Mean Ejection Fraction Research Articles

Recognition of heart failure with micro electro-mechanical sensors using commercially available smartphone, the REFLECS study

Abstract Background Heart failure (HF) is the leading cause of hospitalization in people over the age of 65 years. More recently, cardiac motion sensor technology has emerged as a promising technology to detect HF. Methods In this multicenter study, we examined whether accelerometer and gyroscope signals from motion sensors collected using commercially available smartphones can classify HF status. Participants were enrolled from Finland and the United States. Participants hospitalized with acute decompensated HF were assessed in the acute state and re-assessed in the stabilized state prior to discharge. Outpatient participants were assessed in the stable state. In a pre-specified pooled data analysis, state specific algorithms to detect HF were first derived using logistic regression and validated using boostrap aggregation method (10 repeats) followed by sensitivity analysis in participants with HF with reduced or preserved ejection fractions, participants in atrial fibrillation and according to age, sex or body mass index. Results A total of 217 HF participants had a total of 474 assesment: acute state = 174; stabilized state = 128; stable state = 172. 786 controls were included. The mean age of all participants with HF was 67 years, mean ejection fraction (EF) 39% and mean NT-proBNP 5778 ng/l. 74% had HF with reduced EF (HFrEF) and 38% had atrial fibrillation. Across all three HF states, the algorithm had an AUC of 0.95, sensitivity of 85%, specificity 90%, and an accuracy of 89%. The performance of the algorithm was not affected by HF state, ejection fraction, age, sex, body mass index (BMI) or presence of atrial fibrillation. Conclusion A simple commercially available smartphone based assessment of cardiac function with motion sensors shows distinct features in participants in decompensated, stabilized and stable HF states in comparison to controls.Heart failure detection ROC curves

Quantitative flow ratio for non culprit lesions in ST elevation myocardial infarction and multi vessel disease - a direct comparison with fractional flow reserve

Abstract Objectives In acute myocardial infarction and multivessel disease (MVD), current guidelines recommend treatment of the culprit lesion followed by staged full revascularization of functionally relevant stenoses. We sought to analyze the hemodynamic relevance of intermediate stenoses using quantitative flow ratio (QFR, an angiography-derived fractional flow reserve [FFR]) in a population presenting with ST elevation myocardial infarction (STEMI) and MVD on index procedure. Methods We retrospectively analyzed 36 coronary lesions in 34 Patients presenting with STEMI and MVD from January 2017 to September 2022. 31 (86%) patients were male, mean age 63 ± 7, mean ejection fraction (EF %) 50 ± 8, arterial hypertension 30 (88%), diabetes 13 (38%). The non culprit lesion location was left anterior descending (LAD) in 24 (67%), circumflex artery (RCX) in 8 (22%) and right coronary artery (RCA) in 4 (11%). All patients received an invasive assessment of non culprit lesions using FFR within 3 months after STEMI. A QFR assessment of non culprit lesions in an acute invasive coronary angiography has been compared with FFR results in a staged procedure. Results QFR showed an excellent accuracy in ruling out functionally relevant stenosis with no false negative results (sensitivity 100% compared to FFR). Three coronary lesions (8,3%) were graded false positive (functionally relevant). Due to poor image acquisition, we were unable to perform QFR analysis in ten coronary lesions (28%). Overall specificity (56,5%) was lower than reported in previous trials. After excluding the lesions that could not be analyzed due to poor acquisition we achieved specificity of 81,2% (Fig. 1). Concusion: QFR showed an excellent correlation with FFR (Fig. 1). Performing QFR in STEMI Patients with MVD could reduce the need of repeated invasive coronary angiographies and optimize the clinical therapy management in this high-risk population. Further studies on diagnostic performance and outcomes are needed.Fig. 1: Correlation plot

Safety of early discharge after primary percutaneous coronary intervention in low risk ST-segment elevation myocardial infarction presented in a tertiary center without an established STEMI network

Abstract Introduction The application of ST-segment elevation myocardial infarction (STEMI) networks, is a key factor for improvements in outcomes of STEMI patients, leading to earlier treatment, better outcomes and shorter hospital stay. Current guidelines support an early discharge (48-72 h) in selected low risk patients. Yet, this strategy is not routinely applied, especially in centers without an established STEMI network. Purpose To evaluate safety of early discharge in low risk STEMI patients treated with primary PCI by analyzing 30 days outcomes, in a unique tertiary center without an established STEMI network and serving a large area of population. Methods We prospectively collected data from 220 consecutive patients admitted to our center with diagnosis of STEMI, in two different time periods, categorized as low risk according to Zwolle risk score.175 patients were discharged within 72 hours and 45 patients after 72 hours. Follow-up was done by phone call at 30 days. Primary endpoint was occurrence of a major adverse event - a composite of death from cardiac cause, nonfatal myocardial re-infarction, and repeat intervention. Secondary endpoints were death from any cause, residual angina and re-hospitalization. Results The mean age was 58.12 +/-10.32 years. 193 (87%) of patients were male. 118 (53.6%) of them had inferior MI. Mean ejection fraction was 50% +/- 6.04%. Median symptom to hospital arrival time was 5.17 +/- 0.2 hours. Median length of hospital stay was 69.8 +/-17.09 hours. Primary endpoint occurred in 6 (3.4%) patients, all of them in the <72 hours discharge group. 3 patients had cardiac death, 3 had nonfatal MI and eventually 2 of them had repeat intervention. Secondary endpoint occurred in 8 (4.6%) patients in the <72 hours discharge group and 1 (2.2%) patient in the >72 hours discharge group, all of them having residual angina. Conclusion In low risk STEMI patients treated with successful primary PCI, data from our study suggest that an early discharge strategy within 72 hours is associated with comparable outcomes regarding major adverse events compared to late discharge strategy.

ACUTE HF score predicts in-hospital mortality in patients with acute heart failure

Abstract Background ACUTE HF is a multiparametric score combining clinical, biochemical and echocardiographic indexes, which was developed and validated in different studies as prognostic tool in acute heart failure (HF) patients for the prediction of 30-days, 6-months and 5-years mortality after discharge. However, in these critical patients the prediction of in-hospital mortality may be fundamental to guide therapeutic management during hospital stay. Objective The aim of our study was to assess the prognostic value of ACUTE HF score for in-hospital mortality in an external cohort of patients hospitalized for acute HF. Methods Consecutive patients hospitalized for acute HF between 2020 and 2021 in our University Hospital were retrospectively enrolled. Patients with unclear diagnosis of de-novo, decompensated HF or HF reacutization were excluded. Clinical, biohumoral and echocardiographic data were collected. ACUTE HF score was calculated as : 1.4*[serum creatinine>2mg/dl]+0.8*[ejection fraction<30]+ 0.7*[age>76]+0.7*[prior hospitalization for AHF]+0.9*[prior stroke/transient ischemic attack]+0.5*[more than moderate mitral regurgitation]+0.8*[use of non-invasive ventilation]. Then, it was used to divide the population into three risk groups (low risk: ACUTE HF ≤1.5; intermediate risk: 1.5 Results Overall, 1291 patients were included in the present study (age=77±13 years, mean ejection fraction = 41 ± 13%). Median in-hospital follow up was 9 [6;15] days, during which 115 patients died. Patients who died during hospitalization were older, had worse renal function and higher mitral regurgitation severity, and more frequently had arterial hypertension, diabetes mellitus, chronic obstructive pulmonary disease and history of stroke. With ROC curves, it showed to be a good predictor of in-hospital mortality, with an AUC=0.66, which was even higher in patients with preserved ejection fraction (AUC=0.76, Fig.1). With multivariate analysis, ACUTE HF score showed to be a predictor of in-hospital mortality independent from arterial hypertension, diabetes mellitus, chronic kidney disease (OR = 1.5 [C.I. 1.22 – 1.81 each point increase]. Kaplan Meier analysis showed a good risk stratification of study cohort divided into 3 risk groups according to ACUTE HF (Fig.2) Conclusions ACUTE HF score is an independent and reliable predictor of in-hospital mortality in patients hospitalized for acute HF. After multiple external validation, considering its rapid and easy calculation, we suggest its use in the management algorithms of acute HF patients in daily clinical practice.Fig.1Fig.2

Prognostic value of three-dimensional regurgitant orifice determination in functional mitral regurgitation

Abstract Background Functional mitral regurgitation (FMR) evaluation using effective regurgitant orifice (ERO) by echocardiography remains controversial. Given the morphology of regurgitant jets in FMR, determination of ERO using three-dimensional transesophageal echocardiography (3D-TEE) may be more accurate. However, a clear threshold for this parameter has not been defined. Purpose Our aim is to evaluate the prognostic value of 3D-ERO in FMR. Methods All patients with at least moderate FMR who underwent 3D-TEE in a tertiary center between 2016 and 2020 were retrospectively selected. Echocardiographic variables by transthoracic and transesophageal, as well as demographic and clinical history variables, were collected. A combined event of urgent hospital admission or death was considered. Variables statistically associated with the event were included in multivariate analysis. Results 112 patients (74 men (66.1%), mean age 72.3±10.9 years) were finally included. The most frequent etiology of FMR was ventricular dysfunction (61.6%), followed by annular dilation (23.2%) and posterior leaflet restriction (15.2%). The mean 3D-ERO was 0.53±0.25 cm2 and mean ejection fraction was 40.7±14.2%. At diagnosis, 49 patients (43.8%) were not receiving diuretics, 63 (56.2%) had atrial fibrillation/flutter, 60.3% permanent. FMR was treated in 54 patients (48.2%), 61,1% percutaneously. During a follow-up of 36 [14-54] months, 50 (44,6%) patients were urgently hospitalized (mean 1.9±2.8 admissions) and 49 (43,8%) died, received a heart transplant or LVAD. 3D-ERO was significantly associated with the occurrence of the event (0.55 vs 0.41; p=0.02). Additionally, 3D-ERO was associated with mitral intervention (0.58 vs 0.47 cm2; p=0.01) and had a trend towards death from any cause (0.56 vs 0.5 cm2; p=0.098). The prognostic capacity of 3D-ERO for the combined event was determined using an ROC curve (Figure). An AUC of 0.67 (95% CI 0.55-0.8; p=0.01) and an optimal cutoff value of 0.45 cm2 (sensitivity 0.62, specificity 0.73) were obtained. In univariate analysis, the combined event was also associated with age (73.9 vs. 65.6 years; p=0.01), diabetes (40 vs. 13.6%; p=0.02), chronic kidney disease (42.7 vs. 13.6%; p=0.01), ischemic heart disease (59.6 vs 31,8%, p=0.02) and daily furosemide dose (39.7 vs. 13.6 mg; p<0.01). In multivariate analysis of the event, age, daily furosemide dose, ischemic heart disease and 3D-ERO were included in the final predictive model (Table). Conclusions In patients with FMR, 3D-ERO was significantly associated with the occurrence of events during follow-up, with an optimal prognostic performance cutoff point of 0.45 cm2. Furthermore, it was an independent predictor of mitral intervention and included among the predictors of urgent hospital admission or death. Therefore, 3D-ERO may be useful in risk stratification of FMR.

The impact of outpatient pharmacological optimization on echocardiographic parameters in heart failure with reduced ejection fraction

Abstract Background The 2022 landmark STRONG-HF study demonstrated that aggressive uptitration of guideline directed medical therapy (GDMT) in patients recently hospitalized for heart failure leads to a reduction in the composite endpoint of heart failure hospitalization and mortality. However, the impact of optimization of GDMT on echocardiographic parameters in heart failure with reduced ejection fraction (HFrEF) is unknown. Purpose This goal of this study was to determine the impact of a virtual HFrEF optimization program for achieving GDMT uptake and its impacts of echocardiographic parameters. Methods We conducted a single center study at a Canadian community cardiovascular centre using a prospective pre-post design. NYHA class II/III HFrEF patients referred from inpatient and outpatient settings were enrolled in our virtual 3-month HFrEF optimization program. All participants underwent an initial consult with a nurse and cardiologist. After this, all patients were seen remotely by a nurse every two weeks for adjustment of HFrEF medications with the goal of maximally tolerated GDMT dosing within 3 months was. Transthoracic echocardiograms were performed prior to participation in the program & after completion. Results Over 9 months, 284 NYHA class II/III HFrEF patients enrolled in the virtual HFrEF optimization program. Mean age was 67 and 70% were male. Mean ejection fraction was 34% and 54% had New York Heart Association Class II symptoms. At intake, the proportion of patients prescribed each class of GDMT was: 69% for Beta-blockers, 23% for Mineralocorticoid Receptor Inhibitors (MRA), 16% for Valsartan-Sacubitril and 7% for SGLT2 inhibitors. At 3-month follow-up, rates of GDMT prescription were improved: 90% for beta-blockers (p<0.01), 71% for MRA (p<0.01), 95% for ARNI (p<0.01) and 79% for SGLT2i (p<0.01). From baseline to follow-up echocardiogram, mean Left Ventricular End Diastolic Diameter improved from 5.51 to 5.13 cm (p<0.01). Mean Left Ventricular End Systolic Diameter improved from 4.33 to 3.75 cm (p<0.01). Mean Left Ventricular Mass Index was improved from 112.5 to 102.5 g/m2 (p<0.01). Mean Left Ventricular Ejection Fraction improved 34.4% to 49.8% (p<0.01). No hospitalizations due to medication-related adverse events were reported and 18 patients were hospitalized for HF exacerbation during study follow-up. Mean serum creatinine increased from 97.4 to 104.5 µmol/L (p<0.01); mean serum potassium increased from 4.48 to 4.58 (p<0.01). Conclusions This study demonstrates that a virtual program for GDMT optimization can safely and rapidly promote uptake of therapy in HFrEF patients. Furthermore, medical optimization was associated with significant reductions in left ventricular size, mass and ejection fraction. This provides a structural explanation for reductions in morbidity and mortality seen in STRONG-HF. Future studies should examine the effect of similar interventions on patient outcomes in a randomized setting.

ACEi/ARB after STEMI: prognostic impact and predictors of adherence, results from the real-world FAST STEMI registry

Abstract Background The impact of adherence to angiotensin converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARBs) therapy on cardiovascular outcomes after ST-elevation acute myocardial infarction (STEMI) in real-world patients is understudied. Purpose To identify predictors of lower compliance to ACEi/ARBs and estimate its impact on cardiovascular outcomes and mortality in the first year after the index event. Methods We evaluated real-world adherence to the most common cardiovascular drugs by comparing the number of bought tablets in pharmacies to the expected tablets at 1 year and on total follow-up length. A total of 6043 patients with STEMI from 2012 to 2017 were enrolled in the FAST-STEMI registry and followed up for 4.7±1.6 years. 299 patients with intraprocedural and intrahospital deaths were excluded. The main outcomes evaluated were all-cause death, cardiovascular death, myocardial infarction, major and minor bleeding events and ischemic stroke. The optimal compliance cutoff was found by ROC curve analysis with Youden index; Kaplan Meier and Cox proportional hazard models were performed to evaluate cumulative event rates of mortality at follow-up. Predictors of lower adherence were evaluated at univariate and multivariate analysis with logistic regression. Results A total of 4167 patients with ACEi/ARBs prescription at discharge were considered: mean age was 64 ± 12 years old, 77.3% were men, 18.4% had hypertension, 12% were diabetic, 3.8% had previous coronary artery disease (CAD), mean ejection fraction (EF) was 49.21%±8.9%. Mean ACEi/ARBs adherence was 84.4% (IQR 57.5-99.8): after univariate and multivariate analysis, predictors of lower compliance were age ³75 years old (OR 0.822, 95%CI 0.697-0.970) and known ischemic cardiopathy (OR 0.592, 95%CI 0.422-0.831), whereas preserved EF (OR 1.197, 95%CI 1.048-1.368), hypertension (OR 1.339, 95%CI 1.114-1.609) and beta-blockers prescription at discharge (OR 1.442, 95%CI 1.155-1.802) were predictors of good adherence. ACEi/ARBs compliance higher than 72.06% (identified at Youden’s analysis as best cut-off) was found both at univariate and multivariate analysis as a predictor of lower cardiovascular (0.3% vs 2.6%, HR 0.17, 95%CI 0.07-0.36, p<0.001) and all-cause mortality (1.5% vs 5.9%, HR 0.34, 95%CI 0.23-0.51, p<0.001). Finally, ACEi/ARBs optimal compliance at 1-year was associated to a reduction of myocardial infarctions (7.7% vs 10.4%, p=0.02), as well as minor bleedings (0.2% vs 0.7%, p=0.01), whilst did not impact on ischemic stroke nor major bleedings. Conclusions In our large real-world registry, good adherence to ACEi/ARBs therapy after acute myocardial infarction with ST-elevation was associated with a reduction in mortality (either cardiovascular and all-cause), myocardial infarctions and minor bleedings. Older age and previous coronary artery disease resulted as predictors of poor compliance to ACEi/ARBs therapy.

Beta-blockers after STEMI: prognostic impact and predictors of adherence, results from the real-world FAST-STEMI registry

Abstract Background The impact of beta-blocker therapy on cardiovascular outcomes after ST-elevation acute myocardial infarction (STEMI) is debated. Adherence to beta-blockers after acute myocardial infarction and effect on long term cardiovascular outcomes are also fields with significant knowledge gaps. Purpose To identify predictors of lower compliance to beta-blocker therapy and estimate its impact on cardiovascular outcomes and mortality during the first year of follow-up after the index event. Methods We evaluated real-world adherence to the most common cardiovascular drugs by comparing the number of tablets bought in pharmacies to the expected number of tablets needed at 1 year and at the final follow-up. A total of 6043 patients with STEMI were enrolled in the FAST-STEMI registry from 2012 to 2017 and followed up for 4.7±1.6 years. 299 patients with intraprocedural and intrahospital deaths were excluded. The main outcomes evaluated were all-cause death, cardiovascular death, myocardial infarction, major and minor bleeding events, and ischemic stroke. The best compliance cut-off was found by ROC curve analysis with Youden index; Kaplan Meier and Cox proportional hazard models were performed to evaluate cumulative event rates of mortality at follow-up. Predictors of lower adherence were evaluated in univariate and multivariate analyses with logistic regression. Results A total of 4992 patients with beta-blockers prescription at discharge were enrolled: mean age was 64±12.3 years old, 76% were male, mean ejection fraction was 49±8.8%. Mean adherence to beta-blockers was 95,8% (IQR 82.2-100). After univariate and multivariate analyses, age over 75 years old (OR 0.76, 95%CI 0.63-0.91) and previous coronary artery disease (OR 0.62, 95%CI 0.44-0.87) resulted as predictors of lower compliance, whereas concomitant ACEi/ARB prescription at discharge was a predictor of good adherence (OR 1.23, 95%CI 1.04-1.46). Adherence to beta-blockers higher than 65.68% (identified as best cut-off at Youden’s analysis) was related to a lower cardiovascular (0.65% vs 1.49%, p 0.009) and all-cause mortality (1.98% vs 4.48%, p <0.001). At multivariate analysis, adherence to beta-blockers was significantly associated with lower cardiovascular mortality (HR 0.40, 95%CI 0.20-0.81, p 0.01) as well as EF >50% (HR 0.30, 95%CI 0.14-0.63, p 0.002), while age over 75 years old (HR 4.72, 95%CI 2.23-9.98, p <0.001) and history of atrial fibrillation (HR 2.63, 95%CI 1.02-6.80, p 0.04) were associated with a higher risk of cardiovascular death. Finally, optimal adherence to beta-blockers did not reduce the number of myocardial infarctions, strokes, or bleeding events. Conclusions In our large real-world registry, optimal adherence to beta-blockers after STEMI was associated with a reduction in both cardiovascular and all-cause mortality. Older age and previous coronary artery disease resulted as predictors of poor compliance to beta-blocker therapy.Kaplan Meier on all-cause and CV deathMultivariate analysis on CV death

Validation of a new CPET multivariable score to predict cardiovascular events in heart failure patients

Abstract Introduction Cardiopulmonary exercise testing (CPET) is recommended in patients with heart failure (HF) to optimize exercise prescription and as part of the evaluation for heart transplantation. Recently, a new multivariable score (MVS) was proposed as a powerful method to predict HF events with an optimal cut-off value of 120. Purpose We aimed to evaluate the prognostic value of this tool in patients with HF. Methods We conducted a single-centre study assessing consecutive patients with HF who underwent CPET from 2013 to 2017. Classic and recently proposed variables were collected, including peak O2 uptake (pVO2), minute ventilation–CO2 production (VE/VCO2 slope), partial pressure of end-tidal CO2 at the anaerobic threshold (PETCO2L), circulatory power (CP=pVO2 x peak SBP), and ventilatory power (VP=peak SBP/(VE/VCO2) slope). The score was calculated as follows: (pVO2 × 2.194) + (PETCO2L × 1.545) + (LVEF × 1.134) + (HR × 1.055; 0 if AF, 1 if sinus rhythm). The primary outcome was a composite of HF hospitalization, heart transplant, and all-cause mortality. Results We included 212 patients 76.9% male and with a mean age of 55.4±10.9 years-old. The most frequent aetiology was dilated cardiomyopathy (43.9%) followed by ischaemic heart disease (38.7%). Accordingly, the mean left ventricle ejection fraction was 29±13%. Additionally, 39.8% had atrial fibrillation. The most used exercise protocol was the modified Naughton (76.6%). Mean pVO2 was 16.7±5.9mL O2·kg−1·min−1, median VE/VCO2 slope was 37.5 [32.7-44.3], and PETCO2L 33.5±5.2mmHg. Mean VP was 3.46±1.31mmHg while the median CP was 1927 [1427-2697]mmHg·min/mL/kg. The mean MVS was 116.2±23.1. Despite weak, there were significant positive correlations between the MVS and both VP (r=0.59, p<0.01) and CP (rs=0.64, p<0.01). After a median follow-up of 71 [49-81] months, the primary outcome occurred in 66.0% of patients (rehospitalization, heart transplant, and all-cause death occurred in 56.1%, 25.9%, and 32.5%, respectively). The new CPET MVS was associated with the primary outcome (p<0.01). Additionally, patients with MVS <120 had a higher rate of the primary outcome (83.2% vs. 39.1%, p<0.01). Kaplan-Meier estimates of tthe primary outcome according to the optimal cut-off value of 120 are shown in Figure 1A. Receiver operating characteristic curve revealed that the MVS has higher discriminative power for the primary endpoint (AUC 0.80, p<0.01) compared to pVVO2, VP, and CP (Figure 1B). Conclusion The novel multivariable score is associated with the composite of HF hospitalization, heart transplant, and all-cause mortality in patients with heart failure, enhancing the role of CPET in risk stratification.

Efficacy of remote home telemonitoring (HTM) on congestion control and heart failure (HF) hospitalizations in HF out-patients

Abstract Introduction Heart failure (HF) burden is characterized by high hospitalizations rates, impairing patients survival and quality of life. Yet, early detection and control of congestion with home tele-monitoring (HTM) might help to reduce HF hospitalizations (HFH) (1). Aim To report our experience of congestion management with HTM for HF patients in out-hospital setting. Methods All HF patients followed with the HTM program of our HF clinic between July 2020 and December 2022 were included. For each patient, HTM consisted in daily body weight and symptoms tele-transmission through a connected device. History of HFH were recorded 18 months before and up to 18 months after inclusion in HTM. Alerts were defined as weight gain (WA) (≥ 3 kgs in 2 days or ≥ 2 kgs in 5 days) and/or new symptoms (SA) onset (≥ 3 in 1 day or identical 3 times in 4 days). Relevants HTM alerts were transmitted by the service provider to the local HF team to be managed within 48 hours : phone contact and/or NT-proBNP dosing and/or physical consultation and/or treatment adaptation. Results Among the 147 patients included, mean age was 60±12 years, 110 (75%) were males. Mean left ventricle ejection fraction (LVEF) was 34±11%, and 112 (76%) had HF-rEF, 19 (13%) HF-mrEF and 16 (11%) HF-pEF. Other baselines characteristics are resumed in Table1. Mean HTM duration was 391±250 days and mean device observance was 74±21%. During HTM, 85 (59%) alerts were managed by the HF team in a mean delay of 98±114 days after inclusion : 47 (32%) WA, 34 (23%) SA and 4 (3%) W+SA. After Student-paired test compared to D0 (day of alert transmission), mean weight (kgs) at D2, D5, D10, D21 and D30 were significantly lower (all p<10E-3), respectively 91±17 versus 90±17, 89±17, 89±16, 88±16 and 89±17 kgs (Fig.1A). After Wilcoxon paired-test, the same difference was observed for symptoms (all p<10E-3) : 3±2 (D0) versus 1±1 (D2), 0.7±1 (D5), 0.4±0.8 (D10), 0.5±0.7 (D21) and 0.5±0.9 (D30) (Fig.1B). Patients HFH rates were significantly lower after HTM inclusion : 19 HFH (13%) after HTM versus 70 (48%) before, according to McNemar's X2 test (p<10E-11) (Fig.1C). Notably, post-HTM observed HFH rates (13%) also differed significantly from the 20% expected in a general HF population (2). For the 15 patients (10%) with history of HFH both before and after HTM implementation, mean lengths of stay (LOS) were significantly lower when HFH occurs after HTM inclusion according to Wilcoxon signed rank test : 10±12 vs 22±19 days (-12±17 days, p=0.02) (Fig.1D). Conclusion In our experience, HTM is a efficient to help controling congestion and symptoms of HF patients in out-hospital setting, and can help to reduce HFH, providing that each alerts is being timely and appropriately addressed by the HF team. Prospective studies are needed to confirm these results.Impact of HTM on congestion and HFHTable 1.Patients characteristics.

Fragmented QRS complex as a predictor of all-cause mortality in patients undergoing cardiac resynchronization therapy

Abstract Introduction Heart failure with reduced left ventricle ejection fraction (HFrEF) is a prevalent entity with poor prognosis in the follow-up. Cardiac resynchronization therapy (CRT) in specific situations, have demonstrated to reduce all-cause mortality in this group of patients. However, these patients represent a highly heterogeneous group, so risk stratification is crucial in the approach of these patients. In the recent years, specific electrocardiographic findings such as fragmentation of the QRS complex (fQRS) have been reported as potential prognostic factors in different cardiac conditions, but the role in patients undergoing CRT is unclear. Purpose The aim of this study is to determine if the presence of pre-implantation fQRS in 12-lead surface electrocardiogram (ECG) predicts all-cause mortality in patients undergoing CRT implantation. Methods Consecutive patients undergoing CRT implantation (with or without defibrillator) were prospectively included from October 2009 to December 2022. Demographic, clinical, electrocardiographic and echocardiographic variables as well as outcomes in the follow-up period were recorded from electronic clinical records and telephone interview. Fragmentation of the QRS complex was defined by the presence of different RSR′ patterns including an additional R-wave (R′), notching of the R-wave and S-wave or the presence of more than 1R′ in two contiguous leads corresponding to a main coronary artery territory. Results Finally, 244 patients were included. Mean age at device implantation was 71.8 years (standard deviation, SD ±9.8 years), 79.5% were male and 40.2% were diabetic. Mean left ventricle ejection fraction (LVEF) at baseline was 24.9% and the aetiology was non-ischaemic in 50.8% of the patients and ischaemic in 49.2%. 40.2% had prior history of acute myocardial infarction. Pre-implantation fQRS was found in 58.6% of the patients and mostly in inferior leads. CRT with defibrillator implantation was performed in 71.4% of the patients. The median follow-up time was 27.4 months. At the end of this period, mean LVEF was 33.2% and 76.6% presented NYHA class I-II. 28.7% of the patients died during the follow-up. A multivariate survival study using Cox regression revealed that the only variables were associated with death from any cause were maintaining NYHA functional class III-IV, the aetiology of the LV systolic dysfunction and pre-implantation fQRS. Specifically, the presence of pre-implantation fQRS in the surface ECG was a powerful predictor for all-cause mortality (HR 2.62; 95% CI 1.40-4.91). Kaplan-Meier curves for all-cause mortality are presented in Figure 1. Conclusions According to our results pre-implantation fQRS in the surface ECG is a powerful independent predictor of all-cause mortality in patients undergoing CRT implantation. Consequently, these patients could benefit from stricter follow-up. However, further studies are required to support our results.Figure 1.Kaplan-Meier curves.

Transcatheter edge to edge repair of functional mitral regurgitation as bridge to heart transplantation: 2-years follow up results from MitraBridge international registry

Abstract Background Chronic severe functional mitral regurgitation (FMR) is a common finding in patients with advanced heart failure (AHF) who undergo evaluation for heart transplantation (HTx). Nevertheless, access to surgical strategies for AHF could be limited by scarce availability of donors and by temporary or definitive contraindications. MitraBridge registry already proved that transcatheter edge to edge repair (TEER) of FMR performed as a bridge to HTx is an effective and safe treatment strategy at 1-year follow up with 64% of patients free from composite primary endpoint of all-cause death, new admission for HF, urgent HTx or LVAD implantation. Purpose The aim of this study is to determine whether 1-year results of MitraBridge registry were maintained at 2-years follow up. Methods Mitrabridge is a retrospective, multicenter observational study that enrolled 153 adult patients with AHF and moderate-to-severe or severe FMR and considered candidates for HTx who underwent TEER between 2018 and 2021. Depending on the strategy TEER was performed for, patients were classified in bridge to transplant, candidacy or decision. Primary endpoint of the current analysis was the 2-year composite rate of all-cause death, new admission for HF, urgent HTx or LVAD implantation. Results Median age was 59 years old [53-63], most patients were in INTERMACS class 5-6 (47.5%) and mean left ventricle ejection fraction (LVEF) was 26.9±7.7%. Baseline right heart catheterization was available for 112 (73%) patients, of them 87.5% had pulmonary hypertension with mean pulmonary artery pressure (mPAP) of 33±10 mmHg. Procedural success was achieved in 89.5% of cases and no deaths at 30 days were reported. At 2-years follow up, freedom from primary endpoint was maintained in 47% of patients. A significant reduction of echocardiographic systolic pulmonary artery pressure (sPAP) was observed (from 50 [40-61] mmHg to 43 [33-53] mmHg, p-value<0.001). At the end of follow-up (median time of 26 months, IQR 9-52), elective HTx was successfully performed in 30 cases (21%), 19 patients (13.5%) maintained or obtained the eligibility for transplant, and 32 patients (22.5%) had no longer indication for HTx, due to clinical improvement. Nine patients underwent LVAD implantation for clinical worsening and nine (8%) urgent HTx (15% of already listed population). Conclusions MitraBridge 2-years follow up confirms that TEER is a safe option in AHF population with FMR and shows that haemodynamic and clinical benefits following the procedure are maintained at long term. In particular, it allowed 21% of patients to receive elective HTx reducing need for urgent organ transplantation and helped to expand the candidacy for HTx.

Peak VO2 and VE/VCO2 exhibit differential prognostic capacity for predicting cardiac events

Abstract Background Cardiopulmonary exercise testing (CPET) are commonly used to assess the functional capacity of patients with heart failure. While both peak oxygen uptake (VO2) and ventilatory efficiency (VE/CO2) are significant prognostic factors in heart failure, their values may not always be concordant. Methods This retrospective study included 688 patients who underwent both CPET and supine bicycle echocardiography (SBE) simultaneously. The primary endpoint of the study was defined as heart failure hospitalization or cardiac death. The patients were categorized into subgroups based on their VO2 and VE/VCO2 slope values. Results After median follow-up of 89 months, 111 (16.4%) patients developed cardiac events. The mean age and ejection fraction were 58 years and 59%. In multivariate analysis, both VO2 and VE/VCO2 remained powerful predictors of cardiac events after adjusting for age, ejection fraction, baseline or exercise E/e’, and peak TR velocity. Subgroup analysis revealed that Group III (VO2 >20 and VE/VCO2 >30) and IV (VO2 <20 and VE/VCO2 >30) had a significantly higher risk of cardiac events, with hazard ratios of 3.38 (CI 1.36-8.40) and 8.40 (CI 3.86-18.34), respectively, compared to Group I (VO2 >20 and VE/VCO2 <30). Group II (VO2 <20 and VE/VCO2 <30) had a non-significantly increased risk of cardiac events with a hazard ratio of 2.04 (CI 0.80-5.21) compared to Group I (Fig). Conclusion Both VO2 and VE/VCO2 slope were found to be excellent predictors of cardiac events in patients who underwent CPET and SBE. However, there is a slight difference between the two parameters, and poorer ventilatory inefficiency was found to be more associated with a worsened prognosis. The study suggests that the risk stratification using the VE/VCO2 slope and peak VO2 values can provide valuable information for clinicians in managing patients with heart failure.

Effect of vitamin D receptor genetic polymorphism on the clinical response to angiotensin converting enzyme inhibitors therapy among breast cancer patients with chemotherapy induced cardiomyopathy

Abstract Background Blockade of the renin-angiotensin-aldosterone system (RAAS) is the cornerstone treatment of chemotherapy induced cardiomyopathy (CIC) yet, variability in response to angiotensin converting enzyme inhibitors (ACEIs) acting on the RAAS is well-documented. Vitamin D was found to play a role in regulating RAAS. Previous studies revealed an inverse relationship between levels of vitamin D in serum and RAAS activation. Purpose The current study is primarily to evaluate the association between genetic variants in the vitamin D receptor (VDR) and clinical response to ACEIs among breast cancer patients receiving chemotherapy with CIC. Methods A total of 60 breast cancer patients with CIC (mean ejection fraction 30%) on β-blocker therapy were started on a ACEIs and followed for 6 months. Post-ACEIs-treatment changes in ejection fraction (EF) and serum potassium (K) were evaluated. We genotyped VDR gene polymorphisms including; ApaI (rs7975232), TaqI (rs731236), BsmI (rs1544410) and FokI (rs2228570) variants using TaqMan technique. Stepwise linear regression was performed to identify genetic and clinical factors associated with variability in ACEIs response, with adjustment for all potential confounding covariates. Results BsmI (rs1544410) (CT) heterozygous and TaqI (rs731236) (GA) genotypes had a significant increase in EF (12.8% and 10.8 %, respectively) and serum K (1.1 mEq/L and 0.91 mEq/L respectively); adjusted-p = 0.0001 and 0.004 for ∆EF and adjusted-p = 0.005 and 0.002 for ∆K. In contrast, (AA) homozygous carriers of the ApaI SNP (rs7975232) had a smaller increase in EF (∆EF = 1.2%) and K (∆K = 0.1 mEq/L) compared to (CA) (∆EF = 6.5%, ∆K = 0.73mEq/L) and (CC) (∆EF = 9%, ∆K = 0.9mEq/L) carriers; adjusted-p = 0.003 for ∆EF, adjusted-p = 0.004 for ∆K. Finally, for the FokI SNP (rs2228570), there was no significant change in EF and serum K level. Conclusion The results from this study highlight that BsmI (rs1544410) and TaqI (rs731236) are strong predictors of response to ACEIs therapy in chemotherapy-induced cardiomyopathy (CIC).

Allied health professional-physician collaboration to enhance guideline-directed medical therapy of heart failure: expanding therapeutic opportunities

Abstract Background Guideline-directed medical therapy (GDMT) is the cornerstone of treatment for heart failure patients with reduced ejection fraction (HFrEF). Optimization of GDMT at a targeted allied professional medication titration clinic represents a key opportunity to provide greater access to care and further refine patient care models, leading to improvements in clinical outcomes. Purpose To evaluate the effectiveness of an allied health practitioner optimization clinic model in HFrEF as indicated by changes in rates of triple and quadruple GDMT therapy (see associated table). Methods Qualified patients were either: proactively screened from clinic lists, having demonstrated a diagnosis of heart failure, reduced ejection fraction, and not receiving triple or quadruple therapy, or were physician-referred after initial optimization during 2021-2022. Participants subsequently underwent medication review and optimization by an allied health professional, involving introduction, up-titration, down-titration, or withdrawal of medications across relevant medication classes as tolerated. Results 52 (78.8% male) patients with a mean age of 70.3 (11.4) years and mean ejection fraction of 30.1 (6.7) percent underwent medication optimization. Along with HFrEF, all patients exhibited cardio-metabolic multi-morbidity (2-3 cardio-metabolic diagnoses), including hypertension (59.6%), dyslipidemia (71.2%), coronary artery disease (61.5%), atrial fibrillation (42.3%), and type 2 diabetes (21.2%). Pre-optimization prescription rates ranged from: 53.8% for ACEi/ARB, 30.8% for ARNI, 80.8% for beta-blockers, 59.6% for MRA, 40.4% for diuretics, and 13.5% for SGLT2i. Medication review and optimization spanned an average of 2.8 (1-7) meetings, and lead to an average of 1.9 (range 0-4) medication changes. Among 49 patients considered for ARNI optimization, there were 43 (87.7%) successful introductions and progressive dose adjustments, including 12 (27.9%) dose adjustments among those already prescribed. Additional changes involved optimizations in: beta-blockers (5 introductions, 5 dose-changes), MRA (8 introductions, 4 dose-changes, 2 withdrawals), diuretics (1 introduction, 7 dose-changes, 2 withdrawals), and SGLT2i (17 introductions). Collaboration between allied health professionals and physicians in optimization demonstrated significant improvements in rates of triple (42.3% vs 63.5%, P= 0.003) and quadruple (5.8% vs 26.9%, P= 0.001) therapy post-optimization. Discussion A Collaborative approach to medication optimization increased the use of GDMT in ambulatory patients with HFrEF. Collaboration presents both clinicians and health systems with greater opportunities to improve healthcare access, therapeutic inertia, and disease management.Pre-post Changes in GDMT Rates

Longitudinal Strain Patterns in Stress (Takotsubo) Cardiomyopathy: Evidence of Global Myocardial Injury and Incomplete Recovery

BackgroundStress cardiomyopathy develops after abrupt sympathetic stimulation, likely from catecholamine-induced myocardial toxicity. The evolution of myocardial strain during and following an episode have not been previously characterized. We aimed to determine whether pre-existing contractile abnormalities may explain the observed regional dysfunction during an acute episode, and to investigate the persistence of strain abnormalities after clinical recovery. MethodsWe identified patients who were diagnosed with stress cardiomyopathy and had an echocardiogram performed prior to their episode, during their episode, and within 1 year after. Diagnosis was confirmed based on the absence of obstructive coronary lesions. Left ventricular (LV) longitudinal strain was calculated using speckle-tracking software and compared between baseline, episode, and follow-up echocardiograms. ResultsLV strain analysis was performed on 23 patients. LV ejection fraction was 64±8.7% at baseline, 45±12% during the episode, and 59±10% after a median follow-up of 46 days. LV global longitudinal strain was 24±4.7% at baseline, 11±4.9% during the episode, and 19±4.6% after follow-up. Mean ejection fraction (p<0.01) and global longitudinal strain (p<0.001) remained below baseline levels at follow-up. Longitudinal strain was reduced (<18%) in 80±23% of myocardial segments during an episode and 41±21% of myocardial segments at follow-up. During the acute episode, 35±6% of the abnormal segments were in the base, outside of the region of ballooning. ConclusionsOur findings suggests that stress cardiomyopathy is associated with global rather than regional myocardial injury, and that contractile abnormalities persist after clinical improvement. These findings challenge prior understanding of stress cardiomyopathy and may guide future pathophysiologic understanding of this complex disease.

Abstract 13790: Efficacy of Stellate Ganglion Block for Refractory Ventricular Arrhythmias: An Updated Systematic Review

Background: Stellate ganglion block (SGB) has emerged as an alternative approach to refractory ventricular arrhythmias (VAs). However, data on the outcome of SGB for refractory VAs are limited. Objective: This study aimed to assess the in-hospital efficacy of SGB in refractory VAs. Method: A systematic search was performed in MEDLINE and EMBASE according to the PRISMA guidelines from July 2017 to October 2022. Studies reporting the characteristics of in-hospital VAs before and after the SGB were included. Studies that had missing outcomes were excluded. Results: Of 515 publications reviewed, 162 patients (60.6 ± 13.6 years of age, 81.5% male) were included across 27 studies. Amongst, 103 patients (63.6%) had ischemic cardiomyopathy, and the mean ejection fraction was 29.8 ± 12.7%. Prior to the SGB procedure, 100 patients (61.7%) required two or more anti-arrhythmic medications control. Following SGB, there was a significant 92% reduction of VAs episodes from 13.9 ± 18.5 to 0.9 ± 2.1 (p&lt;0.01) during the hospitalization (31±35 days). Of the reported patients, 46.5% remained free of VAs, and 53.5% had recurrences before discharge. Among 61 patients who required additional neuromodulation after SGB in the same hospitalization, 32 patients (52.5%) received repeated SGB, 15 patients (24.6%) underwent surgical sympathectomy, and 14 patients (23%) underwent catheter ablation. Of the reported patients, 75.4% of patients survived throughout the hospital course. Conclusion: SGB significantly reduced VAs episodes in patients with refractory VAs during hospitalization. More than three-quarters of the patients survived following the SGB for refractory VAs. This highlights the potential effective role of SGB in managing refractory VAs. Figure Change in Ventricular Arrhythmias Burden after Stellate Ganglion Block

Abstract 14769: Peripheral Venous Pressure Measured With a Novel Miniature Pressure Transducer Correlates With Central Venous Pressure in Heart Failure, Heart Transplant, and Left Ventricular Assist Device Patients

Introduction: Peripheral venous pressure (PVP) has been shown to accurately correlate with central venous pressure (CVP) when measured using a conventional manometer and pressure tubing. We investigated the correlation between PVP as measured by a novel pressure transducer and CVP in heart failure (HF), heart transplant (HTx), and left ventricular assist device (LVAD) patients. Methods: A prospective, cross-sectional study examining PVP from February 2022 to May 2023 was conducted. The analysis was limited to patients undergoing right heart catheterization (RHC) admitted for HF, post-HTx monitoring, or LVAD hemodynamic testing. PVP was transduced from an antecubital or more distal peripheral intravenous (IV) catheter site using a miniature digital, disposable pressure transducer (Centurion Compass Universal HG, Medline). Pressures were compared using Pearson’s correlation coefficient. Results: 99 patients were enrolled with a mean age of 62 ± 12 years and a mean ejection fraction (EF) of 41 ± 21%. 74% of the patients had heart failure, 17% were HTx patients, and 9% were LVAD patients. The PVP measured with the novel pressure transducer was found to be highly correlated to CVP measured by RHC (r=0.80, p &lt; 0.0001) (Figure). High correlation was also noted when broken down by HF (r=0.77, p &lt; 0.0001), HTx (r=0.95, p &lt; 0.0001), and LVAD groups (r=0.90, p &lt; 0.0003). There was a high degree of correlation for HF patients with EF &lt; 50% (r=0.74, p &lt; 0.0001) and EF &gt; 50% (r=0.90, p &lt; 0.0001). A high degree of correlation was found for all peripheral IV insertion sites: antecubital (r=0.86, p=0.000071), forearm (r=0.76, p&lt;0.00001), and hand (r=0.84, p&lt;0.00001). Conclusions: There is a high degree of correlation between PVP measured by a novel pressure transducer and CVP in HF, HTx, and LVAD patients. PVP measurements using this transducer are a reliable estimate of volume status in these patient populations.

Abstract 14030: Hemodynamic Metrics Can Be Accurately Assessed by a Non-Invasive Sensor Patch: The Portable Technology for Wireless Cardiomyopathy Tracking (Patchwrk) Study

Background: Echocardiographic timing intervals provide valuable prognostic information in patients with pre-clinical cardiac dysfunction. Diastolic filling time (DFT) can identify left bundle branch block (LBBB) patients at higher risk for cardiomyopathy. The need for specialized equipment limits the utility of echo in longitudinal assessment. Hypothesis: A non-invasive multimodal sensor Sansa patch will enable accurate assessment of hemodynamic parameters such as DFT, ejection time (ET), and pre-ejection period (PEP). Methods: Fifty patients scheduled for clinically indicated echocardiography were prospectively enrolled and had simultaneous application of the Sansa patch at the time of echocardiography. Timing intervals were analyzed using continuous wave (CW), pulsed wave (PW), and tissue Doppler imaging (TDI). Data from the Sansa electrocardiogram (ECG), seismocardiogram (SCG), and phonocardiogram (PCG) were independently analyzed to identify valve openings/closures to estimate DFT, ET and PEP. Agreement between echo and Sansa estimates was assessed using the coefficient of determination (R 2 ) and compared with agreement between different echo views. Results: Forty-six of the 50 patients (92%) had data of sufficient quality for analysis. The mean ejection fraction was 53±8% and 11 patients (24%) had LBBB. By echo, the mean DFT, ET, and PEP were 408±137 milliseconds (ms), 297±35ms, and 107±32ms respectively. Sansa estimates for DFT, ET and PEP were 431±135ms, 286±43ms, and 89±34ms respectively. The R 2 for Sansa DFT compared to echo was 0.85. Comparing TDI and PW estimates of DFT within the same patients demonstrated an R 2 of 0.82. Conclusion: Non-invasive Sansa patch monitoring accurately identified key cardiac timing intervals within the error observed between standard echo views. These measures have prognostic value and monitoring them in the ambulatory setting may allow early cardiomyopathy detection and upstream intervention.

Abstract 13590: Comparative Efficacy and Safety of Bare-Metal versus Drug-Eluting Stents in Managing Saphenous Venous Graft Disease: A Meta-Analysis and Systematic Review

Introduction: Current understanding of the relative safety and efficacy of bare metal stents (BMS) vs. drug eluting stents (DES) in patients with saphenous venous graft disease (SVGD) relies on analysis of small datasets. Methods: Literature search was performed using PubMed, Embase and Web of Science to identify relevant articles on outcomes of BMS vs. DES in patients with SVGD. A random effects model was used to calculate odds ratios (ORs) for several safety and efficacy outcomes including major adverse cardiovascular events (MACE), target lesion revascularization (TLR), total vessel revascularization (TVR), in-stent restenosis, and stent thrombosis. Results: Of 3644 total citations on the initial search, 40 studies comprising 83,151 (33,306 BMS, 49,845 DES) patients qualified for quantitative analysis. The mean age was 72 years, and the mean ejection fraction was 47%. The inter group proportion of hypertension was 78% vs. 83%, diabetes mellitus was 37% vs. 14%, and hyperlipidemia was 69% vs. 78% in patients with BMS vs. DES, respectively (Table). Patients receiving DES had significantly lower odds of MACE (OR 0.63, 95% CI 0.52-0.77), and its components; TLR (OR 0.67, 95% CI 0.49-0.92), TVR (OR 0.61, 95% CI 0.46-0.81); and stent restenosis (OR 0.61, 95% CI 0.45-0.84) compared with BMS (Figure). The risk of stent thrombosis (OR 0.84, 95% CI 0.61-1.15) was similar between the two groups. Conclusions: Compared with BMS, patients receiving DES for SVGD demonstrated a lower risk of adverse events, stent stenosis, and need for revascularization.