Stable Heart Failure Patients Research Articles

Weight telemonitoring of heart failure versus standard of care in a real-world setting: Results on mortality and hospitalizations in a 6-month nationwide matched cohort study.

Evaluating the benefit of telemonitoring in heart failure (HF) management in real-world settings is crucial for optimizing the healthcare pathway. The aim of this study was to assess the association between a 6-month application of the telemonitoring solution Chronic Care Connect™ (CCC) and mortality, HF hospitalizations, and associated costs compared with standard of care (SOC) in patients with a diagnosis of HF. From February 2018 to March 2020, a retrospective cohort study was conducted using the largest healthcare insurance system claims database in France (Système National des Données de Santé) linked to the CCC telemonitoring database of adult patients with an ICD-10-coded diagnosis of HF. Patients from the telemonitoring group were matched with up to two patients from the SOC group based on their high-dimensional propensity score, without replacement, using the nearest-neighbour method. A total of 1358 telemonitored patients were matched to 2456 SOC patients. The cohorts consisted of high-risk patients with median times from last HF hospitalization to index date of 17.0 (interquartile range: 7.0-66.0) days for the telemonitoring group and 27.0 (15.0-70.0) days for the SOC group. After 6 months, telemonitoring was associated with mortality risk reduction (hazard ratio [HR] 0.71, 95% confidence interval [CI] 0.56-0.89), a higher risk of first HF hospitalization (HR 1.81, 95% CI 1.55-2.13), and higher HF healthcare costs (relative cost 1.38, 95% CI 1.26-1.51). Compared with the SOC group, the telemonitoring group experienced a shorter average length of overnight HF hospitalization and fewer emergency visits preceding HF hospitalizations. The results of this nationwide cohort study highlight a valuable role for telemonitoring solutions such as CCC in the management of high-risk HF patients. However, for telemonitoring solutions based on weight and symptoms, consideration should be given to implement additional methods of assessment to recognize imminent worsening of HF, such as impedance changes, as a way to reduce mortality risk and the need for HF hospitalizations. Further studies are warranted to refine selection of patients who could benefit from a telemonitoring system and to confirm long-term benefits in high-risk and stable HF patients.

Efficacy and safety of CDR132L in patients with reduced left ventricular ejection fraction after myocardial infarction: Rationale and design of the HF-REVERT trial.

Inhibition of microRNA (miR)-132 effectively prevents and reverses adverse cardiac remodelling, making it an attractive heart failure (HF) target. CDR132L, a synthetic antisense oligonucleotide selectively blocking pathologically elevated miR-132, demonstrated beneficial effects on left ventricular (LV) structure and function in relevant preclinical models, and was safe and well tolerated in a Phase 1b study in stable chronic HF patients. Patients with acute myocardial infarction (MI) and subsequent LV dysfunction and remodelling have limited therapeutic options, and may profit from early CDR132L treatment. The HF-REVERT (Phase 2, multicenter, randomized, parallel, 3-arm, placebo-controlled Study to Assess Efficacy and Safety of CDR132L in Patients with Reduced Left Ventricular Ejection Fraction after Myocardial Infarction) evaluates the efficacy and safety of CDR132L in HF patients post-acute MI (n = 280), comparing the effect of 5 and 10 mg/kg CDR132L, administered as three single intravenous doses 28 days apart, in addition to standard of care. Key inclusion criteria are the diagnosis of acute MI, the development of systolic dysfunction (LV ejection fraction ≤45%) and elevated N-terminal pro-B-type natriuretic peptide. The study consists of a 6-month double-blinded treatment period with the primary endpoint LV end-systolic volume index and relevant secondary endpoints, followed by a 6-month open-label observation period. The HF-REVERT trial may underpin the concept of miR-132 inhibition to prevent or reverse cardiac remodelling in post-MI HF. The results will inform the design of subsequent outcome trials to test CDR132L in HF.

Shaping the future of Heart Failure Care

Heart failure (HF) hospitalisations are commonly associated with increased mortality and morbidity. The multi-disciplinary HF workgroup was formed in 2016 comprising Cardiologists, HF Case Managers, Advanced Practice Nurses, Cardiac Pharmacists, Allied Health Professionals and Operations personnel. The group focuses on delivering an end-to-end HF care, that aims to improve clinical and functional outcomes, while keeping cost affordable to patients. Our early initiatives were targeted at the inpatient phase; with current shift towards patient-centred and value-driven care, it presents an opportunity to delve deeper into patients’ journey.
 Our HF workgroup aims to implement a series of initiatives targeting pre-admission (HF - Extended Diagnostic and Treatment Unit (EDTU)) and post-discharge phases (HF Shared Care (HFSC) and Medical Home (MH)) of the patient’s journey, supporting their health needs in the community, thus reducing avoidable hospital readmissions.
 Foremost, the team mapped out the patients’ journey and adopted a multi-pronged approach to i) manage mild HF patients presented to Emergency Department (ED) under HF-EDTU protocol and support ii) stable HF patients with co-morbidities (HFSC programme) and mild-to-moderately decompensated HF patients (MH programme) in the community. 
 Under HF-EDTU protocol (commenced Mar’ 22), brainstorming sessions were conducted with ED to determine the inclusion criteria to ensure safe discharge from ED. For HFSC programme (commenced Jul’ 22), we engaged Shared Care Partnership Office (SCPO) to partner General Practitioners (GPs) to co-manage stable HF patients with co-morbidities in the community. GP focus group discussions were held to gather inputs for effective implementation of HFSC programme. We also worked with Population Health and Community Transformation (PHCT) team to identify patients with haemodynamically stable medical conditions for MH programme (commenced Jun’ 22) to reduce unnecessary hospitalisation. Regular meetings were conducted to monitor and evaluate the progress of our initiatives.
 Collectively, these initiatives contributed to a decrease in 30D readmission rate from 8.4% to 6.8% (≈19% relative reduction) and a decrease in total bill size from $4,847 to $4,802, when comparing across the pre (Apr 2021 – Mar 2022) and post-implementation of initiatives (Apr 2022 onwards).
 To date, of the 11 HF-EDTU patients, 5 were discharged from EDTU, avoiding inpatient admission. This resulted in estimated cost savings of $7,595. Separately, 5 patients were enrolled into HFSC programme.
 
 By adopting a strong value-driven methodology, we were able to assess and identify gaps in existing processes to create more value for our patients. Despite the short period of implementation, the drop in 30D readmission rate is testament to better and safer quality of care received by our patients. By working closely with private primary care providers, patients are able to embark on a lifelong relationship with their GPs to manage different aspects of their health (including preventive care). This is crucial as we tackle the wave of an ageing population and the rising impact of multiple chronic diseases.
 With the current promising results, continuous Plan-Do-Study-Act cycles will refine and improve the uptake of our initiatives. Lastly, measurement of patient experience outcomes are underway to truly understand what matters to patients in their care journey.

Eligibility and prescribing rates of SGLT2 inhibitors for ambulatory patients with heart failure and reduced ejection fraction in a multidisciplinary heart failure management programme

Abstract Introduction Sodium-glucose cotransporter 2 (SGLT2) inhibitors dapagliflozin or empagliflozin are recommended, in addition to optimal medical therapy (OMT), for patients with heart failure with reduced ejection fraction (HFrEF) regardless of diabetes status.(1) Both have been licensed for use in the UK NHS by NICE,(2,3) but the proportion of 'real world' heart failure (HF) patients for whom these guidelines are applicable is unknown. For those eligible, multidisciplinary HF management programmes (HF-MPs), may enable more rapid translation of guidelines into practice.(1) Purpose We aimed to identify the patients eligible to start, and those prescribed, SGLT2 inhibitors amongst patients attending a HF-MP at a tertiary centre in the UK. We also assessed for variation by age and sex. Methods In this single-centre retrospective study we selected consecutive patients who attended a heart failure clinic appointment between 01 November 2020 - 01 March 2021. We extracted information pertaining to baseline demographics, investigations, and therapies relevant to eligibility for SGLT2 inhibitors, and prescription of SGLT2 inhibitors at baseline and 2-year follow-up. Differences in SGLT2 inhibitor prescription by age and sex were analysed using the χ2 test. All tests were two-sided, and statistical significance was considered as p value <0.05. Results Over this period, 296 stable chronic HF patients attended the centre. The majority of patients had HFrEF (53%),4 and there was a broad age distribution including the very elderly (28% > 80 years) (Table 1). Patients with HFrEF were well optimised [beta blocker (86%), angiotensin-converting enzyme/ angiotensin receptor blocker (61%), sacubitril- valsartan (23%), mineralocorticoid receptor antagonist (50%)] (Table 1). Of the whole cohort, 107 (36%) patients met eligibility for SGLT2 inhibitor prescription, with 24 (8%) already receiving a SGLT2 inhibitor at the point of guideline implementation, of whom 15 (5%) had diabetes mellitus (Figure 1). At 2-year follow-up 64 eligible individuals (22%) were prescribed a SGLT2 inhibitor, meaning that prescription amongst eligible individuals had increased from 22% to 60%, with greater improvement in younger individuals (Figure 1). Age-stratified analysis revealed that at least 30% of clinic attendees in each decile were eligible for SGLT2 inhibitors, and almost half of sexagenarian attendees (47%). Though there was not a disparity in prescription of SGLT2 inhibitors for women compared to men (51% vs 64% p=0.22), those aged ≥80 years less frequently received SGLT2 inhibitors compared with younger individuals (33% vs 69%, p<0.001). Conclusions Among stable HF patients in a ‘real world’ setting, a significant proportion are eligible for SGLT2 inhibitors. Patients attending a HF-MP have benefitted from early implementation of novel guidelines, though there are age-determined gaps in SGLT2 inhibitor prescription that represent an actionable target.Table 1Figure 1

Abstract 14356: Higher Burdon of Premature Ventricular Complexes is Not Uncommon in Stable Well Treated Heart Failure Patients and Relate to Poorer Outcomes

Introduction: While premature ventricular contractions (PVCs) are generally considered benign, recent evidence suggests that even the contractions preceding PVCs are inefficient so that even a moderate burden of PVCs may be associated with loss of contractile efficiency and increased risk of events. It is however unclear what proportion of stable heart failure (HF) patients have a moderate to high burden of PVCs, despite being well-treated. Aim: The aim of this study was to assess the proportion of HF patients that have more than 5% PVCs and whether this higher number is related to worse outcomes. Methods: We retrospectively analyzed electronic medical records from 676 adult patients with either an ejection fraction < 40% or NTproBNP more than 600 pg/ml at the Amsterdam UMC (AMC) who received Holter monitoring between 2014 and 2022. In a second independent cohort from a heart failure registry at Henry Ford Hospital (HFH) in Detroit, Michigan, we retrospectively reviewed all participants with ejection fraction < 40% that had a Holter monitor at any point (n=180). Results: The median baseline age of the Amsterdam UMC patients was 62 and 40% were female. The HFH cohort had a median age of 64 years and 50% were female. Results are summarized in the table. During the follow-up period, significantly more patients died in the group with more than 5% PVCs (p < 0.05 in the Amsterdam UMC cohort). Conclusions: We show in two independent cohorts that around 8-10% of HF patients have a significant burden of PVCs (i.e. >5% of all heartbeats), despite adequate use of beta-blocker therapy. This proportion of PVCs is associated with an increased risk of death over one year. This suggests that in HFrEF patients, PVCs burden more than 5% of heartbeats may not be as harmless as often thought.

ПОЛИМОРФИЗМ RS247616 ГЕНА CETP У ПАЦИЕНТОВ С ХРОНИЧЕСКОЙ СЕРДЕЧНОЙ НЕДОСТАТОЧНОСТЬЮ И ИШЕМИЧЕСКОЙ БОЛЕЗНЬЮ СЕРДЦА: ОСОБЕННОСТИ ЛИПИДНОГО ОБМЕНА И ЭФФЕКТИВНОСТИ ТЕРАПИИ СТАТИНАМИ

Abstract. Introduction. Dyslipidemia is a modifiable risk factor for cardiovascular complications in patients with chronic ischemia-induced heart failure. Being the best-known class of drugs, statins effectively reduce cardiovascular mortality in all age groups. Effectiveness of using lipid-lowering drugs is determined by some factors, including genetic ones. Polymorphism rs247616 of the CETP (cholesterol ester transfer protein) gene is associated with changing high-density lipoprotein levels in blood serum. Aim. To analyze the clinical parameters and effectiveness of lipid-lowering therapy in stable chronic ischemia-induced heart failure patients with the rs247616 polymorphism of the CETP gene. Materials and Methods. We examined 517 patients with chronic ischemia-induced heart failure, aged 66.4±10.4 years, of both sexes. A genetic control of 118 conditionally healthy individuals was included. We analyzed the allele frequency of the CETP rs247616 occurrences, clinical characteristics, statin administration frequency, dose range, and achieving the lipid metabolism goals, including in relation to the genotype. Results and Discussion. Statins were prescribed to 28.8% of patients with chronic heart failure, with 42.3% receiving the minimum dosage and 35.6% receiving the average therapeutic dosage. Frequency of TT-genotype and T allele of the CETP rs247616 was higher in patients with chronic heart failure compared with controls (13.2% and 10.2%, p=0.026, 35% and 26.7%, p=0.014). It was found that CC-genotype has a protective effect against the development of chronic heart failure (CC vs CT+TT, OR=0.57, 95%CI:0.38-0.86). In patients with CC-genotype chronic heart failure, a lower level of high-density lipoproteins was observed (1.12±0.37 and 1.25±0.37 mmol/l, p=0.012), as compared to the carriers of T allele (CT+TT). Percentage of individuals with total cholesterol levels below 4.5 mmol/l (33.3%, 29.7%, and 37.5%) and triglyceride levels < 1.7 mmol/l (36.5%, 25%, and 37.5%) did not differ between CC-, CT-, and TT-genotypes, respectively. There is a trend towards an increase in the proportion of the carriers of T allele and TT-genotype with low-density lipoprotein levels < 1.8 mmol/l (30.8%, 45.5%, and 50%) and non-high-density lipoproteins levels<2.6 mmol/l (29.4%, 31.2%, and 50%). Conclusions. Effectiveness of statin therapy is low: 38.1 % of patients had the total cholesterol levels < 4.5 mmol/l, 11% had low-density lipoprotein levels <1.8 mmol/l, 50.6% had triglyceride levels <1.7 mmol/l, and 12.2% of patients had non-high-density lipoprotein levels <2.6 mmol/l. Protective effect of CC-genotype was found regarding the genesis of chronic heart failure.

Translation, Cultural Adaptation, Validation and Reliability of Persian Left Ventricular Dysfunction-36 Questionnaire.

The left ventricular dysfunction 36 (LVD-36) questionnaire is considered to be a tool to assess the impact of left ventricle impairment on patients' daily life. This methodological study was aimed to translate and assess the validity and reliability of the Persian draft of the LVD-36 questionnaire among Iranian heart failure (HF) patients. We recruited stable HF patients who referred to an outpatient heart clinic in Isfahan, Iran. The LVD-36 questionnaire was translated using the forward-backward method. Twenty HF patients were recruited for content validity assessment and were asked to express their opinions about the comprehensibility and meaningfulness of each item. We invited 14 experts to assess validity through content validity index (CVI) and content validity ratio (CVR). Reliability was assessed by Cronbach's alpha and intraclass correlation coefficient (ICC), with the latter evaluated after invitation of the participants to complete the questionnaire for the second time. The translation process was performed uneventfully without any significant alterations. A total of 150 HF patients were recruited to assess the reliability of the questionnaire in this study (age: 64.6±16 years, males: 58.6%). All items had acceptable CVI and CVR, ranging 0.85-1.00 and 0.57-1.00, respectively. Cronbach's alpha was 0.971. All participants completed the questionnaire for the second time with no missing data. Test-retest reliability revealed an excellent ICC value of 0.981 (95% CI: 0.977-0.985). The Persian version of the LVD-36 questionnaire is a simple, valid and reliable tool for evaluating the impact of left ventricle impairment on the well-being of Iranian HF patients.

The Relationship Between Atrial Fibrillation and Parathyroid Hormone in Heart Failure Outpatients.

Background Atrial fibrillation (AF) is a common arrhythmia in heart failure (HF). Plasma concentrations of para-thyroid hormone (PTH) have been shown to increase in HF. The relationship between PTH concentrations and the presence of AF in HF is, however, unknown. This study analyzed the relationship between plasma PHT concentrations and AF in patients with systolic HF.Material and methods 131 consecutive, stable HF patients, who were admitted to the HF outpatient clinic, were included in this prospective, observational study. Patients were classified as those with AF (n = 36) and those in sinus rhythm (SR, n = 95).Results PTH concentrations were markedly higher in patients with AF compared to the patients in SR [85 (15-320) vs. 112 (30-326) U / ml, p=0.007]. PTH, creatinine clearance, hemoglobin, creatinine, age, and left ventricular ejection fraction were found to be related to AF by univariate analysis; though, multivariate logistic regression analysis showed that only PTH concentration was independently related to AF.Conclusion PTH concentrations can be used to indicate AF in patients with systolic HF.

Developing a personalized remote patient monitoring algorithm: a proof-of-concept in heart failure.

Non-invasive remote patient monitoring is an increasingly popular technique to aid clinicians in the early detection of worsening heart failure (HF) alongside regular follow-ups. However, previous studies have shown mixed results in the performance of such systems. Therefore, we developed and evaluated a personalized monitoring algorithm aimed at increasing positive-predictive-value (PPV) (i.e. alarm quality) and compared performance with simple rule-of-thumb and moving average convergence-divergence algorithms (MACD). In this proof-of-concept study, the developed algorithm was applied to retrospective data of daily bodyweight, heart rate, and systolic blood pressure of 74 HF-patients with a median observation period of 327 days (IQR: 183 days), during which 31 patients experienced 64 clinical worsening HF episodes. The algorithm combined information on both the monitored patients and a group of stable HF patients, and is increasingly personalized over time, using linear mixed-effect modelling and statistical process control charts. Optimized on alarm quality, heart rate showed the highest PPV (Personalized: 92%, MACD: 2%, Rule-of-thumb: 7%) with an F1 score of (Personalized: 28%, MACD: 6%, Rule-of-thumb: 8%). Bodyweight demonstrated the lowest PPV (Personalized: 16%, MACD: 0%, Rule-of-thumb: 6%) and F1 score (Personalized: 10%, MACD: 3%, Rule-of-thumb: 7%) overall compared methods. The personalized algorithm with flexible patient-tailored thresholds led to higher PPV, and performance was more sensitive compared to common simple monitoring methods (rule-of-thumb and MACD). However, many episodes of worsening HF remained undetected. Heart rate and systolic blood pressure monitoring outperformed bodyweight in predicting worsening HF. The algorithm source code is publicly available for future validation and improvement.

Sodium restriction in patients with chronic heart failure and reduced ejection fraction: A randomized controlled trial.

Sodium restriction is recommended for patients with heart failure (HF) despite the lack of solid clinical evidence from randomized controlled trials. Whether or not sodium restrictions provide beneficial cardiac effects is not known. The present study is a randomized, double-blind, controlled trial of stable HF patients with ejection fraction ≤ 40%. Patients were allocated to sodium restriction (2 g of sodium/day) vs. control (3 g of sodium/day). The primary outcome was change in N-terminal pro-B-type natriuretic peptide (NT-proBNP) at 20 weeks. Secondary outcomes included quality of life and adverse safety events (HF readmission, blood pressure or electrolyte abnormalities). Seventy patients were enrolled. Median baseline sodium consumption was 3268 (2225-4537) mg/day. Adherence to the intervention based on 24-hour urinary sodium was 32%. NT-proBNP and quality of life did not significantly change between groups (p > 0.05 for both). Adverse safety events were not significantly different between the arms (p > 0.6 for all). In the per protocol analysis, patients who achieved a sodium intake < 2500 mg/day at the intervention conclusion showed improvements in NT-proBNP levels (between-group difference: -55%, 95% confidence interval -27 to -73%; p = 0.002) and quality of life (between-group difference: -11 ± 5 points; p = 0.04). Blood pressure decreased in patients with lower sodium intake (between-group difference: -9 ± 5 mmHg; p = 0.05) without significant differences in symptomatic hypotension or other safety events (p > 0.3 for all). Adherence assessed by 24-hour natriuresis and by the nutritionist was poor. The group allocated to sodium restriction did not show improvement in NT-proBNP. However, patients who achieved a sodium intake < 2500 mg/day appeared to have improvements in NT-proBNP and quality of life without any adverse safety signals. gov Identifier: NCT03351283.

Circulating immune checkpoints predict heart failure outcomes.

There are limited data examining the role of immune checkpoint (IC) ligands in the pathophysiology of heart failure (HF). Therefore, we explore this in three HF animal models and in three different human cohorts (healthy, stable, and worsening HF). Transcriptomic analyses of cardiac tissue of three different HF mouse models revealed differentially expressed IC receptors and their ligands compared with control mice. Based on this observation, serum levels of three well-known IC ligands (i.e. sPD-L1, sPD-L2 and galectin-9) were measured in stable HF patients from the Vitamin D Chronic Heart Failure (VitD-CHF) study (n=101), as well as healthy individuals from the Prevention of Renal and Vascular End-stage Disease (PREVEND) study (n=58). sPD-L1, sPD-L2, and galectin-9 were all associated with New York Heart Association classification. In multivariate linear regression analyses, all three IC ligands were associated with galectin-3 (β=0.230, β=0.283, and β=0.304, respectively). sPD-L1 and galectin-9 were also associated with hs-troponin-T (β=0.386 and β=0.314). Regarding prognosis, higher serum levels of sPD-L1 and galectin-9 were significantly associated with increased risk for HF hospitalization and all-cause mortality [hazard ratio 1.69 (1.09-2.59) and hazard ratio 1.50 (1.06-2.12)]. Furthermore, the importance of IC ligands was tested in another stage of HF, namely worsening HF patients. In the worsening HF cohort (The BIOlogy Study to Tailored Treatment in Chronic Heart Failure) (n=2032), sPD-L2 and galectin-9 were associated with New York Heart Association classification and significantly predicted outcome with an increased relative risk of 15% and 20%, after multivariable adjustment, respectively. IC ligands are expressed in cardiac disease models, and serum levels of IC ligands are elevated in HF patients, are associated with disease severity, and significantly predict prognosis. These data indicate a potential role for IC ligands in HF pathogenesis.

Trends in voice characteristics in patients with heart failure (VENTURE) in Switzerland: Protocol for a longitudinal observational pilot study.

Heart Failure (HF) is a major health and economic issue worldwide. HF-related expenses are largely driven by hospital admissions and re-admissions, many of which are potentially preventable. Current self-management programs, however, have failed to reduce hospital admissions. This may be explained by their low predictive power for decompensation and high adherence requirements. Slight alterations in the voice profile may allow to detect decompensation in HF patients at an earlier stage and reduce hospitalizations. This pilot study investigates the potential of voice as a digital biomarker to predict health status deterioration in HF patients. In a two-month longitudinal observational study, we collect voice samples and HF-related quality-of-life questionnaires from 35 stable HF patients. Patients use our developed study application installed on a tablet at home during the study period. From the collected data, we use signal processing to extract voice characteristics from the audio samples and associate them with the answers to the questionnaire data. The primary outcome will be the correlation between voice characteristics and HF-related quality-of-life health status. The study was reviewed and approved by the Cantonal Ethics Committee Zurich (BASEC ID:2022-00912). Results will be published in medical and technical peer-reviewed journals.

The effect of heart failure on gut microbial richness and diversity

Introduction and objectiveWith recent advances in genome sequencing technology, a large body of evidence has accumulated over the last few years linking alterations in microbiota with cardiovascular disease. In this study, we aimed to compare gut microbial composition using 16S ribosomal DNA (rDNA) sequencing techniques in patients with coronary artery disease (CAD) and stable heart failure (HF) with reduced ejection fraction and patients with CAD but with normal ejection fraction. We also studied the relationship between systemic inflammatory markers and microbial richness and diversity. MethodsA total of 40 patients (19 with HF and CAD, 21 with CAD but without HF) were included in the study. HF was defined as left ventricular ejection fraction <40%. Only stable ambulatory patients were included in the study. Gut microbiota were assessed from the participants’ fecal samples. The diversity and richness of microbial populations in each sample were assessed by the Chao1-estimated OTU number and the Shannon index. ResultsThe Chao1-estimated OTU number and Shannon index were similar between HF and control groups. There was no statistically significant relationship between inflammatory marker levels (tumor necrosis factor-alpha, interleukin 1-beta, endotoxin, C-reactive protein, galectin-3, interleukin 6, and lipopolysaccharide-binding protein) and microbial richness and diversity when analyzed at the phylum level. ConclusionIn the current study, compared to patients with CAD but without HF, stable HF patients with CAD did not show changes in gut microbial richness and diversity. At the genus level Enterococcus sp. was more commonly identified in HF patients, in addition to certain changes in species levels, including increased Lactobacillus letivazi.

Acute COVID-19 Management in Heart Failure Patients: A Specific Setting Requiring Detailed Inpatient and Outpatient Hospital Care

The relationship existing between heart failure (HF) and COVID-19 remains questioned and poorly elucidated. Many reports suggest that HF events are reduced during pandemics, although other studies have demonstrated higher mortality and sudden death in patients affected by HF. Several vascular, thrombotic, and respiratory features may deteriorate stable HF patients; therefore, the infection may directly cause direct myocardial damage, leading to cardiac function deterioration. Another concern is related to the possibility that antiviral, anti-inflammatory, and corticosteroid agents commonly employed during acute COVID-19 infection may have potentially deleterious effects on the cardiovascular (CV) system. For these reasons, HF patients deserve specific management with a tailored approach in order to avoid arrhythmic complications and fluid retention events. In this review, we describe the complex interplay between COVID-19 and HF, the evolving trend of infection with related CV events, and the specific management strategy to adopt in this setting.

Feasibility of tele-guided patient-administered lung ultrasound in heart failure

BackgroundReadmission rates for heart failure remain high, and affordable technology for early detection of heart failure decompensation in the home environment is needed. Lung ultrasound has been shown to be a sensitive tool to detect pulmonary congestion due to heart failure, and monitoring patients in their home environment with lung ultrasound could help to prevent hospital admissions. The aim of this project was to investigate whether patient-performed tele-guided ultrasound in the home environment using an ultraportable device is feasible.Affiliations: Journal instruction requires a country for affiliations; however, these are missing in affiliations [1, 2]. Please verify if the provided country are correct and amend if necessary.CorrectMethodsStable ambulatory patients with heart failure received a handheld ultrasound probe connected to a smart phone or tablet. Instructions for setup were given in person during a clinic visit or over the phone. During each ultrasound session, patients obtained six ultrasound clips from the anterior and lateral chest with verbal and visual tele-guidance from an ultrasound trained clinician. Patients also reported their weight and degree of dyspnea, graded on a 5-point scale. Two independent reviewers graded the ultrasound clips based on the visibility of the pleural line and A or B lines.ResultsEight stable heart failure patients each performed 10–12 lung ultrasound examinations at home under remote guidance within a 1-month period. There were no major technical difficulties. A total of 89 ultrasound sessions resulted in 534 clips of which 88% (reviewer 1) and 84% (reviewer 2) were interpretable. 91% of ultrasound sessions produced interpretable clips bilaterally from the lateral chest area, which is most sensitive for the detection of pulmonary congestion. The average time to complete an ultrasound session was 5 min with even shorter recording times for the last session. All patients were clinically stable during the study period and no false positive B-lines were observed.ConclusionsIn this feasibility study, patients were able to produce interpretable lung ultrasound exams in more than 90% of remotely supervised sessions in their home environment. Larger studies are needed to determine whether remotely guided lung ultrasound could be useful to detect heart failure decompensation early in the home environment.

Prognostic value of temporal patterns of global longitudinal strain in patients with chronic heart failure.

We investigated whether repeatedly measured global longitudinal strain (GLS) has incremental prognostic value over repeatedly measured left ventricular ejection fraction (LVEF) and N-terminal pro B-type natriuretic peptide (NT-proBNP), and a single "baseline" GLS value, in chronic heart failure (HF) patients. In this prospective observational study, echocardiography was performed in 173 clinically stable chronic HF patients every six months during follow up. During a median follow-up of 2.7 years, a median of 3 (25th-75th percentile:2-4) echocardiograms were obtained per patient. The endpoint was a composite of HF hospitalization, left ventricular assist device, heart transplantation, cardiovascular death. We compared hazard ratios (HRs) for the endpoint from Cox models (used to analyze the first available GLS measurements) with HRs from joint models (which links repeated measurements to the time-to-event data). Mean age was 58 ± 11 years, 76% were men, 81% were in New York Heart Association functional class I/II, and all had LVEF < 50% (mean ± SD: 27 ± 9%). The endpoint was reached by 53 patients. GLS was persistently decreased over time in patients with the endpoint. However, temporal GLS trajectories did not further diverge in patients with versus without the endpoint and remained stable during follow-up. Both single measurements and temporal trajectories of GLS were significantly associated with the endpoint [HR per SD change (95%CI): 2.15(1.34-3.46), 3.54 (2.01-6.20)]. In a multivariable model, repeatedly measured GLS maintained its prognostic value while repeatedly measured LVEF did not [HR per SD change (95%CI): GLS:4.38 (1.49-14.70), LVEF:1.14 (0.41-3.23)]. The association disappeared when correcting for repeatedly measured NT-proBNP. Temporal evolution of GLS was associated with adverse events, independent of LVEF but not independent of NT-proBNP. Since GLS showed decreased but stable values in patients with adverse prognosis, single measurements of GLS provide sufficient information for determining prognosis in clinical practice compared to repeated measurements, and temporal GLS patterns do not add prognostic information to NT-proBNP.

Translation, cultural adaptation, validation and reliability of Persian version of Edmonton frailty score questionnaire among Iranian heart failure individuals.

Frailty is a common problem in elderly individuals. However, this issue is not well investigated among heart failure (HF) patients with appropriate scales. We aimed to translate and evaluate Edmonton frailty scale (EFS) validity and reliability in Iranian HF adults. We implemented this methodological study on stable HF patients referred to an outpatient heart clinic in Isfahan, Iran. The translation was done using the forward-backward method. Ten individuals were asked to comment about all items in terms of understandability and simplicity. Fifteen experts were invited, and their ratings on each item were collected to measure the content validity index (CVI) and content validity ratio (CVR). Cronbach's alpha was used for the assessment of internal consistency. After completing the scale for the second time with a two-week interval, test-retest reliability with intraclass correlation coefficient (ICC) measurement was done. The translation process was performed uneventfully. All items were reported to be simple and meaningful. CVI of items ranged from the minimum of 0.80 to a maximum of 1.00 plus an acceptable CVR of at least 0.60. Fifty HF patients (age: 67.2±14.1 years, males: 56%) completed the questionnaire twice without missing data. Cronbach's alpha was first to be 0.550. After omitting three items about social support, drug usage, and nutrition, the value was raised to 0.711. Test-retest reliability showed a good index of consistency (ICC: 0.693, 95% confidence interval: 0.527-0.810). Modified Persian EFS is a simple and meaningful tool with high validity and acceptable reliability for assessing frailty in HF individuals irrespective of age.

Abstract 15226: Association of Estimated Pulse Wave Velocity to Mortality in Heart Failure With Reduced Ejection Fraction. Insights From the HF-Action Trial

Introduction: Ventriculo-arterial coupling dynamics influence outcomes in heart failure (HF). Arterial stiffness (AS) is a key determinant of vascular load on the heart. We hypothesized that estimated pulse wave velocity (ePWV) would be associated with mortality. Methods: We analyzed the Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION) database for the association of ePWV with survival. ePWV was calculated using mean blood pressure (MBP) and Age using the equation: 9.587 – 0.402 х age + 4.560 х 10 –3 х age 2 – 2.621 х 10 –5 х age 2 х MBP + 3.176 х 10 –3 х age х MBP – 1.832 х 10 –2 х MBP. MBP was calculated as diastolic BP (DBP) + 0.4(SBP – DBP). Kaplan-Meier survival curves and Cox proportional hazards regression were used for analysis. Results: Among 768 patients (age 58.0 +/- 12.8 years, 31.8 % female), the median ePWV was 8.5 (IQR 7.2 to 10.2). There was a moderate correlation between ePWV and peak VO2 (r=-0.20, p&lt;0.0001) and between ePWV and the six-minute walk duration (r=-0.20, p&lt;0.0001). The unadjusted HR for ePWV and all-cause mortality was 1.15 per unit increase (95% CI 1.05-125). The unadjusted HRs for ePWV component covariates of age and MBP with all-cause mortality were 1.03 per year (95% CI 1.02-1.05, p &lt; 0.0001) and 0.985 per mm Hg (95% CI 0.971-1.000, p=0.053), respectively. With adjustment by peak VO2 above or below the median in a multivariable model, increasing ePWV was still associated with a greater probability of all-cause mortality (HR 1.11 per unit increase, 95% CI 1.01-1.21, p=0.02). In the model with adjustment by the six-minute walk duration, risk associated with ePWV was similar (HR 1.09, 95% CI 0.998-1.120, p=0.056). Kaplan-Meier curves also demonstrated an increased risk for ePWV greater than the median value of 8.5 (Figure). Conclusion: ePWV is associated with all-cause mortality in stable HF patients. More studies are needed to assess the utility of ePWV as a therapeutic target in HF.

Abstract 10990: The Prognostic Significance of Right Ventricular Dilation Assessed by Cardiac Magnetic Resonance Imaging in Heart Failure With Reduced Ejection Fraction

Background: Quantitative volumetric assessment of the right ventricle (RV) can significantly enhance risk stratification in heart failure (HF), especially with the increasing availability of cardiac MRI (CMR). The prognostic value of RV dilation measured by RV end diastolic volume indexed to body surface area (RVEDVi) is not yet well established. In this analysis, we investigate the prognostic significance of RVEDVi measured by CMR in a stable HF cohort. Methods: We conducted a retrospective analysis on the DERIVATE registry, a large cohort of stable HF patients who underwent baseline CMR and echocardiography assessment. We used the cut-off value 90ml/m 2 as the upper limit of normal for CMR-derived RVEDVi. The primary outcome was all-cause mortality (ACM), while the secondary outcome was a composite of ACM and/or heart failure hospitalization (HFH). A Cox proportional hazard model was used to evaluate the association with outcomes. Results: 2,447 patients with HF and reduced ejection fraction (HFrEF) were included, with a median follow-up time of 959 days (IQR: 560-1590). Mean LVEF was 34.0 ± 10.8, mean age was 59.8 ± 14.0 years and 42% were females. Mean RVEDVi was 75.0 ± 29.4 ml/m 2 and 23.2% had an RVEDVi &gt;90 ml/m 2 . Elevated RVEDVi (&gt;90 ml/m 2 ) was significantly associated with an increased risk for ACM (aHR= 1.40, 95% CI [1.17-1.67] p =0.01) and the composite of ACM/HFH (aHR= 1.40, 95% CI [1.03-1.90] p = 0.03). Conclusion: In a large cohort of HFrEF undergoing baseline CMR, elevated RVEDVi was associated with an increased risk of ACM and ACM and/or HFH, independent of LV systolic function.

Endocrine hormone imbalance in heart failure with reduced ejection fraction: A cross-sectional study.

Sustained neurohormonal activation plays a central role in the progression of heart failure (HF). Other endocrine axes may also be affected. It was the aim of this study to examine the endocrine profile (thyroid, parathyroid, glucocorticoid, and sex hormones) in a contemporary sample of patients with HF and reduced ejection fraction (EF) on established disease-modifying therapy. This study prospectively measured morning fasting hormones in 52 ambulatory and stable HF patients with EF < 50% on disease-modifying therapy (mean age 63 ± 11 years, 29% female, mean LVEF 32 ± 9.6%) and compared them to 54 patients at elevated risk for HF (61 ± 12 years, 28% female) and 62 healthy controls (HC; 61 ± 13 years, 27% female). Main comparisons were performed using one-way analysis of variance. Associations with biomarkers were studied with linear regression. HF patients showed a reduced free triiodothyronine (fT3)/free thyroxine (fT4) ratio compared to HC (0.30 ± 0.06 vs. 0.33 ± 0.05, p = 0.046). Parathyroid hormone (PTH) and cortisol were increased in HF compared to both HC (median [IQR] 59 [50-84] vs. 46 [37-52] ng/L,p < 0.001 and 497 ± 150 vs. 436 ± 108 nmol/L, p = 0.03, respectively) and patients at risk (both p < 0.001). Total testosterone was reduced in male HF compared to HC (14.4 ± 6.6 vs. 18.6 ± 5.3 nmol/L; p = 0.01). No differences in TSH, estradiol, progesterone, and prolactin were found. Lower fT3 levels were found in HF with EF < 40% versus EF 40%-49% (4.6 ± 0.3 vs. 5.2 ± 0.7 pmol/L, p = 0.009). In HF patients, fT3 was an independent predictor of NT-proBNP and high-sensitivity troponin T in multiple regression analysis. PTH was positively associated with NT-proBNP. There is evidence of endocrine hormonal imbalance in HF with reduced EF beyond principal neurohormones and despite the use of disease-modifying therapy.