Heart Failure Of Ischemic Etiology Research Articles

Cardiac resynchronization in heart failure: Recent advances and their practical implications.

Cardiac resynchronisation (CRT) improves survival and reduces heart failure hospitalisations, in symptomatic patients with heart failure (HF) with reduced ejection fraction with wide QRS despite guidelines indicated medical therapy. In patients with mild HF symptoms (New York Heart Association [NYHA], class II) CRT delays or reverses disease progression. Still, CRT is largely underused. The results of CRT Survey II indicates wide adoption of class I indications in European Society of Cardiology guidelines but with important national differences. As an example more patients in Poland had ischemic HF etiology and in NYHA III than in the overall CRT cohort. Similar patterns were seen in other countries suggesting that some patients such as those in NYHA II and with non-ischemic etiology may be especially underserved by CRT. But the Survey results also shows wide use in areas with week scientific evidence such in atrial fibrillation (AF) and when upgrading from ongoing implantable cardioverter defibrillator or right ventricular pacing to CRT. This practise may imply the belief of the physcian than CRT may but also highlights the need of randomised studies to elucidate CRT effects in such patients. Besides, gaps of evidence the review further discusses reasons for obstacles for CRT implementation and the challenges with the traditional responder definition which may deter the clinician from offering CRT therapy. Finally, the importance of sex and body size for electrical selection criteria for CRT are discussed. A person with small body size and/or female sex may may derive CRT benefit at shorter QRS durations than a bigger individual indicating the need ato shift to personalized medicine.

Sacubitril/Valsartan in Heart Failure with Reduced Ejection Fraction: Real-World Experience from Italy (the REAL.IT Study).

Sacubitril/valsartan reduces heart failure (HF)-related hospitalizations and cardiovascular mortality in PARADIGM-HF and has become a foundational treatment for HF with reduced ejection fraction (HFrEF). However, data of its routine real-world use are limited, and evidence from Italian settings is lacking. The REAL.IT study aimed to characterize the demographics, pharmacotherapy, clinical characteristics and outcomes of sacubitril/valsartan-treated Italian patients with HFrEF. Electronic medical records of patients initiating sacubitril/valsartan from October 2016 to June 2019 at nine specialized hospital outpatient HF centers across Italy were reviewed. Overall, 924 adults (mean age 64.5 years, 84.6% male) were included. At baseline, 38.7% had an ischemic HF etiology, 45.9% hypertension, 23.2% atrial fibrillation, 25.4% diabetes mellitus, 26.1% an implantable cardioverter-defibrillator and 31.9% coronary artery bypass grafting. There were no clear patterns of patient selection over time. During follow-up, NYHA class improved in 37.5% of patients after a mean of 5.3 ± 3.8 months; 36.1% and 16.7% of patients were in NYHA class III during characterization and after one year of follow-up, respectively. Left ventricular ejection fraction (LVEF) improved ≥5% in 56.3% of patients at one year; 39.7% had ≥30% reduction of N-terminal pro-B-type natriuretic peptide; 2.2% had hyperkalemia during characterization and 2.6% during follow-up; and 3.8% had hypotension during characterization and 12% during follow-up. A total of 50 (5.8%) of patients had device implantation (ICD/CRT) during follow-up. HF-related hospitalization was recorded in 19.6% of patients during follow-up; 3.8% of patients died, approximately 1.3% from cardiovascular causes. Our real-world data confirm the favorable effectiveness and tolerability of sacubitril/valsartan observed in pivotal randomized controlled trials.

Trends and predictors of functional class after high-risk left ventricular assist device implantation at a destination therapy center.

Although left ventricular assist device (LVAD) implantation is associated with improved survival, long-term impact on functional class is less well understood in high-risk implants. We undertook this study to better understand how destination therapy (DT) LVAD implantation affects patient functional status and predictors of functional improvement. We conducted a single-center, retrospective review of all primary LVAD implantations. Primary outcome was New York Heart Association (NYHA) functional class. An improved sustainable functional improvement was defined as being alive at 1-year with NYHA class I or II symptoms. Multivariable logistic regression was performed to identify predictors of sustainable functional improvement. From 2017 to 2023, 151 primary LVAD implantations were performed. Operative mortality was 7.95% (n=12). At 6-month follow-up, 113 (92.62%) of patients had experienced an improvement in functional class with 35 (28.69%) class I, 53 (43.44%) class II, 29 (23.77%) class III, and 5 (4.10%) class IV. At 12 months, 86 (91.49%) patients had sustained improvement in NYHA class with 32 (34.04%) class I, 40 (42.55%) class II, 19 (20.21%) class III, and 3 (3.19%) class IV. At 2 years, 57 (91.94%) patients still experienced improved symptoms. On multivariable logistic regression analysis, an ischemic etiology of heart failure (HF) was associated with a sustainable functional improvement [odds ratio: 5.53 (95% confidence interval: 1.06-28.89), P=0.04]. LVAD implantation is associated with significant functional improvement as measured by NYHA class. The high-risk cohort showed similar improvement in functional status. In our series, the best predictor of a sustainable improvement in functional status is an ischemic etiology of HF.

Activation of the HeartLogic algorithm on top of heart failure care: a multicenter propensity-matched cohort analysis

Abstract Background Hospitalization for decompensated heart failure may be prevented by early detection of fluid retention. The multisensory HeartLogic™ algorithm, incorporated in a cardiac implantable electronic device (CIED) aims to detect impending fluid retention and thereby enables timely adjustment of medical therapy. However, it is to be investigated whether HeartLogic™ provides clinical benefit compared to heart failure care with conventional telemonitoring. This analysis investigates the effects of activating HeartLogic™ on top of heart failure care with telemonitoring on the number of episodes with fluid retention and heart failure related hospitalizations. Methods Heart failure patients with a CIED were recruited from the outpatient clinics of four European cardiology departments. All patients were included from January 2017 until December 2020, and followed-up for 365 days. Patients with a CIED and an activated HeartLogic™ algorithm were compared to a 1:1 propensity score-based matched control group consisting of patients with CIED on routine telemonitoring. Data of all episodes of (impending) fluid retention with ≥2 signs and symptoms of congestion were included for analyses. Results Data of 127 patients with an activated HeartLogic™ algorithm were adequately matched with 127 heart failure patients with a CIED on routine telemonitoring. Median age was 68 [59–75], majority of patients were male (80%), 46% had an ischemic etiology of heart failure. Total follow-up consisted of 254 patient years. During follow up, 77 (61%) individual patients with HeartLogic™ experienced an episode of fluid retention, compared to 85 (67%) induvial patients on routine telemonitoring. Patients with an activated HeartLogic™ algorithm had 1.62±1.78 events of fluid retention per patient year (PPY) compared to 2.61±3.71 events PPY in patients on routine telemonitoring, p<0.01 (Figure 1). Hospitalization for fluid retention occurred in 7 (6%) HeartLogic™ patients (0.06±0.27 hospitalizations PPY) compared to 13 (10%) patients on routine telemonitoring (0.15±0.45 PPY), p=0.07 (Figure 2A). Mean length of hospitalization in days PPY was 0.29±1.46 in patients with HeartLogic™ and 1.59±6.30 in patients on routine telemonitoring, p=0.02 (Figure 2B). Conclusion In a real-world multicenter heart failure population, activation of the HeartLogic™ algorithm was associated with a lower number of episodes of fluid retention per patient and a shorter duration of hospitalization for congestive heart failure. Funding Acknowledgement Type of funding sources: None.

50 ERECTILE DYSFUNCTION IN HEART FAILURE PATIENTS: CORRELATION WITH SEVERITY, COMORBIDITIES, EXERCISE CAPACITY AND TREATMENT

Abstract Aims Erectile dysfunction (ED) is frequent in males with chronic heart failure (HF) with a severe impact on quality of life for many individuals. We evaluated the correlation between ED and HF severity, exercise capacity, treatment and psychological framework. Methods and results We enrolled 328 HF patients aged ≤70 years, with left ventricular ejection fraction ≤40%, and stable clinical condition. We measured: (i) hemoglobin, glycemia, glicated hemoglobin, creatinine, cholesterol, thyroid-stimulating-hormone, C-reactive-protein, total/free testosterone, brain natriuretic peptide, N-terminal prohormone of brain natriuretic peptide; (ii) ED, depression, urological symptoms and signs of low testosterone by means of questionnaires; (iii) HF severity by means of echo and cardiopulmonary exercise test. ED was measured by means of International Index of Erectile Function-5 questionnaire and its score was correlated with exercise cardiopulmonary test parameters, HF severity, treatment and HF comorbidities. Results ED prevalence was 69.94%, 74.46%, and 64.08% in total population and in patients with and without coronary artery lesions, respectively. ED was absent in 98 while it scored mild, mild to moderate, moderate and severe in 65, 57, 32, 73 individuals, respectively. Depression was found in 33.96%, mild urological symptoms in 54,23% and signs of low testosterone in 74.23%. All the individuals with peakVO2 < 10 mL/min/kg had at least a slightly impaired sexual function. We have found no correlation between ED and ejection fraction, use of beta-blockers and ischemic etiology of HF. The only independent predictor of ED presence and severity is the symptomatology related to low testosterone. Conclusions ED is frequent in HF. A normal or only slightly impaired sexual activity is possible with peakVO2 > 10 mL/min/kg. The symptomatology related to low testosterone should be investigated during cardiological examinations.

842 PREVALENCE AND MECHANISMS OF SEVERE MITRAL AND TRICUSPID RECURGITATION IN A HEART FAILURE OUTPATIENTS POPULATION

Abstract Introduction Mitral regurgitation (MR) and tricuspid regurgitation (TR) are an established cause of morbidity and mortality in heart failure (HF) patients. The development of successful transcatheter therapies for mitral and tricuspid diseases have opened new therapeutic opportunities, in addition to guideline-directed medical therapy (GDMT) for HF. However, an accurate evaluation of the mechanisms of valve regurgitation is key to tailor the best treatment for each patient. This study aims at evaluating the prevalence and underlying mechanisms of at least moderate-to-severe (≥3+/4+) MR and/or TR in a cohort of HF outpatients. Methods We retrospectively analyzed the medical records of 1260 outpatients evaluated by our HF Unit between January 2020 and June 2021. All patients with echocardiographic evidence of at least moderate-to-severe MR and/or TR were included in the registry and a thorough review of echocardiographic images and collection of clinical data were also performed. Results Of the 1260 analyzed patients, 173 (13.7%) presented with at least moderate-to-severe MR and/or TR and were included in the registry. The mean age was 80±7 years and median ejection fraction was 45% (IQR 33; 55%) and 77 (45%) had HF of ischemic etiology. All patients were treated with maximal tolerated doses of GDMT and, when appropriate, with devices and myocardial revascularization. At least moderate-to-severe MR and TR was observed in 7.3% (92/1260) and 9.3% (117/1260) patients, respectively. Patients with significant isolated MR were 56 (4.4%), with isolated TR were 81 (6.4%), while with both significant MR and TR were 36 (2.8%). Among patients with significant MR, 54% (50/92) had functional valvular defect, of whom 82% (41/50) had a ventricular etiology (18/41 with asymmetric tethering), while the 18%(9/50) an atrial one (3/9 with atriogenic tethering). Among patients with significant TR, 72.6% (85/117) had functional valvular defect, of whom 35.3% (30/85) had a ventricular etiology while 64.7% (55/85) presented with an atrial one. Conclusion Despite optimized GDMT, the prevalence of patients presenting with significant MR and TR was considerably high in our ambulatory HF population. This registry is the first study to comprehensively detail the mechanisms of atrioventricular valve regurgitations in a wide cohort of HF outpatients. Further studies are needed to assess the reasons for a potential undertreatment and to identify the patients who would benefit the most from the percutaneous correction of their valvular defects.

679 PROGNOSTIC IMPACT OF ECHOCARDIOGRAPHIC DERIVED PRECAPILLARY WEDGE PRESSURE AND PULMONARY VASCULAR RESISTANCES IN PATIENTS WITH HEART FAILURE

Abstract Background A reliable echocardiographic algorithm for the estimation of precapillary wedge pressure (PCWP) and pulmonary vascular resistances (PVR) has been recently validated by our group in a large cohort of patients undergoing right heart catheterization (RHC). Those metrics may add relevant clinical and prognostic information in patients with heart failure (HF). Objective To assess the clinical/prognostic significance of echocardiographic derived PCWP and PVR in a large cohort of chronic HF patients on modern treatments. Methods Outpatients with chronic HF with either reduced (≤40%) or mildly reduced LVEF (41-49%) underwent a thorough clinical multiparametric assessment and were followed-up for a composite endpoint of cardiac death, appropriate ICD shock, or first HF hospitalization. Results Out of 1,483 patients prospectively enrolled (70±12 years, 73% males, 42% ischemic etiology, LVEF 35±8%, 74% HFrEF), PCWP (16.4±5.8 mmHg) was elevated (>15 mmHg) in 53% of cases, while PVR (1.7±0.7) was elevated (>2 WU) in 25% of cases. Of the latter group, most (83%) had also elevated PCWP. Patients with increased PCWP were older, had a higher heart rate and lower cardiac output, showed a higher degree of left and right chamber remodeling, had a higher neurohormonal activation, worse renal function, worse functional capacity and ventilatory efficiency on effort, particularly when also PVR were elevated (all p<0.001). The optimal prognostic cut-point was identified for both PCWP (16.2 mmHg) and PVR (2 WU) by log-rank maximal likelihood ratio. Over a median follow-up of 27 (12-43) months, both measures significantly stratified patients for the risk of the primary endpoint at Kaplan-Meier analysis (Log Rank 99.5, p<0.001 for PCWP; Log Rank 18.4, p<0.001 for PVR). While both increased PCWP and PVR were associated with a higher risk of events in the HFrEF subgroup (both p<0.001), only increased PCWP significantly stratified the outcome in HFmrEF patients (Figure). At multivariable Cox regression analysis (adjusted for age, sex, ischemic HF etiology, glomerular filtrate, LVEF, and NT-proBNP), increased PCWP (hazard ratio, HR 1.67 [95%CI 1.28-2.18], p<0.001) but not PVR (HR 1.25 [95%CI 0.98-1.60], p=0.07) remained an independent predictor of the primary outcome. Conclusion The estimation of PCWP and PVR by echocardiography add relevant clinical and prognostic information and may help in the decision making in patients with HF.

Mental Status and Quality of Life in Patients With Sinus Node Weakness Syndrome and Chronic Coronary Heart Failure of Ischemic Etiology

The frequent combination of sinus node weakness syndrome (SNWS) and chronic heart failure (CHF) in patients has shown the need for a comprehensive study of their impact on the adaptability of these patients. The assessment of quality of life (QOL) and mental status in patients with SNWS and CHF of ischaemic etiology was carried out. Sinus node weakness syndrome accounts for about 9% of all cardiac rhythm disorders and is one of the current problems of modern arrhythmology. This is due to the fact that with sinus node weakness syndrome hemodynamic disorders can develop, the quality of life of patients is reduced, significant difficulties arise in the treatment of the underlying cardiovascular disease and associated rhythm disturbances. Patients with sinus node weakness syndrome have a reduced ability to work. For example, 14.5% of all patients with a first-time disability are with sinus node disorder. In industrialised countries, more than half of the patients implanted with an artificial pacemaker are patients with weak sinus node syndrome. We used 6 minute walking test, as well as level of depression, anxiety, alexithymia; coping>mechanisms and Vital Style Index in 75 CHD patients with and without SNWS, complicated CHF I>II (NYHA) were assessed. No additional negative effect of SNWS on somatic, mental status and QOL was found in patients with CHF

Comparison of Patients with Reduced and Mildly Reduced Left Ventricular Ejection Fraction: Intermediate Data from the FAR NHL Registry

Introduction: We present the results of a study by the Pharmacology and NeuroHumoral Activation Registry (FAR NHL), which collects data on patients with chronic heart failure. The register contains 1088 patients from three workplaces in the Czech Republic which specialize in the care of patients with heart failure. Objectives: The aim was to obtain a comparison of pharmacotherapy and the incidence of comorbidities in patients with reduced ejection fraction (HFrEF) versus patients with mid-range (or newly mildly reduced) ejection fraction (HFmrEF). Methods: Patients with a baseline left ventricular ejection fraction below 50% were included and divided into HFrEF with EF below 40% and HFmrEF with EF 40–49%, according to the 2016 ESC Guidelines. In addition to the clinical condition, we also monitored laboratory parameters, comorbidities and pharmacotherapy in the patients. Results: Patients with HFrEF versus HFmrEF are more likely to be male (p < 0.008), younger (p < 0.001), have lower systolic blood pressure and are less likely to have ischemic etiology of heart failure (p < 0.001). There were no differences between the groups in the proportion of comorbidities: hypertension, diabetes mellitus, dyslipidemia, ischemic lower limb disease or chronic obstructive pulmonary disease. There were no differences in the proportion of smokers and non-smokers between the groups. Patients with HFrEF have a higher class of New York Heart Association (NYHA), a level of N-terminal fraction of natriuretic peptide B (NT-proBNP), and a higher level of urea and uric acid. They are more often treated with loop diuretics or mineral corticosteroid receptor (MRA) blockers and less often with thiazides (p < 0.001), and also have a worse two-year prognosis. Conclusion: Compared to patients with HFmrEF, patients with HFrEF have more severe heart failure, more pronounced neurohumoral activation and a worse prognosis. They do not differ in the presence of comorbidities.

Predictors of proarrhythmic effect in heart failure patients after 9-week hybrid comprehensive telerehabilitation and their influence on cardiovascular mortality in long-term follow-up: Subanalysis of the TELEREH-HF randomized clinical trial

BackgroundRegular exercise training is beneficial in heart failure (HF) patients. However, its potential proarrhythmic effect is possible but has not been sufficiently investigated. ObjectiveTo identify patients at risk for proarrhythmic effect after the 9-week of hybrid comprehensive telerehabilitation (HCTR) program vs the 9-week of usual care (UC) and to investigate its predictors and impact on cardiovascular mortality based on data from the TELEREH-HF RCT. MethodsProarrhythmic effect, strictly defined on the basis of available standards was evaluated by comparing 24-h Holter ECG before and after 9-week of HCTR or UC of 773 HF patients (The New York Heart Association class I-III, left ventricular ejection fraction ≤40%). ResultsThe proarrhytmic effect was found in 78 (20.4%) and in 61 (15.6%) patients in the HCTR and UC group respectively, and the difference between groups was not statistically significant (p = 0.081). However, univariate analysis identified several statistically significant predictors of proarrhythmia in HCTR only vs the UC group. After a multivariate analysis ischaemic aetiology of HF (OR = 2.27, p = 0.008), peak oxygen consumption at baseline <14 ml/kg/min (OR = 2.03, p = 0.012) and level of N-terminal-pro B-type natriuretic peptide (NT-proBNP) in the first and the second tercile (OR = 1.85, p = 0.043) were identified to be independent predictors of proarrhytmic effect of exercise training among the HF patients in HCTR group only. ConslusionsPatients who underwent a 9-week HCTR were not at a higher risk of proarrhythmic effect after its completion compared to UC. However, predictors of proarrhythmia such as ischemic aetiology of HF, poor physical capacity, lower NT-proBNP level were discovered in the HCTR group only, yet it does not cause a significant risk of cardiovascular mortality including sudden cardiac death in long-term follow-up.

Activation of the HeartLogic algorithm on top of heart failure care: a multicenter propensity-matched cohort analysis

Abstract Background Hospitalization for decompensated heart failure may be prevented by early detection of fluid retention. The multisensory HeartLogic™ algorithm, incorporated in a cardiac implantable electronic device (CIED) aims to detect impending fluid retention and thereby enables timely adjustment of medical therapy. However, it is to be investigated whether HeartLogic™ provides clinical benefit compared to heart failure care with conventional telemonitoring. This analysis investigates the effects of activating HeartLogic™ on top of heart failure care with telemonitoring on the number of episodes with fluid retention and heart failure related hospitalizations. Methods Heart failure patients with a CIED were recruited from the outpatient clinics of four European cardiology departments. All patients were included from January 2017 until December 2020, and followed-up for 365 days. Patients with a CIED and an activated HeartLogic™ algorithm were compared to a 1:1 propensity score-based matched control group consisting of patients with CIED on routine telemonitoring. Data of all episodes of (impending) fluid retention with ≥2 signs and symptoms of congestion were included for analyses. Results Data of 127 patients with an activated HeartLogic™ algorithm were adequately matched with 127 heart failure patients with a CIED on routine telemonitoring. Median age was 68 [59–75], majority of patients were male (80%), 46% had an ischemic etiology of heart failure. Total follow-up consisted of 254 patient years. During follow up, 77 (61%) individual patients with HeartLogic™ experienced an episode of fluid retention, compared to 85 (67%) induvial patients on routine telemonitoring. Patients with an activated HeartLogic™ algorithm had 1.62±1.78 events of fluid retention per patient year (PPY) compared to 2.61±3.71 events PPY in patients on routine telemonitoring, p&amp;lt;0.01 (Figure 1). Hospitalization for fluid retention occurred in 7 (6%) HeartLogic™ patients (0.06±0.27 hospitalizations PPY) compared to 13 (10%) patients on routine telemonitoring (0.15±0.45 PPY), p=0.07 (Figure 2A). Mean length of hospitalization in days PPY was 0.29±1.46 in patients with HeartLogic™ and 1.59±6.30 in patients on routine telemonitoring, p=0.02 (Figure 2B). Conclusion In a real-world multicenter heart failure population, activation of the HeartLogic™ algorithm was associated with a lower number of episodes of fluid retention per patient and a shorter duration of hospitalization for congestive heart failure. Funding Acknowledgement Type of funding sources: None.

Prognostic impact of echocardiographic derived precapillary wedge pressure and pulmonary vascular resistances in patients with heart failure

Abstract Background A reliable echocardiographic algorithm for the estimation of precapillary wedge pressure (PCWP) and pulmonary vascular resistances (PVR) has been recently validated by our group in a large cohort of patients undergoing right heart catheterization (RHC) (1). Those metrics may add relevant clinical and prognostic information in patients with heart failure (HF). Objective To assess the clinical/prognostic significance of echocardiographic derived PCWP and PVR in a large cohort of chronic HF patients on modern treatments. Methods Outpatients with chronic HF with either reduced (≤40%) or mildly reduced LVEF (41–49%) underwent a thorough clinical multiparametric assessment and were followed-up for a composite endpoint of cardiac death, appropriate ICD shock, or first HF hospitalization. Results Out of 1,483 patients prospectively enrolled (70±12 years, 73% males, 42% ischemic etiology, LVEF 35±8%), PCWP (16.4±5.8 mmHg) was elevated (&amp;gt;15 mmHg) in 53% of cases, while PVR (1.7±0.7) was elevated (&amp;gt;3 WU) in 6% of cases. Of the latter group, most (92%) had also elevated PCWP. Patients with increased PCWP were older, had a higher heart rate and lower cardiac output, showed a higher degree of left and right chamber remodeling, had a higher neurohormonal activation, worse renal function, worse functional capacity and ventilatory efficiency on effort (all p&amp;lt;0.001). Those patients with high PCWP and PVR showed higher heart rate and pulmonary pressures, lower cardiac output, and right ventricular function, higher neurohormonal activation, lower functional capacity and ventilatory efficiency on effort compared to patients with high PCWP but normal PVR (all p&amp;lt;0.01). The optimal prognostic cut-point was identified for both PCWP (16.2 mmHg) and PVR (2 WU) by log-rank maximal likelihood ratio. Over a median follow-up of 22 (8–37) months, both measures significantly stratified patients for the risk of the primary endpoint at Kaplan-Meier analysis (log-rank 92.9, p&amp;lt;0.001 for PCWP; log-rank 17.3, p&amp;lt;0.001 for PVR). At multivariable Cox regression analysis (adjusted for age, sex, ischemic HF etiology, renal function, LVEF, and NT-proBNP), PCWP (hazard ratio, HR 1.77 [95% CI 1.30–2.40], p&amp;lt;0.001) but not PVR (HR 1.15 [95% CI 0.88–1.51], p=0.31) remained an independent predictor of the primary outcome. Conclusion The estimation of PCWP and PVR by echocardiography add relevant clinical and prognostic information and may help in the decision making in patients with HF. Funding Acknowledgement Type of funding sources: None.

Impact of ischaemic aetiology on the efficacy of intravenous ferric carboxymaltose in patients with iron deficiency and acute heart failure: insights from the AFFIRM-AHF trial.

In AFFIRM-AHF, intravenous ferric carboxymaltose (FCM) reduced heart failure (HF) hospitalisations and improved quality of life versus placebo in iron-deficient patients stabilised after an acute HF episode. This analysis explored the effects of FCM versus placebo in patients with ischaemic and non-ischaemic HF aetiology. We included 1082 patients from AFFIRM-AHF: 590 with ischaemic HF (defined as investigator-reported ischaemic HF aetiology and/or prior acute myocardial infarction and/or prior coronary revascularisation) and 492 with non-ischaemic HF. The prevalences of male sex, comorbidities, and history of HF were higher in the ischaemic versus non-ischaemic HF subgroup. Annualised event rates for the primary composite outcome of total HF hospitalisations and cardiovascular death with FCM versus placebo were 65.3 versus 100.6 per 100 patient-years in the ischaemic HF subgroup (rate ratio [RR] 0.65, 95% confidence interval [CI] 0.47-0.89, p=0.007) and 58.3 versus 52.5 in the non-ischaemic HF subgroup (RR 1.11, 95% CI 0.75-1.66, p=0.60) (pinteraction =0.039). An interaction between HF aetiology and treatment effect was also observed for the secondary outcome of total HF hospitalisations (pinteraction =0.038). A nominal increase in quality of life, assessed using the 12-item Kansas City Cardiomyopathy Questionnaire, was observed with FCM versus placebo, within each subgroup. Heart failure hospitalisations and cardiovascular deaths occurred at a higher rate in patients with ishaemic versus those with non-ischaemic HF and were reduced by FCM versus placebo only in ischaemic patients. Further studies are needed to assess the role of aetiology in FCM efficacy.

Adherence to treatment of patients with chronic heart failure of ischemic etiology

The purpose of the study: to research adherence to therapy in patients with chronic heart failure of ischemic etiology. Materials and methods. The examination was carried out in the Department of Myocardial Infarction, Hospital with the Scientific and Clinical Center for Cardiology.

Prognostic value of TAPSE/PASP ratio in right ventricular failure after left ventricular assist device implantation: Experience from a tertiary center.

Background In this study, we aimed to investigate the prognostic value of the tricuspid annular plane systolic excursion (TAPSE)/ pulmonary arterial systolic pressure (PASP) ratio in right ventricular failure patients undergoing left ventricular assist device implantation. Methods Between February 2013 and February 2020, a total of 75 heart failure patients (65 males, 10 females; median age: 54 years; range, 21 to 66 years) were retrospectively analyzed. The prognostic value of TAPSE/PASP ratio was assessed using the multivariate Cox regression models and confirmed using the Kaplan-Meier analyses. Results Forty-one (55.4%) patients had an ischemic heart failure etiology. The indication for assist device implantation was bridge to transplant in 64 (85.3%) patients. The overall survival rates at one, three, and five years following left ventricular assist device implantation were 82.7%, 68%, and 49.3%, respectively. Right ventricular failure was observed in 24 (32%) patients during follow-up. In the multivariate analysis, TAPSE/PASP was found to be independently associated with postoperative right ventricular failure (HR: 1.63; 95% CI: 1.49-2.23). A TAPSE/PASP of 0.34 mm/mmHg was found to be the most accurate predictor value, with lower ratios correlating with right ventricular failure. The Kaplan-Meier analysis showed a better overall survival using a TAPSE/PASP ≥ of 0.34 mm/mmHg (p<0.001). Conclusion A lower TAPSE/PASP ratio, particularly lower values than 0.34 mm/mmHg, strongly predicts right ventricular failure after left ventricular assist device implantation in patients with advanced heart failure.

Evaluation of Right Ventricular Myocardial Mechanics by 2- and 3-Dimensional Speckle-Tracking Echocardiography in Patients With an Ischemic or Non-ischemic Etiology of End-Stage Heart Failure

BackgroundThe aims of our study were (1) to assess the right ventricular (RV) myocardial mechanics by two-dimensional (2D) and three-dimensional (3D) speckle-tracking echocardiography (STE) in patients with an ischemic or non-ischemic etiology of end-stage heart failure (HF) and (2) to explore which RV index evaluated by 2D- and 3D-STE was the most powerful indicator for identifying the ischemic and non-ischemic etiologies of end-stage HF.MethodsA total of 96 patients with left ventricular ejection fraction (LVEF) < 30% were enrolled in our study: 42 patients (mean age, 52 ± 10 years; 9.5% female) with ischemic cardiomyopathy and 54 patients (mean age, 46 ± 14 years; 16.7% female) with non-ischemic cardiomyopathy. A total of 45 healthy subjects (mean age, 46 ± 13 years; 24.4% female) served as controls. The longitudinal strain of the RV free wall (RVFWLS) was determined by both 2D- and 3D-STE.ResultsCompared to controls, patients with an ischemic or non-ischemic etiology of end-stage HF had lower 2D-RVFWLS, 3D-RVFWLS and RV ejection fraction (RVEF) values (P < 0.05). Patients with non-ischemic cardiomyopathies (NICMs) had significantly lower 3D-RVFWLS and RVEF values than in those with ischemic cardiomyopathies (ICMs), whereas 2D-RVFWLS and conventional RV function parameters did not differ between the two subgroups. RVEF was highly related to 3D-RVFWLS (r = 0.72, P < 0.001), modestly related to 2D-RVFWLS (r = 0.51, P < 0.001), and weakly related to conventional RV function indices (r = –0.26 to 0.46, P < 0.05). Receiver operating characteristic curve analysis revealed that the optimal 3D-RVFWLS cut-off value to distinguish NICM from ICM patients was –14.78% (area under the curve: 0.73, P < 0.001), while 2D-RVFWLS and conventional RV echocardiographic parameters did not.ConclusionOur study demonstrated the superiority of 3D-RVFWLS over 2D-RVFWLS and conventional RV function indices in identifying the ischemic and non-ischemic etiologies of end-stage HF. These findings support the idea that 3D-RVFWLS may be a promising non-invasive imaging marker for distinguishing NICM from ICM.

Dispersion of repolarization increases after cardiac resynchronization therapy in patients who do not undergo left ventricular reverse remodelling

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Wellcome/EPSRC Centre for Medical Engineering CardioInsight Inc. Background The effect of CRT on dispersion of repolarization and arrhythmic risk is unclear. LV epicardial pacing has been associated with increased dispersion of repolarization, which may be due to altered activation and repolarization sequence. However, while CRT-induced ventricular arrhythmias have been reported, evidence from large clinical trials suggest CRT has a favourable effect on arrhythmic risk, with a lower incidence of arrhythmia in patients who undergo LV reverse remodelling. Purpose To investigate the effect of CRT and LV reverse remodelling on dispersion of repolarization using electrocardiographic imaging (ECGi). Methods 11 patients with heart failure and electrical dyssynchrony underwent ECGi after CRT implant and again at 6 months. Reconstructed epicardial electrograms were used to create maps of activation recovery intervals (ARI), an accepted surrogate for action potential duration, which were corrected for heart rate. LV ARI dispersion was calculated as the standard deviation of ARI across the LV epicardium. The methodology is summarized in figure 1. Results Mean age at implant was 74±10 years and 82% of patients were male. 64% had ischaemic aetiology of heart failure, and mean LV ejection fraction was 29±10%. 64% of patients had underlying LBBB, 28% had an RV-paced rhythm and 9% had RBBB. 8 patients had a ≥15% reduction in LV end-systolic volume (LVESV) with CRT at 6 months (volumetric responders). Example ARI maps for 1 patient are shown in figure 2A. There was a significant increase in LV ARI dispersion at 6 months compared to baseline (36.4±7.2ms vs 28.2±7.7ms; P=0.03) [Fig 2B]. In a multiple linear regression analysis, volumetric response was an independent predictor of relative change in LV ARI dispersion from baseline to 6 months (P=0.04). In a sub-analysis, for volumetric responders there was no significant difference in LV ARI dispersion between baseline and CRT at 6 months (36.4 ±6.1 vs 30.1±7.8 ms; P=0.1). In comparison, in volumetric non-responders there was a significant increase in LV ARI dispersion (38.3±1.2 vs 22.6±2.6 ms; P=0.01). The relative change in LV ARI dispersion from baseline to CRT 6-months was greater for volumetric non-responders compared to volumetric responders (70.7 ±21.3% vs 27.0 ±35.4%; P=0.04) [Fig 2C]. There was a moderate negative correlation between relative change in LV ARI dispersion and relative reduction in LVESV (R=-0.5), however this did not meet statistical significance (P=0.12) [Fig 2D]. Conclusion CRT increases dispersion of repolarization at 6 months. However, this potentially arrhythmogenic effect of epicardial pacing was only observed in CRT non-responders, which is in keeping with previous evidence that LV reverse remodelling reduces risk of ventricular arrhythmia.

The Utility of Pentraxin and Modified Prognostic Scales in Predicting Outcomes of Patients with End-Stage Heart Failure.

Risk stratification is an important element of management in patients with heart failure (HF). We aimed to determine factors associated with predicting outcomes in end-stage HF patients listed for heart transplantation (HT), with particular emphasis placed on pentraxin-3 (PXT-3). In addition, we investigated whether the combination of PTX-3 with the Heart Failure Survival Score (HFSS), the Seattle Heart Failure Model (SHFM), or the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) improved the prognostic strength of these scales in the study population. We conducted a prospective analysis of 343 outpatients with end-stage HF who accepted the HT waiting list between 2015 and 2018. HFSS, SHFM, and MAGGIC scores were calculated for all patients. PTX3 was measured by sandwich enzyme-linked immunosorbent assay with a commercially available kit. The endpoints were death, left ventricular assist device implantation, and HT during the one-year follow-up. The median age was 56 (50–60) years, and 86.6% were male. During the follow-up period, 173 patients reached the endpoint. Independent risk factors associated with outcomes were ischemic etiology of HF [HR 1.731 (1.227–2.441), p = 0.0018], mean arterial pressure (MAP) [1.026 (1.010–1.042), p = 0.0011], body mass index (BMI) [1.055 (1.014–1.098), p = 0.0083], sodium [1.056 [(1.007–1.109), p = 0.0244] PTX-3 [1.187 (1.126–1.251, p < 0.0001) and N-terminal pro-brain natriuretic peptide (NT-proBNP) [HR 1.004 (1.000–1.008), p = 0.0259]. The HFSS-PTX-3, SHFM-PTX-3 and MAGGIC-PTX-3 scores had significantly higher predictive power [AUC = 0.951, AUC = 0.973; AUC = 0.956, respectively] than original scores [AUC for HFSS = 0.8481, AUC for SHFM = 0.7976, AUC for MAGGIC = 0.7491]. Higher PTX-3 and NT-proBNP concentrations, lower sodium concentrations, lower MAP and BMI levels, and ischemic etiology of HF are associated with worse outcomes in patients with end-stage HF. The modified SHFM-PTX-3, HFSS-PTX-3, and MAGGIC-PTX-3 scores provide effective methods of assessing the outcomes in the analyzed group.

Sex-Specific Differences in Ventricular Remodeling and Response After Cardiac Resynchronization Therapy

In this study, we investigated the baseline characteristics and "trajectories" of clinical response in men and women after cardiac resynchronization therapy (CRT) implantation. Although women enjoy improved echocardiographic response after CRT compared with men, the kinetics of this response and its relation to functional performance and outcomes are less clear. We identified 592 patients who underwent CRT implantation at our center between 2004 and 2017 and were serially followed in a multidisciplinary clinic. Longitudinal linear mixed effects regression for cardiac response was specified, including interaction terms between time after CRT and sex , and Cox regression models were used to assess differences in all-cause mortality by gender after CRT. Women in our cohort were younger than men, had less frequent ischemic etiology of heart failure (24% vs 60% in men), a shorter QRS (151 vs 161 ms) and more frequent left bundle branch block (77% vs 52%) at baseline. Women had a greater improvement in left ventricular ejection fraction that was evident starting at approximately 1-month after CRT. We did not observe effect modification by gender in New York Heart Association class or 6-minute walk distance after CRT. Although women had improved mortality after CRT, after adjustment for potential confounders, gender was not associated with mortality after CRT. In conclusion, women were more likely to have CRT implantation for left bundle branch block and exhibited improved echocardiographic but not functional response within the first year after CRT. Clinical outcomes after CRT were not associated with gender in adjusted analysis.

Thyroid Function at Left Ventricular Assist Device (LVAD) Implantation Predicts Prognosis During LVAD Support

<h3>Purpose</h3> The purpose of this study was to assess thyroid status before and during left ventricular assist device (LVAD) support and to estimate an impact of thyroid status at LVAD implantation on survival. <h3>Methods</h3> We retrospectively analyzed thyroid function profile including thyroid- stimulating hormone (TSH), free triiodothyronine (fT₃), and free thyroxine (fT₄) in a group of all consecutive 147 patients (93.2%- male, BMI-26.7 ±5.6, mean and median INTERMACS profile- 3; 53% -ischemic etiology of heart failure) implanted with continuous-flow LVAD in our institution within years 2009-2021 (54%-HeartMate3; 40%- HeartWare; 6%- Heart Mate II). One year survival was 78.3%. Fifteen percent of patients received amiodarone, whereas 20.4%- supplementation of levothyroxine and 2% - thyreostatic treatment during LVAD support. Statistical methods used were: ROC curves, when Youden factor > 0.27- Chi 2 test, analysis of variance, Bonferroni test. <h3>Results</h3> Mean values of TSH, fT₃ and fT₄ were respectively 2.33 ± 1.69 uIU/ml; 2.14± 0.56 pg/ml; 1.25 ± 0.36 ng/dl before, 2.95 ± 3.18 uIU/ml; 2.47±1.35 pg/ml; 1.11 ±0.27 uIU/ml and 2.0 ±1.27 ng/dl; 2.43 ±0.42 pg/ml; 1.22 ± 0.25 ng/dl at 3 months and at 12 months post LVAD implantation. Mortality risk was 2.8 times lower for patients presenting TSH ≥ 1.29 uIU/ml (p= 0.01) and 3.8 times lower for patients presenting fT₃ ≥ 1.93 uIU/ml (p=0.003) at LVAD implantation. TSH significantly decreased between 3 and 12 months of LVAD support (Bonferroni test, p<0.009), whereas fT3 increased significantly after 3 and 12 months as compared to values before LVAD implantation (Bonferroni test, p < 0.039 and p<0.041 respectively). <h3>Conclusion</h3> Thyroid function may have an impact on survival in patients with end-stage heart failure implanted with LVAD. Thyroid status surveillance and its corrections could improve the overall prognosis in this group of patients. Further studies are needed to confirm this thesis.