Readmission For Acute Heart Failure Research Articles

Intensive therapeutic education strategy for patients with acute heart failure (EduStra-HF): Design of a randomized controlled trial

Background: Heart failure is associated with reduced quality of life, hospitalizations, death and high healthcare costs. Despite care improvements, the rehospitalization rate after an acute heart failure episode, especially for acute heart failure, remains high.Methods: The Education Strategy for patients with acute Heart Failure (EduStra-HF; ClinicalTrials.gov Identifier NCT03035123) study will randomize patients admitted for acute heart failure in six French hospitals to usual care (control) or therapeutic education (intervention). All patients will be evaluated at baseline and will meet with a therapeutic education nurse before discharge. Those in the usual care arm will have standard appointments with their cardiologist and general practitioner. Those in the intervention arm will have an intensive follow-up schedule of phone calls, home visits and text messages from the therapeutic education nurses, plus cardiologist visits. Patients will be stratified by discharge location (home or cardiac rehabilitation centre) before randomization, and will be followed up for 1 year. The primary outcome will be the readmission rates for acute heart failure during 1 year in the two groups. Secondary outcomes will include: quality of life; time from inclusion to first readmission for acute heart failure; non-heart failure cardiovascular rehospitalization rates; length of stay for heart failure; cardiovascular and all-cause death; rates of patients receiving optimal medical therapies; evolution of knowledge about heart failure; and cost-effectiveness.Conclusions: This study will assess the efficacy and feasibility of a standardized management strategy for the care and follow-up of patients discharged after hospitalization for acute heart failure. The EduStra-HF strategy will combine various nurse care methods to help prevent rehospitalization.

Urinary catheterization of patients with acute heart failure in a hospital emergency department: a factor associated with prognosis.

To analyze whether urinary catheterization in a hospital emergency department (ED) affects short-term prognosis in patients with acute heart failure (AHF). We prospectively recorded baseline and other clinical data in a consecutive cohort of ED patients treated for AHF. Crude and adjusted associations were calculated between catheterization and a primary composite outcome (30-day readmission for AHF and/or death) and secondary outcomes (in-hospital mortality, urinary tract infection [UTI], and duration of hospital stay.). Nine hundred ninety-one patients were admitted for AHF. The mean (SD) age was 66 (10.5) years; 71% were women. Catheterization was required for 29.2% in the ED. The primary composite outcome was observed in 7.7% of the patients who were not catheterized and 12.8% of the catheterized patients (P = .02). In-hospital mortality occurred in 5.9% and 9.7% of non-catheterized and catheterized patients, respectively (P = .04), and UTIs occurred in 19.1% and 26.6% (P = .01). Twelve of the non-catheterized patients (1.7%) were readmitted for AHF (vs 11 (3.8%) of the catheterized patients (P = .06), and there were no differences between the groups in hospital stay (11 vs 10.9 days, P = .78). In the adjusted analysis of associations between catheterization and the primary outcome the odds and hazard ratios (OR and HR, respectively) were OR, 1.7 (95% CI, 1.1-2.7) (P = .02) and HR, 1.6 (95% CI, 1.1-2.5) (P = .03). For secondary outcomes, significant associations emerged between catheterization and UTIs (OR, 1.8 [95% CI, 1.1-2.2]; P = .008) and readmission for AHF (OR, 2.9 [95% CI, 1.2-7.3]; P = .02). Routine insertion of a urinary catheter in patients with AHF in the ED is associated with worse 30-day clinical outcomes.

Differential sex-related effect of left ventricular ejection fraction trajectory on the risk of mortality and heart failure readmission following hospitalization for acute heart failure: A longitudinal study.

There is limited information on the sex-specific longitudinal changes of left ventricular ejection fraction (LVEF) after an acute heart failure (AHF) hospitalization. We aimed to investigate whether LVEF trajectories over time and their impact on mortality and AHF readmission rates differ between men and women. We conducted a retrospective sex-specific analysis of longitudinal LVEF measurements (n = 9581) in 3383 patients with an index hospitalization for AHF in a single tertiary-level hospital. Statistical techniques suited for longitudinal data analysis were used. The mean age of the sample was 73.8 ± 11.2 years, and 47.9% were women. The mean LVEF was 49.4 ± 15.3%. At a median follow-up of 2.58 years (interquartile range 0.77-5.62), we registered 2197 deaths (64.9%) and 2597 AHF readmissions in 1302 (38.5%) patients. The longitudinal analysis showed that women had consistently higher LVEF values throughout the follow-up with both trajectories characterized by an early peak-approximately at 1 year-followed by decreasing values in men but a plateau in women. Multivariate between-sex comparisons across LVEF categories revealed that women had lower rates of AHF readmissions when LVEF ≤40%. On the contrary, women displayed an excess risk of AHF readmissions when LVEF >60%. A trend in the same direction was found for cardiovascular and all-cause mortality. Sex was a significant factor in determining the follow-up trajectory of LVEF and predicting differences in outcomes after an AHF admission. The findings suggest that women have a higher risk of AHF readmissions at higher LVEF values, while men have a higher risk at lower LVEF values. For all-cause and cardiovascular mortality, the same direction of the association was inferred but they were not significant.

Prognostic effect of systematic geriatric assessment on patients with acute heart failure.

Frailty and dependence are frequent in patients admitted for acute heart failure (AHF), but their prognostic significance is unknown, especially in young adults. We aimed to study in adults admitted for AHF, regardless of age, the effect of frailty and dependence on the incidence of mortality and a combined event of mortality, readmissions for AHF, and visits to the emergency room (ER) for AHF at 1 and 6months. We designed a prospective cohort study by including all the patients with AHF admitted in our Cardiology Department from July 2020 through May 2021. A multidimensional geriatric assessment was performed during the admission. We clinically followed up the patients 6months after discharge. We enrolled 202 patients. The mean age was 73±12.32years, and 100 (49.5%) of the patients were elderly (>75years). Just 78 patients (38.6%) were women, and 100 (49.5%) had previous HF. Frailty (FRAIL≥3) was observed in 68 (33.7%) patients (mean FRAIL score: 1.88±1.48). Dependence (Barthel<100) was observed in 65 (32.2%) patients (mean Barthel index: 94.38±11.21). Frailty and dependence showed a significant association with both prognostic events at 1 and 6months. In the multivariable analysis, frailty was associated with higher mortality at 1month [hazard ratio (HR) 12.61, 95% confidence interval (CI) 1.57-101.47, P=0.017] but not at 6months (HR 2.25, 95% CI 0.61-8.26, P=0.224) or with the combined endpoint at neither 1month (HR 1.64, 95% CI 0.54-5.03, P=0.384) nor 6months (HR 1.35, 95% CI 0.75-2.46, P=0.320). Dependence was related to higher mortality at 1month (HR 13.04, 95% CI 1.62-104.75, P=0.016) and 6months (HR 7.18, 95% CI 1.99-25.86, P=0.003) and to higher incidence of the combined event at 1month (HR 5.93, 95% CI 1.63-21.50, P=0.007) and 6months (HR 2.62, 95% CI 1.49-4.61, P=0.001). In AHF patients, frailty and dependence implied a worse prognosis, rising mortality, readmissions, and ER visits for AHF.

Mid-Regional Pro-Adrenomedullin and N-Terminal Pro-B-Type Natriuretic Peptide Measurement: A Multimarker Approach to Diagnosis and Prognosis in Acute Heart Failure.

Acute heart failure (AHF) is a major cause of hospitalization and mortality worldwide. Early and accurate diagnosis, as well as effective risk stratification, are essential for optimizing clinical management and improving patient outcomes. In this context, biomarkers have gained increasing interest in recent years as they can provide important diagnostic and prognostic information in patients with AHF. The primary objective of the present study was to compare the levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP), mid-regional pro-adrenomedullin (MR-proADM), and C-reactive protein (CRP) between patients diagnosed with acute heart failure (AHF) and those without AHF and sepsis. Furthermore, the study aimed to assess the diagnostic and prognostic value of the use of a multimarker approach in AHF patients. To achieve these objectives, a total of 145 patients with AHF and 127 patients without AHF and sepsis, serving as the control group, were consecutively enrolled in the study. Levels of MR-proADM (median: 2.07; (25th-75th percentiles: 1.40-3.02) vs. 1.11 (0.83-1.71) nmol/L, p < 0.0001), and NT-proBNP (5319 (1691-11,874) vs. 271 (89-931.5) pg/mL, p < 0.0001) were significantly higher in patients with AHF compared to controls, whereas CRP levels did not show significant differences. The mortality rate in the AHF group during in-hospital stay was 12%, and the rate of new re-admission for AHF within 30 days after discharge was 10%. During in-hospital follow-up, Cox regression analyses showed that levels of NT-proBNP > 10,132 pg/mL (hazard ratio (HR) 2.97; 95% confidence interval (CI): 1.13-7.82; p = 0.0284) and levels of MR-proADM > 2.8 nmol/L (HR: 8.57; CI: 2.42-30.28; p = 0.0009) predicted mortality. The combined use of MR-proADM and NT-proBNP provided significant additive predictive value for mortality and new re-admission for AHF at 30 days after discharge. A logistic regression analysis showed that the presence of NT-proBNP pg/mL > 12,973 pg mL and/or MR-proADM > 4.2 nmol/L predicted hospital re-admission within 30 days (OR: 3.23; CI: 1.05-9.91; p = 0.041). The combined assay of MR-proADM and NT-proBNP could be helpful in accurately identifying AHF and in defining prognosis and re-admission for AHF. The complementary use of these biomarkers can provide a useful clinical evaluation of AHF while also orienting clinicians to the pathophysiology underlying heart damage and assisting them in tailoring therapy.

Acute heart failure after non-cardiac surgery: incidence, phenotypes, determinants and outcomes.

Primary acute heart failure (AHF) is a common cause of hospitalization. AHF may also develop postoperatively (pAHF). The aim of this study was to assess the incidence, phenotypes, determinants and outcomes of pAHF following non-cardiac surgery. A total of 9164 consecutive high-risk patients undergoing 11 262 non-cardiac inpatient surgeries were prospectively included. The incidence, phenotypes, determinants and outcome of pAHF, centrally adjudicated by independent cardiologists, were determined. The incidence of pAHF was 2.5% (95% confidence interval [CI] 2.2-2.8%); 51% of pAHF occurred in patients without known heart failure (de novo pAHF), and 49% in patients with chronic heart failure. Among patients with chronic heart failure, 10% developed pAHF, and among patients without a history of heart failure, 1.5% developed pAHF. Chronic heart failure, diabetes, urgent/emergent surgery, atrial fibrillation, cardiac troponin elevations above the 99th percentile, chronic obstructive pulmonary disease, anaemia, peripheral artery disease, coronary artery disease, and age, were independent predictors of pAHF in the logistic regression model. Patients with pAHF had significantly higher all-cause mortality (44% vs. 11%, p < 0.001) and AHF readmission (15% vs. 2%, p < 0.001) within 1 year than patients without pAHF. After Cox regression analysis, pAHF was an independent predictor of all-cause mortality (adjusted hazard ratio [aHR] 1.7 [95% CI 1.3-2.2]; p < 0.001) and AHF readmission (aHR 2.3 [95% CI 1.5-3.7]; p < 0.001). Findings were confirmed in an external validation cohort using a prospective multicentre cohort of 1250 patients (incidence of pAHF 2.4% [95% CI 1.6-3.3%]). Postoperative AHF frequently developed following non-cardiac surgery, being de novo in half of cases, and associated with a very high mortality.

MRI Investigation of the Differential Impact of Left Ventricular Ejection Fraction After Myocardial Infarction in Elderly vs. Nonelderly Patients to Predict Readmission for Heart Failure.

Patients with ST-segment elevation myocardial infarction (STEMI), especially elderly individuals, have an increased risk of readmission for acute heart failure (AHF). To study the impact of left ventricular ejection fraction (LVEF) by MRI to predict AHF in elderly (>70 years) and nonelderly patients after STEMI. Prospective. Multicenter registry of 759 reperfused STEMI patients (23.3% elderly). 1.5-T. Balanced steady-state free precession (cine imaging) and segmented inversion recovery steady-state free precession (late gadolinium enhancement) sequences. One-week MRI-derived LVEF (%) was quantified. Sequential MRI data were recorded in 579 patients. Patients were categorized according to their MRI-derived LVEF as preserved (p-LVEF, ≥50%), mildly reduced (mr-LVEF, 41%-49%), or reduced (r-LVEF, ≤40%). Median follow-up was 5 [2.33-7.54] years. Univariable (Student's t, Mann-Whitney U, chi-square, and Fisher's exact tests) and multivariable (Cox proportional hazard regression) comparisons and continuous-time multistate Markov model to analyze transitions between LVEF categories and to AHF. Hazard ratios (HR) with 95% confidence intervals (CIs) were computed. P < 0.05 was considered statistically significant. Over the follow-up period, 79 (10.4%) patients presented AHF. MRI-LVEF was the most robust predictor in nonelderly (HR 0.94 [0.91-0.98]) and elderly patients (HR 0.94 [0.91-0.97]). Elderly patients had an increased AHF risk across the LVEF spectrum. An excess of risk (compared to p-LVEF) was noted in patients with r-LVEF both in nonelderly (HR 11.25 [5.67-22.32]) and elderly patients (HR 7.55 [3.29-17.34]). However, the mr-LVEF category was associated with increased AHF risk only in elderly patients (HR 3.66 [1.54-8.68]). Less transitions to higher LVEF states (n=19, 30.2% vs. n=98, 53%) and more transitions to AHF state (n=34, 53.9% vs. n=45, 24.3%) were observed in elderly than nonelderly patients. MRI-derived p-LVEF confers a favorable prognosis and r-LVEF identifies individuals at the highest risk of AHF in both elderly and nonelderly patients. Nevertheless, an excess of risk was also found in the mr-LVEF category in the elderly group. 2. Stage 2.

Residual ST-segment elevation to predict long-term clinical and CMR-derived outcomes in STEMI

Residual ST-segment elevation after ST-segment elevation myocardial infarction (STEMI) has traditionally been considered a predictor of left ventricular (LV) dysfunction and ventricular aneurism. However, the implications in terms of long-term prognosis and cardiac magnetic resonance (CMR)-derived structural consequences are unclear. A total of 488 reperfused STEMI patients were prospectively included. The number of Q wave leads with residual ST-segment elevation > 1 mm (Q-STE) at pre-discharge ECG was assessed. LV ejection fraction (LVEF, %) and infarct size (IS, % of LV mass) were quantified in 319 patients at 6-month CMR. Major adverse cardiac events (MACE) were defined as all-cause death and/or re-admission for acute heart failure (HF), whichever occurred first. During a mean follow-up of 6.1 years, 92 MACE (18.9%), 39 deaths and 53 HF were recorded. After adjustment for baseline characteristics, Q-STE (per lead with > 1 mm) was independently associated with a higher risk of long-term MACE (HR 1.24 [1.07–1.44] per lead, p = 0.004), reduced (< 40%) LVEF (HR 1.36 [1.02–1.82] per lead, p = 0.04) and large (> 30% of LV mass) IS (HR 1.43 [1.11–1.85] per lead, p = 0.006) at 6-month CMR. Patients with Q-STE ≥ 2 leads (n = 172, 35.2%) displayed lower MACE-free survival, more depressed LVEF, and larger IS at 6-month CMR (p < 0.001 for all comparisons). Residual ST-segment elevation after STEMI represents a universally available tool that predicts worse long-term clinical and CMR-derived structural outcomes.

Prognostic value of cardiac magnetic resonance in elderly patients soon after ST-segment elevation myocardial infarction

Abstract Background Elderly patients with ST-segment elevation myocardial infarction (STEMI) represent a very high-risk population. Data on the prognostic value of cardiac magnetic resonance (CMR) in this scenario are scarce. Purpose We aim to study the prognostic value of an early (1-week) CMR in elderly patients after STEMI and to create a simple risk score including clinical and CMR variables. Methods The registry comprised 247 patients over 70 years of age discharged for a first STEMI treated with percutaneous intervention and included in a multicenter registry. Baseline characteristics, echocardiographic parameters and CMR-derived left ventricular ejection fraction (LVEF, %), infarct size (% of left ventricular mass) and microvascular obstruction (MVO, number of segments) were prospectively collected. The additional prognostic power of CMR was assessed using adjusted C-statistic, net reclassification index (NRI) and integrated discrimination improvement index (IDI). Results During a 4.8-year mean follow-up, 66 (26.7%) first major adverse cardiac events (MACE) occurred (27 all-cause deaths and 39 re-admissions for acute heart failure). Higher GRACE score (HR 1.03 [1.02–1.04], p&amp;lt;0.001), more depressed CMR-LVEF (HR 0.97 [0.95–0.99] per increased %, p=0.006) and more extensive MVO (HR 1.24 [1.09–1.4] per segment, p=0.001) predicted MACE occurrence. The addition of CMR data significantly improved MACE prediction compared to the model with baseline and echocardiographic characteristics (C-statistic 0.759 [0.694–0.824] vs. 0.685 [0.613–0.756], NRI=0.6, IDI=0.08, p&amp;lt;0.001). The best cut-offs for independent variables were GRACE score &amp;gt;155, LVEF &amp;lt;40%, and MVO ≥2 segments. A simple score (0, 1, 2, and 3) based on the number of altered factors accurately predicted the MACE per 100 person-years: 0.78, 5.53, 11.51 and 78.79, respectively (p&amp;lt;0.001). Conclusions CMR data contribute valuable prognostic information in elderly patients submitted to undergo CMR soon after STEMI. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Instituto de Salud Carlos III and “Fondos Europeos de Desarrollo Regional FEDER” and Conselleria de Educaciόn – Generalitat Valenciana.

Cardiac magnetic resonance predictors of readmission for heart failure in elderly vs not elderly patients after ST-segment elevation myocardial infarction

Abstract Background Patients with ST-segment elevation acute myocardial infarction (STEMI) have an increased risk of re-admission for acute heart failure (AHF). However, identification of patients at higher risk of AHF is challenging, especially in elderly individuals. The implications of cardiac magnetic resonance (CMR) imaging soon after the acute event for this specific purpose are unknown. Purpose We aim to study the clinical and CMR predictors of AHF in elderly and not elderly patients after STEMI. Methods STEMI patients treated with percutaneous coronary intervention and discharged from three university hospitals were included in a multicenter registry. We registered baseline clinical characteristics, echocardiographic parameters and early (1-week) CMR parameters - left ventricular ejection fraction (LVEF, %), infarct size (% of left ventricular mass) and microvascular obstruction (MVO, number of segments). Univariate and multivariate comparisons were performed in elderly (&amp;gt;70 years) and not elderly (≤70 years) patients to predict AHF during follow-up. Results The cohort was comprised of 759 patients, of which 177 (23.3%) were elderly (&amp;gt;70 years). During a mean follow-up of 5.23±3.54 years, 79 (10.4%) patients presented AHF. In not elderly patients, Killip class at admission (HR 2.05 [1.32–3.17], p=0.001), anterior infarction (HR 3.43 [1.13–10.36], p=0.03) and CMR-LVEF (HR 0.94 [0.91–0.98] per increased %, p=0.001) independently predicted AHF. However, a combined risk score comprising these variables was not superior to CMR-LVEF alone to predict AHF during follow-up (AUC 0.81 [0.74–0.88] vs. 0.81 [0.73–0.88], p=NS). In elderly patients, CMR-LVEF was the only predictor of AHF in the final multivariable model (HR 0.94 [0.91–0.97], p&amp;lt;0.001), although its predictive power was moderate (AUC 0.68 [0.56–0.80], p=0.001). Most AHF events in the not elderly subgroup occurred in patients with reduced (≤40%) CMR-LVEF (71%), while in the elderly subgroup AHF occurred more frequently in patients with preserved (≥50%, 30%) or mildly reduced (40–49%, 32%) CMR-LVEF than reduced (≤40%) CMR-LVEF (38%). Conclusions LVEF quantified by CMR soon after STEMI can accurately predict the risk of AHF in not elderly (≤70 years) patients and identify those individuals at higher risk (i.e. CMR-LVEF ≤40%). However, in elderly (&amp;gt;70 years) patients most AHF occur in patients with CMR-LVEF &amp;gt;40%, emphasizing the need for better predictive strategies in this population. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Instituto de Salud Carlos III and “Fondos Europeos de Desarrollo Regional FEDER” and Conselleria de Educaciόn – Generalitat Valenciana.

Carbohydrate antigen 125 (CA125) as a prognostic marker in the elderly with acute heart failure and preserved ejection fraction

BackgroundCarbohydrate antigen 125 (CA125) has emerged as a new biomarker in heart failure. The objective of the study is to determine whether serum CA125 levels predict total mortality and readmissions at one year in patients > 70 years old with acute heart failure (AHF) and preserved ejection fraction (PEF). MethodsMulticenter prospective observational study, which included 359 patients (mean age 81.5 years). The primary endpoint was total all-cause mortality and total readmissions for AHF at 1year. A negative binomial regression technique was used to evaluate the association between CA125 and both endpoints. ResultsAt one year of follow-up, 87 deaths (24.2%) were registered. The patients in the lower quartile of CA125 had a lower crude mortality rate (14.4%, 26.7, 26.7, 29.2; p=0.09). After multivariate analysis, the CA125 value was positively associated with a higher risk (p=0.009). Such association was also positive but borderline significant for the risk of readmissions (p=0.089). ConclusionsIn a population older than 70 years hospitalized for AHF with PEF, elevated levels of CA125 are associated with an increased risk of death at one year of follow-up. The association with readmission for AHF was more uncertain. Low levels of CA125 identifies a subgroup at low-risk.

Diagnosis for readmission of senile patients hospitalized with acute decompensated heart failure in different departments: a retrospective cross-sectional study.

BackgroundShort-term hospital readmissions for acute heart failure lead to the rise of health care budget and all-cause death. Elderly patients with acute or decompensated heart failure are often admitted to different wards (either the geriatric department or other departments). The diagnosis for readmission, cost and length of hospital stay in different wards are not well known.MethodsA retrospective study was conducted examining senile patients admitted to the hospital over a 1-year period. Data related to demographic information, comorbidities, ejection fraction (EF), brain natriuretic peptide (BNP) levels, costs, and discharge disposition were collected from electronic medical record.ResultsA total of 3,922 cases were enrolled in this study. There were 1,316 patients with heart failure who were re-hospitalized, among which, 893 were admitted to the geriatric department. The top 3 diagnosis for re-hospitalization for more than 7 days in the geriatric department were pneumonia (38.5%), blood pressure fluctuations (19.4%), and acute coronary syndrome (ACS) (13.3%). The factors for readmission to other departments were pneumonia (32.5%), arrhythmia (17.7%), and blood pressure fluctuations (15.5%). The top 3 diagnosis for rehospitalizations lasting 7 days or less in the geriatric department were blood pressure fluctuations (26.5%), arrhythmia (23.4%), and fatigue or stress (16.9%), while ACS (24.1%), blood pressure fluctuations (22.5%), and arrhythmia (14.7%) were the top 3 diagnosis for other departments. The geriatric department tended to receive more senile patients, with lower BNP levels (625.13±823.71 vs. 929.31±873.38 pg/mL), and longer duration of hospitalization (24.38±5.228 vs. 15.65±5.907 days). However, there was no significant difference in the total cost of admission between geriatric department and other departments ($4,483 vs. $4,415, P=0.129).ConclusionsOur study identified a higher readmission rate in senile acute decompensated heart failure patients. Pneumonia was listed as the top 1 diagnosis for longer hospital stay in different department. Those rehospitalized with pneumonia may benefit from geriatric department.

Inferior Vena Cava And Lung Ultrasound-guided Therapy For The Reduction Of Clinical Events In Acute Heart Failure - Caval Us-hf Trial

<h3>Introduction</h3> Readmissions for acute heart failure (AHF) are frequent, mostly due to persistent congestion on discharge. However, as the optimal evaluation of decongestion is not clearly defined, it is necessary to implement new tools to identify subclinical congestion to guide treatment. <h3>Objective</h3> To develop a therapeutic algorithm guided by lung (LUS) and inferior vena cava (IVC) ultrasound protocol in patients with AHF.Methods: Design of the interventions was carried out between August 2020-January 2021, and was developed in 3 phases: (1)Systematic and narrative review on the use of ultrasound-guided therapy, and treatments algorithms proposed by scientific societies; (2)Panel of experts for the creation of the CAVAL US protocol for the evaluation of right (VCI) and left (LUS) congestion and (3)Algorithms adaptation to our setting with the incorporation of CAVAL US protocol. <h3>Results</h3> Diuretic treatment algorithms were adapted and incorporated into the CAVAL US protocol as part of the daily congestion evaluation (Figure 1). The ultrasound results were divided into 3 categories (Figure 2): Group A) without or mild congestion, Group B) signs of moderate congestion, and Group C) severe signs of congestion and identified as poor prognostic factors. To define persistent congestion, we chose the cut-off point of >5 B lines, since it has been identified as a risk factor for rehospitalization due to AHF or death at six months; and for severe congestion >30 B lines were determined, as they predict hospitalization for HF or mortality at 90 days. <h3>Conclusion</h3> Through a systematic approach we have developed an evidence-based therapeutic algorithm to guide therapeutic interventions in the recently initiated CAVAL US randomized controlled trial. That will investigate whether lung and IVC ultrasound-guided therapy complementing clinical evaluation, reduces the combined end point of readmission, unplanned visit for worsening HF or death at 90 days in AHF.

Acute myocardial infarction and acute heart failure among renal transplant recipients: a national readmissions database study.

The literature on the mortality and 30-day readmissions for acute heart failure and for acute myocardial infarction among renal-transplant recipients is limited. To study the in-hospital mortality, cardiovascular complications, and 30-day readmissions among renal transplant recipients (RTRs). Data from the national readmissions database sample, which constitutes 49.1% of all hospitals in the United States and represents more than 95% of the stratified national population, wasanalyzed for the years 2012-2018 using billing codes. A total of 588,668hospitalizations inrenal transplant recipients (mean age 57.7 ± 14.2years; 44.5% female) were recorded in the study years. A total of 15,788 (2.7%) patients had a diagnosis of acute heart failure; 11,320 (71.7%) had acute heart failure with preserved ejection fraction and 4468 (28.3%) had acute heart failure with reduced ejection fraction; 17,256 (3%) patients had myocardial infarction, 3496 (20%) had ST-Elevation myocardial infarction while 13,969 (80%) had non-ST-elevation myocardial infarction. Overall,11,675 (2%) renal-transplant patients died, of whom 757 (6.5%) had acute heart failure, 330 (2.8%) had acute reduced and 427 (3.7%) had acute preserved ejection fraction failure. Among 1652 (14.1%) patient deaths with myocardial infarction, 465 (4%) were ST-elevation- and 1187 (10.1%) were non-ST-Elevation-related. The absolute yearly mortalityrate due toacute heart failure increased over the years 2012-2018 (p-trend 0.0002, 0.001, 0.002, 0.05, respectively), while the mortality rate due to myocardial infarction withST-elevation decreased (p-trend 0.002). Cardiovascular complications are significantly associated with hospitalizations among RTRs. The absolute yearly mortality, and rate of heart failure (withreduced orpreserved ejection fraction) increasedover the study years, suggesting thatmore research is needed to improve the management ofthese patients.

Tailored risk assessment of 90-day acute heart failure readmission or all-cause death to heart failure with preserved versus reduced ejection fraction.

BackgroundAfter incident heart failure (HF) admission, patients are vulnerable to readmission or death in the 90‐day post‐discharge. Although risk models for readmission or death incorporate ejection fraction (EF), patients with HF with preserved EF (HFpEF) and those with HF with reduced EF (HFrEF) represent distinct cohorts. To better assess risk, this study developed machine learning models and identified risk factors for the 90‐day acute HF readmission or death by HF subtype.Methods and ResultsApproximately 1965 patients with HFpEF and 1124 with HFrEF underwent an index admission. Acute HF rehospitalization or death occurred in 23% of HFpEF and 28% of HFrEF groups. Of the 101 variables considered, multistep variable selection identified 24 and 25 significant factors associated with 90‐day events in HFpEF and HFrEF, respectively. In addition to risk factors common to both groups, factors unique to HFpEF patients included cognitive dysfunction, low‐pulse pressure, β‐blocker, and diuretic use, and right ventricular dysfunction. In contrast, factors unique to HFrEF patients included a history of arrhythmia, acute HF on presentation, and echocardiographic characteristics like left atrial dilatation or elevated mitral E/A ratio. Furthermore, the model tailored to HFpEF (area under the curve [AUC] = 0.770; 95% confidence interval [CI] 0.767–0.774) outperformed a model for the combined groups (AUC = 0.759; 95% CI 0.756–0.763).ConclusionThe UF 90‐day post‐discharge acute HF Re admission or Death Risk Assessment (UF90‐RADRA) models help identify HFpEF and HFrEF patients at higher risk who may require proactive outpatient management.

Antígeno carbohidrato 125 (CA125) como marcador pronóstico en ancianos con insuficiencia cardiaca aguda y fracción de eyección preservada

BackgroundCarbohydrate antigen 125 (CA125) has emerged as a new biomarker in heart failure. The objective of the study is to determine whether serum CA125 levels predict total mortality and readmissions at one year in patients >70 years old with acute heart failure (AHF) and preserved ejection fraction (PEF). MethodsMulticenter prospective observational study, which included 359 patients (mean age 81.5 years). The primary endpoint was total all-cause mortality and total readmissions for AHF at 1 year. A negative binomial regression technique was used to evaluate the association between CA125 and both endpoints. ResultsAt one year of follow-up, 87 deaths (24.2%) were registered. The patients in the lower quartile of CA125 had a lower crude mortality rate (14.4%, 26.7, 26.7, 29.2; p=0.09). After multivariate analysis, the CA125 value was positively associated with a higher risk (p=0.009). Such association was also positive but borderline significant for the risk of readmissions (p=0.089). ConclusionsIn a population older than 70 years hospitalized for AHF with PEF, elevated levels of CA125 are associated with an increased risk of death at one year of follow-up. The association with readmission for AHF was more uncertain. Low levels of CA125 identifies a subgroup at low-risk.

Residual ST-segment elevation at pre-discharge ECG after STEMI: association with long-term prognosis and structural consequences at 6-month CMR

Abstract Introduction Residual ST-segment elevation after ST-segment elevation myocardial infarction (STEMI) has been traditionally interpreted as a predictor of left ventricular dysfunction and ventricular aneurism. More recently, it has also been associated with more severe structural consequences in cardiac magnetic resonance (CMR) performed soon after STEMI. However, the implications in terms of long-term prognosis of patients and structural consequences in CMR performed late after STEMI are unclear. Methods Data was obtained from a prospective registry of reperfused STEMI patients. At pre-discharge ECG, sum and maximum ST-segment elevation (mm), ST-segment resolution (%) and the number of Q-leads with residual ST-segment elevation &amp;gt;1 mm (Q-STE) were assessed. 6-month CMR parameters were quantified: left ventricular ejection fraction (LVEF, %), left ventricular end-diastolic and end-systolic volume indexes (LVEDVI and LVESVI, mL/m2), infarct size (IS, % left ventricular mass) and microvascular obstruction (MVO, % left ventricular mass). The primary end-point was major adverse cardiac events (MACE), defined as all-cause death and/or re-admission for acute heart failure, whichever occurred first. Results 488 patients were included. Mean age was 58±12 years, 80.3% were males and smoking was the most prevalent cardiovascular risk factor. During a 7-year mean and median follow-up, 92 MACE were registered (19%), 39 all-cause deaths and 53 re-admission for acute heart failure. Q-STE &amp;gt;1 lead was detected in 172 patients (35%) and it was the most potent ECG predictor of MACE (26% vs 15%, p=0.002). Q-STE was also associated with structural changes at 6-month CMR: larger LVEDVI (87,39±27,47 mL/m2 vs 74,31±24,13 mL/m2) and LVESVI (45,45±25,24 mL/m2 vs 32,53±20,85 mL/m2), less LVEF (50,48±13,95% vs 58,75±12,3%) and larger infarct size (24,91±11,6% vs 14,38±11,41%) (p&amp;lt;0.001 for all comparisons, Figure 1). After adjustment for baseline and ECG characteristics, Q-STE (per lead with &amp;gt;1 mm) was independently associated with a higher risk of long-term MACE (HR 1.24 [CI 95%: 1.09–1.40], p=0.001), depressed (&amp;lt;40%) LVEF (HR 1.26 [CI 95%: 1.02–1.56], p=0.03) and large (&amp;gt;30% left ventricular mass) infarct size (HR 1.34 [CI 95%: 1.08–1.67], p=0.008) at 6-month CMR. Survival free from MACE was lower in patients with &amp;gt;1 lead Q-STE (log-rank=9.07, p=0.003) (Figure 2). Conclusions Residual ST-segment elevation after STEMI represents a widely available predictor of adverse long-term prognosis and late CMR-derived left ventricular remodelling. It could contribute to select patients who would benefit of close monitoring. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Fondos Europeos de Desarrollo Regional FEDERInstituto de Salud Carlos III Figure 1. Structural changes at 6-month CMRFigure 2. Survival free from MACE

Diagnostic and Prognostic Value of Lung Ultrasound B-Lines in Acute Heart Failure With Concomitant Pneumonia.

Purpose: To evaluate the potential confounding effect of concomitant pneumonia (PNM) on lung ultrasound (LUS) B-lines in acute heart failure (AHF).Methods: We enrolled 86 AHF patients with (31 pts, AHF/PNM) and without (55 pts, AHF) concomitant PNM. LUS B-lines were evaluated using a combined antero-lateral (AL) and posterior (POST) approach at admission (T0), after 24 h from T0 (T1), after 48 h from T0 (T2) and before discharge (T3). B-lines score was calculated at each time point on AL and POST chest, dividing the number of B-lines by the number of explorable scanning sites. The decongestion rate (DR) was calculated as the difference between the absolute B-lines number at discharge and admission, divided by the number of days of hospitalization. Patients were followed-up and hospital readmission for AHF was considered as adverse outcome.Results: At admission, AHF/PNM patients showed no difference in AL B-lines score compared with AHF patients [AHF/PNM: 2.00 (IQR: 1.44–2.94) vs. AHF: 1.65 (IQR: 0.50–2.66), p = 0.072], whereas POST B-lines score was higher [AHF/PNM: 3.76 (IQR: 2.70–4.77) vs. AHF = 2.44 (IQR: 1.20–3.60), p < 0.0001]. At discharge, AL B-lines score [HR: 1.907 (1.097–3.313), p = 0.022] and not POST B-lines score was found to predict adverse events (AHF rehospitalization) after a median follow-up of 96 days (IQR: 30–265) in the overall population.Conclusions: Assessing AL B-lines alone is adequate for diagnosis, pulmonary congestion (PC) monitoring and prognostic stratification in AHF patients, despite concomitant PNM.

Sequential cardiovascular magnetic resonance assessment of left ventricular ejection fraction for prediction of subsequent events in a large multicenter STEMI registry

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This work was supported by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” Background. Cardiovascular magnetic resonance (CMR) is the best tool for left ventricular ejection fraction (LVEF) quantification, but as yet the prognostic value of sequential LVEF assessment for major adverse cardiac event (MACE) prediction after ST-segment elevation myocardial infarction (STEMI) is uncertain. Purpose. We explored the prognostic impact of sequential assessment of CMR-derived LVEF after STEMI to predict subsequent MACE. Methods. We recruited 1036 STEMI patients in a large multicenter registry. LVEF (reduced [r]: &amp;lt;40%; mid-range [mr]: 40-49%; preserved [p]: ≥50%) was sequentially quantified by CMR at 1 week and after &amp;gt;3 months of follow-up. MACE was regarded as cardiovascular death or re-admission for acute heart failure after follow-up CMR. Results. During a 5.7-year mean follow-up, 82 MACE (8%) were registered. The MACE rate was higher only in patients with LVEF &amp;lt; 40% at follow-up CMR (r-LVEF 22%, mr-LVEF 7%, p-LVEF 6%; p-value &amp;lt; 0.001). Based on LVEF dynamics from 1-week to follow-up CMR, incidence of MACE was 5% for sustained LVEF³40% (n = 783), 13% for improved LVEF (from &amp;lt;40 to ³40%, n = 96), 21% for worsened LVEF (from ³40% to &amp;lt;40%, n = 34) and 22% for sustained LVEF &amp;lt;40% (n = 100), p-value &amp;lt; 0.001. Using a Markov approach that considered all studies performed, transitions towards improved LVEF predominated and only r-LVEF (at any time assessed) was significantly related to higher incidence of subsequent MACE. Conclusions. LVEF constitutes a pivotal CMR index for simple and dynamic post-STEMI risk stratification. Detection of reduced LVEF (&amp;lt;40%) by CMR at any time during follow-up identifies a small subset of patients at high risk of subsequent events.

Magnetic Resonance Assessment of Left Ventricular Ejection Fraction at Any Time Post-Infarction for Prediction of Subsequent Events in a Large Multicenter STEMI Registry.

Magnetic resonance imaging (MRI) is the most accurate imaging technique for left ventricular ejection fraction (LVEF) quantification, but as yet the prognostic value of LVEF assessment at any time after ST-segment elevation myocardial infarction (STEMI) for subsequent major adverse cardiac event (MACE) prediction is uncertain. To explore the prognostic impact of MRI-derived LVEF at any time post-STEMI to predict subsequent MACE (cardiovascular death or re-admission for acute heart failure). Prospective. One thousand thirteen STEMI patients were included in a multicenter registry. 1.5-T. Balanced steady-state free precession (cine imaging) and segmented inversion recovery steady-state free precession (late gadolinium enhancement) sequences. Post-infarction MRI-derived LVEF (reduced [r]: <40%; mid-range [mr]: 40%-49%; preserved [p]: ≥50%) was sequentially quantified at 1 week and after >3 months of follow-up. Multi-state Markov model to determine the prognostic value of each LVEF state (r-, mr- or p-) at any time point assessed to predict subsequent MACE. A P-value <0.05 was considered to be statistically significant. During a 6.2-year median follow-up, 105 MACE (10%) were registered. Transitions toward improved LVEF predominated and only r-LVEF (at any time assessed) was significantly related to a higher incidence of subsequent MACE. The observed transitions from r-LVEF, mr-LVEF, and p-LVEF states to MACE were: 15.3%, 6%, and 6.7%, respectively. Regarding the adjusted transition intensity ratios, patients in r-LVEF state were 4.52-fold more likely than those in mr-LVEF state and 5.01-fold more likely than those in p-LVEF state to move to MACE state. Nevertheless, no significant differences were found in transitions from mr-LVEF and p-LVEF states to MACE state (P-value=0.6). LVEF is an important MRI index for simple and dynamic post-STEMI risk stratification. Detection of r-LVEF by MRI at any time during follow-up identifies a subset of patients at high risk of subsequent events. 2 TECHNICAL EFFICACY STAGE: 2.