Prognosis In Heart Failure Patients Research Articles

MicroRNAs in the Management of Heart Failure.

In recent years much research has been devoted to the deployment of biomarkers in the field of heart failure. To study the potential of post-transcriptional regulation by microRNAs on the diagnosis, management and therapy of heart failure. Literature search focuses on the role of microRNAs in heart failure. MicroRNAs are expressed and regulated in the course of the pathological manifestations of heart failure (HF). This wide and uncharted area of genetic imprints consisting of small non-coding RNA molecule is upregulated and released into the bloodstream from organs under certain conditions and or stress. The use of genetically based strategies for the management of HF has gained great interest in the field of biomedical science because they can be used as biomarkers providing information regarding cardiac status and function. They also appear as promising tools with therapeutic potential because of their ability to induce changes at the cellular level without creating alterations in the gene sequence. In addition, with the advances in genomic sequencing, quantification and synthesis in technologies of microRNAs identification as well as the growing knowledge of the biology of miRNAs and their involvement in HF, it is expected to favorably affect the prognosis of HF patients. MicroRNAs are involved in the regulation of multibiological processes involved in the progress of heart failure. More studies are needed to achieve a clinical valuable implementation of microRNAs in the management of HF.

Prognostic value of cardio-hepatic-skeletal muscle syndrome in patients with heart failure

Although heart failure (HF) and liver dysfunction often coexist because of complex cardiohepatic interactions, the association between liver dysfunction and physical dysfunction, and between coexistence of both and prognosis in HF patients remains unclear. We reviewed 895 patients with HF (mean age, 69.4 ± 14.2 years) who underwent liver function test using model for end-stage liver disease excluding international normalized ratio (MELD-XI) score and physical function test (grip strength, leg strength, gait speed, and 6-min walking distance [6MWD]). In the multiple regression analysis, MELD-XI score was independently associated with lower grip strength, leg strength, gait speed, and 6MWD (all P < 0.001). One hundred thirty deaths occurred over a median follow-up period of 1.67 years (interquartile range: 0.62–3.04). For all-cause mortality, patients with high MELD-XI scores and reduced physical functions were found to have a significantly higher mortality risk even after adjusting for several covariates (grip strength, hazard ratio [HR]: 3.80, P < 0.001; leg strength, HR: 4.65, P < 0.001; gait speed, HR: 2.49, P = 0.001, and 6MWD, HR: 5.48, P < 0.001). Liver dysfunction was correlated with reduced physical function. Moreover, the coexistence of lower physical function and liver dysfunction considerably affected prognosis in patients with HF.

Responses to exercise training in patients with heart failure. Analysis by oxygen transport steps

BackgroundExercise training (ET) increases exercise tolerance, improves quality of life and likely the prognosis in heart failure patients with reduced ejection fraction (HFrEF). However, some patients do not improve, whereas exercise training response is still poorly understood. Measurement of cardiac output during cardiopulmonary exercise test might allow ET response assessment according to the different steps of oxygen transport. MethodsFifty-three patients with HFrEF (24 with ischemic cardiomyopathy (ICM) and 29 with dilated cardiomyopathy (DCM) had an aerobic ET. Before and after ET program, peak oxygen consumption (VO2peak) and cardiac output using thoracic impedancemetry were measured. Oxygen convection (QO2peak) and diffusion (DO2) were calculated using Fick's principle and Fick's simplified law. Patients were considered as responders if the gain was superior to 10%. ResultsWe found 55% VO2peak responders, 62% QO2peak responders and 56% DO2 responders. Four patients did not have any response. None baseline predictive factor for VO2peak response was found. QO2peak response was related to exercise stroke volume (r = 0.84), cardiac power (r = 0.83) and systemic vascular resistance (SVRpeak) (r = −0.42) responses. Cardiac power response was higher in patients with ICM than in those with DCM (p < 0.05). Predictors of QO2peak response were low baseline exercise stroke volume and ICM etiology. Predictors of DO2 response were higher baseline blood creatinine and prolonged training. ConclusionThe analysis of the response to training in patients with HFrEF according to the different steps of oxygen transport revealed different phenotypes on VO2peak responses, namely responses in either oxygen convection and/or diffusion.

Regional myocardial work as determinant of heart failure in left bundle branch block

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): The Norwegian Health Association Background Left bundle branch block (LBBB) worsen prognosis in heart failure patients. LBBB may also cause heart failure in otherwise healthy individuals. The mechanical changes induced by LBBB are potential determinants of heart failure in these patients, but their relation to left ventricular (LV) systolic function is incompletely understood. Purpose This study investigates the contribution of regional contractile function to heart failure in patients with LBBB. Methods In 76 patients with LBBB and 11 healthy controls, myocardial strain was measured by speckle-tracking echocardiography and myocardial work by pressure-strain analysis. Patients with ischemic heart disease or myocardial scarring were excluded. LBBB patients were stratified by LV ejection fraction (EF) &amp;gt;50% (EFpreserved), 36-50% (EFmid), and ≤35% (EFlow). 62 LBBB patients subsequently underwent cardiac resynchronization therapy (CRT) implantation and was re-examined at 6 months. Results Septal work was significantly and successively reduced from controls, EFpreserved, EFmid, to EFlow (1977 ± 506, 1025 ± 342, 601 ± 494 and -41 ± 303 mmHg·%, respectively, all p &amp;lt; 0.01) (Figure 1). There was a strong correlation (R = 0.84, p &amp;lt; 0.01) between septal work and LVEF. In contrast, work in the LV lateral wall was preserved in both EFpreserved (2367 ± 459 mmHg·%) and EFmid (2252 ± 449 mmHg·%) vs controls (2062 ± 459 mmHg·%, all NS). In the EFlow group, however, LV lateral wall work was reduced (1473 ± 568 mmHg·%, p &amp;lt; 0.01 vs controls). Thus, lateral wall function was not correlated with LVEF in patients with LVEF &amp;gt;35% (NS). At six month CRT septal work was markedly increased (165 ± 485 vs 1288 ± 523 mmHg·%, p &amp;lt; 0.01) and LV lateral wall work reduced (1730 ± 620 vs 1264 ± 490 mmHg·%, p &amp;lt; 0.01). LVEF increased from 32 ± 8 to 47 ± 10 % (p &amp;lt; 0.01). Conclusions Heart failure in LBBB patients is determined by degree of septal dysfunction. LV lateral wall function, on the other hand, is preserved in the early phase of heart failure and was only reduced in patients with severe heart failure. Further clinical studies should investigate if measuring LV lateral wall function can increase precision in patient selection for CRT. Abstract Figure.

Relative conditional survival analysis provides additional insights into the prognosis of heart failure patients

Relative conditional survival analysis provides additional insights into the prognosis of heart failure patients

Lycorine ameliorates isoproterenol-induced cardiac dysfunction mainly via inhibiting inflammation, fibrosis, oxidative stress and apoptosis

ABSTRACT Alleviating cardiac dysfunction improves the prognosis of heart failure patients. Lycorine is an alkaloid with several beneficial biological properties. Here, we used mice to evaluate the effect of lycorine on cardiac dysfunction elicited by isoproterenol. Mice were divided into four groups: control, lycorine, isoproterenol, and isoproterenol + lycorine. Mice in the combined group were treated daily with 10 mg/kg isoproterenol intraperitoneally for 2 weeks and 5 mg/kg lycorine was given simultaneously intraperitoneally for 4 weeks. Cardiac structure and function were assessed by echocardiography, hematoxylin and eosin staining, and Masson’s trichrome staining. Isoproterenol-induced cardiac dysfunction and histopathological injury that was significantly improved by treatment with lycorine. Western blotting and the quantitative real-time polymerase chain reaction were used to explore the molecular mechanisms of these effects. Levels of the inflammatory cytokines, interleukin (IL)-1β, IL-6, and tumor necrosis factor-α, were increased by treatment with isoproterenol; these increases were significantly reduced by lycorine, with involvement of the NF-κB signaling pathway. The fibrotic factors, collagen I and collagen III, were increased by isoproterenol and decreased by treatment with lycorine through inhibiting activation of the Smad signaling pathway. In addition, lycorine alleviated oxidative stress as evidenced by a reduction in total reactive oxygen species in the isoproterenol + lycorine group compared to the isoproterenol group. Lycorine exerted an anti-apoptotic effect as evidenced by upregulating Bcl-2 and downregulating Bax. Overall, our findings demonstrate that lycorine protects against cardiac dysfunction induced by isoproterenol by inhibiting inflammation, fibrosis, oxidative stress, and apoptosis.

Shear Wave Dispersion Predicts Liver Fibrosis and Adverse Outcomes in Patients with Heart Failure.

Background: It has been recently reported that liver stiffness assessed by transient elastography reflects right atrial pressure (RAP) and is associated with worse outcomes in patients with heart failure (HF). However, the relationship between shear wave dispersion (SWD, a novel indicator of liver viscosity) determined by abdominal ultrasonography and RAP, and the prognostic impact of SWD on HF patients have not been fully examined. We aimed to clarify the associations of SWD with parameters of liver function test (LFT) and right heart catheterization (RHC), as well as with cardiac events such as cardiac death and worsening HF, in patients with HF. Methods: We performed abdominal ultrasonography, LFT and RHC in HF patients (n = 195), and followed up for cardiac events. We examined associations between SWD and parameters of LFT and RHC. Results: There were significant correlations between SWD and circulating levels of direct bilirubin (R = 0.222, p = 0.002), alkaline phosphatase (R = 0.219, p = 0.002), cholinesterase (R = −0.184, p = 0.011), and 7S domain of collagen type IV (R = 0.177, p = 0.014), but not with RAP (R = 0.054, p = 0.567) or cardiac index (R = −0.015, p = 0.872). In the Kaplan–Meier analysis, cardiac event rate was significantly higher in the high SWD group (SWD ≥ 10.0 (m/s)/kHz, n = 103) than in the low SWD group (SWD < 10.0 (m/s)/kHz, n = 92; log-rank, p = 0.010). In the Cox proportional hazard analysis, high SWD was associated with high cardiac event rates (hazard ratio, 2.841; 95% confidence interval, 1.234–6.541, p = 0.014). In addition, there were no interactions between SWD and all subgroups, according to the subgroup analysis. Conclusions: SWD assessed by abdominal ultrasonography reflects liver fibrosis rather than liver congestion, and is associated with adverse prognosis in HF patients.

Transcatheter Mitral Valve Repair in Patients with Heart Failure: A Meta-Analysis

Background: Severe secondary mitral regurgitation (MR) is associated with poor prognosis in heart failure patients with left ventricular systolic dysfunction. Few observational and randomized controlled studies demonstrated the efficacy of transcatheter mitral valve repair in heart failure patients with significant MR. A meta-analysis of published studies was performed to evaluate the role of transcatheter mitral valve repair using the MitraClip device in heart failure patients with significant secondary MR. Methods: A literature search was performed using PubMed, Cochran CENTRAL, and Embase databases using the search terms “percutaneous mitral valve repair” or “transcatheter mitral valve repair” and “heart failure.” Studies that compared medical therapy plus transcatheter mitral valve repair using MitraClip to medical therapy alone in heart failure patients with significant secondary MR were included for pooled analysis. A random-effects model with the Mantel-Haenszel method was used to analyze the data. Results: Four studies, 2 randomized controlled and 2 nonrandomized studies met the criteria for analysis. Pooled analysis included a total of 1,421 patients, of which 746 patients underwent transcatheter mitral valve repair and 675 patients received medical therapy alone. When compared to medical therapy, transcatheter mitral valve repair significantly decreased all-cause mortality (OR 0.58, 95% CI 0.37–0.91; p = 0.02). A trend toward significant reduction in rehospitalizations (OR 0.35, 95% CI 0.12–1.00; p = 0.05) was also observed. Periprocedural complications ranged from 7.5 to 12.6%. Conclusion: Evidence from pooled analysis suggests that transcatheter mitral valve repair using MitraClip on top of medical therapy, in appropriately selected symptomatic heart failure patients with significant secondary MR, provides survival benefit and may decrease hospitalizations when compared with guideline-directed medical therapy alone.

Abstract 13301: Clinical Implications of Hepatic Hemodynamic Evaluation by Abdominal Ultrasonographic Imaging in Patients With Heart Failure

Background: It has been reported that liver stiffness assessed by transient elastography is correlated with right atrial pressure (RAP), which is an important hemodynamic parameter in patients with heart failure (HF). We aimed to clarify clinical implications of hepatic hemodynamic evaluation (liver congestion and hypoperfusion) by abdominal ultrasonography in patients admitted for the treatment of decompensated HF. Methods and Results: We performed abdominal ultrasonography, right-heart catheterization (RHC), and echocardiography in HF patients (n=342) at stable condition after treatment, then followed up for cardiac events such as cardiac death and re-hospitalization due to worsening HF. Regarding liver congestion, liver stiffness assessed by shear wave elastography of the liver (SWE) was significantly correlated with RAP determined by RHC (R=0.343, P&lt;0.01) and right atrial end systolic area determined by echocardiography (R=0.293, P&lt;0.01). With regard to liver hypoperfusion, peak systolic velocity (PSV) of the celiac artery was correlated with cardiac index determined by RHC (R=0.291, P&lt;0.001) and tricuspid annular plane systolic excursion determined by echocardiography (R=0.251, P=0.004). Importantly, cardiac event rate was highest in HF patients with high SWE and low PSV ( Figure , subset 4). In the Cox proportional hazard analysis, the combination of high SWE and low PSV was a strong predictor of cardiac events (HR 4.811, 95% CI 1.562-14.818). Conclusions: Abdominal ultrasonography based evaluations of intrahepatic congestion and hypoperfusion predict adverse prognosis in HF patients.

Abstract 16345: Increase in Serum Chloride Level During Hospitalization Leads to Improved Clinical Outcomes in Patients With Heart Failure

Introduction: Serum chloride levels both at admission and at discharge in patients with heart failure (HF) are independently associated with the incidence of adverse clinical outcomes. However, there has been few reports focusing on the prognostic impact of the change in serum chloride level during the hospitalization on the long-term prognosis after discharge. Hypothesis: We thus hypothesized that changes in serum chloride during the hospitalization is an independent prognostic predictor after discharge in HF patients. Methods: This observational study included 1,913 consecutive patients who admitted to hospital due to worsening of HF and discharged alive in a single university hospital. After excluding patients who received regular hemodialysis, 1,762 patients were ultimately analyzed. The primary endpoint of this study was death from any cause. Result: Overall serum chloride level was significantly decreased from the admission to discharge (103 [100-106] mEq/L to 102 [99-105] mEq/L, P&lt;0.001). During the observation period with 512 days of median follow-up, 286 patients (16.2%) died. Multivariate Cox regression analysis revealed that increase in serum chloride level during the index hospitalization was independently associated with lower rates of mortality, even after the adjustment of diverse covariates including serum chloride level at admission (hazard ratio (HR): 0.94, 95% confidence interval: 0.90-0.98). When dividing the study population into tertiles by chloride levels at admission, patients with the lower baseline chloride level had the greater reduction in HR of the primary endpoint by the increase of chloride level during the hospitalization (Figure). Conclusion: Increase in serum chloride level during hospitalization may be associated with better post-discharge prognosis in HF patients. This could be a new therapeutic target for heart failure to improve long-term prognosis.

Abstract 13304: Liver Dispersion Predicts Adverse Outcomes in Patients With Heart Failure

Background: It has been recently reported that liver stiffness assessed by transient elastography reflects right atrial pressure (RAP), and is associated with worse outcome in patients with heart failure (HF). However, the relationship between liver dispersion (LD, a novel indicator of liver viscosity) determined by abdominal ultrasonography and RAP, and prognostic impacts of LD on HF patients have not been fully examined. We aimed to clarify associations of LD with parameters of liver functional test (LFT) and right-heart catheterization (RHC), and cardiac event such as cardiac death and worsening HF in patients with HF. Methods and Results: We performed abdominal ultrasonography, LFT, RHC, and followed up cardiac events including cardiac death and unplanned hospitalization due to HF in patients with HF (n=157). We examined associations of LD with parameters of LFT and RHC. There were significant correlations between LD and circulating levels of gamma-glutamyl transferase (R=0.197, P=0.018), cholinesterase (R=-0.301, P=0.001), and 7S domain of collagen type IV (P4NP 7S, a marker of fibrosis, R=0.334, P&lt;0.001), but not with RAP (R=0.067, P=0.514) or cardiac index (R=-0.038, P=0.667). During the follow up period (median 305 days), 6 cardiac deaths and 18 unplanned hospitalization due to HF occurred. In the Kaplan-Meier analysis ( Figure ), cardiac event rate was significantly higher in the high LD group (LD ≥10.0 (m/s)/kHz, n=79) than in the low LD group (LD &lt; 10.0 (m/s)/kHz, n=78; log-rank, P=0.007). In the multivariable Cox proportional hazard analysis, high LD was found to be an independent predictor of cardiac event (hazard ratio 3.274, 95% confidence interval 1.203-8.912, P=0.020). Conclusions: LD assessed by abdominal ultrasonography reflects liver fibrosis rather than liver congestion, and is associated with adverse prognosis in HF patients.

Abstract 13678: Serum Hepatokine Selenoprotein P is Upregulated by Hepatic Hypoperfusion and Predicts Adverse Prognosis in Heart Failure Patients

Introduction: Cardiac and multiple organ network is involved in the pathophysiology of heart failure (HF). Hepatokines, which are produced and secreted from the liver, have regulatory functions in the peripheral tissues. However, the interaction between the heart and liver or clinical relevance of hepakokines in HF remains poorly understood. The present study aimed to elucidate the clinical significance of hepatokine selenoprotein P in HF. Methods and Results: We enrolled 250 participants including 171 hospitalized patients with HF and 79 control subjects. The serum concentration of selenoprotein P was measured by an enzyme-linked immunosorbent assay. We found that the serum selenoprotein P levels in HF patients were significantly higher than those in controls (14.8 ± 7.5 vs. 8.4 ± 4.6 mg/L, P&lt;0.01). Next, the HF patients were categorized into 4 groups based on the hepatic hemodynamics assessed by abdominal-ultrasonography, which determined liver congestion by shear wave elastography (liver-SWE, &gt;1.33 m/s) and liver hypoperfusion by peak systolic velocity of the celiac artery (celiac-PSV, &lt;62.4 cm/s). Selenoprotein P levels were significantly upregulated in patients with liver hypoperfusion compared to patients with liver congestion ( Figure A ). Selenoprotein P was negatively correlated with celiac-PSV (P&lt;0.01), cardiac output (P&lt;0.01), and left ventricular stroke volume (P=0.03), whereas no correlations were observed between selenoprotein P and indices of congestion such as liver-SWE and right atrial pressure. Kaplan-Meier analysis demonstrated that a higher selenoprotein P group showed a lower event-free rate from re-hospitalization due to worsening HF ( Figure B ). Conclusion: Upregulation of liver-derived selenoprotein P was associated with hepatic hypoperfusion, not hepatic congestion, and related to the adverse prognosis in HF. Selenoprotein P may be a novel molecule involved in the cardio-hepatic interaction.

Abstract 13324: TRACP5b, a Marker of Osteoporosis, is Associated With Adverse Cardiac Events in Hospitalized Patients With Heart Failure

Introduction: Tarterate-resistant acid phosphatase type 5b (TRACP5b) is derived from osteoclast, and has been used as a maker of osteoporosis. Although heart failure (HF) is associated with catabolic bone remodeling, serum TRACP5b levels have not been rigorously examined in patients with HF. Methods and Results: We conducted a prospective observational study of 688 decompensated HF patients, and patients were divided into tertiles based on serum TRACP5b levels: 1 st (TRACP5b &lt;316 mU/dL, n = 229), 2 nd (316 ≤ TRACP5b &lt;490 mU/dL, n = 229), and 3 rd (490 mU/dL ≤ TRACP5b, n = 230) tertiles. We compared baseline patients’ characteristics and their post-discharge prognosis including cardiac mortality and cardiac events such as cardiac death and worsening HF. Age was significantly higher, and prevalence of female and anemia was significantly higher in the 3 rd tertile than in the 1 st and 2 nd tertiles (age, 71.9 vs. 64.2 and 67.3 years, P&lt;0.001; female, 50.4% vs. 35.4% and 43.2%, P=0.005; anemia, 54.8% vs. 41.9% and 46.7%, P=0.021). In contrast, left ventricular ejection fraction, prevalence of hypertension, diabetes, chronic kidney disease and atrial fibrillation did not differ among the tertiles. In the Kaplan-Meier analysis ( Figure , mean follow up of 426 days), cardiac mortality and cardiac event rates progressively increased from the 1 st to the 3 rd tertiles (cardiac mortality, 3.1%, 5.2% and 8.7%, log-rank P =0.024; cardiac event rates, 10.9%, 14.0% and 20.4%, log-rank P=0.010). In the multivariable Cox proportional hazard analysis, the 3 rd tertile was found to be an independent predictor of cardiac mortality and cardiac events (cardiac mortality, hazard ratio 1.381, P=0.035; cardiac events, hazard ratio 1.664, P=0.044). Conclusion: High serum levels of TRACP5b, a marker of osteoporosis, is associated with adverse prognosis in HF patients.

Hubungan antara Kelas Fungsional Gagal Jantung Kronik dengan Tingkat Keparahan Anemia pada Pasien di Rumah Sakit Atma Jaya

Pendahuluan: Diperkirakan ada 40 juta orang menderita gagal jantung (GJ) di dunia, di Indonesia ditemukan pada 13% populasi. Angka kejadian anemia pada GJ ditemukan berkisar antara 17-50%. Anemia diketahui dapat meningkatkan risiko mortalitas dan prognosis pada pasien GJ dan pengertian lebih akan mekanismenya akan meningkatkan efektivitas pengobatan.Metode: Penelitian ini bersifat observasional analitik dengan desain potong lintang. Data diambil dari rekam medis medis pasien GJ yang masuk dari tahun 2016-2018 dan dikelompokan berdasarkan New York Heart Association Functional Class (NYHA-FC) dan keparahan anemia (WHO anemia cut-off point). Hasil: Terdapat 81 pasien gagal jantung dengan anemia dianalisa dan terdiri atas 34,57% NYHA II, 24,69% NYHA III, dan 40,7% NYHA IV. Sebanyak 50,6% pasien masuk anemia ringan dan 49,4% anemia sedang. Tidak ditemukan anemia berat. Hasil analisis multivariat menunjukan kelas fungsional gagal jantung kronik tidak memiliki hubungan bermakna dengan tingkat keparahan anemia (p = 0,179).Kesimpulan: Kelas fungsional GJ kronik tidak memiliki hubungan dengan tingkat keparahan anemia. Pasien gagal jantung tanpa komplikasi gagal ginjal jarang ditemukan anemia berat.&#x0D;

Changes in nutritional status by recovery phase interventions would be a powerful determinant of cardiovascular prognosis in heart failure patients

Abstract Background Adequate nutrition has been proposed for better cardiovascular prognosis as well as fitness, although the impact of the “changes” in nutrition and fitness at recovery phase on the future prognosis has been unclear. Purpose We aimed to examine whether the change in nutritional level as a result of dietary intervention combined with exercise would determine patients' cardiovascular prognosis. Methods This study involved 398 consecutive patients who participated in phase II comprehensive cardiac rehabilitation (CCR) for at least three months. All patients underwent cardiopulmonary exercise test (CPX) at the initial and completion periods of CCR. Individual dietary guidance was periodically performed with exercise. Peak oxygen uptake (PVO2) was measured through CPX to evaluate the fitness level, whereas nutritional status was evaluated using the geriatric nutritional risk index (GNRI). Patients were divided in two groups according to the baseline GNRI and the change in GNRI (ΔGNRI) by the median, respectively, to compare their prognosis between groups. Then they were classified into four categories according to the median values of the changes in GNRI (ΔGNRI) and PVO2 (ΔPVO2) during CCR: “Both improved”, “Only GNRI improved”, “Only PVO2 improved” and “Both NOT improved”, to compare MACCE-free rate between categories. Results The rate of MACCE showed significant difference between categories (14%, 18%, 19% and 36%, p&amp;lt;0.001), which was approximately 2 times higher in “Both NOT improved” than the others. Kaplan-Meier analysis showed that according to the level of ΔGNRI, “higher ΔGNRI group” showed significantly higher in MACCE-free survival rate than “lower ΔGNRI group” (log rank p=0.010), whereas there was no significant difference according to the baseline GNRI (see figure). According to the categories divided by ΔGNRI and ΔPVO2, MACCE-free rate was significantly lower in “Both NOT improved” (log rank p&amp;lt;0.001) compared to the other categories. Cox proportional hazard regression analysis revealed that “both NOT improved” was an independent predictor of MACCE (hazard ratio, 2.1, 95% confident interval, 1.344–3.175, p&amp;lt;0.001). Conclusion Changes in nutritional level would determine patients' cardiovascular prognosis rather than the baseline nutritional level. Non-responders who showed no improvement in nutritional or fitness by interventions may result in a poor cardiovascular outcome. Funding Acknowledgement Type of funding source: None

A prognostic nomogram for event-free survival in patients with atrial fibrillation before cardiac resynchronization therapy

Abstract Background Atrial fibrillation (AF), one of the most common comorbidities with heart failure (HF), is associated with worse prognosis in HF patients receiving cardiac resynchronization therapy (CRT). However, there is still no convenient tool to evaluate and identify patients with high risk of mortality and hospitalization due to heart failure in CRT candidates with AF. Methods We included 152 consecutive patients with AF for CRT in our hospital from January 2009 to July 2019. Multivariate Cox regression was applied to derive a nomogram, using multiple imputation for missing values and backward stepwise regression for variable selection. Results Five predictors were incorporated in the nomogram, including N-terminal pro brain natriuretic protein (NTproBNP) &amp;gt;1745pg/mL, history of syncope, previous pulmonary hypertension (PHP), moderate or severe tricuspid regurgitation (TR), thyroid stimulating hormone (TSH) &amp;gt;4mIU/L. Concordance index (0.70, 95% CI 0.62–0.77), corrected concordance index (0.67, 95% CI 0.59–0.74) and calibration curve showed optimal discrimination and calibration of the established nomogram. Significant difference of overall event-free survival was recognized by the nomogram-derived scores in patients with high risk (&amp;gt;50 points), intermediate risk (21–50 points) and low risk (0–20 points) before CRT. Conclusion Our nomogram may be an applicable tool for early risk stratification among CRT candidates with AF. Nomogram and risk stratification Funding Acknowledgement Type of funding source: None

Effect of tolvaptan on long-term prognosis in Japanese patients with heart failure: a systematic review and meta-analysis

Abstract Background Tolvaptan (TLV), a vasopressin antagonist, can promote water diuresis and overcome various disadvantages associated with conventional diuretics by ameliorating congestive symptoms and improving hyponatremia while maintaining haemodynamics and renal function. Large-scale clinical trials conducted primarily in Western countries (e.g. EVEREST trial) failed to demonstrate the beneficial effect of TLV on prognosis in patients with heart failure (HF). However, even after these clinical trials, studies on the use of TLV add-on therapy and resultant prognosis have been reported in Asian countries. Racial differences can greatly affect drug efficacy and dosing. Purpose We sought to investigate the long-term prognostic effect of TLV add-on therapy in Asian patients with HF. Methods We searched MEDLINE, Scopus, Cochrane Central, and Google Scholar for articles published till 31 December 2019. Randomized controlled trials (RCTs) and matched case-control studies that had a follow-up period of at least 6 months and that compared TLV add-on therapy and conventional therapy (control group) in Asian patients with acute decompensated HF were included. Primary and secondary outcomes analysed were all-cause mortality and HF readmission, respectively. Pooled analysis was performed using univariate effect size with random effect models. Meta-regression was performed to assess the impact of potential covariates. Results Nine articles that enrolled 1010 patients (the range of patients in the enrolled studies: 58–217) were included in the systematic review. All studies were performed in Japan. The weighted mean follow-up period was 15 months. The weighted mean of sodium level and ejection fraction was 139 mEq/L and 47%, respectively. TLV dose at discharge was available only in five articles, and its weighted mean value was 8.8 mg/day. In the pooled analysis, TLV add-on therapy did not improve the incidence of all-cause mortality (OR: 1.02, 95% CI: 0.69–1.52, p=0.92, I2=23) and HF readmission (OR: 0.73, 95% CI: 0.24–2.22, p=0.58, I2=89) (Figure). Furthermore, the effect of TLV add-on therapy on all-cause mortality was significantly moderated by furosemide dose at discharge in the control group (p=0.03). Conclusions Similar to findings of previous RCTs completed in Western countries, we found that TLV add-on therapy did not improve long-term mortality and HF readmission in Japanese patients with HF; however, mostly small-scale studies were included in our review. TLV add-on therapy might contribute to the improvement in prognosis in HF patients taking large doses of furosemide. Forest plot of tolvaptan's effect Funding Acknowledgement Type of funding source: Private hospital(s). Main funding source(s): Kitaishikai

The prognostic impact of catheter ablation for atrial fibrillation after heart failure hospitalization on long-term mortality – Propensity-score matching analysis

Abstract Background In the last two decades, catheter ablation (CA) for atrial fibrillation (AF) including pulmonary vein isolation (PVI) has been developed as a standard and effective treatment for atrial fibrillation (AF). In patients with chronic heart failure with reduced left ventricular ejection fraction (LVEF) (HFrEF), PVI CA for AF dramatically improves LVEF, resulting in better clinical prognoses. On the contrary, there still has been no data that PVI CA for AF improves the prognosis in heart failure patients with preserved LVEF (HFpEF). Purpose The aim of this study was to evaluate the prognostic impact of PVI CA for AF after the hospitalization due to decompensation of heart failureHF, focusing on LVEF. Methods From the database including 1,793 consecutive patients who were hospitalized due to congestive HF, we ultimately analyzed 624 AF patients who were discharged alive. They were assigned into two groups due that PVI CA for AF procedure done after the index hospitalization for HF; the PVI CA group (n=62) and Non-PVI CA group (n=562). For the two groups, we performed propensity-score (PS) matching using variables as follows: age, sex, LVEF, brain natriuretic peptide (BNP), blood urea nitrogen (BUN) and estimated glomerular filtration rate (eGFR) at discharge. Further analysis was performed separately in HFrEF (LVEF &amp;lt;50%) and HFpEF (LVEF &amp;gt;50%). The primary endpoint of this study was death from any cause. Results In unmatched patients, Kaplan-Meier analysis showed that patients in the PVI CA group had a significantly lower all-cause mortality than those in the Non-PVI CA group during 678 median follow-up period (Log-rank test: P=0.003, Figure A). In 96 PS-matched patients, patients in the PVI CA group still had lower mortality rate than those in the Non-PVI CA group (hazard ratio 0.28, 95% confidence interval 0.09–0.86, p=0.018, Figure B). When the whole study population was classified into HFrEF and HFpEF, HFrEF patients who received PVI showed a significantly lower mortality than those who did not (p=0.007); whereas, in HFpEF patients, PVI CA for AF did not make statistical difference in all-cause mortality (p=0.061). Conclusions In this observational study, PVI CA for AF may improve the mortality in HF patients with reduced LVEF. However, the prognostic impact of PVI CA for AF was not observed in HF patients with preserved LVEF. Funding Acknowledgement Type of funding source: None

The emerging role of iron in heart failure and vascular calcification in CKD.

Iron deficiency is a frequent comorbidity of cardiovascular (CV) diseases and nearly 50% of patients with heart failure (HF) with or without anaemia have low levels of available iron. There is a strong association between anaemia and the increase in mortality and hospitalizations in patients with CV disease and HF. Moreover, anaemia and chronic kidney disease (CKD) often coexist in patients with HF, with anaemia increasing the risk of death in these subjects and with a further increased risk in CKD population. The evidence that the treatment of iron deficiency and the increase in haemoglobin are associated with a better prognosis in HF patients has elicited new interest in the utilization of iron in HF and CKD patients. One of the central players in CV disease is vascular calcification (VC), which has been recognized as a major independent risk factor for incident CV disease and overall mortality in chronic disease patients. In this review, we summarize the evidences generated by clinical trials aimed to study the effect of iron deficiency correction, the effect of iron-based phosphate binder in in vivo models of kidney failure and the effect of iron in in vitro models of VC, trying to give an overview of the present knowledge on iron effect and its mechanisms of action.

Prognostic value of heart failure echocardiography index in HF patients with preserved, mid-ranged and reduced ejection fraction

BackgroundTo investigate the clinical value of heart failure echocardiography index (HFEI) in evaluating the cardiac function and predicting the prognosis of patients with different types of heart failure (HF).MethodsFour hundred eighty-nine consecutively admitted HF patients were divided into three groups: HF with reduced ejection (HFrEF), HF with mid-range ejection fraction (HFmrEF), and HF with preserved ejection fraction (HFpEF). The baseline characteristics and ultrasound indexes were compared between the three groups. The correlation between HFEI and one-year risk of adverse events was compared by multivariate logistic regression. The clinical value of HFEI and plasma level of NT-proBNP in assessing the prognosis of patients with chronic heart failure (CHF) was analyzed by the receiver operating characteristic (ROC) curve.ResultsHFEI in HFrEF was significantly higher than that in HFmrEF and HFpEF. Multivariate regression analysis indicated that HFEI and plasma level of NT-proBNP were independent risk factors for predicting the short-time prognosis of HF patients. The ROC curve indicated that the HFEI cutoff level of 3.5 and the plasma NT-proBNP level of 3000 pg/ml predicted a poor prognosis of CHF patients with a sensitivity of 64% and a specificity of 75% vs. 68 and 65%.ConclusionHFEI can comprehensively evaluate the overall cardiac function of patients with various types of HF, and may prove to be an important index of assessing the prognosis of HF patients.