Baseline characteristics and clinical features of patients with heart failure with reduced ejection fraction: a European real-world, non-interventional registry study

Background

Heart failure (HF) is a major medical and economic burden that is often managed in office based practices. Recently, the angiotensin receptor neprilysin inhibitor (ARNI) sacubitril/valsartan (S/V) was introduced as novel therapeutic option into European guidelines for the management of HF. The ARIADNE registry aims to provide information on how outpatients with HF with reduced ejection fraction (HFrEF) are managed in Europe, in light of this novel treatment option.

Methods

ARIADNE was a prospective registry of patients with HFrEF treated by office-based cardiologists (OBC) or selected primary care physicians (recognized as HF specialists; PCP) in a real world setting. HFrEF patients were included prospectively, independently of whether treatment had been changed recently or not. 9069 patients were recruited from 687 centres in 17 European countries.

Results

The mean age of all patients was 68.1 years (S/V: 67.3 years, Non-S/V: 68.9 years). The majority of patients were in NYHA class II (61.3%), or NYHA class III (37.1%) overall, while more patients in the S/V group showed NYHA class III (S/V: 42.8%, Non-S/V: 30.9%). Mean LVEF was slightly lower in the S/V group than in the Non-S/V group (S/V: 32.7%, Non-S/V: 35.4%, overall 34.0%). The most frequently observed signs of HF were dyspnoea upon effort, followed by fatigue, palpitations on exertion at baseline. More patients tend to have more severe symptoms in the S/V groups (e.g. for dyspnoea on effort, Non-S/V: moderate 40.8%, severe 8.6%; S/V: moderate 46.4%, severe 14.1%). 44.0% of patients from the S/V group and 39.3% of non-S/V patients reported at least one hospitalization within 12 months prior to baseline, of which 73.3% in S/V and 69.9% in non-S/V patients were due to HF., At baseline, 44.7% of the patients used a CV device, of which most were implantable cardioverter defibrillator (ICD: Non-S/V 54.2%, S/V: 52.8%), implantable cardioverter defibrillator (CRT-ICD:Non-S/V 21.9%, S/V: 27.0%), and pacemaker (Non-S/V: 13.4%, S/V: 10.5%). The mean KCCQ overall summary score was 62.6 in the S/V group and 69.5 in the Non-S/V group at baseline.

83.9% of patients were treated with ARB or ACEi in Non-S/V group, (ACEi 57.3%, ARB 26.9%). The most frequently taken drug combinations in either group were ACEi/ ARB or S/V with β -blockers (Non-S/V 69.3%, S/V 67.3%). 40.2% in the Non-S/V group and 42.9% in S/V groups used a combination of ACEi/ARB or S/V, β-blocker and MRA.

Conclusions

The ARIADNE prospective registry provides insights and reflects variations in HF treatment practices in outpatients in Europe and the way S/V was introduced by OBCs and specialized PCPs in a real-world setting. In the observed population, S/V is more often prescribed to slightly younger patients with slightly lower LVEF, there was a greater observed percentage of S/V patients NYHA class III, with lower quality of life measurements and with more severe symptoms and recent hospitalizations for heart failure.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Novartis Pharma AG

P1272 Echocardiographic evaluation of left ventricular filling pressure in patients with heart failure with preserved ejection fraction : usefulness of inferior vena cava measurement

Methods

Invasive hemodynamics and echocardiographic measurements were documented in 132 consecutive patients referred to our centre with dyspnea, left ventricular ejection fraction (LVEF) ≥50%, and suspected pulmonary hypertension on a previous echocardiogram. Echocardiographic measurements of mitral flow (E and A wave velocities), the E/e’ratio, indexed left atrial volume (LAV), tricuspid regurgitation velocity (TRV) and the IVC size and collapsibility were obtained. Increased LVFP was defined by an invasive pulmonary artery wedge pressure (PAWP) > 15 mmHg.

Results

In sinus rhythm patients, the sum of the criteria (E/e’ ratio > 14, TRV > 2.8 m/s and indexed LAV > 34 ml/m²) ≥ 2 had a positive predictive value (PPV) of 63% for PAWP > 15 mmHg, whereas a dilated (> 2.1 cm) and/or non collapsible (≤ 50%) IVC had a PPV of 83%. In atrial fibrillation (AF), a dilated and/or non collapsible IVC had an 86% PPV for increased LVFP. We found that 16% of patients with elevated LVFP were more accurately classified using IVC evaluation than using the current guidelines criteria (net reclassification improvement = 0.25, p <0.05).

Conclusion

Echographic measurements of the IVC size and collapsibility outperformed the classic 2016 recommendations algorithm to evaluate LVFP in sinus rhythm patients with suspected HFpEF. The IVC study was also valuable in patients with atrial fibrillation.

P1658Pharmacological treatment of patients with HFrEF: is it really optimized in case of CRT and/or ICD implantation?

Background

Cardiac resynchronization (CRT) as well as implantable cardiac defibrillator (ICD) in primary prevention should be considered in patients with heart failure and reduced ejection fraction (HFrEF) only when pharmacological treatment has been optimized.

Purpose

we sought to analyze pharmacological treatments according to the presence or not of CRT-P, CRT-D or ICD in real life HFrEF patients by using a multicenter survey.

Methods

the survey (NCT01956539) was carried out between 2015 and 2018 in 32 hospitals and included 2735 patients with HF who gave their consent during consultation or hospitalization. In this study, we analyzed only outpatients with chronic HFrEF treated for more than 6 months.

Results

among 1061 patients studied, 138 had CRT-P or CRT-D and 215 had ICD for primary prevention. The main clinical characteristics were: age 65±13 years, ischemic heart disease in, NYHA classes 1, 2, 3 and 4 in 15%, 52%, 23% and 10% cases respectively, systolic blood pressure 115mmHg [IQR 104–129], heart rate 70bpm [IQR 60–80], eGFR 64ml/min/1.73m2 [IQR 46–83]and LVEF was 30% [IQR 24–34]. The table shows the rate of use of evidence-based drugs and the dose for ACEi/ARB and betablockers, according to the presence of ICD or CRT.

HFrEF CRT-P or D ICD (primary prevention) n=1061 n=138 n=215 Loop diuretics 78.2% 79.7% 74.9% ACEi or ARB 65.2% 75.4% 67.3% Sacubitril/valsartan 5.9% 8.5% 9.5% Betablockers 72.3% 83.9% 76.8% Mineralocorticoid antagonists 45.7% 63.6% 60.2% ACEi/ARB mean % maxi dose 77 81 83 Beta-blockers mean % maxi dose 74 63 79

Conclusion

these results suggest that pharmacological treatment remains poorly optimized in a number of patients with HFrEF who received ICD or CRT

P6321Therapeutic optimization and inclusion in rehabilitation and education programs depend on age in chronic heart failure. A report of the French survey OFICSel

Background

Heart Failure (HF) is a major public health problem resulting in high rates of hospitalization and mortality. Frequency of HF increase due to the aging of population and improvement of treatments. Therefore, we hypothetized that elderly is a factor that might limit access to appropriate HF Care.

Purpose and methods

Our aim was to analyzed the optimization therapy and participation in rehabilitation and education programs depending according to classes of age (<40 years, 40–50; 50–60; 60–70; 70–80 and >80) in a large French HF population (out and in-patients, de novo/chronique/acute; consultation/hospitalization/rehabilitation; all LVEF classes and any type of cardiologist practice). Data were analized according to age groups

Results

A total of 2729 HF patients from 79 French departments were included of whom 36% were out patients, 53% were in-patients and 11% were in rehabilitation center. 16% were de novo Chronic HF and 31% were in Acute HF. Elderly patients were more frequently included in acute HF. Main data according on classes of age are presented in the table. Ischemic etiology and valvular diseases increased with age (p<0.0001). Cardiovascular risk factors (HTA, hypercholesterolemia) and atrial fibrillation were more frequent with ageing (p<0.0001).

Beta-blockers, angiotensin converting enzyme inhibitors, and anti-aldosterone, were less prescribed after 60 years old (p<0.0001) as therapeutic education or rehabilitation programs (p<0.0001). Modern means of communication (e-mail, smartphone and internet) were less used by elderly patients.(p<0.0001).

Main data according on classes of age Characteristics All (n=2729) <40 (n=91) 40–50 (n=197) 50–60 (n=447) 60–70 (n=706) 70–80 (n=715) >80 (n=573) p SBP 120±21 107±15 117±21 117±21 118±21 122±20 126±22 <0.0001 NYHA Class <0.0001   I 339 (13.8) 16 (19.3) 42 (23.5) 87 (21.4) 103 (16.1) 57 (8.8) 34 (6.7)   II 1187 (48.2) 45 (54.2) 95 (53.1) 213 (52.3) 311 (48.5) 314 (48.4) 209 (41.3)   III 763 (31.0) 20 (24.1) 34 (19.0) 97 (23.8) 199 (31.0) 206 (31.7) 207 (40.9)   IV 176 (7.1) 2 (2.4) 8 (4.5) 10 (2.5) 28 (4.4) 72 (11.1) 56 (11.1) LVEF 36 (29–50) 33 (26–44) 35 (25–45) 35 (25–42) 35 (25–45) 40 (30–50) 44 (32–55) <0.0001 NTproBNP 1808 (690–4323) 1176 (569–2434) 737 (294–1945) 1072 (346–2611) 1480 (619–3597) 2287 (1015–5689) 3275 (1500–6240) <0.0001 Plus-minus values are means ± SD, n (%) median (IQR).

Origin of patients according on classes

Conclusion

Elderly patients receive less Chronic HF treatment, and are less included in patient education and rehabilitation program despite having more comorbidities and cardiovascular risk factors. Thus, to improve outcome, the health care system needs to be adapt to the patients'age.

Acknowledgement/Funding

SFC, CNCF, CNCH, FFC, Alliance du coeur, GERS, SNSMCV

132Imaging criteria for the diagnosis of heart failure with midrange and preserved LVEF in the real life

Background

According to last ESC guidelines, the diagnosis of heart failure with midrange and preserved left ventricular ejection fraction (HFmrEF-HF and HFpEF) requires at least one of the following imaging criteria: LV hypertrophy with LVMI >115g/m2 in men and 95g/m2 in women, left atria dilation with LAVI >34ml/m2, TDI e' wave average <9cm/s and E/e' average ≥13.

Purpose

We analyzed the prevalence of these imaging criteria in real life patients who are labeled HFmrEF or HFpEF by using a multicenter survey on HF.

Methods

Our survey (NCT01956539) was carried out in 32 hospitals between 2015 and 2018 and included 2735 HF patients who gave their consent during consultation or hospitalization. The diagnosis of HF was left to the discretion of investigators. Besides clinical and biological data, echocardiographic data (<1 month before or <3 months after inclusion) was collected in an electronic database. No echographic variable except the LVEF was mandatory to be included.

Results

Among the 523 and 765 HF patients who were labeled respectively as HFmrEF-HF and HFpEF, the 4 echographic variables required for the diagnosis of HFmrEF or HFpEF were obtained in 512 patients. The median age was 74y [IQR 62–82], HF was de novo in 28%, AF in 34%, median NTproBNP was 1563 pg/mL [IQR 500–4372]. At least one of the 4 diagnostic criteria was present in all patients but 2, and patients had 2, 3 or 4 criteria in 43%, 37% and 1% of cases. The table shows only little differences between HFmrEF and HFpEF or de novo HF regarding the rate of each diagnostic criteria. There was no difference regarding the date of inclusion, i.e. before or after the last ESC guidelines.

Table 1 All HF patients De novo HF HFpEF HFmrEF mrEF or pEF (n=143) (n=293) (n=219) LVMI >115g/m2 (men) or 95g/m2 (women) 69.6% 64.3% 68.6% 70.2% LAVI >34ml/m2 74.2% 73.3% 80.4% 68.9% e' average <9cm/s 64.1% 55.3% 55.9% 76.1% E/e' average ≥13 35.4% 38.6% 37.3% 32.8%

Conclusion

The diagnosis of HFpEF or mrEF may be difficult and requires comprehensive echocardiography including all diagnostic variables because each single diagnostic criteria are present in only 33 to 80% cases.

Assessment of autonomic innervation of the foot in familial amyloid polyneuropathy

BACKGROUND AND PURPOSE

Distal involvement of autonomic nerve fibers is critical in familial amyloid polyneuropathy (FAP) due to transthyretin (TTR) mutation. This study compares different methods for assessing autonomic foot innervation in TTR-FAP patients.

METHODS

Three groups of seven TTR-FAP patients were included, according to disease severity: clinically asymptomatic, moderate or advanced neuropathy. The autonomic investigation included the eutectic mixture of local anesthetics test and laser Doppler flowmetry for vasomotor aspects and the Sudoscan® (measuring electrochemical skin conductance) and Neuropad® test for sudomotor aspects. Somatic innervation was assessed by performing nerve conduction studies, quantitative sensory testing [including vibration, cold and warm detection threshold (WDT) measurements] and laser evoked potentials.

RESULTS

The results of all neurophysiological tests varied according to TTR-FAP severity (P ≤ 0.01, Kruskal-Wallis test), except for the eutectic mixture of local anesthetics test and laser Doppler flowmetry variables. In addition, the sudomotor tests (Sudoscan or Neuropad) or WDT measurement provided early markers of neuropathy in two of the seven asymptomatic carriers. Finally, all neurophysiological results correlated with the Neuropathy Impairment Score (r values between -0.88 and -0.66, P < 0.005, Spearman test), except the cold detection threshold.

CONCLUSIONS

The Neuropad test could be used to detect TTR-FAP onset, but confirmation requires electrochemical skin conductance and WDT measurement. The Sudoscan technique, but not the Neuropad test (at least assessed at a fixed time point), could be valuable to follow the progression of the neuropathy. Follow-up investigation should also include large-fiber investigation (e.g. nerve conduction studies and vibration detection threshold). Conversely, reliable tests for assessing vasomotor disturbances in limb extremities of TTR-FAP patients are still awaited.