moroccan centre

Left bundle branch block (LBBB) occurs in up to 30% of patients with heart failure (HF). The detrimental effect of LBBB on left ventricular systolic and diastolic function caused by regional delays of electrical activity leads to dyssynchronous left ventricular function and has been established in HF patients. Some studies have reported LBBB as an independent predictor of mortality in HF patients. To study the impact of LBBB on heart failure with reduced ejection fraction (HFrEF) symptoms and outcomes. Transversal retrospective study conducted between May 2006 and June 2019 including all patients beyond the age of 14 with HFrEF, followed-up in the therapeutic unit of HF of our department. We studied 2 groups of patients: group 1 with complete LBBB and group 2 without complete LBBB. We compared clinical, echocardiographic and prognostic features. We collected 3412 patients. Six hundred and ninety-three patients (20.31%) in group1 and 2719 patients (79.69%) in group 2. Male gender was represented in 63 versus 63.7 years ( P = 0.857). Mean age was 68.82 ± 12.47 years versus 64.79 ± 12.88 years ( P < 0.001). Regarding etiologies: ischemic heart disease in 50.1% versus 59.4%, dilated cardiomyopathy in 9.3%vs5.9%, valvular heart disease in 3% versus 3.8%, chemotherapy induced cardiomyopathy in 2.8% versus 2.1% ( P < 0.001). Class IV NYHA in 3.8% vs. 1.9% ( P < 0.001). Echocardiographic features: LVEDD was 61.29 ± 9.24 mm versus 57.06 ± 8.99 mm ( P < 0.001), mean LVEF was 32.24 ± 13.15% versus 35.87 ± 12.98% ( P = 0.022), elevated left ventricle filling pressures in 29.4% versus 21.6% ( P < 0.001), severe secondary mitral regurgitation in 9.6% vs. 5.8% ( P < 0.001). Hospitalization for HF rate in 22.7% vs. 16.5% ( P < 0.001). LBBB patients are more symptomatic, have lower LVEF, more severe secondary mitral regurgitation, higher hospitalization rate and higher mortality rate. These results are important to consider in order to justify the importance of cardiac resynchronization therapy.

Increased Bleeding Risk with Phosphodiesterase-5 Inhibitors after Left Ventricular Assist-Device Implantation

Purpose Phosphodiesterase-5 inhibitors (PDE5I) are frequently implemented after left ventricular assist device implantation (LVAD) to improve right heart hemodynamics. No prospective study has yet evaluated the net benefit of off-label long-term PDE5I on clinical outcomes and their potential risks. We aimed to evaluate the impact of PDE5I on bleeding risk as well as severity and type of bleeding according to The Bleeding Academic Research Consortium (BARC) classification after LVAD implantation. Methods We retrospectively reviewed the database of our heart failure unit to identify adult patients who received a durable LVAD at our institution from December 2010 through May 2019. Patients were included in the analysis if they were discharged on oral PDE5I after LVAD implantation. Patients were excluded if they had received biventricular assist-devices, in case of postoperative death during the index hospitalization, follow-up interruption or follow-up in an affiliated hospital. Major bleeding was defined as fatal bleeding, and/or symptomatic bleeding in a critical area or organ, and/or bleeding causing a fall in hemoglobin level of 2 g/dL (1.24 mmol/L) or more, or leading to transfusion of two or more units of whole blood or red cells. All non-major bleedings were considered minor bleedings. Results The analytic cohort included 109 patients. Seventy-five patients (69%) received long-term PDE5I therapy and thirty-four (31%) did not receive PDE5I. At 12 months 19 (17%) patients experienced cumulatively 28 bleeding events (26 events in patients on PDE5I, 2 not on PDEI5) leading to 27 red blood cell transfusions (all in the PDE5I group). Patients on PDE5I had higher bleeding rates (23% vs. 6%, p = 0.03) and more bleeding events per patient (0.32 vs. 0.06, p = 0.03). Most events concerned major bleeding (24 events, 85.7%) and 50% non-gastrointestinal bleeding. BARC Type 2 had the highest incidence and was more frequent in the PDE5I group (19 vs 3%, p = 0.03). Hospitalizations for bleeding and their duration were numerically higher for PDE5I (0.28 vs 0.03 hospitalizations, p = 0.07 and 2.4 vs. 0.2 days, p = 0.07, respectively). Conclusion Long-term PDE5I treatment after LVAD increases the risk of bleeding at 12 months after LVAD implantation. The role of off-label PDE5I in LVAD patients remains unclear and should be further clarified in contemporary patient and device cohorts.

Impact of hospital and emergency department structural and organizational characteristics on outcomes of acute heart failure

Introduction and objectivesTo determine whether structural/organizational characteristics of hospitals and emergency departments (EDs) affect acute heart failure (AHF) outcomes. MethodsWe performed a secondary analysis of the EAHFE Registry. Six hospital/ED characteristics were collected and were related to 7 postindex events and postdischarge outcomes, adjusted by the period of patient inclusion, baseline patient characteristics, AHF episode features, and hospital and ED characteristics. The relationship between discharge directly from the ED (DDED) and outcomes was assessed, and interaction was analyzed according to the hospital/ED characteristics. ResultsWe analyzed 17 974 AHF episodes included by 40 Spanish EDs. Prolonged stays were less frequent in high-technology hospitals and those with hospitalization at home and with high-inflow EDs, and were more frequent in hospitals with a heart failure unit (HFU) and an ED observation unit. In-hospital mortality was lower in high-technology hospitals (OR, 0.78; 95%CI, 0.65-0.94). Analysis of 30-day postdischarge outcomes showed that hospitals with a short-stay unit (SSU) had higher hospitalization rates (OR, 1.19; 95%CI, 1.02-1.38), high-inflow EDs had lower mortality (OR, 0.73; 95%CI, 0.56-0.96) and fewer combined events (OR, 0.87; 95%CI, 0.76-0.99), while hospitals with HFU had fewer ED reconsultations (OR, 0.83; 95%CI, 0.76-0.91), hospitalizations (OR, 0.85; 95%CI, 0.75-0.97), and combined events (OR, 0.84; 95%CI, 0.77-0.92). The higher the percentage of DDED, the fewer the prolonged stays. Among other interactions, we found that more frequent DDED was associated with more 30-day postdischarge reconsultations, hospitalizations and combined events in hospitals without SSUs, but not in hospitals with an SSU. ConclusionsAHF outcomes were significantly affected by the structural/organizational characteristics of hospitals and EDs and their aggressiveness in ED management.

Care of patients with chronic heart failure: an interdisciplinary challenge

The diverse manifestations of heart failure led to complex treatment guidelines and care scenarios and therefore always require an integrated, multidisciplinary care approach. Patients with chronic heart failure suffer from a large number of cardiac and noncardiac comorbidities. For example, iron deficiency leads to decreased performance and exertional dyspnea and should be diagnosed. Psychological screening questionnaires should be used for the early detection of psychological comorbidities.ARNI and SGLT-inhibitors expand the pharmacotherapeutic possibilities and gain in importance. The constant development of diagnostic possibilities and therapeutic options must be implemented consistently into the care continuum in order to have a lasting effect. The challenge of interdisciplinary coordination can be significantly reduced through jointly agreed process logs (e. g. within the framework of integrated supply contracts or a Heart Failure Unit Network).

Mortality trends in an ambulatory multidisciplinary heart failure unit from 2001 to 2018

To assess mortality trends at 1 and 3 years from 2001 to 2018 in a real-life cohort of HF outpatients from different etiologies with depressed and preserved LVEF. A total of 2368 consecutive patients with HF (mean age 66.4 ± 12.9 years, 71% men, 15.4% with preserved LVEF) admitted to a HF clinic from August 2001 to September 2018 were included in the study. Patients were divided into five quintiles (Q) according to the period of admission. Trends for all-cause and cardiovascular mortality from Q1 to Q5 were assessed by linear regression. Patients with LVEF < 50% had a progressive decrease in the rates of all-cause and cardiovascular death at 1 year (12.1% in Q1 to 6.5% in Q5, p = 0.003; and 8.4% in Q1 to 3.8% in Q5, p = 0.007, respectively) and 3 years (30.5% in Q1 to 17.0% in Q5, p = 0.003; and 23.9% in Q1 to 9.8% in Q5, p = 0.003, respectively). These trends remained significant after adjusting for clinical characteristics and risk. No significant trend in mortality was observed in patients with LVEF ≥ 50%. In a cohort of real-life ambulatory patients with HF, mortality progressively declined in patients with LVEF < 50%, but the same trend was not observed in patients with preserved LVEF.

Impact of New Heart Failure Unit on the Heart Failure Morbidity and Mortality at the Northern Hospital — A Qualitative and Quantitative Study

Currently, heart failure (HF) is estimated to affect 480,000 Australians, with over 60,000 new diagnoses made every year. The continued ageing of the Australian population is expected to further increase the burden of HF on the healthcare system. At Northern Hospital, Melbourne, a dedicated Heart Failure Unit was setup in August 2018 for treatment of patients presenting with heart failure.

Role of a clinical pharmacist in cardiology units: Let's take the example of medication reconciliation (MR)!

MR reduces medication errors by collecting an accurate history of medication of hospitalised patients. The exhaustive medication history is compared to the prescribed treatment. Discrepancies are discussed and resolved with prescribers. To describe unintentional medication discrepancies (UMD) and make a focus on cardiovascular drugs (CV-drugs). Data from MR realised in heart failure and rhythmology units during 2019 were extracted: treatment history, UMD types (unjustified drug addition or omission, difference in dose or rhythm of administration); discrepancies status (resolved or not) and drugs concerned by UMD. CV-drugs are represented by diuretics, antihypertensive drugs, β-blockers, antiarrythmics, but also anticoagulant/antiplatelet and lipid-lowering drugs. Five hundred and forty-three MR were realised and 239 (44%) show at least 1 UMD with a total of 656 highlighted UMD. Table 1 shows the UMD types’ repartition. Omission is the most common UMD (422, 64.3%) and often concerns CV-drugs ( n = 78), psychotropics ( n = 44), eye drops ( n = 43) and inhaled medications ( n = 39). Two hundred and fifty-three UMD with CV-drugs were recorded: 78 omissions (30.8%), 56 wrong dosages (22.1%), 23 differences in the rhythm of administration, 10 errors of medication and 7 unjustified drugs. Most of CV-drugs involved in omissions are lipid-lowering drugs ( n = 16) and RAAS blockers ( n = 15). Most of CV-drugs involved in dosage discrepancies are anticoagulants ( n = 17). Among the 239 MR, 221 were totally or partly resolved and 18 left unresolved. MR is an important process to reduce medication errors, minimizing omissions and dosage errors. As in previous studies, discrepancies frequently involve CV-drugs facing the medical historing of our patients but drugs of other specialties are concerned too. UMD left unresolved could have a clinical impact and increase the average length of stay. Physicians and pharmacists have to work side by side to secure points of transition in patients’ life. MR is a proven process for this issue.

Chronic kidney disease as a prognostic factor in congestive heart failure: A Moroccan series of 3412 patients.

The prevalence of CHF increases greatly as the patient's renal function deteriorates, and, at end-stage CKD, can reach 65–70%. There is evidence that CKD is a major contributor to severe cardiac damage. Purpose is to determine whether end-stage CKD is a prognostic factor in CHF. Transversal retrospective study conducted between May 2006 and June 2019 including patients beyond age of 14 with CHF followed-up in therapeutic unit of heart failure of our department. Data were collected on Excel and statistical analysis was made using SPSS statistics 2.0.We define 2 groups of patients. Group A with end-stage CKD and group B without end-stage CKD.We studied demographic, clinical and paraclinical characteristics among these 2 groups. We collected 3412 patients, 439 (12%) in group A and 2973 (82%) in group B. Main etiology of CHF was ischemic heart disease in both groups. Hypertension and dyslipidemia were more prevalent in group A. Diabetes was as prevalent in 2 groups. Comorbidities were more prevalent in group A as we observe more strokes (20% vs. 8%, P = 0,0001) and myocardial infarctions (31% vs. 28%, P = 0,0001). Group A patients were more symptomatic: stage III and IV NYHA in 30% vs. 19%, P = 0,0001. Patients of group A were more at risk of acute decompensated heart failure (21% vs. 9%, P = 0,005). Atrial fibrillation was more prevalent in group A (14% vs. 9%, P = 0,0001). Elevated left ventricle filling pressure was more prevalent in group A (40% vs. 34%, P = 0,003). Mean LVEF was 35,69 ± 12,56% in group A vs. 33,46 ± 10,42% in group B ( P = 0,63). Left ventricle was more dilated in group A (59,24 ± 8,2 mm vs. 57,91 ± 9,31 mm, P = 0,020). Cooperation between nephrologists and cardiologists may improve quality of care and subsequent prognosis for CHF and CKD.