Noncardiac Comorbidities Research Articles

Cardiac and Noncardiac Disease Burden and Treatment Effect of Sacubitril/Valsartan: Insights From a Combined PARAGON-HF and PARADIGM-HF Analysis.

The net clinical benefit of cardiac disease-modifying drugs might be influenced by the interaction of different domains of disease burden. We assessed the relative contribution of cardiac, comorbid, and demographic factors in heart failure (HF) and how their interplay might influence HF prognosis and efficacy of sacubitril/valsartan across the spectrum of left ventricular ejection fraction. We combined data from 2 global trials that evaluated the efficacy of sacubitril/valsartan compared with a renin-angiotensin antagonist in symptomatic HF patients (PARADIGM-HF [Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor With an Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure; n=8399] and PARAGON-HF [Prospective Comparison of Angiotensin-Converting Enzyme Inhibitor With Angiotensin Receptors Blockers Global Outcomes in Heart Failure With Preserved Ejection Fraction; n=4796]). We decomposed the previously validated Meta-Analysis Global Group in Chronic Heart Failure risk score into cardiac (left ventricular ejection fraction, New York Heart Association class, blood pressure, time since HF diagnosis, HF medications), noncardiac comorbid (body mass index, creatinine, diabetes, chronic obstructive pulmonary disease, smoking), and demographic (age, gender) categories. Based on these domains, an index representing the balance of cardiac to noncardiac comorbid burden was created (cardiac-comorbid index). Clinical outcomes were time to first HF hospitalization or cardiovascular deaths and all-cause mortality. Higher scores of the cardiac domain were observed in PARADIGM-HF (10 [7-13] versus 5 [3-6], P<0.001) and higher scores of the demographic domain in PARAGON-HF (10 [8-13] versus 5 [2-9], P<0.001). In PARADIGM-HF, the contribution of the cardiac domain to clinical outcomes was greater than the noncardiac domain (P<0.001), while in PARAGON-HF the attributable risk of the comorbid and demographic categories predominated. Individual scores from each sub-domain were linearly associated with the risk of clinical outcomes (P<0.001). Beneficial effects of sacubitril/valsartan were observed in patients with preponderance of cardiac over noncardiac comorbid burden (cardiac-comorbid index >5 points), suggesting a significant treatment effect modification (interaction P<0.05 for both outcomes). Domains of disease burden are clinically relevant features that influence the prognosis and treatment of patients with HF. The therapeutic benefits of sacubitril/valsartan vary according to the balance of components of disease burden, across different ranges of left ventricular ejection fraction.

Care of patients with chronic heart failure: an interdisciplinary challenge

The diverse manifestations of heart failure led to complex treatment guidelines and care scenarios and therefore always require an integrated, multidisciplinary care approach. Patients with chronic heart failure suffer from a large number of cardiac and noncardiac comorbidities. For example, iron deficiency leads to decreased performance and exertional dyspnea and should be diagnosed. Psychological screening questionnaires should be used for the early detection of psychological comorbidities.ARNI and SGLT-inhibitors expand the pharmacotherapeutic possibilities and gain in importance. The constant development of diagnostic possibilities and therapeutic options must be implemented consistently into the care continuum in order to have a lasting effect. The challenge of interdisciplinary coordination can be significantly reduced through jointly agreed process logs (e. g. within the framework of integrated supply contracts or a Heart Failure Unit Network).

ADL and IADL Following Open-Heart Surgery: The Role of a Character Strength Factor and Preoperative Medical Comorbidities.

Open-heart surgery (OHS) is common in late life and is expected to improve functioning despite aging of OHS patients. Few studies have explored the influence of both psychosocial strength factors, metal health, and pre- and peri-OHS medical factors, including cardiac indices, on post-OHS functioning. This study explores the role of character strengths (e.g., hope and spirituality) in post-OHS activities of daily living (ADL) and instrumental ADL (IADL), along with cardiac indices used by all cardio-thoracic surgeons, after controlling for self-reported pre-OHS depression, quality of life indicators, and non-cardiac medical comorbidities. Three waves of interview data and cardiac/surgical indices in the Society of Thoracic Surgeon (STS) national database were collected for a cohort of 481 patients (age = 62 +, female 42%). Multiple linear regression was used to identify pre-OHS predictors of post-OHS functional status. ADL and IADL statuses after OHS were better among those who pursued pre-OHS positive spiritual/religious coping than those who did not. Outcomes were poorer for those reporting poor pre-OHS, higher numbers of medical comorbidities, and use of more post-OHS prayer for coping. Perfusion time, a proxy for surgical complexity, was associated with poor IADL only. Pre-OHS positive spiritual coping, a common coping means used among cardiac patients in medical crises, could have played a positive role in better post-OHS functional status during the post-OHS recovery month. Cardiac health providers should pay more attention to patient-centered character strengths and coping and non-cardiac conditions. More nuanced interdisciplinary research is necessary to identify mechanisms underlying these associations.

Knowledge and Practice of Incremental Hemodialysis: A Survey of Canadian Nephrologists.

Background:Incremental hemodialysis, a strategy to individualize dialysis prescription based on residual kidney function, may be associated with enhanced quality of life and decreased health care costs compared with conventional hemodialysis.Objective:We surveyed practicing Canadian nephrologists to assess knowledge, perceptions, and practice pattern on the use of incremental hemodialysis.Design/Setting:We distributed a cross-sectional, web-based survey. We asked about incremental hemodialysis prescribing practices, including frequency of prescription, clinical factors used to determine suitability for treatment, and barriers to implementation. The survey was conducted from September 21 to October 30, 2020.Participants:We distributed the survey to practicing Canadian nephrologists identified from a private membership list of the Canadian Society of Nephrology (CSN), as well as to nephrologists named on a publicly available national list of practicing Canadian nephrologists created from provincial College of Physician registries. These were samples of convenience.Methods:We conducted descriptive analysis of categorical data including frequencies for nominal variables and measures of central tendency (mean) and dispersion (standard deviation) for ordinal variables. We used chi-square analysis to identify association between participant and practice characteristics and their opinions and attitudes toward incremental dialysis. We used simple thematic analysis on free-text responses on questions regarding the prescription of incremental hemodialysis, focusing on age and baseline management of cardiac and noncardiac comorbidities.Results:The response rate was 35% (243/691). Most (138/211, 65%) of the participants prescribed incremental hemodialysis using an individualized approach at the nephrologist’s discretion. Most participants (200/203, 98%) did not report any policy for implementation. Residual urine output was identified as the most important factor for eligibility (112/172, 65%), followed by electrolyte stability (76/172, 44%) and patient goals of care (69/117, 40%). Most participants agreed that dialysis prescriptions should take residual kidney function into consideration; however, 74% of the participants disagreed with a statement that there was strong evidence supporting incremental hemodialysis. Barriers identified included patient safety, patient acceptance of dose escalation, and logistics of scheduling. Despite these barriers, 82% of participants felt that that incremental hemodialysis is feasible with their current resources and 78% agreed that with specific criteria, it is a safe option.Limitations:The generalizability of our study is limited by its response rate of 35%; however, this is comparable with typical response rates seen in electronic surveys. Most participants practice in an academic setting, which may have introduced bias to the results.Conclusions:Despite the perception of limited evidence and a lack of guidance on implementation, incremental hemodialysis is frequently practiced by Canadian nephrologists. Barriers to implementation were identified, highlighting the need for research to guide practice.

Treatment and Prognosis of Myocardial Infarction Outside Cardiology Departments.

Aim: Our aim was to investigate the characteristics, treatment and prognosis of patients with myocardial infarction (MI) treated outside a cardiology department (CD), compared with MI patients treated at a CD. Methods: A cohort of 1310 patients diagnosed with MI at eight Swedish hospitals in 2011 were included in this observational study. Patients were followed regarding all-cause mortality until 2018. Results: A total of 235 patients, exclusively treated outside CDs, were identified. These patients had more non-cardiac comorbidities, were older (mean age 83.7 vs. 73.1 years) and had less often type 1 MIs (33.2% vs. 74.2%), in comparison with the CD patients. Advanced age and an absence of chest pain were the strongest predictors of non-CD care. Only 3.8% of non-CD patients were investigated with coronary angiography and they were also prescribed secondary preventive pharmacological treatments to a lesser degree, with only 32.3% having statin therapy at discharge. The all-cause mortality was higher in non-CD patients, also after adjustment for baseline parameters, both at 30 days (hazard ratio (HR) 2.28; 95% confidence interval (CI) 1.62–3.22), one year (HR 1.82; 95% CI 1.39–2.36) and five years (HR 1.62; 95% CI 1.32–1.98). Conclusions: MI treatment outside CDs is associated with an adverse short- and long-term prognosis. An improved use of percutaneous coronary intervention (PCI) and secondary preventive pharmacological treatment might improve the long-term prognosis in these patients.

Comorbidity as a mediator of depression in adults with congenital heart disease: A population-based cohort study

The population of adults with congenital heart disease (CHD) has increased dramatically with a high prevalence of acquired cardiac and non-cardiac comorbidities. However, the relationship among congenital heart disease, physical comorbidities, and psychological health in this population is not well studied. The purpose of this study was to investigate (a) the association between adult congenital heart disease and the occurrence of depression and (b) whether physical comorbidities mediated the association between congenital heart disease and the occurrence of depression. This retrospective cohort study was followed from 1 January 2010-31 December 2013, based on the data from the National Health Insurance Research Database 2010 in Taiwan. We used mediation analysis in survival data to assess the mediated effect. The hazard ratios were adjusted by age, sex, area of residence, and estimated propensity scores. We recruited 2122 adult congenital heart disease patients and 8488 matched controls. Nearly half of patients diagnosed with simple congenital heart disease, 39.0% had complex congenital heart disease, and 11.2% had unclassified congenital heart disease. Adult congenital heart disease patients had a significantly higher risk of depression than matched controls (adjusted hazard ratio = 1.43 and 1.48, for all and complex congenital heart disease, respectively, p<0.05). Coronary artery disease and chronic obstructive pulmonary disease were the significant comorbidities mediating the relationship between adult congenital heart disease and depression, the proportions mediated by coronary artery disease or chronic obstructive pulmonary disease were 35.5% and 12.9%, respectively. Helping patients to prevent psychological and physical acquired disease is imperative. Coronary artery disease is a potent mediator between congenital heart disease and depression, especially for patients with complex congenital heart disease.

Surgical management of complete atrioventricular septal defect with tetralogy of Fallot: results from a national audit database

Abstract Background Complete atrioventricular septal defect (CAVSD) with tetralogy of Fallot (CAVSD-ToF) is an uncommon association, and the management is more difficult than for each lesion in isolation. Depending on the anatomy, clinical status and ventricular morphology, definitive repair is offered either as staged or single operation with few undergoing single or one and a half ventricle procedures. Currently available data are limited to single centre studies. Purpose We aim to use data from a national audit dataset to describe outcomes in the surgical management of CAVSD-ToF with data from the national audit. Methods All children with CAVSD and tetralogy of Fallot (including double outlet right ventricle and pulmonary atresia variants) undergoing the first cardiac procedure between 2000–2013 were included and all subsequent procedures extracted. Three treatment pathways were defined: definitive primary procedure (“primary complete repair”), staged repair or “unbalanced ventricles repair” (Glenn shunt or modified Fontan). Continuous data is expressed as median (range). Survival data obtained using the Kaplan Meier method and subgroup comparisons done using the log-rank test. Results A total of 125 patients were included, 50.4% male, first procedure at 150 (1–2770) days. Down syndrome was present in 79.4% (63/79 of those with reported non-cardiac comorbidities), while 8% (10/125) had heterotaxy syndrome. “Primary complete repair” was performed in 40% (n=50), at 319 (33–2770) days. Staged repair was undertaken in 28% (n=35), first palliation at 80 (1–733) days. An “unbalanced ventricles” approach was used in 16.8% (n=21), first procedure at 135 (1–1742) days). The other 15.2% (n=19), first procedure at 53 (range 1–436) days, had at least one palliation procedure, but no identifiable committed pathway. Survival at 5 years from the first procedure in “primary complete repair” compared to the remainder of the group is shown in the Figure. No significant differences in survival were found. Specifically in the “unbalanced ventricle repair” group, just 1 patient died during follow-up. A total of 85 patients (68%) achieved either primary or staged “complete repair”. Early mortality (30 day) after the “complete repair” was 6.6% (similar for both approaches, p=0.9). Survival at 5 years after “complete repair” was 82.7% (similar for both approaches, p=0.8). Freedom from any cardiac re-intervention at 5 years was 69.5% (77.6% after primary, 58.1% after staged repair, p=0.03). Conclusion Early-life mortality in this heterogeneous group of CAVSD-ToF remains high, even in patients receiving definitive “complete repair”. We found no survival differences in the medium term between primary repair and a palliation approach, but more cardiac re-interventions were undertaken after staged complete repair. Surprisingly good results were seen in the unbalanced ventricles group, but longer follow up is needed to examine their attrition and longer term outcome. Survival at 5 years by treatment option Funding Acknowledgement Type of funding source: None

Prevalence of Noncardiac Multimorbidity in Patients Admitted to Two Cardiac Intensive Care Units and Their Association with Mortality

BackgroundCurrent cardiac intensive care unit (CICU) practice has seen an increase in patient complexity, including an increase in noncardiac organ failure, critical care therapies, and comorbidities. We sought to describe the changing epidemiology of noncardiac multimorbidity in the CICU population. MethodsWe analyzed consecutive unique patient admissions to 2 geographically distant tertiary care CICUs (n = 16,390). We assessed for the prevalence of 0, 1, 2, and ≥3 noncardiac comorbidities (diabetes, chronic lung, liver, and kidney disease, cancer, and stroke/transient ischemic attack) and their associations with hospital and postdischarge 1-year mortality using multivariable logistic regression. ResultsThe prevalence of 0, 1, 2, and ≥3 noncardiac comorbidities was 37.7%, 31.4%, 19.9%, and 11.0%, respectively. Increasing noncardiac comorbidities were associated with a stepwise increase in mortality, length of stay, noncardiac indications for ICU admission, and increased utilization of critical care therapies. After multivariable adjustment, compared with those without noncardiac comorbidities, there was an increased hospital mortality for patients with 1 (odds ratio [OR] 1.30; 95% confidence interval [CI], 1.10-1.54, P = .002), 2 (OR 1.47; 95% CI, 1.22-1.77, P < .001), and ≥3 (OR 1.79; 95% CI, 1.44-2.22, P < .001) noncardiac comorbidities. Similar trends for each additional noncardiac comorbidity were seen for postdischarge 1-year mortality (P < .001, all). ConclusionsIn 2 large contemporary CICU populations, we found that noncardiac multimorbidity was highly prevalent and a strong predictor of short- and long-term adverse clinical outcomes. Further study is needed to define the best care pathways for CICU patients with acute cardiac illness complicated by noncardiac multimorbidity.

Non-cardiac Cause of Death And Organ Dysfunction Common Among Patients Admitted To The Cardiac Intensive Care Unit

Introduction Over the past decade, there has been an increase in the proportion of patients admitted to the cardiac intensive care unit (CICU) with non-cardiac comorbidities and admission diagnoses. However, organ system dysfunction and causes of death in CICU patients remains poorly characterized. Given the increasing proportion of admissions to the CICU for non-cardiac diagnoses, we hypothesized that there would be a substantial proportion of non-cardiac organ dysfunction and death due to non-cardiac causes. Methods We identified adult patients admitted to a CICU at a large tertiary care center (2015-2019) who died during the hospitalization. Principal hospitalization diagnosis, demographics, organ system dysfunctions, cause of death, and withdrawal of life support were abstracted via a standardized tool used in prior studies. The primary cause of death was defined as the organ system that most directly contributed to death or withdrawal of life support. Results We identified 258 decedents admitted to the CICU. Most patients (76%) had cardiac dysfunction, defined as cardiogenic shock or sustained ventricular arrhythmia. However, only 11% of patients had cardiac dysfunction alone, 89% experienced non-cardiac organ dysfunction, and 24% died without cardiac dysfunction. Multi-organ failure and sepsis were present in 70% and 54% of patients, respectively. The most common primary causes of death were cardiac (58%), pulmonary (15%), and neurologic dysfunction (11%). The majority of patients (76%) died after withdrawal of life-sustaining interventions. Conclusions In this contemporary cohort of CICU decedents, 3 of 4 patients had cardiogenic shock or sustained ventricular arrhythmias. However, non-cardiac organ dysfunction occurred in the vast majority, and nearly half had a non-cardiac primary cause of death. The high frequency of multi-organ failure and non-cardiac causes of death underscores the importance of broad cardiac and non-cardiac critical care training among physicians practicing in the CICU.

Existing Non-cardiac Comorbidities Negatively Impact Quality of Life Gains After Left Ventricular Assist Device Implant

IntroductionThe Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) collects quality of life data via Kansas City Cardiomyopathy Questionnaire (KCCQ-12) and Visual Analog Score (VAS). These data are collected pre- and post-LVAD implantation. Though previous studies have shown that overall health-related quality of life (HRQoL) improves at one year after implantation, specific factors that predict a higher quality of life have not been identified.HypothesisSelf-perceived quality of life after LVAD implant is influenced by demographics and preexisting comorbidities.MethodsWe identified 118 patients in the INTERMACS database who received a LVAD at our institution. Of these, 26 patients completed the KCCQ-12 questionnaire and 32 patients completed VAS at 1-year follow up. An exploratory data analysis was conducted using descriptive statistics, correlation tests, and non-parametric comparison tests such as Wilcoxon rank-sum to identify important trends and predictors for changes in HRQoL. Multiple variables (patient characteristics, clinical data) were tested independently against the KCCQ-12 and VAS scores at one year and with the absolute change in these scores over a one-year period. Due to low sample size, we were not able to perform a multivariate model.ResultsNew York Heart Association Class IV symptoms at baseline (p=0.01) were predictive of large gains in VAS scores at one year. Frailty, although not reaching significance, may be associated with smaller magnitudes of improvement in KCCQ at one year (p=0.067). The presence of peripheral vascular disease at pre-implant predicts a lower VAS score at one year (p=0.03). Demographic factors such as age, sex, and marital status at implant did not predict higher post implant quality of life by either VAS or KCCQ.ConclusionExisting non-cardiac comorbidities should be taken into consideration when assessing the health related quality of life benefit of LVAD implantation.

The relationship between coronary artery disease and clinical outcomes in COVID-19: a single-center retrospective analysis

Recent studies have reported evidence that coronavirus disease 2019 (COVID-19) has disproportionately affected patients with underlying comorbidities. Our study aims to evaluate the impact of both cardiac and noncardiac comorbidities on a high-risk population with COVID-19 infection and coronary artery disease (CAD) compared to those without CAD. This is a retrospective study of patients who tested COVID-19 positive via reverse transcriptase-PCR (RT-PCR) assay. We compared the characteristics and outcomes of patients with and without CAD. Population demographics, comorbidities and clinical outcomes were collected and analyzed. Multivariate logistic regression analysis was used to identify factors associated with inpatient mortality. A final sample population of 355 patients was identified, 77 of which had a known diagnosis of coronary artery disease. Our study population had a higher proportion of females, and those with CAD were significantly older. The rates of cardiovascular risk factors including hypertension, diabetes mellitus and chronic kidney disease, as well as heart failure and chronic obstructive pulmonary disease were significantly higher in the CAD population. Lactate dehydrogenase was the only inflammatory marker significantly lower in the CAD group, while troponin and brain natriuretic peptide were significantly higher in this population. Patients with CAD also had significantly higher inpatient mortality (31% vs 20%, P = 0.046) and need for renal replacement therapy (33% vs 11%, P < 0.0001) compared to the non-CAD group. However, only age [odds ratio 1.041 (1.017-1.066), P = 0.001] was significantly associated with mortality in the overall population after adjusting for demographics and comorbidities, while the presence of CAD was not independently associated with mortality. Patients with CAD and COVID-19 have higher rates of comorbidities, inpatient mortality and need for renal replacement therapy compared to their non-CAD counterparts. However, CAD in itself was not associated with mortality after adjusting for other covariates, suggesting that other factors may play a larger role in the increased mortality and poor outcomes in these patients.

Heart Failure With Preserved Ejection Fraction: A Problem Of Contemporary Cardiology

Heart failure with preserved ejection fraction (HFpEF) is a frequent and overlooked medical condition that represents a great challenge for diagnosis and treatment. Current data shows a temporal trend towards a higher prevalence of HFpEF, even above heart failure with reduced ejection fraction (HFrEF). The pathophysiology of HFpEF is heterogeneous and involves several factors such as genetics, lifestyle, and cardiac and non-cardiac comorbidities. These factors result in remodeling, maladaptation and cardiac stiffness, that later on cause dyspnea, exercise intolerance, and fatigue. Although the mortality outcome of HFpEF is as high as HFrEF, no specific therapy has demonstrated overall benefit in these patients; which is why future therapies will bet on an individualized approach according to the patients phenotype.

Incidence of arrhythmias and electrocardiographic abnormalities in symptomatic pediatric patients with PCR-positive SARS-CoV-2 infection, including drug-induced changes in the corrected QT interval

BackgroundThere is limited data regarding the electrophysiological abnormalities and arrhythmias in children with COVID-19, including those associated with treatment using potentially proarrhythmic hydroxychloroquine (HCQ) and azithromycin (AZN).ObjectivesTo describe the electrophysiologic findings and arrhythmias associated with pediatric COVID-19 and its treatment.MethodsA single-center retrospective chart review was undertaken and included all patients with (1) symptoms of COVID-19 and (2) PCR-positive nasopharyngeal swabs for SARS-CoV-2 who were placed on continuous telemetry for the duration of their hospitalization during March through May, 2020.ResultsThirty-six patients were included in the study. Significant arrhythmias were found in 6 (nonsustained ventricular tachycardia in 5 and sustained atrial tachycardia in 1). All were self-resolving and half prompted prophylactic antiarrhythmic therapy. Patients with significant arrhythmias were likely to have noncardiac comorbidities (4/6), but these were not more common than in patients without arrhythmias (20/30, P = 1). The use of HCQ was associated with statistically significant QTc prolongation (413 ± 19 ms vs 425 ± 16 ms, P =.005). QTc was not statistically different in patients with and without arrhythmias (425 ± 15 ms vs 425 ± 15 ms, P = 1).ConclusionsIn pediatric patients with PCR-positive active COVID-19 infection, significant arrhythmias are infrequent, but are more common than expected in a general pediatric population. Comorbidities are not more common in patients with arrhythmias than in patients without arrhythmias. COVID-19 treatment using HCQ is associated with QTc prolongation but was not associated with arrhythmias in pediatric patients.

In-hospital and long-term mortality for acute heart failure: analysis at the time of admission to the emergency department.

AimsAcute heart failure (AHF) leads to a drastic increase in mortality and rehospitalization. The aim of the study was to identify prognostic variables in a real‐life population of AHF patients admitted to the emergency department with acute shortness of breath.Methods and resultsWe evaluated potential predictors of mortality in 728 consecutive patients admitted to the emergency department with AHF. Possible predictors of all‐cause and cardiovascular (CV) mortality were investigated by Cox and Fine and Gray models at multivariable analysis. Among the 728 patients, 256 died during the entire follow‐up, 142 of these due to CV cause. The 1 year mortality rate was 20%, with the highest risk of death during the index hospitalization (with 8% estimate in‐hospital mortality at 30 days). A higher risk of events during the index hospitalization was more evident for the CV deaths, for which we found a cumulative 1 year incidence of 12% with a cumulative incidence in the first 30 days of hospitalization of about 5%. At multivariable analysis, age (P < 0.001), New York Heart Association (NYHA) class IV vs. I–II–III (P = 0.001), systolic blood pressure (P < 0.001), non‐cardiac co‐morbidities (≥3 vs. 0, P = 0.05), oxygen saturation (P = 0.03), serum creatinine (P < 0.001), and left ventricular ejection fraction (LVEF) (40–49% vs. <40%, P = 0.004; ≥50% vs. <40%, P = 0.003) were independent predictors of all‐cause mortality during the entire follow‐up. Age (P = 0.03), systolic blood pressure (P = 0.01), oxygen saturation (P = 0.03), serum creatinine (P = 0.02), and LVEF (40–49% vs. <40%, P = 0.03; ≥50% vs. <40%, P = 0.004) were independent predictors of CV mortality during the entire follow‐up. NYHA class IV vs. I–II–III (P < 0.001), serum creatinine (P = 0.01), and LVEF (40–49% vs. <40%, P = 0.02; ≥50% vs. <40%, P < 0.001) remained independent predictors for in‐hospital death, while only serum creatinine (P = 0.04), LVEF (40–49% vs. <40%: 0.32, P = 0.04; ≥50% vs. <40%, P < 0.001), and NYHA class vs. I–II–III (P = 0.02) remained predictors for in‐hospital CV mortality.ConclusionsIn this real‐life cohort of patients with AHF, the results showed a similar mortality rate comparing with other analysis and with the most important registries. Age, NYHA class IV, systolic blood pressure, creatinine levels, sodium levels, and ejection fraction were independent predictors of 1 year mortality, while LVEF <40% was the only predictor of both all‐cause mortality and CV mortality.

Outcomes of truncus arteriosus repair and predictors of mortality.

The objective of this study was to identify patient and hospitalization characteristics associated with in-hospital mortality in infants with truncus arteriosus. We conducted a retrospective analysis of a large administrative database, the National Inpatient Sample data set of the Healthcare Cost and Utilization Project for the years 2002 to 2017. We also sought to evaluate the resource utilization in the subgroup of subjects with truncus arteriosus and 22q11.2 deletion syndrome. Neonates with truncus arteriosus were identified by ICD-9 and ICD-10 codes. Hospital and patient factors associated with inpatient mortality were analyzed. Overall, 3009 neonates met inclusion criteria; a total of 326 patients died during the hospitalization (10.8%). Extracorporeal membrane oxygenation utilization was 7.1%. Univariate and multivariate logistic regression analyses were used to identify risk factors for in-hospital mortality. Significant risk factors for mortality were prematurity (adjusted odds ratio [aOR] = 2.43; 95% confidence interval [CI]: 1.40-4.22; P = .002), diagnosis of stroke (aOR = 26.2; 95% CI: 10.1-68.1; P < .001), necrotizing enterocolitis (aOR = 3.10; 95% CI: 1.24-7.74; P = .015) and presence of venous thrombosis (aOR = 13.5; 95% CI: 6.7-27.2; P < .001). Patients who received extracorporeal membrane oxygenation support or had cardiac catheterization procedure during the hospitalization had increased odds of mortality (aOR = 82.0; 95% CI: 44.5-151.4; P < .001, and aOR = 1.65; 95% CI: 0.98-2.77; P = .060, respectively). 22q11.2 deletion syndrome was associated with an inverse risk of death despite having more noncardiac comorbidities; this patient subpopulation also had a higher length of stay and increased cost of hospitalization.

June 2020 at a glance: focus on COVID-19, quality of life and comorbidities.

Patients with heart failure (HF) are at increased risk of infections, and infections may precipitate acute HF and be a major cause of morbidity and mortality.1, 2 These threatening relationships have been magnified by the recent coronavirus disease 2019 (COVID-19) pandemic. Management of HF patients with concomitant COVID-19 is a major challenge. To support HF specialists in this difficult task, the Chinese HF Association and National HF Committee and the HF Association of the European Society of Cardiology developed a joint position paper summarizing current literature and clinical experience to give all possible guidance for the management of patients with HF and COVID-19 in clinical practice.3 The peculiar aspects of COVID-19 were integrated with the most recent findings for HF treatment.3, 4 The renin–angiotensin system has a pivotal role in HF.5 The angiotensin converting enzyme 2 (ACE2) is the receptor for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It was hypothesized that it may be upregulated by angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) treatment. Tomasoni et al.6 reviewed the relationships between HF and COVID-19 and the role of ACE2 and ACEi/ARB treatment in the pathophysiology and outcome of COVID-19 showing the lack of data supporting an untoward role of these drugs in COVID-19. Consistently, Bean et al.7 analysed a large series of HF patients hospitalized for COVID-19 and found a 37% reduction in the risk of death or need for transfer to a critical care unit in patients on ACEi or ARB, thus supporting the recommendation to continue treatment with these drugs also during the COVID-19 pandemic. The COVID-19 pandemic was associated with a dramatic decrease in the number of hospital admissions for acute cardiac emergencies.8 Also admissions for acute HF decreased during the COVID-19 outbreak despite no differences in HF severity, patients' care and pharmacological management compared with before.9 Telemonitoring therefore appears as the best solution for patients' follow-up.3 To date, patients' selection for telemonitoring has been difficult and use of natriuretic peptides was proposed.10 Galinier et al.11 report the results of a randomized, multicentre, open-label study investigating the role of telemedicine, compared to standard care, in preventing death or HF hospitalization (primary endpoint). The advantage of telemonitoring vs. standard care was noted only in patients with New York Heart Association class III/IV and in those with high adherence to body weight measurements. Quality of life (QOL) has become a major endpoint for HF studies.12-14 Butler et al.15 evaluated the association between changes in QOL scores and clinical improvement perceived by the patient, defined as minimal clinically important difference (MCID), in patients with chronic HF and iron deficiency treated with intravenous iron or placebo. They found that QOL scores were consistent although lower than MCID changes, suggesting that even small changes in QOL scores are clinically significant. Reddy et al.16 investigated the association of QOL reported by patients with HF and preserved ejection fraction (HFpEF) and HF severity defined according to aerobic capacity, exercise capacity, volume of daily activity, functional class, resting echocardiography, and plasma natriuretic peptide levels. QOL was found to be poorest in young, obese and diabetic patients. Poorer QOL was associated with worse physical capacity and activity levels, but was not associated with N-terminal pro B-type natriuretic peptide or echocardiographic parameters. Cardiac and non-cardiac comorbidities are associated with poor outcomes in HF patients.17, 18 Nevertheless, Khan et al.19 found that only 51% of HF with reduced ejection fraction (HFrEF) trials and 27% of HFpEF trials reported baseline comorbidities. The most common reported comorbidities were hypertension (63%), ischaemic heart disease (44%), hyperlipidaemia (48%), diabetes (33%), chronic kidney disease (25%) and atrial fibrillation (25%). Patients' heterogeneity is large in acute HF.20, 21 Bhatt et al.22 stratified 6945 patients with acute HF according to the number of non-cardiac comorbidities. The highest rate of all-cause death or HF hospitalization was observed in patients with four or more comorbidities. The relative risk of the composite endpoint increased with the number of comorbidities at both 30 days and 6 months. Higher comorbidity burden was associated with higher costs of care and length of stay.

Noncardiac comorbidity clustering in heart failure: an overlooked aspect with potential therapeutic door.

Heart failure is associated with a range of comorbidities that have the potential to impair both quality of life and clinical outcome. Unfortunately, noncardiac diseases are underrepresented in large randomized clinical trials, and their management remains poorly understood. In clinical practice, the prevalence of comorbidities in heart failure is high. Although the prognostic impact of comorbidities is well known, their prevalence and impact in specific heart failure settings have been overlooked. Many studies have described specific single noncardiac conditions, but few have examined their overall burden and grading in patients with multiple comorbidities. The risk of comorbidities in patients with heart failure rises with more advanced disease, older age, and increased frailty-three conditions that are poorly represented in clinical trials. The pathogenic links between comorbidities and heart failure involve many pathways and include neurohormonal overdrive, inflammatory activation, oxidative stress, and endothelial dysfunction. Such interactions may worsen prognoses, but details of these relationships are still under investigation. We propose a shift from cardiac-focused care to a more systemic approach that considers all noncardiac diseases and related medications. Some new drugs class such as ARNI or SGLT2 inhibitors could change prognosis by acting directly or indirectly on metabolic disorders and related vascular consequences.

Comorbid Conditions and Health-Related Quality of Life in Ambulatory Heart Failure Patients: REVIVAL (Registry Evaluation of Vital Information for VADs in Ambulatory Life REVIVAL).

Patients with heart failure (HF) often have multiple chronic conditions that may impact health-related quality of life (HRQOL) despite HF therapy. We sought to determine the association between noncardiac comorbidities and HRQOL in ambulatory patients with advanced HF. Baseline data from 373 subjects in REVIVAL (Registry Evaluation of Vital Information for Ventricular Assist Devices in Ambulatory Life) were analyzed using multivariable general linear models to evaluate the relationship between comorbidities and HRQOL (EuroQol Visual Analogue Scale, EQ-5D-3L Index Score, and Kansas City Cardiomyopathy Questionnaire). The primary independent variables were a comorbidity index (sum of 14 noncardiac conditions), a residual comorbidity index (without depression), and depression alone. The median (25th to 75th percentile) number of comorbidities was 3 (2-4). Increasing comorbidity burden was associated with a reduction in generic (EQ-5D Index, P=0.005) and HF-specific (Kansas City Cardiomyopathy Questionnaire, P=0.001) HRQOL. The residual comorbidity index was not associated with HRQOL when depression included in the model independently, while depression was associated with HRQOL across all measures. Participants with depression (versus without) scored on average 13 points (95% CI, 8-17) lower on the EuroQol Visual Analogue Scale, 0.15 points (95% CI, 0.12-0.18) lower on the EQ-5D Index, and 24.9 points (95% CI, 21.2-28.5) lower on the Kansas City Cardiomyopathy Questionnaire overall summary score. While noncardiac comorbidities were prevalent in ambulatory advanced HF patients, only depression was associated with decreased generic and HF-specific HRQOL. Other than depression, the presence of noncardiac comorbidities should not impact expected gains in HRQOL following ventricular assist device implantation, provided the conditions are not a contraindication to implant. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01369407.

Fatores de riscos relacionados ao infarto agudo do miocárdio: revisão integrativa da literatura

Analisar evidencias cientificas, relacionado aos fatores de riscos para o ocorrência de Infarto do Miocárdio na literatura. Método: Trata-se de uma revisão integrativa da literatura realizada em bases de dados: LILACS, MEDLINE/PubMed, SCOPUS, BDENF e Web of Science, tendo como critérios de elegibilidade artigos de pesquisa publicados entre os anos de 2013 e 2017, nos idiomas português, inglês e espanhol, disponíveis na íntegra e que respondessem a questão norteadora, sendo selecionados nove artigos. Resultados: ao témino das buscas, nove artigos foram selecionados. Foram evidenciados como fatores de risco: diabetes mellitus, tabagismo e hipertensão arterial. Em contrapartida, a periodontite, o lúpus eritematoso sistêmico, a Doença do Refluxo Gastroesofágico, a menor secreção de melatonina, a depressão, a enxaqueca e os aspectos emocionais são fatores de risco relevantes. Conclusão: Atráves deste estudo sugere-se que as vítimas de infarto do miocárdio apresentam fatores de riscos análogos, por exemplo, diabetes mellitus, tabagismo e hipertensão arterial. Todavia, outros estudos apresentaram outras comorbidades cardíacas ou não cardíacas, como favoráveis ao desenvolvimento do infarto.

Managing Common Co-morbidities in Heart Failure

Heart failure increases in prevalence with age and is usually associated with various cardiac and non-cardiac comorbidities. For common coexisting conditions such as renal dysfunction, anemia and type 2 diabetes mellitus, important pathophysiologic links have been implicated between cardiac dysfunction and the underlying condition. Indeed, the number and severity of comorbidities in the setting of heart failure is an important driver of prognosis. By targeting the management of coexisting diseases, it may be possible to improve functional capacity, quality of life and perhaps even overall mortality in heart failure patients. Recent clinical trial data has provided insights into cardio-renal interactions in acute heart failure, the impact of iron replacement therapy in iron deficient heart failure patients, and the role of pharmacologic therapies to prevent heart failure related events in high risk patients with type 2 diabetes.