Previous Diagnosis Of Heart Failure Research Articles

An electronic consultation programme impacts on heart failure patients prognosis: implications for heart failure care

Abstract Background Multidisciplinary care plans that comprise professionals from different levels of care optimize the diagnosis and treatment of patients with heart failure (HF). Purpose Our objective was to analyse the clinical characteristics, 1 year prognosis and the prognostic determinants of patients with a previous diagnosis of HF, categorized by their previous HF-related hospitalization status (<1year or >1 year before or never hospitalized), referred by general practitioners (GPs) to a cardiology department (CD) by an e-consultation. Methods Data were obtained from 4851 HF patients referred by GPs to the cardiology department for an e-consultation from 2013 to 2020. We analysed the clinical characteristics of HF patient. We studied the whole cohort, and then subdivided it into three groups of diagnosis: patients who had never been hospitalized due to HF, patients with a recent HF-related hospitalization (<1 year), and patients with a remote HF-related hospitalization (≥1 year). To assess 1 year prognosis after e-consultation, we analysed the following health outcomes: HF-related hospitalizations, cardiovascular hospitalizations, HF-related mortality, cardiovascular mortality and all-cause mortality (Fig. 1). Qualitative variables are expressed as percentages (%), and quantitative continuous variables as means (standard deviation), or medians (interquartile range) if the distribution was asymmetric. To verify differences between groups, χ2 was used for quantitative variables, and ANOVA for qualitative variables. Results The delay of time to e-consults were solved was 8.6 + 8.6 days with 84.3% solved in <14 days. For the 1 year prognosis evaluation after the e-consult were assessed the cardiovascular hospitalizations, HF-related hospitalizations, HF-related mortality, cardiovascular mortality, and all-cause mortality. Compared with the group without a previous hospitalization, patients with recent and remote HF hospitalization were at higher risk of a new HF-related hospitalization (OR: 19.41 [95% CI: 12.95–29.11]; OR: 8.44 [95% CI: 5.14–13.87], respectively) (Fig 2), HF-related mortality (OR: 2.47 [95% CI: 1.43–4.27]; OR: 1.25 [95% CI: 0.51–3.06], respectively), as well as cardiovascular hospitalizations and mortality and all-cause mortality. Reduction in the time elapsed because e-consultation was solved was associated with lower risk of HF-related mortality (OR: 0.94 [95% CI: 0.89–0.99]), cardiovascular mortality (OR: 0.96 [95% CI: 0.93–0.98]), and all-cause mortality (OR: 0.98 [95% CI: 0.97–1.00]). Conclusions A clinician-to-clinician e-consultation programme between GPs and cardiologists in patients with HF allows to solve the demand of care in around 25% e-consults without an in-person consultation; the patients with a previous history of HF-related hospitalization showed a worse 1 year outcome. A reduction in the time elapsed because e-consultation was solved was associated with a mortality reduction.

Right ventricular dysfunction after therapy titration, but not at the time of index hospitalization, predicts prognosis in patients with new-onset acute heart failure

Abstract Introduction and aims The prognostic implications of right ventricular dysfunction (RVD) in patients with left ventricular (LV) disease has gained more attention over the last years. However, the role of RV function in new-onset acute heart failure (NoAHF) has only recently come into focus. The description of RVD is often confined to its longitudinal function. In the present study of patients with NoAHF, we aimed at (I) comparing the prognostic ability of RV longitudinal function with a novel echocardiographic RVD score and (II) to test the hypothesis that RVD conveys more prognostic information if it persists after titration of heart failure therapy. Methods Patients aged 18 to 70 years, admitted between 2015 and 2018 to a tertiary center with NoAHF were retrospectively included, provided that they did not have previous heart failure diagnosis or therapy and that complete echocardiograms were available at the time of index hospital admission and after titration of heart failure therapy. The RVD score allocates one point each for tricuspid annular plane systolic excursion (TAPSE) <17 mm (longitudinal dysfunction), right ventricular diastolic area index >11.5 (women) or >12.6 cm2/m2 (men) (RV dilatation), ≥moderate tricuspid regurgitation (RV deformation) and vena cava inferior collapsibility <50% (increased right atrial pressure). An RVD score ≥2 was defined as significant RVD. Patients were followed for the composite endpoint of death from all causes, heart transplantation or implantation of LV assist device until September 2022. Results Two-hundred and ten patients were followed for a median of 60 months. At index hospitalization, LV ejection fraction (LVEF) was 28±10%, TAPSE was 16±4 mm and 36% of the patients had a RVD score ≥2. Eighty-eight percent of the patients had LVEF<40%. At the end of the follow-up, 53 (25%) patients met the endpoint. At index hospitalization, there were no significant differences in any echocardiographic parameters between patients meeting and not meeting the endpoint. After titration of heart failure therapy, there were significant differences in LVEF (33% vs 46%, P<0.001), TAPSE (16 vs 19 mm, P = 0.001) and the proportion of patients with RVD score ≥2 (4% vs 36%, P<0.001). Figure 1 and 2 show Kaplan-Meier curves for survival free of composite endpoint in patients with and without RVD despite therapy titration, defined as TAPSE <17 mm or as RVD score ≥2. The unadjusted hazard ratio (95% CI) for TAPSE was 2.5 (1.5-4.4) and for RVD score 7.9 (4.4-14.0). Conclusions At index hospitalization, neither LVEF nor RV function can predict the prognosis in patients with NoAHF. However, the persistence or onset of RV dysfunction after titration of heart failure therapy does. A multiparametric echocardiographic RVD score might provide improved prognostic stratification when compared to TAPSE.Kaplan-Meier, TAPSE≥17mm vs <17mmKaplan-Meier, RVDS<2 vs ≥2

Deep-learning-based prognostic modeling for incident heart failure in patients with diabetes using electronic health records: A retrospective cohort study.

Patients with type 2 diabetes mellitus (T2DM) have more than twice the risk of developing heart failure (HF) compared to patients without diabetes. The present study is aimed to build an artificial intelligence (AI) prognostic model that takes in account a large and heterogeneous set of clinical factors and investigates the risk of developing HF in diabetic patients. We carried out an electronic health records- (EHR-) based retrospective cohort study that included patients with cardiological clinical evaluation and no previous diagnosis of HF. Information consists of features extracted from clinical and administrative data obtained as part of routine medical care. The primary endpoint was diagnosis of HF (during out-of-hospital clinical examination or hospitalization). We developed two prognostic models using (1) elastic net regularization for Cox proportional hazard model (COX) and (2) a deep neural network survival method (PHNN), in which a neural network was used to represent a non-linear hazard function and explainability strategies are applied to estimate the influence of predictors on the risk function. Over a median follow-up of 65 months, 17.3% of the 10,614 patients developed HF. The PHNN model outperformed COX both in terms of discrimination (c-index 0.768 vs 0.734) and calibration (2-year integrated calibration index 0.008 vs 0.018). The AI approach led to the identification of 20 predictors of different domains (age, body mass index, echocardiographic and electrocardiographic features, laboratory measurements, comorbidities, therapies) whose relationship with the predicted risk correspond to known trends in the clinical practice. Our results suggest that prognostic models for HF in diabetic patients may improve using EHRs in combination with AI techniques for survival analysis, which provide high flexibility and better performance with respect to standard approaches.

28 CONSTRICTIVE PERICARDITIS: A ROOM FOR MULTI-MODALITY IMAGING

Abstract Introduction The diagnosis of constrictive pericarditis can be challenging through conventional imaging. Novel imaging techniques have been proposed to improve it. Clinical Case A 74-year-old man with a previous diagnosis of heart failure with preserved ejection fraction and permanent atrial fibrillation (AF) was admitted because of worsening dyspnea, peripheral edema, and ascites refractory to diuretics therapy. ECG revealed low QRS voltages and AF with normal heart rate and laboratory exams detected increased values of BNP and hepatic stasis indices; blood count and CRP were normal. Echocardiography revealed mildly reduced bi-ventricular pump function (left ventricular ejection fraction = 52%, right ventricular fractional area change = 25%) and slightly increased wall thickness. Atria were moderately dilated (left and right atrium 46 and 44 ml/mq, respectively) and mitral and tricuspid annuli were dilated too. There was inferior vena cava plethora, moderate atriogenic tricuspid regurgitation and mild-to-moderate atriogenic mitral regurgitation. A paradoxical interventricular septal motion and significant respiratory changes on trans-mitral (>25%) and trans-tricuspid (>30%) pulsed Doppler were noted; however, there was no "annulus reversus" (lateral and septal e’ 13 and 11 cm/sec, respectively) at TDI analysis. In contrast, 2D-speckle-tracking global longitudinal strain showed impaired deformation ​​of the lateral segments with relative sparing of the septal segments. The latter pattern has been recently described as "strain reversus" or "hot septum sign". The findings were suspected of constrictive pericarditis, but a chest Computed Tomography excluded pericardial calcifications. Cardiac magnetic resonance (CMR) was then performed revealing a "septal shift" at cine-real time sequences analysis. The pericardium was slightly thickened (4-5 mm) with widespread late gadolinium enhancement but without signs of acute inflammation at T2-weighted imaging. Tricuspid regurgitation was confirmed to be "moderate" after phase-contrast imaging. Cardiac catheterization finally revealed normal coronary arteries and confirmed the diagnosis of constrictive pericarditis (square root sign, equalization of bi-ventricular end-diastolic pressures). The patient underwent pericardiectomy and tricuspid and mitral valve repair and was asymptomatic at 6-months follow-up. Conclusions Constrictive pericarditis represents a potentially reversible cause of heart failure but can be easily missed through conventional imaging. In the present case, advanced echocardiography and CMR were essential to come up with an accurate diagnosis, guiding the patient's clinical management with excellent outcome.

2008. Real-World Experience of Administration of Bezlotoxumab in an Outpatient Infusion Center Upon Discharge in Recurrent Clostridioides difficile patients

Abstract Background Bezlotoxumab is a humanized monoclonal antibody administered as single IV infusion that binds to Clostridioides difficile toxin B. It is currently recommended as a co-intervention in the updated 2021 IDSA guidelines for patients with recurrent C. difficile infection (CDI) in the last 6 months in addition to standard of care (SOC) antibiotics (vancomycin or fidaxomicin) to decrease CDI recurrence. Due to logistical issues and cost restrictions, administration is difficult as part of the inpatient stay. This case series evaluated a novel practice of discharging patients to receive bezlotoxumab immediately upon discharge from our not-for-profit community health system. Methods This was a retrospective chart review of all adult patients who received an outpatient infusion of bezlotoxumab after discharge between June 2019 and January 2022 for recurrent CDI. CDI was defined as ≥ 3 loose stools within 24 hours and a positive stool test for toxigenic C. difficile. The primary objectives were to evaluate the safety of bezlotoxumab in the outpatient setting and the rate of recurrent CDI at 12 weeks and 1 year. Recurrent CDI was defined using the same parameters as initial infection. Results Ten patients received bezlotoxumab in the outpatient setting after discharge and were included. Of the 10 patients, 2 were immunocompromised, 6 had at least stage 2 chronic kidney disease, and 4 required dialysis. All patients had > 1 previous CDI in the past 6 months, ranging between 1-6 with the average being 2.4. The average time to infusion was 9.8 days after starting SOC antibiotics and 80% of patients received treatment within 24 hours of discharge. No patients reported adverse reactions during treatment. One patient with a previous diagnosis of heart failure was readmitted for a heart failure exacerbation 69 days after receiving bezlotoxumab. Two patients and 4 patients experienced CDI recurrence within 12 weeks and 1 year of infusion, respectively. Conclusion Discharging patients to receive bezlotoxumab as an outpatient infusion is a safe and effective way to treat recurrent CDI logistically and may offer a financial advantage to institutions to shift costs to an outpatient payment model. Recurrence rates compared to phase III trials of bezlotoxumab were similar at 12 weeks (20% vs. 16%). Disclosures Christopher M. Bland, PharmD, FCCP, FIDSA, BCPS, biomerieux, Inc.: Honoraria|Merck Pharmaceuticals: Advisor/Consultant|Merck Pharmaceuticals: Honoraria Bruce M. Jones, Pharm.D., FIDSA, BCPS, AbbVie: Advisor/Consultant|AbbVie: Honoraria|La Jolla: Honoraria|Melinta: Advisor/Consultant|Paratek: Honoraria|Regeneron: Honoraria.

Echocardiographic detection of heart valve disease in a community cohort of asymptomatic Australians > 65 years with cardiovascular risk factors

BackgroundValvular heart disease is becoming an increasingly prevalent with population ageing. We sought to define the current prevalence of valvular heart disease in Australia. MethodsThe TasELF and VicELF studies prospectively recruited 962 asymptomatic participants ≥65 years, with at least one cardiovascular risk factor, from the Tasmanian and Victorian communities. People were excluded if they had a previous diagnosis of heart failure, or a life expectancy <1 year. All underwent baseline echocardiography. Those with moderate or severe valvular disease were identified. The current prevalence of clinically significant valve disease was applied to the Australian Bureau of Statistics population projections. ResultsEchocardiograms were interpretable in 943 participants (98%). Clinically significant valve disease was present in 5% of the population, and mitral regurgitation was the most common overall valvular lesion, present in 36% of the population. The projected numbers of people with clinically significant valvular disease is expected to increase significantly across all age groups by the year 2060. ConclusionsClinically significant yet asymptomatic valvular disease was prevalent in a large community cohort of participants with at least one risk factor. The total burden of valvular heart disease is expected to increase dramatically over the coming decades.

Effect of Tricuspid Regurgitation on the Reported Quality of Life and Subsequent Outcomes in Patients With Atrial Fibrillation.

BackgroundAtrial fibrillation and heart failure (HF) possess mutual risk factors and share a common pathophysiological pathway. Tricuspid regurgitation (TR) is a known predictor of adverse events in patients with HF. However, its implications on patients with atrial fibrillation in its early stage remain unknown.Methods and ResultsData of 2211 patients without previous HF diagnosis were extracted from a prospective, multicenter registry of newly diagnosed patients with atrial fibrillation. TR was categorized as absent, mild, moderate, and severe based on the American Society of Echocardiography recommendations. The primary outcome was time to first hospitalization for HF after enrollment. The Atrial Fibrillation Effects on Quality‐of‐Life scores were compared. Overall, 1107 patients (50.1%) had TR (42.3%, 7.2%, and 0.6% for mild, moderate, and severe, respectively). During follow‐up (median 730 [interquartile range, 366–731] days), 44 patients (2.0%) experienced HF hospitalization, and the incidence increased with severity of TR (P<0.001). TR was an associated predictor of the primary outcome (hazard ratio [HR]: 2.51, P=0.050; HR: 6.19, P=0.008; for moderate and severe TR versus no TR). Changes in AFEQT overall score were negatively related to TR severity (8.7±17.5 versus 8.5±17.0 versus 3.1±17.5 versus 1.4±11.8, absent versus mild versus moderate versus severe TR, respectively), although it was not an independent predictor after adjustments.ConclusionsTR severity at atrial fibrillation diagnosis was an associated predictor of subsequent hospitalization for HF, which may warrant the need for a more intensive follow‐up and HF‐related management.

Cardiorenal Effects of Long-Term Phosphodiesterase V Inhibition in Pre-Heart Failure.

BackgroundPhosphodiesterase V (PDEV) is upregulated in heart failure, leading to increased degradation of cGMP and impaired natriuresis. PDEV inhibition improves the renal response to B‐type natriuretic peptide in animal models. We tested the hypothesis that long‐term PDEV inhibition would improve renal function and cardiorenal response after short‐term volume load in subjects with pre–heart failure.Methods and ResultsA total of 20 subjects with pre–heart failure (defined as an ejection fraction ≤45% without previous diagnosis of heart failure) and renal impairment were randomized in a 2:1 manner to tadalafil or placebo. Baseline echocardiography and renal clearance study were performed, followed by a short‐term saline load and repeated echocardiography and renal clearance study. Subjects then received either tadalafil at a goal dose of 20 mg daily or placebo, and the study day was repeated after 12 weeks. Long‐term tadalafil did not improve glomerular filtration rate (median increase of 2.0 mL/min in the tadalafil group versus 13.5 mL/min in the placebo group; P=0.54). There was no difference in urinary sodium or cGMP excretion with PDEV inhibition following short‐term saline loading.ConclusionsGlomerular filtration rate and urinary sodium/cGMP excretion were not significantly different after 12 weeks of tadalafil compared with placebo. These results do not support the use of PDEV inhibition to improve renal response in patients with pre–heart failure.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT01970176.

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.

Echocardiographic Detection of Heart Valve Disease in a Community Cohort Study of Asymptomatic Australians &gt;65 years With Cardiovascular Risk Factors

Valvular heart disease is becoming an increasingly prevalent with population ageing. We sought to define the current prevalence of valvular heart disease in Australia. The TasELF and VicELF studies prospectively recruited 942 asymptomatic participants ≥65 years, with at least one cardiovascular risk factor, from the Tasmanian and Victorian communities. People were excluded if they had a previous diagnosis of heart failure, known significant valve disease, or a life expectancy <1 year. All underwent baseline echocardiography. Those with moderate or severe valvular disease were identified. The current prevalence of clinically significant valve disease was applied to the Australian Bureau of Statistics population projections. Echocardiograms were interpretable in 928 participants (99%). Clinically significant valve disease was present in 5% of the population, and mitral regurgitation was the most common overall valvular lesion, present in 36% of the population. The projected numbers of people with clinically significant valvular disease is expected to increase significantly across all age groups by the year 2060. Clinically significant yet asymptomatic valvular disease was prevalent in a large community cohort of participants with at least one risk factor. The total burden of valvular heart disease is expected to increase dramatically over the coming decades.

Social relationships and the risk of incident heart failure: results from a prospective population-based study of older men.

AimsLimited social relationships, particularly in older adults, have been implicated as a risk factor for cardiovascular disease. However, little is known about the associations between poor social relationships and heart failure incidence.Methods and resultsProspective study of socially representative men aged 60–79 years drawn from general practices in 24 British towns and followed up for a maximum of 18 years. A total of 3698 participants with no previous diagnosis of heart failure were included. Information on social relationships was based on a combination of marital status, living circumstances, and social contacts with friends and family. These provided information on contact frequency, contact satisfaction, and a social relationship score (low to high) combining frequency and satisfaction with contact. Heart failure included both incidents non-fatal heart failure and death from heart failure. Among 3698 participants, 330 developed heart failure. Men with low compared to high frequency of contact with family and friends had an increased risk of incident heart failure [hazard ratio (HR) 1.59, 95% confidence interval (CI) 1.15–2.18]; this remained statistically significant after adjustment for social class, behavioural, and biological risk factors. Low compared to high scores for satisfaction with contacts was associated with increased risk of heart failure (adjusted HR = 1.54; 95% CI 1.14–2.07). Lower social relationship scores (combining frequency and satisfaction with contact) were associated with greater risk of incident heart failure (adjusted HR = 1.38, 95% CI 1.02–1.87). Marital status and living alone were not significantly associated with heart failure.ConclusionWeaker social relationships appear to increase the risk of developing heart failure in older age. Further research is needed to investigate pathways underlying these associations and to test whether interventions to strengthen social relationships can reduce the risk of heart failure.

Abstract 1122‐000166: Stroke Severity Factors in patients with Acute Ischemic Stroke and Heart Failure Stratifying by Age

Introduction : The goal of this study is to investigate the clinical risk factors associated with acute ischemic stroke (AIS) severity in heart failure (HF) patients above and below 70 years old using the National Institutes of Health Stroke Scale (NIHSS) as a measure for stroke severity. Methods : This study uses retrospective analysis of AIS patients who were previously diagnosed with HF. Data was collected from a regional stroke center from January 2010 to June 2016. Multivariate logistic regression identified the factors associated with stroke severity, with a NIHSS score &lt;7 indicating low severity and a score ≥7 indicating high severity. These results were stratified by patient ages of &lt; and ≥70 years old. Results : A total of 590 patients presented with AIS and a previous diagnosis of HF. The AIS‐HF population contained 223 patients that were &lt;70 years old and 367 that were ≥70 years old. In the AIS‐HF population, patients who were ≥70 years old who presented with coronary artery stenosis (CAS) (OR = 8.592, 95% CI, 2.123‐34.772, P &lt;0.003), prosthetic heart valve (OR = 22.028, 95% CI, 1.454‐333.746, P &lt;0.026), elevated systolic blood pressure (OR = 1.014, 95% CI, 1.002‐1.026, P &lt; 0.024), and tissue plasminogen activator (tPA) administration (OR = 4.002, 95% CI, 1.912‐8.377, P &lt; 0.001) were associated with a higher NIHSS. Alternatively, those that presented with gender differences (OR = 0.466, 95% CI, 0.235‐0.925, P &lt; 0.029), family history of stroke (OR = 0.084, 95% CI, 0.010‐0.726, P &lt; 0.024), obesity (OR = 0.493, 95% CI, 0.261‐0.930, P &lt; 0.029), smoking (OR = 0.253, 95% CI, 0.063‐1.022, P &lt; 0.054), serum creatinine (OR = 0.629, 95% CI, 0.399‐0.992, P &lt; 0.046), INR level (OR = 0.457, 95% CI, 0.191‐1.094, P &lt; 0.079) were associated with a lower NIHSS. Conclusions : The data revealed a variety of components that may affect Stroke Severity in AIS patients with HF. The associated factors exhibited significant differences between distinct age groups. AIS‐HF patients ≥70 years old who presented with CAS, prosthetic heart valve, elevated systolic blood pressure, and received tPA administration were associated with higher stroke severity (≥7 NIHSS) compared to &lt;70 years old group. Identifying more concrete clinical and demographic associations may aid in the identification and evidence‐based management of patients who suffer from AIS.

Importance of NT-pro BNP in the Prevention of Heart Failure, Left Ventricular Systolic Dysfunction and Cardiovascular Events

Objective: The importance of the NT-proBNP value in detecting patients at risk of developing heart failure (HF) and its importance in guiding medical management to prevent the development of HF. Material and methods: The study is a prospective study and includes 314 patients who was presented at the Bagdasar-Arseni Emergency Hospital for cardiology consultation, by appointment, for a period of 3 years. The inclusion criteria were as follows: essential hypertension (diagnosed more than 5 years before), diabetes mellitus (insulin-deficient or under treatment with oral ant diabetics diagnosed more than 5 years before), ischemic heart disease, mild or moderate valvulopathy (mild or moderate mitral regurgitation and large or moderate aortic stenosis) and permanent or paroxysmal atrial fibrillation. Exclusion criteria were as follows: a previous diagnosis of heart failure or left ventricular systolic dysfunction, and the presence of signs or symptoms of heart failure at the time of enrollment in the study. Patients were randomized into 2 groups, a control group and a intervention group. Patients in the intervention group were managed according to the NT-proBNP value, and patients in the control group received the conventional intervention. Patients were monitored for 3 years and the following objectives were pursued: new diagnosis of heart failure, systolic or diastolic dysfunction of the left ventricle and hospitalization for cardiovascular pathology. Results: After 3 years, in the control group there were 40 patients (25.5%) who developed HF, compared to 28 patients (17.8%) in the intervention group. In the control group, 60 patients (38.2%) were diagnosed with left ventricular systolic dysfunction, compared to 43 patients (27.4%) in the intervention group. Regarding left ventricular diastolic dysfunction, in the control group there were 98 patients (62.4%), and in the intervention group there were 80 patients (51.0%). Also, the rate of hospitalizations for cardiovascular pathology was higher in the control group, 56 patients (35.7%), compared to 33 patients (21.0%) in the intervention group. Discussions: The incidence of heart failure, left ventricular systolic or diastolic dysfunction, or hospitalizations for cardiovascular events, was lower in the intervention group, in which patients were managed according to the NT-proBNP value, compared to patients in the control group who received conventional intervention. Conclusions: The NT-proBNP biomarker may be useful in the medical management of patients for the prevention of heart failure.

In-hospital and 30-day major adverse cardiac events in patients referred for ST-segment elevation myocardial infarction in Dhaka, Bangladesh

BackgroundThere is a paucity of data regarding acute phase (in-hospital and 30-day) major adverse cardiac events (MACE) following ST-segment elevation myocardial infarction (STEMI) in Bangladesh. This study aimed to document MACE during the acute phase post-STEMI to provide information.MethodsWe enrolled STEMI patients of the National Institute of Cardiovascular Disease, Dhaka, Bangladesh, from August 2017 to October 2018 and followed up through 30 days post-discharge for MACE, defined as the composite of all-cause death, myocardial infarction, and coronary revascularization. Demographic information, cardiovascular risk factors, and clinical data were registered in a case report form. The Cox proportional hazard model was used for univariate and multivariate analysis to identify potential risk factors for MACE.ResultsA total of 601 patients, mean age 51.6 ± 10.3 years, 93% male, were enrolled. The mean duration of hospital stay was 3.8 ± 2.4 days. We found 37 patients (6.2%) to experience an in-hospital event, and 45 (7.5%) events occurred within the 30 days post-discharge. In univariate analysis, a significantly increased risk of developing 30-day MACE was observed in patients with more than 12 years of formal education, diabetes mellitus, or a previous diagnosis of heart failure. In a multivariate analysis, the risk of developing 30-day MACE was increased in patients with heart failure (hazard ratio = 4.65; 95% CI 1.64–13.23).ConclusionsA high risk of in-hospital and 30-day MACE in patients with STEMI exists in Bangladesh. Additional resources should be allocated providing guideline-recommended treatment for patients with myocardial infarction in Bangladesh.

Abstract 16013: Evidence for Improvement in NYHA Class and Freedom From Hospitalization in Bariatric Surgery Patients With an Established Diagnosis of Heart Failure

Introduction: Heart failure patients with severe obesity endure significant morbidity and frequent hospitalizations. Bariatric surgery is proven to provide durable weight loss for those with severe obesity, but the clinical impact and safety of these procedures among patients with heart failure has not been well-demonstrated. Methods: We conducted a medical record query of patients who have a previous diagnosis of heart failure (HFpEF and HFrEF) and underwent subsequent Roux-En-Y gastric bypass or laparoscopic sleeve gastrectomy at a high-volume metabolic and bariatric surgery center. We compared clinical, demographic, and echocardiographic data captured just prior to the bariatric procedure to the most recent data available in the medical record for each patient. Results: There were 50 patients (88% had HFpEF) included in this study. Time from HF diagnosis to most recent follow-up ranged from 0.2 to 20.3 years (median 6.7 years) and there was no recorded mortality. The median time from HF diagnosis to surgery was 2.3 years and median time from surgery to recent follow-up was 2.9 years. Post-operative median decrease in BMI was 8.8 kg/m 2 , HF hospitalizations were 0.4 per patient year (PPY) to 0.15 PPY, p=0.008, and median NYHA Class was II pre-op and I post-op, p=0.048). LVEF, LVESD, and LVEDD were not significantly changed post-operatively (Table 1). Conclusion: Weight loss following bariatric surgery for patients with HF led to improvements in NYHA Class, fewer hospitalizations for HF, and was not associated with perioperative mortality. It is reasonable to consider bariatric surgery for this patient population, but further prospective investigation is warranted.

Abstract 13289: Incidence of Heart Failure Hospital Admissions Among Type 2 Diabetes Mellitus Patients and the Potential Impact of SGLT2 Inhibitors in Japan: A Population-based Study From the Shizuoka Kokuho Database

Introduction: Recent large-scale clinical trials have shown that the use of sodium-glucose cotransporter-2 inhibitors (SGLT2i) reduces the risk of cardiovascular (CV) events, particularly heart failure (HF) hospitalizations, in type 2 diabetes mellitus (T2DM) patients with established CV disease. We aimed to assess (1) the incidence of HF admissions, and (2) the potential reduction in HF admissions with the further introduction of SGLT2i, in a contemporary large administrative claims database in Japan. Methods: We selected patients aged ≥40 years, without previous HF diagnosis, who newly initiated oral antidiabetics in Shizuoka Kokuho Database between 2013 and 2018. We estimated the 5-year cumulative incidence of hospitalization for HF, myocardial infarction (MI), and stroke, treating death as a competing risk. Among the subgroup of patients with laboratory data, we identified patients meeting the inclusion criteria for EMPA-REG OUTCOME (EMPA-REG) or DECLARE-TIMI 58 (DECLARE) regarding HbA1c, eGFR, and CV disease. We estimated the number of events that can be reduced if they benefited the same risk reduction from the trials. Results: Among 23,340 oral antidiabetic drug initiators (46.0% women, 21.9% ≥75 years old) included, 2.6% were initiated on SGLT2i. The 5-year cumulative incidences of hospitalization for HF, MI, and stroke were 5.4% (95% confidence interval: 4.9-5.9%), 1.9% (1.7-2.2%), and 6.1% (5.7-6.6%), respectively. Among 6192 patients with laboratory data, 651 (10.5%) and 2680 (43.3%) patients met the EMPA-REG-like and DECLARE-like criteria, respectively (Figure). The 5-year cumulative incidence among the 2849 patients meeting either of the criteria was estimated to decrease from 97.1 to 75.2 events via 75% adoption of SGLT2i. Conclusion: The burden of HF among Japanese T2DM patients was high, almost equivalent to stroke. Increased use of SGLT2i among patients with high CV risk may significantly reduce its disease burden.

Temporal Trends in Heart Failure Incidence Among Medicare Beneficiaries Across Risk Factor Strata, 2011 to 2016

Heart failure (HF) incidence is declining among Medicare beneficiaries. However, the epidemiological mechanisms underlying this decline are not well understood. To evaluate trends in HF incidence across risk factor strata. Retrospective, national cohort study of 5% of all fee-for-service Medicare beneficiaries with no prior HF followed up from 2011 to 2016. The study examined annual trends in HF incidence among groups with and without primary HF risk factors (hypertension, diabetes, and obesity) and predisposing cardiovascular conditions (acute myocardial infarction [MI] and atrial fibrillation [AF]). The presence of comorbid HF risk factors including hypertension, diabetes, obesity, acute MI, and AF identified by International Classification of Diseases, Ninth Revision, Clinical Modification codes and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes. Incident HF, defined using at least 1 inpatient HF claim or at least 2 outpatient HF claims among those without a previous diagnosis of HF. Of 1 799 027 unique Medicare beneficiaries at risk for HF (median age, 73 years [interquartile range, 68-79 years]; 56% female [805 060-796 253 participants during the study period]), 249 832 had a new diagnosis of HF. The prevalence of all 5 risk factors increased over time (0.8% mean increase in hypertension per year, 1.9% increase in diabetes, 2.9% increase in obesity, 0.2% increase in acute MI, and 0.4% increase in AF). Heart failure incidence declined from 35.7 cases per 1000 beneficiaries in 2011 to 26.5 cases per 1000 beneficiaries in 2016, consistent across subgroups based on sex and race/ethnicity. A greater decline in HF incidence was observed among patients with prevalent hypertension (relative excess decline, 12%), diabetes (relative excess decline, 3%), and obesity (relative excess decline, 16%) compared with those without corresponding risk factors. In contrast, there was a relative increase in HF incidence among individuals with acute MI (26% vs no acute MI) and AF (22% vs no AF). Findings of this study suggest that the temporal decline in HF incidence among Medicare beneficiaries reflects a decrease in HF incidence among those with primary HF risk factors. The increase in HF incidence among those with acute MI and those with AF highlights potential targets for future HF prevention strategies.

French annual national observational study of 2015 outpatient and inpatient healthcare utilization by approximately half a million patients with previous heart failure diagnosis

Heart failure management guidelines have been published, but the degree of adherence to these guidelines remains unknown. To study in 2015 healthcare utilization and causes of death for people previously identified with heart failure. The national health data system was used to identify adult general scheme (86% of the French population) hospitalized for heart failure between 2011 and 2014 or with only a long-term chronic disease allowance for heart failure. The frequency and median (interquartile range) of at least one healthcare use among those still alive in 2015 was calculated. A total of 499,296 adults (1.4% of the population) were included, and 429,853 were alive in 2015; median age 79 (68-86) years. At least one utilization was observed for a general practitioner in 95% of patients (median 8 [interquartile range 5-13] consultations), a cardiologist in 42% (2 [1-3]), a nurse in 78% (16 [4-100]), a loop diuretic in 64% (11 [8-12] dispensations), an aldosterone antagonist in 21% (8 [5-11]), a thiazide in 15% (7 [4-11]), a renin-angiotensin system inhibitor in 68% (11 [8-13]), a beta-blocker in 65% (11 [7-13]), a beta-blocker plus a renin-angiotensin system inhibitor in 57%, and a beta-blocker plus a renin-angiotensin system inhibitor plus an aldosterone antagonist in 37%. Hospitalization for heart failure was present for 8% (1 [1,2]). Higher levels of healthcare utilization were observed in the presence of hospitalization for heart failure before 2015. Among the 13.9% of people who died in 2015, heart failure accounted for 8% of causes, cardiovascular disease accounted for 39%. General practitioners and nurses are the main actors in the regular follow-up of patients with heart failure, whereas cardiologist consultations and dispensing of first-line treatments are insufficient with respect to guidelines.

Serum uric acid, predicts heart failure in a large Italian cohort: search for a cut-off value the URic acid Right for heArt Health study.

To assess the prognostic cut-off values of serum uric acid (SUA) in predicting fatal and morbid heart failure in a large Italian cohort in the frame of the Working Group on Uric Acid and Cardiovascular Risk of the Italian Society of Hypertension. The URic acid Right for heArt Health (URRAH) study is a nationwide, multicentre, cohort study involving data on individuals aged 18-95 years, recruited on a community basis from all regions of Italy under the patronage of the Italian Society of Hypertension with a mean follow-up period of 128 ± 65 months. Incident heart failure was defined on the basis of International Classification of Diseases Tenth Revision codes and double-checked with general practitioners and hospital files. Multivariate Cox regression models having fatal and morbid heart failure as dependent variables, adjusted for sex, age, SBP, diabetes, estimated glomerular filtration rate, smoking habit, ethanol intake, BMI, haematocrit, LDL cholesterol, previous diagnosis of heart failure and use of diuretics as possible confounders, were used to search for an association between SUA as a continuous variable and heart failure. By means of receiver operating characteristic curves, two prognostic cut-off values (one for all heart failure and one for fatal heart failure) were identified as able to discriminate between individuals doomed to develop the event. These cut-off values were used as independent predictors to divide individuals according to prognostic cut-off values in a multivariate Cox models, adjusted for confounders. A total of 21 386 individuals were included in the analysis. In Cox analyses, SUA as a continuous variable was a significant predictor of all [hazard ratio 1.29 (1.23-1.359), P < 0.0001] and fatal [hazard ratio 1.268 (1.121-1.35), P < 0.0001] incident heart failure. Cut-off values of SUA able to discriminate all and fatal heart failure status were identified by mean of receiver operating characteristic curves in the whole database: SUA more than 5.34 mg/dl (confidence interval 4.37-5.6, sensitivity 52.32, specificity 63.96, P < 0.0001) was the univariate prognostic cut-off value for all heart failure, whereas SUA more than 4.89 mg/dl (confidence interval 4.78-5.78, sensitivity 68.29, specificity 49.11, P < 0.0001) for fatal heart failure. The cut-off for all heart failure and the cut-off value for fatal heart failure were accepted as independent predictors in the Cox analysis models, the hazard ratios being 1.645 (1.284-2.109, P < 0.0001) for all heart failure and 1.645 (1.284-2.109, P < 0.0001) for fatal heart failure, respectively. The results of the current study confirm that SUA is an independent risk factor for all heart failure and fatal heart failure, after adjusting for potential confounding variables and demonstrate that a prognostic cut-off value can be identified for all heart failure (>5.34 mg/dl) and for fatal heart failure (>4.89 mg/dl).

Moving the needle towards the democratization of echocardiography: a case report

BackgroundEchocardiography has been traditionally performed in echo labs and the potential benefits of its use by primary care physicians (PCPs) are still unexplored. We present a case where POCUS (point-of-care ultrasound) was used as a complement of physical examination by a family doctor, allowing a prompt clinical decision in a heart failure (HF) patient.Case summaryAn 85-year-old woman, living independently, asks her family doctor for a home consultation due to increasing dyspnoea. On examination, severe dyspnoea and bilateral ankle oedema was noted and a point-of-care echocardiogram was performed by the primary care physician, who observed: severely compromised left ventricular systolic function, moderate mitral and tricuspid regurgitation, and severe dilation of the inferior vena cava. As a result, the diagnosis of HF with decreased ejection fraction was formed supporting the therapeutic decision.DiscussionThis case represents an elderly patient with dyspnoea, without previous HF diagnosis. The primary care physician, used portable ultrasound as a complement of physical examination, which confirmed a HF diagnosis, allowing a prompt decision-making on therapy. POCUS, can be a powerful tool to expedite treatment in different settings, including the home consultations by PCPs.