Reduce Heart Failure Research Articles

Impact of atrioventricular junction ablation and CRT‐D on long‐term mortality in patients with left ventricular dysfunction, permanent, refractory atrial fibrillation, and narrow QRS: Results of a propensity‐matched analysis

In patients with symptomatic permanent atrial fibrillation (PEAF) and narrow QRS, atrio-ventricular junction ablation (AVJA) plus cardiac resynchronization therapy (CRT) is superior to medical therapy in reducing heart failure (HF) hospitalization and all-cause mortality. To compare the mortality of a population of patients with HF, reduced EF (rEF), and PEAF treated with AVJA plus CRT with that of a contemporary cohort of patients in sinus rhythm (SR) with similar baseline characteristics. In this prospective, multicentre, observational study, all-cause mortality in a group of consecutive patients undergoing AVJA and implantable cardioverter-defibrillator (ICD) combined with CRT implantation for HFrEF, narrow QRS, and PEAF with uncontrolled ventricular rate was compared with that of a contemporary cohort of patients in SR undergoing ICD implantation (not combined with CRT) for HFrEF and narrow QRS. Individual 1:1 propensity matching of baseline characteristics was performed. A total of 824 patients were enrolled. Propensity matching yielded 107 matched pairs. After a median follow-up of 52 months, all-cause mortality was similar in patients treated with AVJA plus CRT and in the control group (p = .434). In AVJA plus CRT patients, mortality was significantly lower than in control group patients with a history of paroxysmal/persistent AF (n = 45, p = .020), and similar to that of patients without a history of AF (n = 62, p = .459). After adjustment for patient characteristics, the long-term prognosis of patients with HFrEF, narrow QRS, and PEAF who underwent AVJA plus CRT was similar to that of a population of patients in SR with similar characteristics.

Oral milrinone for management of refractory right ventricular failure in patients with left ventricular assist devices.

We present a single-centre retrospective experience using oral milrinone in patients with a left ventricular assist device (LVAD) and concurrent refractory right ventricular failure. All patients implanted with LVAD between January 2013 and July 2021 from a high-volume advanced heart failure service were reviewed. Eight patients were initiated on oral milrinone during this period. Oral milrinone was started 1.5 [inter-quartile range (IQR) 1-2.3] years after LVAD implantation and continued for 1.2 (IQR 0.5-2.8) years. Therapeutic milrinone levels were achieved (232.2±153.4ng/mL) with 62.4±18% of time within the therapeutic range. Two patients had adverse events (non-sustained ventricular tachycardia and ventricular fibrillation effectively treated by internal cardioverter defibrillator) but did not require milrinone discontinuation. Four deaths occurred, one after transplant and three from disease progression determined to be unrelated to oral milrinone use. Three patients continue oral milrinone therapy in the community. There was no significant difference found after the initiation of oral milrinone on any of the physiological measures; however, there were trends in reduction of New York Heart Association class from 3.4±0.5 to 3.0±0.8 (P=0.08), reduction of right atrial/wedge pressure from 0.9±0.3 to 0.5±0.2 (P=0.08), and improvement of right ventricular stroke work index from 3.8±2 to 5.8±2.7 (P=0.16). Oral milrinone appears safe for long-term use in the outpatient setting when combined with therapeutic monitoring in this complex medical cohort with limited management options. Further study is needed to ascertain whether this treatment is effective in reducing heart failure symptoms and admissions.

Transcatheter interventions for severe tricuspid regurgitation: a literature review.

The prevalence of tricuspid regurgitation (TR) increases with age, affecting 65%-85% of adults. Primary TR is caused by a congenital or acquired abnormality of the tricuspid valve apparatus (leaflets, chordae, papillary muscles, or annulus). Secondary TR is due to insufficient coaptation from dilation of tricuspid valve annulus due to the right ventricle (RV) or right atrium (RA) remodeling and increased RV pressures. Isolated TR is without increased RV pressures and is associated with atrial fibrillation. Mild TR is a benign disease. Moderate to severe tricuspid regurgitation has independently been associated with increased mortality. Most of these patients are treated medically due to poor outcomes with surgical repair of isolated TR. The in-hospital mortality rate is 8.8%, and the median length of stay in hospital is 11 days resulting in higher healthcare costs. Even if the patients undergo surgical repair or replacement, available data do not show improvement in survival. With a more detailed understanding of the complex anatomy and physiology of the tricuspid valve and significant complications from untreated tricuspid valve disease, the approach to the management of TR has shifted from a conservative approach to a process of prevention and intervention. In the past decade, transcatheter tricuspid valve interventions and tricuspid annuloplasty rings have been developed, contributing to decreased mortality from surgical repair. Transcatheter tricuspid valve intervention techniques have improved survival, quality of life, and reduced heart failure rehospitalization. This review summarizes normal anatomy, types of TR, etiology and different mechanisms of TR, echocardiographic assessment of the severe TR, and highlights various percutaneous transcatheter techniques for tricuspid valve repair.

Effectiveness of Sodium-Glucose Cotransporter-2 Inhibitors vs. Dipeptidyl Peptidase-4 Inhibitors in Frail People With Diabetes Who Were Recently Hospitalized.

Introduction: Sodium-glucose cotransporter-2 inhibitors (SGLT-2Is) reduce heart failure (HF) hospitalizations and major adverse cardiovascular events (MACE) in general type 2 diabetes populations. The objective of this study was to determine whether SGLT-2Is vs. dipeptidyl peptidase-4 inhibitors (DPP-4Is) are associated with reductions in MACE, HF hospitalizations and mortality in frail people with type 2 diabetes. Methods: We conducted a cohort study of all patients aged ≥30 years with type 2 diabetes discharged from a hospital in Victoria, Australia between January 2014 and March 2018 who received SGLT-2Is or DPP-4Is within 60 days of discharge. Follow-up commenced 60 days after initial discharge, and MACE, HF hospitalization and mortality were recorded. Cox proportional hazards regression with competing risks and stabilized inverse probability of treatment weights (IPTWs), was used to generate subdistribution hazard ratios (sHRs) with 95% confidence intervals (CIs). Analyses were stratified into frailty quartiles according to Hospital Frailty Risk Scores (HFRS). Results: Of the 32,043 patients, (41.9% female and 5.9% ≥80 years) in the cohort, 5,152 (16.1%) received SGLT-2Is. Overall, SGLT-2I versus DPP-4I recipients had lower rates of MACE (sHR 0.51; 95% CI 0.46–0.56), HF hospitalization (sHR 0.42; 95% CI 0.36–0.49) and mortality (HR 0.38; 95% CI 0.33–0.43). People with HFRSs in the fourth quartile who received SGLT-2Is versus DPP-4Is also had reduced rates of MACE (sHR 0.37; 95% CI 0.29–0.46), HF hospitalization (sHR 0.43; 95% CI 0.33–0.56) and mortality (HR 0.32; 95% CI 0.25–0.41). Conclusion: SGLT-2Is may be preferred to DPP-4Is for preventing MACE, HF hospitalizations and mortality in frail people with type 2 diabetes.

The relationship between left ventricular diastolic dysfunction and hemoglobin A1c levels in the type 2 diabetes mellitus patient population

Objectives: This study aimed to investigate the relationship between hemoglobin A1c (HbA1c) levels, which is a good marker for determining glycemic levels, and left ventricular diastolic dysfunction (LVDD) in the type 2 diabetes mellitus (DM) patient population. Patients and methods: This retrospective study was conducted with 116 type 2 DM patients (62 males, 54 females; mean age: 58.4±9.5 years; range, 18 to 65 years) between July 2019 and November 2021. The patients were divided into two groups as those without LVDD (n=55, Group 1) and those with LVDD (n=61, Group 2). Early to late diastolic transmural flow velocity (E/A) ratio, the mean ratio (E/e') of mitral inflow (E) and mitral annular (e'), HbA1c levels, other hemogram and biochemical parameters, and demographic data were recorded. Results: The HbA1c level was significantly higher in the group with LVDD (6.96±1.23 vs. 9.00±2.19, p<0.001). While the mean E/e' ratio was 9.69±2.73 in the group without LVDD, it was 16.00±1.69 in the group with LVDD, and there was a significant difference between the two groups (p<0.001). The mean E/A ratio was significantly higher in the group without LVDD (1.25±0.51 vs. 1.02±0.53, p=0.021). In regression operating characteristics analysis, a HbA1c cut-off value of 7.35 and was found to be a predictor of LVDD in the type 2 DM patient group with a sensitivity of 80% and specificity of 80% (AUC: 0.805; 95% confidence interval: 0.718-0.892; p<0.001). Conclusion: Providing close glycemic follow-up and monitoring the HbA1c level can reduce heart failure and other comorbid conditions that may develop, particularly after LVDD.

The evolution of “pillars of therapy” to reduce heart failure risk and slow diabetic kidney disease progression

The evolution of therapy to slow chronic kidney disease progression has changed dramatically over the last five years and is anticipated to change even more in the coming two to four years. What was traditionally noted as “renal sparing therapy” with blockers of the renin-angiotensin system (RAS) has now expanded to the use of inhibitors of sodium-glucose transport 2 (SGLT2) agents as well as the nonsteroidal mineralocorticoid receptor blocker, finerenone. These three “pillars of therapy” have slowed kidney disease progression by more than 50% compared to RAS blockers alone. Additionally, finerenone and SGLT2 inhibitors significantly reduce heart failure hospitalizations and the development of heart failure. Moreover, they improve exercise tolerance and reduce the risk of cardiovascular death, even though they do not affect atherosclerotic heart disease development. These data, taken together, demonstrate a “three pillar” therapy approach for cardiorenal risk reduction in people with type 2 diabetes who have any level of kidney disease.

Reducing Heart Failure Readmissions: Combining Clinical Assessment and Technology

Reducing Heart Failure Readmissions: Combining Clinical Assessment and Technology

Cardiodiabetology: newer pharmacologic strategies for reducing cardiovascular disease risks.

Globally, nearly 500 million adults currently have diabetes, which is expected to increase to approximately 700 million by 2040. Cardiovascular diseases (CVD), including coronary heart disease, stroke, heart failure, and peripheral arterial disease, are the principal causes of death in persons with diabetes. Key to the prevention of CVD is optimization of associated risk factors. However, few persons with diabetes are at recommended targets for key CVD risk factors including low-density lipoprotein-cholesterol (LDL-C), blood pressure, glycated hemoglobin, nonsmoking status, and body mass index. While lifestyle management forms the basis for the prevention and control of these risk factors, newer and existing pharmacologic approaches are available to optimize the potential for CVD risk reduction, particularly for the management of lipids, blood pressure, and blood glucose. For higher-risk patients, antiplatelet therapy is recommended. Medication for blood pressure, statins, and most recently, icosapent ethyl, have evidence for reducing CVD events in persons with diabetes. Newer medications for diabetes, including sodium glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 receptor agonists, also reduce CVD and SGLT2 inhibitors in particular also reduce progression of kidney disease and reduce heart failure hospitalizations (HFHs). Most importantly, a multidisciplinary team is required to address the polypharmaceutical options to best reduce CVD risks persons with diabetes.

Predicting Heart Failure in Arrhythmogenic Right Ventricular Cardiomyopathy

Predicting Heart Failure in Arrhythmogenic Right Ventricular Cardiomyopathy

Angiotensin receptor/Neprilysin inhibitor effects in CRTd non-responders: From epigenetic to clinical beside

ObjectivesWe evaluated whether Angiotensin receptor/Neprilysin inhibitors (ARNI) reduce heart failure (HF) hospitalizations and deaths in cardiac resynchronization therapy with defibrillator (CRTd) non-responders patients at 12 months of follow-up, modulating microRNAs (miRs) implied in adverse cardiac remodeling. Backgroundadverse cardiac remodeling characterized by left ventricle ejection fraction (LVEF) reduction, left ventricular end-systolic volume (LVESv) increase, and the 6-minute walking test (6MWT) reduction are relevant pathological mechanisms in CRTd non-responders and could be linked to changes in miRNAs (miRs), regulating cardiac fibrosis, apoptosis, and hypertrophy. MethodsmiRs levels and clinical outcomes (LVEF, cardiac deaths, and 6MWT) were evaluated at baseline and one year of follow-up in CRTd non-responders divided into ARNI-users and Non-ARNI users. ResultsAt baseline, there were no differences in levels of inflammatory markers, miR-18, miR-145, and miR-181 (p > 0.05) between Non-ARNI users (n 106) and ARNI-users (n 312). At one year of follow-up, ARNI-users vs. Non-ARNI users showed lowest inflammatory markers (p < 0.01) and miR-181 levels (p < 0.01) and higher values of miR-18 (p < 0.01)and miR-145 (p < 0.01). At one year of follow-up, ARNI-users had a higher increase of LVEF (p < 0.01) and 6MWT (p < 0.01) along with a more significant reduction of LVESv (p < 0.01) compared to Non-ARNI users. Cox regression analysis evidenced that ARNI-based therapies increase the probability of anti-remodeling effects of CRTd. Based on symptomatic improvements, echocardiographic and functional classification improvements, 37 (34.9%) patients among ARNI-users became responders, while only twenty (6.4%) patients became responders among Non-ARNi-users. ConclusionsARNI might influence epigenetic mechanisms modulating miRs implicated in the adverse cardiac remodeling responses to CRTd.

Cell-Target-Specific Anti-Inflammatory Effect of Empagliflozin: In Vitro Evidence in Human Cardiomyocytes.

The antidiabetic sodium–glucose cotransporter type 2 inhibitor (SGLT2i) empagliflozin efficiently reduces heart failure (HF) hospitalization and cardiovascular death in type 2 diabetes (T2D). Empagliflozin-cardioprotection likely includes anti-inflammatory effects, regardless glucose lowering, but the underlying mechanisms remain unclear. Inflammation is a primary event in diabetic cardiomyopathy (DCM) and HF development. The interferon (IFN)γ-induced 10-kDa protein (IP-10/CXCL10), a T helper 1 (Th1)-type chemokine, promotes cardiac inflammation, fibrosis, and diseases, including DCM, ideally representing a therapeutic target. This preliminary study aims to explore whether empagliflozin directly affects Th1-challenged human cardiomyocytes, in terms of CXCL10 targeting. To this purpose, empagliflozin dose–response curves were performed in cultured human cardiomyocytes maintained within a Th1-dominant inflammatory microenvironment (IFNγ/TNFα), and CXCL10 release with the intracellular IFNγ-dependent signaling pathway (Stat-1) was investigated. To verify possible drug–cell-target specificity, the same assays were run in human skeletal muscle cells. Empagliflozin dose dependently inhibited CXCL10 secretion (IC50 = 76,14 × 10-9 M) in association with Stat-1 pathway impairment only in Th1-induced human cardiomyocytes, suggesting drug-selective cell-type-targeting. As CXCL10 plays multifaceted functions in cardiac remodeling toward HF and currently there is no effective method to prevent it, these preliminary data might be hypothesis generating to open new scenarios in the translational approach to SGLT2i-dependent cardioprotection.

A predictive model for estimating protection against CKD and CVD with SGLT2 inhibition in patients with diabetes

Diabetes affects &gt;450 million people worldwide. Elevated blood glucose caused by diabetes can lead to chronic kidney disease (CKD), which increases the risk of end‐stage kidney disease (ESKD) requiring dialysis or a kidney transplant. In type 2 diabetes (T2D), medications called sodium‐glucose cotransporter‐2 (SGLT2) inhibitors have become part of standard of the care for improving glycemic control by promoting urine glucose excretion. These drugs reduce urinary albumin excretion (quantified as urinary albumin‐to‐creatinine ratio, “UACR”, an effect linked with kidney protection), slow CKD progression and delay ESKD, with similar benefits in males and females. In people with T2D, SGLT2 inhibitors also reduce heart failure and cardiovascular events by 20‐40%. But in people with type 1 diabetes (T1D), there are no studies evaluating SGLT2 inhibitors in patients at the highest risk of ESKD or cardiovascular disease (CVD). Building on the benefits of SGLT2 inhibitors in people with T2D, we seek to evaluate the efficacy and mechanisms in people with T1D and CKD. We hypothesize that SGLT2 inhibition will slow loss of kidney function (glomerular filtration rate, or “GFR”) in people with T1D and CKD. To test that hypothesis, we analyze clinical data for a cohort of patients with diabetes and kidney disease, and identify key features that determine the rate of progression of CKD. We then develop personalized assessment tools that yield estimates for protection against CKD and CVD with SGLT2 inhibition in patients with T1D or T2D.

Reduced Heart Failure and Mortality in Patients Receiving Statin Therapy Before Initial Acute Coronary Syndrome

BackgroundThere is uncertainty regarding the impact of statins on the risk of atherosclerotic cardiovascular disease (ASCVD) and its major complication, acute heart failure (AHF). ObjectivesThe aim of this study was to investigate whether previous statin therapy translates into lower AHF events and improved survival from AHF among patients presenting with an acute coronary syndrome (ACS) as a first manifestation of ASCVD. MethodsData were drawn from the International Survey of Acute Coronary Syndromes Archives. The study participants consisted of 14,542 Caucasian patients presenting with ACS without previous ASCVD events. Statin users before the index event were compared with nonusers by using inverse probability weighting models. Estimates were compared by test of interaction on the log scale. Main outcome measures were the incidence of AHF according to Killip class and the rate of 30-day all-cause mortality in patients presenting with AHF. ResultsPrevious statin therapy was associated with a significantly decreased rate of AHF on admission (4.3% absolute risk reduction; risk ratio [RR]: 0.72; 95% CI: 0.62-0.83) regardless of younger (40-75 years) or older age (interaction P = 0.27) and sex (interaction P = 0.22). Moreover, previous statin therapy predicted a lower risk of 30-day mortality in the subset of patients presenting with AHF on admission (5.2 % absolute risk reduction; RR: 0.71; 95% CI: 0.50-0.99). ConclusionsAmong adults presenting with ACS as a first manifestation of ASCVD, previous statin therapy is associated with a reduced risk of AHF and improved survival from AHF. (International Survey of Acute Coronary Syndromes [ISACS] Archives; NCT04008173)

Mineralocorticoid Receptor Antagonists in the Treatment of Diabetic Kidney Disease: Their Application in the Era of SGLT2 Inhibitors and GLP-1 Receptor Agonists.

This review focuses on new clinical data involving a novel class of drugs, nonsteroidal mineralocorticoid receptor antagonists (NS-MRAs), specifically, finerenone and its effects on cardiovascular and diabetic kidney disease outcomes. NS-MRAs are a novel class of agents for treating diabetic kidney disease (DKD). While they are chemically and pharmacologically distinct from steroidal MRAs (spironolactone, eplerenone), they effectively inhibit the MR receptor differently. Inhibition of MR receptor activation reduces inflammatory and profibrotic pathways involving the cardiorenal/vascular systems. Small diabetic kidney disease (DKD) clinical studies demonstrate that steroidal MRAs reduce albuminuria relative to placebo, although hyperkalemia is a major adverse event that has precluded large outcome trials. The NS-MRA, finerenone, demonstrated slowed progression of DKD and reduction of cardiovascular death primarily driven by reduced heart failure incidence in two separate randomized controlled clinical trials (FIDELIO and FIGARO). Use of NS-MRAs, therefore, provides a third "pillar of therapy" to reduce cardiorenal events added to blockers of the renin-angiotensin system and SGLT2 inhibitors. If the pending outcome trial, FLOW, is positive, potentially, GLP1-RAs may also be part of this "pillar" structure.

Sodium-glucose Co-transporter 2 Inhibitors in Acute Heart Failure: A Review of the Available Evidence and Practical Guidance on Clinical Use.

Sodium-glucose co-transporter 2 (SGLT2) inhibitors were initially conceived as glucose-lowering agents. However, striking renal and cardiovascular benefits were observed in type 2 diabetes trials. This led to evaluate it in dedicated studies in chronic heart failure (HF) and chronic kidney disease, which also showed remarkable clinical results. Given this findings, and taking into account the multiple mechanisms of action, the use of SGLT2 inhibitors in acute heart failure seemed promising. Sotagliflozin was the first SGLT2 inhibitor to reduce heart failure hospitalizations within the acute setting in the SOLOIST-WHF trial. Only type 2 diabetes patients were included, with a preserved and reduced ejection fraction. In slightly less than half of the cohort, this medication was started when the diuretic therapy was transitioned from intravenous to oral, during the hospital admission. In the rest of the patients, sotagliflozin was started early after discharge. Empagliflozin proved to be safe, well-tolerated, increased diuresis, and reduced a combined clinical endpoint (worsening HF, rehospitalization for HF, or death at 60 days) when administered within the first 24 hours of an acute heart failure hospitalization in the EMPA-RESPONSE-AHF trial. More recently, empagliflozin showed a reduction in a composite primary endpoint of death, heart failure events, and quality of life compared to placebo in the EMPULSE trial. Empagliflozin was started after the initial stabilization phase, but while patients were still admitted and receiving intravenous loop diuretics. Less than half of the patients were diabetic and two-thirds had a left ventricular ejection fraction below 40%. Dapagliflozin is currently being tested in the DAPA ACT HF-TIMI 68 trial, which plans to enroll 2400 patients admitted with acute heart failure and reduced ejection fraction. We envision SGLT2 inhibitors as a useful tool in acute heart failure syndrome given the additive diuretic effect, and minimal impact on blood pressure, kidney function, and electrolytes. Its dosage schedule is simple and can help initiation and tolerance of other medical therapy. However, there is an increased risk of genital infections and euglycaemic ketoacidosis. Notwithstanding, once critically ill and fasting patients are excluded, early administration of SGLT2 inhibitors is safe. This review summarizes the development of SGLT2 inhibitors and the available evidence supporting their use during an acute heart failure admission. We also propose a practical guideline for in-hospital initiation and monitoring.

Benefits Of An Interdisciplinary Nurse Practitioner And Clinical Pharmacy Specialist Heart Failure Access Clinic

Background : To help reduce heart failure (HF) readmissions and improve patient outcomes, the Madison VA established a Nurse Practitioner (NP) led Heart Failure Access Clinic (HFAC) to provide patient follow-up within 4-7 days of discharge. Studies have demonstrated medication discrepancies and delayed implementation of guideline-directed medical therapy as potential contributors to 30-day hospital readmission. Thus, a clinical pharmacy specialist (CPS) was incorporated into the Madison VA HFAC model to focus on optimizing medication regimens. The purpose of this project is to evaluate the impact of an interdisciplinary NP-CPS HFAC versus a NP HFAC on 30-day patient outcomes. Methodology A retrospective chart review was completed for all patients hospitalized with a primary discharge diagnosis of acute on chronic systolic heart failure (ADHF) at the Madison VA and seen in a HFAC after discharge between November 2019 and November 2020. Patients with LVEF greater than 50% and those discharged to hospice were excluded. During the early period of the COVID-19 pandemic (mid-March through July 2020), patients were seen by the NP only. Outcomes and interventions for patients who attended an interdisciplinary NP-CPS HFAC were compared to those who attended the NP HFAC. Primary outcomes included rehospitalization, emergency department (ED) visit, and all-cause mortality at 30 days. Secondary outcomes included HF medication adjustments, identification of inappropriate medications in patients with HF, medication discrepancies, alerts to another provider for follow up, referral to another service, or referral to HF CPS for continued optimization of GDMT. Results A total of 90 veterans met the inclusion criteria; 43 were seen in the NP HFAC and 47 were seen in the interdisciplinary NP-CPS HFAC. The incidence of adverse 30-day outcomes in this patient cohort was very low (readmission 5.6%, ED visit 1.1%, death 1.1%) and there were no significant between group differences. Statistically significant secondary outcomes favoring the interdisciplinary HF clinic included identification of medication discrepancies (P=<0.0001), alert to another providers for follow up (P=0.004), as well as referral to the HF CPS for continued medication titration (P=0.02). Conclusion Patients seen in the interdisciplinary NP-CPS HFAC and HP HFAC had similarly low 30-day hospital readmission rates, ED visits and mortality. Involvement of a CPS in the HFAC led to more frequent identification of medication discrepancies, notification to providers regarding medication issues, and referral to a HF CPS for timely GDMT optimization. Further analysis is warranted to assess the impact of these early CPS interventions on long-term patient outcomes. : To help reduce heart failure (HF) readmissions and improve patient outcomes, the Madison VA established a Nurse Practitioner (NP) led Heart Failure Access Clinic (HFAC) to provide patient follow-up within 4-7 days of discharge. Studies have demonstrated medication discrepancies and delayed implementation of guideline-directed medical therapy as potential contributors to 30-day hospital readmission. Thus, a clinical pharmacy specialist (CPS) was incorporated into the Madison VA HFAC model to focus on optimizing medication regimens. The purpose of this project is to evaluate the impact of an interdisciplinary NP-CPS HFAC versus a NP HFAC on 30-day patient outcomes. A retrospective chart review was completed for all patients hospitalized with a primary discharge diagnosis of acute on chronic systolic heart failure (ADHF) at the Madison VA and seen in a HFAC after discharge between November 2019 and November 2020. Patients with LVEF greater than 50% and those discharged to hospice were excluded. During the early period of the COVID-19 pandemic (mid-March through July 2020), patients were seen by the NP only. Outcomes and interventions for patients who attended an interdisciplinary NP-CPS HFAC were compared to those who attended the NP HFAC. Primary outcomes included rehospitalization, emergency department (ED) visit, and all-cause mortality at 30 days. Secondary outcomes included HF medication adjustments, identification of inappropriate medications in patients with HF, medication discrepancies, alerts to another provider for follow up, referral to another service, or referral to HF CPS for continued optimization of GDMT. A total of 90 veterans met the inclusion criteria; 43 were seen in the NP HFAC and 47 were seen in the interdisciplinary NP-CPS HFAC. The incidence of adverse 30-day outcomes in this patient cohort was very low (readmission 5.6%, ED visit 1.1%, death 1.1%) and there were no significant between group differences. Statistically significant secondary outcomes favoring the interdisciplinary HF clinic included identification of medication discrepancies (P=<0.0001), alert to another providers for follow up (P=0.004), as well as referral to the HF CPS for continued medication titration (P=0.02). Patients seen in the interdisciplinary NP-CPS HFAC and HP HFAC had similarly low 30-day hospital readmission rates, ED visits and mortality. Involvement of a CPS in the HFAC led to more frequent identification of medication discrepancies, notification to providers regarding medication issues, and referral to a HF CPS for timely GDMT optimization. Further analysis is warranted to assess the impact of these early CPS interventions on long-term patient outcomes.

Pulmonary Artery Pressures During Cardiopulmonary Exercise Testing Using Cardiomems

<h3>Purpose</h3> Continuous pulmonary artery (PA) pressure monitoring has proven its value in reducing heart failure and all-cause hospitalizations. Invasive hemodynamic testing has shown that exercise in HFrEF leads to a steep increase in PA pressures and this steep rise is independently associated with reduced peak Vo₂. PA pressure response during exercise is likely more closely related to outcomes than resting hemodynamics in HF. The significance and potentially prognostic value of measuring PA pressures during CPET testing in AHF patients is currently unknown. In this feasibility-study we describe PA pressure curves during CPET in a cohort of advanced HF patients. <h3>Methods</h3> 7 advanced HF patients (Etiology: 4 NICM, 3 ICM; age 61 ± 12y; EF 28 ± 15%; 86% on beta blocker) with CardioMEMS device underwent standard stationary bike - CPET. PA pressures were measured at rest, every 2 minutes during exercise and during recovery. <h3>Results</h3> Max VO2 was 13.3±5.2 ml/kg/min; average duration of exercise was 8:56 min. Mean resting PA pressure was 12.5±5.2 mmHg. Mean peak PA pressure was 26.7±10 mmHg. Mean PA pressures increased on average by 2.5-fold (± 1.14) (Figure 1). The slope of mPAP rise was 3.33±2.1. mPAP uniformly returned to baseline values within 3 minutes of recovery. Pt. 3 was admitted 1 week after CPET testing with subacute worsening HF symptoms and underwent OHT, all other patients continue to follow at the centralized HF program at our institution. <h3>Conclusion</h3> PAP assessment using CardioMEMS is feasible during CPET. mPAP rose sharply during exercise. In HF patients with invasive PA pressure monitor devices, exercise PAP assessment may be a valuable tool to assess for functional capacity with possibly prognostic significance.

Using Pulsatility Responses to Breath-Hold Maneuvers to Predict Readmission Rates in Left Ventricular Assist Device Patients

Purpose Respiratory maneuvers induce heterogenous changes to flow pulsatility in continuous flow left ventricular assist device patients. We assessed the association of these pulsatility responses with patient hemodynamics and outcomes. Methods Responses obtained from Medtronic HVAD outpatients during weekly clinics were categorised into three ordinal groups according to the percentage reduction in waveform pulsatility (peak - trough flow) upon inspiratory breath hold, IBH (%∆P): (1) Minimal Change (MC, %∆P≤50), (2) Reduced Pulsatility (RP, 50<%∆P<100), (3) Flatline (FL, %∆P=100). Waveforms were also assessed for IBH-induced suction. Same day echocardiography and right heart catheterization (RHC) were performed. To assess readmissions, patients with ≥1 flatline response (F group) were compared to those without (NF group) and patients with ≥1 suction (S group) were compared to those without (NS group). Results In total, 712 responses were obtained from 55 patients (45 male, age 56±12). The F group (n=28) experienced numerically lower all-cause readmissions (1.51 vs 2.79 events/y, hazard ratio [HR]=0.67, p=0.12), reduced heart failure readmissions (0.07 vs 0.56 events/y, HR=0.15, p<0.01) and superior readmission-free survival (HR=0.47, p=0.04, figure). Readmissions for syncope/presyncope occurred solely in the S group (n=18) (0.25 events/y, p=0.01). Echocardiography was performed in 50 patients and RHC in 31. When compared to MC, RP and FL responses were associated with lower right atrial (14.2 vs 11.4 vs 9.0mmHg, p=0.08) and pulmonary capillary wedge pressures (19.8 vs 14.3 vs 13.0mmHg, p=0.03), lower rates of >mild mitral regurgitation (48% vs 13% vs 10%, p=0.01) and >mild right ventricular impairment (62% vs 25% vs 27%, p=0.03), and increased rates of aortic valve opening (32% vs 50% vs 75%, p=0.03). Conclusion Responses to IBH predicted hemodynamics and readmissions. The impact of IBH on pulsatility can noninvasively guide patient management and optimization. Respiratory maneuvers induce heterogenous changes to flow pulsatility in continuous flow left ventricular assist device patients. We assessed the association of these pulsatility responses with patient hemodynamics and outcomes. Responses obtained from Medtronic HVAD outpatients during weekly clinics were categorised into three ordinal groups according to the percentage reduction in waveform pulsatility (peak - trough flow) upon inspiratory breath hold, IBH (%∆P): (1) Minimal Change (MC, %∆P≤50), (2) Reduced Pulsatility (RP, 50<%∆P<100), (3) Flatline (FL, %∆P=100). Waveforms were also assessed for IBH-induced suction. Same day echocardiography and right heart catheterization (RHC) were performed. To assess readmissions, patients with ≥1 flatline response (F group) were compared to those without (NF group) and patients with ≥1 suction (S group) were compared to those without (NS group). In total, 712 responses were obtained from 55 patients (45 male, age 56±12). The F group (n=28) experienced numerically lower all-cause readmissions (1.51 vs 2.79 events/y, hazard ratio [HR]=0.67, p=0.12), reduced heart failure readmissions (0.07 vs 0.56 events/y, HR=0.15, p<0.01) and superior readmission-free survival (HR=0.47, p=0.04, figure). Readmissions for syncope/presyncope occurred solely in the S group (n=18) (0.25 events/y, p=0.01). Echocardiography was performed in 50 patients and RHC in 31. When compared to MC, RP and FL responses were associated with lower right atrial (14.2 vs 11.4 vs 9.0mmHg, p=0.08) and pulmonary capillary wedge pressures (19.8 vs 14.3 vs 13.0mmHg, p=0.03), lower rates of >mild mitral regurgitation (48% vs 13% vs 10%, p=0.01) and >mild right ventricular impairment (62% vs 25% vs 27%, p=0.03), and increased rates of aortic valve opening (32% vs 50% vs 75%, p=0.03). Responses to IBH predicted hemodynamics and readmissions. The impact of IBH on pulsatility can noninvasively guide patient management and optimization.

Using Personalized Text Messages To Improve Heart Failure Hospital Readmission Rates

<h3>Purpose</h3> Would personalized text messages to patients after heart failure hospitalizations help reduce readmission? <h3>Background</h3> Patients with managed Medicare and some private insurances have triggers for an established telephonic hospital follow up within the health system. But patients with managed Medicaid, "straight" Medicare (part A and B only), and some patients under 65 with private insurance do not have formal follow up by the health system entity after discharge. Through system indicator reports, patients were identified who did not have a following agency. As the phone contacts began, a trend emerged that a phone call was not always an effective way to reach patients. It was hypothesized that a personalized text message might make a better connection with patients after discharge to mitigate transition of care issues and in turn decrease readmission risk. Heart Failure team members have met with the patients during the hospital stay and had established some rapport already. <h3>Method</h3> Patients received a call from the Heart Failure Program, but if the patient was not reached, a text message was sent to their phone. The text message included a personalized message specific to what was discussed during their heart failure education visit while in the hospital. <h3>Results</h3> : There were 29 patients identified and texted from June to December 2020. 86% were male and 14% were female with ethnic breakdown of 66% white, 28% Hispanic/Latino, 3% Asian, 3% Middle Eastern. The mean age was 53 years old. Six patients (21%) of 29 texted replied back to text or called directly to the program office to speak to the Heart Failure Coordinator. Three (10%) patients texted instantly returned calls to program office after text was delivered. There were no 30-day readmissions for the 29 patients. <h3>Conclusion/Discussion</h3> Personalized texting appeared to help reduce heart failure readmissions with this group of patients that did not have other formal entities following hospitalization. The group observed was small, but it is beneficial when even one or two patients can be navigated away from the acute care setting. Additionally, although there wasn't a high number of direct responses, the chances of patients seeing the text were still high. A message with content that is simple and personalized may have been a helpful reminder of engagement of some level of heart failure self-care. The text message may also have served as a reminder that there was a reasonably easy way to communicate with a member of the care team without navigating through the healthcare call center. The quick replies that were received appeared to be prompted by an urgent need for help connecting with their primary provider or with problems related to medications. The text messages further highlighted structural problems patients encounter after discharge, specifically medication disruptions and physician follow up. These identified problems helped direct further readmission reduction work.

Traditional Chinese Medicine Ginseng Dingzhi Decoction Ameliorates Myocardial Fibrosis and High Glucose-Induced Cardiomyocyte Injury by Regulating Intestinal Flora and Mitochondrial Dysfunction.

Myocardial fibrosis refers to the pathological changes of heart structure and morphology caused by various reasons of myocardial damage. It has become an important challenge in the later clinical treatment of acute myocardial infarction/ischemic cardiomyopathy or diabetes complicated with heart failure. Ginseng Dingzhi Decoction (GN), a Chinese herbal medicine, can reduce heart failure and protect cardiomyocytes. We infer that this may be related to the interaction with intestinal microbiota and mitochondrial homeostasis. The regulatory mechanism of GN on gut microbiota and mitochondria has not yet been elucidated. The intestinal microbiota was analyzed by the 16S rRNA gene; the fecal samples were sequenced and statistically analyzed to determine the changes of microbiota in the phenotype of heart failure rats. In addition, GN can regulate the microbial population that increases the proportion of short-chain fatty acids and anti-inflammatory bacteria and reduces the proportion of conditional pathogens to diabetic phenotype. The results suggest that GN may improve myocardial injury by regulating intestinal flora. Our data also show that stress-type heart failure caused by TAC (transverse aortic constriction) is accompanied by severe cardiac hypertrophy, reduced cardiac function, redox imbalance, and mitochondrial dysfunction. However, the use of GN intervention can significantly reduce heart failure and myocardial hypertrophy, improve heart function and improve myocardial damage, and maintain the mitochondrial homeostasis and redox of myocardial cells under high glucose stimulation. Interestingly, through in vitro experiments after TMBIM6 siRNA treatment, the improvement effect of GN on cell damage and the regulation of mitochondrial homeostasis were eliminated. TMBIM6 can indirectly regulate mitophagy and mitochondrial homeostasis to attenuate myocardial damage and confirms the regulatory effect of GN on mitophagy and mitochondrial homeostasis. We further intervened cardiomyocytes in high glucose through metformin (MET) and GN combination therapy. Research data show that MET and GN combination therapy can improve the level of mitophagy and protect cardiomyocytes. Our findings provide novel mechanistic insights for the treatment of diabetes combined with myocardial injury (myocardial fibrosis) and provide a pharmacological basis for the study of the combination of Chinese medicine and conventional diabetes treatment drugs.