Treatment Of Heart Failure Patients Research Articles

Identification of energy metabolism-related biomarkers for risk prediction of heart failure patients using random forest algorithm.

ObjectiveEnergy metabolism plays a crucial role in the improvement of heart dysfunction as well as the development of heart failure (HF). The current study is designed to identify energy metabolism-related diagnostic biomarkers for predicting the risk of HF due to myocardial infarction.MethodsTranscriptome sequencing data of HF patients and non-heart failure (NF) people (GSE66360 and GSE59867) were obtained from gene expression omnibus (GEO) database. Energy metabolism-related differentially expressed genes (DEGs) were screened between HF and NF samples. The subtyping consistency analysis was performed to enable the samples to be grouped. The immune infiltration level among subtypes was assessed by single sample gene set enrichment analysis (ssGSEA). Random forest algorithm (RF) and support vector machine (SVM) were applied to identify diagnostic biomarkers, and the receiver operating characteristic curves (ROC) was plotted to validate the accuracy. Predictive nomogram was constructed and validated based on the result of the RF. Drug screening and gene-miRNA network were analyzed to predict the energy metabolism-related drugs and potential molecular mechanism.ResultsA total of 22 energy metabolism-related DEGs were identified between HF and NF patients. The clustering analysis showed that HF patients could be classified into two subtypes based on the energy metabolism-related genes, and functional analyses demonstrated that the identified DEGs among two clusters were mainly involved in immune response regulating signaling pathway and lipid and atherosclerosis. ssGSEA analysis revealed that there were significant differences in the infiltration levels of immune cells between two subtypes of HF patients. Random-forest and support vector machine algorithm eventually identified ten diagnostic markers (MEF2D, RXRA, PPARA, FOXO1, PPARD, PPP3CB, MAPK14, CREB1, MEF2A, PRMT1) for risk prediction of HF patients, and the proposed nomogram resulted in good predictive performance (GSE66360, AUC = 0.91; GSE59867, AUC = 0.84) and the clinical usefulness in HF patients. More importantly, 10 drugs and 15 miRNA were predicted as drug target and hub miRNA that associated with energy metabolism-related genes, providing further information on clinical HF treatment.ConclusionThis study identified ten energy metabolism-related diagnostic markers using random forest algorithm, which may help optimize risk stratification and clinical treatment in HF patients.

Validation of an electrocardiographic algorithm for the detection of cardiac amyloidosis

Abstract Background Despite new therapies, diagnosis of cardiac amyloidosis (CA) is often delayed. We recently developed a simple electrocardiographic (ECG) algorithm to suspect CA without the aid of advanced imaging modalities (Figure). Methods The aim of this study was to validate the algorithms' usefulness in clinical practice. ECG readings from patients with CA, heart failure with preserved ejection fraction (HFpEF), and hypertrophic cardiomyopathy (HCMP) were analyzed in a blinded fashion. Results 884 patients were included. Patients with pacemakers were excluded, leaving 827 ECGs (237 CA, 407 HFpEF, 183 HCMP) for final analysis. A characteristic pattern defined by the algorithm was visually perceptible in 165 ECGs (69.6%) of the amyloidosis patients vs. 114 (28%) of HFpEF vs. 22 (12.0%) of HCMP patients (p<0.001). The area under the curve (AUC) for the detection CA was 0.75 with a sensitivity of 69.6% and a specificity of 76.9% (Figure). Binary logistic regression analysis revealed that the presence of a distinctive pattern increased the probability of CA with an odds ratio of 7.66 (CI: 5.47–10.72; p<0.001). Conclusion This easy-to-use ECG algorithm has proven helpful to suspect CA. Our tool may significantly improve the treatment of heart failure patients by identifying those with amyloidosis-related disease. Funding Acknowledgement Type of funding sources: None.

The case against premature treatment of heart failure patients with implantable cardioverter-defibrillators: results from an institutional registry

Abstract Introduction Implantable cardioverter-defibrillators (ICD) are gold-standard therapy for primary prevention (PP) of sudden cardiac death (SCD) in patients with heart failure with reduced ejection fraction (HFrEF). According to relevant guidelines, ICDs should be implanted only after patients have been treated with revascularization procedures and/or optimal medical therapy (OMT) [1]. Due to perceived high risk of SCD and low chance of improvement some patients receive ICDs “too early” in the course of the disease [2]. Purpose To investigate adherence to guidelines in our institution with emphasis on premature ICD implantation and early ICD activation. Methods We analysed all ICDs newly implanted for PP in patients with HFrEF in our institution between 2011 and 2017. Follow-up data was collected from hospital medical records. Results Total number of 307 ICDs were implanted during the analysed interval, 147 (47.9%) in ischemic cardiomyopathy (ICM) and 160 (52.1%) in non-ischemic dilated cardiomyopathy (DCM) patients. Only 57.8% of ICM patients have been treated with OMT at least 3 months before implantation. The proportion was similar in DCM patients (60.0%). However, DCM patients were more commonly implanted at the time of diagnosis (13.8% vs. 0.7% in ICM). It is worth noting that OMT was up-titrated after implantation in 35.2% of patients. In 9 cases patients were treated with ICDs less than 3 months after revascularization procedures or less than 6 weeks after STEMI (6 and 3 cases respectively). Follow-up data revealed that among all the patients who prematurely received an ICD, a device activated to deliver appropriate therapy within 3 months of implantation only in 1 ICM patient (0.7% of ICM patients). That patient had established ICM and was suffering from recurrent unexplained syncopes. One DCM patient with prematurely implanted ICD had early inappropriate ICD activation that was due to supraventricular tachycardia. Early ICD activations were generally uncommon even among patients who were treated according to guidelines (1 ICM and 1 DCM patient). Conclusion Results from our institutional ICD registry show that a significant number of patients with HFrEF received premature ICD implants before being treated with OMT. This is even more common in patients newly diagnosed with DCM. Our follow-up data suggests that early ICD activation is extremely rare in all comers and hardly ever happens in patients who received ICD immediately after diagnosis, revascularization or without 3 months of OMT. This data can help improve our future practice and encourage clinicians to follow relevant guidelines when faced with these important decisions. Funding Acknowledgement Type of funding sources: None.

Response to heart failure treatment in patients with anthracyclines and trastuzumab induced left ventricular dysfunction

Abstract Background Chemotherapy treatments with anthracyclines and Trastuzumab are widely used in different hematologic or solid malignancies but myocardial injury and left ventricular dysfunction, usually called cardiotoxicity (CTX), is a frequent adverse effect. Some studies have demonstrated that early detection and treatment of CTX is essential for the recovery of left ventricular ejection fraction (LVEF), however its behavior after starting treatment is not well established. Purpose Evaluate the behavior of LVEF after starting treatment for heart failure in patients with diagnosis of CTX. Methods Patients with diagnosis of solid or hematologic malignancies scheduled to receive therapy including anthracyclines and/or trastuzumab were prospectively included. Echocardiogram was performed before starting treatment, and then 3 and 6 months after. CTX was defined, according to guidelines, as a drop of LVEF ≥10% to a value <53% and in these patients treatment of left ventricular dysfunction with B blockers and Enalapril/Losartan was promptly initiated and up-titrated to the maximal tolerated dose. Myocardial injury was defined as a drop of LVEF ≥10% and a value ≥53%, with a watchful waiting strategie, considering these patients as a control group. LVEF was re-evaluated 6 months after starting treatment or after diagnosis of myocardial injury. Primary endpoint was defined as a recovery of LVEF ≥10%. Results Of a total of 141 patients of the entire cohort (mean age 56±15 years, 85,8% women and 61,7% with diagnosis of breast cancer),17 patients (12%) met criteria of CTX and 21 (14,9%) of myocardial injury. There were no differences in relation to clinical characteristics or chemotherapy schemes between groups. In patients with CTX (intervention group), 88,2% reached the primary endpoint of recovery of LVEF ≥10% while only 23,8% did it in the control group (p<0,001). Patients with CTX had lowest LVEF at baseline, however no significant differences were observed at 12 months of follow up. Figure 1 represents the behavior of LVEF at baseline, 3, 6 and 12 months. A paired before-after analysis was performed between LVEF at baseline and at 12 months. Patients who received treatment showed no differences in LVEF (63,3±7,2% vs 61,5±9,6%, p=0,5). In contrast, patients who did not receive treatment showed a significant drop in LVEF (72,7±4,4% vs 66,2±5,4%; p<0,001) (figure 2). Conclusion Treatment of left ventricular dysfunction in patients with CTX is associated with a greater recovery of LVEF. Funding Acknowledgement Type of funding sources: None.

Effectiveness of Transitional Care Interventions for Heart Failure Patients: A Systematic Review With Meta-Analysis.

Heart failure is a leading cause of hospitalizations. Heart failure patients were found to have a high incidence of re-admission after discharge. This highlights a care gap during the transition from hospital to home environment and interventions were utilized to cover this care gap. The aim of this review was to evaluate the effectiveness of these interventions. This was investigated in terms of re-admissions, mortality, emergency department (ED) visits, and quality of life. An exhaustive systematic search was conducted in electronic databases, which include MEDLINE, CINAHL, AMED, Cochrane library, and PubMed. Databases were explored for literature published in English between April 2012 and April 2022. The review included 13 randomized controlled trials and comprised a total of 7,693 heart failure patients with 3,835 receiving transitional care interventions (TCIs) and 3,858 receiving standard care. It was found that implementing TCIs resulted in a reduction of all-cause re-admission and all-cause mortality. Although it is controversial if TCIs improve quality of life, TCIs were noted to decrease the frequency of ED visits. Telephone support interventions proved most efficacious among other interventions in reducing hospital readmissions, and were found effective in reducing mortality in combination with other interventions, i.e. clinic visits. Additionally, telemonitoring is found beneficial in supporting patients just after discharge, the most vulnerable period, for medically optimizing and monitoring patients during the care gap.

Recent advances in the application of computational fluid dynamics in the development of rotary blood pumps

In recent years, ventricular assist devices (VADs, also known as blood pumps) have gradually entered clinical practice and provide effective treatment for heart failure patients. However, adverse events related to mechanical blood damage in patients receiving the VAD treatment, were often reported and have become a major concern during the development of VADs, limiting their clinical and economic benefits. Compared with bench and in-vivo testing, computational fluid dynamics (CFD) is flexible and inexpensive, offering the possibility to predict hemodynamics and mechanical blood damage in a purely numerical manner. Thus, CFD has become an important tool for the design, optimization and evaluation of blood pumps. The stringent requirements of blood pumps require high fidelity simulations. Thus, this article reviews the current state of the art in high-fidelity methodologies for simulating blood flow and blood damage for the development and evaluation of rotary blood pumps; design and optimization methods of rotatory blood pumps using CFD, as well as future challenges.

Impact of Sleep-Disordered Breathing Treatment on Ventricular Tachycardia in Patients with Heart Failure.

Background: Sleep-disordered breathing (SDB) is a highly common comorbidity in patients with heart failure (HF), and a known risk factor for ventricular tachycardia (VT) development. However, little is known about the impact of SDB treatment on VT burden in HF patients to date. Therefore, this study investigated VT burden, as well as implantable cardioverter-defibrillator (ICD) therapies in HF patients with SDB treatment, in comparison to untreated SDB HF patients. Methods: This retrospective study analyzed VT burden, rate of antitachycardia pacing (ATP), and the number of shocks delivered in a propensity score-matched patient cohort of patients with SDB treatment or control. Patients had moderate or severe SDB (n = 73 per each group; standardized mean difference of 0.08) and were followed for a minimum of one year. In addition, survival over 4 years was assessed. Results: Mean patient age was 67.67 ± 10.78 and 67.2 ± 10.10, respectively, with 15.06% and 10.95% of the patients, respectively, being female. Regarding SDB subtypes in the control and SDB treatment group, central sleep apnea was present in 42.46% and 41.09% of the patients, respectively, and obstructive sleep apnea was present in 26.02% and 31.50% of the patients, respectively. Mixed type sleep disorder was present in 31.50% and 27.40% of cases. Among the SDB treatment group, a significantly lower number of VTs (28.8% vs. 68.5%; p = 0.01), ATP (21.9% vs. 50.7%; p = 0.02), as well as a lower shock rate (5.5% vs. 31.5%; p < 0.01), was observed compared to the control group. Furthermore, the VT burden was significantly lower in the SDB treatment group when compared to the time prior to SDB treatment (p = 0.02). Event-free survival was significantly higher in the SDB treatment group (Log-rank p < 0.01). Conclusion: SDB treatment in HF patients with ICD leads to significant improvements in VT burden, ATP and shock therapy, and may even affect survival. Thus, HF patients should be generously screened for SDB and treated appropriately.

Long-term prognostic potential of microRNA-150-5p in optimally treated heart failure patients with reduced ejection fraction: a pilot study.

In a previous study, we found that miR-150-5p was specifically downregulated in patients with advanced heart failure (HF). Here, we investigated the long-term prognostic potential of miR-150-5p. We studied optimally-treated HF outpatients with reduced ejection fraction. The primary outcome comprised the composite of death, urgent heart transplantation (HT) and ventricular assist device (VAD) implantation within 30 months. We used recursive partitioning analysis to identify the optimal log miR-150-5p cut-off. The association of log miR-150-5p with the primary outcome was examined using Cox regression analysis. We used the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score for adjustment in multivariable analysis. Finally, we compared the global fit of three models (MAGGIC score + miR-150-5p, MAGGIC score + NT-proBNP, and NT-proBNP + miR-150-5p) using Akaike Information Criterion. Recursive partitioning analysis identified the value of -2.22 as the optimal cut-off for log miR-150-5p. Thirty-month survival free of urgent HT/VAD implantation was 31% among the patients with log miR-150-5p<-2.22 and 86% among those with log miR-150-5p>-2.22. Crude hazard ratio (HR) of the primary outcome for log miR-150-5p expression level <-2.22 was 6.70 (95% CI: 2.31-19.38; P<0.001). After adjusting for the MAGGIC score in multivariable analysis, the HR was 4.40 (95% CI: 1.52-12.77; P=0.006). Adding log miR-150-5p to the MAGGIC score led to an increase of 0.047 in C-index. The model combining miR-150-5p and MAGGIC score had a 73% likelihood of representing the best-fit model of those evaluated. Our data generate the hypothesis that miR-150-5p may represent a novel risk marker in HF with reduced ejection fraction.

Cystic fibrosis transmembrane regulator correction attenuates heart failure-induced lung inflammation.

Heart failure (HF) affects 64 million people worldwide. Despite advancements in prevention and therapy, quality of life remains poor for many HF patients due to associated target organ damage. Pulmonary manifestations of HF are well-established. However, difficulties in the treatment of HF patients with chronic lung phenotypes remain as the underlying patho-mechanistic links are still incompletely understood. Here, we aim to investigate the cystic fibrosis transmembrane regulator (CFTR) involvement in lung inflammation during HF, a concept that may provide new mechanism-based therapies for HF patients with pulmonary complications. In a mouse model of HF, pharmacological CFTR corrector therapy (Lumacaftor (Lum)) was applied systemically or lung-specifically for 2 weeks, and the lungs were analyzed using histology, flow cytometry, western blotting, and qPCR. Experimental HF associated with an apparent lung phenotype characterized by vascular inflammation and remodeling, pronounced tissue inflammation as evidenced by infiltration of pro-inflammatory monocytes, and a reduction of pulmonary CFTR+ cells. Moreover, the elevation of a classically-activated phenotype of non-alveolar macrophages coincided with a cell-specific reduction of CFTR expression. Pharmacological correction of CFTR with Lum mitigated the HF-induced downregulation of pulmonary CFTR expression and increased the proportion of CFTR+ cells in the lung. Lum treatment diminished the HF-associated elevation of classically-activated non-alveolar macrophages, while promoting an alternatively-activated macrophage phenotype within the lungs. Collectively, our data suggest that downregulation of CFTR in the HF lung extends to non-alveolar macrophages with consequences for tissue inflammation and vascular structure. Pharmacological CFTR correction possesses the capacity to alleviate HF-associated lung inflammation.

Cardiorenal Crosstalk in Patients with Heart Failure

Worsening renal function is associated with poor outcomes in heart failure and often accompanies the initiation and up-titration of guidelines-directed heart failure therapy. This narrative review summarizes current evidence on immediate and long-term effects of pharmacological or device-based treatment in heart failure patients with reduced or preserved left ventricular ejection fraction.

Exercise and Sports Activities in Patients with Heart Failure

Exercise training is an essential additional non-pharmacological method to treat heart failure patients that has been shown to have significant impacts on mortality, morbidity, exercise capacity and quality of life. Various type of training are developed to resolve the needs of heart failure patients, including those who want to participate in sport activities. It is critical and challenging to prescribe personalized exercise training program perfectly, therefore, this review provides brief overview of the advantages and recommendations to prescribe individualized type of exercise training including aerobic, resistance, respiratory, aquatic and competitive sport activities for patients with heart failure. A comprehensive electronic search was conducted using PubMed, Google Scholar, and ScienceDirect. The search was limited to English-language publications from 2004 to 2021. Hand searching of relevant journals and reference lists was also performed. Exercise training should be component of a comprehensive heart failure care approach. Each patient with heart failure may have a different endurance to tolerate the same relative training. Individualized exercise training combined with a preliminary examination improves disability while also decreasing morbidity and mortality&#x0D; Keywords: heart failure, nonpharmacological management, sport exercise

SGLT2 Inhibitors in Type 2 Diabetes Mellitus and Heart Failure-A Concise Review.

The incidence of both diabetes mellitus type 2 and heart failure is rapidly growing, and the diseases often coexist. Sodium-glucose co-transporter 2 inhibitors (SGLT2i) are a new antidiabetic drug class that mediates epithelial glucose transport at the renal proximal tubules, inhibiting glucose absorption—resulting in glycosuria—and therefore improving glycemic control. Recent trials have proven that SGLT2i also improve cardiovascular and renal outcomes, including reduced cardiovascular mortality and fewer hospitalizations for heart failure. Reduced preload and afterload, improved vascular function, and changes in tissue sodium and calcium handling may also play a role. The expected paradigm shift in treatment strategies was reflected in the most recent 2021 guidelines published by the European Society of Cardiology, recommending dapagliflozin and empagliflozin as first-line treatment for heart failure patients with reduced ejection fraction. Moreover, the recent results of the EMPEROR-Preserved trial regarding empagliflozin give us hope that there is finally an effective treatment for patients with heart failure with preserved ejection fraction. This review aims to assess the efficacy and safety of these new anti-glycemic oral agents in the management of diabetic and heart failure patients.

Micronutrient deficiencies in heart failure: Mitochondrial dysfunction as a common pathophysiological mechanism?

Heart failure is a devastating clinical syndrome, but current therapies are unable to abolish the disease burden. New strategies to treat or prevent heart failure are urgently needed. Over the past decades, a clear relationship has been established between poor cardiac performance and metabolic perturbations, including deficits in substrate uptake and utilization, reduction in mitochondrial oxidative phosphorylation and excessive reactive oxygen species production. Together, these perturbations result in progressive depletion of cardiac adenosine triphosphate (ATP) and cardiac energy deprivation. Increasing the delivery of energy substrates (e.g., fatty acids, glucose, ketones) to the mitochondria will be worthless if the mitochondria are unable to turn these energy substrates into fuel. Micronutrients (including coenzyme Q10, zinc, copper, selenium and iron) are required to efficiently convert macronutrients to ATP. However, up to 50% of patients with heart failure are deficient in one or more micronutrients in cross‐sectional studies. Micronutrient deficiency has a high impact on mitochondrial energy production and should be considered an additional factor in the heart failure equation, moving our view of the failing myocardium away from an “an engine out of fuel” to “a defective engine on a path to self‐destruction.” This summary of evidence suggests that supplementation with micronutrients—preferably as a package rather than singly—might be a potential therapeutic strategy in the treatment of heart failure patients.

Can cardiac shear wave elastography detect the presence of septal scar in patients with left bundle branch block?

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): FWO: Fonds Wetenschappelijk Onderzoek (fund for scientific research Flanders) Background Cardiac resynchronization therapy (CRT) is an established treatment for heart failure patients with left bundle branch block (LBBB). Regardless, CRT has proven to be less effective in patients with ischemic cardiomyopathy, in particular when the septum is affected. The detection of septal scar prior to CRT implantation could therefore help to improve response rate. However, magnetic resonance imaging (MRI), the gold standard to assess myocardial scar, cannot be used in every patient due to already implanted devices or impaired renal function. Cardiac shear wave elastography (SWE) allows for the non-invasive assessment of myocardial stiffness via the detection of shear waves, for example induced by mitral valve closure (MVC), that travel through the myocardium. Shear wave speed is directly related to tissue stiffness. Recently, SWE has shown to be capable to detect myocardial scar, however this has never been demonstrated in the presence of LBBB. Purpose To evaluate whether SWE is able to detect the presence of septal scar in patients with LBBB. Methods We included 34 heart failure patients with LBBB (age: 69 ± 13 y; 56% males) and with ischemic (n = 9) or non-ischemic (n = 25) cardiomyopathy and 9 age-matched healthy volunteers (age: 68 ± 4 y; 66% males) as controls. In order to obtain native ventricular conduction biventricular (BiV) pacing was turned off. All ischemic patients had septal scar only, proven by MRI or scintigraphy. For SWE, left ventricular parasternal long-axis views were acquired with an experimental high frame rate ultrasound scanner (frame rate: 932 ± 32 fps). Shear waves were visualized in M-modes of the septum, colour coded for tissue acceleration. The slope of the shear waves in the M-mode represents their propagation speed (Figure A). Results Patient characteristics including echocardiographic parameters are shown in Table 1. Shear wave speed after MVC was significantly higher in patients with LBBB with or without septal scar compared to healthy controls (7.9 ± 1.2 m/s vs 4.5 ± 1.1 m/s; p = 0.044; 5.6 ± 1.2 m/s vs 4.5 ± 1.1 m/s: p &amp;lt; 0.001; figure B). This implies that the presence of LBBB alone increases myocardial stiffness. Most importantly, however, shear wave speed was significantly higher in LBBB patients with a septal scar compared to LBBB patients without a septal scar (7.9 ± 1.2 m/s vs 5.6 ± 1.2 m/s; p &amp;lt; 0.001; figure B), indicating that the presence of scar increases myocardial stiffness even more than LBBB alone. Conclusions LBBB causes a mild but significant increase in shear wave propagation speed in non-ischemic patients compared to controls. The presence of septal scarring leads to an additional and more significant increase. This indicates that SWE is capable of detecting stiffer scarred myocardium even in the presence of LBBB. Therefore, SWE could potentially be used as a novel method to detect septal scarring in LBBB patients before CRT implantation. Abstract Figure. Abstract Figure.

Instantaneous wave-free ratio and fractional flow reserve: effect of variation in left ventricular end diastolic pressure

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Among patients with intermediate coronary artery stenosis (50-90%), assessment of functional significance of the lesion by instantaneous wave free ratio (iFR)/ fractional flow reserve (FFR) is recommended in latest guidelines. Though iFR is not much affected by change in hemodynamics compared to FFR, the change in iFR vs FFR due to various hemodynamic factors need a validation. Left ventricular end-diastolic pressure (LVEDP) is one of the hemodynamic factors whose variation and effect on FFR vs iFR is largely unknown. In the present study we evaluated the association of change in LVEDP on the changing pattern of iFR/FFR which may hold a clinical significance especially with percutaneous coronary intervention in heart failure patients. Methods This was a prospective, investigator-initiated, single-center study involving 20 patients with stable coronary artery disease and at least one intermediate coronary lesion (50-90%). The enrolled patients were subjected to both iFR and FFR along with baseline LVEDP measurement. Subsequently, intravenous nitroglycerine infusion was given to reduce LVEDP and corresponding iFR and FFR were re-evaluated. The dynamic changes in iFR and FFR were studied in relation to changes in LVEDP using Pearson’s correlation analysis and linear regression analysis. Results The mean LVEDP was lowered from 16.20 ± 1.54 mmHg to 9.50 ± 1.10 mmHg, the mean iFR and FFR got changed from 0.80 ± 0.12 to 0.76 ± 0.12 mmHg and 0.75 ± 0.09 to 0.72 ± 0.09 mmHg respectively. On Pearson’s correlation analysis, LVEDP change did not show statistically significant correlation (linear relationship) with iFR (p = 0.105, r2 = 0.373) and FFR (p = 0.227, r2 = 0.283) changes across the entire range of stenosis severity and in all vessels. Linear regression analysis did not state any independent correlation between LVEDP and iFR and FFR changes in the study group (p &amp;gt;0.05). The % R2 value for iFR and FFR (as a coefficient of determination) of the regression equation were 13.9% and 8%, which means only these percentages of the total variance in iFR and FFR change were explained by LVEDP changes respectively. There was no serious adverse event related to the procedure. Conclusion To the best of our knowledge, this is the first study comparing the effect of changes in LVEDP on both iFR and FFR simultaneously. In our study, 1 mmHg change in LVEDP was associated with a change in FFR by 0.004 and change in iFR by 0.004 which didn’t reveal any significant association (p = 0.227 and 0.105 respectively). This helps us to put FFR at par with iFR under variable hemodynamics. So either of the variables may be used interchangeably with confidence in varied hemodynamic conditions including patients with heart failure. The correlation was non-significant across entire range of stenosis severity, irrespective of sex, age, diabetes and hypertension. This study sets platform for further research with larger number of heterogeneous patient population. Abstract Figure. Box whisker plot

A Clinical Review and Emerging Perspectives in Cardiac Practice

Sodium-Glucose Cotransport-2 inhibitors SGLT2 inhibitors are a new class of oral drugs for Type 2 diabetes mellitus T2DM with a unique mechanism of action. The list in this class is growing and includes Canagliflozin Dapagliflozin Empagliflozin Remogliflozin and Sotagliflozin. SGLT2 inhibitors block glucose reabsorption in the proximal convoluted tubule of the kidney. This causes increased glycosuria resulting in improvement in glycaemic control. In humans this transport mechanism is described as the primary mechanism of transportation of glucose in the kidney. It accounts for nearly complete reabsorption of glucose. The SGLT2 inhibitors are effective in reducing not only blood sugars but also Glycated Hemoglobin HbA1C blood pressure and to some extent body weight. Randomized controlled trials have shown SGLT2 inhibitors to be effective in lowering the hospitalization for heart failure progression of renal dysfunction and reducing cardiovascular mortality. The benefits of SGLT2 inhibitors in cardiovascular were seen independent of baseline HbA1C levels and magnitude of HbA1C reduction. Clinical guidelines have implemented and recommended using SGLT2 inhibitors for the treatment of heart failure patients who have left ventricular dysfunction and also with without T2DM. These paradigm shifts highlight their importance in cardiac care for patients with and without T2DM.

Efficacy of Amiodarone on the Heart Failure Patients with Arrhythmia

To investigate the efficacy of amiodarone on the heart failure patients with arrhythmia is the objective of the study. Between April 2018 and April 2020, 86 heart failure patients with arrhythmia who were admitted to the hospital for treatment were enrolled into the study and numbered, and according to the sequence of admission, they were randomized into the control group and observation group, with 43 patients in each group. Patients in two groups received the regular medication, while those in the observation group additionally took amiodarone. We measured the hemodynamic parameters of patients in two groups before and after treatment, including the mean arterial pressure, cardiac output, cardiac index, ejection fraction, fractional shortening and maximal flow velocity in early diastolic stage/maximal flow velocity in advanced diastolic stage, evaluated the efficacy and recorded the incidence rate of adverse reactions. Following the treatment, the effectiveness rate of patients in the observation group was significantly higher than that in the control group (c2=3.927, p<0.05), while the difference in the incidence rates of adverse reactions showed no statistical significance (p>0.05). Amiodarone in treatment of heart failure patients with arrhythmia can improve the heart function and efficacy, and thus it is safe and efficient in clinical practice.

Chapter 15 - Sleep and breathing disorders in heart failure

Sleep disorders are prevalent in heart failure and include insomnia, poor sleep architecture, periodic limb movements and periodic breathing, and encompass both obstructive (OSA) and central sleep apnea (CSA). Polysomnographic studies show excess light sleep and poor sleep efficiency particularly in those with heart failure. Multiple studies of consecutive patients with heart failure show that about 50% of patients suffer from either OSA or CSA. While asleep, acute pathological consequences of apneas and hypopneas include altered blood gases, sleep fragmentation, and large negative swings in intrathoracic pressure. These pathological consequences are qualitatively similar in both types of sleep apnea, though worse in OSA than CSA. Sleep apnea results in oxidative stress, inflammation, and endothelial dysfunction, best documented in OSA. Multiple studies show that both OSA and CSA are associated with excess hospital readmissions and premature mortality. However, no randomized controlled trial (RCT) has been reported for OSA, but sensitivity analysis of two randomized controlled trials has concluded that use of positive airway pressure devices is associated with excess mortality in patients with heart failure and CSA. Phrenic nerve stimulation has shown improvement in sleep apnea events and daytime sleepiness; however, no randomized controlled trials have demonstrated improvement in survival in patients with heart failure. The correct identification and treatment of heart failure patients with sleep and breathing disorders could affect the long-term outcomes of these patients.

Bridge to transplantation from mechanical circulatory support: a narrative review.

ObjectiveTo highlight recent developments in the utilization of mechanical circulatory support (MCS) devices as bridge-to-transplant strategies and to discuss trends in MCS use following the changes to the United Network for Organ Sharing (UNOS) heart allocation system.BackgroundMCS devices have played an increasingly important role in the treatment of heart failure patients. Over the past several years, technological advancements have led to new developments in MCS devices and expanding indications for MCS use. In October of 2018, the UNOS heart allocation policy was revised to prioritize higher-urgency patients, including those supported with temporary MCS devices. Since then, changes in trends of MCS utilization have been observed.MethodsArticles from the PubMed database regarding the use of MCS devices as bridge-to-transplant strategies were reviewed.ConclusionsOver the past decade, utilization of temporary MCS devices, which include the intra-aortic balloon pump (IABP), percutaneous ventricular assist devices (pVADs), and extracorporeal membrane oxygenation (ECMO), has become increasingly common. Recent advancements in MCS include the development of pVADs that can fully unload the left ventricle (LV) as well as devices designed to provide right-sided support. Technological advancements in durable left ventricular assist devices (LVADs) have also led to improved outcomes both on the device and following heart transplantation. Following the 2018 UNOS heart allocation policy revision, the utilization of temporary MCS in advanced heart failure patients has further increased and the proportion of patients bridged directly from a temporary MCS device has exponentially risen. However, following the start of the COVID-19 pandemic, the trends have reversed, with a decrease in the percentage of patients bridged from a temporary MCS device. As long-term data following the allocation policy revision becomes available, future studies should investigate how trends in MCS use for patients with advanced heart failure continue to evolve.

Heart failure treatment in patients with cardiac implantable electronic devices: Opportunity for improvement.

BackgroundHeart failure and reduced ejection fraction (HFrEF) is the predominant indication for cardiac resynchronization therapy (CRT) and implantable cardioverter-defibrillator (ICD) implantation. The care gap and opportunity to optimize guideline-directed medical therapy (GDMT) is unclear.ObjectiveWe sought to define uptake, eligibility, dose, and adherence to GDMT in patients with CRT/ICD and HFrEF.MethodsMEDLINE was searched from 2000 to July 2021 for major randomized trials, registries, and cohort studies evaluating GDMT in this population. Thirty-eight studies focused on medical therapy in patients with CRT/ICD devices (CRT = 23, ICD = 11, and both = 4).ResultsIn the pivotal device trials, ACEI/ARB and beta-blocker use was high (mean 94%, range 41%–99%; and 83%, range 27%–97%, respectively), but mineralocorticoid receptor antagonists were modest (mean 45%, range 32%–61%), in keeping with guidelines of that era. Similar results were found in observational registries. CRT was associated with beta-blocker uptitration, while the effects on ACEI/ARB were less consistent. For beta blockers, 57%–68% of patients were uptitrated, increasing the mean percent of target dose achieved by 24% from baseline to follow-up. In one study, adherence increased, for ACEI/ARB from 37% to 55% and beta blockers 34% to 58%. Only 1 study assessed potential eligibility at implant for sacubitril-valsartan (72%) or ivabradine (28%), and no study examined sodium-glucose cotransporter-2 inhibitors. Increased uptake, titration, and dose was associated with reduced mortality, hospitalization, and device therapies.ConclusionPatients with HFrEF and ICD/CRT are undertreated with respect to GDMT, and there is opportunity to optimize therapy to improve morbidity and mortality.