Atrial fibrillation in chronic heart failure patients with reduced ejection fraction: The CHECK-HF registry

A Comparison of Prescribing Guideline-Advocated Treatment for Heart Failure at Discharge from Cardiology and Non-Cardiology Wards

BACKGROUND

Adherence to heart failure (HF) management guidelines is important to optimise clinical outcomes but can be variable in practice. This study compared prescribing guideline-advocated pharmacological and non-pharmacological management of HF between patients discharged from cardiology and non-cardiology wards.

METHOD

A retrospective audit of electronic medical records was undertaken of patients discharged from cardiology (n=100) or non-cardiology wards (n=100) of a tertiary hospital with a primary diagnosis of HF. Non-pharmacological management was quantified from documentation in medical records. Drug prescription was determined based on patients' discharge summaries. Comparisons between wards were conducted using Student's t-tests or Mann-Whitney U tests for continuous data and chi square tests or Fisher's tests for categorical data. Binary logistic regression modelling was applied.

RESULTS

Patients discharged from non-cardiology wards were older and had a higher incidence of hypertension, ischaemic heart disease, and renal insufficiency than those discharged from cardiology wards. The prescription of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs)/angiotensin receptor neprilysin inhibitors (ARNIs) and mineralocorticoid receptor antagonists at any dose (52% vs 80%; p<0.01, 25% vs 52%; p<0.01, respectively) were lower in non-cardiology than in cardiology wards, but there was no difference between wards for beta blockers. Referral to cardiac rehabilitation (4% vs 28%; p<0.01) before discharge was significantly lower in non-cardiology wards. Increased age was associated with less likelihood of the prescription of ACEIs/ARBs/ARNIs and mineralocorticoid receptor antagonists at any dose and ≥50% target dose. Better renal function was a predictor for ACEIs/ARBs/ARNIs at any dose and ≥50% target dose. Discharge ward was not in itself an independent predictor of drug prescription at any dose or for any drug class.

CONCLUSIONS

Prescription rates with key components of pharmacological and non-pharmacological HF management were lower in non-cardiology than in cardiology wards. For pharmacological management, this appeared related to higher patient complexity rather than the ward. Quality improvement programs to strengthen adherence to guideline-advocated treatment is warranted to optimise care, especially for higher complexity admitted to a non-cardiology ward.

Characteristics and Outcomes of Atrial Fibrillation in Chronic Heart Failure Patients: A Comprehensive Analysis of the Colombian Heart Failure Registry

Background

Heart failure (HF) and atrial fibrillation (AF) represent conditions that commonly coexist. The impact of AF in HF has yet to be well studied in Latin America. This study aimed to characterize the sociodemographic and clinical features, along with patients' outcomes with AF and HF from the Colombian Heart Failure Registry (RECOLFACA).

Methods

Patients with ambulatory HF and AF were included in RECOLFACA, mainly with persistent or permanent AF. A 6-month follow-up was performed. Primary outcome was all-cause mortality. To assess the impact of AF on mortality, we used a logistic regression model. A P value of < 0.05 was considered significant. All statistical tests were two-tailed.

Results

Of 2,528 patients with HF in the registry, 2,514 records included information regarding AF diagnosis. Five hundred sixty (22.3%) were in AF (mean age 73 ± 11, 56% men), while 1,954 had no AF (mean age 66 ± 14 years, 58% men). Patients with AF were significantly older and had a different profile of comorbidities and implanted devices compared to non-AF patients. Moreover, AF diagnosis was associated with lower quality of life score (EuroQol-5D), mainly in mobility, personal care, and daily activity. AF was prevalent in patients with preserved ejection fraction (EF), while no significant differences in N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels were observed. Although higher mortality was observed in the AF group compared to individuals without AF (8.9% vs. 6.1%, respectively; P = 0.016), this association lost statistical significance after adjusting by age in a multivariate regression model (odds ratio (OR): 1.35; 95% confidence interval (CI): 0.95 - 1.92).

Conclusions

AF is more prevalent in HF patients with higher EF, lower quality of life and different clinical profiles. Similar HF severity and non-independent association with mortality were observed in our cohort. These results emphasize the need for an improved understanding of the AF and HF coexistence phenomenon.

Guideline implementation, drug sequencing, and quality of care in heart failure: design and rationale of TITRATE-HF

AIMS

Current heart failure (HF) guidelines recommend to prescribe four drug classes in patients with HF with reduced ejection fraction (HFrEF). A clear challenge exists to adequately implement guideline-directed medical therapy (GDMT) regarding the sequencing of drugs and timely reaching target dose. It is largely unknown how the paradigm shift from a serial and sequential approach for drug therapy to early parallel application of the four drug classes will be executed in daily clinical practice, as well as the reason clinicians may not adhere to new guidelines. We present the design and rationale for the real-world TITRATE-HF study, which aims to assess sequencing strategies for GDMT initiation, dose titration patterns (order and speed), intolerance for GDMT, barriers for implementation, and long-term outcomes in patients with de novo, chronic, and worsening HF.

METHODS AND RESULTS

A total of 4000 patients with HFrEF, HF with mildly reduced ejection fraction, and HF with improved ejection fraction will be enrolled in >40 Dutch centres with a follow-up of at least 3 years. Data collection will include demographics, physical examination and vital parameters, electrocardiogram, laboratory measurements, echocardiogram, medication, and quality of life. Detailed information on titration steps will be collected for the four GDMT drug classes. Information will include date, primary reason for change, and potential intolerances. The primary clinical endpoints are HF-related hospitalizations, HF-related urgent visits with a need for intravenous diuretics, all-cause mortality, and cardiovascular mortality.

CONCLUSIONS

TITRATE-HF is a real-world multicentre longitudinal registry that will provide unique information on contemporary GDMT implementation, sequencing strategies (order and speed), and prognosis in de novo, worsening, and chronic HF patients.

Heart failure treatment in patients with and without obesity with an ejection fraction below 50

BACKGROUND

The aim of this study was to assess heart failure (HF) treatment in patients with and without obesity in a large contemporary real-world Western European cohort.

METHODS

Patients with a left ventricular ejection fraction (LVEF) <50% and available information on body mass index (BMI) were selected from the CHECK-HF registry. The CHECK-HF registry included chronic HF patients in the period between 2013 and 2016 in 34 Dutch outpatient clinics. Patients were divided into BMI categories. Differences in HF medical treatment were analysed, and multivariable logistic regression analysis (dichotomized as BMI <30 kg/m² and ≥30 kg/m² ) was performed.

RESULTS

Seven thousand six hundred seventy-one patients were included, 1284 (16.7%) had a BMI ≥30 kg/m² , and 618 (8.1%) had a BMI ≥35 kg/m² . Median BMI was 26.4 kg/m² . Patients with obesity were younger and had a higher rate of comorbidities such as diabetes mellitus, hypertension and obstructive sleep apnoea (OSAS). Prescription rates of guideline-directed medical therapy (GDMT) increased significantly with BMI. The differences were most pronounced for mineralocorticoid receptor antagonists (MRAs) and diuretics. Patients with obesity more often received the guideline-recommended target dose. In multivariable logistic regression, obesity was significantly associated with a higher likelihood of receiving ≥100% of the guideline-recommended target dose of beta-blockers (OR 1.34, 95% CI 1.10-1.62), renin-angiotensin system (RAS)-inhibitors (OR 1.34, 95% CI 1.15-1.57) and MRAs (OR 1.40, 95% CI 1.04-1.87).

CONCLUSIONS

Guideline-recommended HF drugs are more frequently prescribed and at a higher dose in patients with obesity as compared to HF patients without obesity.

Digoxin use in contemporary heart failure with reduced ejection fraction: an analysis from the Swedish Heart Failure Registry

AIMS

Digoxin is included in some heart failure (HF) guidelines but controversy persists about the true role for and impact of treatment with this drug, particularly in the absence of atrial fibrillation (AF). The aim of this study was to assess the association between clinical characteristics and digoxin use and between digoxin use and mortality/morbidity in a large, contemporary cohort of patients with HF with reduced ejection fraction (HFrEF) stratified by history of AF.

METHODS AND RESULTS

Patients with HFrEF (EF < 40%) enrolled in the Swedish HF registry between 2005 and 2018 were analysed. The independent association between digoxin use and patient characteristics was assessed by logistic regression, and between digoxin use and outcomes [composite of all-cause mortality or HF hospitalization (HFH), all-cause mortality, and HFH] by Cox regressions in a 1:1 propensity score matched population. Digoxin use was analysed at baseline and as a time-dependent variable. Of 42 456 patients with HFrEF, 16% received digoxin, 29% in the AF group and 2.8% in the non-AF group. The main independent predictors of use were advanced HF, higher heart rate, history of AF, preserved renal function, and concomitant use of beta blockers. Digoxin use was associated with lower risk of all-cause death/HFH [hazard ratio (HR): 0.95; 95% confidence interval (CI): 0.91-0.99] in AF, but with higher risk in non-AF (HR: 1.24; 95% CI: 1.09-1.43). Consistent results were observed when digoxin use was analysed as a time-dependent variable.

CONCLUSION

The great majority of digoxin users had a history of AF. Digoxin use was associated with lower mortality/morbidity in patients with AF, but with higher mortality/morbidity in patients without AF.

Exosomes in atrial fibrillation: therapeutic potential and role as clinical biomarkers

Atrial fibrillation (AF), the most common cardiac arrhythmia, is a global epidemic. AF can cause heart failure and myocardial infarction and increase the risk of stroke, disability, and thromboembolic events. AF is becoming increasingly ubiquitous and is associated with increased morbidity and mortality at higher ages, resulting in an increasing threat to human health as well as substantial medical and social costs. Currently, treatment strategies for AF focus on controlling heart rate and rhythm with medications to restore and maintain sinus rhythm, but this approach has limitations. Catheter ablation is not entirely satisfactory and does not address the issues underlying AF. Research exploring the mechanisms causing AF is urgently needed for improved prevention, diagnosis, and treatment of AF. Exosomes are small vesicles (30-150 nm) released by cells that transmit information between cells. MicroRNAs in exosomes play an important role in the pathogenesis of AF and are established as a biomarker for AF. In this review, a summary of the role of exosomes in AF is presented. The role of exosomes and microRNAs in AF occurrence, their therapeutic potential, and their potential role as clinical biomarkers is considered. A better understanding of exosomes has the potential to improve the prognosis of AF patients worldwide, reducing the global medical burden of this disease.

CardioMEMS™: a tool for remote hemodynamic monitoring of chronic heart failure patients

Remote monitoring is becoming increasingly important for management of chronic heart failure patients. Recently, hemodynamic monitoring by measuring intracardiac filling pressures has been gaining attention. It is believed that hemodynamic congestion precedes clinical congestion by several weeks and that remote hemodynamic monitoring therefore enables clinicians to intervene in an early stage and prevent heart failure hospitalizations. The CardioMEMS HF system (Abbott, CA, USA) is a sensor capable of measuring pulmonary artery pressures as a surrogate of left ventricular filling pressures. Clinical evidence for CardioMEMS has been convincing in terms of efficacy and safety. This article provides detailed information on the CardioMEMS HF system and summarizes all available evidence of this promising technique.

Effects of Atrial Fibrillation-Derived Exosome Delivery of miR-107 to Human Umbilical Vein Endothelial Cells

The aim of this study was to explore the effects of atrial fibrillation (AF)-derived exosome delivery of miR-107 to human umbilical vein endothelial cells (HUVECs) and its related mechanisms. Exosomes were isolated from the plasma of patients with AF and healthy controls, followed by characterization. The expression levels of miR-320d, miR-103a-3p, and miR-107 were measured using real-time quantitative PCR (RT-qPCR). The dual-luciferase reporter gene was used to verify the downstream target of miR-107. Afterward, HUVECs were treated with AF-derived exosomes or transfected with miR-107 mimics. After cell culture, Cell Counting Kit-8, Transwell, and flow cytometry were used to determine cell viability, migration, and apoptosis and cell cycle phase. Finally, RT-qPCR was performed to examine the expression of related genes. NanoSight, transmission electron microscopy, and western blotting showed that exosomes were successfully isolated, and that AF-derived exosomes could be taken up by HUVECs. The expression of miR-107 was significantly higher in AF-derived exosomes than in normal exosomes (p < 0.05). USP14 was shown to be the direct target of miR-107. In addition, miR-107 mimics and AF-derived exosomes significantly suppressed cell viability and migration (p < 0.05) and enhanced cell apoptosis; they also increased G0/G1-phase cells and reduced S-phase cells. RT-qPCR showed that exosomal miR-107 overexpression significantly downregulated the expression of USP14 and Bcl2 (p < 0.05), whereas it markedly upregulated the expression of ERK2, FAK, and Bax (p < 0.05). AF-derived exosomes can deliver miR-107 to HUVECs, and exosomal miR-107 may regulate cell viability, migration, and apoptosis and cell cycle progression by mediating the miR-107/USP14 pathway.

The management of atrial fibrillation in heart failure: an expert panel consensus

Heart failure (HF) and atrial fibrillation (AF) often coexist, being closely interrelated as the one increases the prevalence and incidence and worsens the prognosis of the other. Their frequent coexistence raises several challenges, including under-diagnosis of HF with preserved ejection fraction in AF and of AF in HF, characterization and diagnosis of atrial cardiomyopathy, target and impact of rate control therapy on outcomes, optimal rhythm control strategy in the era of catheter ablation, HF-related thromboembolic risk and management of anticoagulation in patients with comorbidities, such as chronic kidney disease or transient renal function worsening, coronary artery disease or acute coronary syndromes, valvular or structural heart disease interventions and cancer. In the present document, derived by an expert panel meeting, we sought to focus on the above challenging issues, outlining the existing evidence and identifying gaps in knowledge that need to be addressed.