New-onset Heart Failure Research Articles

The Role of the Wearable Defibrillator in Heart Failure.

Wearable cardioverter defibrillators (WCDs) have been developed as a temporary measure for protecting patients at risk for sudden cardiac death that do not meet the indication for implantable cardioverter defibrillator (ICD), most notably in the early stages of heart failure with reduced ejection fraction before reassessment of their left ventricular ejection fraction. In this review, we report available evidence in the literature and guidelines regarding WCD use in order to try to define the role WCDs may have in heart failure. In the last decade, most observational studies found WCDs to be both safe and effective in terminating ventricular arrhythmias in various indications, mostly centered around heart failure with reduced ejection fraction. The only available randomized controlled trial using WCD did not however show a benefit on patients' survival. Hence, recent guidelines only recommended its use in limited indications. Recent data also suggest a possible interest of WCD in monitoring patients, a finding that may prove useful in the context of new-onset heart failure. Data regarding WCD benefit is scarce, and definitive conclusions on its utility are hard to draw. In the context of heart failure, and particularly new-onset heart failure, WCD might find a role in a global comprehensive management of the disease, both acting as an educational tool, a monitoring tool, and, most importantly, a safe and effective tool in preventing sudden cardiac death. The low level of evidence however invites caution, and the decision of prescribing a WCD needs to be individualized and thoroughly discussed with the patient whose compliance is key with this device.

Associations of Heart Failure Onset Age with All-Cause Mortality: The Kailuan Study

Objective: This study was aimed at investigating the correlations between heart failure onset age and all-cause mortality. Methods: The study examined 186,249 patients treated at Kailuan Group hospitals who underwent medical evaluations between 2006 and 2018. Biennial health assessments were conducted, and, as of December 31, 2020, 4022 heart failure instances were identified. For each patient with new-onset heart failure, four control participants were randomly selected, matched for age (within ±1 year) and sex. Cox regression models were used to calculate the hazard ratios of all-cause mortality across age groups. Results: The median follow-up duration was 5.25 (2.65, 8.63) years. All-cause mortality occurred in 1783 participants in the new-onset heart failure group and 2633 participants in in the control group. Refined multivariable Cox regression analysis revealed that patients with heart failure under 55 years of age had the highest relative mortality risk, with an HR (95% CI) 6.86 (4.42–10.64) with respect to their matched controls. Moreover, the relative mortality risk systematically decreased with increasing age of heart failure onset: HR (95% CI) 4.70 (3.73–5.92) for ages 55–64, HR (95% CI) 3.23 (3.73–3.81) for ages 65–74, and HR (95% CI) 1.69 (1.48–1.94) for 75 years or older. Conclusion: Heart failure significantly elevates the risk of all-cause mortality, and the risk is more pronounced with earlier manifestation of the condition.

Predicting incident heart failure from population-based nationwide electronic health records: protocol for a model development and validation study

IntroductionHeart failure (HF) is increasingly common and associated with excess morbidity, mortality, and healthcare costs. Treatment of HF can alter the disease trajectory and reduce clinical events in HF. However,...

Heyde Syndrome as Cause of New-onset Heart Failure in the Setting of Bioprosthetic Aortic Valve: A Case Report

This report describes the case of a 70-year-old female with a history of bioprosthetic aortic valve replacement. She presented to the emergency department with significant shortness of breath and bilateral lower extremity edema, which was found to be secondary to new-onset acute symptomatic congestive heart failure in the setting of Heyde syndrome.

Risk stratification in patients with structurally normal hearts: Does fibrosis type matter?

The study sought to assess the prognostic significance of nonischemic myocardial fibrosis (MF) on cardiovascular magnetic resonance (CMR)-both macroscopic MF assessed by late gadolinium enhancement (LGE) and diffuse microscopic MF quantified by extracellular volume fraction (ECV)-in patients with structurally normal hearts. The clinical relevance of tissue abnormalities identified by CMR in patients with structurally normal hearts remains unclear. Consecutive patients undergoing CMR were screened for inclusion to identify those with LGE imaging and structurally normal hearts. ECV was calculated in patients with available T1 mapping. The associations between myocardial fibrosis and the outcomes of all-cause mortality, new-onset heart failure [HF], and an arrhythmic outcome were evaluated. In total 525 patients (mean age 43.1±14.2 years; 30.5% males) were included. Over a median follow-up of 5.8 years, 13 (2.5%) patients died and 18 (3.4%) developed new-onset HF. Nonischemic midwall /subepicardial LGE was present in 278 (52.9%) patients; isolated RV insertion fibrosis was present in 80 (15.2%) patients. In 276 patients with available T1 mapping, the mean ECV was 25.5 ± 4.4%. There was no significant association between LGE and all-cause mortality (HR: 1.36, CI: 0.42-4.42, p = 0.61), or new-onset HF (HR: 0.64, CI: 0.25-1.61, p = 0.34). ECV (per 1% increase) correlated with all-cause mortality (HR: 1.19, CI: 1.04-1.36, p = 0.009), but not with new-onset HF (HR: 0.97, CI: 0.86-1.10, p = 0.66). There was no significant association between arrhythmic outcomes and LGE (p = 0.60) or ECV (p = 0.49). In a multivariable model after adjusting for covariates, ECV remained significantly associated with all-cause mortality (HR per 1% increase in ECV: 1.26, CI: 1.06-1.50, p = 0.009). Nonischemic LGE in patients with structurally normal hearts is common and does not appear to be associated with adverse outcomes, whereas elevated ECV is associated with all-cause mortality and may be an important risk stratification tool.

Cardiovascular and mortality outcomes with GLP-1 receptor agonists vs other glucose-lowering drugs in individuals with NAFLD and type 2 diabetes: a large population-based matched cohort study.

We aimed to determine whether the use of glucagon-like peptide-1 receptor agonists (GLP-1RA) in individuals with non-alcoholic fatty liver disease (NAFLD) and type 2 diabetes mellitus decreases the risk of new-onset adverse cardiovascular events (CVEs) and mortality rate compared with other glucose-lowering drugs in a real setting at a population level. We conducted a population-based propensity-matched retrospective cohort study using TriNetX. The cohort comprised patients over 20 years old who were newly treated with glucose-lowering drugs between 1 January 2013 and 31 December 2021, and followed until 30 September 2022. New users of GLP-1RAs were matched based on age, demographics, comorbidities and medication use by using 1:1 propensity matching with other glucose-lowering drugs. The primary outcome was the new onset of adverse CVEs, including heart failure, composite incidence of major adverse cardiovascular events (MACE; defined as unstable angina, myocardial infarction, or coronary artery procedures or surgeries) and composite cerebrovascular events (defined as the first occurrence of stroke, transient ischaemic attack, cerebral infarction, carotid intervention or surgery), and the secondary outcome was all-cause mortality. Cox proportional hazards models were used to estimate HRs. The study involved 2,835,398 patients with both NAFLD and type 2 diabetes. When compared with the sodium-glucose cotransporter 2 (SGLT2) inhibitors group, the GLP-1RAs group showed no evidence of a difference in terms of new-onset heart failure (HR 0.97; 95% CI 0.93, 1.01), MACE (HR 0.95; 95% CI 0.90, 1.01) and cerebrovascular events (HR 0.99; 95% CI 0.94, 1.03). Furthermore, the two groups had no evidence of a difference in mortality rate (HR 1.06; 95% CI 0.97, 1.15). Similar results were observed across sensitivity analyses. Compared with other second- or third-line glucose-lowering medications, the GLP-1RAs demonstrated a lower rate of adverse CVEs, including heart failure (HR 0.88; 95% CI 0.85, 0.92), MACE (HR 0.89; 95% CI 0.85, 0.94), cerebrovascular events (HR 0.93; 95% CI 0.89, 0.96) and all-cause mortality rate (HR 0.70; 95% CI 0.66, 0.75). In individuals with NAFLD and type 2 diabetes, GLP-1RAs are associated with lower incidences of adverse CVEs and all-cause mortality compared with metformin or other second- and third-line glucose-lowering medications. However, there was no significant difference in adverse CVEs or all-cause mortality when compared with those taking SGLT2 inhibitors.

Diabetes and the Risk of Heart Failure Among More Than 60,000 Acute Myocardial Infarction Survivors: A Systematic Review and Meta-Analysis

BackgroundDiabetes mellitus (DM) has raided its incidence across the last decades. It brings several cardiovascular complications. DM increases acute myocardial infarction (AMI) risk and affects systolic and diastolic function. Several studies have explored the association between DM and AMI complications, like heart failure (HF). Therefore, we synthesized evidence regarding the association between DM and HF among AMI survivors. MethodsWe performed a systematic review of longitudinal studies that explored the association between DM and HF after AMI. The search was from inception to January 2023 in Pubmed, Scopus and EMBASE. We excluded studies that did not clearly state if HF was new-onset after AMI. We performed a meta-analysis following the randomed-effect model with the inverse variance method. ResultsFrom 4,512 articles, we selected 19 cohort studies (n=60 451) of AMI survivors. Mean age ranged from 55.4 to 77.8 years. More than 60% of patients were male. In comparison with non-diabetics, those AMI survivors with diabetes had higher risk of new-onset heart failure (RR: 1.78, 95%CI: 1.58-2.01) (attached figure). In addition, left ventricular ejection fraction (%) was lower among diabetic survivors (MD: -1.57, 95%CI: -2.69 to -0.45). As exploratory analysis, AMI in the anterior wall was the most frequent without significant differences between DM and non-DM (pooled prevalence in DM: 54% vs. non-DM: 49%). Diabetes was associated with higher risk of mortality (RR: 2.09, 95% CI: 1.52-2.88) and reinfarction (RR: 1.59, 95% CI: 1.22-2.08) after an AMI event. All studies had low risk of bias. ConclusionsAfter AMI, DM patients have a strong risk of HF. Comprehensive clinical follow-up should be done among this population.

How Would You Manage This Patient With Heart Failure With Preserved Ejection Fraction? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

The proportion of patients with new-onset heart failure who have preserved rather than reduced left ventricular ejection fraction (HFpEF and HFrEF) has been increasing over recent decades. In fact, HFpEF now outweighs HFrEF as the predominant heart failure subtype and likely remains underdiagnosed in the community. This is due in part to an aging population and a rise in other risk factors for HFpEF, including obesity and associated cardiometabolic disease. Whereas the diagnosis of HFrEF is relatively straightforward, the diagnosis of HFpEF is often more challenging because there can be other causes for symptoms, including dyspnea and fatigue, and cardinal physical examination findings of elevated jugular venous pressure or pulmonary congestion may not be evident at rest. In 2022, the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America published a comprehensive guideline on heart failure that included recommendations for the management of HFpEF. The use of diuretics for the management of congestion remained the only class 1 (strong) recommendation. New recommendations included broader use of sodium-glucose cotransporter-2 inhibitors (SGLT2i, class 2a), and angiotensin receptor-neprilysin inhibitors (class 2b). In 2023, the American College of Cardiology published an expert consensus decision pathway for the management of HFpEF that suggests treatment strategies based on sex assigned at birth, ejection fraction, clinical evidence of congestion, and candidacy for SGLT2i therapy. Here, 2 experts, a cardiologist and a geriatrician, discuss their approach to the diagnosis and management of HFpEF and how they would apply guidelines to an individual patient.

Comparing Artificial Intelligence-Enabled Electrocardiogram Models in Identifying Left Atrium Enlargement and Long-term Cardiovascular Risk

BackgroundThe role of P-wave in identifying left atrial enlargement (LAE) with the use of artificial intelligence (AI)–enabled electrocardiography (ECG) models is unclear. It is also unknown if AI-enabled single-lead ECG could be used as a diagnostic tool for LAE surveillance. We aimed to build AI-enabled P-wave and single-lead ECG models to identify LAE using sinus rhythm (SR) and non-SR ECGs, and compare the prognostic ability of severe LAE, defined as left atrial diameter ≥ 50 mm, assessed by AI-enabled ECG models vs echocardiography. MethodsThis retrospective study used data from 382,594 consecutive adults with paired 12-lead ECG and echocardiography performed within 2 weeks of each other at Chang Gung Memorial Hospital. UNet++ was used for P-wave segmentation. ResNet-18 was used to develop deep convolutional neural network–enabled ECG models for discriminating LAE. External validation was performed with the use of data from 11,753 patients from another hospital. ResultsThe AI-enabled 12-lead ECG model outperformed other ECG models for classifying LAE, but the single-lead ECG models also showed excellent performance at a left atrial diameter cutoff of 50 mm. AI-enabled ECG models had excellent and fair discrimination on LAE using the SR and the non-SR data set, respectively. Severe LAE identified by AI-enabled ECG models was more predictive of future cardiovascular disease than echocardiography; however, the cumulative incidence of new-onset atrial fibrillation and heart failure was higher in patients with echocardiography-severe LAE than with AI-enabled ECG-severe LAE. ConclusionsP-Wave plays a crucial role in discriminating LAE in AI-enabled ECG models. AI-enabled ECG models outperform echocardiography in predicting new-onset cardiovascular diseases associated with severe LAE.

Frequency and Clinical Implications of Referrals to Heart Failure Among Patients with Peripartum Cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare but significant cause of new-onset heart failure (HF) during the peri- and post-partum periods. Advances in GDMT for HF with reduced ventricular function have led to substantial improvements in survival and quality of life, yet few studies examine the longitudinal care received by patients with PPCM. The aim of this research is to address this gap by retrospectively characterizing patients with PPCM across a multihospital health system and investigating the frequency of cardiology and HF specialty referrals. Understanding whether surveillance and medical management differ among patients referred to HF will help to underscore the importance of referring patients with PPCM to HF specialists for optimal care.

Impact of Atrial Fibrillation on Heart Failure in Patients Treated With Anthracycline Chemotherapy

Atrial fibrillation (AF) and anthracyclines are known risk factors for heart failure (HF). The magnitude of the effect of preexisting AF (preanthracycline AF) and newly developed AF (postanthracycline AF) in patients treated with anthracyclines on the occurrence of HF is unknown. The aim of our study was to characterize the impact of preanthracycline and postanthracycline AF on the subsequent occurrence of HF in patients treated with anthracyclines. In 5,598 patients treated with new anthracycline therapy at a tertiary center between 2008 and 2021, propensity score matching was used to match 204 pairs with or without preanthracycline AF and 135 pairs with or without postanthracycline AF. The primary outcome was new-onset symptomatic HF defined by the American Heart Association/American College of Cardiology guidelines. Patients with and without preanthracycline and postanthracycline AF were well matched for age, gender, medications, and cardiovascular risk factors. A total of 45 patients with preanthracycline AF and 23 matched patients developed HF (5-year cumulative incidence: 29% in the preanthracycline AF group and 13% in the matched group, p=0.003; hazard ratio 2.1, 95% confidence interval 1.3 to 3.4, p=0.004). A total of 161 patients (2.9%) developed postanthracycline AF. A total of 39 patients (5-year cumulative incidence: 40%) with postanthracycline AF and 9 matched patients (5-year cumulative incidence: 7%) developed HF (hazard ratio 6.1, 95% confidence interval 3.0 to 12.4, p <0.001). Preanthracycline AF and postanthracycline AF are associated with a high incidence of subsequent HF in patients treated with anthracyclines. Prospective studies of therapies are required to decrease HF in these high-risk patients.

Risk factors and prognostic implications for new-onset heart failure with ventricular pacing - a nationwide study

Abstract Background Studies have shown that the incidence of new-onset heart failure (HF) is higher for patients receiving pacemaker therapy with traditional right ventricular pacing, compared to age matched controls. Conduction system pacing may overcome this, but is more expensive and technically challenging. Objectives To investigate risk factors and implications for long-term prognosis of new-onset HF in patients after pacemaker-implant, with the aim of identifying patients at high risk already prior to device implant. Methods All patients without preexisting HF, who received a pacemaker with a right ventricular lead in Sweden during the period 2005-2020, were identified via the nationwide Pacemaker Registry. Data was crossmatched with the population registry and national disease registries. Outcome was new-onset HF within 5 years post-implant, HF hospitalization and all-cause mortality. Results In all, 65579 patients met the inclusion criteria (10351 single chamber ventricular and 55228 dual chamber pacemakers). 13792 (21.0%) patients were diagnosed with HF within five years post-implant. Of these, 6244 (45.3%) were hospitalized for HF (see Figure 1). Patients with heart failure were older (80.6 vs. 76.7 years, p&amp;lt;0.001), had a higher burden of comorbidities, and were more likely to die within five years compared to those without HF (41.2% vs. 19.7%, p&amp;lt;0.001). Independent risk factors with more than 25% increased odds ratio for developing heart failure within 5 years included increasing age, diabetes, atrial fibrillation, chronic lung- and kidney disease, ischemic heart disease, and AV block. A combined score using these variables was strongly associated with increased risk of both HF-hospitalization (OR 1.48 [1.46-1.51], p&amp;lt;0.0001) and 5-year mortality (OR 1.81[1.77-1.98], p&amp;lt;0.0001). There was a progressively increasing risk proportional to the summed score. Patients with at least five points on the score had &amp;gt;25% risk of new-onset heart failure within five years, and patients with at least seven points had &amp;gt;25% risk of new-onset heart failure within two years. In figure 2 we present a suggested score model, based on the results. Conclusions Pacemaker therapy with a lead in the right ventricle was associated with &amp;gt;20% risk of new-onset HF within five years. This in turn was associated with higher risk of death. Based on clinical risk factors, our proposed score can be used to identify patients at high risk for new-onset heart failure. These patients may be eligible for conduction system pacing or resynchronisation therapy. Randomized trials are needed to determine if a score-based pacing strategy (right ventricular or conduction system pacing) approach results in better clinical outcome, and if it is cost-effective.Included patients and risk of HF hosp.Decision algorithm based on results

Multimodality imaging and immunophenotyping of COVID-19 related myocardial injury (the MIIC-MI Study)

Abstract Background Cardiac injury is a well-recognised complication of acute COVID-19 infection, with varied aetiologies ranging from myocarditis to endothelial dysfunction, micro-embolic phenomena, and acute coronary syndromes. While persistent cardiac symptoms in patients with post-acute COVID-19 syndrome are also common, the underlying mechanisms remain unclear. A better understanding of immune-mediated drivers of chronic cardiac injury after COVID-19 infection is urgently needed to inform the management of patients with, or at risk of, long-term sequelae. Purpose To examine immune mechanisms associated with clinically detectable imaging abnormalities across a spectrum of patients with unexplained cardiac injury and/or symptoms after COVID-19 infection. Methods Participants with a history of COVID-19 infection and suspected cardiac involvement based on: a) troponin I elevation (&amp;gt;99th percentile upper reference limit), b) new-onset heart failure not attributable to another cause, or c) persistence of unexplained cardiac symptoms, were enrolled at a single centre in the United Kingdom between October 2020 and February 2022. Individuals with prior myocardial infarction or heart failure and those treated with immunosuppression within the past four weeks, were excluded. Cardiac magnetic resonance imaging (MRI) was performed on a 1.5T scanner following a standard clinical protocol. In parallel to cardiac imaging, peripheral blood samples were analysed for immunophenotyping using cytometry by time of flight (Fluidigm, 32 marker panel) and proteomic analysis (Olink, Target 96 Inflammation panel). Results Twenty-one patients (mean age 47 (SD 13) years, 71% female) were enrolled who had unexplained cardiac symptoms (n=17), raised troponin I (n=2), or new-onset heart failure (n=2). In total, 9/21 (43%) patients had MRI abnormalities, including a non-ischaemic pattern of late gadolinium enhancement (Figure 1a; arrow) and/or visually overt myocardial oedema on T2-weighted imaging (Figure 1b; arrow) in 8 patients, and one with impaired ventricular function in the absence of fibrosis. Patients with MRI abnormalities had higher CCL3, CCL7 (MCP-3), FGF21, and CD4 Th2 cells, and lower CD8 T effector memory cells (Figure 2, volcano plot), compared to those without. CCL7 (MCP-3) levels were correlated with native T1 mapping (r=0.45, p&amp;lt;0.05) and these along with CD8 T effector memory cell counts were the strongest predictors of MRI abnormalities in a LASSO regression model incorporating all clinical, cell phenotyping and proteomic data (composite AUC 0.96, CI 0.88-1). Conclusion Here we show for the first time that COVID-19 related cardiac injury in patients with MRI abnormalities is associated with increased CCL7 (MCP-3), a chemokine known to be important in viral myocarditis1, as well as decreased CD8 T effector memory cells. These findings provide novel insights into the immune-mediated mechanisms underlying non-ischemic cardiac complications of COVID-19.Fig. 1.Post-COVID imaging abnormalitiesFig. 2.Immunophenotyping and proteomics

Effect of a restrictive vs. liberal blood transfusion strategy among patients with acute myocardial infarction and anemia according to heart failure. A subgroup analysis of the REALITY trial

Abstract Background/Introduction The optimal Red Blood Cell (RBC) transfusion strategy in patients with acute myocardial infarction (MI) and anemia remains debated. In REALITY, the largest randomized trial to date in this population (n=666), a restrictive compared with a liberal transfusion strategy resulted in a noninferior rate of major adverse cardiovascular events (MACE; composite of all-cause death, stroke, recurrent myocardial infarction, or emergency revascularization prompted by ischemia) at 30 days, but did not achieve non-inferiority at 1 year. One of the main concerns with RBC transfusion is the risk of fluid overload and acute heart failure (HF). Therefore, the balance of benefit and risk of transfusions strategies may differ between patients with and without heart failure. Purpose We aimed to evaluate the potential interaction between HF and RBC transfusion on outcomes in REALITY. Methods HF was defined as either a history of heart failure or Killip class &amp;gt; 1 at randomization (data available for 658 patients). All events until day 30, including HF, were adjudicated by a Critical Event Committee blinded to the transfusion arm and hemoglobin levels. The primary clinical outcome was MACE at 30 days. Secondary endpoints included MACE at one year, individual components of MACE and new onset of heart failure at 30 days and 1 year. Results Among 658 patients, 311 (47.3 %) had HF. HF patients had a higher rate of MACE and a higher rate of new HF than patients without HF at 30 day and at 1 year (Fig 1). There was no interaction between HF and the effect of randomized assignment on the primary outcome or on new HF. In contrast, a liberal strategy was associated with increased all-cause death at 30 days and at 1 year in patients with HF but not in pts without HF (interaction p = 0.0088 and p = 0.049 respectively, Fig 1). Conclusion(s) Heart failure is frequent in MI patients with anemia (nearly half of the patients) and is associated with higher risks of MACE and of HF. While no interaction was observed between HF and transfusion strategies on the primary outcome of MACE, a liberal transfusion strategy was associated with higher all-cause mortality than a restrictive strategy both at 30-days and 1 year. The mechanism of this interaction deserves further investigation.

Risk stratification in patients with structurally normal hearts: does fibrosis type matter?

Abstract Background The clinical relevance of tissue abnormalities identified by CMR in patients with structurally normal hearts remains unclear. Purpose The study sought to assess the prognostic significance of nonischemic myocardial fibrosis (MF) on cardiovascular magnetic resonance (CMR) – both macroscopic MF assessed by late gadolinium enhancement (LGE) and diffuse microscopic MF quantified by extracellular volume fraction (ECV) – in patients with structurally normal hearts. Methods Consecutive patients undergoing CMR were screened for inclusion to identify those with LGE imaging and structurally normal hearts. ECV was calculated in patients with available T1 mapping. The associations between myocardial fibrosis and the outcomes of all-cause mortality, new-onset heart failure [HF], and an arrhythmic outcome were evaluated. Results In total 525 patients (mean age 43.1±14.2 years; 30.5% males) were included. Over a median follow-up of 5.8 years, 13 (2.5%) patients died and 18 (3.4%) developed new-onset HF. Nonischemic midwall (Figure 1B-C)/subepicardial LGE (Figure 1D) was present in 278 (52.9%) patients; isolated RV insertion fibrosis was present in 80 (15.2%) patients (Figure 1A). In 276 patients with available T1 mapping, the mean ECV was 25.5 ± 4.4%. There was no significant association between LGE and all-cause mortality (HR: 1.36, CI: 0.42-4.42, p=0.61), or new-onset HF (HR: 0.64, CI: 0.25-1.61, p=0.34). ECV (per 1% increase) correlated with all-cause mortality (HR: 1.19, CI: 1.04-1.36, p=0.009), but not with new-onset HF (HR: 0.97, CI: 0.86-1.10, p=0.66)(Figure 2). There was no significant association between arrhythmic outcomes and LGE (p=0.60) or ECV (p=0.49). In a multivariable model after adjusting for covariates, ECV remained significantly associated with all-cause mortality (HR per 1% increase in ECV: 1.26, CI: 1.06-1.50, p=0.009). Conclusion Nonischemic LGE in patients with structurally normal hearts is common and does not appear to be associated with adverse outcomes, whereas elevated ECV is associated with all-cause mortality and may be an important risk stratification tool.

Right ventricular dysfunction after therapy titration, but not at the time of index hospitalization, predicts prognosis in patients with new-onset acute heart failure

Abstract Introduction and aims The prognostic implications of right ventricular dysfunction (RVD) in patients with left ventricular (LV) disease has gained more attention over the last years. However, the role of RV function in new-onset acute heart failure (NoAHF) has only recently come into focus. The description of RVD is often confined to its longitudinal function. In the present study of patients with NoAHF, we aimed at (I) comparing the prognostic ability of RV longitudinal function with a novel echocardiographic RVD score and (II) to test the hypothesis that RVD conveys more prognostic information if it persists after titration of heart failure therapy. Methods Patients aged 18 to 70 years, admitted between 2015 and 2018 to a tertiary center with NoAHF were retrospectively included, provided that they did not have previous heart failure diagnosis or therapy and that complete echocardiograms were available at the time of index hospital admission and after titration of heart failure therapy. The RVD score allocates one point each for tricuspid annular plane systolic excursion (TAPSE) &amp;lt;17 mm (longitudinal dysfunction), right ventricular diastolic area index &amp;gt;11.5 (women) or &amp;gt;12.6 cm2/m2 (men) (RV dilatation), ≥moderate tricuspid regurgitation (RV deformation) and vena cava inferior collapsibility &amp;lt;50% (increased right atrial pressure). An RVD score ≥2 was defined as significant RVD. Patients were followed for the composite endpoint of death from all causes, heart transplantation or implantation of LV assist device until September 2022. Results Two-hundred and ten patients were followed for a median of 60 months. At index hospitalization, LV ejection fraction (LVEF) was 28±10%, TAPSE was 16±4 mm and 36% of the patients had a RVD score ≥2. Eighty-eight percent of the patients had LVEF&amp;lt;40%. At the end of the follow-up, 53 (25%) patients met the endpoint. At index hospitalization, there were no significant differences in any echocardiographic parameters between patients meeting and not meeting the endpoint. After titration of heart failure therapy, there were significant differences in LVEF (33% vs 46%, P&amp;lt;0.001), TAPSE (16 vs 19 mm, P = 0.001) and the proportion of patients with RVD score ≥2 (4% vs 36%, P&amp;lt;0.001). Figure 1 and 2 show Kaplan-Meier curves for survival free of composite endpoint in patients with and without RVD despite therapy titration, defined as TAPSE &amp;lt;17 mm or as RVD score ≥2. The unadjusted hazard ratio (95% CI) for TAPSE was 2.5 (1.5-4.4) and for RVD score 7.9 (4.4-14.0). Conclusions At index hospitalization, neither LVEF nor RV function can predict the prognosis in patients with NoAHF. However, the persistence or onset of RV dysfunction after titration of heart failure therapy does. A multiparametric echocardiographic RVD score might provide improved prognostic stratification when compared to TAPSE.Kaplan-Meier, TAPSE≥17mm vs &amp;lt;17mmKaplan-Meier, RVDS&amp;lt;2 vs ≥2

The effect of sodium-glucose co-transporter-2 inhibitors following anterior ST-segment elevation myocardial infarction

Abstract Background Sodium-glucose co-transporter-2 (SGLT-2) inhibitors have been clearly demonstrated to be associated with lower rate of new-onset heart failure(HF) in patients under risk of HF. In addition, due to lower rehospitalisation and better functional status in HF patients, SGLT-2 inhibitors have became the cornerstone of treatment regardless of the diabetes status. New-onset HF is very common in survivors of anterior ST-segment elevation myocardial infarction(STEMI) and requires preventive strategies, however the role of SGLT-2 inhibition in this population is not well established yet. Purpose In this study, we aimed to demonstrate the role of the SGLT-2 inhibitors in patients with anterior STEMI. Methods We prospectively enrolled patients with diabetes mellitus who had anterior STEMI, which was managed with primary percutaneous coronary intervention. Patients with previous myocardial infarction, heart failure, under SGLT-2 inhibitor treatment and chronic kidney disease were excluded. Patients were divided into two groups according to SGLT-2 inhibitor treatment; group 1 patients treated with empaglifosine or dapaglifosine and group 2 received other classes of diabetes medicine. Comorbidities regarding smoking history (p: 0.871), hypertension (p: 0.064), previous cerebrovascular accident(p: 0,348) and coronary artery disease(p: 0.201) were comparable between groups. Presence of multivessel coronary artery disease (p: 0.259) and left main coronary artery involvement (p: 0.062) were also similar between groups. Glucose level on admission was similar (p: 0.782) between groups, however HBa1C level was significantly higher in group 1(p: &amp;lt;0.001). Left ventricular ejection fraction which was calculated prior to hospital discharge was also similar between groups(p: 0.297). Mean follow-up duration was 12 months and new-onset heart failure was significantly lower in group 1 patients(p:&amp;lt;0.001). In line with the rate of new onset-heart failure, pro-BNP levels at the 12th month visit were lower in group 1 patients (p: 0.042) which was similar during the STEMI hospitalization (p: 0.668). Multivariate analyses demonstrated that the use of SGLT-2 inhibitors independently associated with lower rate of new-onset HF. Conclusion Our results indicate that SGLT-2 inhibitors decrease the rate of new-onset heart failure during the follow-up in patients with previous myocardial infarction.Baseline characteristicsUnivariate and multivariate analysis

Improved heart failure screening and prevention in type 2 diabetes mellitus by cardiologist in rural areas

Abstract Purpose Guidelines recommend screening in type 2 diabetes mellitus (T2DM) for unrecognised asymptomatic left ventricular systolic dysfunction (LVSD), reduced (HFrEF), mid-range (HFmrEF) or preserved (HFpEF) heart failure (HF) with periodic evaluation of natriuretic peptides (NTproBNP) or echocardiography (echo). Tissue doppler and speckle-tracking echo may be needed to facilitate HF diagnosis at earlier, more treatable stage. Methods 2185 consecutive asymptomatic T2DM (age 62 ±4 years, 62% women) patients (pts) were referred from January 2015 by rural diabetologists (dia) to echolab with elevated NTproBNP (&amp;gt;125 pg/mL) or 5-year HF risk score WATCH-DM ≥14 points. After exclusion of abnormal electrocardiogram or chest x-ray and significant valvular heart disease was compared continued usual care by diabetologist with randomly assigned prospective follow-up by regional cardiologist. Results At referral in both groups were similar baseline characteristics, 20% pts were treated with ACE-inhibitor (ACEi), 2% beta-blockers (BB). After cardiologist consultation ACEi and BB use increased significantly to 96% and 84% in both groups (all p &amp;lt;0.001). Global LVSD (EF≤50%) was detected in 8% at baseline and 29% pts after 5 years in diabetologist group, respectively 9% at baseline and 13% after 5 years in cardiologist group (p &amp;lt;0.001). Systolic dysfunction (S’≤6.0 cm/s) occured in 20% at baseline and 41% pts after 5 years in dia group, respectively 19% at baseline and 24% after 5 years in cardiologist group (p &amp;lt;0.001). Reduced global longitudinal (GLS&amp;lt;16%) observed in 26% at baseline and 59% pts after 5 years in dia group, respectively 26% at baseline and 36% after 5 years in cardiologist group (p &amp;lt;0.001). At baseline we found 1% pts with new-onset HF in both groups (only HFmrEF). After mean follow-up of 54 ±7 months in cardiologist group developed new HF in 4% pts (2% HFmrEF, 2% HFpEF) compared with 25% pts (3% HFrEF, 7% HFmrEF, 15% HFpEF) in diabetologist group (p &amp;lt;0.001). Significant (p &amp;lt;0.001) predictors of incident HFmrEF were systolic dysfunction (S’≤6.0 cm/s), hazard ratio (HR) 3.6, 95% CI 2.96-4.2) and reduced GLS (HR 4.6, 95% CI 3.8-5.2), all p &amp;lt;0.01. The strongest (p &amp;lt;0.001) predictors of incident HFpEF were new-onset atrial fibrillation (HR 2.5, 95% CI 1.2-3.7) and echo-detected left ventricular hypertrophy (septal and posterior wall thickness ≥13 mm, HR 1.7, 95% CI 1.2-2.1), all p &amp;lt;0.01. Conclusions For preventing HF progression is required additional research focused on cooperative care between diabetologists and specialised HF outpatient clinic.

Association between obstructive sleep apnea and heart failure in patients with and without obesity: a population-based cohort study

Abstract Background Obstructive sleep apnea (OSA) is a prevalent disorder characterized by partial or complete airway collapse during sleep, which often leads to sleep disruption and intermittent hypoxia. Previous research has suggested that patients with heart failure (HF) are more likely to have OSA. However, not enough evidence is available for association between new-onset OSA and HF. A recent Danish cohort study found that OSA, without continuous positive airway pressure therapy, is linked to a higher risk of HF across all age groups (1). In addition, the association between OSA and HF in patients with and without obesity has not been extensively studied in a large Asian cohort. Purpose To investigate the association between obstructive sleep apnea (OSA) and heart failure (HF) in a large Asian cohort stratified by obesity, as defined by World Health Organization (WHO) criteria for the Asian population, in both patients with and without obesity. Methods Using a nationally representative cohort of Korean adults over 40 years old who underwent national health screening between 2009 and 2010 with no prior history of HF or cardiovascular disease, we identified OSA using outpatient visit records (ICD-10: G47.3). Participants were tracked from January 1, 2011 to December 31, 2019 for new HF events, death from HF or other causes, or the end of follow-up, whichever occurred first. A Cox proportional hazards model adjusted for sociodemographic factors, health status, health behavior, and family history of heart disease was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Obesity was defined as a body mass index greater than 25.0 kg/m2 based on WHO criteria for the Asian population. Results The final study population included 326,662 participants (32.7% of them were with obesity). Among obese patients, those with OSA had a higher risk of developing HF (HR=1.52; 95% CI: 1.07-2.19) than those without OSA. The association between OSA and HF was less pronounced in non-obese patients (HR=1.07; 95% CI: 0.65-1.78 for HF in patients with OSA compared to those without OSA) with a significant interaction between obesity and OSA-HF association (P-value for interaction&amp;lt;0.001). Conclusions Our findings suggest that OSA is linked to an increased risk of HF, particularly in obese patients. Further research is necessary to examine important clinical subgroups regarding prevention of HF in patients with OSA.

Predictive value of STEP-HF risk score in patients with ST-segment elevation myocardial infarction (Killip I) treated by primary percutaneous coronary intervention

Abstract Background New-onset heart failure (HF) during the first hospitalization was considered as an earlier indicator for poor prognosis in acute ST-segment elevation myocardial infarction (STEMI) without overt HF (Killip I). Purpose This study aims to develop a practical risk score to predict the in-hospital occurrence of new-onset HF and to evaluate its ability for prognosis. Methods The Chinese STEMI pPCI Registry is registered with ClinicalTrials.gov (NCT04996901). Within 24 h of symptom onset, 2940 STEMI patients with Killip class I on admission were treated by pPCI from five hospitals between January 2015 and January 2021; 1869 patients from three of the hospitals served as a derivation cohort, and 1071 from the other two hospitals constituted the external validation cohort. In-hospital HF was defined as Killip class ≥II at the first hospital presentation (8.7% in the derivation cohort vs. 14.3% in the validation cohort). Multivariable logistic regression was used to develop the in-hospital HF score. For 2-year following-up, all-cause mortality rate was estimated using the Cox regression analysis. Results Eight variables were independently associated with the development of in-hospital HF: age &amp;gt;65 years, previous atrial fibrillation, triple vessel lesion, anterior myocardial infarction, symptom onset-to-balloon time &amp;gt; 5 h, TIMI flow grade 0 before pPCI, neutrophil-to-lymphocyte ratio &amp;gt; 6.3 and aspartate aminotransferase &amp;gt; 65U/L on admission. STEP-HF score was created based on these 8 variables, and classified patients into three risk categories: low (0-3), intermediate (4-7), and high (≥8). Observed in-hospital HF rates were 3.47% (3.5%), 12.35% (8.34%), and 30.8% (17.05%) across the three risk categories, respectively in derivation (validation) cohort. The STEP-HF score demonstrated high discrimination (c-statistic of 0.705 in the derivation cohort, 0.656 in the validation cohort) and adequate calibration (Hosmer-Lemeshow goodness-of-fit test P values &amp;gt; 0.05) in both cohorts. After two-year follow up, 202 patients were lost to follow-up and finally a total of 2738 patients were included. 30-day all-cause mortality occurred in 0.13%, 0.66% and 1.71% of patients in low, intermediate and high risk group, respectively (p = 0.041). The association persisted during 1 year and 2 years of follow-up. Two-year all-cause mortality were 8 (1.03%), 32 (2.33%), and 37 (6.32%) for the low, intermediate, and high score groups, respectively (p&amp;lt;0.001). Receiver operating characteristic (ROC) analysis demonstrated the STEP-HF score can effectively predict all-cause mortality as compared with GRACE score for 30d, 1 year, and 2 years, respectively (STEP-HF: AUC 0.76, 0.71,0.68 vs. GRACE: AUC 0.75, 0.67, 0.67, p = 0.923, 0.202, 0.619, respectively). Conclusion The STEP-HF score can be used to predict prognosis in STEMI (Killip I) with pPCI. Higher scores are associated with higher in-hospital HF at first admission and all-cause mortality for long-term following up.