Poor Outcomes In Heart Failure Research Articles

The impact of multimorbidity and functional limitation on quality of life in patients with heart failure: A multi-site study.

Multimorbidity and functional limitation are associated with poor outcomes in heart failure (HF). However, the individual and combined effect of these on health-related quality of life in patients with HF is not well understood. Patients aged ≥30 years with two or more HF diagnostic codes and one or more HF-related prescription drugs from four U.S. institutions were mailed a survey to measure patient-centric factors including functional status (activities of daily living [ADLs]) and health-related quality of life (PROMIS-29 Health Profile). Patients with HF from January 1, 2013 to February 1, 2018 were included. Multimorbidity was defined as ≥2 non-cardiovascular comorbidities; functional limitation as any limitation in at least one of eight ADLs. Patients were categorized into four groups by multimorbidity (Yes/No) and functional limitation (Yes/No). We dichotomized the PROMIS-29 sub-scale scores at the median and calculated odd ratios for the four multimorbidity/functional limitation groups. A total of 3330 patients with HF returned the survey (response rate 31%); 3020 completed the questions of interest and were retained. Among these patients (45% female; mean age 73 [standard deviation: 12] years), 29% had neither multimorbidity nor functional limitation, 24% had multimorbidity only, 22% had functional limitation only, and 25% had both. After adjustment, having functional limitation only was associated with higher anxiety (odds ratio [OR]: 3.44, 95% confidence interval [CI]: 2.66-4.45), depression (OR: 3.11, 95% CI: 2.39-4.06), and fatigue (OR: 4.19, 95% CI: 3.25-5.40); worse sleep (OR: 2.14, 95% CI: 1.69-2.72) and pain (OR: 6.73, 95% CI: 5.15-8.78); and greater difficulty with social activities (OR: 9.40, 95% CI: 7.19-12.28) compared with having neither. Results were similar for having both multimorbidity and functional limitation. Patients with only functional limitation have similar poor health-related quality of life scores as those with both multimorbidity and functional limitation, underscoring the important role that physical functioning plays in the well-being of patients with HF.

Body mass index and cardiorenal outcomes in the EMPEROR-Preserved trial: Principal findings and meta-analysis with the DELIVER trial.

Both low and high body mass index (BMI) are associated with poor heart failure outcomes. Whether BMI modifies benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in heart failure with preserved ejection fraction (HFpEF) requires further investigation. Using EMPEROR-Preserved data, the effects of empagliflozin versus placebo on the risks for the primary outcome (hospitalization for heart failure [HHF] or cardiovascular [CV] death), change in estimated glomerular filtration rate (eGFR) slopes, change in Kansas City Cardiomyopathy Questionnaire clinical summary score (KCCQ-CSS), and secondary outcomes across baseline BMI categories (<25 kg/m2, 25 to <30 kg/m2, 30 to <35 kg/m2, 35 to <40 kg/m2 and ≥40 kg/m2) were examined, and a meta-analysis conducted with DELIVER. Forty-five percent had a BMI of ≥30 kg/m2. For the primary outcome, there was a consistent treatment effect of empagliflozin versus placebo across the BMI categories with no formal interaction (p trend = 0.19) by BMI categories. There was also no difference in the effects on secondary outcomes including total HHF (p trend = 0.19), CV death (p trend = 0.20), or eGFR slope with slower declines with empagliflozin regardless of BMI (range 1.12-1.71 ml/min/1.73 m2 relative to placebo, p trend = 0.85 for interaction), though there was no overall impact on the composite renal endpoint. The difference in weight change between empagliflozin and placebo was -0.59, -1.48, -1.54, -0.87, and - 2.67 kg in the lowest to highest BMI categories (p trend = 0.016 for interaction). A meta-analysis of data from EMPEROR-Preserved and DELIVER showed a consistent effect of SGLT2i versus placebo across BMI categories for the outcome of HHF or CV death. There was a trend toward greater absolute KCCQ-CSS benefit at 32 weeks with empagliflozin at higher BMIs (p = 0.08). Empagliflozin treatment resulted in broadly consistent cardiac effects across the range of BMI in patients with HFpEF. SGLT2i treatment yields benefit in patients with HFpEF regardless of baseline BMI.

Right ventricular uncoupling in heart failure with preserved ejection fraction: a simple parameter to predict long-term mortality?

Abstract Introduction Several prognostic models have been developed for risk stratification of mortality in patients with acute heart failure (AHF). eRecent evidence suggests that the right ventricular (RV)-pulmonary artery (PA) uncoupling is associated with poor outcomes in heart failure. Patients with heart failure and preserved ejection fraction (HFpEF) are a heterogeneous population with a wide range of clinical outcomes. However, the prognostic utility of RV-PA uncoupling for predicting long-term mortality in these patients remains elusive. Objective To assess the prognostic value of right ventricle-pulmonary artery coupling for long-term mortality in hospitalized patients with HFpEF. Methods Retrospective analysis of a consecutive, prospective, single-center cohort. Adult patients hospitalized between 2015 and 2020 with a primary diagnosis of AHF and left ventricular ejection fraction (LVEF) &amp;gt;40% were included. The primary endpoint was long-term all-cause mortality. Ventricular uncoupling was assessed as the ratio of tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) estimated from an echocardiogram performed within 3 months of the index hospitalization. Univariable Cox proportional hazards regression models were used to calculate hazard ratios (HR), and multivariable Cox regression was performed with previously analyzed covariates: age, sex, atrial fibrillation, renal dysfunction and E/e'. Results Of 465 patients with HFpEF, 361 (77%) PASP and TAPSE could be estimated simultaneously. During a mean follow-up of 20.9 months, the primary outcome event occurred in 100 patients (27.7%). The optimal cut-off for the primary endpoint was TAPSE/PASP=0.38. Univariable Cox regression showed that RV-PA uncoupling was associated with the primary endpoint of long-term mortality (hazard ratio [HR] 1.96 [95% CI, 1.32-2.92], P=0.001). Kaplan-Meier analysis showed that patients with a ratio &amp;lt;0.38 were at high risk of all-cause mortality (Figure 1). Multivariable analysis also showed that RV-PA uncoupling was significantly associated with long term mortality independent of age, sex, atrial fibrillation, renal dysfunction and E/e' (HR 2.21 [95% CI, 1.26-3.81], P=0.005). Conclusions In patients hospitalized for AHF with preserved ejection fraction, RV-PA uncoupling as determined by the TAPSE/PASP ratio was independently associated with long-term all-cause mortality. TAPSE/PASP was associated with mortality independently of age, sex, renal function, atrial fibrillation and diastolic dysfunction. This simple echocardiographic parameter may identify a population at higher risk for events during follow-up.Kaplan-Meier for all-cause mortality

Cognitive transitions based on functional status in older adults with heart failure: a population-based study.

Cognitive impairment and functional status are both important determinants of poor outcomes in heart failure (HF). However, little is known about how functional status impacts the changes in cognitive status during the disease course. This study aimed to describe the cognitive transitions in patients with HF and assess the relationship of these transitions to functional status, which was assessed by the dependency of activities of daily living (ADL). This retrospective cohort study included 1764 patients with an International Classification of Diseases-10 code of HF (≥65years, mean age 82.3±7.9years, 39% male) from a long-term care and medical insurance database from Nobeoka city, a rural city of south-western Japan. Cognitive status at baseline and 6, 12, 18, and 24month time points was collected, and participants were stratified based on ADL status at baseline. Generalized estimating equations and multi-state modelling were used to examine associations between ADL dependency and cognitive changes/mortality. Transition probabilities were estimated using multi-state modelling. At baseline, there were 1279 (73%) and 485 (27%) patients with independent and dependent ADL, respectively. In overall patients, 1656 (93.9%) patients had normal/mild cognitive status and 108 (6%) patients had a moderate/severe cognitive status at baseline. The majority [104 (96%) patients] of patients with moderate/severe cognitive status at baseline had dependent ADL. In patients with moderate/severe cognitive status, the number of patients with dependent ADL always outnumbered that of the independent ADL throughout the follow-up. Multi-state modelling estimated that patients with dependent ADL and normal/mild cognitive status at baseline had 47% probability of maintaining the same cognitive status at 24months, while the probability of maintaining the same cognitive status was 86% for those with independent ADL. Patients with normal/mild cognitive status in the dependent ADL group at baseline had a higher risk of experiencing a transition to moderate/severe cognitive status at any time point during 24months compared with those with independent ADL [hazard ratio 5.24 (95% confidence interval 3.47-7.90)]. In older patients with HF, the prevalence of cognitive impairment was always higher for those with reduced functional status. Despite having a normal/mild cognitive status at baseline, patients with dependent ADL are at high risk of experiencing cognitive decline over 24months with substantially less chance of maintaining their cognitive status. ADL dependency was an important risk factor of cognitive decline in patients with HF.

Bariatric surgery improves outcomes of hospitalizations for acute heart failure: a contemporary, nationwide analysis.

The link between obesity and poor outcomes in heart failure (HF) has been well-established. This retrospective study sought to examine national rates and outcomes of acute HF hospitalizations in obese individuals with a prior history of bariatric surgery. Academic, university-affiliated; the United States. Adult admissions (≥18 years) including a diagnosis of severe obesity were identified in the 2016-2019 Nationwide Readmissions Database. Patients who previously underwent bariatric operations were categorized into the Bariatric cohort. Multivariable linear and logistic models were used to assess the association of prior bariatric surgery with outcomes of interest. Of an estimated 10,343,828 admissions for a diagnosis of severe obesity, 925,716 (8.9%) comprised the bariatric cohort. After risk adjustment, bariatric surgery was associated with significantly decreased odds of acute HF hospitalization (adjusted odds ratio [AOR]: .40, 95% confidence interval [CI]: .38-.41). Among acute HF hospitalizations, prior bariatric surgery was linked to lower odds of mortality (AOR: .68, 95% CI: .52-.89), prolonged mechanical ventilation (AOR .44, 95% CI: .32-.61), acute renal failure (AOR: .76, 95% CI: .70-.82), and prolonged hospitalization (AOR: .77, 95% CI: .68-.87). Bariatric surgery was linked to a decrement of 1 day (95% CI: .7-1.1) and $1200 in hospitalization costs (95% CI: 400-1900), but no significant difference in odds of 30-day readmission. Bariatric surgery is associated with reduced admissions for acute HF. Among acute HF hospitalizations, bariatric surgery is linked to significantly improved clinical and financial outcomes. Given its potential benefits in obesity and related diseases, bariatric surgery holds promise for promoting value-based healthcare for HF.

Left atrial stiffness in predicting poor exercise oxygen consumption and ventilatory inefficiency

Abstract Funding Acknowledgements Type of funding sources: None. Background and Introduction Cardiopulmonary exercise test (CPET) provides integrative information of cardiovascular, pulmonary, muscular, and cellular oxidative systems. Peak exercise O2 consumption (VO2) and ventilatory efficiency (VE/VCO2) are potent predictors of poor outcome in heart failure (HF). Purpose We studied to find echocardiographic parameters to predict peak VO2 and VE/VCO2. Methods We analyzed 680 patients who underwent CPET and supine bicycle stress echocardiography simultaneously. CPET was performed using semi-supine ramp bicycle exercise with encouraging R &amp;gt; 1.0. Results Both poor exercise tolerance (peak VO2 &amp;lt; 14 mL/kg/min) and ventilatory inefficiency (VE/VCO2 &amp;gt; 36) were associated with age, LV mass index, LV ejection fraction, baseline or exercise E/e’, TR velocity, LA strain, peak apical rotation, and LA stiffness ((E/e’)/LA strain). In multivariate analysis, only LA stiffness was highly associated in both poor exercise tolerance(p &amp;lt; 0.001, odds ratio 0.96, 95% CI [0.94 0.98]) and ventilatory inefficiency(p&amp;lt;0.001, odds ratio 1.05, 95% CI [1.02 1.08]). Conclusion LA stiffness is independently associated with poor exercise tolerance and ventilatory inefficiency.

Prognostic role and relationship of thyroid dysfunction and lipid profile in hospitalized heart failure patients.

Thyroid dysfunction might have a negative impact on the prognosis of patients with heart failure (HF) and affect the lipid metabolism. The aim of our study was to investigate the prognostic role of thyroid dysfunction and its relationship with lipid profile in hospitalized HF patients. Thyroid dysfunction strongly correlates with prognosis of HF patients and combination with lipid profile improves the prognostic value. We performed a single-center retrospective cohort study including hospitalized HF patients between March 2009 and June 2018. Among enrolled 3733 patients, low fT3 (hazard ratio [HR] 1.33; 95% CI: 1.15-1.54; p < .001), elevated TSH (HR 1.37; 95% CI 1.15-1.64; p < .001), LT3S (HR 1.39; 95% CI: 1.15-1.68; p < .001), overt hyperthyroidism (HR 1.73; 95%CI: 1.00-2.98; p = .048), subclinical hypothyroidism (HR 1.43; 95%CI: 1.13-1.82; p = .003) and overt hypothyroidism (HR 1.76; 95%CI: 1.33-2.34; p < .001) independently increased the risk of composite endpoint defined as the combination of all-cause mortality, heart transplantation, or left ventricular assist device requirement. Higher total cholesterol (HR 0.64; 95%CI: 0.49-0.83; p < .001) was still a protective factor in HF patients. When divided into four groups by fT3 and median lipid profiles, comparison of Kaplan-Meier survival curves for various groups showed good risk stratification (p < .001). LT3S, overt hyperthyroidism, subclinical and overt hypothyroidism were independently associated with poor outcomes in HF. The combination of fT3 and lipid profile improved the prognostic value.

Multi-organ sonographic assessment of congestion has incremental prognostic value in outpatients with heart failure irrespective of left ventricular ejection fraction

Abstract Funding Acknowledgements Type of funding sources: None. Background Congestion is a key driver of symptoms, disease progression and prognosis for patients with heart failure (HF), irrespective of left ventricular ejection fraction (LVEF). However, clinically overt congestion is often undiagnosed unless severe. Recent research has shown that ultrasonographic quantification of systemic venous (i.e. inferior vena cava), renal venous and lung (B-lines) congestion is feasible and identifies HF patients with a worse prognosis. Purpose Whether a simultaneous multi-organ evaluation of congestion by ultrasound may improve risk stratification in HF is unknown. In the present study, we assessed signs of ultrasonographic congestion in the inferior vena cava, lungs and kidneys in HF patients across the LVEF spectrum and investigated their association with pathophysiology, clinical characteristics and prognosis. Methods We prospectively enrolled 326 patients with a prior clinical diagnosis of HF attending a routine follow-up visit. We also enrolled 102 consecutive patients with cardiovascular risk factors (including hypertension, type II diabetes mellitus or chronic ischaemic heart disease) and no history of HF; these latter patients had NT-proBNP levels &amp;lt;125 ng/L, LVEF &amp;gt;50%, and were not taking loop diuretics. All patients underwent a complete clinical assessment, blood and urine tests, and an ultrasound evaluation. Ultrasound congestion was defined as inferior vena cava ≥21 mm, highest tertile of lung B-lines or discontinuous renal venous flow. Results The final population consisted of 310 HF patients (median age 77 years, median NT-proBNP 1037 ng/L, 51% with LVEF &amp;lt;50%), and 101 subjects without HF. Among the 224 HF patients (72%) with no clinical signs of congestion, 95 (42%) had at least one sign of congestion by ultrasound (p&amp;lt;0.0001). HF patients with ≥2 ultrasound signs were older, had greater neurohormonal activation (i.e., higher NT-proBNP; Figure 1), lower urinary sodium concentration, and larger left atria despite similar LVEF. During a median follow-up of 13 (interquartile range 6–15) months, 77 HF patients (19%) died or were hospitalized for HF. HF patients without ultrasonographic evidence of congestion had a similar outcome to subjects without HF (reference; HR 1.02, 95% CI 0.86 – 1.35), while those with ≥2 ultrasound signs had the worst outcome (HR 26.7, 95% CI 12.4–63.6), even after adjusting for multiple clinical variables and NT-proBNP (Figure 2). Adding multi-organ assessment of congestion by ultrasound to a clinical model, including NT-proBNP, provided a 28% net reclassification improvement (p=0.03). Conclusion Simultaneous assessment of pulmonary, systemic venous and kidney congestion by ultrasound identifies a high prevalence of sub-clinical congestion associated with poor outcomes in HF, irrespective of LVEF. The speed of investigation, along with the widespread availability and relatively low cost of ultrasound, makes this protocol easy to implement for real-time assessment of congestion.

Abstract P584: The Impact of Multimorbidity and Functional Limitation on Mental Health and Quality of Life Among Patients With Heart Failure

Background: Multimorbidity (MM) and functional limitation (FL) are associated with poor outcomes in heart failure (HF). However, the individual and combined effect of these on mental health and quality of life in patients with HF is not well understood. Methods: Patients aged ≥ 30 years with 2 or more HF diagnostic codes and 1 or more HF-related prescription drugs from four US institutions were mailed a survey to measure functional status (activities of daily living [ADLs]), quality of life and mental health (PROMIS-29 Health Profile) and social support (PROMIS Informational Support, Instrumental Support, and Social Isolation Short Forms). The sampling frame was restricted to patients with a first ever-diagnosis of HF on or after 1/1/2013 at 1 of the participating sites and on or after 1/1/2015 for the other 3 participating sites. A total of 3330 patients returned the survey (response rate 35%); among these, 3020 completed the questions of interest for this analysis and were retained. MM was defined as the presence of ≥ 2 non-cardiovascular comorbidities, and FL was defined as reporting any limitation in at least 1 of 8 ADLs. Patients were categorized into 4 groups by MM (Yes/No) and FL (Yes/No). We dichotomized the subscale scores of the PROMIS-29 at the median and calculated odd ratios for the 4 MM/FL groups. Results: Among 3020 patients with HF (45% female; mean age 73±12 years), 29% had neither MM or FL, 24% had MM only, 22% had FL only, and 25% had both. After adjustment, having both MM and FL or only FL was associated with increased odds of higher anxiety, depression, fatigue, sleep, and pain scores compared to having neither (Figure); having MM only was associated with a higher pain score. Conclusions: Patients with both FL and MM and only FL have similar odds of poor mental health and quality of life scores, underscoring the importance of the role that FL plays in outcomes in patients with HF.

Evaluating Health Care Provider Perspectives on the Use of Mobile Apps to Support Patients With Heart Failure Management: Qualitative Descriptive Study.

Nonadherence to diet and medical therapies in heart failure (HF) contributes to poor HF outcomes. Mobile apps may be a promising way to improve adherence because they increase knowledge and behavior change via education and monitoring. Well-designed apps with input from health care providers (HCPs) can lead to successful adoption of such apps in practice. However, little is known about HCPs' perspectives on the use of mobile apps to support HF management. The aim of this study is to determine HCPs' perspectives (needs, motivations, and challenges) on the use of mobile apps to support patients with HF management. A qualitative descriptive study using one-on-one semistructured interviews, informed by the diffusion of innovation theory, was conducted among HF HCPs, including cardiologists, nurses, and nurse practitioners. Transcripts were independently coded by 2 researchers and analyzed using content analysis. The 21 HCPs (cardiologists: n=8, 38%; nurses: n=6, 29%; and nurse practitioners: n=7, 33%) identified challenges and opportunities for app adoption across 5 themes: participant-perceived factors that affect app adoption-these include patient age, technology savviness, technology access, and ease of use; improved delivery of care-apps can support remote care; collect, share, and assess health information; identify adverse events; prevent hospitalizations; and limit clinic visits; facilitating patient engagement in care-apps can provide feedback and reinforcement, facilitate connection and communication between patients and their HCPs, support monitoring, and track self-care; providing patient support through education-apps can provide HF-related information (ie, diet and medications); and participant views on app features for their patients-HCPs felt that useful apps would have reminders and alarms and participative elements (gamification, food scanner, and quizzes). HCPs had positive views on the use of mobile apps to support patients with HF management. These findings can inform effective development and implementation strategies of HF management apps in clinical practice.

Assessing potassium levels in critically ill patients with heart failure: application of a group-based trajectory model.

Abnormalities in potassium homeostasis are frequently seen in hospitalized patients. A poor outcome in heart failure (HF) has been linked to both hypokalaemia and hyperkalaemia. The studies on the connection between variations in potassium levels and all-cause mortality remain scarce. We delineated trajectories of potassium levels and investigated the association of these trajectories with all-cause mortality of critically ill patients with HF. A retrospective analysis of blood potassium levels (9 times) in patients with HF after being admitted to the intensive care unit (ICU). Potassium levels were divided into three groups according to the first serum potassium level in ICU and thereafter categorized as follows: hypokalaemia group (n=336) (<3.5mmol/L), normal blood potassium-level group (n=3322) (3.5-5.0mmol/L), and hyperkalaemia group (n=395) (>5.0mmol/L). According to the group-based trajectory modelling (GBTM), the hyperkalaemia group and the normal blood potassium-level group can be divided into three trajectory groups: the low-level stable group, the medium-level stable group, and the high-level decline group. The hypokalaemia group can be divided into two trajectory groups: the low-level rise group and the high-level rise group. A total of 4053 HF patients were included (mean age 71.81±13.12years, 54.90% males, 45.10% females). After adjusting for possible confounding variables, in the hyperkalaemia group, the low-level stable group had lower 28day [high-level decline group vs. low-level stable group hazard ratio (HR), 95% confidence interval (CI): 2.917, 1.555-5.473; P<0.05] and 365day (high-level decline group vs. low-level stable group HR, 95% CI: 2.854, 1.820-4.475; P<0.05) all-cause mortality. In the normal blood potassium-level group, the medium-level stable group had lower 28day (medium-level stable group vs. low-level stable group HR, 95% CI: 0.776, 0.657-0.918; P<0.05) and 365day (medium-level stable group vs. low-level stable group HR, 95% CI: 0.827, 0.733-0.934; P<0.05) all-cause mortality. In the hypokalaemia group, the cumulative survival of the high-level rise group and the low-level rise group did not differ significantly. Critically ill patients with HF have blood potassium trajectories. And the trajectories are associated with all-cause mortality for hyperkalaemia and normal blood potassium-level patients. GBTM is a granular method to describe the evolution of blood potassium, which may increase the current knowledge of blood potassium-level adjustment.

Cardiorenal Crosstalk in Patients with Heart Failure

Worsening renal function is associated with poor outcomes in heart failure and often accompanies the initiation and up-titration of guidelines-directed heart failure therapy. This narrative review summarizes current evidence on immediate and long-term effects of pharmacological or device-based treatment in heart failure patients with reduced or preserved left ventricular ejection fraction.

Role Of Ejection Fraction On Discharge Diuretic Dose And Cardiac Rehospitalizations

<h3>Introduction</h3> Acute decompensated heart failure (ADHF) is one of the most common causes of hospitalizations in the United States - accounting for 57.4 million hospitalizations between 2001 and 2014. Patients discharged from the hospital for ADHF are prescribed oral loop diuretics to prevent signs and symptoms of volume overload. Currently, there is conflicting literature regarding home loop diuretic dose adjustments during hospitalizations. As a result, we sought to compare the effects of dose adjustments at discharge on clinical outcomes in both heart failure preserved ejection fraction (HFpEF) and heart failure reduced ejection fraction (HFrEF). <h3>Hypothesis</h3> Patients with lower ejection fractions will have a higher risk for rehospitalization at 60 days. <h3>Methods</h3> 2193 hospital encounters for ADHF in a WellSpan affiliated hospital in Pennsylvania between December 1, 2017 to January 1, 2020 were identified and included in this retrospective study. Baseline characteristics, rehospitalizations, and cardiac hospitalizations at 60 days were compared for patients with HFpEF and HFrEF using one-way ANOVA, chi-square tests, and linear regression. <h3>Results</h3> There were 831 HFrEF and 1362 HFpEF hospitalizations The average age for the cohort was 75.53 + 12.26 with a weight of 93.69 + 29.51 kg. Average discharge diuretic dose for HFrEF patients was 101 + 74.1 mg and 90.2 + 70.6 mg for HFpEF patients. There was a statistically significant difference between both cohorts in terms of brain-natriuretic peptide, baseline creatinine, CAD, HTN, and atrial fibrillation history. There was a significant correlation between decreasing diuretic dose and increased cardiac hospitalizations in the HFrEF cohort (p = 0.04), but not in the HFpEF population (p = 0.96) at 60 days. There was no association between dose adjustments at discharge with rehospitalizations at 60 days (p = 0.93), and cardiac hospitalizations at 60 days (p = 0.37). When combining both cohorts, there was a lack of significance with discharge diuretic dose adjustments with rehospitalizations (p = 0.40) and cardiac hospitalizations (p = 0.47) at 60 days. <h3>Conclusions</h3> Patients with HFrEF were more likely to have cardiac rehospitalizations compared to HFpEF patients with decreasing home diuretic doses at discharge at 60 days. Most likely, decreasing home diuretic dose at discharge results in an increased risk of volume overload. The reason for decreasing diuretic doses could include low blood pressures as well as increasing creatinine. Both variables have been shown to be independent predictors of poor outcomes in heart failure. Interestingly, the HFpEF patients did not have any changes in 60-day outcomes with changes in diuretic dosing. As a result, there may be other factors may be in play affecting cardiac rehospitalizations in patients with HFpEF moreso than symptoms of congestion.

Racial and Gender Disparities in the Prognostic Value of Galectin-3 in Post Left Ventricular Assist Device Outcomes

<h3>Purpose</h3> Galectin-3 is a novel biomarker, with elevated levels being linked to greater cardiovascular risk and poor outcomes in heart failure (HF) patients. McEvoy et al. found that Galectin-3 has better predictive value of HF outcomes in Caucasians compared to African Americans, however, this relationship and gender disparities have not been well explored in the Left Ventricular Assist Device (LVAD) population. The purpose of this study was to investigate gender and racial disparities in the LVAD population. <h3>Methods</h3> From 2012 to 2020, 171 LVAD patients at our institution had lab values collected for Galectin-3. Of these, 73 were African American, 76 were Caucasian, 110 were male, and 61 were female. Their outcomes, including right ventricular failure (RVF), time on inotropes, need for right ventricular assist device (RVAD), length ICU stay, and mortality were collected retrospectively. <h3>Results</h3> There was no significant difference in demographic variables besides age and BSA (Table 1). Galectin-3 correlated to inotrope duration in both African Americans (r=0.312, p=0.008) and Caucasians (r=0.295, p=0.013), but was only correlated with ICU stay in Caucasians (r=0.352, p=0.003), and not in African Americans (r=-0.006, p=0.963) There was significant correlation between Galectin-3 and Creatinine in Caucasians (r=0.425, p=0.001), but not in African Americans (r=0.078, p=0.509)Galectin-3 predicted inotrope duration in males (r=0.32, p=0.001) but not in females (r=0.28, p=0.07). Correlation was also found between Galectin-3 and Creatinine in males (r=-0.27, p=0.005), but not in females (r=-0.09, p=0.55). Galectin-3 predicted mortality in males with mean Galectin-3 of 28.6 ± 11.3 in those who died compared to 25.0 ± 12.2 in those who did not (p=0.05), while it did not in females, with mean Galectin-3 of 29.3 ± 17.6 in those who died compared to 28.0 ± 13.1 in those who did not (p=0.78). <h3>Conclusion</h3> The prognostic implications of Galectin-3 may be more pronounced in certain gender and racial groups.

Prevalence, correlates and in-hospital outcomes of kidney dysfunction in hospitalized patients with heart failure in Buea-Cameroon

BackgroundKidney dysfunction is common in patients with heart failure (HF) and has been associated with poor outcomes. This study aimed to determine the prevalence, correlates, and prognosis of kidney dysfunction in patients with HF in Cameroon, an understudied population.MethodsWe conducted a cross-sectional study in consecutive patients hospitalized with HF between June 2016 and November 2017 in the Buea Regional Hospital, Cameroon. Kidney dysfunction was defined as an estimated glomerular filtration rate < 60 ml/min/1.73m2. Prognostic outcomes included death and prolonged hospital stay (> 7 days). We also performed a sensitivity analysis excluding racial considerations.ResultsSeventy four patients (86.1% of those eligible) were included. Their median age was 60 (interquartile range: 44–72) years and 46.0% (n = 34) were males. Half of patients (n = 37) had kidney dysfunction. Correlates of kidney dysfunction included previous diagnosis of HF (adjusted odds ratio [aOR]4.3, 95% CI: 1.1–17.5) and left ventricular hypertrophy (aOR3.4, 95% CI: 1.1–9.9). Thirty-six (48.9%) had prolonged hospital stay, and seven (9.5%) patients died in hospital. Kidney dysfunction was not associated with in-hospital death (aOR 0.4, 95% CI: 0.1–2) nor prolonged hospital stay (aOR 2.04, 0.8–5.3). In sensitivity analysis (excluding racial consideration), factors associated with Kidney dysfunction in HF were; anemia (aOR: 3.0, 95% CI: 1.1–8.5), chronic heart failure (aOR: 4.7, 95% CI: 0.9–24.6), heart rate on admission < 90 bpm (aOR: 3.4, 95% CI: 1.1–9.1), left atrial dilation (aOR: 3.2, 95% CI: 1.04–10), and hypertensive heart disease (aOR: 3.1, 95% CI: 1.2–8.4). Kidney dysfunction in HF was associated with hospital stay > 7 days (OR: 2.6, 95% CI: 1–6.8).ConclusionModerate-to-severe kidney dysfunction was seen in half of the patients hospitalized with HF in our setting, and this was associated with a previous diagnosis of HF and left ventricular hypertrophy. Kidney dysfunction might not be the main driver of poor HF outcomes in this population. In sensitivity analysis, this was associated with anemia, chronic heart failure, heart rate on admission less than 90 bpm, left atrial dilatation, and hypertensive heart disease. Kidney dysfunction was associated with hospital stay > 7 days.

Serum uric acid and outcomes in patients with chronic heart failure through the whole spectrum of ejection fraction phenotypes: Analysis of the ESC-EORP Heart Failure Long-Term (HF LT) Registry

BackgroundRetrospective analyses of clinical trials indicate that elevated serum uric acid (sUA) predicts poor outcome in heart failure (HF). Uric acid can contribute to inflammation and microvascular dysfunction, which may differently affect different left ventricular ejection fraction (LVEF) phenotypes. However, role of sUA across LVEF phenotypes is unknown. ObjectivesWe investigated sUA association with outcome in a prospective cohort of HF patients stratified according to LVEF. MethodsThrough the Heart Failure Long-Term Registry of the European Society of Cardiology (ESC-EORP-HF-LT), 4,438 outpatients were identified and classified into: reduced (<40% HFrEF), mid-range (40–49% HFmrEF), and preserved (≥50% HFpEF) LVEF. Endpoints were the composite of cardiovascular death/HF hospitalization, and individual components. ResultsMedian sUA was 6.72 (IQ:5.48-8.20) mg/dl in HFrEF, 6.41 (5.02-7.77) in HFmrEF, and 6.30 (5.20-7.70) in HFpEF. At a median 372-day follow-up, the composite endpoint occurred in 648 (13.1%) patients, with 176 (3.6%) deaths and 538 (10.9%) HF hospitalizations. Compared with lowest sUA quartile (Q), Q-III and Q-IV were significantly associated with the composite endpoint (adjusted HR 1.68: 95% CI 1.11–2.54; 2.46: 95% CI 1.66–3.64, respectively). By univariable analyses, HFrEF and HFmrEF patients in Q-III and Q-IV, and HFpEF patients in Q-IV, showed increased risk for the composite endpoint (P<0.05 for all); after model-adjustment, significant association of sUA with outcome persisted among HFrEF in Q-IV, and HFpEF in Q-III-IV. ConclusionsIn a large, contemporary-treated cohort of HF outpatients, sUA is an independent prognosticator of adverse outcome, which can be appreciated in HErEF and HFpEF patients.

Clinical Implications of Uric Acid in Heart Failure: A Comprehensive Review.

Affecting more than 26 million people worldwide and with rising prevalence, heart failure (HF) represents a major global health problem. Hence, further research is needed in order to abate poor HF outcomes and mitigate significant expenses that burden health care systems. Based on available data, experts agree that there is an urgent need for a cost-effective prognostic biomarker in HF. Although a significant number of biomarkers have already been investigated in this setting, the clinical utility of adding biomarker evaluation to routine HF care still remains ambiguous. Specifically, in this review we focused on uric acid (UA), a purine metabolism detriment whose role as cardiovascular risk factor has been exhaustingly debated for decades. Multiple large population studies indicate that UA is an independent predictor of mortality in acute and chronic HF, making it a significant prognostic factor in both settings. High serum levels have been also associated with an increased incidence of HF, thus expanding the clinical utility of UA. Importantly, emerging data suggests that UA is also implicated in the pathogenesis of HF, which sheds light on UA as a feasible therapeutic target. Although to date clinical studies have not been able to prove the benefits of xanthine oxidase in HF patients, we discuss the putative role of UA and xanthine oxidase in the pathophysiology of HF as a therapeutic target.

Impact of sarcopenia on prognosis in patients with heart failure with reduced and preserved ejection fraction.

Sarcopenia, one of the extracardiac factors for reduced functional capacity and poor outcome in heart failure (HF), may act differently between HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF). We sought to investigate the impact of sarcopenia on mortality in HFpEF and HFrEF. We performed a post hoc analysis of a multicentre prospective cohort study, including 942 consecutive older (age ≥65 years) hospitalized patients: 475 with HFpEF (ejection fraction ≥45%, age 81 ± 7 years, 48.8% men) and 467 with HFrEF (ejection fraction <45%, age 78 ± 8 years, 68.1% men). Sarcopenia was diagnosed according to the international criteria incorporating muscle strength (handgrip strength), physical performance (gait speed), and skeletal muscle mass (appendicular skeletal mass). The HFpEF group consisted of fewer patients with low appendicular skeletal muscle mass index measured using bioelectrical impedance analysis [<7.0 kg/m2 (men) and <5.7 (women); 22.1% vs. 31.0%, P = 0.003], and more patients with low handgrip strength [<26 kg (men) and <18 (women); 67.8% vs. 55.5%, P < 0.001], and slow gait speed [<0.8 m/s (both sexes); 54.5% vs. 41.1%, P < 0.001] than the HFrEF group, resulting in a similar sarcopenia prevalence in the two groups (18.1% vs. 21.6%, P = 0.191). Sarcopenia was an independent predictor of 1-year mortality in both HFpEF and HFrEF [hazard ratio (95% confidence interval) 2.42 (1.36-4.32), P = 0.003 in HFpEF and 2.02 (1.08-3.75), P = 0.027 in HFrEF; P for interaction = 0.666] after adjustment for other predictors. In older patients with HF, sarcopenia contributes to mortality similarly in HFpEF and HFrEF.

Serum potassium and heart failure: association, causation, and clinical implications

Dyskalemia (hypo- and hyperkalemia) is a common clinical encounter in patients with heart failure (HF), linked to underlying pathophysiologic alterations, pharmacological treatments, and concomitant comorbidities. Both hypo- and hyperkalemia have been associated with a poor outcome in HF. However, it is not known if this association is causal. In order to investigate this relation, we implemented the Bradford Hill criteria for causation examining the available literature. Of note, hypokalemia and low-normal potassium levels (serum potassium <4.0mmol/L) appear to be associated with adverse clinical outcomes in HF in a cause-and-effect manner. Conversely, a cause-and-effect relationship between hyperkalemia (serum potassium >5.0mmol/L) and adverse clinical outcomes in HF appears unlikely. We also examined the benefits of renin-angiotensin-aldosterone system inhibitors (RAASi) therapy uptitration in patients with HF and reduced ejection fraction. In fact, hyperkalemia often limits RAASi use, thereby negating or mitigating their clinical benefits. Finally, serum potassium levels in HF should be maintained within the range of 4.0-5.0mmol/L, and although the correction of hyperkalemia does not appear to improve clinical outcomes per se, it may enable the optimal titration of RAASi, offering indirect clinical benefit.

Use of Low Dose Dopamine in Heart Failure with Preserved Ejection Fraction Patients with Right Ventricular Dysfunction

Right ventricular dysfunction (RVD) is associated with poor outcomes in heart failure with preserved ejection fraction (HFpEF) and serves as an important therapeutic target. Though treatment with low-dose dopamine (DA) has not shown benefit decompensated HF, we sought to evaluate the effect of DA on HFpEF patients with RVD (HFpEF-RVD), which is currently is unknown. We analyzed subjects enrolled in the Randomized Evaluation of Heart Failure With Preserved Ejection Fraction Patients With Acute Heart Failure and Dopamine trial (NCT01901809) for the presence of RVD and compared clinical outcomes based on treatment with DA. RVD was defined by ≥1 trait on echocardiography: tricuspid annular plane systolic excursion <1.7 cm, fractional area change <35%, tissue Doppler imaging velocity (S') <10 cm/s, or semi-quantitative visual assessment of RVD. Bivariable analysis was performed using median tests for continuous variables and chi-square tests for categorical variables. Multivariable logistic regression was performed to assess for predictors of RVD in our cohort. RVD was present in 29% (24 of 82) of our cohort. HFpEF-RVD patients had lower BMI (34 kg/m2 [14.6] v 42 kg/m2 [14.2], p=0.01), higher Cr (1.4 mg/dL [0.6] v 1.2 mg/dL [1], p=0.01), and higher NT-proBNP (2327 pg/mL [3260] v 1425 pg/mL [2370], p=0.002) compared to HFpEF-no RVD. BMI was inversely associated with HFpEF-RVD after adjustment for age, sex, and race (p=0.02). HFpEF-RVD had increased 30-D hospital readmission (35% v 19%, p=0.12) and worse survival at 1 year (70% v 88%, p=0.06), though not statistically significant. DA had no significant effect on renal function in HFpEF-RVD; however, the presence of RVD positively modified the effect of DA on length of stay (LOS) (p=0.01, Figure). HFpEF-RVD reflects a sicker subgroup of HFpEF patients. In hospitalized HFpEF, low-dose DA was associated with shorter LOS in HFpEF-RVD. Future studies should be performed to find useful therapies in HFpEF-RVD.