Outpatient Heart Failure Clinic Research Articles

Empowering patients with heart failure: a digital health solution improved self-care and metabolic outcomes in a randomized controlled trial

Abstract Background/Introduction Heart failure is a common cause of morbidity and mortality and poses a significant burden on patients and healthcare providers. Purpose The aim of the study was to evaluate whether a digital health program improves quality of life and clinical outcomes for patients with heart failure. Methods A single-center, randomized controlled trial (RCT) was conducted with patients receiving standard of care (SoC) at a heart failure outpatient clinic. Patients were randomized (1:1) to receive either SoC alone or SoC with an additional six-month digital health program. The program consisted of remote patient monitoring (RPM) with symptom tracking, disease-specific education, and lifestyle coaching, designed to empower patients with heart failure. After the main program concluded, a six-month maintenance program was initiated, consisting of recurrent educational materials, with reduced coaching- and RPM frequency. The primary endpoint was the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ-12) at six months. Secondary endpoints included the European Heart Failure Self-care Behaviour Scale-9 (EHFScB-9), 6-question heart failure knowledge questionnaire, and metabolic outcomes. Here we report on the Intention-to-Treat (ITT) population analysis for the primary and significant secondary endpoints at six and 12 months. Results The ITT included 175 participants, 86 in the program group and 89 in the control. Program group: mean age (SD) 64.7 (13.2), 66.3% male, 87.2% with NYHA stages I-II. Control group: mean age (SD) 66.2 (11.1) years, 69.7% male, 87.6% with NYHA stages I-II. Median compliance with RPM was 93% and in-app retention was 80% at six months. Results for primary and secondary endpoints are presented in Table 1 and Figure 1. No statistical difference was observed in the KCCQ score between groups at six or 12 months. The program group had statistically significant improvements in EHFScB-9 score at six and 12 months and in heart failure knowledge at 12 months compared to the control group. Metabolic outcomes: a significant difference in glucose levels was also observed between groups at six months, and in HbA1c and triglycerides levels at 12 months. Conclusions The difference between groups in the primary endpoint of heart failure symptoms and quality of life, as measured by the KCCQ-12, was not statistically significant. However, significant differences were observed in self-care behaviour and heart failure knowledge, as well as metabolic outcomes at six and 12 months, when compared with standard care alone. These findings, along with good retention and engagement, indicate the value to patients of digital health interventions in the management of heart failure.

Determinants of changes in peak oxygen consumption in patients with new onset heart failure

Abstract Background Patients with heart failure (HF) with reduced ejection fraction (HFrEF) have a high risk of mortality. Cardio-Pulmonary Exercise Test (CPET) assesses peak oxygen consumption (pVO2) which is considered a key predictor of mortality and morbidity in patients with HFrEF. Factors responsible for the changes in pVO2 could consequently be of interest, as optimizing these factors may improve prognosis and overall quality of life in patients with HFrEF. Purpose To investigate factors contributing to changes in pVO2 within a contemporary cohort of new-onset patients with HFrEF. Methods From December 2022 to September 2023, patients with new-onset HFrEF (European Society of Cardiology (ESC) criteria) were included from a HF outpatient clinic, who after referral to the clinic underwent 12 weeks of HF management according to ESC guidelines. This included physical training and optimization of pharmacological management of HFrEF. Baseline characteristics, CPET, medication and echocardiography were collected at referral and after 12 weeks. Changes in pVO2 were investigated according to baseline characteristics, changes in medication, and changes in echocardiographic parameters in both uni- and multivariable linear regression models. Significant independent variables were identified using stepwise selection (p<0.1), adjusted for age and sex. A p-value of 0.05 was considered significant. Results We included 48 patients with new-onset HFrEF with a median age of 73 (interquartile range (IQR): 60-77) years, 10 (20.8%) women, a baseline median left ventricular ejection fraction (LVEF) of 30% (IQR: 25-35), and a baseline median pVO2 of 17.3 ml/min/kg (IQR: 14.1-21.9). After 12 weeks, pVO2 improved with a mean of +2.18 ml/min/kg (95% confidence interval (CI) 1.25 to 3.10, p<0.01) and LVEF improved with a mean of +11.7% (95% CI 7.9 to 15.6, p<0.01). In univariable analyses increasing age were negatively associated with pVO2 changes (p=0.04) and increasing minute ventilation (MV) and initiation of sodium-glucose cotransporter (SGLT2) inhibitors were all positively associated with pVO2 changes (p<0.01 and p=0.03, respectively). Other clinical variables included in the analysis were not significantly associated with a change in pVO2. In the multivariable analysis, body mass index emerged as an independent variable negatively associated with pVO2 changes, and MV and initiation of SGLT2 inhibitors remained significantly positively associated with pVO2 changes. Conclusion Optimal pharmacological management and physical training in patients with new-onset HFrEF, induce a significant recovery of cardiorespiratory performance and ejection fraction. Furthermore, our results suggest that the initiation of SGLT2 inhibitors in patients with new-onset HFrEF appears to improve their pVO2 already after 12 weeks of optimal HF management.Table 1:BaselineTable 2:Associations

Secondary erythrocytosis / polycythemia due to sodium glucose co-transporter 2 inhibitors: a real world heart failure cohort

Abstract Background Sodium glucose co-transporter 2 inhibitors (SGLT2-i) are one of the four pillars of guideline-directed medical therapy in heart failure with reduced ejection fraction and preserved ejection fraction according to the current ESC and AHA/ACC heart failure guidelines 1,2. As a result, there has been a significant increase in their use worldwide. Although SGLT2 inhibitors are known to increase hemoglobin and hematocrit levels, there is a lack of data on the burden of erythrocytosis or polycythemia in pivotal trials 3,4. Purpose In this retrospective cohort study, we investigated the prevalence and clinical outcomes of SGLT2-i related erythrocytosis in a tertiary heart failure outpatient clinic. Methods We reviewed clinical data from heart failure patients treated with an SGLT2 inhibitor at our tertiary centre between September 2019 and October 2023. Patients were included if they were taking SGLT2-i continuously for more than one month. Data were collected on Hb/Hct levels at baseline before initiation of SGLT2-i, at peak levels during therapy and at the last follow-up. Erythrocytosis was defined according to the 2017 WHO classification as Hb> 10.3 mmol/L and/or Hct> 49% in men and Hb> 10.0 mmol/L and/or Hct> 48% in females. Results A total of 173 patients with heart failure were included (median age 58 [49-66] years, 65% male). One hundred and fifty-six patients (90%) were using dapagliflozin, while 16 patients (9%) were using empagliflozin. The overall prevalence of SGLT2i related erythrocytosis was 39/173 (22.5%; median age 60 and 82% males). Eleven (6.3%) patients had pre-existing erythrocytosis at baseline. During a mean follow-up of 14±10 months, 28/173 (16.2%) patients developed new onset erythrocytosis. The median time to the peak of the Hb/Hct level was 6.5 months. Although the group with erythrocytosis had significantly higher Hb and Hct at baseline compared to the group without erythrocytosis (Hb 9.7 mmol/L ± 1.0 vs. 8.5 mmol/L ± 1.0; p<0.001 in men and 9.1 mmol/L ± 0.8 mmol/L vs. 8.1 ± 0.8; p=0.006 in females), they also experienced a significantly greater median increase in Hb from baseline to peak (1.05 mmol/L vs. 0.60mmol/L; p=0.01) (see Figure 1) There were significantly more males (82% vs 60%; p=0.01) in the erythrocytosis group compared to the non-erythrocytosis group. In addition, the prevalence of OSAS was significantly higher in the group with erythrocytosis compared to the group without erythrocytosis (31% vs. 8%; p<0.001). Conclusion Secondary erythrocytosis or polycythemia is common in patients with chronic heart failure. It is particularly common in men and in patients with obstructive sleep apnoea syndrome (OSAS). There were no excess thrombotic or thromboembolic events, probably because of the routine use of anticoagulants/antiplatelets and limited follow-up. To avoid unnecessary haematological referrals and potential clinical adverse events, increased awareness among clinicians is needed.Table 1.Baseline and clinical outcomesFig1.Hemoglobin levels over time

20 year picture of a heart failure clinic: changes in the patients profiles' and 2-year mortality

Abstract Background Heart failure (HF) is one of the most prevalent diseases. Improvements in cardiac disease management in the last two decades and in HF itself might have influenced the referral of patients with HF to a specialised HF clinic. Purpose To evaluate changes in the profile of patients referred to an outpatient HF clinic over the span of 20 years, and to analyse trends in 2-year mortality. Methods A retrospective analysis of a prospective registry of HF patients in a specialised ambulatory HF clinic was conducted, from January 1st 2002 to December 31st 2021. We divided the 20 years of the study into five periods of four years each, in order to compare the clinical characteristics of patients at admission. The variables analysed include age, sex, aetiology, HF type (preserved - HFpEF, reduced - HFrEF, mildly-reduced - HFmrEF), NYHA class, left ventricle ejection fraction (LVEF), NT-proBNP level, number of previous hospitalizations, and treatment at referral (first visit). Two-year mortality was also analysed. Results A total of 2973 patients were included (mean age 67.1± 12,9, 69.7% men). Age remained stable across the five periods, p=0.43), while the referral of women increased throughout the study period (27.7% in 2002-2005 vs 32.9% in 2018-2021, p-for-trend=0.037). Patients with HFpEF were also increasingly referred (12.3% first period vs. 27.6% last period, p-for-trend<0.001) and LVEF tended to be higher (33.09% vs. 40,9%, p<0.001). The main aetiology of the referred patients was ischaemic heart disease, although it progressively decreased in favour of other aetiologies (Table 1) (p<0.001). NYHA class tended to improve (NYHA 3-4 40.3% vs. 21.3%, p-for-trend <0.001) and NT-proBNP levels tended to decrease, predominantly in the last period (p-for-trend=0.025), as well as hospitalisation rates in the previous year (p-for-trend<0.001). Treatment with ACEi/ARB was progressively less frequent (p<0.001), at least partially due to replacement by ARNi (p<0.001). Treatment with digoxin and loop diuretics also diminished (p<0.001 and p=0.04 respectively), whereas treatment with betablockers, ARM, ivabradine and SGLT-2i increased during the study periods (all p<0.001) (Table 2); Patients carrying ICD and CRT also increased (p=0.014 and p<0.001 respectively). Adjusted 2-year mortality significantly decreased, mainly in the last period (p<0.001) (Figure 1). Conclusion The profile of HF patients referred to a tertiary HF ambulatory Clinic changed along 20 years of study. HFrEF remained the most common, but is declining in favour of HFpEF. Ischaemic aetiology also remained the most frequent but, again, showed a decreasing trend. Two-year mortality has globally decreased, markedly in the last period.Figure 1

Measures of left atrial structure and function predict cardiovascular death in patients with heart failure with reduced ejection fraction

Abstract Background The role of the left atrium (LA) is increasingly recognized as a predictor of cardiovascular health outcomes. This study aimed to investigate the prognostic value of LA strain in relation to cardiovascular (CV) death in patients with heart failure (HF) with reduced ejection fraction (HFrEF). Methods In this retrospective cohort analysis, patients diagnosed with stable HFrEF and free from atrial fibrillation at baseline were included. All patients had a Left Ventricular Ejection Fraction (LVEF) of 45% or below at the time of referral. Baseline clinical and echocardiographic parameters were collected from the database of the HF outpatient clinic, and data on CV death was gathered through the Danish National Patient Registry. LA function was assessed by means of LA emptying fraction (LAEF), peak atrial longitudinal strain (PALS), peak atrial contraction strain (PACS), and LA conduit strain (LACS). Uni- and multivariable Cox regression models adjusted for clinical and echocardiographic baseline characteristics were used to determine the association between LA parameters and CV death. Cubic splines were used to identify cutoff values for LA parameters corresponding to a HR of 1. Results The study population consisted of 495 patients (mean age 66 ±11.5 years, 71% males). During a follow-up of 10.9 years [IQR: 6.2; 13.4], 134 (27%) patients reached the outcome of CV death. At baseline, patients who died of CV death were generally older (70.7±9.7 years vs. 64.2±11.7, p<0.001), had a higher prevalence of diabetes (25.4% vs. 13.9%, p=0.004), and a higher prevalence of moderate or severe valve disease (11.2% vs. 3.9%, p=0.004), as well as a lower LVEF (25.1%±8.5 vs. 29.4±8.9, p<0.001). Among LA parameters, the patients who met the outcome had a significantly lower LAEF (30.5% [IQR: 18.0; 42.0] vs. 38.9% [IQR: 29.0; 49.3], p<0.001), PALS (18.2% [IQR: 12.7; 24.4] vs. 23.0% [IQR: 18.3; 29.9], p<0.001), PACS (7.7% [IQR: 2.9; 13.6] vs. 11.7% [IQR: 7.9; 16.4], p<0.001), and LACS (9.4% [IQR: 7.2 ; 12.4] vs. 11.9% [IQR: 8.8; 15.0], p<0.001). Lower levels of all LA parameters were associated with an increased risk of CV death in univariable analysis (p<0.0001 for all parameters). However, in multivariable analysis, only LAEF (HR 0.99 per 1% increase, 95% CI 0.973-0.999, p=0.039), PALS (HR 0.96 per 1% increase, 95% CI 0.931–0.991, p=0.011), and PACS (HR 0.94 per 1% increase, 95% CI 0.90–0.98, p=0.002) remained significant. Splines for LAEF, PALS, and PACS were constructed with identified cutoff points for higher CV death risk (Figure 1), which were utilized to generate Kaplan-Meier curves (Figure 2). Conclusion Lower LA parameters, including LAEF, PALS, and PACS, are associated with increased risk of CV death in patients with HFrEF.Spline curves for LAEF, PALS, and PACS.Kaplan-Meier survival estimates for CVD

Changes in 6-min walk test is an independent predictor of death in chronic heart failure with reduced ejection fraction.

Functional capacity provides important clinical information in patients with heart failure (HF) and reduced ejection fraction (HFrEF). The 6-min walk test (6MWT) is a simple and inexpensive tool for assessing functional capacity and risk. Although change in 6MWT is frequently used as a surrogate outcome in HF trials, the association with mortality is unclear. We aimed to assess the prognostic importance of changes in 6MWT. Patients with chronic HFrEF referred to HF outpatient clinics in Norway completed a 6MWT at the first visit (baseline) and at a stable follow-up visit after treatment optimization (follow-up). Absolute and relative changes in 6MWT were analysed in association with mortality risk using Cox regression models and flexible cubic splines. The study included 3636 HFrEF patients aged 67.3 ± 11.6 years, 23% women, with left ventricular ejection fraction 30 ± 7%. At baseline, mean 6MWT was 438 ± 125 m, median N-terminal pro-B-type natriuretic peptide (NT-proBNP) 1574 (732-3093) ng/L, and 27% had New York Heart Association (NYHA) class III/IV. After optimization of guideline-directed medical therapy (median 147 [86-240] days), 6MWT increased by mean 40 ± 74 m, NT-proBNP decreased by median 425 (14-1322) ng/L, and NYHA class improved in 38% of patients. Patients with greater improvements in 6MWT were younger, with greater improvements in NYHA class (r = 0.27, p < 0.001) and larger reductions in NT-proBNP concentrations (r = 0.19, p < 0.001). After mean 845 ± 595 days, 419 (11.5%) patients were dead. Both absolute and relative changes in 6MWT were non-linearly associated with survival, attenuating as 6MWT increased. A 50 m increase in 6MWT was associated with a 17% lower mortality risk (hazard ratio 0.84, 95% confidence interval 0.77-0.90, p < 0.001) in the fully adjusted model, including changes in NYHA class, NT-proBNP concentrations, and other established risk factors. The associations were more pronounced in patients with lower baseline 6MWT and higher age. Improvement in 6MWT in patients with HFrEF is associated with increased survival, independent of changes in NT-proBNP and NYHA class. These findings support 6MWT change as a surrogate outcome in HF trials.

Quality of life in patients with heart failure and implantable cardioverter defibrillator. Results from 42 heart failure clinics in norway

Abstract Background Patients with heart failure (HF) have an increased risk of sudden cardiac death, and treatment with an implantable cardioverter defibrillator (ICD) has become standard treatment for selected patient groups. HF is associated with impaired QoL, but there is no consensus regarding the implication of having an ICD. Knowledge regarding QoL in patients with HF and ICD attending follow-up in outpatient HF-clinics is sparse. Purpose The aim of this study was to determine QoL in patients with HF and ICD. Further, to compare QoL in patients with HF with and without ICD, using data from the first and follow-up visits in outpatient HF clinics. Methods Longitudinal data from the National Norwegian Heart Failure Registry (NNHFR), including 9 274 patients, of which 1 206 with an ICD, were studied. QoL was assessed using the Minnesota Living with Heart Failure Questionnaire (MLHFQ). Data was collected at the first and follow-up visits in outpatient HF clinics approximately six months after optimal treatment was achieved. Results Patients with an ICD were younger, more often men, and had higher frequency of coronary artery disease (all p&amp;lt;0.001). At the first visit, there was no significant difference in QoL between patients with and without ICD, with both groups reporting moderate QoL. Both groups had a significant improvement in QoL from the first visit to the follow-up visit (p&amp;lt;0.001). However, patients with ICD reported significantly less improvement in QoL (p&amp;lt;0.001) at follow-up. This disparity was evident regarding both the physical (p&amp;lt;0.001) and the emotional (p&amp;lt;0.001) dimension. Conclusion QoL in patients with HF and ICD improves after follow-up in outpatient HF clinics, although not to the same extent as in patients without ICD. Thus, tailored interventions in outpatient HF clinics may be necessary to improve outcomes in this subgroup of patients with both HF and ICD.

Xerostomia in patients with heart failure - prevalence, intensity and reported strategies of symptom reduction

Abstract Background Xerostomia is a common symptom in patients with chronic heart failure (CHF), with a reported prevalence rate of up to 62%. It is defined as the perception of oral dryness, along with swallowing difficulties, oral burning, and altered taste. Despite being a widespread symptom, xerostomia is insufficiently studied CHF patients from german-speaking countries. Purpose The purpose of this study was to assess the prevalence, perceived intensity, and severity of xerostomia in German CHF patients. Additionally, patients´ reported strategies of symptom reduction were investigated. Methods Multi-center, cross-sectional study. Patients with a confirmed diagnosis of heart failure were recruited during visits to heart failure outpatient clinics or while hospitalized for any reason. If they consented to participate, they received a self-administered questionnaire containing questions about xerostomia, perceived distress and severity of xerostomia, and patients' measures to reduce xerostomia. Disease-related data were extracted from the patients' medical records. Perceived intensity of mouth dryness was measured using a visual analog scale (VAS) with 0 for "little dry" and 100 for "maximum imaginable dryness." To assess the severity of xerostomia, the short version of the xerostomia inventory (XI) was used with 5 items inquiring about the frequency of specific xerostomia symptoms. Sumscores of the XI ranged from 5 to 15, with higher scores indicating a higher severity of xerostomia. Measures to reduce dry mouth could be stated in patients' own words. Results Overall, 371 patients with a mean age of 62.4 (± 14.9) took part in this study. Most patients (230; 62%) had CHF with reduced ejection fraction. The main aetiology for heart failure was ischemic heart disease (118; 31.8%), followed by dilated cardiomyopathy (116; 31.3%). Out of 371 patients, 361 answered the question of whether they had suffered from dry mouth in the last three days. The prevalence rate of xerostomia was 65% (n=234) (95% CI: 60%; 70%). Perceived intensity of mouth dryness, using VAS, was 55.5 (± 22.3). The median severity score of the XI was 9 (Interquartile-Range: 8;11). Patients mostly experienced dry mouth in the morning and at night. The most frequently mentioned measures against dry mouth were drinking something (water, juice, coffee, tea, buttermilk), rinsing or moistening the mouth, sucking candies (sugar-free candies, peppermint, lemon, menthol), eating fruits, and using chewing gums. Conclusion Xerostomia is a widespread symptom in German heart failure patients, affecting more than half of the patients included in the study. The intensity and degree of severity appear to be in a medium range. CHF patients used various interventions to relieve the burden of xerostomia. These measures should be further investigated for their effectiveness.

Optimizing heart failure pathways to enhance patient care: the Program to Optimize Heart Failure Patient Pathways (PRO-HF).

Many European healthcare providers struggle to adopt multidisciplinary, integrated care pathways for people with heart failure (HF) as recommended by the European Society of Cardiology. PRO-HF (Program to Optimize Heart Failure Patient Pathways) was developed to help clinicians identify strengths, gaps, and shortcomings in their HF pathways and support tailored interventions to optimize pathways and enhance patient care. We report initial findings from baseline assessments of HF pathway characteristics and challenges from 10 hospitals in six European countries (France, Ireland, Portugal, Spain, The Netherlands, and United Kingdom). Baseline assessments were holistic appraisals of full HF services to calibrate current status and development needs and assist management teams in prioritizing improvement projects. Assessments were performed using a comprehensive checklist of measures covering the HF patient journey from diagnosis to ongoing follow-up. These included a digital survey sent to full HF care teams and one-to-one interviews. The digital survey focused on four key areas (HF outpatient clinic; remote patient management; efficient device implantation and inpatient pathways; and network maximization) and 16 dimensions of excellence. Priority areas and themes for action identified in baseline assessments were (i) provision of HF specialist care; (ii) data capture and analysis; (iii) institutional care protocols; (iv) hospital-wide strategies; and (v) multidisciplinary teams (MDTs). Suboptimal specialist care of emergency inpatients was an issue at all hospitals and prioritized at 8/10. Availability and accessibility of data on patients, activities, and outcomes was an issue at all hospitals and prioritized by 4/10. A lack of clear protocols, templates, and tools for some HF activities created variability in patient care (e.g., HF specialist consultations, diagnostic testing, follow-up appointments, medications, and device eligibility) and inefficient use of clinician time. This made it difficult to initiate new technologies (e.g., remote patient monitoring) due to the risk of overburdening staff. MDTs were frequently understaffed. Multiple interventions were identified to address gaps and shortcomings that could be tailored to specific needs of individual hospitals (e.g., inpatient pathway optimization, creation/optimization of HF outpatient clinics, development of an HF performance dashboard, enhancement of protocol adherence, streamlining cardiac resynchronisation therapy pathways, and MDT coordination). PRO-HF provides a valuable opportunity to identify gaps and significant shortcomings in HF pathways in European hospitals. Preliminary findings from hospitals that have initiated suggested changes to address these challenges are encouraging, though longer-term follow-up from more hospitals is needed to confirm the impact of PRO-HF on HF pathway optimization and patient care.

Loop diuretic discontinuation in chronic heart failure patients: A retrospective study

Introduction and ObjectivesThe use of loop diuretics is central in managing congestion in heart failure (HF), but their impact on prognosis remains unclear. In euvolemic patients, dose reduction is recommended, but there is no recommendation on their discontinuation. This study aims to assess the impact of loop diuretic discontinuation on the prognosis of outpatients with HF with reduced ejection fraction. MethodsThis retrospective cohort study collected data from medical records of patients followed in an outpatient HF clinic at a university hospital center. Patients were included if they had been on loop diuretics and these were discontinued. Demographic, clinical and laboratory data were collected, and number and type of congestive events during the one-year period after discontinuation were recorded. ResultsAmong 265 patients on loop diuretics, almost half (129) discontinued them at some point. Patients had optimized medical therapy, low median age, low New York Heart Association class, low B-type natriuretic peptide values, normal blood pressure, controlled heart rate and kidney function within normal limits. Among 122 patients with one year of follow-up, 18 (14.8%) had a congestive event. Fifteen events (83.3%) were low-dose diuretic reinitiation at a scheduled visit. There were only three worsening heart failure events (2.5%) during the one-year period. A significant improvement in kidney function from discontinuation to the one-year follow-up appointment was also observed. ConclusionsIn our cohort, loop diuretic discontinuation was possible and safe in a large proportion of patients. The results should be interpreted with caution and cannot be extrapolated to a broader population of HF patients.

A TAVI VALV IN VALV AT ALMOST 90 YEARS

Abstract Degeneration of the biologic aortic valve prosthesis represents an increasingly important issue. This process often affects frail elderly patients who are not candidates for cardiac re–intervention. TAVI valve–in–valve implantation therefore probably remains the only viable option in such patients.We report the clinical case of Mrs. Luciana F., currently 94 years old, who underwent biological aortic valve replacement in 2016. In charge of the Elderly Patient‘s Heart Failure Outpatient Clinic (SOD Geriatrics–UTIG) since January 2023.At first evaluation,89 years old, widowed, living alone; MMSE 29/30. SPPB 7/12. Totally autonomous in BADL, and partially in IADL.She complained of decreased exercise tolerance (NYHA Class III). No alterations in left ventricular kinetics. Calcified and degenerated aortic valve prosthesis with markedly reduced box opening and severe stenosis (Vel 4.7 m/s; Grad max/med (86/55 mmHg) mild insufficiency. May 2023 access to DEA for syncopal episode, complicated by fall down stairs and head injury; on echocardiogram relief of further degeneration of aortic bioprosthesis (moderate–grade intra–prosthetic insufficiency at 2 jets with PTH 300 msec and severe stenosis, Gmax/Gmed 88/55 mmHg, DVI 0.20 June 2023 worsening of dyspnea that appeared even at rest NYHA IV. At echocolordoppler confirmed severe aortic stenosis severe bioprosthesis degeneration. She was evaluated in Heart Team: low overall risk (MPI 0.31) therefore percutaneous implantation of Medtronic Evolut R aortic bioprosthesis has been performed. At discharge asymptomatic, eupnoic, walking independently without aids for short stretches. At subsequent follow–up.–1 month: substantial clinical well–being in the absence of dyspnea on ordinary exertion (NYHA II), no orthopnea or paroxysmal nocturnal dyspnea; denies angor, heart palp or syncopal episodes. She has resumed household chores and leaves the house almost every day –6 months: clinical stability. She walks long distances every day in the absence of symptomatology. –1 years (turned 90 years old): clinical stability with dyspnea for moderate exertion continues active life. Trans prosthetic gradient max/medium 22/12 mmHg, VD–AD 30 mmHg. In conclusion TAVI procedure on degenerated biological prosthesis should be an option to be considered in the elderly patient selected and evaluated by a multidisciplinary Heart Team to achieve improvement of cardiovascular symptoms and concomitantly recovery of functional autonomy.

Contemporary guideline-directed medical therapy in de novo, chronic, and worsening heart failure patients: First data from the TITRATE-HF study.

Despite clear guideline recommendations for initiating four drug classes in all patients with heart failure (HF) with reduced ejection fraction (HFrEF) and the availability of rapid titration schemes, information on real-world implementation lags behind. Closely following the 2021 ESC HF guidelines and 2023 focused update, the TITRATE-HF study started to prospectively investigate the use, sequencing, and titration of guideline-directed medical therapy (GDMT) in HF patients, including the identification of implementation barriers. TITRATE-HF is an ongoing long-term HF registry conducted in the Netherlands. Overall, 4288 patients from 48 hospitals were included. Among these patients, 1732 presented with de novo, 2240 with chronic, and 316 with worsening HF. The median age was 71 years (interquartile range [IQR] 63-78), 29% were female, and median ejection fraction was 35% (IQR 25-40). In total, 44% of chronic and worsening HFrEF patients were prescribed quadruple therapy. However, only 1% of HFrEF patients achieved target dose for all drug classes. In addition, quadruple therapy was more often prescribed to patients treated in a dedicated HF outpatient clinic as compared to a general cardiology outpatient clinic. In each GDMT drug class, 19% to 36% of non-use in HFrEF patients was related to side-effects, intolerances, or contraindications. In the de novo HF cohort, 49% of patients already used one or more GDMT drug classes for other indications than HF. This first analysis of the TITRATE-HF study reports relatively high use of GDMT in a contemporary HF cohort, while still showing room for improvement regarding quadruple therapy. Importantly, the use and dose of GDMT were suboptimal, with the reasons often remaining unclear. This underscores the urgency for further optimization of GDMT and implementation strategies within HF management.

Guideline-Directed Medical Therapy in Patients With Heart Failure With Reduced Ejection Fraction and Incident Cancer

It has been postulated that cancer hampers the delivery of guideline-directed medical therapy (GDMT) for heart failure (HF). However, few data are available in this regard. We performed a retrospective analysis from the HF Outpatient Clinic of the IRCCS Ospedale Policlinico San Martino in Genova, Italy. All HF patients evaluated between 2010 and 2019, with a left ventricular ejection fraction <50% and at least two visits ≥3 months apart with complete information about GDMT were included in the study. We assessed the prescription of GDMT-in particular, beta-blockers (BB), renin-angiotensin system inhibitors (RASi), and mineralocorticoid antagonists (MRA)-at the time of the last HF evaluation and compared it between patients with and without incidental cancer. For those with incidental cancer, we also evaluated modifications of GDMT comparing the HF evaluations before and after cancer diagnosis. Of 464 HF patients, 39 (8%) had incidental cancer. There were no statistical differences in GDMT between patients with and without incidental cancer at last evaluation. In the year following cancer diagnosis, of 33 patients with incidental cancer on BB, none stopped therapy, but two had a down-titration to a dosage <50%; of 27 patients on RASi, two patients stopped therapy and three had a down-titration to a dosage <50%; of 19 patients on MRA, four stopped therapy. Although HF patients with incidental cancer may need to have GDMT down-titrated at the time of cancer diagnosis, this does not appear to significantly hinder the delivery of HF therapies during follow-up.

A novel referral strategy to enhance the enrollment of patients with heart failure in cardiac rehabilitation: A feasibility study.

Rehabilitation targeting patients with cardiac conditions are evident and acknowledged in clinical guidelines. However, participation rates remain suboptimal, with only 50% of all patients with cardiac conditions participating in these programs across Europe. Considering the well-documented effects of rehabilitation, increasing the referral rate to cardiac rehabilitation would be desirable. This study aimed to evaluate the feasibility of a novel referral strategy that could potentially enhance enrollment in cardiac rehabilitation for patients with heart failure. This prospective feasibility study incorporating both quantitative and qualitative methods was conducted in an outpatient heart failure clinic and a municipal health care center. 106 patients with heart failure were referred to the heart failure clinic from September 2021 through July 2022. A 15-20 min face-to-face physiotherapy consultation was incorporated into usual care, evaluating patients' habitual and actual level of functioning, disability, and physical activity and assessing their potential need and motivation for cardiac rehabilitation. Three predefined quantitative feasibility outcomes: reach, referral rate, and data completeness were assessed. Additionally, semi-structured interviews explored acceptability among patients and health care professionals at the municipal health care center and the hospital. Finally, the potential effect was assessed based on the enrollment rate. Physiotherapy consultations were offered to 86% of eligible patients; of these, 52% were referred to cardiac rehabilitation. Ninety-one percent data completeness was achieved. The intervention was well-accepted by patients and health care professionals. The enrollment rate reached 79%. The novel referral strategy proved feasible concerning reach and data completeness, although the referral rate suggested that further refinements are required before a full-scale trial. The novel referral strategy was well-accepted, and enrollment rate approached an acceptable level.

Rates of Reproductive Counseling and Contraception Use in Patients with Heart Failure at a Tertiary Care Center

BackgroundIncreasing numbers of women of childbearing age have cardiac disease, including heart failure (HF). In these women, pregnancy can cause significant morbidity and mortality. Contraceptive use and pregnancy counseling in women with HF is an essential part of their medical care. Here, we assess contraceptive use and pregnancy counseling of patients with HF at a single tertiary care center. Methods and ResultsThis was a retrospective, single-center cohort study of female patients with HF with reduced ejection fraction, left ventricular assist devices (LVADs), and heart transplants who were seen in the adult advanced HF outpatient clinics. Patients were identified in the electronic health care record system, and records were reviewed to assess for documentation of contraception and pregnancy counseling. We identified 156 women of childbearing age (aged >18 to <45), seen in the HF clinics between 2018 and 2023. Patients were subdivided by their most recent diagnosis and therapy: HF with reduced ejection fraction (83 [53.2%]), LVAD (18 [11.5%]), and heart transplant (55 [35.3%]). Contraception was documented for 74% of women with HF, 56% of women with LVAD, and 85% of women with heart transplants. Pregnancy counseling was documented for 18.00% of women with HF, 0.06% of women with LVAD, and 29.00% of women with heart transplants. ConclusionsIn our study, many women with HF, LVAD, or transplant have documented contraceptive therapy; however, pregnancy counseling seems to be limited. This vital aspect of medical care should be available for all patients given potential pregnancy-associated risks.

Secretoneurin levels are higher in dilated cardiomyopathy than in ischaemic cardiomyopathy: preliminary results.

Secretoneurin (SN) is a neuropeptide with potential utility as a biomarker of cardiovascular episodes. The main effect of SN is mediated through its inhibition of calmodulin-dependent kinase II (CaMKII), which influences calcium handling. We aimed to associate the levels of SN in plasma with different causes of heart failure. We prospectively enrolled consecutive patients with ischaemic (ICM) and dilated (DCM) cardiomyopathy from the outpatient heart failure clinic and healthy individuals. SN was analysed from venous blood by use of the ELISA method. SN plasma levels were compared in DCM, ICM and healthy individuals with non-parametric tests. A total of 53 patients (81.1% male, 18.9% female; mean age 67.9 ± 12.6 years) and 34 healthy individuals (38% male, 62% female) were included in the analysis. Plasma SN levels were significantly higher in the dilated cardiomyopathy (38.8 ± 27 pmol/L) as compared with the ischaemic cardiomyopathy (19.7 ± 22.6 pmol/L) group (P = 0.006). There was no significant difference between females vs. males (27.1 ± 23 vs. 25.5 ± 26.2 pmol/L, P = NS). Plasma SN levels allowed DCM and ICM to be differentiated with 88% sensitivity and 61% specificity (P = 0.007), the cut of value is 13.3 pmol/L. Plasma SN levels differed significantly between healthy volunteers and both ICM (P < 0.0001) and DCM (P = 0.049). Plasma SN levels did not differ according to age and were not associated with comorbidities, left ventricular ejection fraction, heart failure medication, troponin, creatinine, or natriuretic peptide plasma levels. Plasma secretoneurin levels differed significantly in DCM vs. ICM, being higher in the former. Based on plasma SN levels, discrimination between DCM and ICM might be possible. Healthy individuals produce higher SN plasma levels than stable HFrEF patients.

The Relationship between the Presence of Cardiohepatic Syndrome and Mortality in Heart Failure with Reduced Ejection Fraction.

Heart failure (HF) is a major health burden that commonly affects liver function. Therefore, cardiohepatic syndrome (CHS) has been defined to describe the relationship between the heart and the liver. In this study, we aimed to evaluate the effect of CHS on long-term mortality in HF with reduced ejection fraction (HFrEF). Patients followed at the outpatient HF clinic of our hospital with HFrEF between 2010 and 2018 were retrospectively analyzed. CHS was defined as elevation of at least two of three cholestasis parameters (total bilirubin, alkaline phosphatase, and gamma-glutamyl transferase) above the upper limit of normal. Patients were divided into two groups according to the presence of CHS. The endpoint was all-cause mortality. Patients were followed up for a median of 4.4 (3.3-5.9) years. A total of 469 patients were included in the study. The mean age of the group was 52.2 ± 11.9 years and 75.5% of the patients were males. About 22.4% (n = 105) of the patients had CHS. Patients with CHS were older and had more comorbidities than patients without CHS. Furthermore, significantly worse left and right ventricular functions were observed in CHS (+) group. All-cause mortality was significantly higher in CHS (+) group (61.9% vs. 19.5%, P < 0.001). Multivariate analysis revealed the presence of CHS (HR: 2.92, 95% CI: 2.09-4.07, P < 0.001) as an independent predictor of long-term mortality. The presence of CHS is associated with increased long-term mortality in outpatients with HFrEF. As an easy parameter to assess from routine laboratory parameters, CHS should be used to evaluate the long-term prognosis of patients with HFrEF.

Incidence and predictors of heart failure with improved ejection fraction category in a HFrEF patient population.

The aim of the study was to assess the incidence and predictive factors of the development of heart failure with improved ejection fraction (HFimpEF) category during a 1year follow-up period in a heart failure with reduced ejection fraction (HFrEF) patient population managed in a heart failure outpatient clinic. The study evaluated data from patients enrolled in the Hungarian Heart Failure Registry (HHFR). The incidence and predictive factors of the development of the HFimpEF category after 1year follow-up were assessed in the group of patients who had HFrEF at baseline. We evaluated the incidence and predictors of the development of HFimpEF after a 1year follow-up in relation to time since diagnosis of HFrEF in patients diagnosed within 3months, between 3months and 1year, and beyond 1year. The predictive factors of the development of HFimpEF were analysed using univariate and multivariate logistic regression analysis. Of the 833 HFrEF patients enrolled in the HHFR, the development of HFimpEF was observed in 162 patients (19.5%) during 1year follow-up. In the whole patient population, independent predictors of the development of HFimpEF were female gender [odds ratio (OR): 1.73; 95% confidence interval (CI): 1.01-2.96; P<0.05], non-ischaemic aetiology (OR: 1.95; 95% CI: 1.15-3.30; P<0.05), and left ventricular end-diastolic diameter (LVEDD) <60mm (OR: 2.04; 95% CI: 1.18-3.51; P<0.05). The 1year incidence of HFimpEF decreased in relation to time since diagnosis of HFrEF. The incidence of HFimpEF was 27.1% in patients diagnosed within 3months, 18.4% in patients diagnosed between 3months and 1year, and 12.2% in patients diagnosed beyond 1year. Non-ischaemic aetiology (OR: 4.76; 95% CI: 1.83-12.4; P<0.01) and QRS width (OR: 0.81; 95% CI: 0.71-0.94; P<0.01) for patients diagnosed within 3months, LVEDD (OR: 0.54; 95% CI: 0.32-0.90; P<0.05) and left atrial diameter ≤45mm (OR: 5.44; 95% CI: 1.45-20.4; P<0.05) for patients diagnosed between 3months and 1year, and LVEDD<67mm (OR: 2.71; 95% CI: 1.07-6.88; P<0.05) for patients diagnosed beyond 1year were found to be independent predictive factors. In our study, in this HFrEF patient population managed in a heart failure outpatient clinic, the 1year incidence of HFimpEF was found to be ~20%. The 1year incidence of HFimpEF decreased in relation to time since diagnosis of HFrEF. The most important predictors of the development of HFimpEF were female sex, non-ischaemic aetiology, narrower QRS width, and smaller diameter of the left ventricle and left atrium.

Is the obesity paradox in outpatients with heart failure reduced ejection fraction real?

The obesity occurrence has achieved epidemic levels worldwide and several studies indicate a paradoxical similarity among obesity and the prognosis in heart failure (HF). The primary objective was to understand the association between body mass index (BMI) and heart failure with reduced ejection fraction (HFREF) of ischemic etiology in outpatients, using mortality as a parameter. The secondary objectives were to determine the differences in HF functional class, pharmacological therapy and evaluate the prognostic value of MAGGIC Score in this population. We analyzed 1,556 medical records from the HF outpatient clinic of a quaternary hospital and 242 were selected according to the criteria. Most were male, average age 62.6 (56-70), BMI 18.5-24.9 = 35.1%, 25-29.9 = 37.2%, 30-34.9 = 17.8%, 35-39.9 = 7%; BMI <18.5 and >40 groups were eliminated from the central analyzes because of scarce testing. BMI 30-34.9 and BMI 18.5-24.9 had the best prognosis, BMI 25-29.9 had an average performance, and BMI -39.9 group provided the worst outcome (p = 0.123). In the subcategory analysis, BMI 30-34.9 group had a better prognosis compared to the BMI 35-39.9 group (p = 0.033). In the multivariate analysis The MAGGIC score was not able to foretell mortality in this population according to BMI. In not hospitalized patients with HFREF of ischemic etiology, obesity was not a protective factor.

Candidacy and predicted efficacy of vericiguat in contemporary heart failure outpatient clinics

Abstract Background Vericiguat is a novel drug class (soluble guanylate cyclase stimulator) approved for the treatment of symptomatic heart failure with reduced ejection fraction (HFrEF) patients who are stable after recent decompensation. Its safety and efficacy in high-risk HFrEF patients (ejection fraction &amp;lt;45%) with recent hospitalisation was demonstrated in the VICTORIA trial, along with advantages: lesser impact on blood pressure, sustained efficacy up to eGFR 15 mL/min/1.73m2. Subgroup analyses have shown variability in heart failure hospitalisation (HFH) and cardiovascular death (CVD) reduction according to NT-proBNP levels. While real-world candidacy for Vericiguat have been described in hospitalised patients, data on Vericiguat eligibility within contemporary heart failure outpatient (HF OPD) clinics is limited. Purpose We describe the proportion of HFrEF patients reviewed in HF OPD clinics eligible for vericiguat (according to the VICTORIA trial criteria) and likely to benefit from therapy based on NT-proBNP levels. Methods A retrospective review was performed on HFrEF patients reviewed in HF OPD services in 2022. Hospital records were assessed to identify community managed HFrEF patients experiencing HFH in 2022 and the VICTORIA trial's selection criteria was applied to determine Vericiguat eligibility. Predicted efficacy (reduction in HFH and/or CVD) in Vericiguat eligible patients was based on NT-proBNP level cut-off: &amp;gt;8000 ng/L: no benefit; ≤8000 ng/L: net benefit; ≤5314 ng/L: strong benefit. Stable NT-proBNP value was taken as the peak value within 30 days of discharge of the HFH event. Results 333 HFrEF patients were reviewed in HF OPD services in 2022. 94 (28.2%) patients experienced HFH in 2022, of which 33 (9.9%) occurred after guideline directed medical therapy (GDMT) was optimized in HF OPD review. Pharmacotherapy patterns of patients with HFH were identified at HF OPD review: 24 (33.8%) quadruple GDMT, 18 (25.4%) triple GDMT, 21 (40.8%) dual or single GDMT. 71 (21.3%) patients with HFH met the VICTORIA trial criteria and were eligible for Vericiguat. When subdivided according to NT-proBNP level cut-off, the following predicted efficacy were identified: 52 (15.6%) net benefit, 42 (12.6%) strong benefit, and 19 (5.7%) no benefit. Conclusions In HF OPD services, 28.2% of HFrEF patients may experience HFH within 1 year with 9.9% occurring despite GDMT optimization. 40.8% of community managed HFrEF patients were still only on dual or single GDMT. The proportion of community managed HFrEF patients eligible for Vericiguat is 21.3%. Based on NT-proBNP levels, the proportion likely to experience net and strong beneficial effects from Vericiguat were 15.6% and 12.6% respectively. Considering Vericiguat has advantages over the traditional barriers (hypotension, renal function) of conventional HFrEF pharmacotherapy agents, our findings provide insight into the potential real-world use of Vericiguat within contemporary HF OPD clinics.Figure 1Table 1