Suspected Heart Failure Research Articles

A neglected comorbidity of chronic heart failure: iron deficiency

The functioning of the heart muscle is particularly sensitive to iron deficiency, the easily curable comorbidity most frequently associated with heart failure. Iron-deficient heart failure patients are more often rehospitalized and have reduced survival. Heart muscle function is particularly susceptible to martial deficiency. Recent randomized studies have shown that exogenous iron intake is accompanied by improved functional capacity (walking test), quality of life, and re-hospitalization rate in these patients. The symptoms of iron deficiency are not very specific and often confused with those of heart failure or other comorbidities, which explains why management is often too late. Anemia is only a late consequence of this iron deficiency. Due to the inflammatory state associated with chronic heart failure, only the parenteral route can bypass the macrophage tissue sequestration of iron and inhibit its intestinal absorption. Recent European guidelines recommend screening for iron deficiency (serum ferritin and transferrin saturation coefficient) in all patients with suspected heart failure, routine iron parameters assessment in all patients with heart failure, and intravenous iron supplementation in case of deficiency in symptomatic patients. Given the pejorative nature of iron deficiency on disease progression, the frequency and financial impact of hospitalizations linked to episodes of decompensation, as well as the effectiveness of simple supplementation, screening for this comorbidity, screening for this frequent comorbidity should now be part of routine testing in all heart failure patients.

Age and gender differences in diagnostic decision-making of early heart failure: results of a mixed-methods interview-study using video vignettes

ObjectivesMen and women at any age show similar symptoms and signs of heart failure (HF). Since early HF symptoms are ambiguous, doctors may overlook HF as possible cause and misinterpret...

Peripheral Venous Pressure-Assisted Exercise Stress Echocardiography in the Evaluation of Pulmonary Hypertension During Exercise in Patients With Suspected Heart Failure With Preserved Ejection Fraction.

Identification of elevated pulmonary artery (PA) pressures during exercise may provide diagnostic, prognostic, and therapeutic implications in heart failure with preserved ejection fraction. Although widely performed, exercise stress echocardiography may underestimate true PA pressures due to the difficulty in estimating right atrial pressure (RAP) during exercise. We hypothesized that peripheral venous pressure (PVP) could allow for reliable estimation of RAP, and thus PA pressures during exercise stress echocardiography. In protocol 1, we investigated the accuracy of PVP compared with simultaneously measured RAP at rest and during exercise right heart catheterization in 19 subjects. In protocol 2, we examined whether the addition of PVP to Doppler exercise echocardiography (tricuspid regurgitant velocity) would increase the ability to identify exercise-induced pulmonary hypertension compared with inferior vena cava-based RAP estimation in 60 patients with dyspnea. In protocol 1, PVP was strongly correlated with simultaneously measured RAP at rest and during exercise (r=0.77 and 0.90), with little overestimation of invasively measured RAP (bias 3.4 mm Hg at rest and 1.7 mm Hg during exercise). In protocol 2, PVP increased dramatically during exercise echocardiography (14±5 mm Hg) while an increase in inferior vena cava-based RAP was modest (6±4 mm Hg). Exercise PA pressures calculated from PVP and tricuspid regurgitant velocity were significantly higher than those estimated from inferior vena cava and the use of PVP increased the proportion of patients with exercise-induced pulmonary hypertension from 40% to 68%. PVP may prevent underestimation of PA pressures during exercise echocardiography and could be a preferred approach to identify exercise-induced pulmonary hypertension in patients with suspected heart failure with preserved ejection fraction.

The clinical influence of hand-held ultrasound examinations by general practitioners in patients with suspected heart failure supported by tools for automatic quantification and telemedicine

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Research Council of Norway, Norwegian University of Science and Technology Nord-Trøndelag Hospital Trust Background Heart failure (HF) affects large populations. Echocardiography is the diagnostic cornerstone related to identification of cardiac pathology and classification of the disease. The availability of echocardiography may be a bottleneck in HF diagnostics. Hand-held ultrasound devices (HUDs) are easy to use and have a high availability. So far, the clinical limitations of HUDs have been related to user experience and lack of quantification of cardiac function. Purpose We aimed to evaluate the clinical influence of HUDs by general practitioners (GPs), supported by automatic tools for quantification of ejection fraction (autoEF) and mitral annular plane systolic excursion (autoMAPSE), as well as telemedical support in HF diagnostics. Methods Five GPs with limited ultrasound experience participated in the study. They were equipped with a HUD with automatic tools for LV quantification (autoEF and autoMAPSE). All GPs underwent lectures and 6 days of practical training. In total, 167 patients referred to an outpatient cardiac clinic with suspected HF were included. The GPs examined the patients in chronological stages. First by a clinical examination. Secondly, by adding HUD, then the automatic quantification tools, and finally all recordings were transferred for telemedical support by an external cardiologist. At all stages, the GPs considered whether the patients had HF. A cardiologist’s clinical and echocardiographic examination served as a reference. Results Age was mean ± SD 70 ± 13 years, mean BMI was 29 ± 19 kg/m2 and mean NT-pro-BNP 702 ± 1216 ng/L. Sinus rhythm was present in 76%. Ejection fraction was mean 53 ± 10 %. Of the 167 patients, 28 were diagnosed with HF. The clinical importance of the HUD examinations is shown in the Figure. The GPs correctly classified 55% of the patients (15 with and 77 without HF) after the clinical evaluation. After adding the HUD examination, the proportion increased to 71% (19 with and 99 without HF). The proportion was highest after telemedical support (74%; 20 with and 103 without). The use of HUDs with and without telemedicine improved the clinical benefit compared to the clinical evaluation, p <0.001. There was no significant benefit after adding the automatic tools (autoEF 55%; 15 with and 77 without, autoMAPSE 54%; 17 with and 73 without). The proportion of uncertain assessment were lowest for HUD and telemedicine (clinical 43 (26%), HUD only 20 (12%), autoMAPSE 37 (25%), autoEF 41 (25%), telemedicine 25 (15%)). Conclusion By adding HUD examinations to the clinical evaluation of suspected HF, the GPs diagnostic precision improved both in ruling in and ruling out HF. The use of HUDs combined with telemedical support had the highest proportion of correct reclassification. Tools for automatic quantification of LV function were not of clinical importance. Future studies are needed to evaluate how automatic quantification of cardiac function can support inexperienced users. Abstract Figure.

Feasibility of the cardiac output response to stress test in suspected heart failure patients.

BackgroundDiagnostic tools available to support general practitioners diagnose heart failure (HF) are limited.Objectives(i) Determine the feasibility of the novel cardiac output response to stress (CORS) test in suspected HF patients, and (ii) Identify differences in the CORS results between (a) confirmed HF patients from non-HF patients, and (b) HF reduced (HFrEF) vs HF preserved (HFpEF) ejection fraction.MethodsSingle centre, prospective, observational, feasibility study. Consecutive patients with suspected HF (N = 105; mean age: 72 ± 10 years) were recruited from specialized HF diagnostic clinics in secondary care. The consultant cardiologist confirmed or refuted a HF diagnosis. The patient completed the CORS but the researcher administering the test was blinded from the diagnosis. The CORS assessed cardiac function (stroke volume index, SVI) noninvasively using the bioreactance technology at rest-supine, challenge-standing, and stress-step exercise phases.ResultsA total of 38 patients were newly diagnosed with HF (HFrEF, n = 21) with 79% being able to complete all phases of the CORS (91% of non-HF patients). A 17% lower SVI was found in HF compared with non-HF patients at rest-supine (43 ± 15 vs 51 ± 16 mL/beat/m2, P = 0.02) and stress-step exercise phase (49 ± 16 vs 58 ± 17 mL/beat/m2, P = 0.02). HFrEF patients demonstrated a lower SVI at rest (39 ± 15 vs 48 ± 13 mL/beat/m2, P = 0.02) and challenge-standing phase (34 ± 9 vs 42 ± 12 mL/beat/m2, P = 0.03) than HFpEF patients.ConclusionThe CORS is feasible and patients with HF responded differently to non-HF, and HFrEF from HFpEF. These findings provide further evidence for the potential use of the CORS to improve HF diagnostic and referral accuracy in primary care.

Prognostic Value of T1 Mapping and Feature Tracking by Cardiac Magnetic Resonance in Patients With Signs and Symptoms Suspecting Heart Failure and No Clinical Evidence of Coronary Artery Disease

BackgroundThe ability of left ventricular ejection fraction (LVEF) and late gadolinium enhancement (LGE) by cardiac magnetic resonance for risk stratification in suspected heart failure is limited. We aimed to evaluate the incremental prognostic value of cardiac magnetic resonance‐assessed extracellular volume fraction (ECV) and global longitudinal strain (GLS) in patients with signs and symptoms suspecting heart failure and no clinical evidence of coronary artery disease.Methods and ResultsA total of 474 consecutive patients (57±21 years of age, 56% men) with heart failure‐related symptoms and absence of coronary artery disease underwent cardiac magnetic resonance. After median follow‐up of 18 months, 59 (12%) experienced the outcome of all‐cause death or heart failure hospitalization (DeathCHF). In univariate analysis, cardiac magnetic resonance‐assessed LVEF, LGE, GLS, and ECV were all significantly associated with DeathCHF. Adjusted for a multivariable baseline model including age, sex, LVEF and LGE, ECV, and GLS separately maintained a significant association with DeathCHF (ECV, hazard ratio [HR], 1.44 per 1 SD increase; 95% CI 1.13–1.84; P=0.003, and GLS, HR, 1.78 per 1 SD increase; 95% CI, 1.06–2.96; P=0.028 respectively). Adding both GLS and ECV to the baseline model significantly improved model discrimination (C statistic from 0.749 to 0.782, P=0.017) and risk reclassification (integrated discrimination improvement 0.046 [0.015–0.076], P=0.003; continuous net reclassification improvement 0.378 [0.065–0.752], P<0.001) for DeathCHF, beyond LVEF and LGE.ConclusionsIn patients with signs and symptoms suspecting heart failure and no clinical evidence of coronary artery disease, joint assessment of GLS and ECV provides incremental prognostic value for DeathCHF, independent of LVEF and LGE.

Assessment of the impact of different N terminal pro brain natriuretic peptide thresholds on echocardiography services.

AimsN terminal pro brain natriuretic peptide (NT‐proBNP) is considered a rule‐out test for patients with suspected heart failure. The NT‐proBNP thresholds recommended for echocardiography by the European Society of Cardiology (ESC) and National Institute for Health and Care Excellence (NICE) are based on small studies of patients with heart failure and left ventricular (LV) systolic dysfunction (LVSD). The purpose of our study was to examine the relation between NT‐proBNP and LVSD in a larger number of patients with symptoms suggestive of heart failure in a non‐acute setting.Methods and resultsOne thousand patients with suspected chronic heart failure underwent echocardiography within 6 months of NT‐proBNP measurement. NT‐proBNP was the strongest predictor of any form of LVSD in univariate (OR 2.52, 95% CI 2.19–2.91, P value < 0.001) and multivariate (OR 2.73, 95% CI 2.32–3.21, P value < 0.001) analyses. Negative predictive value (NPV) of NT‐proBNP for impaired LV systolic function (ejection fraction 35–49%) was 98% at 125 pg/mL (the ESC threshold), 93% at 400 pg/mL (the NICE threshold), 91% at 1000 pg/mL and 90% at 2000 pg/mL. Corresponding values for severe LVSD (ejection fraction <35%) were 100%, 99%, 98% and 96%. The number of patients per 1000 with suspected chronic heart failure requiring echocardiography at each threshold was 851, 543, 324, and 182, respectively.ConclusionsN terminal pro brain natriuretic peptide thresholds recommended by ESC and NICE result in large numbers of patients with suspected chronic heart failure being referred for echocardiography. Raising the NT‐proBNP threshold would improve access to echocardiography with minimal negative impact on the clinical performance of this cardiac biomarker.

Upright exercise stress echocardiography may unmask dynamic left ventricular obstruction also beyond hypertrophic cardiomyopathy

Abstract Background Dynamic left ventricular outflow obstruction (LVOTO) during exercise stress echocardiography (ESE) is recommended in hypertrophic cardiomyopathy (HCM) to identify the obstructive phenotype. Aim To assess left ventricular outflow gradient (LVOTG) during ESE in different conditions. Methods In a single-group, prospective, observational study, we performed peak and/or post-treadmill ESE with systematic assessment of LVOTG in the orthostatic position by continuous-wave Doppler in 1333 subjects (837 males, mean age 38,2±20 ranging from 6 to 87 years) recruited over a period of twenty years, from 2001 to 2021. Peak LVOTG ≥30 mm Hg was considered abnormal for LVOTO during ESE. We enrolled 7 different populations: asymptomatic healthy controls (n=35); HCM (n=81); genotype-positive, phenotype negative asymptomatic HCM (n=6); patients with chest pain symptoms, suspected myocardial ischemia and either normal coronary arteries (INOCA, n=131,or with very low pre-test probability of coronary artery disease (probable INOCA, n=416) and; fatigue and suspected heart failure with preserved ejection fraction (HFpEF, n=206); amateur athletes with ischemia-like ECG changes during exercise-test or symptoms such as near syncope or chest pain or dizziness (n=457); aborted sudden death and with negative screening (n=1). Results Technical success rate of LVOTG assessment was 1333/1333 at rest and at peak stress (feasibility 100%). Imaging and analysis time were &amp;lt;1 minute. LVOTG at rest was present in 25 pts (2.8%) of the overall population: 23 HCM, 1 INOCA, and 1 HFpEF. Overall prevalence during ESE was 432/1333 (32%). During ESE, LVOTO (see Figure 1 and 2) was 0% (0/35) in normals, 58% (47/81) in HCM (23 with obstruction at rest), 33% (2/6) in genotype-positive, phenotype negative HCM, 37% (33/131) in INOCA, 40% (135/416) in athletes and 1/1 in the patient with aborted sudden death on strenuous exercise. Conclusion LVOTO in orthostatic position is detectable during treadmill ESE in several cardiovascular conditions associated with symptoms such as dyspnea, chest pain or near syncope, and even in asymptomatic patients with genotype-positive, phenotype-negative HCM. The identification of the obstructive phenotype is easy to capture during ESE without any significant additional imaging and analysis burden and can be important also outside HCM. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Upper Reference Limits for High-Sensitivity Cardiac Troponin T and N-Terminal Fragment of the Prohormone Brain Natriuretic Peptide in Patients With CKD

The utility of conventional upper reference limits (URL) for N-terminal pro-brain natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hsTnT) in chronic kidney disease (CKD) remains debated. We analyzed the distribution of hsTnT and NT-proBNP in people with CKD in ambulatory settings to examine the diagnostic value of conventional URL in this population. Observational study. We studied participants of the Chronic Renal Insufficiency Cohort (CRIC) with CKD and no self-reported history of cardiovascular disease. Estimated glomerular filtration rate (eGFR). NT-proBNP and hsTnT at baseline. We described the proportion of participants above the conventional URL for NT-proBNP (125pg/mL) and hsTnT (14ng/L) overall and by eGFR. We then estimated 99th percentile URL for NT-proBNP and hsTnT. Using quantile regression of the 99th percentile, we modeled the association of eGFR with NT-proBNP and hsTnT. Among 2,312 CKD participants, 40% and 43% had levels of NT-proBNP and hsTnT above the conventional URL, respectively. In those with eGFR <30mL/min/1.73m2, 71% and 68% of participants had concentrations of NT-proBNP and hsTnT above the conventional URL, respectively. Among all CKD participants, the 99th percentile for NT-proBNP was 3,592 (95% CI, 2,470-4,849) pg/mL and for hsTnT it was 126 (95% CI, 100-144) ng/L. Each 15mL/min/1.73m2 decrement in eGFR was associated with a ~40% higher threshold for the 99th percentile of NT-proBNP (1.43 [95% CI, 1.21-1.69]) and hsTnT (1.45 [95% CI, 1.31-1.60]). Study included ambulatory patients, and we could not test the accuracy of the URL of NT-proBNP and hsTnT in the acute care setting. In this ambulatory CKD population with no self-reported history of cardiovascular disease, a range of 40%-88% of participants had concentrations of NT-proBNP and hsTnT above the conventional URL, depending on eGFR strata. Developing eGFR-specific thresholds for these commonly used cardiac biomarkers in the setting of CKD may improve their utility for evaluation of suspected heart failure and myocardial infarction.

Correlation between N-Terminal-Pro-Brain Natriuretic Peptide and Heart Failure in Children with Acyanotic Congenital Heart Disease Left-to-Right Shunt

Background: Heart failure is a significant problem causing morbidity and mortality in children with acyanotic CHD left-to-right shunt. Congenital heart disease is often associated with ventricular dysfunction, volume or pressure overload, resulting in a high risk of heart failure. N-Terminal-pro-Brain Natriuretic Peptide (NT- pro-BNP) is a biochemical marker in the left ventricle, which is used as a diagnostic marker for adult heart failure since it has depicted a significant correlation between heart failure and elevated levels of NT-pro-BNP. This study aimed to analyze the relationship between NT-pro-BNP levels and heart failure in children with acyanotic CHD left-to-right shunt. Methods: An observational analytic examination with a cross-sectional study design was conducted on children aged 1 month to 18 years with acyanotic CHD left-to-right shunt with suspected heart failure at the Pediatric Cardiology Outpatient Clinic, Emergency Department, and Pediatric Ward of Dr. Soetomo General Hospital Surabaya from September 2020 to March 2021. Statistical analysis was carried out using Mann-Whitney test and contingency correlation test of Chi-Square with a significance value of p < 0.05. Results: There were 43 subjects fulfilling the inclusion criteria in which 53.5% of them were female with a mean age of 48 months. Furthermore, the most common type of acyanotic CHD left-to-right shunt with heart failure was VSD, followed by ASD and PDA. There was a significant relationship between increasing NT-pro-BNP levels with heart failure with p < 0.001 based on chi-square test with moderate correlation strength (r = 0.57) based on the contingency correlation test. Conclusion: There is a significant positive correlation between NT-pro-BNP and heart failure in children with acyanotic CHD left-to-right shunt.

Current clinical applications of spectral tissue Doppler echocardiography (E/e’ ratio) as a noninvasive surrogate for left ventricular diastolic pressures in the diagnosis of heart failure with preserved ejection fraction. Revisited 15 years later

It is currently well established that more than half of heart failure patients have preserved ejection fraction. The diagnosis of heart failure with preserved ejection fraction is complex in clinical practice despite ESC recommendations issued in 2019. In this context, the demonstration of increased left ventricular filling pressures at rest or during exercise allows a definite diagnosis of heart failure with preserved ejection fraction in patients with signs and/or symptoms compatible with the diagnosis and a preserved ejection fraction. The spectral tissue Doppler-derived E/e’ ratio by transthoracic Doppler echocardiography has been validated in the noninvasive assessment of left ventricular diastolic pressures at rest and during exercise. Several studies report the validity of E/e’ in the diagnosis of heart failure with preserved ejection fraction in patients with both isolated exertional and acute dyspnea, as well as in risk stratification. In light of the current literature, E/e’ deserves to be included on every transthoracic Doppler echocardiography report in patients with suspected heart failure with preserved ejection fraction. This updated review provides an overview of the diagnostic relevance of E/e’ in patients in its two modes of clinical presentation, isolated exertional dyspnea and the decompensated congestive form.

Clinical and demographic correlates of accelerometer-measured physical activity in participants enrolled in the OPTIMISE HFpEF study.

This study aimed to measure physical activity (PA) in participants with suspected heart failure with preserved ejection fraction (HFpEF) and assess associations between PA and participant characteristics. Adults with presumed HFpEF were recruited and received diagnostic evaluation and clinical assessment. Physical activity was objectively measured using accelerometers over 7 days. To examine predictors of PA, a best subset analysis was used, with the optimal model defined as that with the lowest Bayesian information criterion. One hundred and twenty-four participants with presumed HFpEF who had valid accelerometer data were included in this study. Seventy-six were confirmed by a cardiologist as meeting the European Society of Cardiology diagnosis criteria for HFpEF. The median age of all participants was 80.1 years, and 47.4% were female. Patients spent most of each 24-h period at low-intensity PA and few or no durations at high-intensity PA, with lower activity for those with HFpEF. Gait speed was the best univariate correlate of activity levels (adjusted R2 0.29). The optimal model using best subsets regression included six variables and improved adjusted R2 to 0.47. In the model, lower levels of PA were associated with slower gait speed, lower levels of anxiety, higher levels of depression, past smoking history, a confirmed HFpEF diagnosis, and higher body mass index. Participants demonstrated very low PA levels. The study has identified important patient characteristics associated with PA, which may help to identify those most in need of interventions. Notably, participants with confirmed HFpEF were more inactive than participants with other heart failure phenotypes.

Characterisation of the patients with suspected heart failure: experience from the SHEAF registry

ObjectivesTo characterise and risk-stratify patients presenting to a heart failure (HF) clinic according to the National Institute for health and Care Excellence (NICE) algorithm.MethodsThis is an observational study of prospectively...

Rationale and Study Design of Differences in Cardiopulmonary Exercise Capacity According to Coronary Microvascular Dysfunction and Body Composition in Patients with Suspected Heart Failure with Preserved Ejection Fraction.

Coronary microvascular dysfunction (CMD) is one of the mechanisms of myocardial ischemia and left ventricular (LV) diastolic dysfunction, which is closely related to heart failure with preserved ejection fraction (HFpEF). Frailty, associated with sarcopenia, is often accompanied by HFpEF. In the present study, we aim to evaluate the relationship between CMD, body composition, and cardiopulmonary exercise capacity in patients with suspected HFpEF. We will enroll patients experiencing chest symptoms (chest pain or dyspnea) with an indication of non-obstructive coronary artery disease (<50% stenosis) on coronary angiography and preserved LV ejection fraction (≥50%) on echocardiography. All patients will undergo body composition analysis and adenosine stress echocardiography with the evaluation of coronary artery blood flow and maximal oxygen consumption by cardiopulmonary exercise test. LV end-diastolic pressure will be assessed using coronary angiography. Coronary flow reserve (CFR) is defined as the ratio of the peak to the baseline mean diastolic velocity of coronary blood flow. A CFR <2.3 is defined as coronary microvascular dysfunction. The correlation of CFR and body composition with LV diastolic function and cardiopulmonary exercise capacity will be assessed. This trial will suggest the specific phenotypes of HFpEF according to body composition and CMD and the specific management of the different phenotypes of HFpEF.Trial RegistrationClinicalTrials.gov Identifier: NCT04822649

N-Terminal Pro B-Type Natriuretic Peptide as a Tool to Triage Inpatient Echocardiogram Requirement Among Patients With Suspected Heart Failure: Using NT-proBNP to Reduce Hospital Length of Stay

N-terminal Pro B-Type Natriuretic Peptide (NT-proBNP) is a cardiac biomarker with diagnostic and prognostic utility in patients with heart failure (HF). Whether NT-proBNP can be used to triage transthoracic echocardiogram (TTE) requirement, and whether this impacts hospital length of stay (LOS), is not known.

Diagnosis, treatment, and follow-up of heart failure patients by general practitioners: A Delphi consensus statement.

AimsCreation of an algorithm that includes the most important parameters (history, clinical parameters, and anamnesis) that can be linked to heart failure, helping general practitioners in recognizing heart failure in an early stage and in a better follow-up of the patients.Methods and resultsThe algorithm was created using a consensus-based Delphi panel technique with fifteen general practitioners and seven cardiologists from Belgium. The method comprises three iterations with general statements on diagnosis, referral and treatment, and follow-up. Consensus was obtained for the majority of statements related to diagnosis, referral, and follow-up, whereas a lack of consensus was seen for treatment statements. Based on the statements with good and perfect consensus, an algorithm for general practitioners was assembled, helping them in diagnoses and follow-up of heart failure patients. The diagnosis should be based on three essential pillars, i.e. medical history, anamnesis and clinical examination. In case of suspected heart failure, blood analysis, including the measurement of NT-proBNP levels, can already be performed by the general practitioner followed by referral to the cardiologist who is then responsible for proper diagnosis and initiation of treatment. Afterwards, a multidisciplinary health care process between the cardiologist and the general practitioner is crucial with an important role for the general practitioner who has a key role in the up-titration of heart failure medication, down-titration of the dose of diuretics and to assure drug compliance.ConclusionsBased on the consensus levels of statements in a Delphi panel setting, an algorithm is created to help general practitioners in the diagnosis and follow-up of heart failure patients.

Non-invasive blood pressure monitoring underestimates hypertensive response to exercise in suspected heart failure with preserved ejection fraction.

Non-invasive blood pressure monitoring underestimates hypertensive response to exercise in suspected heart failure with preserved ejection fraction.

PCV48 Budget Impact of NT-proBNP for Diagnosing Suspected Chronic Heart Failure Patients in Portuguese Primary Care

PCV48 Budget Impact of NT-proBNP for Diagnosing Suspected Chronic Heart Failure Patients in Portuguese Primary Care

Ejection fraction and mortality: a nationwide register-based cohort study of 499 153 women and men.

We investigated the sex-based risk of mortality across the spectrum of left ventricular ejection fraction (LVEF) in a large cohort of patients in Australia. Quantified levels of LVEF from 237 046 women (48.1%) and 256 109 men undergoing first-time, routine echocardiography (2000-2019) were linked to 119 232 deaths (median 5.6 years of follow-up). Overall, 17.6% of men vs. 8.3% of women had an LVEF <50%. An LVEF <40% was associated with the highest crude cardiovascular-related and all-cause mortality at 5 years (∼20-30% and ∼ 40-50%, respectively). Thereafter, actual cardiovascular-related and all-cause mortality at 5 years in both sexes steeply improved to a nadir LVEF of 65.0-69.9% (reference group). Below this LVEF level, the adjusted hazard ratio (HR) for cardiovascular-related mortality for a LVEF of 55.0-59.9% was 1.36 [95% confidence interval (CI) 1.16-1.59; P< 0.001] in women and 1.21 (95% CI 1.05-1.39; P= 0.008) in men. In women, an LVEF of 60.0-64.9% was also associated with a HR 1.33 (95% CI 1.16-1.52; P< 0.001) for cardiovascular-related mortality. These associations were most striking in women and men aged <65 years and were replicated in those with suspected heart failure (32 403 cases aged 65.2 ± 16.1 years, 57.0% women). For pre-existing heart failure (33 738 cases aged 67.6 ± 16.9 years, 46.5% women), the specific threshold of increased mortality was at and below 50.0-54.9%. Among patients investigated for suspected or established cardiovascular disease, we found clinically relevant sex-based differences in the distribution and mortality associated with an LVEF <65.0-69.9%. Specifically, they suggest a greater risk of mortality at higher LVEF levels among women.

Abstract 13157: Deep Learning for Detection of Elevated Pulmonary Artery Wedge Pressure Using Standard Chest X-ray

Introduction: Chest X-ray (CXR) is a useful and economical modality for the detection of congestive heart failure. However, the accuracy is limited by the subjective nature of its interpretation. Deep learning (DL) can be used to recognize diseases or findings objectively in various imaging modalities, and may outperform previous diagnostic techniques. Hypothesis: We hypothesized that DL-based analysis of CXR detect the presence of elevated pulmonary arterial wedge pressure (PAWP) in patients with suspected heart failure. Methods: We enrolled 1,013 patients with paired right heart catheterization and CXR performed from October 2009 to February 2020 in our hospital. DL algorithm for the detection of elevated PAWP was developed using the training dataset, based on a single CXR image. Independent evaluation cohort of 115 patients was performed using CXR-based DL model and echocardiographic data to detect the presence of high PAWP. The area under the receiver operating characteristic curve (AUC) was used to evaluate the performance of the DL-based models compared with echocardiographic data. Results: The study included 1,013 patients (mean age, 67±13 years; 569 males [56%]). The mean PAWP was 12.5±6.4 mmHg and 218 patients (22%) had more than 18mmHg. To detect high PAWP, the AUC produced by DL algorithms was effective, and the DL algorithm with the largest AUC was ResNet50. In an evaluation cohort, to detect high PAWP, the AUC using the DL model with CXR was similar to the AUC produced by the echocardiographic left ventricular diastolic dysfunction algorithm (0.77 vs. 0.70; respectively; p=0.27), and significantly higher than the AUC by measurements of echocardiographic parameters (ResNet50 vs. other parameters; all compared p &lt;0.05) (Figure) . Conclusions: The present results demonstrated that DL based on analysis of CXR can detect the presence of high PAWP. This finding suggests that the DL based approach may support an objective evaluation of CXR in the clinical setting.