Including Heart Failure Patients Research Articles

Optimization of Cardiorespiratory Fitness and Quality of Life in Women with Chronic Heart Failure after a Cardiac Rehabilitation Program

Introduction: Women with heart failure (HF) tend to experience a greater symptom burden and lower quality of life, possibly due to phenotypic differences and unique gender-associated risk factors. Despite evidence on the effects of cardiac rehabilitation programs (CRP) in the general population, there is underrepresentation of women in these programs. Additionally, the impact of CRP on cardiorespiratory variables obtained through cardiopulmonary exercise testing (CPET) and health-related quality of life (HRQoL) in women with HF remains unknown. Objective: To assess the impact of a CRP on cardiorespiratory fitness (CRF) in cardiorespiratory variables obtained through CPET and HRQoL in women with HF. Methods: A quasi-experimental study included HF patients who completed a CRP from June 2019 to December 2023. The CRP involved nutritional assessment, psychosocial evaluation, educational sessions, and concurrent training. It comprised 30 minutes of aerobic resistance training at 65-80% of heart rate reserve (HRR) and 30 minutes of strength training at 30-50% of 1-repetition maximum (1RM), with a frequency of 3 sessions per week for 4 to 6 weeks. CPET was conducted at the beginning and end of the program, analyzing cardiorespiratory variables. HRQoL was assessed using the SF-36 questionnaire. Gains in CRF and HRQoL at the end of the program in both men and women were analyzed. Results: Out of 217 included patients, 29.9% were women. At the program's onset, women showed lower exercise tolerance than men (workload 5.4±2.57 METs vs. 6.62±2.53 METs) and worse HRQoL (62.03%±18.37 vs. 68.38%±18.37). However, post-intervention, they optimized their CRF (%predicted VO2 [%VO2p] initial 56.62%±20.11 vs final 80.12%±30.32, p=<0.001). Significant improvements in cardiorespiratory variables were observed in both cases: delta METs-load 3.02, p=<0.001, delta peak oxygen consumption (VO2peak) 1.83 ml/kg/min, p=<0.001, delta oxygen pulse (PO2) 1.21, p=0.021, delta cardiac power output (CPO) 1917, p=0.004, with a rightward shift in ventilatory thresholds and improvement in HRQoL (62.03%±18.37 vs. 78.81%±12.9, p=<0.001) post-CRP. The only variable with no significant changes in either case was VE/VCO2 slope (delta -0.51, p=0.736). Additionally, in women with reduced left ventricular ejection fraction (<50%), variables with no significant improvement included CPO (delta 959.22, p=0.283) and time to recovery of VO2 kinetics (TRCVO2) (delta -0.74, p=0.957). In patients with preserved left ventricular ejection fraction (≥50%), variables with no significant change included PO2 (delta 1.08, p=0.173), TRCVO2 (delta 26.82, p=0.099), and the first ventilatory threshold (VT1) (delta 0.09, p=0.504). Program attendance was 87.5% in both groups. Conclusion: Implementing a CRP in women with HF resulted in significant improvements in all evaluated cardiorespiratory variables (except for VE/VCO2 slope) and quality of life. These findings support the importance of ensuring women's access and participation in cardiac rehabilitation programs. Addressing existing barriers is crucial to maximize the long-term benefits of CRP in the female population with HF.

B-lines by lung ultrasound as a predictor of re-intubation in mechanically ventilated patients with heart failure.

There have been few studies on predictors of weaning failure from MV in patients with heart failure (HF). We sought to investigate the predictive value of B-lines measured by lung ultrasound (LUS) on the risk of weaning failure from mechanical ventilation (MV) and in-hospital outcomes. This was a single-center, prospective observational study that included HF patients who were on invasive MV. LUS was performed immediate before ventilator weaning. A positive LUS exam was defined as the observation of two or more regions that had three or more count of B-lines located bilaterally on the thorax. The primary outcome was early MV weaning failure, defined as re-intubation within 72 h. A total of 146 consecutive patients (mean age 70 years; 65.8% male) were enrolled. The total count of B-lines was a median of 10 and correlated with NT-pro-BNP level (r2 = 0.132, p < 0.001). Early weaning failure was significantly higher in the positive LUS group (9 out of 64, 14.1%) than the negative LUS group (2 out of 82, 2.4%) (p = 0.011). The rate of total re-intubation during the hospital stay (p = 0.004), duration of intensive care unit stay (p = 0.004), and hospital stay (p = 0.010) were greater in the positive LUS group. The negative predictive value (NPV) of positive LUS was 97.6% for the primary outcome. B-lines measured by LUS can predict the risk of weaning failure. Considering the high NPV of positive LUS, it may help guide the decision of weaning in patients on invasive MV due to acute decompensated HF.

Prognostic value of NT-proBNP and cardiac troponin levels in ambulatory patients with congestive heart failure - Insight from NHANES

Abstract Background Recently there has been increased interest in the utility of cardiac troponin and NT-proBNP to predict the prognosis in patients with CHF. The aim of this study was to investigate the prognostic significance of NT-proBNP and cardiac troponin in CHF patients in ambulatory settings. Methods The NHANES, conducted by the National Center for Health Statistics, collects nationally representative data on the health and nutritional status of the non-institutionalized US population. We included heart failure patients aged ≥ 40 years with valid entries for NT-proBNP and cardiac troponin. We used data collected during the period 1999 -2004. The primary endpoint was all-cause mortality. Vital status (dead or alive) was determined by linkage to a record match of the National Death Index, conducted by the National Center for Health Statistics through December 31, 2020. Follow up period was from the examination date to either the date of death or December 31, 2020, whichever came first. NT-proBNP and cardiac troponin levels were stratified into tertiles, and mortality was assessed using cox proportional hazard mortality multivariate logistic regression models. K-M survival curves were used to display mortality over time. All analyses were done using STATA version 17, with p-values less than 0.05 considered statistically significant. Results In all, there were 551 persons, corresponding to 4.4 million, with a diagnosis of CHF. Of this, 379, corresponding to 4.1 million persons, were retained for analyses. Hypertension (61.6%), diabetes (34.26%), CKD (32.7%), nicotine use (65.45%), and cardiovascular diseases (CVD) were the most prevalent comorbidities. On the multivariate analysis, compared to lower tertile for elevated NT-proBNP, being in the middle tertile increased the risk of all-cause mortality up to 54% (HR 1.54, CI 1.03 – 2.3, P = 0.035) and up to 2 fold for being in upper tertile (HR 1.95, CI 1.29 – 2.96, P = 0.002)(Figure 1). Similarly, compared to the lower tertile for elevated troponin, being in the upper tertile increased the risk of all-cause mortality up to threefold (HR 2.84, CI 1.82- 4.44, P = 0.000) while being in the middle tertile could not achieve statistical significance for predicting the outcome (HR 1.44, CI 0.95 - 2.17, P = 0.082)(Figure 2). Among other predictors included in the analysis, CKD and history of smoking were associated with overall worse survival (HR 1.68, CI 1.25- 2.23, P = 0.000) and (HR 1.5, CI 1.099-2.076, P = 0.011), respectively. Conclusion CHF patients in the middle and upper tertile for NT-proBNP and cardiac troponin compared to the lower tertile showed an overall poor prognosis on follow up in the ambulatory settings. Our findings suggest that monitoring NT-proBNP and cardiac troponin levels can be useful tools for predicting prognosis. Further studies are needed for the clinical implications of this strategy.K-M survival estimates for NT-proBNPK-M survival estimates for troponin

Proteomics and phosphoproteomics of failing human left ventricle identifies dilated cardiomyopathy-associated phosphorylation of CTNNA3

The prognosis and treatment outcomes of heart failure (HF) patients rely heavily on disease etiology, yet the majority of underlying signaling mechanisms are complex and not fully elucidated. Phosphorylation is a major point of protein regulation with rapid and profound effects on the function and activity of protein networks. Currently, there is a lack of comprehensive proteomic and phosphoproteomic studies examining cardiac tissue from HF patients with either dilated dilated cardiomyopathy (DCM) or ischemiccardiomyopathy (ICM). Here, we used a combined proteomic and phosphoproteomic approach to identify and quantify more than 5,000 total proteins with greater than 13,000 corresponding phosphorylation sites across explanted left ventricle (LV) tissue samples, including HF patients with DCM vs. nonfailing controls (NFC), and left ventricular infarct vs. noninfarct, and periinfarct vs. noninfarct regions of HF patients with ICM. Each pair-wise comparison revealed unique global proteomic and phosphoproteomic profiles with both shared and etiology-specific perturbations. With this approach, we identified a DCM-associated hyperphosphorylation cluster in the cardiomyocyte intercalated disc (ICD) protein, αT-catenin (CTNNA3). We demonstrate using both exvivo isolated cardiomyocytes and invivo using an AAV9-mediated overexpression mouse model, that CTNNA3 phosphorylation at these residues plays a key role in maintaining protein localization at the cardiomyocyte ICD to regulate conductance and cell-cell adhesion. Collectively, this integrative proteomic/phosphoproteomic approach identifies region- and etiology-associated signaling pathways in human HF and describes a role for CTNNA3 phosphorylation in the pathophysiology of DCM.

What's the Alternative?: CONSIDERING THE PATIENT PERSPECTIVE OF ALTERNATIVE CARDIAC REHABILITATION PROGRAMMING.

What's the Alternative?: CONSIDERING THE PATIENT PERSPECTIVE OF ALTERNATIVE CARDIAC REHABILITATION PROGRAMMING.

Effect of Influenza Vaccination in Patients with Cardiovascular Disease: An Updated Meta-Analysis of Randomized Controlled Trials

Background: Influenza is a major cause of morbidity and mortality in patients with cardiovascular disease (CVD). The aim of this updated systematic review and meta-analysis was to evaluate the effect of influenza vaccination (IV) on morbidity and morbidity in adult patients with CVD. Methods: We conducted a systematic review and meta-analysis (PubMed, Cochrane Library, International Clinical Trials Registry Platform, and manual search of conference presentations) of randomized clinical trials published up to April 2022 analyzing whether IV reduced all-cause mortality in adult patients with CVD, including heart failure (HF) and coronary artery disease (CAD), compared with patients who were not vaccinated. Results: A total of six clinical trials comprising 9316 patients were analyzed. Five trials included CAD patients, and one trial included HF patients. Mean follow-up was 16 ± 9.7 months. Influenza vaccine was associated with a reduction of mortality compared to controls: relative risk (RR) 0.67, 95% confidence interval (95% CI), 0.47-0.95; p = 0.03; I2 = 53%, and with reduction of cardiovascular death compared to controls: RR 0.64; 95% CI 0.44-0.94; p = 0.02; I2 = 54%. There was a non-statistically significant reduction in myocardial infarction compared to control: RR 0.82, 95% CI 0.60-1.12; p = 0.57; I2 = 0%. Conclusion: In this meta-analysis of six randomized controlled clinical trials, IV was associated with a 33% and 36% relative risk reduction of all-cause mortality and cardiovascular death, respectively, in patients with CVD. We sought to promote consensus about the persistent benefits of influenza vaccination in patients with CVD by including two new clinical trials in CAD and HF, confirming the association of vaccination with risk reduction in subjects with CVD.

Guideline-directed medical therapy in heart failure patients with reduced ejection fraction in Oman: utilization, reasons behind non-prescribing, and dose optimization

Background: Objective:To determine the reasons behind guideline-directed medical therapy (GDMT) non-prescribing, drug utilization before and after excluding those intolerable to GDMT, as well as dose optimization in heart failure (HF) patients with reduced ejection fraction (<40%) (HFrEF) in Oman.Methods:The study included HF patients seen at the medical outpatient clinics at Sultan Qaboos University Hospital, Muscat, Oman, between January 2016 and December 2019 and followed up until the end of June 2021. The use of renin-angiotensin-system (RAS) blockers (angiotensin-converting-enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) or angiotensin receptor-neprilysin inhibitors (ARNIs)), beta blockers and mineralocorticoid receptor antagonists (MRAs) were evaluated as per the European, American, and Canadian HF guidelines. Analyses were performed using univariate statistics.Results:A total of 171 HFrEF patients were enrolled for this study, the overall mean age of the cohort was 63 ± 15 years old and 59% were male. Over 65% of the patients had chronic kidney disease. Almost 55% of the patients were intolerable to GDMT. The proportion of patients on beta blockers, RAS blockers/ hydralazine-isosorbide dinitrate combination, and MRAs, before and after excluding those intolerable to GDMT, were 89%, 97%, and 77%, and, 94%, 47% and 85%, respectively, while the proportion of patients on the GDMT combination concomitantly was 41% and 83%, respectively. A total of 61%, 44% and 100% of the patients were prescribed ≥50% of the target dose for beta blockers, RAS blockers/ HYD-ISDN combination and MRAs respectively, while 19%, 8.2% and 94% of the patients attained 100% of the target dose for beta blockers, RAS blockers/ HYD-ISDN combination and MRAs respectively.Conclusions:Reasons behind GDMT non-prescribing were frequent and not clearly obvious in patients’ medical notes. The majority of the patients were prescribed GDMT. However, dose optimization, specifically for beta blockers and RAS blockers/ HYD-ISDN combination, was still suboptimal. The findings should be interpreted in the context of low study power and that future studies, with larger sample sizes, are warranted to minimize this limitation.

High-Intensity Interval Training Among Heart Failure Patients and Heart Transplant Recipients: A Systematic Review.

High-intensity interval training (HIIT), an exercise training modality of cardiac rehabilitation, has shown growing evidence of improving cardiovascular patients' prognosis and health outcomes. This study aimed to identify and summarize the effects of HIIT in heart failure (HF) patients, heart transplantation (HTx) recipients, and HF patients before and after HTx. This systematic review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. For the past five years, a systematic search was done using PubMed, PubMed Central, Cochrane, Google Scholar, and ScienceDirect databases on September 15, 2021. Studies were selected based on the following predefined eligibility criteria: English-language randomized controlled trials (RCTs), observational studies, systematic reviews, and meta-analyses, which included HF patients and HTx patients, and assessment of effects HIIT. The relevant data were extracted to a predefined template.Consequently, quality assessment was done using each study's most commonly used assessment tools. The initial search generated 551 studies. Nine studies were included in the final selection - four RCTs, one cohort, one quasi-experimental study, two systematic reviews with meta-analyses, and one narrative review. HIIT was found to be generally superior or similar with other exercise training on VO2 peak, heart rate, LVEF, cardiac biomarkers, vascular function, blood pressure, body composition, and adverse events in HF patients and the aforementioned with QoL among HTx recipients. Data on cardiac remodeling and QoL of HF patients were inconclusive.

Variability in Cardiovascular Risk Factor Control in Patients with Heart Failure According to Gender and Socioeconomic Status.

Background: Despite considerable evidence concerning heart failure (HF) risk factors, there is scarce information about the effect and degree of control regarding socioeconomic and gender inequalities. Methods: Cohort study including HF patients >40 years of age attended in 53 primary health care centers in Barcelona (Spain). Socioeconomic status (SES) was determined by an aggregated deprivation index (MEDEA) according to the neighborhood of residence. Logistic multivariable regression was performed to analyze differences in cardiovascular risk factor control, stratifying by SES and sex. Results: A total of 8235 HF patients were included. Mean age was 78.1 (standard deviation 10.2) years, and 56.0% were women. The most prevalent cardiovascular risk factors were hypertension, diabetes, and dyslipidemia. Blood pressure was the worst controlled factor in both genders with the lowest SES (odds ratio [OR] 0.56 95% confidence interval [CI] 0.56-0.71) and (OR 0.52, 0.46-0.71), respectively. In women, a social gradient was observed for glycemic and body mass index control, which were worse in the most unfavorable socioeconomic position (OR 0.54, 95% CI 0.38-0.77), and (OR 0.45, 95% CI 0.32-0.64), respectively. Men presented worse control of blood pressure (OR 0.55, 95% CI 0.42-0.71) and smoking habit (OR 0.67, 95% CI 0.47-0.90) in the most deprived socioeconomic bracket. Conclusion: Patients with HF in the most disadvantaged socioeconomic levels presented the worst degree of control for cardiovascular risk factors, and this negative effect was stronger in women.

Effect of cardiac rehabilitation on exercise ventilatory oscillations in patients with chronic heart failure

Cardiovascular rehabilitation (CVR) is recommended in patients with heart failure (HF) to reduce mortality and new hospitalizations. A cardiopulmonary exercise testing (CPX) presents prognostic criteria such as the presence of exercise oscillatory ventilation (EOV). The aim of our study was to analyse the impact of CVR on EOV and the prognostic value of an evolution of EVO after CVR in a population of chronic heart failure patients. Retrospective, monocentric study including HF patients with reduced/intermediate left ventricular ejection fraction (i.e. < 50%) who participated to a CVR programme in our institution from July 2013 to November 2020, consisting of 21 sessions with a CPX at the first and last sessions. The presence of EOV at the CPX priori to CVR defined the EOV+ and EOV- groups. The main outcome of the study was the resolution of EOV after CVR. The secondary outcome was the occurrence of rehospitalisation for HF and/or death during follow-up, and according to the EOV status. Among the 142 patients included, 24 (17%) had EOV (EOV+ group). The VE/VCO2 slope before CVR was significantly increased in the EOV+ vs. EOV- patients (39.6 ± 5.9 vs. 36.8 ± 6.1 P = 0.05). Regarding the main outcome, EOV resolution was noted after CVR in 14 patients (58.3%, P < 0.01). The 10 patients (7%) with maintained EOV had a significant decrease of the length of the EOV cycle (40.2 ± 12.8 vs. 49.5 ± 15.3 sec, P = 0.005). After a mean follow-up of 31 ± 22 months, we found no difference in the rates of occurrence of the secondary outcome according to the post-CVR EOV status. Cardiovascular rehabilitation is associated with a substantial resolution of EOV (or EOV cycle length) in patients with chronic heart failure. However, the prognostic value of this phenomenon is uncertain.

Telehealth and 30-Day Readmissions Among Heart Failure Patients During the COVID-19 Pandemic

This study examined whether outpatient follow-up within 14 days of discharge via telehealth visits are as effective as in-person visits for reducing 30-day readmission in heart failure (HF) patients. Using electronic health records from a large health system, we included HF patients (n=1,722) who were hospitalized during the period of March 15-July 15, 2020. Overall, 28.1% of patients received an early outpatient follow-up visit. Patients who received telehealth visits (n=119) were more likely to be older and live in areas with higher median household incomes than those with in-person visits (n=365). Thirty-day readmission rates were 20.5% during the COVID-19 period. Multivariate models showed that patients who received a telehealth (OR=0.36, 95%CI [0.23-0.56]) or an in-person (OR=0.42, 95%CI [0.31-0.57]) visit were less likely to be readmitted within 30 days compared with patients without an early outpatient follow-up. Telehealth visits were just as effective as in-person visits at reducing 30-day readmissions.

Atrial fibrillation in heart failure: Prime time for ablation!

Among heart failure (HF) patients, the onset of atrial fibrillation (AF) is often associated with a marked worsening of HF symptoms and increased morbidity and mortality. Among AF patients, 30%–40% experience at least 1 HF episode. New data suggest that, in HF patients, AF rhythm control is superior to rate control and that rhythm control by catheter ablation is superior to antiarrhythmic drugs. In recent years, several trials that addressed the impact of AF ablation on morbidity and mortality included HF patients; however, studies also have specifically investigated the growing cohort of patients suffering from both HF and AF. Although the majority of these trials showed a marked benefit of AF ablation, there are hints that not all HF patients benefit equally from AF ablation. AF treatment in HF is challenging because the same cardiac morbidities that lead to HF can also act as risk factors for the development of the arrhythmogenic substrate that causes AF. In many patients, this arrhythmogenic substrate can be successfully treated by antral pulmonary vein isolation pulmonary vein isolation (PVI). However, due to advanced atrial disease, some patients also might require multiple procedures and/or “PVI plus” ablation strategies. In this review, we summarize current data on the effect of AF ablation in HF patients, with a special focus on the beneficial effect of AF ablation in different clinical HF subgroups.

THE IMPACT OF TELEHOMECARE ON HEART FAILURE PATIENTS, NURSES, AND INFORMAL CAREGIVERS: A LONGITUDINAL COHORT STUDY

THE IMPACT OF TELEHOMECARE ON HEART FAILURE PATIENTS, NURSES, AND INFORMAL CAREGIVERS: A LONGITUDINAL COHORT STUDY

Incidence of Depression Among Chronic Heart Failure Patients Presented at Tertiary Care Hospital

Objective: To determines the incidence of depression in patients presenting with chronic heart failure at tertiary care Hospital. Materials and methods: This study was descriptive cross-sectional study conducted at Punjab institute of cardiology Lahore during six months from September 2018 to April 2019. Patients were of chronic heart failure with reduced ejection fraction (&lt;40%) on echocardiography and either of the gender were included in the study. Cases were assessed for depression according to Hospital Anxiety and Depression Scale (HADS). Depression subscale of HADS Questionnaire with score more than 11 was used to diagnose depression. Data was collected via study proforma. Results: Mean age of included heart failure patients was 58±11.26 years. Out of all 62% were males and 38% were female. Out of all 57% cases were found with depression while 43% cases didn’t had depression. Incidence of depression was found statistically insignificant according to age, gender, duration of disease and socioeconomic status, p-values were quite insignificant. Conclusion: Incidence of depression was observed to be higher among patients presented with chronic heart failure. Key word: Depression, chronic heart failure

Predictors of clinical improvement in heart failure patients with iron deficiency treated with ferric carboxymaltose

Introduction and objectivesIntravenous iron is recommended to correct iron deficiency in heart failure (HF) patients, although not all patients had the same response. We evaluated the impact of ferric carboxymaltose (FCM) in analytical and clinical improvement and analyzed the response according to different parameters. MethodsWe included HF patients who received FCM in the daily hospital to correct iron deficiency. We recorded clinical and analytical parameters at baseline and 3 months follow-up. ResultsWe included 236 patients (age 73.5±10.7 years) with left ventricular ejection fraction 44.5±15.3%. There were no adverse effects during the infusion. All ferric analytical parameters significantly increased at 3 months. 25.1% of patients improved functional class, and New York Heart Association (NYHA) III patients were more likely to improve. Mean corpuscular volume predicted NYHA improvement (OR, 0.97; 95%CI, 0.93–1.00; P=.05). Body mass index (OR, 0.86; 95%CI, 0.78–0.95; P=.002) and ferritin (OR, 1.00; 95%CI, 1.00–1.01; P=.042) were also predictors of N-terminal pro-B-type natriuretic peptide reduction of at least 30% from basal levels. 61.3% received lower doses of FCM than the theoretical ones, and those with the correct dose were more likely to improve NYHA and reduce natriuretic peptides. ConclusionsFCM was useful to correct iron deficiency in clinical practice, independently to anemia, without relevant adverse effects. Clinical improvement was especially relevant in more symptomatic patients and those with absolute deficiency. Mean corpuscular volume, body mass index, ferritin, and dose of FCM were predictors of clinical improvement.

Effect of levosimendan combined with recombinant human brain natriuretic peptide on diuretic resistance

ABSTRACT Levosimendan is a calcium sensitizer used for managing heart failure (HF) because of its inotropic and vasodilatory effects. As many patients do not respond to levosimendan as a monotherapy, it may be necessary to combine it with other diuretic agents such as recombinant human brain natriuretic peptide (rhBNc P). The aim of this study was to investigate efficacy of levosimendan when combined with rhBNP in patients with diuretic resistance and low ejection fraction (EF) rate. The study included HF patients with diuretic resistance and low EF. Before grouping, patients with a 24-hour urine volume of <0.5 mL/kg/h were administered with furosemide injection. Treatment group was administered levosimendan injection based on the original diuretic and rhBNP. One hundred twenty-eight patients were included, with 64 patients each in the control and treatment arms. 24-hour urine volume of the treatment group was significantly higher than that of the control group. Moreover, dyspnea score of the treatment group significantly improved compared with control group. In the treatment group, 12.5% of patients had no significant changes in the urine volume, weight, and dyspnea score before and after the treatment, indicating poor curative effect of the treatment, whereas in the control group, 23.4% of patients had poor curative effect (P < .05). No significant change was observed in the systolic blood pressure, heart rate, and serum creatinine level before and after treatment in both groups. Levosimendan in combination with rhBNP can effectively relieve diuretic resistance, reduce body weight, improve dyspnea, and ensure safety in the treatment process.

Evaluation of guideline-based cardiovascular medications and their respective doses in heart failure patients in Oman.

Background Significant gaps exist between guidelines and practice in the management of heart failure, not only in Oman but the Arabian Gulf region in general. Currently, only limited research exists on the use of these guideline-based cardiovascular medications and their corresponding target doses in the region. Objective To evaluate the use of guideline-based cardiovascular medications and their corresponding target doses in heart failure patients with reduced (< 40%) and mid-range (40-49%) ejection fraction in Oman. Setting Cardiology clinics at Sultan Qaboos University Hospital, Muscat, Oman. Methods The study included heart failure patients seen at the clinics between January 2016 and December 2019. The use of angiotensin-converting-enzyme inhibitors (captopril, lisinopril) or angiotensin II receptor blockers (irbesartan, valsartan), β-blockers (bisoprolol, carvedilol) and spironolactone along with their respective target doses were evaluated as per the European, American, and Canadian heart failure guidelines. Analyses were performed using univariate statistics. Main outcome measure The proportion of patients that was prescribed guideline-based heart failure medications along with their target doses as per guidelines. Results The overall mean age of the cohort (N = 249) was 63 ± 15years and 61% (n = 151) were males. Seventy-one percent (n = 177) of the patients had heart failure with reduced ejection fraction while 29% (n = 72) had heart failure with mid-range ejection fraction. A total of 87% (n = 216), 62% (n = 154) and 39% (n = 96) of the patients were on β-blockers, angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers and spironolactone, respectively. Only 33% (n = 81) of the patients were on the triple guideline-based cardiovascular medication classes concurrently. Patients with reduced ejection fraction were more likely to be prescribed the triple guideline-based cardiovascular medication classes concurrently than those that had heart failure with mid-range ejection fraction (37% vs 22%; p = 0.027). A total of 100% (96/96), 56% (121/216) and 42% (64/153) of the patients were prescribed ≥ 50% of target dose for spironolactone, β-blockers and angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers, respectively. Conclusions The use of guideline-based cardiovascular medications in heart failure patients with reduced and mid-range ejection fraction is low in Oman. They were also largely not optimally dosed at target levels.

GENECHOC study: genetic markers of arrhythmic risk in heart failure

Abstract Background Ventricular arrhythmic events are responsible for 50% of death in heart failure but no reliable predictive marker is known to discriminate patients at risk of fatal arrhythmia. Interestingly, familial predisposition has been reported suggesting a role of genetic factors. Purpose Identify genetic markers increasing the arrhythmic risk in heart failure population. Method We prospectively included heart failure patients with left ventricular ejection fraction (LVEF) under 35% and a cardioverter defibrillator in primary prevention in 22 French centres between 2009 and 2017. Patients were followed for 72 months and divided into two groups: cases with an arrhythmic event during follow-up and controls. A Genome Wide Association Study (GWAS) was done. Single Nucleotide Polymorphisms (SNPs) genotyping was performed on Affymetrix Axiom Precision Medicine Research Array plates. To complement the directly genotyped SNPs we performed large-scale imputation based on the Haplotype Reference Consortium European ancestry panel leading to a dataset of 7,5 million of SNPs. Results 332 cases and 567 controls were included (86% men, mean age at implantation 52±11 years). 78% of patients had ischaemic cardiopathy, 20% had dilated cardiomyopathy. Mean LVEF was 27±5%. No statistical difference was found between cases and controls on clinical parameters, biological results, electrocardiographic measures. No locus shows genome-wide significant association (p&amp;lt;5.10–8) on the GWAS analysis. However, 16 signals with a p-value between 5.10–8 and 5.10–5 were investigated. eQTL and chromatin conformation point to 35 genes with cardiac expression previously associated with heart failure, cardiomyopathies, cardiogenesis, arrhythmias and inflammation. Variants identified point to regulatory regions of the genome and may then propose a molecular mechanism predisposing patients to arrhythmias. Conclusion No locus raises genome-wide significance, but several signals with a nominal p-value point to relevant genes and pathways. Replication of the GWAS is ongoing on a cohort of 156 new patients with a less severe cardiopathy implanted with a cardioverter defibrillator in secondary prevention. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Nantes University Hospital

Endothelial dysfunction and cardiovascular mortality in patients with acute coronary syndrome

Abstract Background Although the prognostic value of non-invasive endothelial function test has been reported in several populations including heart failure patients and angina pectoris patients, it is unknown in patients with acute coronary syndrome (ACS). Furthermore, the role of endothelial dysfunction in increased risk for specific causes of death has not been investigated. Purpose To study the relation between endothelial dysfunction and the risk of death in ACS patients, both overall and with regard to the main causes of death. Method Six hundred and ninety-two patients who were hospitalized for ACS from 2010 to 2014 were enrolled. Reactive hyoeremia index (RHI) was measured to assess endothelial function non-invasively in all patients using the peripheral arterial tonometry. RHI values below 1.67 were interpreted as signs of endothelial dysfunction in accordance with the manufacturer. Patients were followed up for a median of 6.5 years. Result A mean age (standard deviation) was 66 (12) years, and 542 patients (78%) were male. The patients in this study consist of 377 ST-elevation myocardial infarction (54%), and 263 non ST-elevation myocardial infarction (38%), and 52 unstable angina (8%). Endothelial dysfunction was detected in 276 patients (40%). During the follow-up period, 84 patients (12%) died (48 from cardiovascular disease, 36 from other causes). Patients with endothelial dysfunction had an increased risk of death (hazard ratio (HR) 1.83, 95% confidence interval (95% CI): 1.19–2.83, p=0.006) compared with those without endothelial dysfunction. Analyses for specific causes of death showed that patients with endothelial dysfunction had a 2.4-fold higher increased risk of cardiovascular death (HR: 2.44, 95% CI: 1.35 ro 4.59, p=0.003) after multivariate adjustment. However there was no significant relation between endothelial dysfunction and non-cardiovascular mortality (HR: 0.69, 95% CI: 0.34 to 1.36, p=0.29). Conclusion Endothelial dysfunction is strongly associated with an increased risk of cardiovascular mortality in ACS patients. Figure 1 Funding Acknowledgement Type of funding source: None

Genechoc Study Genetic markers of arrhythmic risk in heart failure

Ventricular arrhythmic events are responsible for 50% of death in heart failure but no reliable predictive marker is known to discriminate patients at risk of fatal arrhythmia. Interestingly, familial predisposition has been reported suggesting a role of genetic factors. Identify genetic markers increasing the arrhythmic risk in heart failure population. We prospectively included heart failure patients with left ventricular ejection fraction (LVEF) under 35% and a cardioverter defibrillator in primary prevention in 22 French centres between 2009 and 2017. Patients were followed for 72 months and divided into two groups: cases with an arrhythmic event during follow-up and controls. A Genome Wide Association Study (GWAS) was done. Single Nucleotide Polymorphisms (SNPs) genotyping was performed on Affymetrix Axiom Precision Medicine Research Array plates. 332 cases and 567 controls were included (86% men, mean age at implantation 52 ± 11 years). 78% of patients had ischaemic cardiopathy, 20% had dilated cardiomyopathy. Mean LVEF was 27 ± 5%. No statistical difference was found between cases and controls on clinical parameters or electrocardiographic measures. No locus shows genome-wide significant association ( P < 5.10 − 8) on the GWAS analysis. However, 16 signals with a p-value between 5.10 − 8 and 5.10 − 5 were investigated. eQTL and chromatin conformation point to 35 genes with cardiac expression previously associated with heart failure, cardiomyopathies, arrhythmias and inflammation. Variants identified point to regulatory regions of the genome and may then propose a molecular mechanism predisposing patients to arrhythmias ( Fig. 1 ). No locus raises genome-wide significance, but several signals with a nominal p-value point to relevant genes and pathways. Replication of the GWAS is ongoing on a cohort of 156 new patients with a less severe cardiopathy implanted with a cardioverter defibrillator in secondary prevention.