Heart Failure With Reduced Ejection Fraction Group Research Articles

Tailored risk assessment of 90-day acute heart failure readmission or all-cause death to heart failure with preserved versus reduced ejection fraction.

BackgroundAfter incident heart failure (HF) admission, patients are vulnerable to readmission or death in the 90‐day post‐discharge. Although risk models for readmission or death incorporate ejection fraction (EF), patients with HF with preserved EF (HFpEF) and those with HF with reduced EF (HFrEF) represent distinct cohorts. To better assess risk, this study developed machine learning models and identified risk factors for the 90‐day acute HF readmission or death by HF subtype.Methods and ResultsApproximately 1965 patients with HFpEF and 1124 with HFrEF underwent an index admission. Acute HF rehospitalization or death occurred in 23% of HFpEF and 28% of HFrEF groups. Of the 101 variables considered, multistep variable selection identified 24 and 25 significant factors associated with 90‐day events in HFpEF and HFrEF, respectively. In addition to risk factors common to both groups, factors unique to HFpEF patients included cognitive dysfunction, low‐pulse pressure, β‐blocker, and diuretic use, and right ventricular dysfunction. In contrast, factors unique to HFrEF patients included a history of arrhythmia, acute HF on presentation, and echocardiographic characteristics like left atrial dilatation or elevated mitral E/A ratio. Furthermore, the model tailored to HFpEF (area under the curve [AUC] = 0.770; 95% confidence interval [CI] 0.767–0.774) outperformed a model for the combined groups (AUC = 0.759; 95% CI 0.756–0.763).ConclusionThe UF 90‐day post‐discharge acute HF Re admission or Death Risk Assessment (UF90‐RADRA) models help identify HFpEF and HFrEF patients at higher risk who may require proactive outpatient management.

Abstract 13703: Outpatient Cardiac Rehabilitation Reduces Heart Failure Re-Hospitalization in Patient With Heart Failure With Reduced Ejection Fraction When Compared to Patients With Heart Failure With Preserved Ejection Fraction

Introduction: Cardiac rehabilitation has been increasingly recognized as an integral part in the management of patients with congestive heart failure. It has been shown to improve the quality of life in this patient population. However, It is unknown how much cardiac rehabilitation reduces heart failure hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF) versus heart failure with preserved ejection fraction (HFpEF). Hypothesis: We hypothesize that outpatient cardiac rehabilitation is associated with reduced re-hospitalization for heart failure symptoms in patients with heart failure with HFrEF when compared with patients with HFpEF. Methods: We retrospectively analyzed data from 128 heart failure patients enrolled in an outpatient cardiac rehabilitation center from January 2015 to December 2020. The number of heart failure re-hospitalizations was measured in each of these patients. A Student t-test was used to analyze the difference between the two groups, while fisher’s test or chi square was used to analyze categorical variables. Results: Among the 128 patients enrolled in the outpatient cardiac rehabilitation center, age 68.1+-14 years, 63 (57.1%) were males. There were 70 patients (54.6%) in the HFrEF group and 58 (55.28%) in the HFpEF group. Hospitalization for acute exacerbation of heart failure symptoms was lower in the patients with HFrEF when compared with patients with HFpEF (41.3% vs 70.69% p value <0.0009). Conclusion: Outpatient cardiac rehabilitation program is associated with reduced hospitalization for heart failure symptoms in patients with HFrEF when compared to patients with HFpEF.

Heart failure re-hospitalization differently affects the following mortality in patients with reduced, mid-range and preserved LVEF

Abstract Introduction The recent advances in the treatment for heart failure with reduced ejection fraction (HFrEF) have been remarkable, while no therapy has convincingly improved the prognosis in HF patients with preserved (HFpEF) and mid-range (HFmrEF) ejection fraction. Frequent decompensations of HF lead to progressive deterioration of cardiac and renal function, and quality of life. Hence, prior studies have reported that the mortality of HFrEF patients increases as hospitalization for HF repeats. However, it is still unclear whether this trend applies for HFpEF and HFmrEF patients. Purpose We aimed to compare the prognostic impact of re-hospitalization due to HF on cardiovascular death (CVD) among HFrEF, HFmrEF and HFpEF patients. Methods This observational study included 1,930 consecutive patients who were hospitalized for worsening of HF and discharged alive. Of them, patients who have never or have not been hospitalized for HF at least last 2 years, were finally analyzed. Patients were consisted of the population with HFrEF (EF<40%, n=421), HFmrEF (EF 40–49%, n=202) and HFpEF (EF>50%, n=291). Patients in each EF-classified population were divide into 2 subgroups based on whether patients were re-hospitalized for HF during the observational period, respectively. The primary endpoint of this study was CVD. Results During the observation period, Kaplan-Meier analysis showed that patients who were re-hospitalized for HF had higher event rate of CVD in HFrEF group (Log-rank p=0.008, Figure). Even after adjusting with multivariate covariates including age, sex, EF, brain natriuretic peptide and estimated glomerular filtration rate, re-hospitalization for HF was an independent predictor for CVD in HFrEF group (HR: 1.95, 95% CI: 1.11–2.86, p=0.029). However, in HFmrEF group and HFpEF group, there was no significant difference in the rates of CVD between 2 subgroups divided whether patients were re-hospitalized for HF or not (p=0.91, p=0.34, respectively). Conclusion Re-hospitalization for HF affected the CVD rate in HFrEF group, but not in HFmrEF and HFpEF groups. The prevention of re-hospitalization for HF is important particularly in HFrEF patients in order to improve cardiovascular mortality. Funding Acknowledgement Type of funding sources: None.

Cardiovascular death risk in mid-range ejection fraction heart failure: insights from cardiopulmonary exercise test

Abstract Background The pivotal role of cardiopulmonary exercise testing (CPET) in the assessment of functional capacity and prognosis of patients with heart failure with reduced ejection fraction (HFrEF), either as a single CPET parameter (i.e. peak oxygen uptake, peak VO2), as a combination of CPET parameters (i.e. oxygen uptake at the anaerobic threshold (AT) and ventilatory efficiency (VE/VCO2 slope), or as a part of more comprehensive scores (i.e. Metabolic Exercise combined with Cardiac and Kidney Indexes, MECKI) is well established. Just few studies are available with respect a possible role of CPET in risk stratification of patients in HF with midrange EF (HFmrEF) subset, namely HF patients with LVEF between 40% and 49%. Purpose The aim of the present large Italian multicenter study was to characterize and to compare stable HFmrEF and HFrEF patients in terms of exercise capacity as well as of instrumental and laboratory variables. We analyzed a possible independent and incremental prognostic value of CPET parameters in identifying those HFmrEF patients at high cardiovascular death risk. Methods We retrospectively analyzed clinical and CPET data of stable HF patients with HFrEF and HFmrEF from the MECKI Score database. Five-thousand-seven-hundred-eleven patients, 4,535 with HFrEF and 1,176 with HFmrEF, were considered for the study. The end-point was cardiovascular death at 5 years. The median follow-up was 1343 days (25th–75th range, 627–2403 days). Results Cardiovascular death occurred in 552 HFrEF (12.2% event rate) and 61 HFmrEF (5.2% event rate) patients. At multivariate analysis, an independent role of variables included in the MECKI score (age, atrial fibrillation, LVEF, haemoglobin, sodium, MDRD, AT identification, VO2 at AT, peak VO2 also expressed as percentage of the maximum predicted, VE/VCO2 slope) was confirmed in HFrEF group (C-index=0.744) whereas, in the HFmrEF group, only age and peak VO2 remained outcome predictors (C-index=0.745). We identified a peak VO2 <55% of predicted and a VE/VCO2 slope >31 as the most accurate cut-off values able to identify a HFmrEF subgroup with a cardiovascular mortality rate significantly higher than the overall HFmrEF (5.2% vs 8.5%) (Figure 1). By using both cut-off values contextually, we recognized a relatively small HFmrEF population with a cardiovascular risk quite similar to the HFrEF sample (11.4% vs 12.2%) (Figure 1). Conclusions Present data support the CPET as a useful tool in the HFmrEF management. Besides the peak VO2, which resulted as a strong independent outcome predictor, also a number of other CPET variables were associated to the cardiovascular death risk. Particularly, a peak VO2 ≤55% of the maximum and a VE/VCO2 slope ≥31 identified a HFmrEF subgroup of patients with a high cardiovascular death risk, similar to the one observed in the HFrEF group. Funding Acknowledgement Type of funding sources: None. Figure 1

Characteristics and outcomes of heart failure with recovered left ventricular ejection fraction.

AimsThere is an emerging interest in elucidating the natural history and prognosis for patients with heart failure with reduced ejection fraction (HFrEF) in whom left ventricular ejection fraction (LVEF) subsequently improves. The characteristics and outcomes were compared between heart failure with recovered ejection fraction (HFrecEF) and persistent HFrEF.Methods and resultsThis is a retrospective study of adults who underwent at least two echocardiograms 3 months apart between 1 November 2015 and 31 October 2019 with an initial diagnosis of HFrEF. The subjects were divided into HFrecEF group (second LVEF > 40%, ≥10% absolute improvement in LVEF) and persistent HFrEF group (<10% absolute improvement in LVEF) according to the second LVEF. To further study the characteristics of HFrecEF patients, the cohort was further divided into LVEF improvement of 10–20% and >20% subgroups. The primary outcomes were all‐cause mortality and rehospitalization. A total of 1160 HFrEF patients were included [70.2% male, mean (standard deviation) age: 62 ± 13 years]. On the second echocardiogram, 284 patients (24.5%) showed HFrecEF and 876 patients (75.5%) showed persistent HFrEF. All‐cause mortality was identified in 23 (8.10%) HFrecEF and 165 (18.84%) persistent HFrEF, whilst 76 (26.76%) and 426 (48.63%) showed rehospitalizations, respectively. Survival analysis showed that the persistent HFrEF subgroup experienced a significantly higher mortality at 12 and 24 months and a higher hospitalization at 12, 24, 48, and more than 48 months following discharge. Multivariate Cox regression showed that persistent HFrEF had a higher risk of all‐cause mortality [hazard ratio (HR) 2.30, 95% confidence interval (CI) 1.49–3.56, P = 0.000] and rehospitalization (HR 1.85, 95% CI 1.45–2.36, P = 0.000) than the HFrecEF group. Subgroup analysis showed that the LVEF ≥ 20% improvement subgroup had lower rates of adverse outcomes compared with those with less improvement of 10–20%.ConclusionsHeart failure with recovered ejection fraction is a distinct HF phenotype with better clinical outcomes compared with those with persistent HFrEF. HFrecEF patients have a relatively better short‐term mortality at 24 months but not thereafter.

Association of the classification and severity\xa0of heart failure with the incidence\xa0of contrast-induced acute kidney injury

Congestive heart failure (HF) is a known risk factor of contrast-induced acute kidney injury (CI-AKI). However, the relationship of the classification and severity of HF with CI-AKI remains under-explored. From January 2009 to April 2019, we recruited patients undergoing elective PCI who had complete pre- and post-operative creatinine data. According to the levels of ejection fraction (EF), HF was classified as HF with reduced EF (HFrEF) [EF < 40%], HF with mid-range EF (HFmrEF) [EF 40–49%] and HF with preserved EF (HFpEF) [EF ≥ 50%]. CI-AKI was defined as an increase of either 25% or 0.5 mg/dL (44.2 μmoI/L) in serum baseline creatinine level within 72 h following the administration of the contrast agent. A total of 3848 patients were included in the study; mean age 67 years old, 33.9% females, 48.1% with HF, and 16.9% with CI-AKI. In multivariate logistic regression analysis, HF was an independent risk factor for CI-AKI (OR 1.316, p value < 0.05). Among patients with HF, decreased levels of EF (OR 0.985, p value < 0.05) and elevated levels of N-terminal pro b-type natriuretic peptide (NT-proBNP) (OR 1.168, p value < 0.05) were risk factors for CI-AKI. These results were consistent in subgroup analysis. Patients with HFrEF were more likely to develop CI-AKI than those with HFmrEF or HFpEF (OR 0.852, p value = 0.031). Additionally, lower levels of EF were risk factors for CI-AKI in the HFrEF and HFmrEF groups, but not in the HFpEF group. NT-proBNP was an independent risk factor for CI-AKI in the HFrEF, HFmrEF and HFpEF groups. Elevated levels of NT-proBNP are independent risk factors for CI-AKI irrespective of the classification of HF. Lower levels of EF were risk factors for CI-AKI in the HFrEF and HFmrEF groups, but not in the HFpEF group.

223-OR: Heart Failure with Reduced, Midrange and Preserved Ejection Fraction in Chinese with Type 2 Diabetes: Risk Factors and Prognosis

Background: Diabetes predisposes to heart failure (HF). In a prospective cohort of Chinese with type 2 diabetes, we examined 1) clinical factors associated with incident HF, and 2) mortality post-HF, stratified by ejection fraction (EF). Methods: Between 1 Jun 1993 and 30 Jun 2015, 23348 patients with type 2 diabetes without history of HF were enrolled in the Hong Kong Diabetes Register, and followed for incident HF until 30 Jun 2017. HF subtypes were defined according to EF on echocardiogram: HF with reduced EF (HFrEF), EF &amp;lt;40%; HF with midrange EF (HFmrEF), EF 40-49%; HF with preserved EF (HFpEF), EF &amp;gt;=50%. Multivariate Cox regression was used to identify clinical factors associated with incident HF vs. no HF, by HF subtypes. 1-year and 5-year mortality rates were compared by HF subtypes. Results: Over a follow-up of 7.1 years from enrolment, 1195 patients developed HF, of whom 611 (51.1%) had an echocardiogram within 2 years of HF episode. Distribution of HF subtypes as follows: HFrEF 24.1%, HFmrEF 15.2%, HFpEF 60.7%. Old age, low GFR, albuminuria and history of coronary artery disease were associated with increased hazards for all HF subtypes. In addition, female sex, high BMI and history of neuropathy were associated with HFpEF, and low HDL cholesterol was associated with HFmrEF. Over a follow-up of 2.1 years post-HF, 760 patients (63.6%) died with a mortality rate of 189.4 per 1000 person-year. 1-year mortality rate was lower in HFpEF group (16.2%) than those with HFmrEF (vs. 26.9%, p=0.034) and HFrEF (vs. 31.3%, p&amp;lt;0.001). At 5 years, mortality rate in HFpEF group (45.6%) remained lower than those with HFmrEF (vs. 63.4%, p=0.008), but similar to HFrEF group (vs. 49.0%, p=0.199). Conclusions: HFpEF was the predominant HF subtype in Chinese with diabetes. Clinical factors predicting incident HF differed according to subtypes. 1-year mortality was lower in HFpEF group but mortality at 5 years were similar between HFpEF and HFrEF with a trend of higher mortality in HFmrEF group. Disclosure A. Luk: None. J. C. Chan: Consultant; Self; Bayer AG, Boehringer Ingelheim International GmbH, MSD Corporation, Sanofi, Other Relationship; Self; Asia Diabetes Foundation, GemVCare, Research Support; Self; Applied Therapeutics, AstraZeneca, Hua Medicine, Lilly Diabetes, Merck KGaA. X. Zhang: None. E. Fung: None. H. Wu: None. E. S. Lau: None. A. Yang: None. E. Chow: Research Support; Self; Medtronic, Speaker’s Bureau; Self; Novartis Pharmaceuticals Corporation, Sanofi-Aventis. A. P. Kong: Advisory Panel; Self; Lilly Diabetes, Speaker’s Bureau; Self; Abbott, AstraZeneca, Bayer Healthcare Pharmaceuticals Inc., Lilly Diabetes, Sanofi, Stock/Shareholder; Self; Aptorum. R. C. Ma: Other Relationship; Self; AstraZeneca, Medtronic, Research Support; Self; AstraZeneca, Bayer Healthcare Pharmaceuticals Inc., Novo Nordisk, Pfizer Inc., Sanofi-Aventis, Tricida, Inc.

PERIPAPILLARY RETINAL NERVE FIBER ALTERATIONS IN HEART FAILURE WITH REDUCED EJECTION FRACTION

Objectives: To evaluate the effect of heart failure with reduced ejection fraction (HFrEF) on retinal nerve fiber layer (RNFL) thickness.&#x0D; Methodology: The study included patients who were being followed at Kartal Kosuyolu High Speciality Training and Research Hospital for HFrEF and were referred to the Eye Clinic of the Dr. Lütfi Kırdar Kartal Training and Research Hospital, Istanbul, Turkey between 2017-2019. Study participants were divided into two groups, one comprising HFrEF patients and a control group of patients without HF. Each patient underwent a routine ophthalmologic examination including best corrected visual acuity evaluation, intraocular pressure measurement, slit-lamp biomicroscopy and fundus examination. The RNFL of each patient was measured using spectral domain OCT.&#x0D; Results: A total of eyes of 37 HFrEF patients and 38 controls were evaluated. Superior RNFL thickness was 113.71±17.08 μm in the HFrEF group and 126.22 ± 13.68 μm in the control group (p=0.001). Inferior RNFL thickness was 117.88 ± 14.5 μm in the HFrEF group and 131.69 ± 12.93 μm in the control group (p&lt;0.001). Average RNFL thickness in the HFrEF and control groups was 92.32 ± 10.22 μm and 103.31 ± 8.14 μm, respectively. There were significant differences between the study groups in all five parameters.&#x0D; Conclusion: In this study, RNLF thinning occurs in HFrEF compared to the control group that may be useful for demonstrate tissue perfusion deficiency in HFrEF.

PERIPAPILLARY RETINAL NERVE FIBER ALTERATIONS IN HEART FAILURE WITH REDUCED EJECTION FRACTION

Objectives : To evaluate the effect of heart failure with reduced ejection fraction (HFrEF) on retinal nerve fiber layer (RNFL) thickness. Methodology: The study included patients who were being followed at Kartal Kosuyolu High Speciality Training and Research Hospital for HFrEF and were referred to the Eye Clinic of the Dr. Lutfi Kirdar Kartal Training and Research Hospital, Istanbul, Turkey between 2017-2019. Study participants were divided into two groups, one comprising HFrEF patients and a control group of patients without HF. Each patient underwent a routine ophthalmologic examination including best corrected visual acuity evaluation, intraocular pressure measurement, slit-lamp biomicroscopy and fundus examination. The RNFL of each patient was measured using spectral domain OCT. Results : A total of eyes of 37 HFrEF patients and 38 controls were evaluated. Superior RNFL thickness was 113.71±17.08 μm in the HFrEF group and 126.22 ± 13.68 μm in the control group (p=0.001). Inferior RNFL thickness was 117.88 ± 14.5 μm in the HFrEF group and 131.69 ± 12.93 μm in the control group (p<0.001). Average RNFL thickness in the HFrEF and control groups was 92.32 ± 10.22 μm and 103.31 ± 8.14 μm, respectively. There were significant differences between the study groups in all five parameters. Conclusion : In this study, RNLF thinning occurs in HFrEF compared to the control group that may be useful for demonstrate tissue perfusion deficiency in HFrEF.

Left Atrial Strain Associated with Functional Recovery in Patients Receiving Optimal Treatment for Heart Failure

Heart failure with recovered ejection fraction (HFrecEF) has been reported in several previous studies to have a better prognosis than heart failure with reduced ejection fraction (HFrEF). However, the factors associated with HFrecEF have not been identified. The aim of this study was to test the hypothesis that left atrial (LA) strain could help identify patients with recovered ejection fraction (EF) among those with heart failure (HF) with low EF on admission. One hundred consecutive patients hospitalized for the first time for new-onset HF were enrolled. Patients were clinically diagnosed with HFrEF on admission (left ventricular EF<40%) and received optimal treatment for HF. Twenty-eight patients improved to HFrecEF during 6months of follow-up. Regarding clinical background, there were significantly more women and a lower rate of atrial fibrillation in the HFrecEF group than in the HFrEF group. In a multivariate logistic regression analysis, LA strain was an independent predictor of HFrecEF, even after adjustment for gender and left ventricular EF (odds ratio: 4.06; 95% CI: 2.04-8.07; P<.001). A cutoff value of 10.8% for LA strain showed high sensitivity (96%) and specificity (82%) in identifying HFrecEF in patients with HF presenting with low EF on admission. During a follow-up period of 24±13months, 31 patients (31%) had cardiovascular death or readmission for HF. Patients with reduced LA strain (<10.8%) had significantly shorter event-free survival than those with preserved LA strain (P=.02). LA strain is a useful indicator for predicting HFrecEF and should be considered as a routine measurement in patients with HFrEF on admission.

Association Between Physical Status and the Effects of Combination Therapy With Renin-Angiotensin System Inhibitors and β-Blockers in Patients With Acute Heart Failure.

Background: This study investigated whether combination therapy (CT) with renin-angiotensin system inhibitors and β-blockers improved endpoints in acute heart failure (AHF).Methods and Results: AHF patients were recruited to this prospective multicenter cohort study between April 2015 and August 2017. Patients were divided into 3 categories based on ejection fraction (EF), namely heart failure (HF) with reduced EF (HFrEF), HF with midrange EF (HFmrEF), and HF with preserved EF (HFpEF), and a further into 2 groups according to physical status (those who could walk independently outdoors and those who could not). The composite endpoint included all-cause mortality and hospitalization for HF. Data at the 1-year follow-up were available for 1,018 patients. The incidence of the composite endpoint was significantly lower in the CT than non-CT group for HFrEF patients, but not among HFmrEF and HFpEF patients. For patients who could walk independently outdoors, a significantly lower rate of the composite endpoint was recorded only in the HFrEF group. The differences were maintained even after adjustment for comorbidities and prescriptions, with hazard ratios (95% confidence intervals) of 0.39 (0.20–0.76) and 0.48 (0.22–0.99), respectively.Conclusions: In this study, CT was associated with the prevention of adverse outcomes in patients with HFrEF. Moreover, CT prevented adverse events only among patients without a physical disorder, not among those with a physical disorder.

Catheter ablation for non-paroxysmal atrial fibrillation accompanied by heart failure with preserved ejection fraction: feasibility and benefits in functions and B-type natriuretic peptide.

We aimed to examine the benefits of catheter ablation in patients with non-paroxysmal atrial fibrillation (AF) accompanied by heart failure (HF) with preserved ejection fraction (HFpEF), in comparison with the benefits in patients with AF accompanied by HF with reduced ejection fraction (HFrEF) or patients with no HF. From 1173 consecutive patients undergoing catheter ablation, 502 with non-paroxysmal AF were divided into three groups: no history of HF [plasma B-type natriuretic peptide (BNP) <100 pg/mL and no HF hospitalization; n = 125], HFpEF [left ventricular (LV) EF ≥50%; n = 293], and HF with midrange EF (HFmrEF) + HFrEF (LVEF <50%; n = 84) groups. The endpoints were AF recurrence at 1 year, changes in symptomatic and image-based functional status, and changes in BNP levels from baseline to 1 year. In the HFpEF group, AF recurred in 48 patients (16.4%) and 278 patients (94.8%) had sinus rhythm at 1 year; these values were comparable with those in the other groups. Significant improvement was observed in the left atrial diameter, LVEF, and New York Heart Association functional class in the HFpEF and HFmrEF + HFrEF groups. The BNP level significantly decreased irrespective of the index rate control status, and freedom from AF recurrence was an independent predictor of HF remission, defined as BNP <100 pg/mL at 1 year, in the HFpEF group. Catheter ablation is highly feasible for restoring sinus rhythm in non-paroxysmal AF with coexisting HFpEF, thereby improving cardiac function and BNP levels. Catheter ablation for AF may be an optional management strategy.

Stroke and systemic embolism in patients with atrial fibrillation and heart failure according to heart failure type.

AimsThis study aimed to elucidate the risk for stroke and systemic embolism (SE) in patients with atrial fibrillation and heart failure (HF) according to HF type.Methods and resultsA total of 10 780 patients with atrial fibrillation were enrolled in a multicentre prospective registry and divided according to HF type: no‐HF, HF with preserved ejection fraction (EF) (HFpEF), HF with mid‐range EF (HFmrEF), and HF with reduced EF (HFrEF). Each group included 237 age‐matched and sex‐matched patients (age, 69.0 ± 10.3 years; men, 69.6%). The baseline characteristics, cumulative incidence, and hazard ratios for stroke/SE and major bleeding were compared across the groups. Patients with HF accounted for 10.3% of the total population; HFpEF, HFmrEF, and HFrEF represented 43.7%, 23.6%, and 32.7% of the patients with HF, respectively. The CHA2DS2‐VASc score was significantly higher in the HFpEF, HFmrEF, and HFrEF groups than in the no‐HF group. The annual stroke/SE incidence rates were 2.8%, 0.7%, 1.1%, and 0.9% in the HFpEF, HFmrEF, HFrEF, and no‐HF groups, respectively. The cumulative incidence of stroke/SE was significantly highest in the HFpEF group at 22.8 ± 10.0 months (P = 0.020). The stroke/SE risk was higher in the HFpEF group than in the HFmrEF and HFrEF groups (hazard ratio, 3.192; 95% confidence interval, 1.039–9.810; P = 0.043). E/e' value was an independent risk factor for stroke/SE. There were no significant differences in the incidence of major bleeding across the groups.ConclusionsThe stroke/SE risk was the highest in the HFpEF group and comparable between the HFmrEF and HFrEF groups.

Role of N-terminal pro-B-type natriuretic peptide in predicting mortality in heart failure

Background: N-terminal pro-B-type natriuretic peptide (NT-proBNP) improves emergency room diagnosis and is a prognostic marker of acutely decompensated heart failure (HF) after hospitalization. We tried to assess the prognosis in heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) using the biomarker. Methods: Patients were categorized into HFpEF (left ventricular ejection fraction [LVEF] ≥50%) (n = 102), HF with midrange EF (LVEF of 40%–49%) (n = 106), and HFrEF (LVEF ≤40%) (n = 112) as per the ESC classification of HF subtypes. Prognosis by absolute and percentage change in NT-proBNP at admission and at the 10th day of treatment was found in 3-month follow-up. Mortality after discharge was also assessed. Results: Among all HF groups, a reduction of NT-proBNP <20% at 10 days predicted mortality, hazard ratio (HR) – 14.9 (95% confidence interval [CI]: 3.8–57.9), P = 0.0001. The risk of mortality in HF patients with NT-proBNP reduction of <20% in 10 days was 14.9 times higher in 3-month follow-up. NT-proBNP more than 12,000 pg/mL at admission had a mortality risk of 23.3% in the HFrEF group, HR – 23.45 (95% CI: 2.9–189.4), P = 0.003. NT-proBNP on the 10th day, more than 9000 pg/mL, had a mortality risk of 21.4% in the HFrEF group, HR – 23.3 (95% CI: 4.9–110.5), P = 0.001. Conclusion: NT-proBNP proved to be a superior modality in finding out prognosis in HF. Patients with the HFrEF group had a higher mortality in our study. Comorbidities play an important role in affecting the prognosis in patients with HFpEF with lower NT-proBNP.

Impact of sarcopenia on prognosis in patients with heart failure with reduced and preserved ejection fraction.

Sarcopenia, one of the extracardiac factors for reduced functional capacity and poor outcome in heart failure (HF), may act differently between HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF). We sought to investigate the impact of sarcopenia on mortality in HFpEF and HFrEF. We performed a post hoc analysis of a multicentre prospective cohort study, including 942 consecutive older (age ≥65 years) hospitalized patients: 475 with HFpEF (ejection fraction ≥45%, age 81 ± 7 years, 48.8% men) and 467 with HFrEF (ejection fraction <45%, age 78 ± 8 years, 68.1% men). Sarcopenia was diagnosed according to the international criteria incorporating muscle strength (handgrip strength), physical performance (gait speed), and skeletal muscle mass (appendicular skeletal mass). The HFpEF group consisted of fewer patients with low appendicular skeletal muscle mass index measured using bioelectrical impedance analysis [<7.0 kg/m2 (men) and <5.7 (women); 22.1% vs. 31.0%, P = 0.003], and more patients with low handgrip strength [<26 kg (men) and <18 (women); 67.8% vs. 55.5%, P < 0.001], and slow gait speed [<0.8 m/s (both sexes); 54.5% vs. 41.1%, P < 0.001] than the HFrEF group, resulting in a similar sarcopenia prevalence in the two groups (18.1% vs. 21.6%, P = 0.191). Sarcopenia was an independent predictor of 1-year mortality in both HFpEF and HFrEF [hazard ratio (95% confidence interval) 2.42 (1.36-4.32), P = 0.003 in HFpEF and 2.02 (1.08-3.75), P = 0.027 in HFrEF; P for interaction = 0.666] after adjustment for other predictors. In older patients with HF, sarcopenia contributes to mortality similarly in HFpEF and HFrEF.

Risk for stroke and systemic embolism in patients with atrial fibrillation and heart failure according to heart failure type

Abstract Introduction Risk for stroke and systemic embolism (SE) in patients with atrial fibrillation (AF) and heart failure (HF) with mid-range (mr) ejection fraction (EF) is not well known. Methods Total 10,780 patients (age, 66.8±11.1 years; men, 64.7%) with AF were included in a prospective, multicenter AF registry. The patients were grouped into four according to HF type: no-HF, HF with preserved EF (HFpEF), HFmrEF, and HF with reduced EF (HFrEF). Baseline characteristics, cumulative incidence and hazard ratios for stroke/SE, major bleeding, and mortality were compared among the four groups. Results Proportion of patients with HF was 10.3%: HFpEF, 43.7%; HFmrEF, 23.6%; HFrEF, 32.7%. CHA2DS2-VASc score was significantly higher in the HFpEF, HFmrEF, and HFrEF groups than the no-HF group (4.0±1.7, 3.8±1.8, 3.5±1.8, and 2.5±1.6, respectively). Oral anticoagulants were administered in 83.6% of patients with CHA2DS2-VASc score ≥1. Annual incidence of stroke/SE was 2.0% in HFpEF group, 0.6% in HFmrEF group, 1.1% in HFrEF group, and 0.7% in no-HF group for 23.0±9.5 months of follow-up period. Cumulative incidence of stroke/SE was significantly higher in the HFpEF group than the no-HF and HFmrEF groups (p&amp;lt;0.001 and p=0.042, respectively; Figure). Risk for stroke/SE was significantly higher in the HFpEF group than the no-HF group [hazard ratio, 1.929; 95% confidence interval, 1.171–3.179, p=0.010]. There were no significant differences in risk for stroke/SE in the HFmrEF and HFrEF groups, compared with the no-HF group. There were no significant differences in major bleeding and mortality among the groups. Conclusions Risk for stroke/SE is highest in HFpEF and lowest in HFmrEF in patients with AF and HF. Figure 1 Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Research Foundation of Korea

Aerobic Capacity (V̇O2peak) In Congenital Heart Disease Versus Heart Failure: Prognostic Implications

Introduction VO2peak (peak oxygen consumption) during cardiopulmonary exercise testing is a key prognostic test in patients with non-congenital heart failure (HF). It helps physicians decide which HF patients would derive the greatest survival benefit from cardiac transplant. The predictive value of VO2peak in patients with congenital heart disease on outcomes is not as clear. Hypotheses 1) VO2peak will predict event-free survival in patients with congenital cardiac disease; 2) Patients with congenital heart disease will have longer event-free survival for the primary outcome of death, heart transplant, or LVAD placement compared to patients with heart failure with reduced ejection fraction (HFrEF) even after adjustment for VO2peak. Methods Patients were from a registry of cardiac patients who completed an exercise test in the VO2 Laboratory at Washington University School of Medicine between May 1993 and October 2012. Patients with HFrEF (left ventricular ejection fraction Results A total of 276 patients (138 congenital, 138 HFrEF) were included. Mean (±SD) age was 33.9 ± 11.7y in the congenital group and 40.3 ± 9.7 in the HFrEF group (p=0.00001). Women made up 44.9% of each sample. VO2peak was 21.56 ± 7.15 ml•kg−1•min−1 in the congenital group and 15.99 ± 5.95 ml•kg−1•min−1 in the HFrEF group (p Conclusions A congenital cardiac diagnosis portends longer event-free survival compared to patients with non-congenital HFrEF. Further studies are warranted to investigate if peak VO2 can be used to guide timing for cardiac transplant in the congenital cardiac population.

Relationship of anemia and clinical outcome in heart failure patients with preserved versus reduced ejection fraction in a rural area of Thailand.

BackgroundHeart failure (HF) has become a significant health burden in developing countries where anemia is highly prevalent. Limited data exists on the effects of anemia on HF in these population.MethodsA retrospective observational study was conducted in all adult patients hospitalized due to HF at Buriram Hospital in Thailand, during July 2010 to June 2015. Survival analysis was performed to evaluate the impact of anemia on 1- year all-cause mortality for the overall cohort, patients with HF with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF).ResultsA total of 414 HF patients including 287 HFpEF patients (69.3%) and 127 HFrEF patients (30.7%) were included in our analysis. Mean age was 62.51 ± 14.89 years, with 55% female. Overall prevalence of anemia in HF was 62.6% (259 patients). One-year all-cause mortality was significantly higher in patients with anemia than in non-anemia groups (20.08% vs 12.26%, p = 0.041). When analyzed based on types of HF, anemia significantly increased mortality risk in HFpEF group [adjusted hazard ratio (HR) 2.667, 95%CI, 1.216–5.853, p = 0.014] but not with HFrEF group (adjusted HR 0.901, 95%CI, 0.376–2.155, p = 0.804). The mortality of anemic patients who were left untreated was significantly higher than those who were treated (adjusted HR 2.13, 95%CI, 1.13–3.99, p = 0.027).ConclusionAnemia significantly increased mortality in HF patients, especially among HFpEF. Attempts to identify, diagnose and manage anemia should be integrated in HF care plan in developing countries with high prevalence of anemia.

The Immune Response To Cardiorespiratory Exercise Testing In Heart Failure Patients With Reduced Ejection Fraction

PURPOSE: Long-term exercise training reduces systemic inflammation in heart failure patients. However, due to the impaired immune system in these patients, an acute exercise challenge may trigger pro-inflammatory responses. We compared the acute response to a standardized cardiopulmonary exercise test (CPET) in patients with heart failure with reduced ejection fraction (HFrEF) to age and gender matched controls. METHODS: Patients with HFrEF (n=13; left ventricular ejection fraction [LVEF] < 40%) and controls (n=14, LVEF > 50%) participated in a CPET. Blood samples were taken before, immediately after and 2 hours after CPET. Flow cytometry was used to assess quantitative and morphological alterations in leukocyte subpopulations as well as the formation of leukocyte-platelet aggregates. Only significant findings are reported (p < 0.05) and are given as median and inter-quartile range (IQR). RESULTS: HFrEF (mean LVEF: 36%) and controls (mean LVEF: 57%) were 59 (range: 41 to 80) and 57 (range: 50 to 65) years old, respectively. CPET increased the leukocyte (control: 1.37-fold [IQR: 1.16 to 1.49]; HFrEF: 1.24-fold [IQR: 1.20 to 1.32]), natural killer (NK) cell (controls: 2.11-fold [IQR: 1.30 to 3.13]; HFrEF: 1.67-fold [IQR: 1.56 to 1.71]) and NK-T cell (control: 1.69-fold [IQR: 1.52 to 3.60]; HFrEF: 1.62-fold [IQR: 1.60 to 2.53]) concentration in the HFrEF and control group. CD4+ cells (control: 1.15-fold [IQR: 0.84 to 1.54]; HFrEF: 1.45-fold [IQR: 1.10 to 1.98]) and CD8+ T-cells (control: 1.33-fold [IQR: 1.01 to 1.68]; HFrEF: 1.70-fold [IQR: 1.25 to 2.15]) only increased in HFrEF patients. Aggregation of thrombocytes with monocytes (control: 0.86-fold [IQR: 0.78 to 1.49]; HFrEF: 1.59-fold [IQR: 1.05 to 7.30-fold]), T-lymphocytes (control: 1.27-fold [IQR: 1.05 to 1.68]; HFrEF: 1.49-fold [IQR: 1.03 to 2.64]) and neutrophils (control: 1.08-fold [IQR: 0.87 to 1.25]; HFrEF: 2.13-fold [IQR: 1.62 to 2.19]) increased 2 hour post CPET in patients with HFrEF, but not in controls. CONCLUSIONS: CPET differentially induced specific immune responses in patients with HFrEF compared to age and gender matched controls. The prolonged immune response in these patients suggests differences in immune resolving mechanisms which deserve further research.

Epidemiology and clinical characteristics of hospitalized elderly patients for heart failure with reduced, mid-range and preserved ejection fraction

Introduction: Elderly patients hospitalized with heart failure (HF) have high mortality rates and requires specific evidence based theraphy, however there are few studies which have focused on patients older than 80 years hospitalized with HF. The aim of the present study is to evaluate the overall clinical characteristics, management, and in-hospital outcomes of elderly patients hospitalized with HF. Methods: Journey-HF study was conducted in 37 different centers in Turkey and recruited 1606 patients who were hospitalized with HF between September 2015 and September 2016. In this study, clinical profile of patients ≥ 80 years old and 65-79 years old hospitalized with HF were described and compared based on EF-related classification: HFrEF (HF with reduced ejection fraction), HFmrEF (HF with mid-range ejection fraction) and HFpEF (HF with preserved ejection fraction). Results: A total of 1034 elder patients (71.6% 65–79 years old and 28.4% ≥80 years old) were recruited. Of the 65–79 years old patients 67.4% had HFrEF, 16.2% had HFmrEF and 16.3% had HFpEF. Among patients ≥80 years old 61.6% had HFrEF, 15.6% had HmrEF and 22.8% had HFpEF.When compared with patients with HFrEF and HFmrEF, patients ≥80 years old with HFpEF were more likely to be older, have atrial fibrilation (AF), and less likely to have diabetes mellitus (DM), coronary artery disease (CAD) or to be recieving an angiotensin-converting enzyme inhibitor (ACEi) or beta blocker theraphy. When compared to patients 65–79 years old with HFpEF, patients ≥80 years with HFpEF had a higher rate of AF and less likely DM. Acute coronary syndrome was the most common precipitant factor for hospitalization in both age groups with HFrEF group. Arrhythmia was a major precipitant factor for hospitalization of patients ≥80 years old with HFpEF. Non-compliance with theraphy was a major problem of patients ≥80 years old with HFrEF. Conclusion: Elderly patients with HFrEF, HFmrEF and HFpEF each had characterized unique patient profiles and the guideline recommended medications were less likely to be used in these patient populations. In hospital mortality rate is worrisome and reflects a need for more specific tretment strategy.