The influence of comorbidities on the prognosis after an acute heart failure decompensation and differences according to ejection fraction: Results from the EAHFE and RICA registries

Type 2 diabetes increases the risk of mortality and cardiovascular events in ischemic HFmrEF patients: a retrospective cohort study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is known to worsen the prognosis of heart failure (HF), but its specific impact on patients with ischemic versus non-ischemic heart failure with mildly reduced ejection fraction (HFmrEF) remains unclear due to limited research and conflicting evidence.

METHODS

We conducted a retrospective study of 1,691 HFmrEF patients at Xiangtan Central Hospital. Participants were divided into four groups: ischemic with T2DM (467 patients), ischemic without T2DM (856 patients), non-ischemic with T2DM (87 patients), and non-ischemic without T2DM (281 patients). We utilized the Cox proportional hazards model to analyze differences in all-cause mortality and cardiovascular events among the groups.

RESULTS

After adjusting for multiple confounding factors using the Cox proportional hazards model, the ischemic heart disease and T2DM group had a significantly higher risk of all-cause mortality compared to the ischemic group without T2DM (HR = 1.5, 95% CI = 1.2-1.9, P = 0.001). The risk of cardiovascular events was also significantly increased (HR = 1.3, 95% CI = 1.1-1.5, P = 0.001). In non-ischemic HFmrEF patients, T2DM was not associated with a significantly increased risk of all-cause mortality (HR = 1.0, 95% CI = 0.6-1.7, P = 0.957) or cardiovascular events (HR = 1.3, 95% CI = 0.9-1.9, P = 0.113).

CONCLUSION

T2DM significantly increases the risk of all-cause mortality and cardiovascular events in ischemic HFmrEF patients, while its impact on non-ischemic HFmrEF patients is limited. These findings underscore the importance of managing T2DM in patients with ischemic HFmrEF.

Diagnosis and Management of Hypertensive Heart Disease: Incorporating 2023 European Society of Hypertension and 2024 European Society of Cardiology Guideline Updates

Hypertensive heart disease (HHD) continues to be a leading cause of cardiovascular morbidity and mortality worldwide, necessitating the evolution of evidence-based management strategies. This literature review examines the most recent updates from the 2023 and 2024 hypertension guidelines issued by the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC). These guidelines are compared with previous key recommendations, such as the 2017 American College of Cardiology/American Heart Association guidelines and the 2018 ESC/ESH guidelines. The updated recommendations reflect a paradigm shift in the approach to hypertension diagnosis and management, including a stricter systolic blood pressure (BP) target of 120-129 mmHg, which underscores the importance of early and precise BP control. The difference between the classification of "elevated BP" and hypertension in the ESC versus ESH guidelines, particularly, regarding their implications for early detection and prevention of HHD, are critically examined, highlighting areas of clinical and academic debate. The introduction of a new "elevated BP" category (120-139/70-89 mmHg) highlights a proactive strategy aimed at identifying at-risk individuals earlier in the disease course to prevent progression to HHD. Additionally, the divergent roles of hypertension-mediated organ damage (HMOD), including HHD, in risk stratification as recommended by the ESC and ESH are discussed, emphasising their significance in tailoring management approaches. For patients with resistant hypertension, the 2023 and 2024 updates also endorse innovative therapies, such as renal denervation, an interventional procedure that has demonstrated significant promise in managing treatment-resistant cases. This review synthesises these updates, focusing on their implications for clinical practice in diagnosing and managing HHD. By emphasising aggressive intervention and the integration of novel treatment modalities, the review aims to bridge existing gaps in earlier approaches to hypertension management. The critical evaluation of guideline discrepancies and evolving evidence seeks to provide clinicians with a nuanced understanding to optimise outcomes for patients with HHD, particularly considering emerging therapeutic possibilities and more stringent BP control targets.

Benefits of a comprehensive care model in patients with heart failure and chronic obstructive pulmonary disease: UMIPIC Program

BACKGROUND

Patients with heart failure (HF) and chronic obstructive pulmonary disease (COPD) have a high risk of hospital admission and mortality. This study evaluated the benefit of a care model, characterized by comprehensive and continuous care (UMIPIC program) in patients with HF and a history of COPD.

METHODS

A total of 5644 patients were prospectively recruited, of which 1320 had a history of COPD between March 2008 and March 2020. They were divided into 2 follow-up groups at the time of discharge, one in follow-up in the UMIPIC program (435 patients) and another treated conventionally (885 patients). The baseline characteristics of each group were analyzed and patients in each group were selected by propensity score matching and admissions and mortality were evaluated during 12 months of follow-up, after an episode of hospitalization for HF.

RESULTS

The UMIPIC group, compared to the conventional group in the matched cohort, had a lower rate of admissions for HF (21% vs 30 respectively; hazard ratio [HR] = 0.64; 95% confidence interval [95% CI]: 0.54-0.84; p = 0.002) and mortality (28% vs 36%, respectively; HR = 0.68; 95% CI: 0.51-0.90; p = 0.008). From a therapeutic point of view, patients with HF and a history of COPD who were followed in the UMIPIC program received a higher percentage of beta-blockers (64% vs 54%; p < 0.05) and direct-acting anticoagulants (17% vs 9%: p < 0.05) than those followed conventionally.

CONCLUSIONS

The implementation of the UMIPIC care program for patients with HF and a history of COPD, based on comprehensive and continuous care, reduces both admissions and mortality at one year of follow-up. The prescription of beta-blockers and direct-acting anticoagulants was also higher during follow-up in the UMIPIC program.

Clinical features, management in the emergency department and mortality of acute heart failure episodes in patients with chronic obstructive pulmonary disease

OBJECTIVES

This study aims to analyse differences in clinical and therapeutic management for patients with chronic obstructive pulmonary disease (COPD) who present to the emergency department with acute heart failure (AHF). Additionally, it examines mortality rates during such episodes.

METHODS

We included patients diagnosed with AHF at 50 Spanish emergency departments from 2012 to 2022 who also had COPD. We compared their baseline characteristics, decompensation episodes, and emergency department management with those of AHF patients without COPD during the same period. We collected data on in-hospital and 30-day all-cause mortality, investigating differences between the two groups using crude and adjusted logistic regression models.

RESULTS

A total of 21,694 AHF patients were analysed (median age = 83 years, 56% female), including 4,942 (23%) with COPD. COPD patients were generally younger and more frequently male, with a higher prevalence of comorbidities (excluding valve disease and dementia, which were more common in non-COPD patients). They exhibited a worse respiratory functional class (NYHA) but a better overall functional capacity (Barthel Index). Decompensation in COPD patients was more often triggered by infection and less frequently by tachyarrhythmia, hypertensive crisis, or acute coronary syndrome. While there were differences in clinical findings in the emergency department, the severity assessed by the MEESSI-AHF Scale was similar across both groups. In terms of emergency department management, a higher proportion of COPD patients received oxygen therapy, non-invasive ventilation, bronchodilators, corticosteroids, and antibiotics, while fewer received intravenous nitroglycerin, and they were hospitalized more frequently. In-hospital mortality rates were 8.1% for patients with COPD and 7.5% for those without (OR = 1.088, 95% CI = 0.968-1.224), with 30-day mortality rates of 11.0% and 10.0%, respectively (OR = 1.111, 95% CI = 1.002-1.231). After adjusting for clinical characteristics, decompensation episodes, and emergency department management, these odds ratios decreased to 1.040 (95% CI = 0.905-1.195) and 1.080 (95% CI = 0.957-1.219), respectively.

CONCLUSION

Patients with AHF and COPD exhibit distinct clinical and therapeutic management characteristics in the emergency department and require more frequent hospitalization. Although they show higher crude 30-day mortality, this is attributable to their differing clinical profiles rather than the presence of COPD itself.

The RICA-2 registry: design and baseline characteristics of the first 1,000 patients

BACKGROUND AND OBJECTIVE

Heart failure (HF) is a syndrome of epidemic proportions and one of the main reasons for hospital admission. Patient registries provide real-world clinical practice information which is complementary to clinical trials. RICA-2 is a registry of the Spanish Society of Internal Medicine. Its main goal is to know the clinical and epidemiological characteristics and prognostic factors of patients with HF treated in Internal Medicine Departments. The objective of this study is to present the design of the RICA-2, the baseline characteristics of the first 1000 patients included and their comparison with those of the historical cohort of the RICA registry.

METHODS

Observational, multicentre and prospective study of patients with HF with the following inclusion criteria: age equal to or greater than 18 years old, diagnosis of HF according to the European Guidelines, indistinct inclusion in decompensation or stable phase, of patients with de novo HF or chronic HF, regardless of left ventricular ejection fraction, aetiology and comorbidities.

RESULTS

RICA-2 patients have advanced age (83 years old) and 51% are women. The comorbidity burden is higher than in the RICA registry (5 points in the Charlson comorbidity index), with predominating chronic decompensated HF (74%), hypertensive aetiology (39%) and preserved ejection fraction (52%). Most patients are pre-frail or vulnerable and are at risk of malnutrition.

CONCLUSION

The RICA-2 represents a contemporary cohort of patients that will provide us with clinical, epidemiological and prognostic information on patients with acute and chronic HF treated in Internal Medicine.

The significance of metabolic alkalosis on acute decompensated heart failure: the ALCALOTIC study

AIMS

To determine the prevalence and the impact on prognosis of metabolic alkalosis (MA) in patients admitted for acute heart failure (AHF).

METHODS AND RESULTS

The ALCALOTIC is a multicenter, observational cohort study that prospectively included patients admitted for AHF. Patients were classified into four groups according to their acid-base status on admission: acidosis, MA, respiratory alkalosis, and normal pH (reference group for comparison). Primary endpoint was all-cause in-hospital mortality, and secondary endpoints included 30/90-day all-cause mortality, all-cause readmission, and readmission for HF. Associations between endpoints and acid-base alterations were estimated in a multivariate Cox regression model including sex, age, comorbidities, and Barthel index and expressed as hazard ratio (HR) with 95% confidence interval (95% CI). Six hundred sixty-five patients were included (84 years and 57% women), and 40% had acid-base alterations on admission: 188 (28%) acidosis and 78 (12%) alkalosis. The prevalence (95% CI) of MA was 9% (6.8-11.2%). Patients with MA were more women; had fewer comorbidities, better renal function, and higher left ventricle ejection fraction values; and received more treatment with oral acetazolamide during hospitalization and at discharge. MA was not associated with a higher risk of in-hospital mortality and 30/90-day all-cause mortality or readmissions but was associated with a significant increase in readmissions for HF at 30 and 90 days (adjusted HR [95% CI] 3.294 [1.397-7.767], p = 0.006 and 2.314 [1.075-4.978], p = 0.032).

CONCLUSION

The prevalence of MA in patients admitted for AHF was 9%, and its presence was associated with more readmissions for HF but not with all-cause mortality.

Atrial fibrillation and risk of adverse outcomes in heart failure with reduced, mildly reduced, and preserved ejection fraction: A systematic review and meta-analysis

INTRODUCTION

Heart failure (HF) and atrial fibrillation (AF) frequently co-exist. Contemporary classification of HF categorizes it into HF with reduced ejection fraction (HFrEF), HF with mildly reduced ejection fraction (HFmrEF), and HF with preserved ejection fraction (HFpEF). Aggregate data comparing the risk profile of AF between these three HF categories are lacking.

METHODS

We conducted a systematic review and meta-analysis aimed at determining any significant differences in AF-associated all-cause mortality, HF hospitalizations, cardiovascular mortality (CV), and stroke between HFrEF, HFmrEF, and HFpEF. A systematic search of PubMed, EMBASE, and Cochrane Library databases until February 28, 2023. Data were combined using DerSimonian-Laird random effects model.

RESULTS

A total of 22 studies comprising 248 323 patients were retained: HFrEF 123 331 (49.7%), HFmrEF 40 995 (16.5%), and HFpEF 83 997 (33.8%). Pooled baseline AF prevalence was 36% total population, 30% HFrEF, 36% HFmrEF, and 42% HFpEF. AF was associated with a higher risk of all-cause mortality in the total population with pooled hazard ratio (HR) = 1.13 (95% confidence interval [CI] = 1.07-1.21), HFmrEF (HR = 1.25, 95% CI = 1.05-1.50) and HFpEF (HR = 1.16, 95% CI = 1.09-1.24), but not HFrEF (HR = 1.03, 95% CI = 0.93-1.14). AF was associated with a higher risk of HF hospitalizations in the total population (HR = 1.29, 95% CI = 1.14-1.46), HFmrEF (HR = 1.64, 95% CI = 1.20-2.24), and HFpEF (HR = 1.46, 95% CI = 1.17-1.83), but not HFrEF (HR = 1.01, 95% CI = 0.87-1.18). AF was only associated with CV in the HFpEF subcategory but was associated with stroke in all three HF subtypes.

CONCLUSIONS

AF appears to be associated with a higher risk of all-cause mortality and HF hospitalization in HFmrEF and HFpEF. With these findings, the paucity of data and treatment guidelines on AF in the HFmrEF subgroup becomes even more significant and warrant further investigations.