Prevalence Of Heart Failure Research Articles

Exploring the Mechanistic Link Between Obesity and Heart Failure.

Among subtypes of cardiovascular disease, obesity has a potent and unique association with heart failure (HF) that is unexplained by traditional cardiovascular risk mediators. The concomitant rise in the prevalence of obesity and HF necessitates better understanding of their relationship to develop effective prevention and treatment strategies. The purpose of this review is to provide mechanistic insight regarding the link between obesity and HF by elucidating the direct and indirect pathways linking the two conditions. Several direct pathophysiologic mechanisms contribute to HF risk in individuals with excess weight, including hemodynamic alterations, neurohormonal activation, hormonal effects of dysfunctional adipose tissue, ectopic fat deposition with resulting lipotoxicity and microvascular dysfunction. Obesity further predisposes to HF indirectly through causal associations with hypertension, dyslipidemia, and most importantly, diabetes via insulin resistance. Low levels of physical activity and fitness further influence HF risk in the context of obesity. These various processes lead to myocardial injury and cardiac remodeling that are reflected by abnormalities in cardiac biomarkers and cardiac function on myocardial imaging. Understanding and addressing obesity-associated HF is a pressing clinical and public health challenge which can be informed by a deeper understanding of the complex pathways linking these two conditions together.

Timing of Thrombosis with Myeloproliferative Neoplasm Diagnosis Among Veterans and Civilians

Rates of Arterial (AT) and Venous Thrombosis (VT) are increased in Veterans with Myeloproliferative Neoplasms (Vet-MPN), including Essential Thrombocythemia (ET), Polycythemia Vera (PV), and Primary Myelofibrosis (PMF), compared to matched controls (J Clin Oncology 2023 41:16_suppl, 7011). The timing of first AT or VT episode in Vet-MPNs remains undefined when compared to Civilians with MPN (Civ-MPN). These findings could elucidate optimal timing for risk mitigation strategies to prevent thrombotic complications and should help to determine duration of thrombotic risk and need for systemic anticoagulation prophylaxis. The Veterans Affairs Informatics and Computing Infrastructure (VINCI) database was queried from January 1, 2006 to January 26, 2023 to identify Vet-MPNs, AT, and VT through ICD-9 and -10 codes. This process yielded 2,752 Vet-MPN and 583,803 Veterans without MPN from Illinois, the state most representative of the US population. These cohorts were compared to data derived from a retrospective chart review of Civ-MPN cared for between January 1, 2019 to December 31, 2022, at MedStar Georgetown University Hospital and MedStar Washington Hospital Center. Service-Connected Exposures (SCE) to potential carcinogens among Veterans were verified through their duration and location of service. We subdivided time to first AT and VT from MPN diagnosis as follows: more than 3 months prior to MPN diagnosis, within 3 months of diagnosis, 3 months to 1 year post diagnosis, 1 to 5 years, and more than 5 years after MPN diagnosis. Mean data from various cohorts were analyzed utilizing Fisher's exact test. Vet-MPN experienced a statistically higher incidence of AT compared to Civ-MPN (p=.0019) and Civ-MPN experienced a statistically higher incidence of AT compared to Veterans without MPN (p=0.02) which served as a control. In contrast, there was a higher incidence of VT among both Vet- and Civ-MPN cohorts compared to Veterans without MPN (p<.0001) (Table 1). The mean ages at MPN diagnosis and onset of first AT were similar (≥63 years) in both Civ- and Vet-MPN. In contrast, the mean age of MPN diagnosis and age of first VT were considerably earlier for Civ-MPN (51 years) versus both Vet-MPN with VT and Veterans without MPN with VT (≥67 years). There was a higher prevalence of hypertension, hyperlipidemia, diabetes, heart failure, and smoking among Veterans with or without MPN compared to Civ-MPN with either AT or VT (Table 1). A trend toward statistical significance was observed for the presence of hypertension and hyperlipidemia (p=0.049 and p=0.02, respectively) in Vet-MPN compared to Civ-MPN, while Veterans without MPN had a statistically higher prevalence of hyperlipidemia (p=0.02) and heart failure (p=0.001) in AT. Notably, a trend toward statistical significance in VT was observed for the presence of diabetes among all Veterans with or without MPN compared to Civ-MPN (p=0.01 and p=0.007, respectively). There was a biphasic distribution in time to onset of first AT and VT in all Vet- and Civ-MPN cohorts (Figure 1). There was a higher cumulative incidence of first AT and VT in Vet-MPN at more than 3 months prior to MPN diagnosis compared to Civ-MPN with AT and VT (Figure 1). On the other hand, the Civ-MPN cohort had a late surge of first VT more than 5 years after MPN diagnosis compared to the other MPN cohorts. A biphasic distribution in time to onset of first AT and VT was also observed among the Vet-MPN cohort when stratified by SCEs from World War II, the Korean War, the Vietnam War, and the Gulf War. The vast majority of both AT and VT in Vet-MPN from all SCE examined experienced onset of thrombotic events more than 3 months prior to MPN diagnosis. Most VT in Gulf War Vet-MPN occurred within 3 months of MPN diagnosis. In conclusion, the predominant risk for developing thrombotic complications in MPN, particularly in Vet-MPN, occurs in a biphasic pattern, beginning more than 3 months prior to MPN diagnosis and becoming apparent again at more than 5 years after MPN diagnosis. These findings suggest that the MPNs convey an enduring hypercoagulability potential throughout the natural history of the disease. There appears to be an accelerated onset of thrombotic complications earlier in the course of disease in Vet-MPN, perhaps reflecting their SCE with toxic carcinogens. More work is necessary to determine epigenetic influences on MPN natural history.

Forensic, legal, and clinical aspects of deaths associated with implanted cardiac devices

As the population ages, the prevalence of heart failure and individuals wearing an implanted cardiac device is increasing. The combination of different underlying pathophysiologies and (the combination of) implanted cardiac devices can become a challenge with regard to the determination of cause and manner of death in such individuals. Additionally, heart disease is frequently associated with mental disease, ranging from anxiety and depression to suicidality and suicide (attempts). At the same time, the correct diagnosis of cause and manner of death is the basis for quality assurance, further therapeutic advances, legal safety, and suicide prevention. By that, an interdisciplinary field between legal medicine, clinicians, and law enforcement opens up. In this field, the different participants can simultaneously benefit from and need each other. For example, legal medicine experts need investigatory results and clinical expertise for the interpretation of readout data of implanted cardiac devices in order to correctly determine the cause of death. A correctly determined cause of death can assist law enforcement and help clinicians to further improve various therapeutic approaches based on correct mortality data collection. In addition, it is the basis for identification of suicides of device carriers, allowing psychological and psychiatric experts to better understand the burden of mental disease in this particular cohort. Against this interdisciplinary background, this manuscript summarizes information about psychiatric comorbidities and suicidality while being on a device. Thereby, basic information on complications and malfunctions of implanted cardiac devices, device-associated deaths with particular emphasis on device manipulation is displayed as basic information needed for correct determination of the cause of death. Also, legal and ethical issues in this field are outlined. The final result is a proposal of an interdisciplinary assessment workflow for a conjoint approach to improve the diagnosis of deaths associated with implanted cardiac devices. It will allow for a differentiation between an individual who died with or due to the device.

Cardiovascular Outcomes Among Myeloproliferative Neoplasm Patients with or without Agent Orange Exposure Using a Large Veteran Database

Cardiovascular Disease (CVD) and its complications contribute significantly to the morbidity and mortality of individuals with Myeloproliferative Neoplasms (MPNs), apart from the increased incidence of untoward thrombosis and bleeding. The prevalence of CVD, such as Heart Failure (HF) and Pulmonary Hypertension (PH) in individuals with MPNs and its association with exposure to Agent Orange (AO), a dioxin-containing carcinogen, remain undefined. These findings will be essential in risk stratification and multidisciplinary management of MPNs to prevent progression of CVD. Utilizing the Veterans Affairs Informatics and Computing Infrastructure (VINCI) database, a case-control study was performed from January 1, 2006 - January 26, 2023 to characterize the association of CVD in Veterans with MPNs, arterial thrombosis (AT), venous thrombosis (VT), bleeding, and AO exposure. ICD-9 and -10 codes identified Veterans with MPN, AT, VT, bleeding, CV risk factors, such as hypertension (HTN), hyperlipidemia (HLD), diabetes (DM), smoking, and CVD sequelae, such as HF and PH. Age-, sex-, and race-matched controls (1:1) were selected from VINCI, who are Veterans without MPNs from Illinois, the state most representative of the U.S. population. Composite CVD outcome includes any Veteran with either HTN, HLD, DM, HF, or PH. Exposure to AO was self-reported and verified through Veterans' duration and location of service. Qualitative data were compared by chi-square tests. Among 93,269 Veterans with MPN, there were higher rates of composite CVD, CV risk factors, HF, PH, AT, VT, and bleeding (Figure 1) compared to matched controls. All MPN subtypes, Essential Thrombocythemia (ET), Polycythemia Vera (PV), and Primary Myelofibrosis (PMF) were each associated with increased prevalence of HTN, HLD, DM, HF, and PH (p<0.0001). Among Veterans with MPNs with AT, VT, or bleeding, there was a significant association with each CV risk factors, HF, and PH (p<.001). Among Veterans with MPN with AO exposure, there were higher rates of composite CVD, CV risk factors, HF, PH, AT, and bleeding (Figure 1) when compared to those without AO exposure. Among matched controls with AO, there were higher rates of HLD and AT compared to matched controls without AO. Veterans born before 1960 with AO exposure had younger mean age at MPN diagnosis compared to those without AO, 66 ± 7 (SD) years vs. 69 ± 10 (SD) years, p<0.0001, respectively. Among the 24,385 (26.1%) Veterans with MPNs with HF vs. 1,749 (1.9%) Veterans with MPNs with PH: 46.1% vs. 38.9% had ET; 48.8% vs. 56% had PV; and 5.1% vs. 5.1% had PMF; 92.7% vs. 91.2% were born before 1960; 96.8% vs. 95.3% were male; 75.8% vs. 72.1% White; 14.7% vs. 19.3% Black; 7.5% vs. 6.9% unknown race, respectively. Among MPNs with PH, there is a higher rate of pulmonary embolism (4.87% vs. 1.1%, p<0.0001) when compared to matched controls. There is decreased overall survival among Veterans with MPNs with HF and PH (Figure 2) and Veterans with MPNs compared to matched controls. In summary, the CV risk factors, HF and PH, are increased in Veterans with MPNs and are associated with increased risk for AT, VT, and bleeding complications. Not only is AO exposure associated with development of MPN, as previously reported (J Clin Oncology 2023 41:16_suppl, 7011), but AO exposure appears to increase CVD complications among Veterans with MPNs. Further studies evaluating contributions of driver mutation and CHIPs to cardiac and vascular remodeling are needed and will elucidate the implications of AO and its imputed toxic effects on DNA to the accelerated development of MPNs and its CVD complications. Future targeted therapies and strategies should be developed to mitigate the consequences of progressive CVD, and prevention of AT, VT, and bleeding complications in individuals with MPNs.

Assessment of Inpatient Mortality in the Peri-Transplant Period in Elderly Allogeneic Stem Cell Transplant Recipients with Co-Existing Mental Health Illnesses

Background Allogeneic hematopoietic stem cell transplant (alloHCT) is a potentially curative treatment for patients with hematological malignancies and nonmalignant conditions. AlloHCT involves invasive procedures, conditioning chemotherapy regimens, and prolonged isolation during hospitalization, which is physically and emotionally challenging. Transplant related mortality is higher in older individuals. Careful assessment of mortality risk before transplant is essential for optimal patient selection and informed decision-making, especially in elderly patients. Hematopoietic cell transplantation-specific comorbidity index (HCT-CI), an important prognostic scoring tool used in patients before alloHCT, includes psychiatric comorbidity as one of the scoring criteria. Patients with depression or anxiety disorders receive one point on the scoring scale, with the assumption that the two groups of patients are at an equivalent risk. However, there is literature showing decreased overall survival and worse inpatient outcomes in patients receiving alloHCT with co-morbid depression. Our primary objective was to evaluate the inpatient outcomes of elderly patients undergoing allogeneic stem cell transplant with a concurrent diagnosis of depression and patients with anxiety and adjustment disorders. Methods: Patients of ages ≥ 60 years, admitted with a principal procedure code of allogeneic stem cell transplant, were recruited from the 2016-2020 National Inpatient Sample. Three cohorts were created based on ICD-10 diagnostic codes for Depression and Anxiety and adjustment disorders: patients without depression and anxiety disorders, patients with depression only, and patients with anxiety and adjustment disorders only. Patients with diagnoses of other mental illnesses were excluded. The patient characteristics between the three cohorts were evaluated. Multiple Logistic Regression models were used to determine the impact of depression and anxiety disorders on inpatient mortality. Results: We evaluated 11655 hospital admissions with the primary procedure code for Allogeneic Stem Cell Transplant in patients aged 60 years and above. 8375 patients did not have any mental illness. 800 patients (9.5%) had a diagnosis of Depression, and 1640 patients (19.5%) had a diagnosis of Anxiety and adjustment disorders. Comparing the primary outcomes in patients with and without Depression, the length of stay was 31.3 days vs 28.2 days (p<0.01), the mean hospital charge was 558398.01 USD vs 498971.9 USD (p <0.01), and in-patient mortality was 8.1% vs 5.9% (aOR = 1.359, 95% CI 1.010-1.829, p=0.04). Utilization of mechanical ventilation was more prevalent in patients with depression (8.8 %vs 5.8 %, p <0.01). Out of different infectious complications, pneumonia was more common in patients with depression (14.4 % vs 9.8 %, p <0.01) (Table 1a). Baseline socio-demographic characteristics that were associated with having depression included: Female gender, White race, and Medicare insurance. Patients with depression had an increased prevalence of congestive heart failure, prior stroke, Obesity with BMI >= 35, chronic kidney disease, and COPD compared to patients without depression (p<0.01). For the primary outcomes in patients with and without anxiety and adjustment disorders, the length of stay was 29.15 days vs 28.2 days (p <0.01), the mean hospital charge was 474274.71 USD vs 498971.94 USD (p 0.612), and the in-patient mortality was 4% vs 5.9 % (aOR=0.61, 95% CI 0.45-0.83, p<0.01). Baseline socio-demographic characteristics that were prevalent in patients with anxiety and adjustment disorders were: female gender, white race, and Medicare as the most common insurance (P<0.01) (Table 1b). Conclusion We found that in elderly patients admitted for alloHCT, depression was independently associated with worse inpatient outcomes, while anxiety was not. Patients with depression were noted to have an increased incidence of infectious complications as compared to those without depression, possibly accounting for their increased mortality. Prognostic scoring systems like HCT-CI may need to be modified to assign more weight to depression as a psychiatric co-morbidity. Elderly transplant recipients with depressive disorders are a vulnerable group and multidisciplinary teams such as psychiatry and palliative care should be involved in their care.

Effect of SGLT2 inhibitors on cardiovascular events in patients with atrial fibrillation:A systematic review and meta-analysis of randomized controlled trials.

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) is reported to reduce incident atrial fibrillation (AF) in patients with or without diabetes; however, its cardiovascular (CV) benefit for AF patients remains unclear. To investigate the effect of SGLT2i on the incidence of CV events in patients with AF. Six randomized controlled trials (RCTs) assessing the effects of SGLT2i on CV outcomes in patients with or without AF were included (PROSPERO: CRD 42023431535). The primary endpoint was the composite outcome of heart failure (HF) hospitalization and CV death. Additionally, we assessed the effects of treatment in prespecified subgroups on HF hospitalization, CV death, and all-cause mortality. Among 38,529 participants from all trials, 5018 patients with AF were treated with SGLT2i. The follow-up period of these trials ranged from 2.3 to 3.3 years. SGLT2i treatment was significantly associated with the risk reduction of primary endpoint in patients with AF (risk ratio [RR] 0.81, 95% confidence interval [CI] 0.74-0.88; p<0.001), consistent with the finding in the general population (p for interaction=0.76). SGLT2i was also associated with a consistent reduction in the risk of HF hospitalization in patients with AF (RR 0.76, 95% CI 0.69-0.84; p<0.001) or not (RR 0.72, 95% CI 0.64-0.80; p<0.0001), with no statistical difference between them (p for interaction=0.41). Meta-regression further revealed no significant association between the prevalence of HF with reduced ejection fraction or diabetes and the effect size of SGLT2i. The treatment effects of SGLT2i were associated with a lower incidence of CV events, especially HF hospitalization, in patients with AF.

Radiomics of pericardial fat: a new frontier in heart failure discrimination and prediction

ObjectivesTo use pericardial adipose tissue (PAT) radiomics phenotyping to differentiate existing and predict future heart failure (HF) cases in the UK Biobank.MethodsPAT segmentations were derived from cardiovascular magnetic resonance (CMR) studies using an automated quality-controlled model to define the region-of-interest for radiomics analysis. Prevalent (present at time of imaging) and incident (first occurrence after imaging) HF were ascertained using health record linkage. We created balanced cohorts of non-HF individuals for comparison. PyRadiomics was utilised to extract 104 radiomics features, of which 28 were chosen after excluding highly correlated ones (0.8). These features, plus sex and age, served as predictors in binary classification models trained separately to detect (1) prevalent and (2) incident HF. We tested seven modeling methods using tenfold nested cross-validation and examined feature importance with explainability methods.ResultsWe studied 1204 participants in total, 297 participants with prevalent (60 ± 7 years, 21% female) and 305 with incident (61 ± 6 years, 32% female) HF, and an equal number of non-HF comparators. We achieved good discriminative performance for both prevalent (voting classifier; AUC: 0.76; F1 score: 0.70) and incident (light gradient boosting machine: AUC: 0.74; F1 score: 0.68) HF. Our radiomics models showed marginally better performance compared to PAT area alone.Increased PAT size (maximum 2D diameter in a given column or slice) and texture heterogeneity (sum entropy) were important features for prevalent and incident HF classification models.ConclusionsThe amount and character of PAT discriminate individuals with prevalent HF and predict incidence of future HF.Clinical relevance statementThis study presents an innovative application of pericardial adipose tissue (PAT) radiomics phenotyping as a predictive tool for heart failure (HF), a major public health concern. By leveraging advanced machine learning methods, the research uncovers that the quantity and characteristics of PAT can be used to identify existing cases of HF and predict future occurrences. The enhanced performance of these radiomics models over PAT area alone supports the potential for better personalised care through earlier detection and prevention of HF.Key Points•PAT radiomics applied to CMR was used for the first time to derive binary machine learning classifiers to develop models for discrimination of prevalence and prediction of incident heart failure.•Models using PAT area provided acceptable discrimination between cases of prevalent or incident heart failure and comparator groups.•An increased PAT volume (increased diameter using shape features) and greater texture heterogeneity captured by radiomics texture features (increased sum entropy) can be used as an additional classifier marker for heart failure.

Deep learning-based NT-proBNP prediction from the ECG for risk assessment in the community.

The biomarker N-terminal pro B-type natriuretic peptide (NT-proBNP) has predictive value for identifying individuals at risk for cardiovascular disease (CVD). However, it is not widely used for screening in the general population, potentially due to financial and operational reasons. This study aims to develop a deep-learning model as an efficient means to reliably identify individuals at risk for CVD by predicting serum levels of NT-proBNP from the ECG. A deep convolutional neural network was developed using the population-based cohort study Hamburg City Health Study (HCHS, n=8,253, 50.9 % women). External validation was performed in two independent population-based cohorts (SHIP-START, n=3,002, 52.1 % women, and SHIP-TREND, n=3,819, 51.2 % women). Assessment of model performance was conducted using Pearson correlation (R) and area under the receiver operating characteristics curve (AUROC). NT-proBNP was predictable from the ECG (R, 0.566 [HCHS], 0.642 [SHIP-START-0], 0.655 [SHIP-TREND-0]). Across cohorts, predicted NT-proBNP (pNT-proBNP) showed good discriminatory ability for prevalent and incident heart failure (HF) (baseline: AUROC 0.795 [HCHS], 0.816 [SHIP-START-0], 0.783 [SHIP-TREND-0]; first follow-up: 0.669 [SHIP-START-1, 5 years], 0.689 [SHIP-TREND-1, 7.3 years]), comparable to the discriminatory value of measured NT-proBNP. pNT-proBNP also demonstrated comparable results for other incident CVD, including atrial fibrillation, stroke, myocardial infarction, and cardiovascular death. Deep learning ECG algorithms can predict NT-proBNP concentrations with high diagnostic and predictive value for HF and other major CVD and may be used in the community to identify individuals at risk. Long-standing experience with NT-proBNP can increase acceptance of such deep learning models in clinical practice.

Echocardiographic Changes in Saudi Patients with Type 2 Diabetes Mellitus.

Background and Objectives: Cardiovascular disease is one of the leading causes of morbidity and mortality among the diabetic population. Given the high prevalence of diabetes mellitus (DM) in Saudi Arabia and the high prevalence of heart failure in the diabetic population, this study assesses the echocardiographic changes in Saudi patients with type 2 DM (T2DM) compared with healthy controls. Materials and Methods: In this retrospective case-control study, 80 patients with diabetes (45 males, age: 58.78 ± 10.2 years) were compared with 80 controls (45 males, age: 58.6 ± 10 years) who underwent an echocardiographic study in the King Saud University Medical City, Riyadh, Saudi Arabia. Results: There were no significant differences between the patients with diabetes and controls in terms of aortic root diameter, left atrium diameter, posterior wall, interventricular wall thickness, left ventricular diameters and ejection fraction. However, diastolic dysfunction was statistically significantly higher in the diabetic group than in the control group (p < 0.05). Conclusions: This is the first case-control study in Saudi Arabia that assesses echocardiographic parameters in T2DM patients. DM is an independent risk factor for diastolic dysfunction regardless of its association with hypertension and dyslipidemia.

Artificial intelligence-derived ECG bio-index as a tool for predicting the prognosis of patients with ST-segment elevation myocardial infarction underwent primary percutaneous coronary intervention

Abstract Background/Introduction Electrocardiogram (ECG) changes after primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) patients, such as the recovery of ST elevation, are associated with prognosis, but quantifying them is challenging. Deep-learning algorithms (DLA) can diagnose STEMI and quantify the probability as a bio-index. However, the prognostic value of this index has yet to be well studied. Purpose This study aims to investigate the feasibility of predicting the prognosis of patients with STEMI by analyzing serial ECGs post-primary PCI using an DLA designed to detect AMI and STEMI. Methods We developed a DLA to detect acute myocardial infarction (AMI) and STEMI using 12-lead ECGs from hospital A. The DLA was based on convolutional neural network and presented the index for probability of AMI and STEMI as a number between 0 and 1. We subsequently analyzed serial ECGs from hospital B, taken more than one month prior to the STEMI event (baseline), at pre-PCI (at emergency department [ED]), immediate post-PCI, 6h, 24h, 1 month after PCI, using the DLA. The primary endpoint was a post-STEMI heart failure defined as left ventricular ejection fraction (LVEF) less than 50%. Results A total of 22,259 ECGs (13,916 ECGs of non-AMI and 8,343 ECGs of AMI) from 15,113 patients were used to develop and validate the DLA. The area under the curve (AUC) of the final DLA was 0.950 for AMI and 0.954 for STEMI. Serial ECGs of 639 STEMI patients were analyzed. The mean index value at different time points were as follows: 0.061 ± 0.158 in baseline ECG, 0.801 ± 0.333 in ECG at ED, 0.525 ± 0.429 in immediate post-PCI, 0.467 ± 0.425 in 6-hour, 0.482 ± 0.423 in 24-hour, and 0.273 ± 0.348 in 1-month after PCI (ANOVA P-value &amp;lt;0.001). To evaluate the predictive value of the DLA index, we stratified the study population into low, intermediate, and high-risk group based on the DLA index, with thresholds of 0.03 and 0.45 of the immediate post-PCI AI indices. The mean LVEF was 53.0 ± 10.1% in the low-risk group, 49.6 ± 10 %, and 47.4 ± 10.2 % in the intermediate and the high-risk group (ANOVA P-value &amp;lt; 0.001). The prevalence of post-STEMI heart failure was 30.6%, 46.4%, and 60.6%, respectively (P &amp;lt; 0.001). Furthermore, the DLA index was significantly associated with the recovery of left ventricular function. The prevalence of heart failure in 3-month follow-up echocardiography was highest in the high-risk group (15.4% vs. 27.1% vs. 31.8%, respectively, P = 0.022). Conclusion Our study shows that the DLA-derived bio-index is an effective tool to quantify ECG changes after primary PCI in STEMI patients and predict post-AMI heart failure. The DLA index is also associated with left ventricular function recovery, indicating its potential as a prognostic marker. Further studies are needed to validate our results and explore the use of the DLA index in assessing myocardial reperfusion after primary PCI.

Current overview of heart failure in adults with congenital heart disease in a latin american centre

Abstract Background Congenital heart disease (CHD) affects a significant number of newborns globally. While survival rates have increased, many interventions provide only palliative therapies and not total repair, leading to chronic complications such as heart failure (HF). Treatment options for adult patients with CHD (ACHD) with HF are similar to those for HF with reduced ejection fraction (HFrEF), but there is a need for trials with hard clinical endpoints. Treatment options include cardiac resynchronization therapy, coronary revascularization, valve repair/replacement, defibrillators, and heart transplantation. More research is needed to understand the prevalence, demographic characteristics, and variables associated with ACHD-HF. Purpose By studying the prevalence of HF in ACHD we can better understand the long-term outcomes and health risks for this population. CHD is one of the most common birth defects, and while survival rates have improved, there is still a risk for HF and other complications as individuals age. When researching HF in this population, investigators can identify potential risk factors, develop targeted interventions, and improve health outcomes for ACHD. Methodology This study was piloted with a private database, filtering patients with CHD who have HF based on the ESC 2022 guides. Parameters such as the severity, left ventricle ejection fraction (LVEF), and functional class were considered. A statistical software was used to filter patients, and the resulting data was then analysed, applying the most relevant variables to the study. Results 3539 patients, with a median age of 34 years included, 56.3% were women. Based on the ESC guidelines, patients were classified according to their CHD complexity, 1977 as mild, 642 as moderate, and 920 as severe. The most common treatment was the total repair, in 58.1% of cases, while 31.5% were in surveillance and 3.6% had no treatment. Mortality was 3.2%, 22.7% of patients lost follow-up. The most common CHD was atrial septal defect. Most patients (76.7%) were in NYHA functional class I, 18.7% in class II, 3.4% in class III, and 0.7% in class IV. LVEF was &amp;gt;50% in 87.7% of patients, 4.7% had a LVEF between 49% and 41%, and 5.8% had LVEF &amp;lt;40%. Bicuspid aortic valve was the most frequent CHD with reduced LVEF, in 9.8% of patients. Of the deceased, 37.5% had a LVEF &amp;lt;40%; and severe CHD was more associated with a LVEF &amp;lt;40%. According to the AHA patients were classified as stages B (84.5%), C (14.6%), and D (0.3%), no patients in stage A identified. Conclusions This study provided an overview of HF in ACHD, identifying important correlations between severity of ACHD-HF and LVEF, and the prevalence of HF among different cardiopathies. The overall mortality of this review was scarce, and of these patients, one-third had previous history of reduced LVEF. HF associated with ACHD is becoming increasingly common in cardiology practice; thus, further studies regarding its prevalence need to be done.

Amiodarone is associated with increased mortality compared with other antiarrhythmic drugs in female patients with atrial fibrillation

Abstract Objective Antiarrhythmic drug (AAD) is the first-line therapy in patients with atrial fibrillation (AF) to maintain sinus rhythm. Amiodarone is one of the commonly used AAD that is known to lead to cardiac and extra-cardiac toxicities including pulmonary fibrosis and thyroid function abnormalities. However, the effect of amiodarone as compared with other-AADs (mainly Ic sodium channel blockers) on all-cause mortality is not fully evaluated. Methods This study used nationwide healthcare insurance system data. Patients with new-onset AF between 2013 and 2019 were enrolled. Use of AADs were confirmed if the patient were prescribed with AAD for more than six months during first year of AF diagnosis (medication possession ratio &amp;gt; 0.5). Clinical follow-up duration was three years from the moment AAD prescription after AF diagnosis. All-cause mortality was compared between amiodarone vs. other-AAD users. Results A total of 770,977 new-onset AF cases were detected. Among these people, 15,142 and 38,707 were identified as amiodarone and other-AAD users, respectively. Significant differences were observed in mean age and prevalence of heart failure, myocardial infarction, chronic kidney disease, diabetes mellitus, and dyslipidemia. After propensity score matching, 9,672 amiodarone users were compared with other-AAD users with same sample size and baseline characteristics were well matched. In multivariate adjusted analysis, amiodarone was associated with 2.5-fold increase in all-cause mortality (hazard ratio=2.520; 95% confidence interval=2.202 – 2.883; p&amp;lt; 0.001). Amiodarone did not show any significant interactions with age, thyroid disease, chronic kidney disease, heart failure, myocardial infarction, diabetes mellitus, dyslipidemia, and hypertension. However, the association between amiodarone and increased mortality was more pronounced in women compared with men (HR=3.124 vs. 2.231; p for interaction=0.022). Conclusion This study showed that all-cause mortality was significantly higher in amiodarone users than other-AAD users due to the toxicities, not by underlying diseases, which was more profound in female. This findings suggests that avoiding amiodarone as a first-line therapy should be considered in AF patients who have no compelling indications such as significant coronary artery disease or heart failure.All-cause mortality

Impact of atrial fibrillation burden on longitudinal changes in left ventricular structure and function: a post-hoc analysis of a randomized clinical trial

Abstract Background Atrial fibrillation (AF) is a well-established risk factor for heart failure (HF), stroke, and left ventricular (LV) dysfunction. However, only limited longitudinal data exist regarding the impact of AF burden on left ventricular (LV) structure and function. Purpose The aim of this study was to investigate the association between AF burden and longitudinal changes in LV structure and function in an older patient population with cardiac risk factors. Methods This study was a post-hoc analysis of a randomized clinical trial, which investigated whether AF screening with implantable loop recorders (ILRs) and subsequent initiation of anticoagulation could prevent stroke in high-risk individuals. As a substudy, a group of participants had extensive transthoracic echocardiography performed at baseline and a re-examination after ILR end-of-life. We included participants with available ILR data and echocardiographic data from both baseline and follow-up. We excluded participants with ongoing AF during the baseline echocardiogram. AF episodes were adjudicated by two cardiologists and AF burden was calculated as the percentage of time spent in AF during the total ILR monitoring period. Univariable and multivariable linear regression models were used to investigate the association between AF burden and changes in echocardiographic measures. The multivariable model was adjusted for age, sex, systolic blood pressure, diabetes, smoking status, previously acute myocardial infarction, previous coronary artery bypass grafting, prevalent HF, body mass index, estimated glomerular filtration rate, number of days monitored by ILR, and the number of days between the two echocardiographic examinations. Both models included adjustment for the baseline value of the echocardiographic measure. Results The study population consisted of 640 participants with available baseline and follow-up echocardiograms. Mean age was 73.6 years (±3.4 years) and 278 (43.4%) were women. AF was documented in 188 (29.4%) participants during a median ILR monitoring period of 3.2 years (IQR 2.9-3.4 years). The mean timespan between the echocardiographic examinations was median 5.0 (IQR 4.6-5.2) years. Among participants with AF, the median AF burden was 0.098% (IQR 0.026-0.758%). Over the course of echocardiographic follow-up, mean ∆GLS was -0.59% (±3.49%), mean ∆LVEF was -1.44% (±8.5%), and mean ∆E/e’ was -1.12(±3.23) in those with AF. Increasing AF burden was significantly associated with an accelerated decline in absolute global longitudinal strain in both univariable (ß= -0.12, p=0.002) and multivariable (ß= -0.11, p=0.003) models (Table 1/Figure 1). Conclusions In an older at-risk population, AF was frequent, and increasing AF burden was found to be independently associated with an accelerated decline in LV function. These findings support AF as an independent risk factor in the development of HF.

Contemporary insights into the epidemiology, impact and treatment of secondary tricuspid regurgitation across the heart failure spectrum

Abstract Background Tricuspid regurgitation secondary to heart failure (sTR) is common with considerable impact on survival and hospitalization rates. Currently, insights into epidemiology, impact, and treatment of sTR across the entire heart failure (HF) spectrum are lacking yet are necessary for informed health care decision-making. Purpose To investigate (i) the demographic aspects of sTR overall and according to HF subtype, (ii) the association of sTR with mortality compared to expected survival in the age and sex matched community (iii) differences in subgroups, to identify patients at increased risk of mortality and (iv) to assess treatment demand and utilization for sTR in a unique setting with a population-wide health-care plan and state-of-the-art medical facilities. Methods This population-based study included individual data from 13469 patients with HF and sTR over a 10-year period. Primary outcome measure was long-term mortality. Results Overall, heart failure with preserved ejection fraction (HFpEF) was the most frequent (57%, n = 7733) HF subtype and the burden of comorbidities was high. Severe sTR was present in 1514 patients (11%), most common among patients with reduced EF (HFrEF) (20%, n = 496). Mortality of patients with sTR was higher than expected survival of sex- and age-matched community and independent of HF subtype (moderate sTR: Hazard ratio [HR] 6.32; 95% Confidence Interval [CI] 5.88-6.80, P&amp;lt;0.00, severe sTR: HR 9.04; 95% CI 8.27-9.87, P&amp;lt;0.001). In comparison to HF and no/mild sTR patients, mortality increased for moderate sTR (HR 1.58, 95%CI 1.48-1.69, P&amp;lt;0.001) and for severe sTR (HR 2.19, 95%CI 2.01-2.38, P&amp;lt;0.001). Survival is presented in Figure 1. This effect prevailed after multivariate adjustment and was similar across all HF subtypes (Figure 2). In subgroup analysis severe sTR mortality-risk was more pronounced in younger patients (&amp;lt;70a). Moderate and severe sTR were rarely treated surgically or percutaneously (3%, n = 147), despite availability of state-of-the-art facilities and universal health care. Conclusion sTR is frequent, increasing with age and associated with excess mortality independent of left ventricular ejection fraction. Nevertheless, sTR is rarely treated surgically or percutaneously. With the projected increase in HF prevalence and population ageing the data suggest a major burden for health-care systems, that needs to be adequately addressed. Low-risk transcatheter treatment options may provide a suitable alternative.Figure 1Figure 2

The association between left ventricular ejection fraction and long-term survival: a large hospital-based cohort study in taiwan

Abstract Background Left ventricular ejection fraction (LVEF) is the most commonly used metric for quantifying left ventricular function. A U-shaped relationship between LVEF and long-term survival with a nadir between 60-70% has been reported in the western, regardless of age, sex, or prevalent heart failure. However, the distribution of mortality risk across the spectrum of LVEF among Asian population remains unclear. Purpose We aim to investigate the distribution of mortality risk across the spectrum of LVEF among Asian population, as well as among different subgroups. Methods In this large hospital-based cohort study, consecutive participants who underwent echocardiography (2002-2021) in a tertiary medical center in Taiwan were included. LVEF was measured by echocardiography using biplane Simpson’s method. All LVEFs were categorized into intervals of 5% from &amp;lt;20% to ≥70%. The National Death Registry was linked to identify mortality and causes of death. Cox proportional hazards regression was used for analyses with adjustment for age, sex, body mass index, and comorbidities. Results A total of 142,834 participants (age 60.6 ± 18.4, men 50.5%) were included. During a mean follow-up of 58.1 ± 47.1 months, 17,317 subjects (12.1%) died. Overall, adjusted hazard ratios (HR) for all-cause mortality showed a U-shaped relationship between LVEF and long-term survival with a nadir of risk at LVEF of 60-70%. Compared with the reference group (LVEF: 60-65%), subjects with LVEF&amp;gt; 70% had a HR of 1.21 (95% confidence interval [CI]: 1.12-1.30) and those with LVEF of 50-55% had a HR of 1.28 (95% CI: 1.22-1.35). (Figure) Similar results with a nadir at 60-70% could also be observed when stratified by the age of 65, sex, comorbidities of hypertension, or diabetes. Conclusions A U-shaped relationship between LVEF and long-term survival with a nadir at LVEF of 60-70% can also be observed in the Asian population. This result may support the use of LVEF&amp;gt; 70% to define supranormal LVEF in Asian subjects.Figure

Hypoxemia in patients with heart failure and preserved ejection fraction

Abstract Background Pulmonary abnormalities are common in patients with prevalent heart failure (HF). Arterial hypoxemia is considered rare in HF, but this has not been rigorously evaluated in patients with HF and preserved EF (HFpEF). Methods Results Patients with HFpEF (n=539) and no clinically-relevant lung disease underwent invasive cardiopulmonary exercise testing with simultaneous blood and expired gas analysis. Exertional hypoxemia was defined by oxyhaeemoglobin saturation &amp;lt;94%. As compared to those without hypoxemia (n=403), patients with hypoxemia (n=136, 25%) were slightly older, heavier, and had higher NT-proBNP levels. They had higher cardiac filling pressures, higher pulmonary vascular pressures, greater alveolar-arterial O2 difference compared to those without hypoxemia. These differences were replicated in a sensitivity analysis where patients with any spirometric abnormalities were excluded. Regression analyses revealed that increases in pulmonary arterial and capillary pressures were related to lower PaO2. The presence of exertional hypoxemia was associated with two-fold increased risk for death over 2.8 (IQR 0.7-5.5) years of follow up, (Adjusted:HR 2.00 (95%CI: 1.01−3.96), p=0.046). Conclusion One quarter of HFpEF patients displayed arterial desaturation during exercise. Patients with hypoxemia display more severely abnormal hemodynamics and increased mortality. Further study is required to better understand the mechanisms in patients with HFpEF.Hemodynamic changes at rest/exerciseRisk of death in HFpEF with hypoxemia

Diastolic dysfunction and its association to renal outcomes in patients with chronic kidney disease

Abstract Background Left ventricular diastolic dysfunction is frequent in chronic kidney disease (CKD) and is suspected to be linked to a worse renal prognosis. Purpose To investigate the association between the ratio of early mitral inflow velocity to early diastolic tissue velocity (E/e') measured by Doppler echocardiography and development of end-stage kidney disease in patients with non-dialysis-dependent CKD. Methods This prospective cohort study included individuals with non-dialysis-dependent CKD with previous nephrology-related hospital contact. All participants underwent thorough, protocolized echocardiographic examination. Exclusion criteria were inadequate image quality for E/e'-assessment and prevalent heart failure at baseline. The primary endpoint was the composite outcome of time to dialysis treatment and/or kidney transplantation. The association between E/e' and the composite outcome was assessed with multivariable Cox proportional hazards regression models adjusted for age, sex, estimated glomerular filtration rate (eGFR), diabetes, Body Mass Index, albuminuria, systolic blood pressure, heart rate, coronary artery disease, and left ventricular ejection fraction. Results A total of 731 participants were included in the final study sample. Mean age was 57 ± 13 years and 61% were male. Median E/e' was 7.8 (IQR: 6.4; 9.5), median eGFR was 43 mL/min/1.73 m² (IQR: 28; 62), and 36% had a urine albumin/creatinine ratio &amp;gt;300. During a median follow-up of 3.8 years (IQR: 3.3; 4.5), 102 individuals met the composite outcome. In univariable Cox regression both continuous E/e' and elevated E/e' (E/e' &amp;gt;14) were significantly associated with the outcome (P&amp;lt;0.001). Following multivariable adjustments, increasing E/e' remained significantly associated with the outcome (HR = 1.09, 95% CI [1.03; 1.15], P=0.004, per 1 unit increase) (Figure 1A). Elevated E/e' also remained significantly associated with the outcome following adjustments (HR = 2.95, 95% CI [1.33; 6.53], P=0.008), and more than 40% of patients with E/e' &amp;gt;14 were estimated to have reached the primary endpoint after 4 years (Figure 1B). Conclusion In patients with non-dialysis dependent CKD increasing E/e' and E/e' &amp;gt;14 were both associated with worse renal prognosis.

Malignant arrhythmias and advanced heart failure in patients with RBM20 cardiomyopathy: a single center cohort study and review of the literature

Abstract Background Sudden cardiac death (SCD), and death rate attributable to heart failure (HF) are common causes of death in the general population. Both are seen in cardiomyopathy patients. RBM20 mutations associated with a cardiomyopathy phenotype and a high risk of SCD and HF. Purpose The aim of this study is to investigate the genotype-phenotype correlations, and clinical outcomes of the RBM20 mutations. Methods Peripheral blood from patients was drawn as a routine diagnostic procedure and genomic DNA extracted according to standard protocols. Patients were tested for at least 45 cardiomyopathy-related genes included in the Dutch core panel. 23 patients with a likely pathogenic or pathogenic RBM20 mutation and a cardiomyopathy phenotype were retrospectively enrolled in a single-center cohort. Patient data on clinical characteristics, imaging and pathology were extracted retrospectively. Furthermore, a literature search was conducted for a literature review on RBM20 mutations in cardiomyopathies. Peer reviewed studies with patients aged 18 or older, a RBM20 mutation, and a cardiomyopathy were included. Results Whole genome sequencing found 5 different RBM20 protein altering mutations. The c.1900C&amp;gt;T mutation was the most frequently seen in 18 patients. Four RBM20 mutations were novel mutations; c.1912, c.2919, c.414 and c.1118_1119 (Table1). The 23 patients had a mean age of 52 ± 15 years, and 13 (59%) were male. The phenotype was predominantly dilated cardiomyopathy (DCM). This was seen in 18 (82%)patients compared to 2 (12%) noncompaction cardiomyopathy (NCCM) patients. Nine (41%) patients had experienced malignant ventricular arrhythmia (VA). The mean age of first VA was 49 ± 10 years. An implantable cardioverter-defibrillator (ICD) was implanted in 13 (57%) patients, and gave appropriate therapy in 5 (23%) patients compared to 1 (9%) patient receiving inappropriate therapy. Ten (46%) patients were diagnosed with heart failure (HF) at a mean age of 50 ± 11 years. One patient died of heart failure, while 5 (25%) patients underwent heart transplantation (HTx). Delayed enhancement (DE) was shown on MRI in 5 (50%) patients, of which 3 had DE located in the mid-myocardial and inferolateral segments. They all had c.1900C&amp;gt;T, but did not differ in clinical outcomes compared to patients without DE. The literature review included 32 studies with 394 total patients. Five studies reported on c.1900C&amp;gt;T, of which 4 case reports/series and 1 cohort study. The mean age at diagnosis was lower in 4 studies and varied between 26 and 52 years compared to 51 ± 15 years in our c.1900C&amp;gt;T group. The prevalence of VA was 66%-100% in the case reports/series, and 28% in the cohort study. In our cohort had 5 (42%) patients a VA. Conclusion This study found 4 novel RBM20 mutations. Moreover, the RBM20 mutation phenotype was predominantly DCM combined with a high prevalence of malignant VA and/or HF, which both had an peak age of early onset between 45-54 years.

Predictors of optical coherence tomography-defined calcified nodules in patients with acute coronary syndrome: a substudy from TACTICS registry

Abstract Background We investigated the clinical predictors of optical coherence tomography (OCT)-defined calcified nodules (CN) in patients with acute coronary syndrome in a prospective multicenter registry. Methods We investigated 695 patients enrolled in TACTICS registry who underwent OCT assessment of the culprit lesion during primary percutaneous coronary intervention. OCT-CN was defined as eruptive calcific nodules into the lumen with disruption of the fibrous cap and an underlying calcified plate. Patient characteristics were compared between patients with and without OCT-CN. Results OCT-CN was detected in 28 patients (4.0%). Patients with OCT-CN were older (75.0 ± 11.3 vs. 65.7 ± 12.7 years, p &amp;lt; 0.001) and had a higher prevalence of diabetes mellitus (50.0% vs. 29.4%, p = 0.034), hemodialysis (21.4% vs. 1.6%, p &amp;lt; 0.001) and heart failure (Killip 3/4, 21.4% vs. 5.7%, p = 0.003) than patients without OCT-CN. The angiographic SYNTAX score was higher in patients with OCT-CN than those without (median, 15 [interquartile range, 11, 25] vs. 11 [7, 19], p = 0.003). Multivariable analysis demonstrated that age (odds ratio [OR], 1.072; 95% confidence interval [CI], 1.033–1.116; p &amp;lt; 0.001), Killip class 3/4 (OR, 4.466; 95% CI, 1.472–11.943; p = 0.004) and hemodialysis (OR, 16.571; 95% CI, 4.946–52.863; p &amp;lt; 0.001) were significantly associated with the presence of OCT-CN. In non-dialysis patients (n=678), age (OR, 1.081; 95% CI, 1.035–1.135; p &amp;lt; 0.001), Killip class 3/4 (OR, 4.414; 95% CI, 1.327–12.709; p = 0.009) and diabetes mellitus (OR, 3.046; 95% CI, 1.251–7.594; p = 0.014) were significantly associated with the presence of OCT-CN. Conclusions TACTICS registry demonstrated the clinical predictors of OCT-CN, which may be associated with worse prognosis.

The global burden of heart failure: a systematic analysis for the Global Burden of Disease Study 2021

Abstract Background Heart failure is a common reason for hospitalization and is associated with high health care costs and high symptom burden. Updated estimates of global and regional prevalence and underlying causes of HF may be helpful in guiding health policy and investment priorities. Purpose To provide comparable and consistent estimates of heart failure burden as part of the Global Burden of Disease (GBD) 2021. Methods We identified all available data on prevalence, incidence, and mortality for heart failure in the general population. Sources included published scientific literature, administrative records from national health systems, and vital registration data. We generated estimates of heart failure prevalence using DisMod-MR 2.1, a geospatial modelling software program. We then estimated the proportion of prevalent heart failure due to each of 27 underlying aetiologies to produce age-, sex-, location-, year-, and aetiology-specific estimates of heart failure burden. Results In 2021, there were 56.5 million (95% Uncertainty Interval (UI): 49.7 million to 63.7 million) prevalent cases of heart failure globally. There were 27.3 million (24.0 to 30.8) prevalent cases in females and 29.2 million (25.6 to 33.0) cases among males. Age-standardized prevalence increased from 647.9 (556.3 to 739.9) per 100,000 in 1990 to 682.7 (602.8 to 766.8) per 100,000 in 2021. The North Africa and Middle East super region had the highest age-standardized prevalence in 2021 (780.5 per 100,000 (658.7 to 907.6)) and South Asia had the lowest age-standardized prevalence (600.1 per 100,000 (526.5 to 671.4)). In 2021, Ischaemic heart disease, hypertensive heart disease, and other cardiomyopathy were responsible for the majority of prevalent heart failure cases worldwide, at 33.8% (28.4% to 38.3%), 22.6% (19.0% to 27.1%), and 8.2% (7.0% to 9.6%), respectively. Country specific estimates for both sexes combined in 2021 are shown in the map. Conclusion Heart failure is a highly prevalent condition, particularly in older age groups. As populations age and risk profiles change around the world, knowledge of the global epidemiology of heart failure will be critical in preventing or treating its underlying aetiologies in order to decrease its overall burden.Heart failure prevalence, 2021