Excitation-Contraction Coupling Time is More Sensitive in Evaluating Cardiac Systolic Function

Background:

Pressure overload-induced myocardial hypertrophy is a key step leading to heart failure. Previous cellular and animal studies demonstrated that deteriorated excitation–contraction coupling occurs as early as the compensated stage of hypertrophy before the global decrease in left ventricular ejection fraction (LVEF). This study was to evaluate the cardiac electromechanical coupling time in evaluating cardiac systolic function in the early stage of heart failure.

Methods:

Twenty-six patients with Stage B heart failure (SBHF) and 31 healthy controls (CONs) were enrolled in this study. M-mode echocardiography was performed to measure LVEF. Tissue Doppler imaging (TDI) combined with electrocardiography (ECG) was used to measure cardiac electromechanical coupling time.

Results:

There was no significant difference in LVEF between SBHF patients and CONs (64.23 ± 8.91% vs. 64.52 ± 5.90%; P = 0.886). However, all four electromechanical coupling time courses (Qsb: onset of Q wave on ECG to beginning of S wave on TDI, Qst: onset of Q wave on ECG to top of S wave on TDI, Rsb: top of R wave on ECG to beginning of S wave on TDI, and Rst: top of R wave on ECG to top of S wave on TDI) of SBHF patients were significantly longer than those of CONs (Qsb: 119.19 ± 35.68 ms vs. 80.30 ± 14.81 ms, P < 0.001; Qst: 165.42 ± 60.93 ms vs. 129.04 ± 16.97 ms, P = 0.006; Rsb: 82.43 ± 33.66 ms vs. 48.30 ± 15.18 ms, P < 0.001; and Rst: 122.37 ± 36.66 ms vs. 93.25 ± 16.72 ms, P = 0.001), and the Qsb, Rsb, and Rst time showed a significantly higher sensitivity than LVEF (Rst: P =0.032; Rsb: P = 0.003; and Qsb: P = 0.004).

Conclusions:

The cardiac electromechanical coupling time is more sensitive than LVEF in evaluating cardiac systolic function.

Influence of sex and pregnancy on survival in patients admitted with heart failure: Data from a prospective multicenter registry

BACKGROUND

Female sex is an independent predictor of better survival in patients with heart failure (HF), but the mechanism of this association is unknown. On the other hand, pregnancies have a strong influence on the cardiovascular system.

HYPOTHESIS

Sex and previous gestations might have a prognostic impact on 1-year mortality in patients admitted with HF.

METHODS

We conducted an observational, prospective, consecutive, multicenter registry of 1831 patients (756 females [41.2%]) admitted with HF.

RESULTS

Females had a more advanced age (75.2 ±11.4 vs 70.4 ±12.2 years), less ischemic heart disease (167 [25.3%] vs 446 [47.3%]), and higher left ventricular ejection fraction (52.0% ±16.6% vs 41.1% ±17.0%) than did men (all P values <0.001). During 1-year follow-up, 373 (20.4%) patients died (151 females and 222 males). Female sex was an independent predictor for survival (hazard ratio: 0.79, 95% confidence interval: 0.64-0.98, P = 0.03). In 504 women (65.9%), the exact number of previous pregnancies could be determined; 62 women (12.3%) had no previous pregnancies, 288 (57.1%) women had 1 or 2 pregnancies, and 154 women (30.6%) had ≥3 pregnancies. We found an association between the number of previous gestations and better survival (hazard ratio: 0.878, 95% confidence interval: 0.773-0.997, P = 0.045).

CONCLUSIONS

In patients admitted with HF, female sex and the number of previous pregnancies are independently associated with better 1-year survival.

Safety and Feasibility of a Nocturnal Heart Rate Elevation-Exploration of a Novel Treatment Concept

BACKGROUND

Diastolic dysfunction and heart failure with preserved ejection fraction (HFpEF) are associated with myocardial fibrosis and concentric left ventricular hypertrophy (LVH). In a preclinical model of LVH, we demonstrated that a moderate increase in heart rate can reduce interstitial fibrosis and improve LV compliance. We therefore hypothesized that moderately elevated heart rates can be used to beneficially modify the myocardial substrate in patients with diastolic dysfunction and HFpEF. As a preliminary step to test this hypothesis, we evaluated if patients can tolerate this novel pacemaker-based treatment approach without adverse effects.

METHODS AND RESULTS

A pacemaker-mediated increase in heart rate to 100 beats/min for 5 hours at night was tested over 4 weeks in 10 patients with diastolic dysfunction. The patients underwent a physical examination, biomarker collection, 6-minute walk test, heart failure questionnaire, and echocardiography before and after the pacing intervention. None of the patients reported any symptoms at night. No arrhythmias were induced. Eight patients completed the protocol. Three patients experienced unanticipated daytime pacing from an interfering pacemaker function. There were no detrimental changes in biomarkers or LV systolic function.

CONCLUSIONS

Nocturnal pacing at a rate of 100 beats/min appears to be safe and well tolerated in this small exploratory patient cohort.

Rate pressure product and the components of heart rate and systolic blood pressure in hospitalized heart failure patients with preserved ejection fraction: Insights from ASCEND-HF

BACKGROUND

Heart rate and systolic blood pressure (SBP) are prognostic markers in heart failure (HF) with reduced ejection fraction (HFrEF). Their combination in rate pressure product (RPP) as well as their role in heart failure with preserved ejection fraction (HFpEF) remains unclear.

HYPOTHESIS

RPP and its components are associated with HFpEF outcomes.

METHODS

We performed an analysis of Acute Study of Clinical Effectiveness of Nesiritide in Subjects With Decompensated Heart Failure (ASCEND-HF; http://www.clinicaltrials.gov NCT00475852), which studied 7141 patients with acute HF. HFpEF was defined as left ventricular ejection fraction ≥40%. Outcomes were assessed by baseline heart rate, SBP, and RPP, as well as the change of these variables using adjusted Cox models.

RESULTS

After multivariable adjustment, in-hospital change but not baseline heart rate, SBP, and RPP were associated with 30-day mortality/HF hospitalization (hazard ratio [HR]: 1.17 per 5-bpm heart rate, HR: 1.20 per 10-mm Hg SBP, and HR: 1.02 per 100 bpm × mm Hg RPP; all P < 0.05). Baseline SBP was associated with 180-day mortality (HR: 0.88 per 10-mm Hg, P = 0.028). Though change in RPP was associated with 30-day mortality/HF hospitalization, the RPP baseline variable did not provide additional associative information with regard to outcomes when compared with assessment of baseline heart rate and SBP variables alone.

CONCLUSIONS

An increase in heart rate and SBP from baseline to discharge was associated with increased 30-day mortality/HF hospitalization in HFpEF patients with acute exacerbation. These findings suggest value in monitoring the trend of vital signs during HFpEF hospitalization.

California Study of Ablation for Atrial Fibrillation:Re-hospitalization for Cardiac Events (CAABL-CE)

Background

Catheter ablation (ABL) for non-valvular (NV) atrial fibrillation (AF) improves rhythm control. Our aim was to compare re-hospitalization for heart failure (HF), acute coronary syndrome (ACS), or recurrent AF among patients with NVAF who underwent ABL versus controls.

Methods

From the Office of Statewide Planning and Development (OSHPD) database, we identified all patients who had at least one hospitalization for AF between 2005-2013. Patients who subsequently underwent ABL were compared to controls (up to fivematched controls by age, sex and duration of AF between diagnosis and time of ABL). Cases with valve disease, open maze, other arrhythmias, or implanted cardiac devices were excluded. Pre-specified clinical outcomes including readmission for HF, ACS, severe or simple AF (severe = with HF or ACS; simple= without HF or ACS)were assessed using a weighted proportional hazard model adjusting for number of hospital admissions with AF before the ABL, calendar year of ABL, and presence of chronic comorbidities.

Results

The study population constituted 8338 cases and controls, with mean 3.5+ 1 patient-year follow up. In the ABL cohort, there was lower risk of re-hospitalizations for HF, HR=0.55(95%CI: 0.43-0.69,); ACS,HR=0.5(95%CI: 0.35-0.72,); severe AF [HR=0.86 (CI:0.74-0.99), and higher for simple AF, HR=1.25 (CI:1.18-1.33).

Conclusions

In patients with NVAF,although ABL is associated with increased risk of re-hospitalization for simple AF, ABL was associated with a significant reduction in the risk of re-hospitalization for HF, ACS and severe AF. These findingsrequireconfirmation in a prospective clinical trial.

Impact of Heart Rate Reduction with Maximal Tolerable Dose of Bisoprolol on Left Ventricular Reverse Remodeling

BACKGROUND

We aimed to evaluate effect of heart rate (HR) reduction on left ventricular reverse remodeling (LVRR) in Korean patients with heart failure with reduced ejection fraction (HFrEF).

METHODS

Ambulatory patients with HFrEF, who had paired echocardiograms, N-terminal prohormone brain natriuretic peptide (NT-proBNP), and global assessment score (GAS) at baseline and 6-month (n = 157), were followed up on preset treatment schedule with bisoprolol.

RESULTS

The LVRR occurred in 49 patients (32%) at 6-month. In multivariable analysis, independent predictors associated with LVRR were use of anti-aldosterone agent (odds ratio [OR], 4.18; 95% confidence interval [CI], 1.80-9.71), young age (OR, 0.96; 95% CI, 0.92-0.99), high baseline HR (OR, 3.76; 95% CI, 1.40-10.10), and favorable baseline GAS (OR, 1.73; 95% CI, 1.06-2.81). Beneficial effect of bisoprolol, in terms of LVRR, NT-proBNP, and GAS, was remarkable in the high HR group (baseline HR ≥ 75 beats per minute [bpm]), which showed a large HR reduction.

CONCLUSION

High baseline HR (≥ 75 bpm) showed an association with LVRR and improvement of NT-proBNP and GAS in patients with HFrEF. This seems to be due to a large HR reduction after treatments with bisoprolol. Trial registry at www.ClinicalTrials.gov, NCT00749034.

Galectin-3 and ST2 as predictors of therapeutic success in high-risk patients undergoing percutaneous mitral valve repair (MitraClip)

BACKGROUND

Percutaneous mitral valve repair (PMVR) is an interventional treatment option in patients with severe mitral regurgitation (MR) and at high risk for open-heart surgery. Currently, limited information exists about predictors of procedural success after PMVR. Galectin-3 (Gal-3) and suppression of tumorigenicity 2 (ST2) induce fibrotic alterations in severe MR and heart failure. We sought to examine the predictive value of Gal-3 and ST2 as specific indicators of therapeutic success in high-risk patients undergoing PMVR.

HYPOTHESIS

We hypothesize that extended cardiac fibrotic alterations might have impact on successful MR reduction after the MitraClip procedure.

METHODS

A total of 210 consecutive patients undergoing PMVR using the MitraClip system were included in this study. Procedural success was defined as an immediate reduction of MR by ≥2 grades, assessed by echocardiography. Venous blood samples were collected prior to PMVR and at 6 months follow-up for biomarker analysis.

RESULTS

After PMVR there was a significant reduction in the severity of MR (MR grade: 3 ±0.3 vs 1.6 ±0.6, P <0.001). Low baseline Gal-3 levels (PMVR_success : 22.0 ng/mL [IQR, 17.3-30.9] vs PMVR_failure : 30.6 ng/mL [IQR, 24.8-42.3], P <0.001) and ST2 levels (PMVR_success : 900.0 pg/mL [IQR, 619.5-1114.5] vs PMVR_failure : 1728.0 pg/mL [IQR, 1051.March 1, 1930], P < 0.001) were associated with successful MR reduction after PMVR. Also, ROC analysis identified low baseline Gal-3 and ST2 levels as predictors of therapeutic success after PMVR (AUC_Gal-3 :0.721 [IQR, 0.64-0.803], P < 0.001; AUC_ST2 : 0.807 [IQR, 0.741-0.872], P < 0.001).

CONCLUSIONS

There was an association between low Gal-3 and ST2 plasma levels and successful MR reduction in patients with severe MR undergoing PMVR using the MitraClip system.

Evaluation of Echocardiographic Abnormalities in HIV Positive Patients Treated with Antiretroviral Medications

BACKGROUND

Echocardiography is a reliable means for the diagnosis of functional and valvular diseases of the heart in HIV positive and HIV negative patients. The current study was to evaluate echocardiographic abnormalities in HIV positive patients under an antiretroviral therapy (ART) program in Tehran, Imam Khomeini Hospital, Iran.

METHODS

This is a descriptive cross-sectional study, conducted among 231 HIV-1 positive patients under ART. All HIV positive patients including 150 men (65%) and 81 women (35%) (mean age of 41 years) were assessed by trans-thoracic echocardiography (TTE) in Imam Khomeini Hospital, over the period from 2013 to 2014.

RESULTS

The mean CD4 count was 408 cell/μl, and the average left ventricular ejection fraction (LVEF) was 59.5%. There was an inverse correlation between age and LVEF level. Nevirapine users showed a significantly higher LVEF than non-users. Left ventricular systolic dysfunction (LVSD) was diagnosed in 5.6% along with the increase in age, while left ventricular diastolic dysfunction (LVDD) was reported in 19.5% of patients associated with age and smoking. Here, the mean systolic pulmonary arterial pressure (SPAP) was only 20 mmHg and just four percent of the patients suffered pulmonary hypertension. Almost 44% had a heart valve disorder among which mitral valve prolapse is the most common problem. Pericardial effusion was not found in any patients.

CONCLUSION

It seems that heart disorders with no suggestive symptoms in HIV positive patients, and mainly older adults who have traditional risk factors for heart diseases, should be seriously considered by health providers.

Cardiac resynchronization therapy is associated with a reduction in ICD therapies as it improves ventricular function

BACKGROUND

Repeated implantable cardioverter-defibrillator (ICD) therapies cause myocardial damage and, thus, an increased risk of arrhythmias and mortality.

HYPOTHESIS

Cardiac resynchronization therapy-defibrillator (CRT-D) reduces the number of appropriate therapies in patients with left ventricular dysfunction (left ventricular ejection fraction [LVEF] <50%).

METHODS

The retrospective study involved 175 consecutive patients (mean age, 64.6 ±10.4 years; 86.9% males) with reduced LVEF of 27.9% ±7.6% treated with an ICD (56.6%) or CRT-D (43.4%), according to standard indications, between January 2009 and July 2014. Devices were placed for either primary (54.3%) or secondary prevention (45.7%). Mean follow-up was 2.5 ±1.5 years. Predictors of first appropriate therapy were assessed using Cox regression analysis.

RESULTS

Forty-four (25.1%) patients received ≥1 appropriate therapy. Although patients treated with CRT-D had lower LVEF and poorer New York Heart Association class, CRT-D patients with LVEF improvement >35% at the end of follow-up had a significantly lower risk of receiving a first appropriate therapy relative to those with an ICD (adjusted hazard ratio: 0.24, 95% confidence interval: 0.07-0.83, P = 0.025), independently of ischemic cardiomyopathy, baseline LVEF, and secondary prevention. There were no differences in mortality between the ICD and the CRT-D groups.

CONCLUSIONS

Although patients receiving CRT-D had a worse clinical profile, they received fewer device therapies in comparison with those receiving an ICD. This reduction is associated with a significant improvement in LVEF.

Changes in myocardial iron content following administration of intravenous iron (Myocardial-IRON): Study design

Treatment with intravenous ferric carboxymaltose (FCM) has been shown to improve symptoms, functional capacity, and quality of life in patients with heart failure and iron deficiency. However, the underlying mechanisms for these beneficial effects remain undetermined. The aim of this study is to quantify cardiac magnetic resonance changes in myocardial iron content after administration of intravenous FCM in patients with heart failure and iron deficiency and contrast them with parameters of heart failure severity. This is a multicenter, double-blind, randomized study. Fifty patients with stable symptomatic heart failure, left ventricular ejection fraction <50%, and iron deficiency will be randomly assigned 1:1 to receive intravenous FCM or placebo. Intramyocardial iron will be evaluated by T2* and T1 mapping cardiac magnetic resonance sequences before and at 7 and 30 days after FCM. After 30 days, patients assigned to placebo will receive intravenous FCM in case of persistent iron deficiency. The main endpoint will be changes from baseline in myocardial iron content at 7 and 30 days. Secondary endpoints will include the correlation of these changes with left ventricular ejection fraction, functional capacity, quality of life, and cardiac biomarkers. The results of this study will add important knowledge about the effects of intravenous FCM on myocardial tissue and cardiac function. We hypothesize that short-term (7 and 30 days) myocardial iron content changes after intravenous FCM, evaluated by cardiac magnetic resonance, will correlate with simultaneous changes in parameters of heart failure severity. The study is registered at http://www.clinicaltrials.gov (NCT03398681).

Atrioventricular Nodal Catheter Ablation in Atrial Fibrillation Complicating Congestive Heart Failure

The development of atrial fibrillation (AF) during the course of the evolution of heart failure (HF) worsens the clinical outcomes and the prognosis accounting for an enormous economic burden on healthcare. AF is considered to be an independent predictor of morbidity and mortality increasing the risk of death and hospitalization in 76% in HF patients. Despite the good clinical results obtained with conventional pharmacological agents and different new drugs, the optimal medical treatment can fail in the intention to improve symptoms and quality of life of HF patients with severe left ventricular dysfunction and AF with uncontrolled ventricular rate. Therefore, the necessity to utilize cardiac devices to perform cardiac resynchronization therapy (CRT), or the need to use catheter ablation, or both, emerges facing the failure of optimal medical treatment in order to achieve hemodynamic improvement. Some of these AF patients will require atrio-ventricular nodal (AVN) catheter ablation in order to restore 100% CRT functionality and improvements in clinical outcomes. It is hard to imagine that the deliberate destruction of a natural and normally functional specialized tissue of the main conduction system of the heart would do any good. However, in the presence of AF with rapid ventricular response due to normal conduction through the AV node in HF patients, the fast ventricular rate can cause deleterious consequences in the clinical outcome. Moreover, there are interesting published data which will be analyzed in this manuscript documenting significant acute and long-term improvement in left ventricular function, symptoms, exercise tolerance, clinical outcomes, and quality of life in selected HF patients with paroxysmal and persistent drug-refractory AF who have undergone AVN ablation and permanent pacemaker implantation.

Differential Response to Heart Failure Medications in Children

There have been many advances in the treatment of heart failure over the past several years. While these advancements have resulted in improved outcomes in adults with heart failure, these same treatments do not seem to be as efficacious in children with heart failure. Investigations of the failing pediatric heart suggest that there are unique phenotypic, pathologic and molecular differences that could influence how children with heart failure response to adult-based therapies. In this review, several recent studies and the potential implications of their findings on informing the future of the management of pediatric heart failure are discussed.

Calcium-dependent potassium channels control proliferation of cardiac progenitor cells and bone marrow-derived mesenchymal stem cells

KEY POINTS

Ex vivo proliferated c-Kit⁺ endogenous cardiac progenitor cells (eCPCs) obtained from mouse and human cardiac tissues have been reported to express a wide range of functional ion channels. In contrast to previous reports in cultured c-Kit⁺ eCPCs, we found that ion currents were minimal in freshly isolated cells. However, inclusion of free Ca²⁺ intracellularly revealed a prominent inwardly rectifying current identified as the intermediate conductance Ca²⁺ -activated K⁺ current (KCa3.1) Electrical function of both c-Kit⁺ eCPCs and bone marrow-derived mesenchymal stem cells is critically governed by KCa3.1 calcium-dependent potassium channels. Ca²⁺ -induced increases in KCa3.1 conductance are necessary to optimize membrane potential during Ca²⁺ entry. Membrane hyperpolarization due to KCa3.1 activation maintains the driving force for Ca²⁺ entry that activates stem cell proliferation. Cardiac disease downregulates KCa3.1 channels in resident cardiac progenitor cells. Alterations in KCa3.1 may have pathophysiological and therapeutic significance in regenerative medicine.

ABSTRACT

Endogenous c-Kit⁺ cardiac progenitor cells (eCPCs) and bone marrow (BM)-derived mesenchymal stem cells (MSCs) are being developed for cardiac regenerative therapy, but a better understanding of their physiology is needed. Here, we addressed the unknown functional role of ion channels in freshly isolated eCPCs and expanded BM-MSCs using patch-clamp, microfluorometry and confocal microscopy. Isolated c-Kit⁺ eCPCs were purified from dog hearts by immunomagnetic selection. Ion currents were barely detectable in freshly isolated c-Kit⁺ eCPCs with buffering of intracellular calcium (Ca²⁺_i ). Under conditions allowing free intracellular Ca²⁺ , freshly isolated c-Kit⁺ eCPCs and ex vivo proliferated BM-MSCs showed prominent voltage-independent conductances that were sensitive to intermediate-conductance K⁺ -channel (KCa3.1 current, I_KCa3.1 ) blockers and corresponding gene (KCNN4)-expression knockdown. Depletion of Ca²⁺_i induced membrane-potential (V_mem ) depolarization, while store-operated Ca²⁺ entry (SOCE) hyperpolarized V_mem in both cell types. The hyperpolarizing SOCE effect was substantially reduced by I_KCa3.1 or SOCE blockade (TRAM-34, 2-APB), and I_KCa3.1 blockade (TRAM-34) or KCNN4-knockdown decreased the Ca²⁺ entry resulting from SOCE. I_KCa3.1 suppression reduced c-Kit⁺ eCPC and BM-MSC proliferation, while significantly altering the profile of cyclin expression. I_KCa3.1 was reduced in c-Kit⁺ eCPCs isolated from dogs with congestive heart failure (CHF), along with corresponding KCNN4 mRNA. Under perforated-patch conditions to maintain physiological [Ca²⁺ ]_i , c-Kit⁺ eCPCs from CHF dogs had less negative resting membrane potentials (-58 ± 7 mV) versus c-Kit⁺ eCPCs from control dogs (-73 ± 3 mV, P < 0.05), along with slower proliferation. Our study suggests that Ca²⁺ -induced increases in I_KCa3.1 are necessary to optimize membrane potential during the Ca²⁺ entry that activates progenitor cell proliferation, and that alterations in KCa3.1 may have pathophysiological and therapeutic significance in regenerative medicine.

Long-term results of combined cardiac contractility modulation and subcutaneous defibrillator therapy in patients with heart failure and reduced ejection fraction

BACKGROUND

Cardiac contractility modulation (CCM) is an electrical-device therapy for patients with heart failure with reduced ejection fraction (HFrEF). Patients with left ventricular ejection fraction (LVEF) ≤35% also have indication for an implantable cardioverter-defibrillator (ICD), and in some cases subcutaneous ICD (S-ICD) is selected.

HYPOTHESIS

CCM and S-ICD can be combined to work efficaciously and safely.

METHODS

We report on 20 patients with HFrEF and LVEF ≤35% who received CCM and S-ICD. To exclude device interference, patients received intraoperative crosstalk testing, S-ICD testing, and bicycle exercise testing while CCM was activated. Clinical and QOL measures before CCM activation and at last follow-up were analyzed. S-ICD performance was evaluated while both CCM and S-ICD were active.

RESULTS

Mean follow-up was 34.3 months. NYHA class improved from 2.9 ± 0.4 to 2.1 ± 0.7 (P < 0.0001), Minnesota Living With Heart Failure Questionnaire score improved from 50.2 ± 23.7 to 29.6 ± 22.8 points (P < 0.0001), and LVEF improved from 24.4% ± 8.1% to 30.9% ± 9.6% (P = 0.002). Mean follow-up time with both devices active was 22 months. Three patients experienced a total of 6 episodes of sustained ventricular tachycardia, all successfully treated with first ICD shock. One case received an inappropriate shock unrelated to the concomitant CCM. One patient received an LVAD, so CCM and S-ICD were discontinued.

CONCLUSIONS

CCM and S-ICD can be successfully combined in patients with HFrEF. S-ICD and CCM remain efficacious when used together, with no interference affecting their function.

Impact of Ethnicity, Sex, and Socio-Economic Status on the Risk for Heart Failure Readmission: The Importance of Context

Background

Hispanics are a fast-growing minority in the United States and have a high risk for the development of heart failure (HF). Hispanics have higher HF-related hospital readmission rates compared with non-Hispanics. However, the risk of readmission in a largely disadvantaged and majority Hispanic population has not been evaluated.

Methods

We analyzed data for patients discharged with a principal discharge diagnosis of HF from the University of New Mexico Hospital from 2010-2014. Student t-test and chi-square analysis were used to assess the unadjusted associations between baseline characteristics and 30-day readmission rate. Multivariable logistic regression modeling evaluated the associations between 30-day hospital readmission rate, socio-demographic characteristics, and clinical variables.

Results

A total of 1,594 patients were included in our analysis. Mean age (SD) was 63.1 ± 14 and 62.9 ±13.8 (P=.07) for Hispanics and non-Hispanics, respectively. Sixty percent of Hispanics had HF with reduced ejection fraction compared with 53.9% of non-Hispanics (P=.012). In unadjusted analysis, Hispanic ethnicity was associated with a two-fold increase in HF readmission rate compared with non-Hispanic ethnicity (OR 2.0, 95% CI 1.5-2.7). In fully adjusted models, Hispanic ethnicity showed an 80% increase in HF readmission rate compared with non-Hispanic ethnicity (OR 1.8, 95% CI 1.2-2.6).

Conclusion

Among patients from a socioeconomically disadvantaged background living in a Hispanic-majority area, being Hispanic is associated with higher odds of 30-day hospital re-admission after adjusting for demographic, clinical and socioeconomic covariates. Our findings show that further research is needed to understand disparities in Hispanic's heart failure-related outcomes.

Developing and implementing a heart failure data mart for research and quality improvement

OBJECTIVE

The purpose of this project was to build and formatively evaluate a near-real time heart failure (HF) data mart. Heart Failure (HF) is a leading cause of hospital readmissions. Increased efforts to use data meaningfully may enable healthcare organizations to better evaluate effectiveness of care pathways and quality improvements, and to prospectively identify risk among HF patients.

METHODS AND PROCEDURES

We followed a modified version of the Systems Development Life Cycle: 1) Conceptualization, 2) Requirements Analysis, 3) Iterative Development, and 4) Application Release. This foundational work reflects the first of a two-phase project. Phase two (in process) involves the implementation and evaluation of predictive analytics for clinical decision support.

RESULTS

We engaged stakeholders to build working definitions and established automated processes for creating an HF data mart containing actionable information for diverse audiences. As of December 2017, the data mart contains information from over 175,000 distinct patients and >100 variables from each of their nearly 300,000 visits.

CONCLUSION

The HF data mart will be used to enhance care, assist in clinical decision-making, and improve overall quality of care. This model holds the potential to be scaled and generalized beyond the initial focus and setting.

Improvement in clinical outcomes of patients with heart failure and active cocaine use after β-blocker therapy

BACKGROUND

Cocaine use has a high prevalence in the United States and can be associated with significant cardiovascular disease, even in asymptomatic users. β-Adrenergic receptor hyperactivation is the underlying pathophysiologic pathway of cocaine cardiotoxicity. β-Blocker therapy is controversial in patients with active cocaine use.

HYPOTHESIS

β-Blocker therapy is associated with clinical improvement in patients with heart failure despite active cocaine use.

METHODS

In a single-center, retrospective chart analysis, patients with newly diagnosed heart failure and active cocaine use who had been started on β-blocker therapy were reviewed. The New York Heart Association (NYHA) functional class and the left ventricular ejection fraction (LVEF) were recorded at baseline and after 12 monthsnthsnths of β-blocker use. Patients were excluded if they had been on prior β-blocker therapy, had other reasons for volume overload, had chronic kidney disease stages G4 or G5, or had a life expectancy <12 months.

RESULTS

Thirty-eight patients were identified; most were African American males. A statistically significant improvement was found in both NYHA functional class (P < 0.0001) and LVEF (P < 0.0001) after 12 months of β-blocker therapy. No major adverse cardiovascular events occurred in this population.

CONCLUSIONS

β-Blocker use in cocaine users with heart failure with a reduced ejection fraction is associated with a lower NYHA functional class and a higher LVEF at 12-month follow-up. No major adverse cardiovascular events were observed.

Early effects of empagliflozin on exercise tolerance in patients with heart failure: A pilot study

BACKGROUND

Sodium-glucose linked transporter 2 inhibition recently emerged as a promising therapy for reducing the risk of heart failure (HF) in patients with type 2 diabetes mellitus (T2DM). However, there is a lack of data endorsing its role in symptomatic HF patients. We sought to evaluate the short-term effects of empagliflozin on maximal exercise capacity in these patients.

HYPOTHESIS

We postulate tretament with empagliflozin may improve functional capacity in patients with T2DM and established HF.

METHODS

Nineteen T2DM patients with symptomatic HF were prospectively included and underwent cardiopulmonary exercise testing before and 30 days after initiation of empagliflozin therapy. A mixed-effects model for repeated measures was used.

RESULTS

Median patient age was 72 years (interquartile range, 60-79 years); 42.1% were in New York Heart Association class III. Baseline mean (± SD) peak oxygen consumption (peak VO₂ ) was 10.9 ± 4.0 mL/min/kg. Peak VO₂ increased significantly at 30 days (∆: +1.21 [0.66 to 1.76] mL/min/kg; P < 0.001). A significant improvement in ventilatory efficiency during exercise, 6-minute walking distance, and quality of life, and a reduction in antigen carbohydrate 125, were also found. Estimated glomerular filtration rate and natriuretic peptides did not significantly change.

CONCLUSIONS

In this pilot study, empagliflozin was associated with 1-month improvement in exercise capacity in T2DM patients with symptomatic HF. This beneficial effect was also found for other surrogates of severity.

Digoxin use and lower risk of 30-day all-cause readmission in older patients with heart failure and reduced ejection fraction receiving β-blockers

BACKGROUND

Digoxin use has been associated with a lower risk of 30-day all-cause admission and readmission in patients with heart failure and reduced ejection fraction (HFrEF).

HYPOTHESIS

Digoxin use will be associated with improved outcomes in patients with HFrEF receiving β-blockers.

METHODS

Of the 3076 hospitalized Medicare beneficiaries with HFrEF (EF <45%), 1046 received a discharge prescription for β-blockers, of which 634 were not on digoxin. Of the 634, 204 received a new discharge prescription for digoxin. Propensity scores for digoxin use, estimated for each of the 634 patients, were used to assemble a matched cohort of 167 pairs of patients receiving and not receiving digoxin, balanced on 30 baseline characteristics. Matched patients (n = 334) had a mean age of 74 years and were 46% female and 30% African American.

RESULTS

30-day all-cause readmission occurred in 15% and 27% of those receiving and not receiving digoxin, respectively (hazard ratio [HR]: 0.51, 95% confidence interval [CI]: 0.31-0.83, P = 0.007). This beneficial association persisted during 4 years of follow-up (HR: 0.72, 95% CI: 0.57-0.92, P = 0.008). Digoxin use was also associated with a lower risk of the combined endpoint of all-cause readmission or all-cause mortality at 30 days (HR: 0.54, 95% CI: 0.34-0.86, P = 0.009) and at 4 years (HR: 0.76, 95% CI: 0.61-0.96, P = 0.020).

CONCLUSIONS

In hospitalized patients with HFrEF receiving β-blockers, digoxin use was associated with a lower risk of 30-day all-cause readmission but not mortality, which persisted during longer follow-up.

Sex differences in heart failure

Heart failure (HF) numbers continue to grow in the United States and approximately 50% of patients living with HF are women. For the provider, it is critical to understand the role that gender plays in recognition, diagnosis, and management. The purpose of this literature review is to highlight the prevalence of heart failure in women and discuss gender variations in epidemiology, symptoms, pharmacology, and treatment as well as examine the representation of women in clinical trials.

Taking cardiology clinical trials to the next level: A call to action

Physicians previously perceived heart disease to be a man's disease; yet, since 1984, more women have died of ischemic heart disease. Because women who develop obstructive coronary heart disease and heart failure tend to do so 10 years later than men, cardiology clinical trials that use arbitrary age cutoffs or exclusion criteria based on comorbidities and polypharmacy often limit the pool of potential participants to a greater extent for women. Issues related to trial design and insufficient accounting for female-predominant disease patterns have contributed to low rates of enrollment of women in certain domains of cardiology research. Accordingly, women do not benefit from as rich an evidence base for cardiology as men. Here, we review major sex differences in heart disease and discuss areas of cardiology research in which women have been underrepresented. Considering the widespread sex differences in cardiovascular structure and function, it is important to include balanced numbers of women and men in cardiovascular clinical trials. Beyond inclusion, sex-specific reporting is also essential. Moreover, with ongoing developments of clinical-trial methodology, it is imperative to seek innovative ways to learn as much as possible about how interventions behave in women and men. Adaptive trials are specifically identified as promising opportunities to consider sex-based analyses at interim stages, allowing sex-specific flexibility as these trials unfold. Finally, we emphasize the importance of factoring sex as a biological variable into the design, analysis, and reporting of preclinical research, because this research critically informs the design and execution of clinical trials.

Effects of simulation-based educational program in improving the nurses' self-efficacy in caring for patients' with COPD and CHF in a post-acute care (PACU) setting

The 2014 national percentage for 30-day readmissions among Medicare recipients from Post-Acute Care Unit (PACU) showed: Heart Failure (HF) with major complications and co-morbidities, an average of 24.09%, and Chronic Obstructive Pulmonary Disease (COPD) with complications and co-morbidities 23.12%. The percentage of readmissions for New Jersey among PACU showed: HF with major complications and co-morbidities, an average of 24.40% and COPD 26.35% (Avalere Health, 2014). For this study site, the hospital readmission rate was not specifically broken down according to condition/diagnosis. Overall, the hospital readmission rate was approximately 20%. A few percent lower than the national and state average, but still a considerable number. This study is significant in finding out whether a simulation based educational program will increase the nurses' self-efficacy in caring for these patients. The positive outcome of this study can provide a template for training PACU nurses to aid in decreasing hospital readmissions in this vulnerable population. The simulation-based educational program was approximately 5h in length, and it was divided into two parts, a presentation on HF and COPD, and the actual simulation scenario, using a low-fidelity manikin (LFM). There were approximately 20 Registered nurses as participants but 4 did not complete the post-simulation self-efficacy scale, and the 16 were included in the actual study. This study was able to define the effects of simulation-based educational program on the RNs self-efficacy in caring for COPD and HF patients. The participants' demographic information, i.e. age, educational attainment, years of experience, and previous work experience, did not show any differences in how much the nurses' self-efficacy improved. The post-simulation self-efficacy score of the participants showed approximately 5% increase compared to the pre-simulation score. The outcome of the study concluded the simulation-based educational program as having a significant effect on the participants' self-efficacy post-simulation.

Clinical and prognostic relationships of pulmonary artery to aorta diameter ratio in patients with heart failure: a cardiac magnetic resonance imaging study

BACKGROUND

The pulmonary artery (PA) distends as pressure increases.

HYPOTHESIS

The ratio of PA to aortic (Ao) diameter may be an indicator of pulmonary hypertension and consequently carry prognostic information in patients with chronic heart failure (HF).

METHODS

Patients with chronic HF and control subjects undergoing cardiac magnetic resonance imaging were evaluated. The main PA diameter and the transverse axial Ao diameter at the level of bifurcation of the main PA were measured. The maximum diameter of both vessels was measured throughout the cardiac cycle and the PA/Ao ratio was calculated.

RESULTS

A total of 384 patients (mean age, 69 years; mean left ventricular ejection fraction, 40%; median NT-proBNP, 1010 ng/L [interquartile range, 448-2262 ng/L]) and 38 controls were included. Controls and patients with chronic HF had similar maximum Ao and PA diameters and PA/Ao ratio. During a median follow-up of 1759 days (interquartile range, 998-2269 days), 181 patients with HF were hospitalized for HF or died. Neither PA diameter nor PA/Ao ratio predicted outcome in univariable analysis. In a multivariable model, only age and NT-proBNP were independent predictors of adverse events.

CONCLUSIONS

The PA/Ao ratio is not a useful method to stratify prognosis in patients with HF.

Variation in practice patterns and outcomes across United Network for Organ Sharing allocation regions

BACKGROUND

The number of heart transplants performed is limited by organ availability and is managed by the United Network for Organ Sharing (UNOS). Efforts are underway to make organ disbursement more equitable as demand increases.

HYPOTHESIS

Significant variation exists in contemporary patterns of care, wait times, and outcomes among patients undergoing heart transplantation across UNOS regions.

METHODS

We identified adult patients undergoing first, single-organ heart transplantation between January 2006 and December 2014 in the UNOS dataset and compared sociodemographic and clinical profiles, wait times, use of mechanical circulatory support (MCS), status at time of transplantation, and 1-year survival across UNOS regions.

RESULTS

We analyzed 17 096 patients undergoing heart transplantation. There were no differences in age, sex, renal function, and peripheral vascular resistance across regions; however, there was 3-fold variation in median wait time (range, 48-166 days) across UNOS regions. Proportion of patients undergoing transplantation with status 1A ranged from 36% to 79% across regions (P < 0.01), and percentage of patients hospitalized at time of transplantation varied from 41% to 98%. There was also marked variation in MCS and inotrope utilization (28%-57% and 25%-58%, respectively; P < 0.001). Durable ventricular assist device implantation varied from 20% to 44% (P < 0.001), and intra-aortic balloon pump utilization ranged from 4% to 18%.

CONCLUSIONS

Marked differences exist in patterns of care across UNOS regions that generally trend with differences in waitlist time. Novel policy initiatives are required to address disparities in access to allografts and ensure equitable and efficient allocation of organs.

Randomized, Controlled Trial of TRC101 to Increase Serum Bicarbonate in Patients with CKD

BACKGROUND AND OBJECTIVES

Metabolic acidosis is common in patients with CKD and has significant adverse effects on kidney, muscle, and bone. We tested the efficacy and safety of TRC101, a novel, sodium-free, nonabsorbed hydrochloric acid binder, to increase serum bicarbonate in patients with CKD and metabolic acidosis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

One hundred thirty-five patients were enrolled in this randomized, double-blind, placebo-controlled, multicenter, in-unit study (designated the TRCA-101 Study). Patients had a mean baseline eGFR of 35 ml/min per 1.73 m2, a mean baseline serum bicarbonate of 17.7 mEq/L, and comorbidities, including hypertension (93%), diabetes (70%), and heart failure (21%). Patients ate a controlled diet and were treated for 14 days with placebo or one of four TRC101 dosing regimens (1.5, 3, or 4.5 g twice daily or 6 g once daily). After treatment, patients were discharged and followed for 7-14 days.

RESULTS

All TRC101 treatment groups had a mean within-group increase in serum bicarbonate of ≥1.3 mEq/L (P<0.001) within 72 hours of the first dose and a mean increase in serum bicarbonate of 3.2-3.9 mEq/L (P<0.001) at the end of treatment compared with placebo, in which serum bicarbonate did not change. In the combined TRC101 treatment group, serum bicarbonate was normalized (22-29 mEq/L) at the end of treatment in 35% of patients and increased by ≥4 mEq/L in 39% of patients. After discontinuation of TRC101, serum bicarbonate decreased nearly to baseline levels within 2 weeks. All adverse events were mild or moderate, with gastrointestinal events most common. All patients completed the study.

CONCLUSIONS

TRC101 safely and significantly increased the level of serum bicarbonate in patients with metabolic acidosis and CKD.

[Correlation between the parameters of acoustic cardiography and BNP, LVEF and cardiac function grading in patients with chronic heart failure]

Objective: To explore the correlation between the parameters of the new generation of Acoustic Cardiography and brain natriuretic peptide (BNP), left ventricular ejection fraction (LVEF) and cardiac function grading in the diagnosis of heart failure. Methods: One hundred and sixty-eight inpatients, who were hospitalized in Department of Cardiology, Haikou People's Hospital from May 2016 to July 2017, were enrolled as heart failure group, including NYHA class Ⅰ(n=29), NYHA class Ⅱ(n=40), NYHA class Ⅲ(n=64), NYHA class Ⅳ (n=35). And eighty-seven patients with normal cardiac function were selected as healthy control group. The data of the two groups were analyzed after the Acoustic Cardiography test, BNP determination and LVEF examination. Results: The differences in QRS duration, electromechanical activation time (EMAT), EMAT%, systolic dysfunction index (SDI), third heart sound (S3) and other indicators among the groups with different levels of cardiac function were statistically significant (P<0.05). The difference in left ventricular systolic time (LVST) between the cardiac function grade Ⅰ and healthy group was not significant (P>0.05), while the differences among the rest groups were significant. There was a positive correlation between QRS duration, EMAT%, SDI, S3 and BNP (t=9.46, 11.38, 12.14, 9.67, respectively, P<0.05); LVST and BNP were negatively correlated (t=-14.27, P<0.05). There was a negative correlation between QRS duration, EMAT%, SDI, S3 and LVEF (t=11.24, -8.764, -2.393, -0.579, respectively, P<0.05). There was a positive correlation between LVST and LVEF (t=23.48, P<0.05). There was a positive correlation between QRS duration, EMAT%, SDI, S3 and cardiac function grading (β=0.003, 0.234, 0.419, 0.352, respectively, P<0.05). There was a negative correlation between LVST and cardiac function grade (β=-0.021, P<0.05). Conclusion: The parameters of the Acoustic Cardiography test (EMAT%, EMAT, SDI, S3 ) are closely related to BNP, LVEF and cardiac function grading, and can be used as assistant indexes for the diagnosis and evaluation of heart failure.

Regional Differences in Predicting Risk of 30-Day Readmissions for Heart Failure

Many researchers are working toward the goal of data-driven care by predicting the risk of 30-day readmissions for patients with heart failure. Most published predictive models have used only patient level data from either single-center studies or secondary data analysis of randomized control trials. This study describes a hierarchical model that captures regional differences in addition to patient-level data from 1778 unique patients across 31 geographically distributed hospitals from one health system. The model was developed using Bayesian techniques operating on a large set of predictors. It provided Area Under Curve (AUC) of 0.64 for the validation cohort. We confirmed that the regional differences indeed exist in the observed data and verified that our model was able to capture the regional variances in predicting the risk of 30-day readmission for patients in our cohort.

Aorto-left ventricular tunnel: a rare cause of heart failure in the newborn

Aorto-left ventricular tunnel is a rare congenital cardiac anomaly, consisting of a short abnormal pathway, usually from a sinus of Valsalva into the left ventricular cavity. It is usually diagnosed with echocardiography. We report a case of a newborn presenting with heart murmur and rapid progression to heart failure and left ventricular enlargement due to an aorto-left ventricular tunnel. Despite successful closure of the tunnel, the patient required a Ross procedure due to progressive aortic disease.

Predictors of arrhythmia recurrence in patients with heart failure undergoing left atrial ablation for atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) ablation is increasingly used in patients with reduced left ventricular ejection fraction (LVEF). The aim of the present study was to evaluate the long-term results of a single radiofrequency catheter ablation procedure in heart failure (HF) patients with AF.

HYPOTHESIS

We tested the hypothesis that left atrial ablation is an effective therapeutic modality in patients with heart failure.

METHODS

Our study included HF patients with LVEF <50% who underwent catheter ablation for AF at our department between January 2010 and March 2017. All patients underwent our institution's protocol for follow-up post-ablation.

RESULTS

The study enrolled a total of 38 patients (mean age, 54.1 ± 12.2 years; 28 [73.7%] males; mean LVEF, 38.2% ± 6.3%). After a mean follow-up period of 38.2 months (range, 5-92 months), 28 patients (73.7%) were free from arrhythmia recurrence. In multivariate analysis, early arrhythmia recurrence (P = 0.03) and amiodarone antiarrhythmic drug administration (P = 0.003) remained independent predictors of arrhythmia recurrence.

CONCLUSIONS

The main findings of this study are that (1) a single radiofrequency catheter ablation procedure is an effective and safe modality for AF in patients with concomitant HF; (2) after a mean 3.3 years of follow-up, 73.7% of HF patients remained in sinus rhythm; and (3) early arrhythmia recurrence was a significant predictor of arrhythmia recurrence after the blanking period.

Predicting Risk of 30-Day Readmissions Using Two Emerging Machine Learning Methods

Decades-long research efforts have shown that Heart Failure (HF) is the most expensive diagnosis for hospitalizations and the most frequent diagnosis for 30-day readmissions. If risk stratification for readmission of HF patients could be carried out at the time of discharge from the index hospitalization, corresponding appropriate post-discharge interventions could be arranged to avoid potential readmission. We, therefore, sought to explore and compare two newer machine learning methods of risk prediction using 56 predictors from electronic health records data of 1778 unique HF patients from 31 hospitals across the United States. We used two approaches boosted trees and spike-and-slab regression for analysis and found that boosted trees provided better predictive results (AUC: 0.719) as compared to spike-and-slab regression (AUC: 0.621) in our dataset.

Life After Surviving Fontan Surgery: A Meta-Analysis of the Incidence and Predictors of Late Death

AIM

We now know that 20-40% of patients with a single ventricle will develop heart failure after the second decade post-Fontan surgery. However, we remain unable to risk-stratify the cohort to identify patients at highest risk of late failure and death. We conducted a systematic review of all reported late outcomes for patients with a Fontan circulation to identify predictors of late death.

METHODS

We searched MEDLINE, Embase and PubMed with subject terms ("single ventricle", "Hypoplastic left heart syndrome", "congenital heart defects" or "Fontan procedure") AND ("heart failure", "post-operative complications", "death", "cause of death", "transplantation" or "follow-up studies") for relevant studies between January 1990 and December 2015. Variables identified as significant predictors of late death on multivariate analysis were collated for meta-analysis. Survival data was extrapolated from Kaplan-Meier survival curves to generate a distribution-free summary survival curve.

RESULTS

Thirty-four relevant publications were identified, with a total of 7536 patients included in the analysis. Mean follow-up duration was 114 months (range 24-269 months). There were 688 (11%) late deaths. Predominant causes of death were late Fontan failure (34%), sudden death (19%) and perioperative death (16%). Estimated mean survival at 5, 10 and 20 years post Fontan surgery were 95% (95%CI 93-96), 91% (95%CI 89-93) and 82% (95%CI 77-85). Significant predictors of late death include prolonged pleural effusions post Fontan surgery (HR1.18, 95%CI 1.09-1.29, p<0.001), protein losing enteropathy (HR2.19, 95%CI 1.69-2.84, p<0.001), increased ventricular end diastolic volume (HR1.03 per 10ml/BSA increase, 95%CI 1.02-1.05, p<0.001) and having a permanent pacemaker (HR12.63, 95%CI 6.17-25.86, p<0.001).

CONCLUSIONS

Over 80% of patients who survive Fontan surgery will be alive at 20 years. Developing late sequelae including protein losing enteropathy, ventricular dysfunction or requiring a pacemaker predict a higher risk of late death.

Longitudinal Analysis of Quality of Life, Clinical, Radiographic, Echocardiographic, and Laboratory Variables in Dogs with Preclinical Myxomatous Mitral Valve Disease Receiving Pimobendan or Placebo: The EPIC Study

Background

Changes in clinical variables associated with the administration of pimobendan to dogs with preclinical myxomatous mitral valve disease (MMVD) and cardiomegaly have not been described.

Objectives

To investigate the effect of pimobendan on clinical variables and the relationship between a change in heart size and the time to congestive heart failure (CHF) or cardiac‐related death (CRD) in dogs with MMVD and cardiomegaly. To determine whether pimobendan‐treated dogs differ from dogs receiving placebo at onset of CHF.

Animals

Three hundred and fifty‐four dogs with MMVD and cardiomegaly.

Materials and Methods

Prospective, blinded study with dogs randomized (ratio 1:1) to pimobendan (0.4–0.6 mg/kg/d) or placebo. Clinical, laboratory, and heart‐size variables in both groups were measured and compared at different time points (day 35 and onset of CHF) and over the study duration. Relationships between short‐term changes in echocardiographic variables and time to CHF or CRD were explored.

Results

At day 35, heart size had reduced in the pimobendan group: median change in (Δ) LVIDDN −0.06 (IQR: −0.15 to +0.02), P < 0.0001, and LA:Ao −0.08 (IQR: −0.23 to +0.03), P < 0.0001. Reduction in heart size was associated with increased time to CHF or CRD. Hazard ratio for a 0.1 increase in ΔLVIDDN was 1.26, P = 0.0003. Hazard ratio for a 0.1 increase in ΔLA:Ao was 1.14, P = 0.0002. At onset of CHF, groups were similar.

Conclusions and Clinical Importance

Pimobendan treatment reduces heart size. Reduced heart size is associated with improved outcome. At the onset of CHF, dogs treated with pimobendan were indistinguishable from those receiving placebo.

Perceived Sexual Difficulties and Sexual Counseling in Men and Women Across Heart Diagnoses: A Nationwide Cross-Sectional Study

BACKGROUND

Ischemic heart disease and heart failure often lead to sexual difficulties in men, but little is known about the sexual difficulties in women and patients with other heart diagnoses or the level of information patients receive about the risk of sexual difficulties.

AIM

To investigate perceived sexual difficulties and associated factors in a mixed population of men and women newly diagnosed with heart disease and provide insight into sexual counseling and information given by health care professionals.

METHODS

This article reports on a cross-sectional, questionnaire study sent to a randomly selected sample of men and women newly diagnosed with heart failure, ischemic heart disease, atrial fibrillation, or heart valve surgery. Eligible patients were identified by diagnosis using the Danish National Patient Register, which contains all diagnoses.

OUTCOMES

Sexual difficulties were self-reported using single-item questions, and factors associated with sexual difficulties were collected from the survey and national registers.

RESULTS

The study population consisted of 1,549 men and 807 women (35-98 years old) with heart failure (n = 243), ischemic heart disease (n = 1,036), heart valve surgery (n = 375), and atrial fibrillation (n = 702). Sexual difficulties were reported by 55% of men and 29% of women. In a multiple regression analysis, difficulties in men were associated with being older (≥75 years old; odds ratio [OR] = 1.97, 95% CI = 1.13-3.43), having heart failure (OR = 2.07, 95% CI = 1.16-3.71), diabetes (OR = 1.80, 95% CI = 1.15-2.82), hypertension (OR = 1.43, 95% CI = 1.06-1.93), receiving β-blockers (OR = 1.37, 95% CI = 1.02-1.86), or having anxiety (OR = 2.25, 95% CI = 1.34-3.80) or depression (OR = 2.74, 95% CI = 1.38-5.43). In women, difficulties were significantly associated with anxiety (OR = 3.00, 95% CI = 1.51-5.95). A total of 48.6% of men and 58.8% of women did not feel informed about sexuality, and 18.1% of men and 10.3% of women were offered sexual counseling.

CLINICAL IMPLICATIONS

Heart disease increases the risk of sexual difficulties and there is a need for improved information and counseling about sex and relationships for patients.

STRENGTHS AND LIMITATIONS

This large nationwide survey of men and women combined a survey with administrative data from national registries. However, this study used non-validated single-item questions to assess sexual difficulties without addressing sexual distress.

CONCLUSION

More than half the men and one fourth the women across common heart diagnoses had sexual difficulties. No difference was found among diagnoses, except heart failure in men. Despite guidelines recommending sexual counseling, sexual difficulties were not met by sufficient information and counseling. Rundblad L, Zwisler AD, Johansen PP, et al. Perceived Sexual Difficulties and Sexual Counseling in Men and Women Across Heart Diagnoses: A Nationwide Cross-Sectional Study. J Sex Med 2017;14:785-796.

[Hemodynamic regime of asymptomatic heart disease patients studied by echocardiogram]

BACKGROUND

Viewing heart failure as a clinical syndrome delays treatment and impairs prognosis, which leads to the question: Is it possible to make an early diagnosis based on echocardiography studies?

METHODS

It was carried out a review of medical records of asymptomatic heart disease patients, with no treatment, who were studied by echocardiogram in order to measure cardiac output (CO) and total peripheral vascular resistance (TPVR), for which mean blood pressure was calculated. It is described the hemodynamic regime on the basis of the proportion of three integrated groups according to CO and TPVR.

RESULTS

The hemodynamic regime in 200 heart disease patients was hypokinetic in 36%, hyperkinetic in 17% and eukinetic in 47%.

CONCLUSIONS

Non-invasive hemodynamic study identified asymptomatic heart failure in one third of the cases.

Renal and Cardiovascular Effects of sodium-glucose cotransporter 2 (SGLT2) inhibition in combination with loop Diuretics in diabetic patients with Chronic Heart Failure (RECEDE-CHF): protocol for a randomised controlled double-blind cross-over trial

INTRODUCTION

Type 2 diabetes (T2D) and heart failure (HF) are a frequent combination, where treatment options remain limited. There has been increasing interest around the sodium-glucose cotransporter 2 (SGLT2) inhibitors and their use in patients with HF. Data on the effect of SGLT2 inhibitor use with diuretics are limited. We hypothesise that SGLT2 inhibition may augment the effects of loop diuretics and the benefits of SGLT2 inhibitors may extend beyond those of their metabolic (glycaemic parameters and weight loss) and haemodynamic parameters. The effects of SGLT2 inhibitors as an osmotic diuretic and on natriuresis may underlie the cardiovascular and renal benefits demonstrated in the recent EMPA-REG study.

METHODS AND ANALYSIS

To assess the effect of SGLT2 inhibitors when used in combination with a loop diuretic, the RECEDE-CHF (Renal and Cardiovascular Effects of SGLT2 inhibition in combination with loop Diuretics in diabetic patients with Chronic Heart Failure) trial is a single-centre, randomised, double-blind, placebo-controlled, cross-over trial conducted in a secondary care setting within NHS Tayside, Scotland. 34 eligible participants, aged between 18 and 80 years, with stable T2D and CHF will be recruited. Renal physiological testing will be performed at two points (week 1 and week 6) on each arm to assess the effect of 25 mg empagliflozin, on the primary and secondary outcomes. Participants will be enrolled in the trial for a total period between 14 and 16 weeks. The primary outcome will assess the effect of empagliflozin versus placebo on urine output. The secondary outcomes are to assess the effect of empagliflozin on glomerular filtration rate, cystatin C, urinary sodium excretion, urinary protein/creatinine ratio and urinary albumin/creatinine ratio when compared with placebo.

ETHICS AND DISSEMINATION

Ethics approval was obtained by the East of Scotland Research Ethics Service. Results of the trial will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03226457; Pre-results.

[Cardiac rehabilitation in heart failure]

Heart failure is a malignant disorder with increasing prevalence and a high socioeconomic impact. Sceletal muscle myopathy seems to play a key role in the development of exercise intolerance. Cardiac rehabilitation for heart failure mainly adresses training, namely moderate continuous endurance training or interval training in combination with resistance training, and is highly recommended in the current ESC-guidelines. Following a multimodal concept cardiac rehabilitation also implements optimisation of neurohumoral therapy, education and counselling to empower self-care as well as psychosocial support.

Intramyocardial Injection of Stem Cells in Pig Myocardial Infarction Model: The First Trial in Korea

Although cell therapy is emerged for cardiac repair, its efficacy is modest by intracoronary infusion. Therefore, we established the intramyocardial delivery technique using a left ventricular (LV) mapping system (NOGA® XP) using 18 pigs. After adipose tissue-derived mesenchymal stem cells (ATSCs) were delivered intramyocardially to porcine infarcted heart, LV ejection fraction (EF) was increased, and LV chamber size was decreased. We proved the therapeutic effect of intramyocardial injection of ATSC through a LV mapping system in the porcine model for the first time in Korea. The adoption of this technique may accelerate the translation into a clinical application in the near future.

Awareness of physicians and pharmacists of aldosterone antagonists in heart failure and myocardial infarction in Jordan

Objective:

to evaluate physicians and clinical pharmacists’ awareness and practices regarding use of aldosterone antagonists in heart failure (HF) and post-myocardial infarction (MI).

Methods:

First, we reviewed the prescription of aldosterone antagonists among 408 patients presenting to the cardiology clinic at a major hospital in Jordan. Second, physicians and pharmacists working in cardiovascular departments completed a questionnaire related to use of aldosterone antagonists in HF and post-MI.

Results:

Thirty patients (7.59%) were eligible for aldosterone antagonist; only 4 received them at discharge (13.3%). The survey was completed by 153 professionals (response rate 76.12%). About 72.1% of participants were aware of studies regarding use of aldosterone antagonists post-MI and in HF. Moreover, 10.45%/53.6% of participants strongly agreed/agreed that these agents are useful in normotensive post-MI and HF patients. Spironolactone was the most prescribed drug by 92.1% of participants. About 41.8% of participants reported use of spironolactone in post-MI and HF. With respect to guidelines, only 39.2% of participants agreed that adding spironolactone to standard therapy in HF is recommended, and 48.3% agreed on adding it directly post-MI. Clinical pharmacists and cardiologists were generally more aware of guidelines than pharmacists, cardiac surgeons and residents/fellows.

Conclusions:

there is an under-use of aldosterone antagonists in HF and post-MI patients, and a lack of detailed awareness of current guidelines among health care providers. Dissemination of evidence-based guidelines and usage protocols may improve management of post-MI and HF.

Uso de recursos y costos de hospitalizaciones por insufi ciencia card í aca: un estudio retrospective multic é ntrico en Argentina

OBJECTIVES

Heart failure has a great impact on health budget, mainly due to the cost of hospitalizations. Our aim was to describe health resource use and costs of heart failure admissions in three important institutions in Argentina.

METHODS

Multi-center retrospective cohort study, with descriptive and analytical analysis by subgroups of ejection fraction, blood pressure and renal function at admission. Generalized linear models were used to assess the association of independent variables to main outcomes.

RESULTS

We included 301 subjects; age 75.3±11.8 years; 37% women; 57% with depressed ejection fraction; 46% of coronary etiology. Blood pressure at admission was 129.8±29.7 mmHg; renal function 57.9±26.2 ml/min/1.73 m². Overall mortality was 7%. Average length of stay was 7.82±7.06 days (median 5.69), and was significantly longer in patients with renal impairment (8.9 vs. 8.18; p=0.03) and shorter in those with high initial blood pressure (6.08±4.03; p=0.009). Mean cost per patient was AR$68,861±96,066 (US$=8,071; 1US$=AR$8.532); 71% attributable to hospital stay, 20% to interventional procedures and 6.7% to diagnostic studies. Variables independently associated with higher costs were depressed ejection fraction, presence of valvular disease, and impaired renal function.

CONCLUSIONS

Resource use and costs associated to hospitalizations for heart failure is high, and the highest proportion is attributable to the costs related to hospital stay.

Anemia in severe heart failure patients: does it predict prognosis?

Background

Anemia is highly prevalent in heart failure (HF) patients. However, the prevalence, clinical impact and prognostic factor of anemia in heart failure patients is widely varies. The aim of this study was to evaluate the prevalence of anemia in patients with HF, to compare baseline clinical characteristic and outcomes of severe HF patients with and without anemia admitted to Gondar University Referral Hospital (GURH), Gondar, Ethiopia.

Method

A retrospective cohort study was conducted and we assessed medical records of heart failure patients who were admitted Gondar University Referral Hospital in the period between December 02, 2010 and November 30, 2016. Kaplan Meier curve was used to analyze the survival status and log rank test was used to compare the curves. Multivariate Cox regression was used to analyze independent predictors of mortality in all HF patients. P value less than 0.05 was considered statistically significant.

Result

Three hundred and seventy patients participated in the study. The prevalence of anemia in the study cohorts was 41.90% and majority of the participants were females (64.59%). There was a significant difference in the level of hemoglobin, creatinine, and sodium among anemic and non-anemic patients. Anemic patients with HF tend to take angiotensin converting enzyme inhibitors (ACEI) less frequently. Kaplan Meier survival curves and Log rank test (P = 0.042) showed a significant difference in the prognosis of HF patients with anemia and non – anemic. More significant difference was observed (Log rank test, P = 0.001) in the study participants based on hemoglobin level. Furthermore, multivariate Cox regression showed: advanced age, levels of lower sodium and higher creatinine, and absences of medications like ACEI and Spironolactone independently predicted overall mortality.

Conclusion

HF patients with anemia tend to be older age, had lower hemoglobin and sodium level and higher creatinine value. Moreover, there was a significant difference in the prognosis between study cohorts, as anemic pateints tend to have a worse survival status . Even though, anemia is a significant risk marker, it is not an independent predictor of mortality in the current study.

Seasonal variation in hospitalization outcomes in patients admitted for heart failure in the United States

BACKGROUND

There is lack of evidence of the impact of varying season on heart failure (HF) hospitalization outcomes in the U.S.

HYPOTHESIS

HF hospitalization outcomes exhibit significant seasonal variation in the U.S.

METHODS

Using data from the National Inpatient Sample (2011-2013), seasonal variation was classified based on meteorological classification of Northern Hemisphere-Spring, Summer, Fall, & Winter-and analysis was conducted via multivariable-adjusted mixed-effect model.

RESULTS

An estimated 2.8 million adults were hospitalized for HF in the U.S. from 2011 to 2013. Of all hospitalizations, admissions were highest in Winter (27%), followed by Spring (26%), Fall (24%), and Summer (23%). The overall mortality rate was 3.1%. Compared with Spring, there was significantly lower mortality in Summer (odds ratio [OR]: 0.95, 95% CI: 0.91-0.99) and Fall (OR: 0.94, 95% CI: 0.89-0.98), but the highest mortality was in Winter (OR: 1.06, 95% CI: 1.02-1.11). In addition, mean length of stay and median cost of hospitalization were highest in Winter (5.3 days, USD7459, respectively) and lowest in Summer (5.1 days, USD7181, respectively). However, age and sex differences existed (e.g. seasonal variation in inpatient mortality was only significant for patients age ≥65 years, and, compared with the Spring season, males had higher risk of inpatient mortality in Winter (OR: 1.10, 95% CI: 1.04-1.17) and females had lower risk of inpatient mortality in Summer (OR: 0.94, 95% CI: 0.88-1.00) and Fall (OR: 0.92, 95% CI: 0.87-0.98).

CONCLUSIONS

Among HF patients in the U.S., hospitalization outcomes were worse in Winter but better in Summer.

Aluminium phosphide poisoning with severe cardiac dysfunction and the role of digoxin

Aluminium phosphide (ALP) is a common cause of suicidal poisoning in India where it is easily available and commonly known as 'rice tablet'. In rural areas of India, it is still used to protect rice and stored grains from rodents and pests. 1 There is no specific antidote for phosphide poisoning and treatment involves meticulous supportive care. Ingestion can lead to severe cardiac suppression and cardiogenic shock. For patients poisoned with ALP who continue to have refractory shock with persistent myocardial suppression despite the use of adrenergic inotropic agents, the addition of digoxin may be beneficial. We present a case where digoxin was utilised with beneficial patient outcomes.

Right Heart Function During and After Community-Acquired Pneumonia in Adults

BACKGROUND

New-onset or worsening heart failure is the most common extra-pulmonary complication of community-acquired pneumonia (CAP) during the first 30 days after diagnosis.

METHODS

We evaluated the changes in the right ventricular function amongst adult CAP survivors from the time of acute infection to its resolution. We performed comprehensive transthoracic echocardiographic examinations to assess right heart function during the acute illness and the convalescent period (4 to 6 weeks after hospital discharge).

RESULTS

Twenty-six patients underwent acute measurements, of which convalescent measurements were completed in 19 subjects. There was no significant change in any of the right heart function parameters from the acute to convalescent stage of CAP.

CONCLUSIONS

Our results suggest that right ventricular function does not meaningfully change in the transition from the acute to convalescent stage of CAP in non-critically ill adult CAP survivors.

Psychiatric conditions as predictors of rehospitalization among African American patients hospitalized with heart failure

INTRODUCTION

African Americans (AAs) have the highest risk of developing heart failure (HF) among all ethnicities in the United States and are associated with higher rates of readmissions and mortality. This study aims to determine the prevalence and relationship of common psychiatric conditions to outcomes of patients hospitalized with HF.

HYPOTHESIS

Psychiatric conditions lead to worse outcomes in HF patients.

METHODS

This single-center retrospective study enrolled 611 AA patients admitted to an urban teaching community hospital for HF from 2010 to 2013. Patient demographics, clinical variables, and history of psychiatric disorders were obtained. Cox proportional hazards regression was used to assess impact of psychiatric disorders on readmission rates and mortality.

RESULTS

The mean age was 66 ± 15 years; 53% were men. Median follow-up time from index admission for HF was 3.2 years. Ninety-seven patients had a psychiatric condition: 46 had depression, 11 had bipolar mood disorder (BMD), and 40 had schizophrenia. After adjustment of known risk factors and clinical metrics, our study showed that AA HF patients with a psychiatric illness were 3.84× more likely to be admitted within 30 days for HF, compared with those without (P < 0.001). Individually, adjusted Cox multivariable logistic regression analysis also showed that, for 30-day readmission, schizophrenia had a hazard ratio (HR) of 4.92 (P < 0.001); BMD, an HR of 3.44 (P = 0.02); and depression, an HR 3.15 (P = 0.001). No associations were found with mortality.

CONCLUSIONS

Psychiatric conditions of schizophrenia, BMD, and depression were significantly associated with a higher 30-day and overall readmission rate for HF among AA patients.

Heart failure in patients with kidney disease

Heart failure (HF) is a leading cause of morbidity and mortality in patients with chronic kidney disease (CKD), and the population of CKD patients with concurrent HF continues to grow. The accurate diagnosis of HF is challenging in patients with CKD in part due to a lack of validated imaging and biomarkers specifically in this population. The pathophysiology between the heart and the kidneys is complex and bidirectional. Patients with CKD have greater prevalence of traditional HF risk factors as well as unique kidney-specific risk factors including malnutrition, acid-base alterations, uraemic toxins, bone mineral changes, anemia and myocardial stunning. These risk factors also contribute to the decline of kidney function seen in patients with subclinical and clinical HF. More targeted HF therapies may improve outcomes in patients with kidney disease as current HF therapies are underutilised in this population. Further work is also needed to develop novel HF therapies for the CKD population.

Current trends in admissions and outcomes of cardiac diseases in Ghana

Cardiovascular diseases (CVDs) pose a major burden in Africa, but data on temporal trends in disease burden are lacking. We assessed trends in CVD admissions and outcomes in central Ghana using a retrospective analysis of data from January 2004 to December 2015 among patients admitted to the medical wards of a tertiary medical center in Kumasi, Ghana. Rates of admissions and mortality were expressed as CVD admissions and deaths divided by the total number of medical admissions and deaths, respectively. Case fatality rates per specific cardiac disease diagnosis were also computed. Over the period, there were 4226 CVD admissions, with a male-to-female ratio of 1.1 to 1. There was a progressive increase in percentage of CVD admissions from 4.6% to 8.2%, representing an 78% increase, between 2004 and 2014. Of the 2170 CVD cases whose data were available, the top 3 causes of CVD admissions were heart failure (HF; 88.3%), ischemic heart disease (IHD; 7.2%), and dysrhythmias (1.9%). Of all HF admissions, 52% were associated with hypertension. IHD prevalence rose by 250% between 2005 and 2015. There were 976 deaths (23%), with an increase in percentage of hospital deaths that were cardiovascular in nature from 3.6% to 7.3% between 2004 and 2014, representing a 102% increase. Cardiac disease admissions and mortality have increased progressively over the past decade, with HF as the most common cause of admission. Once rare, IHD is emerging as a significant contributor to the CVD burden in sub-Saharan Africa.

Angioedema Spotlight: A Closer Examination of Sacubitril/Valsartan Safety Results

Incorporation of neprilysin inhibition into heart failure pharmacotherapy regimens has recently been recommended by U.S. guidelines, based on results from the PARADIGM-HF trial comparing sacubitril/valsartan to enalapril. While most of the discussion has focused on efficacy, a closer examination of the safety results, particularly the incidence of angioedema during the run-in and double-blind periods, is also warranted. Although no major safety concerns were identified, an angioedema risk comparable to enalapril was found, primarily in the black population. Therefore, despite combination with an angiotensin receptor blocker, which historically has a lower incidence of angioedema, the addition of neprilysin inhibition yields an angioedema risk profile comparable to angiotensin converting enzyme (ACE) inhibitors. Clinicians should recognize this safety risk when prescribing sacubitril/valsartan and remain vigilant in counseling patients regarding the signs and symptoms of angioedema. As recommended by the guidelines, avoiding sacubitril/valsartan use concurrently or within 36 hours of the last dose of an ACE inhibitor or in patients with a history of angioedema is also crucial to minimize angioedema risk and prevent patient harm.