Angiotensin-converting enzyme 2 and COVID-19 in cardiorenal diseases

The rapid spread of the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has brought into focus the key role of angiotensin-converting enzyme 2 (ACE2), which serves as a cell surface receptor required for the virus to enter cells. SARS-CoV-2 can decrease cell surface ACE2 directly by internalization of ACE2 bound to the virus and indirectly by increased ADAM17 (a disintegrin and metalloproteinase 17)-mediated shedding of ACE2. ACE2 is widely expressed in the heart, lungs, vasculature, kidney and the gastrointestinal (GI) tract, where it counteracts the deleterious effects of angiotensin II (AngII) by catalyzing the conversion of AngII into the vasodilator peptide angiotensin-(1-7) (Ang-(1-7)). The down-regulation of ACE2 by SARS-CoV-2 can be detrimental to the cardiovascular system and kidneys. Further, decreased ACE2 can cause gut dysbiosis, inflammation and potentially worsen the systemic inflammatory response and coagulopathy associated with SARS-CoV-2. This review aims to elucidate the crucial role of ACE2 both as a regulator of the renin–angiotensin system and a receptor for SARS-CoV-2 as well as the implications for Coronavirus disease 19 and its associated cardiovascular and renal complications.

Feasibility of Group Visits for Advance Care Planning Among Patients with Heart Failure and Their Caregivers

BACKGROUND

Group visits have the potential to help patients identify their health care values and engage in the emotionally and cognitively challenging task of advance care planning (ACP) in a resource-efficient manner by providing a forum for social learning and social support.

OBJECTIVE

To evaluate the feasibility and acceptability of disease-specific group visits for patients with heart failure and their caregivers.

DESIGN

Feasibility trial of a 90-minute group visit held for 10 separate groups and led by a trained facilitator using the video-based PREPARE for Your Care ACP tool.

SETTING/SUBJECTS

Older adults with recent hospitalization for heart failure (n = 36; median age, 74 years) and their caregivers (n = 21).

MEASUREMENTS

Pre- and post-visit surveys and a postvisit telephone interview assessing perceived value and acceptability; structured nonparticipant observations to assess process and feasibility.

RESULTS

Mean scores from the postgroup visit evaluation showed that participants reported that they felt comfortable discussing ACP in a group (4.59), understood the information covered (4.70), and were able to identify and clarify their health care values (4.43). Interview and observation data demonstrated that participants were able to identify and clarify their preferences by listening and learning from a diverse range of perspectives in the group and that the disease-focused nature of the group visit created a supportive space for participants to share their experiences.

CONCLUSIONS

Disease-focused ACP group visits were feasible to conduct and acceptable to participants, underscoring their value as an efficient intervention to engage patients and caregivers in the otherwise time- and resource-intensive task of ACP.

[Frailty in older adults with chronic heart failure in a hospital from Lima]

Objective

To determine the prevalence of frailty in older adults with heart failure and to examine the association between frailty and socio-demographic and clinical characteristics in patients in the Chronic Heart Failure program of the Guillermo Almenara Irigoyen National Hospital in the period 2018-2020.

Materials and methods

Observational, cross-sectional, correlational study with quantitative approach in patients older than 60 years who had a frailty assessment using the Edmonton scale; as non-frail (0-4), apparently vulnerable (5-6), mildly frail (7-8), moderately frail (9-10) and severely frail (11-17). The association of frailty and patient characteristics was assessed using Pearson's Chi-Square test, values of p<0.05 and with a 95% confidence interval were considered significant.

Results

The prevalence of frailty was 58.8%, most patients were male (71.8%) and the average age was 72.9 years. Age and number of comorbidities were statistically significant factors associated with frailty with p=0.004 and p<0.001 respectively.

Conclusions

The prevalence of frailty was high in patients older than 60 years in the chronic heart failure program. Older patients with more comorbidities were at higher risk of frailty, highlighting the need for comprehensive assessment and screening for frailty in order to design secondary prevention programs in a timely manner.

[Impact of variation in altitude above sea level on clinical and hemodynamic parameters in pulmonary arterial hypertension: case report]

Clinical monitoring of pulmonary arterial hypertension in our country, in which patients come from different altitudes above sea level, forces us to rule out pulmonary hypertension in relation to chronic exposure to high heights, described in third group of international classification. When reviewing the hemodynamic variations in pulmonary pressure with exercise at altitude with respect to sea level in healthy patients, this is greater in height, this would explain that the patient with pulmonary arterial hypertension is more symptomatic while living at a higher altitude above sea level.

[Myocardial revascularization in left ventricular dysfunction]

Left ventricular dysfunction due to adverse remodeling constitutes the underlying structural anatomical condition of heart failure and is the main and most severe sequela of long-term coronary artery disease, and it is the only pathology that can benefit from surgical myocardial revascularization. For its control, there are current medical treatment guidelines supported by the favorable results of contemporary clinical trials. However, in recent studies, there was no benefit of surgical revascularization in addition to optimal medical therapy when compared to optimal medical therapy alone. The identification of myocardial viability to guide revascularization was also not favorable. The results of the extension of these trials showed benefit of revascularization treatment, but the detection of viability remained unfavorable. Increased left ventricular ejection fraction, as a marker of benefit from revascularization, was not associated with lower mortality. There are many reasons why the known advantages of revascularization were not identified. Despite this discrepancies, myocardial revascularization and the identification of viability in these patients are supported and are usually indications for routine treatment.

[Rupture of a sinus of valsalva aneurysm into the right atrium in the adult: a case report]

Rupture of a Valsalva aneurysm in the adult is extremely rare and is often complicated by acute heart failure. We present the case of a 39-year-old patient with a non-coronary sinus of Valsalva aneurysm complicated by rupture into the right atrium associated with severe aortic regurgitation and moderate tricuspid regurgitation. The treatment was surgical and was based on the repair with a pericardial patch over the aneurysm, aortic valve replacement, and tricuspid plasty. We emphasize the importance of an early diagnosis and timely surgical treatment due to the high associated mortality.

Neddylation, an Emerging Mechanism Regulating Cardiac Development and Function

Defects in protein quality control have been increasingly recognized as pathogenic factors in the development of heart failure, a persistent devastating disease lacking efficacious therapies. Ubiquitin and ubiquitin-like proteins, a family of post-translational modifying polypeptides, play important roles in controlling protein quality by maintaining the stability and functional diversity of the proteome. NEDD8 (neural precursor cell expressed, developmentally downregulated 8), a small ubiquitin-like protein, was discovered two decades ago but until recently the biological significance of NEDD8 modifications (neddylation) in the heart has not been appreciated. In this review, we summarize the current knowledge of the biology of neddylation, highlighting several mechanisms by which neddylation regulates the function of its downstream targets, and discuss the expanding roles for neddylation in cardiac physiology and disease, with an emphasis on cardiac protein quality control. Finally, we outline challenges linked to the study of neddylation in health and disease.

Heart Failure with Preserved Ejection Fraction and 30-Day Readmission

OBJECTIVE

Several studies identify heart failure (HF) as a potential risk for hospital readmission; however, studies on predictability of heart failure readmission is limited. The objective of this work was to investigate whether a specific type of heart failure (HFpEF or HFrEF) has a higher association to the rate of 30-day hospital readmission and compare their predictability with the two risk scores: HOSPITAL score and LACE index.

DESIGN

Retrospective study from single academic center.

METHODS

Sample size included adult patients from an academic hospital in a two-year period (2015 - 2017). Exclusion criteria included death, transfer to another hospital, and unadvised leave from hospital. Baseline characteristics, diagnosis-related group, and ICD diagnosis codes were obtained. Variables affecting HOSPITAL score and LACE index and types of heart failure present were also extracted. Qualitative variables were compared using Pearson chi² or Fisher's exact test (reported as frequency) and quantitative variables using non-parametric Mann-Whitney U test (reported as mean ± standard deviation). Variables from univariate analysis with P values of 0.05 or less were further analyzed using multivariate logistic regression. Odds ratio was used to measure potential risk.

RESULTS

The sample size of adult patients in the study period was 1,916. All eligible cohort of patients who were readmitted were analyzed. Cumulative score indicators of HOSPITAL Score, LACE index (including the Charlson Comorbidity Index) predicted 30-day readmissions with P values of <0.001. The P value of HFpEF was found to be significant in the readmitted group (P < 0.001) compared to HFrEF (P = 0.141). Multivariate logistic regression further demonstrated the association of HFpEF with higher risk of readmission with odds ratio of 1.77 (95% CI: 1.25 - 2.50) and P value of 0.001.

CONCLUSIONS

Our data from an academic tertiary care center supports HFpEF as an independent risk factor for readmission. Multidisciplinary management of HFpEF may be an important target for interventions to reduce hospital readmissions.

Patient-Reported Outcomes Measurement Information System (PROMIS) in Left Ventricular Assist Devices

BACKGROUND

Appropriate collection of quality of life (QOL) measurements for left ventricular assist device (LVAD) patients is challenging. Patient-Reported Outcomes Measurement Information System (PROMIS) is a popular tool that has been validated across multiple disciplines, but its applicability to the LVAD population remains unknown.

METHODS

This single-center, retrospective review included LVAD patients that completed a PROMIS assessment and Kansas City Cardiomyopathy Questionnaire (KCCQ-12) survey at clinical encounters postoperatively. Patients completed computer adaptive PROMIS assessments for physical function, pain interference and depression. All PROMIS domains are designed to follow a normal distribution (mean T-score 50, standard deviation 10) in the general population. Assessments were aggregated over time and correlation between the KCCQ-12 summary score and each PROMIS domain was assessed individually.

RESULTS

A total of 178 LVAD patients were included in the study. The median time between LVAD implantation and PRO collection was 16.5 [interquartile range, 7.9-37.8] months. Patients typically had worse physical function (T-score 38.8 [33.6-44.2]) but comparable pain (51.1 [38.7-59.2]) and depression (49.9 [41.7-57.5]) as the general population. The KCCQ-12 was more strongly correlated to PROMIS physical function (Spearman's ρ = 0.746) than pain (ρ = -0.539) or depression (ρ = -0.591).

CONCLUSIONS

PROMIS provides a robust QOL data collection system that can be implemented in a clinical setting without imposing a significant burden. Using this more holistic system may allow for better patient-centered care in order to address QOL limitations imposed by LVAD support that are not directly related to heart failure symptoms.

Implantable Cardioverter-defibrillator Utilization and Its Outcomes in Korea: Data from Korean Acute Heart Failure Registry

BACKGROUND

There are sparse data on the utilization rate of implantable cardioverter-defibrillator (ICD) and its beneficial effects in Korean patients with heart failure with reduced left ventricular ejection fraction (LVEF).

METHODS

Among 5,625 acute heart failure (AHF) patients from 10 tertiary university hospitals across Korea, 485 patients with reassessed LVEF ≤ 35% at least 3 months after the index admission were enrolled in this study. The ICD implantation during the follow-up was evaluated. Mortality was compared between patients with ICDs and age-, sex-, and follow-up duration matched control patients.

RESULTS

Among 485 patients potentially indicated for an ICD for primary prevention, only 56 patients (11.5%) underwent ICD implantation during the follow-up. Patients with ICD showed a significantly lower all-cause mortality compared with their matched control population: adjusted hazard ratio (HR) (95% confidence interval [CI]) = 0.39 (0.16-0.92), P = 0.032. The mortality rate was still lower in the ICD group after excluding patients with cardiac resynchronization therapy (adjusted HR [95% CI] = 0.09 [0.01-0.63], P = 0.015). According to the subgroup analysis for ischemic heart failure, there was a significantly lower all-cause mortality in the ICD group than in the no-ICD group (HR [95% CI] = 0.20 [0.06-0.72], P = 0.013), with a borderline statistical significance (interaction P = 0.069).

CONCLUSION

Follow-up data of this large, multicenter registry suggests a significant under-utilization of ICD in Korean heart failure patients with reduced LVEF. Survival analysis implies that previously proven survival benefit of ICD in clinical trials could be extrapolated to Korean patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01389843.

Emerging therapeutic targets for cardiac arrhythmias: role of STAT3 in regulating cardiac fibroblast function

Introduction : Cardiac fibrosis contributes to the development of cardiovascular disease (CVD) and arrhythmia. Cardiac fibroblasts (CFs) are collagen-producing cells that regulate extracellular matrix (ECM) homeostasis. A complex signaling network has been defined linking environmental stress to changes in CF function and fibrosis. Signal Transducer and Activator of Transcription 3 (STAT3) has emerged as a critical integrator of pro-fibrotic signals in CFs downstream of several established signaling networks. Areas covered : This article provides an overview of STAT3 function in CFs and its involvement in coordinating a vast web of intracellular pro-fibrotic signaling molecules and transcription factors. We highlight recent work elucidating a critical role for the fibroblast cytoskeleton in maintaining spatial and temporal control of STAT3-related signaling . Finally, we discuss potential opportunities and obstacles for therapeutic targeting of STAT3 to modulate cardiac fibrosis and arrhythmias. Relevant publications on the topic were identified through Pubmed. Expert opinion : Therapeutic targeting of STAT3 for CVD and arrhythmias presents unique challenges and opportunities. Thus, it is critical to consider the multimodal and dynamic nature of STAT3 signaling. Going forward, it will be beneficial to consider ways to maintain balanced STAT3 function, rather than large-scale perturbations in STAT3 function.

Incremental Predictive Value of Plasma Renin Activity as a Prognostic Biomarker in Patients with Heart Failure

BACKGROUND

The association of N-terminal pro-B type natriuretic peptide (NT-proBNP) and plasma renin activity (PRA) for the prognosis of the patients with acute heart failure (HF) has not been fully investigated. This study aimed to determine the association between NT-proBNP and PRA and to investigate the incremental value of PRA to NT-proBNP for predicting long term prognosis in patients with acute HF.

METHODS

Three hundred and ninety-six patients (mean age, 64.7 ± 15.9 years; 46.5% female) presenting with acute HF were enrolled between December 2004 and July 2013. Patients with newly diagnosed HF as well as patients with acute exacerbated chronic HF were included. The prognosis was assessed with the composite event of all-cause mortality and readmission for HF during a 2-year follow-up period.

RESULTS

The etiology of HF was ischemic in 116 (29.3%) patients. In a Cox proportional hazards model, log-transformed PRA (hazard ratio [HR], 1.205; P = 0.007) was an independent predictor of the composite outcome of all-cause mortality and readmission for HF in addition to age (HR, 1.032; P = 0.001), white blood cell (WBC) count (HR, 1.103; P < 0.001), and left ventricular ejection fraction (LVEF) (HR, 0.978; P = 0.013). Adding PRA to age, sex, LVEF, and NT-proBNP significantly improved the prediction for the composite outcome of all-cause mortality and readmission for HF, as shown by the net reclassification improvement (0.47; P < 0.001) and integrated discrimination improvement (0.10; P < 0.001).

CONCLUSION

PRA could provide incremental predictive value to NT-proBNP for predicting long term prognosis in patients with acute HF.

Sodium-Glucose Cotransporter-2 Inhibitors in Heart Failure: A Meta-Analysis of Randomized Clinical Trials

BACKGROUND

We aimed to conduct this study with the goal of further clarifying the role of sodium-glucose cotransporter-2 inhibitors (SGLT2i) in patients with preexisting heart failure with reduced ejection fraction with or without diabetes and to leverage increased sample size and power to evaluate clinically important secondary safety and efficacy outcomes.

METHODS

This meta-analysis was completed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcome was a composite of cardiovascular death or heart failure hospitalization. Secondary outcomes included the individual components of the primary outcome; major adverse cardiovascular events (defined as a composite of cardiovascular death, myocardial infarction, stroke), any death, myocardial infarction, or stroke, along with adverse events such as volume depletion, acute kidney injury, adverse events leading to drug discontinuation, amputation, and severe hypoglycemia. Other outcomes included the Kansas City Cardiomyopathy Questionnaire (KCCQ) total symptom score and changes in N-terminal pro-hormone BNP (NT-proBNP). Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) for dichotomous variables and weighted difference (MD) and 95% CI for continuous variables.

RESULTS

Compared with placebo, SGLT2i use was associated with a significant reduction of cardiovascular death or heart failure hospitalization (HR = 0.74; 95% CI = 0.66-0.82; P <0.01), heart failure hospitalization (HR = 0.69; 95% CI = 0.57-0.84; P <0.01), cardiovascular death (HR = 0.79; 95% CI = 0.68-0.92; P <0.01), and any death (HR = 0.80; 95% CI = 0.70-0.92; P <0.01).

CONCLUSIONS

SGLT2i was associated with a decreased risk of clinically relevant cardiovascular death, heart failure hospitalization, and heart failure symptoms with similar rates of adverse events.

[Classification of heart failure and etiological approach]

Classification of heart failure and etiological approach. Heart failure, once viewed as a homogeneous disease, has become a heterogeneous syndrome in which several forms of heart failure are distinguished depending on the level of left ventricular ejection fraction (LVEF). While the diagnosis and treatment strategies are well established for patients with reduced LVEF, we are still lacking such efficient strategies for patients with heart failure with preserved ejection fraction (which represent up to half of patients with heart failure). New diagnostic scores and algorithms have thus recently been proposed to help in the management of these patients. The recognition of etiologies leading to heart failure with preserved ejection fraction is an important step because it can lead to the initiation of new targeted therapies, as is the case for example for patients with cardiac amyloidosis.

[Cancer treatment and risk of heart failure]

Cancer treatment and risk of heart failure. As new advancements in oncology have radically changed the prognosis in millions of cancer patients, these have become at high risk of multiple cardiovascular complications. Heart failure is likely the most common cardiovascular side effect of cancer therapies. Definition of heart failure induced by cancer treatment resides in the reduction of left ventricular ejection fraction under 50%. Biomarkers as the reduction of left ventricular longitudinal function or troponin raise are associated with the advent of heart failure. Risk of cardiotoxicity includes traditional cardiovascular risk factors, lifestyle and cancer treatment(s). In addition to anthracyclins, which may lead to persistent heart failure, target therapies, radiotherapy and immune checkpoint inhibitors may be responsible for cardio-toxicity. Early screening of drug related heart failure may lead to medical treatment thus enabling the continuation of cancer cardiotoxic drugs when no other alternative is available. Cardio-oncology, a new discipline, guides decision making in these complex patients.

The Simulated Cardiology Clinic: A Standardized Patient Exercise Supporting Medical Students' Biomedical Knowledge and Clinical Skills Integration

INTRODUCTION

Development of cardiac disease-related diagnostic skills-including hypothesis-driven data gathering, heart sound interpretation, and ECG interpretation-is an important component of medical student training. Prior studies indicate trainees' performance of these skills is limited. Simulation provides students with opportunities to practice integrating their developing knowledge in a relevant clinical context. We developed a simulated clinic activity for second-year medical students consisting of standardized patient (SP) cases representing cardiovascular (CV) diseases.

METHODS

Student small groups rotated through four SP encounters. For each case, one student performed the history, after which the whole small group listened to audio files of heart sounds, interpreted an ECG, and collaboratively developed a prioritized differential diagnosis. The CV course director met with students for a large-group debrief, highlighting key learning points. We collected learners' evaluations of the event through an online survey.

RESULTS

Of students, 276 participated in this activity over the course of 2 years. Nearly all students assessed the activity as extremely or quite effective for applying learning content from the CV course (97%, 2018; 93%, 2019), and for practicing how to approach chest pain, shortness of breath, palpitations, and fatigue (100%, 2018; 95%, 2019). The most helpful aspects were reinforcement of CV disease illness scripts, hypothesis-driven data gathering practice, ECG interpretation, and applying knowledge and skills in a realistic context.

DISCUSSION

SP encounters representing CV conditions can effectively provide opportunities for students to integrate basic science knowledge and clinical skills. Students assessed the activity as helpful and engaging.

Implications of Managing Chronic Obstructive Pulmonary Disease in Cardiovascular Diseases

Globally, cardiovascular diseases and chronic obstructive pulmonary disease (COPD) are the leading causes of the noncommunicable disease burden. Overlapping symptoms such as breathing difficulty and fatigue, with a lack of awareness about COPD among physicians, are key reasons for under-diagnosis and resulting sub-optimal care relative to COPD. Much has been published in the past on the pathogenesis and implications of cardiovascular comorbidities in COPD. However, a comprehensive review of the prevalence and impact of COPD management in commonly encountered cardiac diseases is lacking. The purpose of this study was to summarize the current knowledge regarding the prevalence of COPD in heart failure, ischemic heart disease, and atrial fibrillation. We also discuss the real-life clinical presentation and practical implications of managing COPD in cardiac diseases. We searched PubMed, Scopus, EMBASE, and Google Scholar for studies published 1981-May 2020 reporting the prevalence of COPD in the three specified cardiac diseases. COPD has high prevalence in heart failure, atrial fibrillation, and ischemic heart disease. Despite this, COPD remains under-diagnosed and under-managed in the majority of patients with cardiac diseases. The clinical implications of the diagnosis of COPD in cardiac disease includes the recognition of hyperinflation (a treatable trait), implementation of acute exacerbations of COPD (AECOPD) prevention strategies, and reducing the risk of overuse of diuretics. The pharmacological agents for the management of COPD have shown a beneficial effect on cardiac functions and mortality. The appropriate management of COPD improves the cardiovascular outcomes by reducing hyperinflation and preventing AECOPD, thus reducing the risk of mortality, improving exercise tolerance, and quality of life.

[Antithrombotic therapy in patients with atrial fibrillation]

Atrial fibrillation is associated with a higher risk of stroke and peripheral embolism. CHA2DS2-VASc clinical stroke risk score allows to identify patients at 'low stroke risk' (CHA2DS2-VASc score = 0 in men, or 1 in women) who should not be offered antithrombotic therapy. Anticoagulation (especially using new oral anticoagulant agents) is recommended in patients with significant risk of ischemic events (CHADSVASC ≥ 2 in men and ≥ 3 in women), and should be initiated in patients with CHADSVASC ≥ 1 in men and ≥ 2 in women, in absence of major risk for severe bleeding. Risk of bleeding must be evaluated at the time of anticoagulation initiation, as well as during follow- up. Presently, the type of atrial fibrillation (paroxysmal or permanent) should not be considered in the thromboembolism risk stratification process. There is no room for antiplatelet therapy in patients with atrial fibrillation.

Heart Failure Training and Job Satisfaction: A Survey of Home Care Workers Caring for Adults with Heart Failure in New York City

Background

Home care workers (HCWs), who include home health aides and personal care attendants, frequently care for adults with heart failure (HF). Despite substantial involvement in HF care, prior qualitative studies have found that HCWs lack training and confidence, which creates challenges for this workforce and potentially for patient care. Herein, we quantified the prevalence of HF training among HCWs and determined its association with job satisfaction.

Methods

We conducted a cross-sectional survey of agency-employed HCWs caring for HF patients across New York, NY from 2018-2019. HF training was assessed with, "Have you received prior HF training?" Job satisfaction was assessed with, "How satisfied are you with your job?" The association between HF training and job satisfaction was determined with robust poisson regression.

Results

323 HCWs from 23 agencies participated; their median age was 50 years (IQR: 37,58), 94% were women, 44% were non-Hispanic Black, 23% were Hispanic, 78% completed ≥ high school education, and 72% were foreign-born. They had been caregiving for a median of 8.5 years (IQR: 4,15) and 73% had cared for 1-5 HF patients. Two-thirds received none/a little HF training and 82% felt satisfied with their job. In a fully adjusted model, HCWs with some/a lot of HF training had 14% higher job satisfaction than those with none/a little HF training (aPR 1.14; 95% CI 1.03-1.27).

Conclusions

The majority of HCWs have not received HF training. HF training was associated with higher job satisfaction, suggesting that HF training programs may improve HCWs' experience caring for this patient population.

Relative contribution of risk factors/co-morbidities to heart failure pathogenesis: interaction with ejection fraction

Aims

The relative impact of each individual coexisting morbidity on the pathogenesis of heart failure (HF) is incompletely understood. This study aimed to evaluate the prevalence of individual cardiac and non‐cardiac coexisting morbidities both in the overall HF population and in the subgroup of HF patients with a single coexisting morbidity, stratified by left ventricular ejection fraction (LVEF) categories, as a measure of the relative contribution of each co‐morbidity to the pathogenesis of HF.

Methods and results

This is a prospective, observational study, in which unselected ambulatory patients with chronic HF visiting the HF clinic of a tertiary university hospital from January 2016 to January 2019 were classified according to baseline LVEF into three groups: (i) LVEF < 40%, (ii) LVEF = 40–49%, and (iii) LVEF ≥ 50% and then evaluated for various coexisting morbidities. Overall, 1064 patients (age 73.4 ± 12.1 years, male gender 57.7%, LVEF 43.6 ± 13.9, N‐terminal pro‐brain natriuretic peptide 2187 ± 710 ng/L, and estimated glomerular filtration rate 67.2 ± 25 mL/min/1.73 m²) were recruited in this study. Of these, 361 (33.9%) had an LVEF < 40%, 247 (23.2%) an LVEF = 40–49%, and 456 (42.9%) an LVEF ≥ 50%. There were 90 (8.5%) HF patients with a single coexisting morbidity, 33 (36.7%) with LVEF ≥ 50%, 27 (30.0%) with LVEF = 40–49%, and 30 (33.3%) with LVEF < 40%. Among these patients, those with LVEF ≥ 50% suffered mostly from hypertension (85.7%), whereas the second most common coexisting morbidity was atrial fibrillation (AF) (9.5%). HF patients with LVEF = 40–49% usually suffered from hypertension (35.7%), AF (28.6%), or myocardial infarction (MI) (21.4%). Finally, HF patients with LVEF < 40% usually suffered from MI (30.8%), AF (30.8%), or hypertension (15.4%).

Conclusions

Hypertension is strongly associated with the development of HF with low, intermediate, or near‐normal/normal LVEF whereas a history of MI or AF with HF with a low or an intermediate LVEF.