Risk Of All-cause Hospitalization Research Articles

Risk of outcomes in a Spanish population with heart failure

To assess mortality, cardiovascular and renal outcomes among patients with heart failure (HF) (primary objective), with a particular focus on the risk of developing chronic kidney disease (CKD) (secondary). Observational cohort study, comprising cross-sectional and longitudinal retrospective analyses using secondary data from electronic health records. For the primary objective, adults with prevalent HF, defined as at least one diagnosis of HF prior to the index date (1 January 2017) were included. For the secondary objective, adults with incident HF in 2017 were enrolled. A total of 21 575 patients had HF in the prevalent population (8391 with CKD at baseline), whereas 3045 patients were included in the incident population. In the prevalent population, the risk of all-cause death (HR, 1.227; 95%CI, 1.172–1.285), CKD hospitalization (HR, 1.427; 95%CI, 1.379–1.479) and acute kidney failure (HR, 1.377; 95%CI, 1.222–1.524) was greater in those patients with HF and CKD vs HF only after 3 years of follow-up. For the incident population, within 24 months from HF diagnosis, 5.9% of patients developed CKD. Overall, 23.4% were taking angiotensin-converting enzyme inhibitors, 26.3% angiotensin receptor blockers, 7.9% sacubitril/valsartan, 64.2% beta blockers, 11.5% aldosterone antagonists and 4.5% sodium-glucose Cotransporter-2 inhibitors. In Spain, patients with HF have a high risk of developing cardiovascular and renal complications. Despite that, there is a substantial proportion of patients that are not taking guideline recommended drugs. A higher use of these drugs could reduce HF burden and complications in clinical practice. Determinar la mortalidad y los eventos cardiovasculares y renales en pacientes con insuficiencia cardiaca (IC) (objetivo primario), en particular sobre el desarrollo de enfermedad renal crónica (ERC) (secundario). Estudio observacional, con análisis transversal y retrospectivo, empleando datos secundarios de registros electrónicos de salud. Para el objetivo primario se incluyeron adultos con IC prevalente, definida como al menos un diagnóstico de IC antes de la fecha índice (1 de enero de 2017). Para el secundario se incluyeron adultos con IC incidente en 2017. Se incluyeron 21.575 pacientes con IC en la población prevalente (8.391 con ERC basal) y 3.045 en la población incidente. En la población prevalente el riesgo de muerte (HR = 1,227; IC 95%, 1,172-1,285), hospitalización por ERC (HR = 1,427; IC 95%, 1,379-1,479) y fallo renal agudo (HR = 1,377; IC 95%, 1,222-1,524) fue mayor en los pacientes con IC y ERC frente a IC sola, tras 3 años de seguimiento. En la población incidente, a los 24 meses del diagnóstico el 5,9% desarrollaron ERC. Globalmente, el 23,4% tomaban inhibidores de la enzima convertidora de angiotensina, el 26,3% antagonistas de los receptores de angiotensina II, el 7,9% sacubitrilo/valsartán, el 64,2% bloqueadores beta, el 11,5% antialdosterónicos y el 4,5% inhibidores del cotransportador sodio-glucosa tipo 2. En España, los pacientes con IC tienen un riesgo elevado de desarrollar complicaciones cardiovasculares y renales. Sin embargo, existe una proporción importante de pacientes que no toman los fármacos recomendados por las guías. Un mayor uso podría reducir la carga de IC y las complicaciones en la práctica clínica.

Emergency Department/Urgent Care as Usual Source of Care and Clinical Outcomes in CKD: Findings From the Chronic Renal Insufficiency Cohort Study

Rationale & ObjectiveHaving a usual source of care increases use of preventive services and is associated with improved survival in the general population. We evaluated this association in adults with chronic kidney disease (CKD).Study DesignProspective, observational cohort study.Setting & ParticipantsAdults with CKD enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study.PredictorUsual source of care was self-reported as: 1) clinic, 2) emergency department (ED)/urgent care, 3) other.OutcomesPrimary outcomes included incident end-stage kidney disease (ESKD), atherosclerotic events (myocardial infarction, stroke, or peripheral artery disease), incident heart failure, hospitalization events, and all-cause death.Analytical ApproachMultivariable regression analyses to evaluate the association between usual source of care (ED/urgent care vs clinic) and primary outcomes.ResultsAmong 3,140 participants, mean age was 65 years, 44% female, 45% non-Hispanic White, 43% non-Hispanic Black, and 9% Hispanic, mean estimated glomerular filtration rate 50 mL/min/1.73 m2. Approximately 90% identified clinic as usual source of care, 9% ED/urgent care, and 1% other. ED/urgent care reflected a more vulnerable population given lower baseline socioeconomic status, higher comorbid condition burden, and poorer blood pressure and glycemic control. Over a median follow-up time of 3.6 years, there were 181 incident end-stage kidney disease events, 264 atherosclerotic events, 263 incident heart failure events, 288 deaths, and 7,957 hospitalizations. Compared to clinic as usual source of care, ED/urgent care was associated with higher risk for all-cause death (HR, 1.53; 95% CI, 1.05-2.23) and hospitalizations (RR, 1.41; 95% CI, 1.32-1.51).LimitationsCannot be generalized to all patients with CKD. Causal relationships cannot be established.ConclusionsIn this large, diverse cohort of adults with moderate-to-severe CKD, those identifying ED/urgent care as usual source of care were at increased risk for death and hospitalizations. These findings highlight the need to develop strategies to improve health care access for this high-risk population.

Impact of lung function decline on time to hospitalisation events in systemic sclerosis-associated interstitial lung disease (SSc-ILD): a joint model analysis

BackgroundInterstitial lung disease (ILD) is a common organ manifestation in systemic sclerosis (SSc) and is the leading cause of death in patients with SSc. A decline in forced vital capacity (FVC) is an indicator of ILD progression and is associated with mortality in patients with SSc-associated ILD (SSc-ILD). However, the relationship between FVC decline and hospitalisation events in patients with SSc-ILD is largely unknown. The objective of this post hoc analysis was to investigate the relationship between FVC decline and clinically important hospitalisation endpoints.MethodsWe used data from SENSCIS®, a phase III trial investigating the efficacy and safety of nintedanib in patients with SSc-ILD. Joint models for longitudinal and time-to-event data were used to assess the association between rate of decline in FVC% predicted and hospitalisation-related endpoints (including time to first all-cause hospitalisation or death; time to first SSc-related hospitalisation or death; and time to first admission to an emergency room [ER] or admission to hospital followed by admission to intensive care unit [ICU] or death) during the treatment period, over 52 weeks in patients with SSc-ILD.ResultsThere was a statistically significant association between FVC decline and the risk of all-cause (n = 78) and SSc-related (n = 42) hospitalisations or death (both P < 0.0001). A decrease of 3% in FVC corresponded to a 1.43-fold increase in risk of all-cause hospitalisation or death (95% confidence interval [CI] 1.24, 1.65) and a 1.48-fold increase in risk of SSc-related hospitalisation or death (95% CI 1.23, 1.77). No statistically significant association was observed between FVC decline and admission to ER or to hospital followed by admission to ICU or death (n = 75; P = 0.15). The estimated slope difference for nintedanib versus placebo in the longitudinal sub-model was consistent with the primary analysis in SENSCIS®.ConclusionsThe association of lung function decline with an increased risk of hospitalisation suggests that slowing FVC decline in patients with SSc-ILD may prevent hospitalisations. Our findings also provide evidence that FVC decline may serve as a surrogate endpoint for clinically relevant hospitalisation-associated endpoints.Trial registrationClinicalTrials.govNCT02597933. Registered on 8 October 2015.

Long-term clinical outcomes in patients after catheter ablation for atrial fibrillation or atrioventricular node ablation: A French nationwide cohort study

Catheter ablation of atrial fibrillation (AF) has become a therapy of choice to treat symptomatic AF in current practice. As an alternative, atrioventricular node (AVN) ablation is an older but efficient procedure to control ventricular rate. To assess long-term clinical outcomes of AF ablation and AVN ablation in large cohort of patients with AF and to compare these two procedures. This French multicentric retrospective study enrolled all patients hospitalized with a primary or secondary diagnosis of AF from 1st January 2010 to 31st December 2019, using an administrative hospital-discharge database. Clinical outcomes were analyzed in overall population and in propensity-matched samples. During follow-up (mean [SD]: 2.0 [2.2], median [IQR]: 1.0 [0.1–3.3] years), 2,438,015 patients were analysed (no ablation 2,360,833, AF ablation 62,490 and AVN ablation 14,692). Compared to patients treated without ablation, incidence of all-cause death was lower in patients treated with AF ablation [hazard ratio (HR): 0.272, 95% confidence interval (CI): 0.259–0.287, P < 0.0001] or AVN ablation (HR: 0.762, 95% CI: 0.734–0.791, P < 0.0001). After propensity-score matching, in patients treated with AF ablation, incidence of all-cause death (HR: 0.662, 95% CI: 0.557–0.788, P < 0.0001), cardiovascular death (HR: 0.617, 95% CI: 0.471–0.807, P < 0.0001) and hospitalization for heart failure (HF) (HR: 0.732, 95% CI: 0.620–0.865, P < 0.0001) were lower compared to patients treated with AVN ablation, unlike incidence of ischemic stroke (HR: 1.447, 95% CI: 1.122–1.865, P < 0.0001) (Fig. 1). AF ablation and AVN ablation may be associated with better survival compared to non-invasive strategy. Compared to AVN ablation, AF ablation is associated with lower risk of all-cause death, cardiovascular death and hospitalization for HF, but higher incidence of ischemic stroke.

Current use of inotropes according to initial blood pressure and peripheral perfusion in the treatment of congestive heart failure: findings from a multicentre observational study

ObjectivesCurrent guidelines restrict the use of inotropes for the treatment for heart failure (HF) unless the patients are hypotensive or hypoperfused because of safety concerns. This study sought to characterise...

Long-term mortality and cardiovascular outcomes in patients with atrial flutter after catheter ablation.

For patients with typical and atypical atrial flutter (AFL) but without history of atrial fibrillation (AF), the long-term cardiovascular (CV) outcomes after catheter ablation for AFL remain unclear. We compared the long-term all-cause mortality and CV outcomes in patients with AFL receiving catheter ablation compared with the results with medical therapy. Atrial flutter patients receiving catheter ablation for typical AFL were identified using the Health Insurance Database, and constituted the 'AFL ablation group'. Patients with typical and atypical AFL but without ablation (AFL without ablation group) were propensity matched to the AFL ablation group. Patients with prior AF diagnosis were excluded. Primary outcomes included all-cause and CV mortality, heart failure (HF) hospitalization, and stroke. The multivariable cox hazards regression model was used to evaluate the hazard ratio (HR) for study outcomes. A total of 3784 AFL patients (1892 patients in each group) was studied. Their mean follow-up durations were 7.85 ± 2.57 years (AFL without ablation group) and 8.31 ± 4.53 years (AFL ablation group). Atrial flutter with ablation patients had lower risks of all-cause mortality (HR: 0.68, P < 0.001), CV deaths (HR: 0.78, P = 0.001), HF hospitalization (HR: 0.84, P = 0.01), and stroke (HR: 0.80, P = 0.01). Catheter ablation for AFL in patients without prior AF was associated with lower risks of all-cause mortality and CV events compared with AFL patients without ablation during long-term follow-ups.

Sodium-Glucose Cotransporter 2 Inhibitors, Glucagon-Like Peptide-1 Receptor Agonists, and Dipeptidyl Peptidase-4 Inhibitors, and Risk of Hospitalization

Clinical trials have demonstrated cardiovascular benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1RA). However, their impact on all-cause and cause-specific hospitalization in real-world practice remains unclear. We identified patients with diabetes who initiated SGLT2i (n=2,492), GLP-1RA (n=1,982), or dipeptidyl peptidase-4 inhibitors (DPP4i, n=2,492) between 2015 and 2018 in Geisinger Health System. We examined all-cause hospitalization (net benefit indicator) and cardiovascular disease (CVD) hospitalization (CV benefit indicator), as well as non-CVD hospitalization (harm indicator), using Cox proportional hazards regression. During a median follow-up of 16 months, SGLT2i and GLP-1RA were associated with lower risk of all-cause hospitalization (hazard ratio [HR] 0.85, 95% CI 0.75 to 0.95 for SGLT2i; HR 0.89, 95% CI 0.78 to 0.98 for GLP-1RA), as well as CVD hospitalization (HR 0.61, 95% CI 0.47 to 0.79) for SGLT2i; HR 0.77, 95% CI 0.60 to 0.99 for GLP-1RA) compared with DPP4i. The risks of all-cause and CVD hospitalization were similar between SGLT2i and GLP-1RA. SGLT2i was associated with substantially lower risk of myocardial infarction and heart failure hospitalization compared with DPP4i and lower risk of heart failure hospitalization compared with GLP-1RA. The risk of non-CVD hospitalization did not differ among the treatment groups. These results from real-world comparison further encourage SGLT2i and GLP-1RA use in routine diabetes care, particularly among patients at high risk of cardiovascular events.

480 Catheter pulmonary vein ablation vs. medical therapy or atrioventricular node ablation and resynchronization in patients with atrial fibrillation and heart failure: a systematic review and meta-analysis

Abstract Aims Atrial fibrillation (AF) and heart failure (HF) are increasing in prevalence worldwide and, when present altogether, are associated with significant mortality and morbidity. Several and recent randomized clinical trials have reported an improvement of clinical outcomes in patients with HF and AF with catheter ablation. To provide a comprehensive and updated synthesis of effect estimates of the available randomized and observational clinical trials comparing pulmonary vein isolation with optimal medical therapy (rate or rhythm) or atrioventricular node ablation and resynchronization. Methods and results MEDLINE database was searched from inception to 4 March 2021 by two reviewers (F.C. and M.C.) for relevant studies. The following key words were used: ‘atrial fibrillation’, ‘heart failure’, ‘ablation’, ‘medical’, ‘drug’, ‘rate’, ‘rhythm’, ‘resynchronization’, and ‘atrial flutter’. The co-primary outcomes were all-cause death and hospitalization for HF. A total of 16 studies enrolling 42 908 patients were included; of these, 9 were randomized controlled trials, 3 unadjusted observational studies, and 4 adjusted observational trials. Patients treated with catheter ablation had a statistically significant reduction for the risk of all-cause death {Figure on the left: odds ratio [OR]: 0.51, [95% confidence interval (CI): 0.31–0.84], P = 0.008, NNT 33} and hospitalization for HF [Figure on the right: OR: 0.52, (95% CI: 0.31–0.87), P 0.014, NNT 24]. Subgroup analysis confirmed these results only in HF with reduced ejection fraction subgroup. Meta-regression analyses showed a direct correlation between a higher burden of persistent/long-standing persistent AF and the positive impact of catheter ablation of AF. Moreover, the age of 70 years emerged as the cut-off age for a greater impact of catheter ablation. Conclusions Catheter ablation of AF is associated with a lower risk of all-cause death and HF hospitalizations in patients with AF and HF, as compared to medical therapy or atrioventricular node ablation and resynchronization. These results are mainly applicable for HF with reduced ejection fraction.

Outcomes associated with pacemaker implantation following transcatheter aortic valve replacement: A nationwide cohort study.

Conduction abnormalities following transcatheter aortic valve replacement (TAVR) often may require permanent pacemaker implantation (PPM). The purpose of this study was to evaluate outcomes associated with PPM after a TAVR procedure in a large, nationwide-level population. Based on the administrative hospital discharge database, the incidence of all-cause death, cardiovascular death, and hospitalization for heart failure (HF) were retrospectively collected, based on the presence or absence of PPM, in the first 30 days following all TAVRs in France from 2010 to2019. Among 520,662 patients hospitalized for aortic stenosis, 49,201 were treated with TAVR. A total of 29,422 patients had follow-up ≥6 months (median 1.7 years), 22% already had PPM at baseline, and 22% underwent PPM within the first 30 days post-TAVR. Adjusted hazard ratios for the combined risk of all-cause death and hospitalization for HF, during the whole follow-up, were higher in both patients with a previous PPM and in those implanted within 30 days (hazard ratio [95% confidence interval] 1.12 [1.07-1.17] and 1.11 [1.06-1.16], respectively). PPM at baseline and within 30 days post-TAVR are independently associated with higher mortality and HF hospitalization during follow-up.

Risk of hospitalization and death associated with sodium glucose cotransporter-2 inhibitors: A comparison with five other classes of antidiabetic drugs

We assessed the risk of all-cause hospitalization and all-cause death associated with the use of Sodium Glucose Cotransporter-2 inhibitors (SGLT2i). Population-based propensity scores-matched cohort study of new users of metformin who subsequently initiated SGLT2i compared to those who initiated dipeptidyl peptidase-4 inhibitors (DPP4i) (primary comparison), sulfonylureas, thiazolidinediones, GLP1-Receptors agonists, and insulin, respectively. Alberta (Canada) health administrative data and United Kingdom Clinical Practice Research Datalink (CPRD) data were used to assess the study outcomes. Conditional Cox regressions were performed to assess the risk of each outcome, separately for each dataset and then results were combined using random-effects meta-analysis. For SGLT2i versus DPP4i, 7531 and 1647 SGLT2i-DPP4i matched pairs were analyzed in Alberta and CPRD data respectively. The mean age of patients was 56 and 57 years, and 39% and 43% were females, respectively in Alberta and CPRD cohorts. Compared with DPP-4-i, SGLT2i use was associated with a significant lower risk of all-cause hospitalization (combined hazard ratio (HR): 0.84, 95% confidence interval (95%CI): 0.75-0.95), and all-cause death (0.56, 0.38-0.83). SGLT2i use was also associated with a significant lower risk of all-cause hospitalization and all-cause death when compared to sulfonylureas (HRs: 0.80, 95%CI: 0.71-0.90 and 0.56, 95%CI: 0.38-0.82, respectively) and insulin (HRs: 0.55, 95%CI: 0.41-0.74, and 0.33, 95%CI: 0.24-0.46, respectively). SGLT2i initiation was associated with a decreased risk of all-cause hospitalization and all-cause death when compared to DPP4i, sulfonylureas, and insulin.

Unexplained anemia of aging: Etiology, health consequences, and diagnostic criteria.

BackgroundUp to 15% of people aged 60 and over are anemic, and the prevalence of anemia increases with age. In older men and women, anemia is associated with increases in the risk of death and all‐cause hospitalization, poor functional capacity, quality of life, and depression.Methods and ResultsWe reviewed the literature describing anemia in aging populations, focusing on the specific diagnostic criteria of anemia and potential causes in older men and women. Even after extensive etiologic workup that involves careful medical history, physical examination, laboratory measurements, and additional studies such as bone marrow biopsy, anemia of aging is unexplained in up to 40% of older patients with anemia. As a result, treatment options remain limited.ConclusionsThe prevalence of unexplained anemia of aging (UAA; also called unexplained anemia of the elderly, UAE), its deleterious impacts on health, physical function, and quality of life, and the lack of effective treatment or therapy guidelines represent a compelling unmet clinical need. In this review and consensus document, we discuss the scope of the problem, possible causes of UAA, diagnostic criteria, and potential treatment options. Because even mild anemia is strongly linked to poor clinical outcomes, it should receive clinical attention rather than simply being considered a normal part of aging.

Abstract 10616: HIV Infection and the Risk of Heart Failure Hospitalization and Mortality: A Systematic Review and Meta-Analysis of Cohort Studies

Introduction: Incidence of heart failure (HF) is increased among individuals living with human immunodeficiency virus (HIV). Whether HIV adversely affects hospitalization and mortality rates among patients with diagnosed HF has not been systematically evaluated. Hypothesis: We hypothesized that HIV infection would increase the risk of hospitalization and all-cause mortality rates in patients with HF, independent of established risk factors. Methods: We performed a systematic search of PubMed, EMBASE, Cochrane Library and Web of Science through March 7 th , 2021 for cohort studies conducted in adult patients (age≥18 years) with diagnosed HF and ascertainment of HIV infection at baseline. Outcomes assessed include all-cause mortality, HF-associated hospitalization, and all-cause hospitalization. All studies included multivariable adjustments for demographics, cardiovascular risk factors, and comorbidities. Pooled hazard ratio (HR) and 95% confidence intervals (CI) were calculated using a random-effects model. Results: We identified 7 studies consisting of 10,363 HF patients living with HIV and 48,933 HIV negative HF controls. HF patients with HIV had a higher risk of all-cause mortality compared to HIV-negative HF patients, HR (95% CI): 1.20 (1.14, 1.25), I 2 =0%. Similarly, HIV infection was associated with increased risks of both HF-associated hospitalization and all-cause hospitalization, with HR (95% CI) of 1.31 (1.03, 1.65) and 1.27 (1.12, 1.44), respectively; though significant heterogeneity was observed for both of these outcomes, I 2 =80% and 62%, respectively. Conclusions: HIV infection was independently associated with increased risk of all-cause mortality and both HF-associated and all-cause hospitalizations among individuals with HF. Our data may have important implications for HF management in this high-risk population.

Abstract 10603: Risk Factors for Development of Advanced Heart Failure: A Population-Based Study

Introduction: Some patients with heart failure (HF) will go on to develop advanced HF, characterized by severe HF symptoms despite attempts to optimize medical therapy. Our understanding of advanced HF at a population level remains limited. The goals of this study were to determine the risk of developing advanced HF in patients with newly diagnosed HF, identify risk factors for developing advanced HF, and evaluate the impact of advanced HF on outcomes. Methods: This was a population-based, retrospective cohort study of Olmsted County, Minnesota residents with a new clinical diagnosis of HF between 2007-2017. The primary outcome was development of advanced HF, defined using the 2018 European Society of Cardiology Criteria. Risk factors for development of advanced HF from the time of incident HF diagnosis were examined using cause-specific Cox proportional hazard regression models. The associations of development of advanced HF with risks of hospitalization and mortality were examined using Andersen-Gill and Cox models, respectively, with advanced HF treated as a time dependent covariate. Results: There were 4597 residents with incident HF from 2007 to 2017. The cumulative incidence of advanced HF was 6.0%, 9.1%, and 11.5% at 2, 4, and 6 years after incident HF diagnosis. Characteristics independently associated with development of advanced HF included older age, male sex, diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, lower serum sodium, worse right ventricular function, left atrial enlargement, higher estimated filling pressures, and higher right ventricular systolic pressure (p&lt;0.05 for each). Development of advanced HF was associated with increased risks of all-cause hospitalization (adjusted HR 3.00; 95% CI 2.65-3.41, p&lt;0.001), HF hospitalization (HR 10.24, 95% CI 8.67-12.10), all-cause mortality (HR 5.00, 95% CI 4.46-5.59, p&lt;0.001), and cardiovascular mortality (HR 7.84, 95% CI 6.74-9.12). Conclusions: In this population-based study, clinical, laboratory and echocardiographic characteristics at the time of incident HF diagnosis were associated with future risk of advanced HF. Development of advanced HF was associated with markedly increased morbidity and mortality.

Predictive Role of Platelet-Associated Indices on Admission and Discharge in the Long-Term Prognosis of Acute Coronary Syndrome Patients.

Our study aimed to investigate the association between platelet indices and their in-hospital change and long-term prognosis in acute coronary syndrome (ACS). Data from a randomized controlled trial (NCT02927808) recruiting ACS patients were analyzed (survival analysis). The examined variables were platelet count (PC), mean platelet volume (MPV), platelet distribution width (PDW), and plateletcrit (PCT) on admission and discharge, as well as their alteration during hospitalization. The primary endpoint was major adverse cardiac events (MACE) (cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke or hospitalization for unstable angina) and all-cause mortality, while secondary endpoints were all-cause hospitalization and bleeding events. The study included 252 patients with a follow-up of 39 (28-45) months. In the univariate analysis, MACE was associated with discharge PC [hazard ratio (HR) 2.20, 95% confidence interval (CI) 1.10-4.40], discharge MPV (HR 0.48, 95% CI 0.25-0.94), and in-hospital PC difference (HR 0.25, 95% CI 0.13-0.51). In the multivariable analysis, only in-hospital PC decrease correlated with lower MACE incidence (adjusted HR .27, 95% CI 0.14-0.54) and lower all-cause hospitalization risk (adjusted HR 0.36, 95% CI 0.19-0.68). PC reduction during hospitalization for ACS is an independent predictor of better prognosis.

Impact of SGLT2 inhibitors on major clinical events and safety outcomes in heart failure patients: a meta-analysis of randomized clinical trials.

BACKGROUNDSodium-glucose co-transporter-2 inhibitors (SGLT2i) significantly reduce the risk of cardiovascular (CV) and renal adverse events in patients with diabetes mellitus, heart failure (HF) and/or chronic kidney disease. We performed a meta-analysis to explore the impact of several different SGLT2i on all-cause mortality, CV mortality, HF hospitalizations and the combined outcome CV death/HF hospitalization in HF patients across the spectrum of left ventricular ejection fraction (LVEF) phenotypes.METHODSA systematic search in MEDLINE database and Cochrane library through March 2021 was performed without limitations. Randomized clinical trials that provided data about the impact of SGLT2i on all-cause mortality, CV mortality, HF hospitalizations or the combined outcome of CV death/HF hospitalization in HF patients were included. A random effects model was used for calculating the effect estimates.RESULTSNine studies (n = 16,723 patients, mean age: 65.9 years, males: 70.7%) were included in the quantitative synthesis. Compared to placebo, SGLT2i use was associated with 14% lower risk of all-cause mortality [hazard ratio (HR) = 0.86, 95% CI: 0.78−0.94,I2 = 0, P = 0.0008], 32% lower risk of HF hospitalizations (HR = 0.68, 95% CI: 0.62−0.74,I2 = 0, P < 0.001), 14% lower risk of CV mortality (HR = 0.86, 95% CI: 0.77−0.95, I2 = 0, P = 0.003) and 26% lower risk of CV death/HF hospitalization (HR = 0.74, 95% CI: 0.68−0.80,I2 = 0, P < 0.001). Regarding the safety outcomes, our data revealed no significant differences between SGLT2i and placebo groups in drug related discontinuations, amputations, severe hypoglycemia, hypotension, volume depletion, ketoacidosis and genital infections. By contrast, a protective role of SGLT2i against placebo was found for serious adverse events and acute kidney injury. CONCLUSIONSIn patients with HF, regardless of LVEF phenotype, all SGLT2i had an excellent safety profile and significantly reduced the risk of all-cause mortality, CV mortality, HF hospitalizations and CV deaths/HF hospitalizations compared to placebo.

Association of Membership at a Medical Fitness Facility With Adverse Health Outcomes

Interventions that increase physical activity behavior can reduce morbidity and prolong life, but long-term effects in large populations are unproven. This study investigates the association of medical fitness facility membership and frequency of attendance with all-cause mortality and rate of hospitalization. A propensity weighted retrospective cohort study was conducted by linking individuals who attended medical fitness facilities in Winnipeg, Canada to provincial health administrative databases. Members aged ≥18 years who had ≥1 year of provincial health coverage from their index date between January 1, 2005 and December 31, 2015 were included. Controls were assigned a pseudo-index date at random on the basis of the frequency distribution of index dates in the intervention group. Members were stratified into low-frequency attenders (<1 weekly visit), moderate-frequency attenders (1-3 weekly visits), and high-frequency attenders (>3 weekly visits). The primary outcomes were time to all-cause mortality and rate of hospitalizations. Statistical analyses were performed between 2018 and 2020. Among 19,300 adult members and 515,810 controls, members had a 60% lower risk of all-cause mortality during the first 651 days and 48% after 651 days. Membership was associated with a 13% lower risk of hospitalizations. A dose-response effect was apparent because higher weekly attendance was associated with a lower risk of hospitalizations (low frequency: 9%, moderate frequency: 20%, high frequency: 39%). Membership at a medical fitness facility was associated with a reduced risk of all-cause mortality and hospitalizations. Healthcare systems should consider the medical fitness model as a preventative public health strategy to encourage physical activity participation.

Urate lowering therapy is associated with a lower risk of heart failure hospitalisation or mortality in hyperuricaemic patients with heart failure: a comparative effectiveness study

Abstract Background There is a strong association between hyperuricemia (elevated serum uric acid) and the risk of heart failure. However, it remains unclear whether prescribing urate lowering therapies have any bearing on long term clinical outcomes. Purpose In this study, we assessed the impact of urate lowering therapy treatment on the risk of adverse health outcomes (hospitalisation for heart failure and all-cause mortality) in patients with hyperuricemia and heart failure. Methods We utilised data from Clinical Practice Research Datalink (CPRD) GOLD, a UK-based primary care database linked to secondary care (Hospital Episode Statistics) and mortality data (Office of National Statistics). The study population included patients with a first record of hyperuricemia (serum uric acid &amp;gt;7 mg/dl for men and &amp;gt;6 mg/dl for women or a gout diagnosis) between 1990 and 2019 with a history of heart failure. Incident urate lowering therapy users were identified post hyperuricemia diagnosis. To account for potential confounding variables and potential treatment paradigm changes over the study period, a propensity score matched cohort was constructed for urate lowering therapy initiators and non-initiators within 6 month accrual blocks. Adverse health outcomes were compared between matched treatment groups using Cox regression analysis adjusted for the same variables used in the propensity score. Due to extensive treatment switching and discontinuation, on-treatment analysis was the main analysis. Results A total of 2,174 propensity score matched pairs were identified. We found that urate lowering therapy was associated with a 43% lower risk of all-cause mortality or hospitalization for heart failure (Figure 1, adjusted hazard ratio 0.57, 95% confidence interval 0.51–0.65), and a 19% lower risk of cardiovascular mortality or hospitalization for heart failure (Figure 2, adjusted hazard ratio 0.81, 95% confidence interval 0.71–0.92) within five years compared to those not on therapy (on-treatment analysis). In an intention-to-treat sensitivity analysis, urate lowering therapy was associated with a 17% lower risk of all-cause mortality or hospitalization for heart failure (adjusted hazard ratio 0.83, 95% confidence interval 0.76–0.91), and a 11% lower risk of cardiovascular mortality or hospitalization for heart failure (adjusted hazard ratio 0.89, 95% confidence interval 0.81–0.98) within five years compared to those not on urate lowering therapy. Adjusted and non-adjusted hazard ratios were consistent for all outcomes. Conclusion We found that urate lowering therapy was associated with a lower risk of adverse outcomes in hyperuricemia or gout patients with a history of heart failure. These results are consistent with the hypothesis that uric acid lowering may lead to improved outcome in patients with heart failure and hyperuricemia, emphasizing the need to investigate the potential benefits of intense uric acid lowering in prospective randomized controlled trials. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): AstraZeneca Figure 1 (HF = heart failure)Figure 2 (CV = cardiovascular)

Effectiveness of telemedicine in patients with heart failure according to frailty phenotypes: insights from the iCOR randomised controlled trial

Abstract Background/Introduction The potential impact of telemedicine (TM) in the monitoring of heart failure (HF) patients is still uncertain, largely due to the heterogeneity of the studies published to date. A subgroup of patients in which its key role is particularly uncertain is that of the frailest patients mainly due to TM-based strategies have been often discouraged on the basis of a foreseeable limited benefit in them. Purpose The aim of this study was to define the efficacy of a TM-based managed care solution across different HF patient frailty phenotypes in a cohort of HF patients recruited in a randomized clinical trial (The Insuficiència Cardíaca Optimitzaciό Remota [iCOR] study) evaluating the efficacy of a TM-based management compared to usual care (UC) in the early post-discharge period. Methods Five previously described frailty clusters were analysed. Cox proportional-hazards regression models were used to evaluate the effect of each cluster and group of treatment (and its interaction) on a series of endpoints (the incidence of non-fatal HF events as primary endpoint and all-cause hospitalization, all-cause death and the composite endpoint combining of all-cause death or non-fatal HF events as secondary endpoints). The incidence proportion of the first occurrence of each of the study endpoints was calculated for each study arm and for cluster, and these compared using χ2 tests. Additionally, a survival analysis was conducted using Cox regression to describe the event-free survival experience of the combination of the clusters with each of the 2 treatment groups for the study endpoints evaluated, and p-value was used to compare the different curves. Results The positive effect of TM compared to UC strategy was consistent across all frailty phenotypes (p-value for interaction 0.711). The risk of experiencing a primary event was significantly lower in patients that underwent allocation to the TM arm compared to UC (p-value=0.016). As shown for the primary endpoint, the positive effect of TM compared to UC strategy was consistent across all frailty phenotypes also for the secondary endpoints (all p-value for interaction &amp;gt;0.05). Likewise, the risk of all-cause hospitalization or the composite end-point of all-cause death or non-fatal HF event was significantly lower in patients that underwent allocation to the TM arm compared to UC (p-value=0.030 and 0.016 respectively). However, the risk of all-cause death did not differ across subgroup strata (p-value&amp;gt;0.05). Conclusion(s) This study showed that non-invasive TM-based follow-up tools are effective compared to UC in preventing fatal and non-fatal adverse events in the early post-discharge period, regardless of the 5 different frailty phenotypes. Importantly, when comparing TM-based follow-up with UC management in patients belonging to equal frailty cluster, those who were followed-up by eHealth had a considerably lower risk of non-fatal HF events, hospitalization or death. Funding Acknowledgement Type of funding sources: None. Cox regression non-fatal HF eventsCox regression all-cause hospitalization

Right ventricular remodeling and prognostic relevance after ST-segment elevation myocardial infarction in patients treated with primary percutaneous coronary intervention

Abstract Background ST-segment elevation myocardial infarction (STEMI) often involves changes in right ventricular (RV) function and size over time. However, the prognostic implications of RV remodeling after STEMI are unknown. The aim of current study was to characterize RV remodeling in post-STEMI patients and to investigate it's prognostic relevance. Methods RV remodeling in post-STEMI patients who underwent primary percutaneous coronary intervention (PCI) was defined by RV end-systolic area (RV ESA) change at 6 months after STEMI, compared to baseline. The optimal threshold of RV ESA change (≥40%) to define RV remodeling was derived from spline curve analysis (Figure 1A). The primary endpoint was the composite of all-cause mortality and heart failure (HF) hospitalization. Long term outcomes were compared between patients with and without RV remodeling by means of a log rank test. Results A total of 2280 patients were analyzed (mean age 60±11 years, 76% male) and RV remodeling was present in 320 patients (14%). After a median follow-up of 75 months (interquartile range 50–106 months), the composite endpoint of all-cause mortality and HF hospitalization occurred in 292 patients (13%). After adjustment for various risk factors, including tricuspid annular plane systolic excursion (TAPSE), post-STEMI RV remodeling was independently associated with a higher risk of all-cause mortality and HF hospitalization (HR=1.37, 95% CI 1.00–1.87, p=0.049. Finally, patients with RV remodeling were had a significantly lower event-free survival rate compared with patients without RV remodeling during follow-up (log-rank test p=0.009) (Figure 1B). Conclusion RV post-infarct remodeling is associated with mortality and HF hospitalization, independent of RV systolic function. Funding Acknowledgement Type of funding sources: None. Figure 1. A) Spline and B) Kaplan-Meier curve

Long-term clinical outcomes in patients after catheter ablation for atrial fibrillation or atrioventricular node ablation: a French nationwide cohort study

Abstract Background Catheter ablation of atrial fibrillation (AF) has become a therapy of choice to treat symptomatic AF in current practice. As an alternative, atrioventricular node (AVN) ablation is an older but efficient procedure to control ventricular rate. Purpose To assess long-term clinical outcomes of AF ablation and AVN ablation in large cohort of patients with AF and to compare these two procedures. Methods This French multicentric retrospective study enrolled all patients hospitalized with a primary or secondary diagnosis of AF from 1st January 2010 to 31st December 2019, using an administrative hospital-discharge database. Clinical outcomes were analyzed in overall population and in propensity-matched samples. Results During follow-up (mean [SD] 2.0 [2.2], median [IQR] 1.0 [0.1–3.3] years), 2,438,015 patients were analysed (No ablation 2,360,833, AF ablation 62,490 and AVN ablation 14,692). Compared to patients treated without ablation, incidence of all-cause death was lower in patients treated with AF ablation (hazard ratio (HR) 0.272, 95% confidence interval (CI) 0.259–0.287, p&amp;lt;0.0001) or AVN ablation (HR 0.762, 95% CI 0.734–0.791, p&amp;lt;0.0001). After propensity-score matching, in patients treated with AF ablation, incidence of all-cause death (HR 0.662, 95% CI 0.557–0.788, p&amp;lt;0.0001), cardiovascular death (HR 0.617, 95% CI 0.471–0.807, p&amp;lt;0.0001) and hospitalization for heart failure (HF) (HR 0.732, 95% CI 0.620–0.865, p&amp;lt;0.0001) were lower compared to patients treated with AVN ablation, unlike incidence of ischemic stroke (HR 1.447, 95% CI 1.122–1.865, p&amp;lt;0.0001). Conclusion AF ablation and AVN ablation may be associated with better survival compared to non-invasive strategy. Compared to AVN ablation, AF ablation is associated with lower risk of all-cause death, cardiovascular death and hospitalization for HF, but higher incidence of ischemic stroke. Funding Acknowledgement Type of funding sources: None. Baseline characteristics matched cohortMain results