Outcome Of Heart Failure Hospitalization Research Articles

Management and outcomes of heart failure hospitalization among older adults in the United States and Japan.

Despite advances in therapies, the disease burden of heart failure (HF) has been rising globally. International comparisons of HF management and outcomes may reveal care patterns that improve outcomes. Accordingly, we examined clinical management and patient outcomes in older adults hospitalized for acute HF in the United States (US) and Japan. We identified patients aged >65 who were hospitalized for HF in 2013 using US Medicare data and the Japanese Registry of Acute Decompensated Heart Failure (JROADHF). We described patient characteristics, management, and healthcare utilization and compared outcomes using multivariable Cox regression during and after HF hospitalization. Among 11193 Japanese and 120289 US patients, age and sex distributions were similar, but US patients had higher comorbidity rates. The length of stay was longer in Japan (median 18 vs. 5days). While Medicare patients had higher use of implantable cardioverter defibrillator or cardiac resynchronization therapy during hospitalization (1.32% vs. 0.6%), Japanese patients were more likely to receive cardiovascular medications at discharge and to undergo cardiac rehabilitation within 3months of HF admission (31% vs. 1.6%). Physician follow-up within 30days was higher in Japan (77% vs. 57%). Cardiovascular readmission, cardiovascular mortality and all-cause mortality were 2.1-3.7 times higher in the US patients. The per-day cost of hospitalization was lower in Japan ($516 vs. $1323). We observed notable differences in the management, outcomes and costs of HF hospitalization between the USand Japan. Large differences in length of hospitalization, cardiac rehabilitation rate and outcomes warrant further research to determine the optimal length of stay and assess the benefits of inpatient cardiac rehabilitation to reduce rehospitalization and mortality.

The Efficacy and Safety of Sacubitril/Valsartan Compared to Valsartan in Patients with Heart Failure and Mildly Reduced and Preserved Ejection Fractions: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background: Sacubitril/valsartan improves heart failure (HF) outcomes in patients with heart failure with reduced ejection fraction (HFrEF). However, randomized controlled trials (RCTs) in patients with heart failure and mildly reduced ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF) have shown inconsistent results. We conducted this meta-analysis to comprehensively evaluate the efficacy and safety of sacubitril/valsartan compared to valsartan within this specific patient population. Methods: We searched the MEDLINE database and ClinicalTrials.gov and identified four RCTs that could be included in our analysis, with 3375 patients in the sacubitril/valsartan group and 3362 in the valsartan group. Results: Our study shows that, in patients with HFmrEF and HFpEF, sacubitril/valsartan was superior to valsartan in some of the key HF outcomes, such as the Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (KCCQ CSS), with a small but significant mean difference of 1.13 (95% confidence interval or CI of 0.15 to 2.11, p-value 0.024), an improvement in the New York Heart Association (NYHA) class (odds ratio or OR of 1.32, 95% CI 1.11 to 1.58, p-value 0.002), and the composite outcome of hospitalizations for HF and cardiovascular death, with a relative risk (RR) of 0.86 (95% CI 0.75 to 0.99, p-value 0.04). However, there was no additional benefit with sacubitril/valsartan compared to valsartan for the outcomes of cardiovascular death and all-cause mortality. In terms of side effects, sacubitril/valsartan was associated with a higher risk of hypotension when compared to valsartan (OR 1.67, 95% CI 1.27 to 2.19, p-value < 0.0001), but did not show an increased risk of hyperkalemia or worsening renal function. Conclusions: In individuals with HFmrEF or HFpEF, sacubitril/valsartan can result in improvements in the HF outcomes of the KCCQ CSS, the NYHA class, and the composite outcome of hospitalization for HF and cardiovascular death when compared to valsartan. While there was a higher risk of hypotension with sacubitril/valsartan compared to valsartan, there was no corresponding increase in the risk of hyperkalemia or worsening renal function.

Palliative Care Consultation And Outcomes Of Heart Failure Hospitalizations With Covid Infection During The 2020 Pandemic. Insight From The 2020 Nationwide Inpatient Sample Database

Palliative Care Consultation And Outcomes Of Heart Failure Hospitalizations With Covid Infection During The 2020 Pandemic. Insight From The 2020 Nationwide Inpatient Sample Database

Outcomes Of Heart Failure Hospitalization In Patients With Housing-related Problems: A Nationwide Analysis

Outcomes Of Heart Failure Hospitalization In Patients With Housing-related Problems: A Nationwide Analysis

Management and Outcomes of Acute Heart Failure Hospitalizations in Japan.

Heart failure (HF) is a global burden on healthcare systems, but the literature regarding nationwide trends in the care and outcomes of HF hospitalization in Japan is limited. Therefore, we aimed to investigate the trends in patient characteristics, treatment patterns, and outcomes of patients hospitalized with acute HF.Methods and Results: We used data from the Japanese Registry of All Cardiac and Vascular Diseases and the Diagnosis Procedure Combination database between April 2012 and March 2021 to analyze 840,357 patients aged ≥18 years who were hospitalized with an acute HF diagnosis. Over the study period (2012-2020), the mean (±standard deviation) age increased from 78.9 (±11.9) years to 80.9 (±11.8) years (P for trend <0.001), the proportion of female patients decreased from 48.7% to 47.5% (P for trend=0.02), crude in-hospital mortality rate decreased from 11.5% to 10.9%, and 30-day HF readmissions decreased from 7.4% to 7.0% (both P for trend <0.001). The reduction in outcomes was more apparent in the older age groups. The standardized outcomes demonstrated the same trends as the crude outcomes. Our nationwide hospital admission analysis clarified that patients hospitalized with acute HF were getting older, but mortality and readmission rates also decreased, especially in older patients during the 2010s.

Comorbidities and clinical response to cardiac resynchronization therapy: Patient-level meta-analysis from eight clinical trials.

Patients with heart failure usually have several other medical conditions that might alter the effects of interventions. We investigated whether the burden of comorbidity modified the clinical response to cardiac resynchronization therapy (CRT). Original patient-level data from eight randomized trials exploring the effects of CRT versus no CRT were pooled (BLOCK-HF, MIRACLE, MIRACLE-ICD, MIRACLE-ICD II, RAFT, COMPANION, MADIT-CRT and REVERSE). A prior history of the following comorbidities was considered: episodic or persistent atrial fibrillation (n = 920), coronary artery disease (n = 3732), diabetes (n = 2171), and hypertension (n = 3353). Patients were classified into three groups based on the number of comorbidities: 0, 1-2, or ≥3. The outcomes of interest were time to all-cause mortality and time to the composite outcome of heart failure hospitalization (HFH) or all-cause mortality. Outcomes were evaluated within each comorbidity group using a Bayesian hierarchical Weibull survival regression model. Of 6324 patients, 970 (15%) had no comorbidities, 4052 (64%) had 1-2 and 1302 (21%) had ≥3 comorbidities. The adjusted hazard ratio (aHR) for CRT versus no CRT for all-cause mortality in the overall cohort was 0.79 (95% credible interval [CI] 0.68-0.93) (p = 0.010); for no comorbidities the aHR was 0.54 (95% CI 0.34-0.86), for 1-2 comorbidities was 0.81 (95% CI 0.67-0.97) and for ≥3 comorbidities was 0.83 (95% CI 0.64-1.07) (no significant interaction between CRT and comorbidity burden: p = 0.13). For the endpoint of HFH or all-cause mortality, the aHR for the overall cohort was 0.74 (95% CI 0.65-0.84) (p = 0.001), for no comorbidities was 0.69 (95% CI 0.50-0.94), for 1-2 comorbidities was 0.77 (95% CI 0.66-0.90) and for ≥3 comorbidities was 0.68 (95% CI 0.55-0.82) (no significant interaction between CRT and comorbidity burden: p = 0.081). In a meta-analysis of patient-level data from eight major trials, the totality of evidence suggests that CRT reduces HFH and/or all-cause mortality even when several comorbid diseases are present. NCT00271154, NCT00251251, NCT00267098, NCT00180271.

Abstract P3102: Sex Differences In Outcomes Among Heart Failure Hospitalizations

Background: Both men and women have a comparable overall lifetime chance of developing heart failure, but there are clear sex differences in the nature of this condition that are both significant and yet underexplored. In this study, we investigate gender differences in clinical characteristics and in-hospital outcomes of heart failure hospitalizations using a large national database. Methods: This study is a retrospective analysis of National Inpatient Sample data, 2016-2019. Hospitalizations ≥41 years of age, admitted for heart failure were included in the study and stratified by sex. The outcomes of the study were in-hospital mortality rate, prolonged hospital length of stay, mechanical ventilation, mechanical circulatory support, vasopressors use, and adverse disposition. Propensity score matching with conditional logistic regression analysis was done to compare outcomes between males and females. Results: A total of 4,704,684 primary heart failure hospitalizations were included for the analysis. Of these 2,447,784 (52.0%) were males and 2,256,899 (48.0%) were females. In-hospital mortality ( P &lt;0.001), mechanical ventilation ( P &lt;0.001), mechanical circulatory support ( P &lt;0.001), and vasopressors use ( P &lt;0.001) were significantly lower among females, while prolonged length of stay ( P &lt;0.001) and disposition other than home ( P &lt;0.001) were higher among females. Conditional logistics regression analysis showed that females had significantly lower odds for mortality (aOR, 0.92, 95% CI: 0.89-0.94), mechanical ventilation (aOR, 0.89, 95% CI: 0.86-0.92), mechanical circulatory support (aOR, 0.54, 95% CI: 0.50-0.58), vasopressor use (aOR, 0.70, 95% CI: 0.66-0.74), and significantly higher odds for prolonged length of stay (aOR, 1.05, 95% CI: 1.04-1.06) and disposition other than home (aOR, 1.32, 95% CI: 1.31-1.34) Conclusion: Results of our study show that there are significant differences in outcomes between males and females hospitalized for heart failure. Further research is required to delineate how sex affects several aspects of heart failure, including epidemiology, risk factors, pathogenesis, response to medication, and eventually outcomes.

Association of Nondihydropyridine Calcium Channel Blockers Versus β-Adrenergic Receptor Blockers With Risk of Heart Failure Hospitalization

Heart failure (HF) with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) are interrelated and often coexisting conditions in older adults. Although equally recommended, nondihydropyridine calcium channel blockers (non-DHP CCBs), such as diltiazem and verapamil, are less often used than β blockers. Because recent studies suggested that β-blocker use in both HFpEF and AF may increase the risk for HF, we tested whether non-DHP CCBs were associated with lower HF hospitalization risk than β blockers. We examined fee-for-service Medicare beneficiaries who were aged ≥66years, had HFpEF or AF, and newly initiated a β blocker (n=83,458) or non-DHP CCB (n=18,924) from 2014 to 2018. The outcomes of HF hospitalization and all-cause mortality were analyzed using multivariable-adjusted Cox regression in the full cohort and, separately, in the subset without a recent hospital or skilled nursing discharge. Follow-up was analyzed using 2 frameworks: intention-to-treat and censored-at-drug-switch-or-discontinuation. There was a modestly protective association of non-DHP CCBs for the risk of HF hospitalization. Before drug switch or discontinuation, the use of diltiazem or verapamil was associated with decreased risk of HF hospitalization in the full cohort (hazard ratio [HR] 0.90, 95% confidence interval [CI] 0.81 to 1.00, p=0.05) and in the subgroup (HR 0.70, 95% CI 0.56 to 0.89, p=0.003). However, the association with all-cause mortality tended to favor β blockers, including in the intention-to-treat analysis (HR 1.21, 95% CI 1.17 to 1.25, p <0.001). In conclusion, compared with β blockers, the initiation of diltiazem or verapamil in patients with HFpEF or AF may be associated with fewer HF hospitalization events but also with more all-cause deaths.

Trends And Outcomes Of Heart Failure Hospitalizations During Covid 19 Pandemic In California

Trends And Outcomes Of Heart Failure Hospitalizations During Covid 19 Pandemic In California

Negative Predictive Value and Prognostic Associations of Rb-82 PET/CT with Myocardial Blood Flow in CAV

BackgroundInvasive coronary angiography (ICA) is the traditional screening modality for cardiac allograft vasculopathy (CAV). Positron emission tomography/computed tomography (PET/CT) scan with myocardial blood flow (MBF) quantification has emerged as a potential noninvasive alternative. ObjectivesThe aim of the study was to validate the diagnostic and prognostic value of a previously published algorithm for diagnosing CAV via PET/CT scans with MBF in a larger population. The study also sought to assess the downstream use of ICA when using PET/CT scanning as a screening modality. MethodsPatients with heart transplantation without prior revascularization who underwent PET/CT scans with MBF were identified retrospectively. The accuracy of the algorithm was assessed in patients who underwent PET/CT scanning within 1 year of ICA. The prognostic value was assessed via a composite outcome of heart failure hospitalization, myocardial infarction, retransplantation, and all-cause mortality. ResultsA total of 88 patients for the diagnostic portion and 401 patients for the prognostic portion were included. PET CAV 0 had high negative predictive value for moderate to severe CAV (97%) and PET CAV 2/3 had a high positive predictive value for moderate to severe CAV (68%) by ICA. The cohort was followed for a median of 1.2 (IQR: 1.0-1.8) years with 46 patients having an adverse event. The annualized event rates were 6.9%, 9.3%, and 30.8% for PET CAV 0, 1, and 2/3, respectively (P < 0.001). ConclusionsAn algorithm using PET/CT scanning with MBF demonstrates high a negative predictive value for CAV. PET CAV 2/3 is associated with a higher risk of adverse events and need for revascularization. PET/CT scanning with MBF is a reasonable alternative to ICA for screening for CAV.

Impact of right atrial enlargement on clinical outcome in patients with atrial fibrillation.

BackgroundLeft atrial (LA) remodeling is associated with adverse cardiovascular events, including heart failure (HF) and stroke in patients with atrial fibrillation (AF). However, there are limited data on the value of right atrial (RA) remodeling in this population. We investigated the prognostic role of RA enlargement in patients with non-valvular AF.Methods and resultsWe analyzed 254 consecutive patients (age = 69 ± 12years, male:female = 165:89, mean left ventricular ejection fraction = 58.0 ± 7.2%) with non-valvular AF who underwent two-dimensional echocardiography from a single center. RA and LA volumes were measured from apical views and indexed to the body surface areas (right atrial volume index [RAVI] and left atrial volume index [LAVI]) and RAVI > 30mL/m2 and LAVI > 34mL/m2 were considered as enlarged. The relationship between RA enlargement and composite clinical outcome of hospitalization for HF (HHF), stroke, systemic embolism, or death from any cause was assessed. Right atrial (RA) enlargement was associated with older age and more frequent prevalence of persistent or permanent AF. During a median follow-up of 47.1 months, 77 patients (30%) had experienced primary composite outcome. In a multivariable model, RA enlargement, but not LA enlargement, was independently associated with adverse clinical outcomes even after adjusting for clinical and echocardiographic factors {adjusted hazard ratio [HR], 1.90 [95% confidence interval (CI), 1.14–3.18], p = 0.014 for primary composite outcome; adjusted HR, 2.70 [95% CI, 1.27–5.67], p = 0.001 for HHF or all cause death}.ConclusionRA enlargement was independently associated with an increased risk of HF, stroke, systemic embolization or death in patients with non-valvular AF, suggesting that RA volume can be helpful in assessing future cardiovascular risk in this population.

Prognostic relevance of left atrial function and stiffness in heart failure with preserved ejection fraction patients with and without diabetes mellitus.

BackgroundAlthough the left atrium (LA) plays a key role in the pathophysiology and disease progression of heart failure with preserved ejection fraction (HFpEF), the impact of type 2 diabetes mellitus (T2DM) on LA function and stiffness in HFpEF patients remains unclear. Furthermore, the prognostic value of different phases of LA function and stiffness is less well-established in HFpEF patients.MethodsThis study prospectively enrolled 164 HFpEF patients who were in sinus rhythm at the time of echocardiography, including 61 (37%) HFpEF patients with T2DM. LA reservoir, conduit, and pump function were assessed using two-dimensional volume indices and speckle tracking echocardiography. The LA stiffness was calculated as the ratio of early mitral inflow velocity-to-early annular tissue velocity (E/e’) and LA reservoir function. The primary end point was a combined outcome of heart failure hospitalization or death.ResultsLeft atrium reservoir function [measured by peak LA strain (LAS-peak)] and LA pump function (measured by LAS-active) remained significantly lower in the HFpEF patients with T2DM compared with those without T2DM, even after adjustment for potential confounders. In addition, the LA stiffness of HFpEF patients with T2DM was higher than those without T2DM. After a median follow-up of 13.7 months, 46 patients (28.1%) reached the composite end point. LAS-peak (hazard ratios: 0.88; 95% confidence interval: 0.81–0.95; P = 0.001) was significantly associated with the risk of heart failure hospitalization or death after adjusting for demographic and clinical characteristics, LV global longitudinal strain, E/e’, and LA volume index. In contrast, other LA function and stiffness parameters did not independently predict the risk of adverse events. Kaplan-Meier analysis showed that HFpEF patients with T2DM and low LAS-peak (<27.2%) had a significantly increased risk of heart failure-related hospitalization or death (log-rank P < 0.001).ConclusionLeft atrium reservoir and pump function are impaired, whereas LA stiffness is increased in HFpEF patients with T2DM compared with those without T2DM. LAS-peak is a powerful predictor of adverse clinical outcomes and may be crucial for risk stratification in HFpEF patients with and without T2DM.

Targeting the latest site of left ventricular mechanical activation is associated with improved long-term outcomes for recipients of cardiac resynchronization therapy.

BackgroundPrevious studies have suggested that targeting the site of latest mechanical activation of the left ventricle (LV) results in improved cardiac resynchronization therapy (CRT) outcomes. It is not known whether these benefits are sustained over medium-term follow-up.ObjectiveTo assess the clinical outcome of imaging-guided LV lead position.MethodsWe sought to assess the medium-term clinical outcome by performing a patient-level meta-analysis of 2 previously published randomized controlled trials (the “STARTER” trial and the “CRT Clinic” trial). These 2 trials compared imaging-guided LV lead placement in the latest activated scar-free segment (intervention group) to standard of care (control). Mortality and heart failure hospitalization outcomes over extended follow-up were gathered from the medical records and merged. Results were stratified for native electrocardiogram (ECG) morphology.ResultsA total of 289 patients were followed for a median of 6.3 years. Seven years post implant, 47 (28%) in the intervention group had died, vs 47 (38%) in the control group (P = .13); 49 (30%) vs 53 (42%) had been hospitalized for heart failure (P = .035); and 47% vs 59% (P = .057) had reached the combined endpoint. In Kaplan-Meier analysis, patients in the intervention group had better survival free of heart failure hospitalization (P = .045) and lower risk of heart failure hospitalization (P = .019).ConclusionTargeting the latest mechanically activated segment in CRT results in better medium-term clinical outcome, mainly driven by a reduced risk of hospitalization for heart failure. The effect was seen regardless of native ECG morphology.

Cystatin C Predicts Adverse Outcomes In Heart Failure With Preserved Ejection Fraction

<h3>Background</h3> Serum creatinine (Cr) is used to estimate glomerular filtration rate (GFR). Cr levels vary with lean muscle mass and diet, confounding measurement of renal function. Cystatin C (CysC) is an alternative marker used to estimate GFR which is not subject to these sources of variability. In conditions where frailty and low muscle mass are common, such as heart failure with preserved ejection fraction (HFpEF), Cr may overestimate GFR, leading to under detection of renal disease. Chronic kidney disease (CKD) is a common co-morbidity in HFpEF and portends worse prognosis; however, there are currently minimal data on CysC in HFpEF. <h3>Methods</h3> Patients enrolled in the Johns Hopkins HFpEF Program from July 2014 to March 2020 were included for study. Patients underwent a comprehensive clinical evaluation and echocardiography. Estimated GFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations for Cr (CKD-EPIcr) and CysC (CKD-EPIcys). Distributions of GFR were compared with a Wilcoxon matched-pairs test. Trends in clinical and echocardiographic variables with CysC were assessed using multivariate linear regression. Cox proportional hazard models examined the association of CysC with the combined outcome of heart failure hospitalization and all-cause mortality. <h3>Results</h3> The study cohort included 190 patients. The average age was 64 years; 65% of patients were female and 59% were black. Median follow-up was 28 months. The median estimated GFR by CKD-EPIcr and CKD-EPIcys were 54.0 mL/min/1.73m² and 46.7 mL/min/1.73m², respectively (<b>Figure A and C;</b> z=3.81, p<0.001). As compared to CKD-EPIcr, CKD-EPIcys reclassified 74 patients (39% of cohort) to a higher stage of CKD (<b>Figure B and D</b>). CysC was significantly associated with greater left ventricular mass index (β =7.16 [0.23-14.01], p=0.043) and E/e' ratio (β=2.28 [0.33-4.22], p=0.022) after adjustment for GFR by CKD-EPIcr. CysC was predictive of the combined outcome in the univariate model and after adjustment for relevant medical comorbidities and estimated GFR by CKD-EPIcr (<b>Figure</b>). <h3>Conclusion</h3> In this prospective study, CysC estimated a lower median GFR in HFpEF patients as compared to Cr. CysC was predictive of worse diastolic function and adverse outcomes, even after accounting for GFR by CKD-EPIcr and relevant comorbidities. These results suggest CysC provides clinical and prognostic information beyond traditional Cr-based assessment of renal function in HFpEF. Further investigation of the use of CysC in clinical practice is warranted.

Target Vessel Versus Complete Revascularization in Non-ST Elevation Myocardial Infarction Without Cardiogenic Shock.

IntroductionThe role of complete revascularization (CR) vs target vessel revascularization (TVR) in non-ST-elevation myocardial infarction (NSTEMI) in patients without cardiogenic shock is still not established. In this study, we compared outcomes at one and six months among patients with NSTEMI with multivessel disease (MVD) undergoing CR vs TVR.MethodsIt was a prospective, observational study carried out among 60 NSTEMI patients with MVD (30 undergoing TVR and 30 CR) from October 2018 to November 2019. They were assessed at one and six months for primary and secondary outcomes.ResultsThe mean age of the patients was 56.13 ± 9.23 years and both the groups were well matched with respect to age, gender, risk factors, and comorbidities. In the majority of patients, the target vessel was left anterior descending (LAD) followed by right coronary artery (RCA) and left circumflex (LCX) in both groups. The primary outcomes of death from any cause, non-fatal myocardial infarction, and the need for revascularization of the ischemia-driven vessel showed no significant difference at one and six months follow-up between the CR and TVR groups. However, the secondary outcomes of heart failure hospitalizations and angina episodes were significantly more in the TVR group than CR group at one month (6 vs 1, P=0.044), (8 vs 2, P=0.038) and six months (8 vs 2, P=0.038), (9 vs 2, P=0.02), respectively.ConclusionCR was associated with no difference in death from all-cause or future revascularization but significantly lesser secondary outcomes of heart failure hospitalizations and angina episodes as compared to TVR in NSTEMI without cardiogenic shock.

Alirocumab after acute coronary syndrome in patients with a history of heart failure.

AimsPatients with heart failure (HF) have not been shown to benefit from statins. In a post hoc analysis, we evaluated outcomes in ODYSSEY OUTCOMES in patients with vs. without a history of HF randomized to the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor alirocumab or placebo.Methods and resultsAmong 18 924 patients with recent acute coronary syndrome (ACS) receiving intensive or maximum-tolerated statin treatment, the primary outcome of major adverse cardiovascular events (MACE) was compared in patients with or without a history of HF. The pre-specified secondary outcome of hospitalization for HF was also analysed. Overall, 2815 (14.9%) patients had a history of HF. Alirocumab reduced low-density lipoprotein cholesterol and lipoprotein(a) similarly in patients with or without HF. Overall, alirocumab reduced MACE compared with placebo [hazard ratio (HR): 0.85; 95% confidence interval (CI): 0.78–0.93; P = 0.0001]. This effect was observed among patients without a history of HF (HR: 0.78; 95% CI: 0.70–0.86; P < 0.0001), but not in those with a history of HF (HR: 1.17; 95% CI: 0.97–1.40; P = 0.10) (P interaction = 0.0001). Alirocumab did not reduce hospitalization for HF, overall or in patients with or without prior HF.ConclusionAlirocumab reduced MACE in patients without a history of HF but not in patients with a history of HF. Alirocumab did not reduce hospitalizations for HF in either group. Patients with a history of HF are a high-risk group that does not appear to benefit from PCSK9 inhibition after ACS.

Patient Characteristics and Outcomes of Type 2 Myocardial Infarction During Heart Failure Hospitalizations in the United States

BackgroundType 2 myocardial infarction (MI) is increasingly diagnosed in patients with heart failure (HF). A paucity of data exists pertinent to the contemporary prevalence and impact of type 2 MI in patients with HF. We studied the patient profiles and the prognostic impact of type 2 MI on outcomes of HF hospitalizations. MethodsThe Nationwide Readmission Database 2018 was queried for patients with HF hospitalizations with and without type 2 MI. Baseline characteristics, inpatient outcomes, and 30-day all-cause readmissions between both cohorts were compared. ResultsOf 1,072,674 primary HF hospitalizations included in the study, 28,813 (2.7%) had type 2 MI. Patients with type 2 MI were more likely to be males (56.5% vs 51.6%; P < .001) and had a higher prevalence of hypertension (94% vs 92.2%; P < .001), prior myocardial infarction (17.1% vs 14.9%; P < .001), anemia (9.1% vs 8.1%; P < .001), chronic kidney disease (55.7% vs 49.4%; P < .001), neurological disorders (9.4% vs 7.3%; P < .001), and weight loss (7.3% vs 5.6%; P < .001). Compared with their counterparts without type 2 MI, patients with HF with type 2 MI had significantly higher in-hospital mortality (adjusted odds ratio [aOR], 1.53; 95% confidence interval [CI], 1.37-1.72), hospital costs (adjusted parameter estimate, $1785; 95% CI, 1388-2182), discharge to nursing facility (aOR, 1.22; 95% CI, 1.15-1.29), longer length of stay (adjusted parameter estimate, 0.53; 95% CI, 0.42-0.64), and rate of 30-day all-cause readmissions (aOR, 1.06; 95% CI, 1.01-1.12). ConclusionType 2 MI in patients hospitalized with HF is associated with higher mortality and resource utilization in the United States.

Associations of obesity and malnutrition with cardiac remodeling and cardiovascular outcomes in Asian adults: A cohort study.

BackgroundObesity, a known risk factor for cardiovascular disease and heart failure (HF), is associated with adverse cardiac remodeling in the general population. Little is known about how nutritional status modifies the relationship between obesity and outcomes. We aimed to investigate the association of obesity and nutritional status with clinical characteristics, echocardiographic changes, and clinical outcomes in the general community.Methods and findingsWe examined 5,300 consecutive asymptomatic Asian participants who were prospectively recruited in a cardiovascular health screening program (mean age 49.6 ± 11.4 years, 64.8% male) between June 2009 to December 2012. Clinical and echocardiographic characteristics were described in participants, stratified by combined subgroups of obesity and nutritional status. Obesity was indexed by body mass index (BMI) (low, ≤25 kg/m2 [lean]; high, >25 kg/m2 [obese]) (WHO-recommended Asian cutoffs). Nutritional status was defined primarily by serum albumin (SA) concentration (low, <45 g/L [malnourished]; high, ≥45 g/L [well-nourished]), and secondarily by the prognostic nutritional index (PNI) and Global Leadership Initiative on Malnutrition (GLIM) criteria. Cox proportional hazard models were used to examine a 1-year composite outcome of hospitalization for HF or all-cause mortality while adjusting for age, sex, and other clinical confounders. Our community-based cohort consisted of 2,096 (39.0%) lean–well-nourished (low BMI, high SA), 1,369 (25.8%) obese–well-nourished (high BMI, high SA), 1,154 (21.8%) lean–malnourished (low BMI, low SA), and 681 (12.8%) obese–malnourished (high BMI, low SA) individuals. Obese–malnourished participants were on average older (54.5 ± 11.4 years) and more often women (41%), with a higher mean waist circumference (91.7 ± 8.8 cm), the highest percentage of body fat (32%), and the highest prevalence of hypertension (32%), diabetes (12%), and history of cardiovascular disease (11%), compared to all other subgroups (all p < 0.001). N-terminal pro B-type natriuretic peptide (NT-proBNP) levels were substantially increased in the malnourished (versus well-nourished) groups, to a similar extent in lean (70.7 ± 177.3 versus 36.8 ± 40.4 pg/mL) and obese (73.1 ± 216.8 versus 33.2 ± 40.8 pg/mL) (p < 0.001 in both) participants. The obese–malnourished (high BMI, low SA) group also had greater left ventricular remodeling (left ventricular mass index, 44.2 ± 1.52 versus 33.8 ± 8.28 gm/m2; relative wall thickness 0.39 ± 0.05 versus 0.38 ± 0.06) and worse diastolic function (TDI-e′ 7.97 ± 2.16 versus 9.87 ± 2.47 cm/s; E/e′ 9.19 ± 3.01 versus 7.36 ± 2.31; left atrial volume index 19.5 ± 7.66 versus 14.9 ± 5.49 mL/m2) compared to the lean–well-nourished (low BMI, high SA) group, as well as all other subgroups (p < 0.001 for all). Over a median 3.6 years (interquartile range 2.5 to 4.8 years) of follow-up, the obese–malnourished group had the highest multivariable-adjusted risk of the composite outcome (hazard ratio [HR] 2.49, 95% CI 1.43 to 4.34, p = 0.001), followed by the lean–malnourished (HR 1.78, 95% CI 1.04 to 3.04, p = 0.034) and obese–well-nourished (HR 1.41, 95% CI 0.77 to 2.58, p = 0.27) groups (with lean–well-nourished group as reference). Results were similar when indexed by other anthropometric indices (waist circumference and body fat) and other measures of nutritional status (PNI and GLIM criteria). Potential selection bias and residual confounding were the main limitations of the study.ConclusionsIn our cohort study among asymptomatic community-based adults in Taiwan, we found that obese individuals with poor nutritional status have the highest comorbidity burden, the most adverse cardiac remodeling, and the least favorable composite outcome.

No prognostic benefit of multimodality imaging-guided left ventricular lead placement in cardiac resynchronization therapy: Long-term follow-up of the ImagingCRT study

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Aarhus University, the Danish Heart Foundation, Health Research Foundation of Central Denmark Region, and Gangstedfonden. Background Observational data indicate that left ventricular (LV) lead placement at the latest contracting region and separate from myocardial scar is associated with improved prognosis in cardiac resynchronization therapy (CRT). In a double-blinded, randomized controlled trial (ImagingCRT), we tested the strategy of multimodality imaging-guided LV lead placement towards the latest mechanically activated non-scarred myocardial segment in CRT. Patients were included between 2011 and 2014 and allocated either to (1) imaging-guided LV lead placement using cardiac computed tomography, 99mTechnetium myocardial perfusion imaging, and speckle-tracking echocardiography (imaging group, n = 89) or to (2) routine LV lead implantation in a posterolateral region with late electrical activation (control group, n = 93). The multimodality imaging-guided strategy was found to reduce proportion of non-responders to CRT after 6 months. Impact on long-term clinical outcome is unknown. Purpose To evaluate the long-term effect of individualized multimodality imaging-guided LV lead placement compared to a routine fluoroscopic approach on the composite endpoint of death or heart failure (HF) hospitalization after CRT. Method We reviewed follow-up data until November 2020 for all 182 patients included in the ImagingCRT trial for the occurrence of HF hospitalization and all-cause death. Continuous variables are presented as median (interquartile range) or mean ± standard deviation. We used Kaplan-Meier plot and Cox proportional hazard regression analysis (unadjusted) to assess the risk of HF hospitalization and all-cause death, and used log-rank test for comparison between the two groups. Results All patients had standard CRT indication (left bundle branch block, New York Heart Association functional class II/ III/ IV 84 [46%]/ 92 [51%]/ 6 [3%], LV ejection fraction 25 ± 6%, QRS width 166 ± 22 milliseconds). Mean age was 70 ± 9 years, and 39 (21%) were female. During a median follow-up period of 6.7 years (3.3–7.9 years), the proportion of patients meeting the composite endpoint of HF hospitalization (n = 45 [25%]) or all-cause death (n = 56 [31%]) was 60% (n = 53) in the imaging group compared with 52% (n = 48) in the control group (hazard ratio [HR] 1.22, 95% confidence interval [CI] 0.83–1.81, p = 0.31) (Figure 1). Neither the risk of HF hospitalization (HR 1.11, 95% CI 0.62–1.99, p = 0.72) or of all-cause death differed between the two groups (HR 1.23, 95% CI 0.82–1.85, p = 0.32). Conclusion An individualized multimodality imaging-guided strategy targeting LV lead placement towards the latest mechanically activated non-scarred myocardial segment during CRT implantation did not reduce the composite outcome of HF hospitalization or all-cause death during long-term follow-up. Abstract Figure 1

Impact of Canagliflozin in Patients with Type 2 Diabetes after Hospitalization for Acute Heart Failure: A Cohort Study.

Background: Heart failure (HF) is one of the mayor contributors to cardiovascular morbidity and mortality in patients with diabetes. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have demonstrated to reduce the risk of hospitalization for HF in patients with type 2 diabetes mellitus (T2D). We aimed to assess the risk for re-hospitalization in a cohort of patients hospitalized for HF according to whether or not they received canagliflozin at discharge, as well as changes in N-terminal pro–B-type natriuretic peptide (NT-ProBNP) concentration during follow-up. Methods: We conducted a retrospective longitudinal study at a tertiary centre including 102 consecutive T2D patients discharged for acute HF without contraindication for SGLT2 inhibitors. We compared adverse clinical events (HF rehospitalization and cardiovascular death) and NT-ProBNP changes according to canagliflozin prescription at discharge. Results: Among the 102 patients included, 45 patients (44.1%) were prescribed canagliflozin and the remaining 57 (55.9%) were not prescribed any SGLT2 inhibitors (control group). After a median follow-up of 22 months, 45 patients (44.1%) were hospitalized for HF. Most of the rehospitalizations occurred during the first year (37.3%). HF readmission at first year occurred in 10 patients (22.2%) in the canagliflozin group and 29 patients (49.1%) in the control group (hazard ratio (HR): 0.45; 95% confidence interval (CI): 0.21–0.96; p < 0.039). A composite outcome of hospitalization for HF or death from cardiovascular causes was lower in the canagliflozin group (37.8%) than in the control group (70.2%) (HR: 0.51; 95% CI: 0.27–0.95; p < 0.035). Analysis of NT-ProBNP concentration showed an interaction between canagliflozin therapy and follow-up time (p = 0.002). Conclusions: Canagliflozin therapy at discharge was associated with a lower risk of readmission for HF and a reduction in NT-ProBNP concentration in patients with diabetes after hospitalization for HF.