Low Ejection Fraction Heart Failure Research Articles

P340 REMOTE MONITORING IN HEART FAILURE: EFFECTIVE TOOL TO REDUCE HOSPITALIZATIONS AND MORTALITY

Abstract Introduction The prevalence of heart failure in the general population in the idustrialized countries is estimated to be around 2%, a prevalence that increases with age until it reaches 10% at 70 aa of age. The disease is burdened by a high mortality rate and high expense related mainly to repeated hospitalizations. Patients with low ejection fraction heart failure are often implanted with devices, which have the ability to be monitored remotely. The Ministry of Health‘s 2017 annual report on hospitalization activity shows dramatic data: 60% of patients with heart failure are re–hospitalized within one year of discharge and in 14% of cases even within one month of discharge with an annual mortality rate of 18%. The aim of our study is to investigate whether remote monitoring allows improving the outcome of patients with heart failure in terms of reduction of hospitalizations and reduction of all–cause mortality. Materials and Methods In the year 2021, 241 patients with heart failure and reduced ejection fraction, implanted with devices of mean age 73 yr (+/– 11 yr) were remotely monitored in our center; Other population data: see Table 1. On the occasion of transmissions presenting with alarm events, our operational flow chart provides: first telephone contact and possible subsequent outpatient follow–up within 24 h working hours. Results During the year 2021, all–cause mortality in our population was 10.7% (26 patients), while re–hospitalizations were 70 (28.8%). As a result of alarms reported to remote monitoring, 83 patients were contacted whose therapy was changed or device reprogrammed. The causes of alarms were in order: reduced thoracic impedance, arrhythmic events, and reduced biventricular pacing rate. Conclusions The use of remote monitoring in heart failure patients and device wearers allows early and timely diagnosis of clinical changes that anticipate heart failure exacerbation and active intervention by modifying the clinical course, often avoiding hospitalization, with a significant social and economic impact. Thanks to the operational organization of our center, the management of remote monitoring has allowed a low rate of hospitalization and low mortality year compared with literature data.

Perioperative Management in a Case of Heart Failure with Severe Low Ejection Fraction

Radical cystectomy is the standard treatment for muscle-invasive non-metastatic bladder cancers. Patients with muscle-invasive bladder cancer often have an increased rate of surgical complications due to comorbidities such as cardiovascular comorbidity, diabetes, and obesity. In these patients, a multidisciplinary approach is required at every stage, from the preoperative period to the postoperative follow-up. Heart failure is a complex clinical syndrome resulting from any structural or functional impairment of ventricular filling or blood ejection. The main symptoms of heart failure are shortness of breath and fatigue, which can limit exercise tolerance, and fluid retention, which can lead to pulmonary and/or splanchnic congestion and/or peripheral edema. An ejection fraction of ≤40% is defined as low ejection fraction heart failure.

The role of three dimensional transesophageal echocardiography in predicting the effect of cardiac resynchronization therapy on mitral regurgitation in patients with low ejection fraction heart failure.

Cardiac resynchronization therapy (CRT) positively affects the improvement of functional mitral regurgitation (MR) in patients with heart failure with reduced ejection fraction (HFrEF). However, geometric changes in the mitral valve apparatus, subvalvular structures and their contribution to improving mitral regurgitation after CRT have not been clearly defined. Our study aimed to evaluate the geometric parameters of mitral valve apparatus measured with three-dimensional (3D) transesophageal echocardiography (TEE) before CRT implantation and to determine the parameters predicting the improvement of MR after CRT. In this prospective study, we included thirty patients with moderate or severe MR and HFrEF planned for CRT implantation who had an indication for TEE. Before CRT implantation, effective regurgitant orifice (ERO) and regurgitant volume (RV) measurements were performed. Detailed quantitative measurements of the mitral valve were done from recorded images by 3D TEE. ERO and RV measurements were repeated to evaluate MR at the end of the third month. There were no significant changes in left ventricular EF and left ventricular diameters at third-month follow-up, whereas ERO and RV values were decreased. The posterior leaflet angle was higher in the non-responder group than the responder group (28.93 ± 8.41vs 41.25 ± 10.90, p=0.006). The posterior leaflet angle was an independent predictor of decreased RV and ERO. Among HFrEF patients with moderate or severe functional MR who underwent CRT implantation had a lower posterior leaflet angle, which was measured by 3D TEE, in the patient group whose MR improved after CRT.

ACE2 and Apelin-13: Biomarkers with a Prognostic Value in Congestive Heart Failure.

The progression of heart failure is the result of the interaction of several pathogenetic processes that involve the activation of biomarkers belonging to the renin angiotensin aldosterone system (RAAS), to its counterregulatory mechanisms, to the sympathetic nervous system and inflammation, and to oxidative stress. This study is aimed at determining the prognostic role of biomarkers in the evolution of patients with heart failure. These biomarkers are representative of different pathogenetic pathways involved in the progression of heart failure and the possible interrelationships between them and heart remodelling. Method. This is a progressive observational study on 53 hospitalized patients with low ejection fraction heart failure, who were followed up for 12 months. The aetiology of heart failure was ischemic heart disease and dilated cardiomyopathy. The patients were clinically and biochemically evaluated by EKG (echocardiography) on admission and at 6 and 12 months. The biomarkers included in the present study were angiotensin-converting enzyme type 2 (ACE2), apelin-13, NT-proBNP (biomarkers involved in the counterregulation of RAAS), interleukin 17 (IL-17), hsCRP (inflammatory biomarkers), and urinary 8-iso-PGF2α (oxidative stress biomarker). The evolution was considered unfavourable if the patients presented complications during hospitalization, were readmitted for decompensated heart failure, or died. Results. From the study group, 14 patients (24.52%) presented an unfavourable clinical evolution. The biomarkers that were associated with the evolution of patients during hospitalization were ACE2, apelin-13, NT-proBNP, and hsCRP. Multivariate logistic regression analysis identified ACE2 and apelin-13 as independent, predictive biomarkers for the unfavourable evolution of patients over the study period. Values of ACE2 above 4000.75 pg/mL and of apelin-13 less than 402.5 pg/mL were associated with an unfavourable evolution (poor clinical outcomes). Conclusion. The serum values of ACE2 and apelin-13 correlate with the unfavourable evolution of patients with reduced ejection fraction heart failure.

Loss of Pacer Spikes as electrocardiographic (EKG) Artifact Due to Microdebrider Use During Endoscopic Dacryocystorhinostomy.

As intraoperative use of electronic equipment becomes more common, familiarity with the potential for electrocardiographic artifact generated by these instruments is increasingly important. The authors' patient underwent endoscopic dacryocystorhinostomy under general anesthesia for treatment of acute on chronic dacryocystitis secondary to acquired nasolacrimal duct obstruction. She had previously had pacemaker placement for treatment of sick sinus syndrome and low ejection fraction heart failure, and use of a microdebrider intraoperatively resulted in loss of pacer spikes and interference signal on electrocardiographic leading to placement of a magnet. Post-operatively, examination of the microdebrider cord revealed a tear that likely lead to the artifactual electrocardiographic signal influencing the decision for magnet placement. Although there were no long-term ill effects, placement of the magnet was an unnecessary intervention that may have been avoided by prompt recognition of artifactual changes that may be induced by intraoperative use of electronic instrumentation.

Predictive Value of Endoplasmic Reticulum Stress Markers in Low Ejection Fractional Heart Failure

Endoplasmic reticulum (ER) stress plays a critical role in the development of cardiac hypertrophy and heart failure. Heart failure is a crucial health problem that affects 23 million people worldwide, causes approximately 2.4 million people to be hospitalized every year in the USA, and leads to the death of more than 300,000 people. In this study, we aimed to investigate the clinical significance of ER stress markers and the predictive value of acute decompensated heart failure in patients with low ejection fraction heart failure (ADHF). This is a prospective case control study. The data included laboratory parameters pertaining to patients with ADHF in the emergency service and lipid parameters obtained during their admission to the hospital. In addition, the same parameters obtained from the control group patients with chronic heart failure (CHF) during their routine polyclinic control were recorded in the data set. Admission time to the hospital and length of hospital stay were included in the data. The levels of glucose regulated protein (GRP78), protein kinase RNA-like endoplasmic reticulum kinase (PERK), and C/EBP homologous protein (CHOP) in peripheral blood serum obtained from the patients and the control group were measured using the ELISA method. Serum GRP78 concentration was lower in the HF group (p=0.003) compared to the control. The median value of serum PERK concentration in the HF group was higher than that of the control group (573 pg/ml, IQR=477.5-650 vs. 495.5 pg/ml, IQR=294-648, respectively) (p=0.001). However, there were no statistically significant differences in GRP78 and PERK serum concentrations between ADHF and CHF subgroups. Receiver operating characteristic (ROC) curve analysis showed greater area under the curve (AUC) for the serum GRP78 levels of the healthy individuals (AUC=0.748, 95% CI=0.681-0.814, p=0.0003). The serum GRP78 level was found to be 80% sensitive and 70% specific at 147.5 pg/ml (p=0.0003) for distinguishing healthy individuals from HF patients. In the ADHF subgroup, there was a moderate correlation between hospitalization time and serum CHOP concentrations (Spearman rho=0.586 and p=0.001). High GRP78 serum concentration may protect the patient from ER stress. In addition, the serum PERK level is high in patients with HF, whereas it is insufficient in predicting acute decompensation. CHOP may be useful in predicting the length of hospital stay in patients with ADHF.

Increased visit-to-visit blood pressure variability is associated with worse cardiovascular outcomes in low ejection fraction heart failure patients: Insights from the HEAAL study

BackgroundRecent data have highlighted shortcomings of the usual blood pressure (BP) hypothesis in several populations, and emphasized the importance of visit-to-visit variability of BP in predicting cardiovascular events. Herein, we aimed at assessing the association between visit-to-visit BP variability and outcomes in chronic heart failure (CHF) patients enrolled in the Heart failure Endpoint evaluation of Angiotensin II Antagonist Losartan (HEAAL). Methods and resultsThe HEAAL study randomized 3834 patients with HF and reduced ejection fraction administered 150mg or 50mg losartan daily in a double blind, randomized, controlled trial. The patients were followed up for up to 6.8years after randomization, and BP was measured at 3 time points in the first year and at semi-annual visits in the years thereafter. Three measures of visit-to-visit BP variability were computed for each subject: the standard deviation, the coefficient of variation and the average absolute visit-to-visit variation. Cox proportional hazard models were used to investigate the relationship between variations in systolic blood pressure, baseline covariates and the time to death or heart failure hospitalization (i.e. primary outcome). In multivariate analyses stratified on baseline BP, the patients with higher visit-to visit BP variability exhibited poorer outcomes (average absolute difference in SBP in mmHg:hazard ratio: 1.023 [95% CI (1.013, 1.034), P<0.0001]), independent from high dose losartan (still beneficial). ConclusionsFor the first time, visit-to-visit BP variability was found elevated in CHF patients with reduced ejection fraction, and associated with poorer cardiovascular outcomes. Such assessments should be prioritized for testing prevention strategies in CHF. Clinical trial registrationThis study is registered with the ClinicalTrials.gov, number NCT00090259.

Ischemia-Induced Model of Diastolic Dysfunction in Sheep

ABSTRACTBackground: Ischemic heart failure with normal ejection fraction (HFNEF) is an increasingly recognized entity that carries similar morbidity and mortality than low ejection fraction heart failure. Animal models of diastolic dysfunction mimicking this condition are lacking and are essential for the development of therapeutic strategies. Methods and Results: Eight Corriedale sheep, 18 ± 5 months old, were included in the study. Basal echocardiography and myocardial perfusion evaluation (SPECT) was performed. Acute myocardial infarction (AMI) was made by occlusion (90 min) and reperfusion of the second diagonal branch of the anterior descending coronary artery. Two months after AMI, echocardiography and SPECT evaluation were performed prior to sacrifice. Basal and 2 months echocardiography showed similar fractional shortening and ventricular dimensions in each animal except for an increase in left atrial diameter. No mitral regurgitation was evidenced. SPECT imaging and pathology confirmed infarction in the apical, apico-anterior, and apico-septal segments. Conclusion: A novel model of ischemia-induced diastolic dysfunction with preserved ventricular thickness and ejection fraction is described. This model opens the possibility of testing therapeutic options for patients with this condition.

Novel CHF Drug Shows Great Promise

Novel CHF Drug Shows Great Promise

Chronic vagal stimulation for the treatment of low ejection fraction heart failure: results of the NEural Cardiac TherApy foR Heart Failure (NECTAR-HF) randomized controlled trial.

AimThe neural cardiac therapy for heart failure (NECTAR-HF) was a randomized sham-controlled trial designed to evaluate whether a single dose of vagal nerve stimulation (VNS) would attenuate cardiac remodelling, improve cardiac function and increase exercise capacity in symptomatic heart failure patients with severe left ventricular (LV) systolic dysfunction despite guideline recommended medical therapy.MethodsPatients were randomized in a 2 : 1 ratio to receive therapy (VNS ON) or control (VNS OFF) for a 6-month period. The primary endpoint was the change in LV end systolic diameter (LVESD) at 6 months for control vs. therapy, with secondary endpoints of other echocardiography measurements, exercise capacity, quality-of-life assessments, 24-h Holter, and circulating biomarkers.ResultsOf the 96 implanted patients, 87 had paired datasets for the primary endpoint. Change in LVESD from baseline to 6 months was −0.04 ± 0.25 cm in the therapy group compared with −0.08 ± 0.32 cm in the control group (P = 0.60). Additional echocardiographic parameters of LV end diastolic dimension, LV end systolic volume, left ventricular end diastolic volume, LV ejection fraction, peak V02, and N-terminal pro-hormone brain natriuretic peptide failed to show superiority compared to the control group. However, there were statistically significant improvements in quality of life for the Minnesota Living with Heart Failure Questionnaire (P = 0.049), New York Heart Association class (P = 0.032), and the SF-36 Physical Component (P = 0.016) in the therapy group.ConclusionVagal nerve stimulation as delivered in the NECTAR-HF trial failed to demonstrate a significant effect on primary and secondary endpoint measures of cardiac remodelling and functional capacity in symptomatic heart failure patients, but quality-of-life measures showed significant improvement.

Association of Smoking, Sleep Apnea, and Plasma Alkalosis With Nocturnal Ventricular Arrhythmias in Men With Systolic Heart Failure

Excess sudden death due to ventricular tachyarrhythmias remains a major mode of mortality in patients with systolic heart failure. The aim of this study was to determine the association of nocturnal ventricular arrhythmias in patients with low ejection fraction heart failure. We incorporated a large number of known pathophysiologic triggers to identify potential targets for therapy to reduce the persistently high incidence of sudden death in this population despite contemporary treatment. Eighty-six ambulatory male patients with stable low (≤ 45%) ejection fraction heart failure underwent full-night attendant polysomnography and simultaneous Holter recordings. Patients were divided into groups according to the presence or absence of couplets (paired premature ventricular excitations) and ventricular tachycardia (VT) (at least three consecutive premature ventricular excitations) during sleep. In multiple regression analysis, four variables (current smoking status, increased number of arousals, plasma alkalinity, and old age) were associated with VT and two variables (apnea-hypopnea index and low right ventricular ejection fraction) were associated with couplets during sleep. We speculate that cessation of smoking, effective treatment of sleep apnea, and plasma alkalosis could collectively decrease the incidence of nocturnal ventricular tachyarrhythmias and the consequent risk of sudden death, which remains high despite the use of β blockades.

Clinical Outcomes According to Baseline Blood Pressure in Patients With a Low Ejection Fraction in the CHARM (Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity) Program

This study sought to investigate the efficacy and tolerability of candesartan, according to baseline blood pressure (BP), in the 4,576 patients with a low ejection fraction (EF) (<or=0.40) in the CHARM (Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity) program. Hypotension is a predictor of poor prognosis in heart failure, yet many treatments shown to reduce morbidity and mortality lower blood pressure. This paradox creates a dilemma for physicians and may explain why low BP is reported as a reason for under-use of these agents. The interaction between treatment and baseline systolic blood pressure (SBP) and diastolic blood pressure (DBP) was examined with patients divided into 6 SBP categories (<or=100, 101 to 110, 111 to 120, 121 to 130, 131 to 140 and >or=141 mm Hg) and 4 DBP categories (<or=60, 61 to 70, 71 to 80 and >or=81 mm Hg). Low SBP and DBP were associated with worse clinical outcomes. Baseline BP did not modify the effects of candesartan on clinical outcomes: the interaction p value between SBP category and treatment was 0.38 (0.22 for DBP category). For both placebo and candesartan, study drug discontinuation for adverse effects (especially hypotension) was highest in patients in the lowest baseline BP categories. However, the relative risk of discontinuation for hypotension, renal dysfunction, and hyperkalemia in the candesartan compared with placebo group was not increased in patients with a low baseline BP. In patients with low EF heart failure, the relative risks and benefits of candesartan treatment were similar in patients with a low BP compared to those with a higher BP.

Impact of diabetes on outcomes in patients with low and preserved ejection fraction heart failure: An analysis of the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) programme

To determine whether the risk of adverse cardiovascular (CV) outcomes associated with diabetes differs in patients with low and preserved ejection fraction (EF) heart failure (HF). We analysed outcomes in the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) programme which randomized 7599 patients with symptomatic HF and a broad range of EF. The prevalence of diabetes was 28.3% in patients with preserved EF (>40%) and 28.5% in those with low EF (<or=40%). Diabetes was associated with a greater relative risk of CV death or HF hospitalization in patients with preserved EF [hazard ratio (HR) 2.0 (1.70-2.36)] than in patients with low EF [HR 1.60 (1.44-1.77); interaction test P = 0.0009]. For all-cause mortality, the risk conferred by diabetes was similar in both low and preserved EF groups. The effect of candesartan in reducing CV morbidity and mortality outcomes was not modified by having diabetes at baseline (P = 0.09 test for interaction). Diabetes was an independent predictor of CV morbidity and mortality in patients with HF, regardless of EF. The relative risk of CV death or HF hospitalization conferred by diabetes was significantly greater in patients with preserved when compared with those with low EF HF.

544 Candesartan improves outcome in patients with low ejection fraction heart failure, irrespective of background dose of ACE inhibitor: a post-hoc analysis of the CHARM-Added trial

544 Candesartan improves outcome in patients with low ejection fraction heart failure, irrespective of background dose of ACE inhibitor: a post-hoc analysis of the CHARM-Added trial