2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

A multicenter pragmatic implementation study of AI-ECG-based clinical decision support software to identify low LVEF: Clinical trial design and methods

Background

Artificial intelligence (AI) enabled algorithms can detect or predict cardiovascular conditions using electrocardiogram (ECG) data. Clinical studies have evaluated ECG-AI algorithms, including a recent single-center study which evaluated outcomes when clinicians were provided with ECG-AI results. A Multicenter Pragmatic IMplementation Study of ECG-AI-Based Clinical Decision Support Software to Identify Low LVEF (AIM ECG-AI) will evaluate clinical impacts of clinical decision support software (CDSS) integrated within the electronic health record (EHR) to provide point-of-care ECG-AI results to clinicians during routine outpatient care.

Methods

AIM ECG-AI is a multicenter, cluster-randomized trial recruiting and randomizing clinicians to receive access to the CDSS (intervention) or provide usual care. Clinicians are recruited from 5 geographically distinct health systems and clustered at the care team level. AIM ECG-AI will evaluate clinical care provided during >32,000 eligible clinical encounters with adult patients with no history of low LVEF and who have a digital ECG documented within the health system's EHR, with 90 day follow up.

Results

Study data includes clinician surveys, study software metrics, and EHR data as a read-out for clinician decision-making. AIM ECG-AI will evaluate detection of left ventricular ejection fraction ≤40 % by echocardiography, with exploratory endpoints. Subgroup analyses will evaluate the health system, clinician, and patient-level characteristics associated with outcomes (NCT05867407).

Conclusion

AIM ECG-AI is the first multisite clinical evaluation of an EHR-integrated, point-of-care CDSS to provide ECG-AI results in the clinical workflow. The findings will provide valuable insights for clinically focused software design to bring AI into routine clinical practice.

AI-based measurement of cardiothoracic ratio in chest X-rays and prediction of echocardiographic congestive heart failure

Background

This study presents an artificial intelligence (AI) model for automated cardiothoracic ratio (CTR) measurement from chest X-rays (CXRs) and evaluates its association with severe left ventricular hypertrophy (SLVH) and dilated left ventricle (DLV) diagnosed by echocardiography. The study also assesses CTR's prognostic value for predicting future SLVH/DLV development.

Methods

In this retrospective cohort study, an AI algorithm measured CTR on 71,129 CXRs from 24,673 patients from 2013 to 2018 in the CheXchoNet database. SLVH/DLV was defined using echocardiographic criteria. Diagnostic accuracy was assessed using AUROC and AUPRC alongside sensitivity and specificity at various CTR thresholds. Logistic regression was performed for CXR-echocardiogram pairs. Time-to-event analysis was performed on 9,890 patients without baseline SLVH/DLV.

Results

Among 24,673 patients (mean age: 62.1 years; female sex: 56.9 %), mean CTR was higher in SLVH/DLV patients (0.56 ± 0.07) than those without (0.52 ± 0.07; p < 0.001). AUROC was 0.70 (95 % CI: 0.69-0.70). At a CTR threshold of 0.53, sensitivity was 70 % and specificity 60 %. Increased CTR was associated with SLVH/DLV risk on paired echocardiogram, with an odds ratio of 1.26 at a CTR of 0.65 compared to CTR at 0.50 (95 % CI: 1.24-1.27, p < 0.001). Time-to-event analysis on patients without baseline SLVH/DLV showed patients with baseline CTR > 0.65 had a 4.13-fold increased risk of developing SLVH/DLV in the future compared to patients with CTR ≤ 0.50 (adjusted HR: 4.13; 95 % CI: 2.48-6.89; p < 0.01).

Conclusion

AI-based CTR measurement helps predict SLVH/DLV and could be used for risk stratification for cardiovascular care.

A multidisciplinary transition of care approach to reduce 30-day readmissions in heart failure patients

BACKGROUND

While advancements in pharmacologic and device therapies have improved survival, one in five adults with heart failure (HF) patients is readmitted within 30 days of discharge. Thus, the epidemic of HF is largely one of increasing hospitalizations.

OBJECTIVE

To determine if a comprehensive HF program reduces 30-day readmission rate.

METHODS

A convenience sample of adults with Medicare and HF (N = 1617) admitted to a large academic medical center were identified. Patients received HF education by a specialized registered nurse while inpatient and were seen by a pharmacist prior to discharge. Post-discharge, patients were called by a pharmacist within 72 h, followed by an ambulatory care manager for 90 days, and scheduled for a multidisciplinary clinic visit with a nurse practitioner within 7 days of hospitalization. High risk patients were referred to a community health worker (CHW). Clinic services included phlebotomy, education, point-of-care ultrasound, intravenous diuretic administration, and referrals to appropriate services. Data were analyzed descriptively.

RESULTS

The 30-day readmission rate was 18.39 % (N = 930) during the intervention period compared to 22.71 % (N = 617) at baseline, resulting in a 4.32 % reduction, p value 0.0325. Approximately 40 percent of the patient cohort was over age 85. Pharmacy was able to contact greater than 86 % of patients post discharge. Only half of patients were agreeable to ambulatory care management. Less than half (42 %) of eligible patients were seen in the post-discharge clinic. The CHW supported approximately 146 patients in a 9-month period.

CONCLUSIONS

A real-world comprehensive multidisciplinary team approach to the management of HF patients can reduce 30-day hospital readmissions.

A STRONG call for intensive oral heart failure therapy in acute heart failure patients

Heart failure (HF), a chronic and progressive disease, is increasing in prevalence worldwide and is associated with increased hospitalizations and death. Despite notable improvements in medical therapy for HF, patients are still at risk of future negative outcomes. Current guidelines recommend four classes of medication for treating patients with HF, deemed guideline-directed medical therapy (GDMT). The use and adherence of these GDMTs serve as a major predictor of outcomes in those with chronic HF; however, implementation of therapy remains poor, despite substantial evidence of benefit. The acute hospitalization for HF and the subsequent vulnerable period serve as important milestones for adequate disease modification, and implementing a strategy for aggressive medical therapy can improve HF outcomes. Current guidelines also recommend that follow-up with multidisciplinary chronic disease management specific to HF be provided to those living with heart failure, which is essential for improving readmissions and mortality. This follow-up, although important by itself, serves as an important avenue for disease modification through medication titration, and implementing such structured follow-up is essential for further population-wide improvements in HF mortality. In this context, the STRONG-HF trial investigators developed an implementation trial providing evidence for the rapid inpatient initiation and subsequent titration of HF GDMT, demonstrating the importance of implementation strategies in the care of HF patients. In this narrative review, we review the evidence base for treating patients with HF, highlight deficits in our current real-world experience, and provide support for trial evidence like STRONG-HF in the global fight to reduce the burden of HF.

Reducing 30-day Acute Care Readmissions for Heart Failure Patients Through Implementation of a Discharge Bundle

PURPOSE

Hospital readmissions have been a long-standing problem in the American health care system. Despite many efforts, programs, papers, and interventions identified and studied, 14% of all adult admissions result in a readmission. Readmissions are mostly considered preventable and are considered an indicator of care quality for a hospital. Due to unexpected readmissions, patients are at an increased risk for illness or injury, increased stress, financial strain, and diminished quality of life. Readmissions also negatively impact hospital systems related to decreased bed availability, stretched resources, and potential financial penalties and payment reductions. Patients with an admission related to heart failure are at an increased risk of readmission, with a national readmission rate of 23%.

PRIMARY PRACTICE SETTING

The quality improvement project was implemented on two telemetry units at an acute care hospital.

METHODOLOGY AND SAMPLE

A gap analysis identified procedural and organizational reasons for readmission in the heart failure population at an acute care hospital. Using evidence-based best practice guidelines established by the American Heart Association, American College of Cardiology, and the Heart Failure Society of America, a four-pronged proactive discharge bundle was implemented using the plan-do-study-act framework for continuous improvement. All patients admitted to the telemetry units with a primary or secondary diagnosis of heart failure received the discharge planning bundle: (1) an early assessment by the case management department, (2) patient-centered specialty heart failure education, (3) predischarge medication delivery, and (4) predischarge physician follow-up appointment scheduling within 7 days of discharge. A total of 133 patients were evaluated for inclusion in the heart failure cohort. Of those, 52 patients received the evidence-based intervention.

RESULTS

The evidence-based project was implemented over 7 weeks, September through October of 2023 on the medical telemetry units. Of the 52 patients receiving the evidence-based sample, two of the patients experienced a readmission due to heart failure (3.85%). Incidentally, it was found that patients without a readmission had an average of 2.3 completed interventions, while those with readmissions had an average of 1.5 interventions.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Case managers are an integral part of the care transition from the acute care setting back to the community. Often, it is the case manager leading this effort through various interventions. Findings from this quality improvement project suggest the use of the evidence-based, four-pronged approach to discharge planning for the heart failure patient population reduced the risk and rate of heart failure-related readmissions for the involved nursing units. These findings also surmise that there is a correlation between the number of interventions and the rate of readmission.

Initiation and sequencing of guideline-directed medical therapy for heart failure across the ejection fraction spectrum

Strong evidence supports the importance of rapid sequence or simultaneous initiation of quadruple guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) for substantially reducing risk of mortality and hospitalization. Barring absolute contraindications for each individual medication, employing the strategy of rapid sequence, simultaneous, and/or in-hospital initiation at the time of HF diagnosis best ensures patients with HFrEF have the opportunity to benefit from proven medications and achieve large absolute risk reductions for adverse clinical outcomes. However, despite guideline recommendations supporting this approach, implementation in clinical practice remains persistently low, with less than one-fifth of eligible patients being prescribed the quadruple GDMT regimen. Additionally, for heart failure with mildly reduced or preserved ejection fraction (HFpEF), sodium-glucose co-transporter 2 inhibitors (SGLT2i) and non-steroidal mineralocorticoid receptor antagonists (MRA) constitute foundational therapy for all eligible patients with significant clinical benefits within just weeks of medication initiation. Nonetheless, the burden of symptoms, functional limitations, and hospitalizations remains substantial for many of these patients, even with SGLT2i and non-steroidal MRA therapy. Additional evidence supports consideration of adjunctive therapies for HF with EF > 40% that can be tailored to the patient phenotype, including glucagon-like peptide-1 receptor agonists (GLP-1 RA) for patients with obesity, as well as angiotensin receptor-neprilysin inhibitors (ARNI) for patients with EF below normal. This article reviews the evidence-based sequencing of GDMT for HF across the spectrum of EF, emphasizing the rationale and benefits of early up-front initiation of quadruple medical therapy for HFrEF, rapid initiation of SGLT2i for HF regardless of EF, and prompt phenotype-specific tailored approach to adjunctive therapies for HF with EF > 40%.

Cardiovascular death in patients with acute heart failure in sinus rhythm: results from the RICA registry

INTRODUCTION

Patients with heart failure in sinus rhythm may be at significant risk of major cardiovascular events, including cardiovascular death (CV death).

OBJECTIVE

To assess CV mortality at a one-year follow up of those patients with heart failure and sinus rhythm, according to LVEF subgroups.

METHODS

A prospective and multicentric study was conducted with patients in sinus rhythm included in the National Registry of Heart Failure. Firstly, a demographic, clinical and treatment analysis has been made comparing CV death. Secondly, a multivariate analysis of logistic regression was made including those CV death factors. Lastly, a Kaplan Meyer one year survival was made including LVEF.

RESULTS

Of all 2040 patients included 14,8% presented CV death. The mortality predictors were Barthel index (OR 0,987 (0,982-0,992) [p<0,001]), LVEF <40% (OR 1,514 (1,144-2,003) [p 0,003]) and Charlson index (OR 1,069 (1,016-1,124) [p 0,01]).

CONCLUSION

According to our results CV death has been shown to be higher in those patients with reduced LVEF in sinus rhythm and worst score in Barthel index and Charlson scale.

Natriuretic response prediction equation for use with oral diuretics in heart failure

BACKGROUND AND AIMS

Limited data are available to assess oral diuretic response in outpatients with heart failure (HF). The natriuretic response prediction equation (NRPE) predicts natriuresis following a loop diuretic dose using a urine sample 2 h after the dose and was validated to accurately predict intravenous diuretic response. The primary aim was to validate the NRPE's assessment of oral diuretic response in patients with HF.

METHODS

The NRPE was evaluated in two HF patient cohorts receiving oral loop diuretics: Mechanisms of Diuretic Resistance (MDR) and TRANSFORM-Mechanism. Participants received their home oral loop diuretic followed by a supervised timed urine collection including spot urine samples at 1 and 2 h. Patients quantified their self-assessed diuretic response (urine volume) via a standardized survey. A poor diuretic response was defined as cumulative natriuresis < 50 mmol over the study visit.

RESULTS

The MDR cohort included 318 oral diuretic administrations from 237 patients. The NRPE predicted a poor natriuretic response with an area under the curve (AUC) of .87 [95% confidence interval (CI) .83-.91] and similar accuracy to the previously validated intravenous NRPE performance (P = .16). Patient's ability to self-estimate their diuretic response was poor with an AUC of .57 (95% CI .44-.70) and significantly worse than the oral NRPE (P < .001). In TRANSFORM-Mechanism (110 oral diuretic administrations), the NRPE had similar operating characteristics (AUC .89, 95% CI .80-1.0) for poor diuretic response.

CONCLUSIONS

Natriuretic response to an oral diuretic can be rapidly and accurately assessed with a urine sample collected 2 h after an oral diuretic dose and the NRPE.

A Randomized Controlled Trial of Thoracentesis in Acute Heart Failure

BACKGROUND

TAP-IT (Thoracentesis to Alleviate Cardiac Pleural Effusion-Interventional Trial) investigated the effect of therapeutic thoracentesis in addition to standard medical therapy in patients with acute heart failure and sizeable pleural effusion.

METHODS

This multicenter, unblinded, randomized controlled trial, conducted between August 31, 2021, and March 22, 2024, included patients with acute heart failure, left ventricular ejection fraction ≤45%, and non-negligible pleural effusion. Patients with very large effusions (more than two-thirds of the hemithorax) were excluded. Participants were randomly assigned 1:1 to upfront ultrasound-guided pleural pigtail catheter thoracentesis in addition to standard medical therapy or standard medical therapy alone. The primary outcome was days alive out of the hospital over the following 90 days; key secondary outcomes included length of admission and 90-day all-cause mortality. All outcomes were analyzed according to the intention-to-treat principle.

RESULTS

A total of 135 patients (median age, 81 years [25th; 75th percentile, 75; 83]; 33% female; median left ventricular ejection fraction, 25% [25th; 75th percentile, 20%; 35%]) were randomized to either thoracentesis (n=68) or standard medical therapy (n=67). The thoracentesis group had a median of 84 days (77; 86) alive out of the hospital over the following 90 days compared with 82 days (73; 86) in the control group (P=0.42). The mortality rate was 13% in both groups, with no difference in survival probability (P=0.90). There were no differences in the duration of the index admission (control group median, 5 days [3; 8]; thoracentesis group median, 5 days [3; 7], P=0.69). Major complications occurred in 1% of thoracenteses performed during the study period.

CONCLUSIONS

For patients with acute heart failure and pleural effusion, a strategy of upfront routine thoracentesis in addition to standard medical therapy did not increase days alive out of the hospital for 90 days, all-cause mortality, or duration of index admission. The current findings lay the groundwork for future research to confirm the results.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05017753.

Heart failure outcomes in Sub-Saharan Africa: a scoping review of recent studies conducted after the 2022 AHA/ACC/HFSA guideline release

BACKGROUND

Heart failure (HF) in Sub-Saharan Africa (SSA) presents unique challenges, with high prevalence and distinct epidemiological features compared to high-income settings. Despite its burden, recent comprehensive data are lacking, especially amidst recent 2022 AHA/ACC/HFSA guideline release. This scoping review aims to map the literature on HF in SSA, focusing on aetiologies, structural abnormalities, management practices, and outcomes to identify research gaps and inform clinical practice.

METHODS

Studies from 2022-2024 published in English or French were included, covering adult patients > 18 years, all study designs except case reports. Studies not reporting any outcomes or focusing solely on one HF subtype were excluded. Literature from all SSA countries was searched using a FACET approach in databases including PubMed, Google Scholar, Cochrane and Scopus.

RESULTS

Ten studies, evaluating 2039 patients, were analysed. Dilated cardiomyopathy (DCM), and Hypertensive cardiomyopathy (HCM) emerged as prominent aetiologies. Rheumatic heart disease was reported in only four studies. Common issues included high rates of electrolyte disturbances and anemia, which influenced patient outcomes. Guideline adherence exhibited significant deficiencies, notably with a suboptimal prescription rate of SGLT2 inhibitors (8.3-24.7%). Mortality rates ranged from 3.7% to 19%, linked to factors like low blood pressure and electrolyte imbalances. Hospital stays were variable but significant rehospitalization were common within 8-15 days post discharge and associated with non-compliance and lifestyle factors.

CONCLUSION

HCM and DCM are prevalent heart failure aetiologies in SSA. Longitudinal studies are recommended to contextualise aetiological diagnosis and validate prognostic tools amidst limited resources. Enhanced guideline adherence, hypertension control and efficient post-discharge care are essential to reduce morbidity and mortality.

Machine Learning-Based Prediction Models for Healthcare Outcomes in Patients Participating in Cardiac Rehabilitation: A Systematic Review

PURPOSE

Cardiac rehabilitation (CR) has been proven to reduce mortality and morbidity in patients with cardiovascular disease. Machine learning (ML) techniques are increasingly used to predict healthcare outcomes in various fields of medicine including CR. This systemic review aims to perform critical appraisal of existing ML-based prognosis predictive model within CR and identify key research gaps in this area.

REVIEW METHODS

A systematic literature search was conducted in Scopus, PubMed, Web of Science, and Google Scholar from the inception of each database to January 28, 2024. The data extracted included clinical features, predicted outcomes, model development, and validation as well as model performance metrics. Included studies underwent quality assessments using the IJMEDI and Prediction Model Risk of Bias Assessment Tool checklist.

SUMMARY

A total of 22 ML-based clinical models from 7 studies across multiple phases of CR were included. Most models were developed using smaller patient cohorts from 41 to 227, with one exception involving 2280 patients. The prediction objectives ranged from patient intention to initiate CR to graduate from outpatient CR along with interval physiological and psychological progression in CR. The best-performing ML models reported area under the receiver operating characteristics curve between 0.82 and 0.91, with sensitivity from 0.77 to 0.95, indicating good prediction capabilities. However, none of them underwent calibration or external validation. Most studies raised concerns about bias. Readiness of these models for implementation into practice is questionable. External validation of existing models and development of new models with robust methodology based on larger populations and targeting diverse clinical outcomes in CR are needed.

Geographic remoteness-based differences in in-hospital mortality among people admitted to NSW public hospitals with heart failure, 2002-21: a retrospective observational cohort study

OBJECTIVE

To examine associations between remoteness of region of residence and in-hospital mortality for people admitted to hospital with heart failure in New South Wales during 2002-21.

STUDY DESIGN

Retrospective observational cohort study; analysis of New South Wales Admitted Patient Data Collection data.

SETTING, PARTICIPANTS

Adult (16 years or older) NSW residents admitted with heart failure to NSW public hospitals, 1 January 2002 - 30 September 2021. Only first admissions with heart failure during the study period were included.

MAIN OUTCOME MEASURES

In-hospital mortality, by remoteness of residence (Australian Statistical Geography Standard), adjusted for age (with respect to median), sex, socio-economic status (Index of Relative Socioeconomic Advantage and Disadvantage [IRSAD], with respect to median), other diagnoses, hospital length of stay, and calendar year of admission (by 4-year group).

RESULTS

We included 154 853 admissions with heart failure; 99 687 people lived in metropolitan areas (64.4%), 41 953 in inner regional areas (27.1%), and 13 213 in outer regional/remote/very remote areas (8.5%). The median age at admission was 80.3 years (interquartile range [IQR], 71.2-86.8 years), and 78 591 patients were men (50.8%). The median IRSAD score was highest for people from metropolitan areas (metropolitan: 1000; IQR, 940-1064; inner regional: 934; IQR, 924-981; outer regional/remote/very remote areas: 930; IQR, 905-936). During 2002-21, 9621 people (6.2%) died in hospital; the proportion was 8.0% in 2002, 4.9% in 2021. In-hospital all-cause mortality was lower during 2018-21 than during 2002-2005 (adjusted odds ratio [aOR], 0.52; 95% confidence interval [CI], 0.49-0.56); the decline was similar for all three remoteness categories. Compared with people from metropolitan areas, the odds of in-hospital death during 2002-21 were higher for people from inner regional (aOR, 1.12; 95% CI, 1.07-1.17) or outer regional/remote/very remote areas (aOR, 1.35; 95% CI, 1.25-1.45).

CONCLUSION

In-hospital mortality during heart failure admissions to public hospitals declined across NSW during 2002-21. However, it was higher among people living in regional and remote areas than for people from metropolitan areas. The reasons for the difference in in-hospital mortality should be investigated.

Impact of Mitral Regurgitation on Outcomes of Catheter Ablation for AF With Left Ventricular Systolic Dysfunction

BACKGROUND

Atrial fibrillation (AF) and left ventricular (LV) systolic dysfunction (LVSD) may be associated with function mitral and tricuspid regurgitation (FMR/FTR). Prior studies have largely assessed impact of MR on AF ablation outcomes in the presence of preserved LV ejection fraction.

OBJECTIVES

This study sought to determine the impact of FMR on the outcomes of catheter ablation (CA) in patients with AF and LVSD.

METHODS

We examined baseline clinical characteristics, CA outcomes, and change in echocardiographic parameters (FMR and FTR severity, LV and left atrial [LA] dimensions, LVEF) at baseline and 12 months in individuals with AF and LVSD with at least mild FMR undergoing CA. Patients with primary mitral valve disease were excluded.

RESULTS

235 patients (age 62.8 years,16.2% female, NYHA functional class III (Q1-Q3: II-III)) underwent CA and were categorized by FMR severity at baseline (mild n = 117; moderate/severe n = 118). Baseline characteristics were comparable irrespective of degree of FMR, other than lower LVEF (LVEF 29% [Q1-Q3: 22.8%-35.0%] vs 35% [Q1-Q3: 30.0%-41.0%]; P < 0.001) and increased tricuspid regurgitation in moderate/severe MR (22%) vs mild MR (8%, P < 0.001). LA size did not differ significantly across FMR groups (P = 0.233). At 12 months following CA, recurrent atrial arrhythmia occurred in 101 of 235 (43.0%) including 42.7% in mild vs 43.2% in moderate-to-severe MR (P = 0.940). The severity of FMR did not influence arrhythmia recurrence (OR: 1.15; 95% CI: 0.54-1.86; P = 0.601) nor LV recovery (OR: 1.07; 95% CI: 0.67-1.25; P = 0.153). After CA, 89% of those with significant FMR and 85% with significant FTR exhibited ≥1 grade reduction at 12 months. Change in LV dimensions was associated with MR responders (OR: 0.93; 95% CI: 0.87-0.99; P = 0.022) with a greater reduction in LV size at 12 months in MR improvement (-5.0 (Q1-Q3: -9.3 to -1.0) vs non-improvement -1.0 (Q1-Q3: -5.0 to 2.5), P = 0.004) whereas change in LA size was not (OR: 0.98; 95% CI: 0.97-1.03; P = 0.984).

CONCLUSIONS

In patients with AF and LVSD, the degree of FMR did not impact the success of ablation. There was a significant reduction in FMR and FTR at 12 months following CA. Patients with AF and LVSD should be strongly considered for AF ablation irrespective of the degree of mitral regurgitation.

Appraisal of β-Blocker Use in Patients with Cardiovascular Disease and Chronic Obstructive Pulmonary Disease

β-blockers are a fundamental component of cardiovascular disease (CVD) management, while β2-agonists are used to treat chronic obstructive pulmonary disease (COPD). Current guidelines recommend that these conditions be treated as usual, even when they coexist. However, there have been concerns over COPD exacerbation risk with β-blockers and attenuation of the beneficial effects of β2-agonists in this comorbid population, leading to β-blocker underuse. Recent evidence suggests that β-blockers, particularly cardioselective β-blockers, do not increase COPD exacerbations, demonstrate good efficacy and safety, and improve survival in patients with COPD after first-time myocardial infarction. In atrial fibrillation with COPD, both cardioselective and nonselective β-blockers may be associated with a lower COPD exacerbation risk than calcium channel blockers, as well as improving outcomes and reducing mortality risk. In this review, we summarize the β-blocker prescribing patterns in patients with CVD and COPD; describe the reasons for β-blocker underuse in patients with CVD with COPD; collate up-to-date evidence on the effects of β-blockers on symptoms and outcomes in each of these comorbid populations; and review the current treatment guidelines for coexisting COPD and CVD to support the rational prescribing of β-blockers. Finally, we provide recommendations for future research needed to demonstrate the clinical rationale of prescribing β-blockers and to encourage the generation of more robust evidence-based guidelines for β-blockers use. Future large-scale, prospective, randomized controlled trials are needed to expand the body of evidence and better understand the effects of β-blockers in CVD with comorbid COPD.

AI analysis for ejection fraction estimation from 12-lead ECG

Heart failure (HF) remains a leading global cause of cardiovascular deaths, with its prevalence expected to rise in the upcoming decade. Measuring the heart ejection fraction (EF) is crucial for diagnosing and monitoring HF. Although echocardiography is the gold standard for EF measurement, it is often inaccessible in remote areas due to its cost and complexity. In contrast, electrocardiography (ECG) is more readily available and affordable, and emerging research suggests a possible link between ECG signals and EF. In this work, we explore the potential of 12-lead ECG signals to estimate EF using various machine learning (ML) and deep learning (DL) models. While recent studies have considered the use of ML or DL for estimating EF, these algorithms are often trained and tested on urban-based populations. However, demographics like those in rural Appalachia, where disease prevalence is extremely high, have been overlooked, potentially due to the unavailability of large volumes of data. Moreover, there have been concerning reports regarding the fairness of AI predictions across different populations, making it crucial to understand the performance of AI models across diverse demographics before their widespread application. To address this, our study focuses on analyzing AI models for EF estimation in the rural Appalachian population. We utilized a 12-lead ECG dataset of 55,500 patients from WVU Medicine hospitals in West Virginia and employed a wide array of AI algorithms, ranging from Random Forest to modern deep learning-based methods like Transformers, to estimate EF. We also considered different thresholds for analyzing these AI algorithms and examined the impact of single and multi-lead ECG signals, and conducted model interpretability analysis. Overall, our comprehensive analysis demonstrated that deep learning-based algorithms achieved the highest performance, with an AUROC of around 0.86 for EF estimation from 12-lead ECG signals. Additionally, we found that while individual ECG leads were insufficient for accurate EF estimation, specific lead combinations significantly improved classification performance.

Plasma metabolomics identifies signatures that distinguish heart failure with reduced and preserved ejection fraction

AIMS

Two general phenotypes of heart failure (HF) are recognized: HF with reduced ejection fraction (HFrEF) and with preserved EF (HFpEF). To develop phenotype-specific approaches to treatment, distinguishing biomarkers are needed. The goal of this study was to utilize quantitative metabolomics on a large, diverse population to replicate and extend existing knowledge of the plasma metabolic signatures in human HF.

METHODS

Plasma metabolomics and proteomics was conducted on 787 samples collected by the Penn Medicine BioBank from subjects with HFrEF (n = 219), HFpEF (n = 357) and matched controls (n = 211). A total of 90 metabolites were analysed, comprising 28 amino acids, 8 organic acids and 54 acylcarnitines. Seven hundred thirty-three of these samples also underwent proteomic profiling via the O-Link proteomics panel.

RESULTS

Unsaturated forms of medium-/long-chain acylcarnitines were elevated in the HFrEF group. Amino acid derivatives, including 1- and 3-methylhistidine, homocitrulline and symmetric and asymmetric (ADMA) dimethylarginine were elevated in HF, with ADMA elevated uniquely in HFpEF. While the branched-chain amino acids (BCAAs) were minimally changed, short-chain acylcarnitine species indicative of BCAA catabolism were elevated in both HF groups. 3-hydroxybutyrate (3-HBA) and its metabolite, C4-OH carnitine, were uniquely elevated in the HFrEF group. Linear regression models demonstrated a significant correlation between plasma 3-HBA and N-terminal pro-brain natriuretic peptide in both forms of HF, stronger in HFrEF.

CONCLUSIONS

These results identify plasma signatures that are shared as well as potentially distinguish HFrEF and HFpEF. Metabolite markers for ketogenic metabolic re-programming were identified as unique signatures in the HFrEF group, possibly related to increased levels of BNP. Our results set the stage for future studies aimed at assessing selected metabolites as relevant biomarkers to guide HF phenotype-specific therapeutics.

How do doctors address heart failure patients' disclosures of medication adherence problems during hospital and primary care consultations? An exploratory interaction-based observational cohort study

OBJECTIVES

To investigate how doctors and self-managing older patients with heart failure (HF) discuss the patients' potential or ongoing medication adherence problems, and how such discussions evolve as patients transition from hospital to home, with particular focus on: (1) doctors' communicative actions aimed at addressing patient disclosures of adherence problems and (2) patients' feedback indicating whether their doctor's supportive actions were acceptable to them.

DESIGN

Exploratory interaction-based observational cohort study. Inductive microanalysis of authentic patient-doctor consultations, audio recorded for each patient at: (1) first ward visit in hospital, (2) discharge visit from hospital and (3) follow-up visit with general practitioner (GP).

SETTING

Hospital and primary care, Norway (2022-2023).

PARTICIPANTS

25 patients with HF (+65 years) and their attending doctors (23 hospital doctors, 25 GPs).

RESULTS

Analysis of 74 consultations revealed that 25 HF patients disclosed 23 practical adherence problems indicating risks of unintentional non-adherence (eg, limited resources to manage medications) and 39 perceptual problems indicating risks of intentional non-adherence (eg, worries, negative experience or stance). Doctors addressed 79% of patients' disclosures by: (1) exploring the scope of the problem or (2) providing supportive actions to improve patients' ability or motivation to adhere. We calculated nearly five times higher odds for doctors to address patients' practical problems to their perceptual problems (OR 4.79, 95% CI 1.25 to 25.83). Unresolved problems included: (1) doctors addressed patients' disclosures, but patients signalled the supportive actions were unsuitable (37%) and (2) doctors left disclosures unaddressed (21%).

CONCLUSIONS

In this explorative study, the doctors were more likely to address the patients' adherence problems associated with unintentional non-adherence risks than those associated with intentional non-adherence risks. Even when doctors attempted to address HF patients' medication adherence problems, half of the problems remained unresolved, usually because patients indicated that the doctor's suggestion to improve their situation was against their preference.

Out-of-Hospital 30-Day Mortality After Mitral TEER: Insights From the STS/ACC TVT Registry

BACKGROUND

Transcatheter edge-to-edge repair of mitral valve (mTEER) is increasingly being adopted, with improved outcomes. However, it remains crucial to evaluate short-term out-of-hospital mortality to elucidate areas for further improvement.

OBJECTIVES

The authors sought to evaluate incidence and predictors of out-of-hospital 30-day mortality after mTEER.

METHODS

We used the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry to identify patients who underwent mTEER between January 2014 and April 2023. Primary and secondary outcomes were 30-day out-of-hospital all-cause and cardiovascular mortality, respectively. Logistic regression and survival analysis models were used to identify factors associated with these outcomes.

RESULTS

Of 61,139 patients who underwent mTEER, 1,813 (3.0%) died within 30 days of the procedure. Of these, 744 (41.0%) died out-of-hospital after discharge. Cardiovascular causes accounted for 63.4% of out-of-hospital mortality at 30 days. The median time from discharge to 30-day out-of-hospital all-cause mortality was 11 (Q1-Q3: 5-19) days. Older age, White race, non-Hispanic ethnicity, lower baseline hemoglobin, poor baseline health status, presentation as non-ST-segment elevation myocardial infarction, lower left ventricular ejection fraction, higher acuity presentation, in-hospital complications, ≥moderate residual mitral regurgitation, and lack of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers at discharge were independently associated with higher 30-day out-of-hospital all-cause and cardiovascular mortality.

CONCLUSIONS

Although overall 30-day all-cause mortality after mTEER was low, 2 of 5 deaths occurred out-of-hospital after discharge. Multiple modifiable factors such as patient selection, guideline-directed medical therapy underutilization and procedural complications require optimization to mitigate out-of-hospital mortality after mTEER.

Plant-based diets and cardiovascular events: a proteomics approach to examine the underlying pathways

BACKGROUND

Plant-based diets are associated with a lower risk of cardiovascular disease (CVD). Proteomics may improve our understanding of the biological pathways underlying these associations.

OBJECTIVES

Using large-scale proteomics, we aimed to examine if plant-based diet-related proteins, which have been previously identified, are associated with incident CVD and subtypes of CVD in the Atherosclerosis Risk in Communities (ARIC) Study and Framingham Heart Study (FHS) Offspring cohort.

METHODS

Discovery analyses were based on 9,078 participants free of CVD at ARIC visit 3 (1993-1995). Cox proportional hazards regression was used to evaluate the associations between plant-based diet-related proteins and incident CVD, coronary heart disease, heart failure, and stroke. Replication analyses were based on 1,279 participants without CVD in FHS Offspring cohort.

RESULTS

In the ARIC Study, over a median follow-up of 21 years, there were 3,167 CVD events. At a false discovery rate (FDR) <0.05, 26 out of 73 plant-based diet-related proteins were significantly associated with incident CVD, after adjusting for important confounders. 18, 1, and 0 proteins were associated with heart failure, stroke, and coronary heart disease, respectively. Three, and 2 additional proteins were associated with CVD, and heart failure risk in FHS Offspring cohort at the nominal threshold (p value <0.05). Soluble advanced glycosylation end product-specific receptor (AGER) was inversely associated with incident CVD whereas thrombospondin-2 (THBS2) and N-terminal pro-BNP (NT-proBNP) was positively associated with incident CVD. THBS2 was positively associated with incident heart failure, whereas neuronal growth factor regulator 1 (NEGR1) and insulin-like growth factor-binding protein 1 (IGFBP1) was inversely associated.

CONCLUSION

These proteins highlight several pathways that could explain plant-based diets-CVD associations.

Gaps in knowledge and management of iron deficiency in heart failure: a nationwide survey of cardiologists in China

BACKGROUND

Heart failure (HF) guidelines recommend routine testing for iron deficiency (ID) and, for those with ID, intravenous iron if the left ventricular ejection fraction is <50%. Guideline adherence to these recommendations by cardiologists in China is unknown.

METHODS AND RESULTS

An independent academic web-based survey was designed and distributed via social networks to cardiologists across China. Overall, 1342 cardiologists (median age 34 years, IQR 30-39, 51% women) from all provinces of China completed this survey. More than half were unaware of the need to screen for ID in HF and did not do so routinely in their clinical practice. Approximately 80% were not familiar with the diagnostic criteria for ID in HF guidelines, and only 0.8% recognised transferrin saturation <20% as an independent marker of ID. Regarding iron repletion, only 14% preferred intravenous to oral iron for correcting ID compared with 68% favouring oral iron. Three-quarters were unfamiliar with methods for calculating intravenous iron dose. Furthermore, over 80% were unaware that current guidelines only recommend ferric carboxymaltose or ferric derisomaltose for correcting ID. The main barriers to using intravenous iron were lack of knowledge and experience. Despite such poor awareness and practice, most cardiologists were interested in learning more about managing ID in HF.

CONCLUSIONS

In this nationwide survey of cardiologists in China, we identified large gaps in both knowledge and management of ID. This survey will help guide the development of educational programmes to improve care for patients with HF and ID in China.

Current Evidence on SGLT-2 Inhibitors in Prediabetes: A Review of Preclinical and Clinical Data

Individuals with prediabetes have a higher risk of cardiovascular events and diabetes mellitus. Therefore, the prevention or delay of prediabetes progression to diabetes via lifestyle modification and medications is an important measure to reduce morbidity and mortality in this population. Based on the American Diabetes Association (ADA) guidelines, metformin is the only recommended drug for prediabetes. A growing body of evidence has shown the beneficial effects of sodium-glucose transporter 2 (SGLT-2) inhibitors in prediabetes. These drugs offer cardiovascular mortality benefits over metformin. This review aimed to summarize current evidence about the clinical effects of SGLT-2 inhibitors in prediabetes.

Cardiac rhythm devices in heart failure with reduced ejection fraction - role, timing, and optimal use in contemporary practice. European Journal of Heart Failure expert consensus document

Guidelines for management of heart failure with reduced ejection fraction (HFrEF) emphasize personalized care, patient engagement, and shared decision-making. Medications and cardiac rhythm management (CRM) devices are recommended with a high level of evidence. However, there are significant disparities: patients who could benefit from devices are frequently referred too late or not at all. Misconceptions about device therapy and the notion that the needs of patients (especially the prevention of sudden cardiac death) can now be met by expanding drug therapies may play a role in these disparities. This state-of-the-art review is produced by members of the DIRECT HF initiative, a patient-centred, expert-led educational programme that aims to advance guideline-directed use of CRM devices in patients with HFrEF. This review discusses the latest evidence on the role of CRM devices in reducing HFrEF mortality and morbidity, and provides practical guidance on patient referral, device selection, implant timing and patient-centred follow-up.

Using guideline-directed medical therapies to improve kidney and cardiovascular outcomes in patients with chronic kidney disease

PURPOSE

An estimated 37 million people currently live with chronic kidney disease in the US, which places them at increased risk for kidney disease progression, cardiovascular disease, and mortality. This review discusses current standard-of-care management of patients with chronic kidney disease, identifies key gaps in care, and briefly highlights how pharmacists can address gaps in care as members of the multidisciplinary care team.

SUMMARY

Recent advances in guideline-directed medical therapies for patients with chronic kidney disease, including agents from the sodium-glucose cotransporter, glucagon-like peptide-1 receptor agonist, and nonsteroidal mineralocorticoid receptor antagonist classes, can dramatically improve cardiovascular-kidney-metabolic care and outcomes. Unfortunately, gaps in screening, diagnosis, and implementation of recommended therapies persist. Team-based models of care-inclusive of the person with chronic kidney disease-have the potential to significantly improve care and outcomes for people with chronic kidney disease by addressing current gaps in care.

CONCLUSION

As members of the multidisciplinary care team, pharmacists can play a critical role in addressing current gaps in care, including optimized use of guideline-directed medical therapies, in patients with chronic kidney disease.

Racial and ethnic disparities in longitudinal trajectories of hospitalizations in patients diagnosed with heart failure

BACKGROUND

Racial and ethnic disparities in hospitalizations among heart failure (HF) patients have been well documented. However, little is known about racial and ethnic differences in the long-term trajectories of hospital admissions that follow the diagnosis of HF.

METHODS

We used electronic health records (EHR) of 5,606 patients with newly-diagnosed HF between January 1, 2015 and July 28, 2018 in the Duke University Health System. Patients were followed for up to 5 years (until July 28, 2023) to identify all-cause hospital admissions after their initial diagnosis of HF. Group-based trajectory models were used to identify major trajectories of hospitalization, and multinomial logistic regression models were used to identify patients' clinical and non-clinical characteristics associated with the trajectories of admissions.

RESULTS

In our study cohort (mean age 74.8 ± 5.8 years), we identified four distinct trajectories of hospitalization during follow up: 45.6% (Group 1: N = 2,556) had "low risks" of hospitalization, 36.6% (Group 2: N = 2,052) had elevated risks of admission shortly after diagnosis ("early risk" group), 9.9% (Group 3: N = 553) had elevated risks at later stages of illness ("late risk" group), and 7.9% (Group 4: N = 445) had consistently "high risks" of hospitalization. Non-Hispanic Black patients were more likely to exhibit early risks of hospitalization (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.16-1.52; P<.001), late risks of hospitalization (OR = 1.92; 95% CI, 1.58-2.34; P<.001), or consistently high risks of hospitalization (OR = 1.89; 95% CI, 1.52-2.35; P<.001) compared with non-Hispanic White patients. Diabetes, chronic kidney disease, and residence in a disadvantaged neighborhood significantly contributed to the excess risks of admissions among non-Hispanic Black patients. We found no significant differences in patterns of admissions between patients from other racial and ethnic groups compared with non-Hispanic White patients.

CONCLUSIONS

Non-Hispanic Black patients had early, late, and consistently high risks of hospitalization following the diagnosis of HF compared with non-Hispanic White patients. These findings have important implications for targeting interventions to reduce hospitalizations during the course of HF management.

Evidence-Based Application of Natriuretic Peptides in the Evaluation of Chronic Heart Failure With Preserved Ejection Fraction in the Ambulatory Outpatient Setting

BACKGROUND

Plasma NT-proBNP (N-terminal pro-B-type natriuretic peptide) is commonly used to diagnose heart failure with preserved ejection fraction (HFpEF), but its diagnostic performance in the ambulatory/outpatient setting is unknown because previous studies lacked objective reference standards.

METHODS

Among patients with chronic dyspnea, diagnosis of HFpEF or noncardiac dyspnea was determined conclusively by exercise catheterization in a derivation cohort (n=414), multicenter validation cohort 1 (n=560), validation cohort 2 (n=207), and a nonobese Japanese validation cohort 3 (n=77). Optimal NT-proBNP cut points for HFpEF rule out (optimizing sensitivity) and rule in (optimizing specificity) were derived and tested, stratified by obesity and atrial fibrillation. Derived cut points were tested in 3 additional validation cohorts (cohorts 4-6) in whom HFpEF was diagnosed by resting catheterization only (n=260), previous hospitalization for heart failure (n=447), or exercise echocardiography (n=517), respectively.

RESULTS

Current recommended rule-out NT-proBNP threshold <125 pg/mL had 82% sensitivity (95% CI, 77%-88%) with a body mass index (BMI) <35 kg/m2, decreasing to 67% (95% CI, 58%-77%) with a BMI ≥35 kg/m2. A lower rule-out NT-proBNP threshold <50 pg/mL displayed good sensitivity with a BMI <35 kg/m2 (97% [95% CI, 95%-99%]), with a modest decline in sensitivity with a BMI ≥35 kg/m2 (86% [95% CI, 79%-93%]); diagnostic thresholds were confirmed in validation cohorts 1 and 2 (91% [95% CI, 88%-95%] and 86% [95% CI, 80%-93%] with a BMI <35 kg/m2; 80% [95% CI, 74%-87%] and 84% [95% CI, 74%-93%] with a BMI ≥35 kg/m2). Current consensus age- and BMI-stratified rule-in thresholds demonstrated only 65% specificity (95% CI, 57%-72%). Rule-in NT-proBNP threshold ≥500 pg/mL had 85% specificity (95% CI, 78%-91%) with a BMI <35 kg/m2 (87% [95% CI, 80%-94%] and 90% [95% CI, 81%-99%] in validation cohorts), with 100% specificity at a BMI ≥35 kg/m2 (93% [95% CI, 81%-100%] and 100% in validation cohorts). With a BMI ≥35 kg/m2, lower rule-in thresholds (≥220 pg/mL) provided good specificity (88% [95% CI, 73%-100%]; 93% [95% CI, 81%-100%] and 100% in validation cohorts). Findings were consistent in validation cohorts 3 through 6 (sensitivity of <50 pg/mL, 93%-98%; specificity of ≥500 pg/mL, 82%-89%). NT-proBNP provided no incremental discrimination among patients with history of AF; ≥98% of patients with AF and dyspnea were found to have HFpEF in our cohorts.

CONCLUSIONS

In patients with chronic unexplained dyspnea, current rule-in and rule-out NT-proBNP diagnostic thresholds lead to unacceptably high error rates, with important interactions by obesity and AF status. In our study, NT-proBNP provided little value in those with AF and dyspnea because the presence of AF is by itself a robust biomarker of HFpEF. Use of separate rule-in and rule-out diagnostic thresholds stratified by BMI reduces miscategorization and can guide more appropriate use of exercise testing for possible HFpEF.

Sodium-glucose co-transporter 2 inhibitors and new-onset diabetes in cardiovascular or kidney disease

BACKGROUND AND AIMS

Individuals with heart failure (HF), other forms of cardiovascular disease, or kidney disease are at increased risk for the development and adverse health effects of diabetes. As such, prevention or delay of diabetes is an important treatment priority in these groups. The aim of this meta-analysis was to determine the effect of sodium-glucose co-transporter 2 inhibitors (SGLT2i) on incident diabetes in HF across the spectrum of left ventricular ejection fraction (LVEF) and across the broader spectrum of cardiovascular or kidney disease.

METHODS

First, the effects of dapagliflozin vs. placebo on new-onset diabetes were assessed in a pooled, participant-level analysis of the DAPA-HF and DELIVER trials. New-onset diabetes was defined as the new initiation of glucose-lowering therapy during follow-up, and time from randomization to new-onset diabetes was evaluated using Cox proportional hazards models. Second, PubMed and Embase were searched to identify large-scale randomized clinical outcomes trials (RCTs) comparing SGLT2i with placebo among adults with cardiovascular or kidney disease. A trial-level meta-analysis was then conducted to summarize the treatment effects of SGLT2i on the incidence of new-onset diabetes.

RESULTS

In the pooled analysis of DAPA-HF and DELIVER including 5623 participants with HF but without diabetes at baseline, dapagliflozin reduced the incidence of new-onset diabetes by 33% [hazard ratio (HR), 0.67; 95% confidence interval (CI), .49-.91; P = .012] when compared with placebo. There was no evidence of heterogeneity across the spectrum of continuous LVEF or key subgroups. Among seven complementary RCTs including 17 855 participants with cardiovascular or kidney disease, SGLT2i reduced the of new-onset diabetes by 26% (HR, 0.74; 95% CI .65-.85; P < .001), with consistent effects across trials.

CONCLUSIONS

SGLT2i reduced the incidence of new-onset diabetes among individuals with cardiovascular or kidney disease. These findings suggest that SGLT2i implementation may have an important ancillary benefit on prevention or delay of diabetes in these high-risk populations.

Metabolomic profiling in heart failure as a new tool for diagnosis and phenotyping

Classifying heart failure (HF) by stages and ejection fraction (EF) remains a debated topic in cardiology. Metabolomic profiling (MP) offers a means to identify unique pathophysiological changes across different phenotypes, presenting a promising approach for the diagnosis and prognosis of HF, as well as for the development of targeted therapies. In our study, MP was performed on 408 HF patients (54.9% male). The mean ages of patients were 62 [53;68], 67 [65;74], 68 [61;72], and 69 [65;73] years for stages A, B, C, and D, respectively. This study demonstrates high accuracy in HF stage classification, distinguishing Stage A from Stage B with an AUC ROC of 0.91 and Stage B from Stage C with an AUC ROC of 0.97, by integrating chromatography-mass spectrometry data through multiparametric machine learning models. The observed metabolic similarities between HF with mildly reduced EF and HF with reduced EF phenotypes (AUC ROC 0.96) once again highlight the fundamental differences at the cellular and molecular levels between HF with preserved EF and HF with EF < 50%. Hierarchical clustering based on MP identified four distinct HF phenotypes and 26 key metabolites, including metabolites of tryptophan catabolism, glutamine, riboflavin, norepinephrine, serine, and long- and medium-chain acylcarnitines. The average follow-up period was 542.37 [16;1271] days. A downward change in the trajectory of EF [HR 3,008, 95% CI 1,035 to 8,743, p = 0,043] and metabolomic cluster 3 [HR 2,880; 95% CI 1,062 to 7,810, p = 0,0376] were associated with increased risk of all-cause mortality. MP can refine HF phenotyping and deepen the understanding of its underlying mechanisms. Metabolomic analysis illuminates the biochemical landscape of HF, aiding in its classification and suggesting new therapeutic pathways.

In-hospital use of beta-blockers for critically ill patients with acute heart failure: Whether and when to initiate

BACKGROUND

The use of beta-blockers during hospitalization for acute heart failure (AHF) remains controversial. This study aimed to investigate whether beta-blocker use is associated with a reduced risk of mortality in critically ill patients with AHF and to determine the optimal timing for initiating beta-blocker therapy.

METHODS

Data from critically ill patients with AHF in the MIMIC-IV version 2.2 database were analyzed. Baseline characteristics, laboratory tests, comorbidities, vital signs, and medication usage at admission and during hospitalization were collected to perform inverse probability of treatment weighting (IPTW). IPTW-weighted logistic regression models were then used to examine the relationship between beta-blocker use and mortality.

RESULTS

In the IPTW-weighted regression model, patients who newly started beta-blockers or continued their use had a lower risk of in-hospital mortality compared to those not treated with beta-blockers (odds ratio [OR]: 0.45; 95 % confidence interval [CI]: 0.34 to 0.61, and OR: 0.53; 95 % CI: 0.41 to 0.69, respectively). Conversely, those who had beta-blockers withdrawn showed a higher risk of in-hospital mortality (OR: 2.59; 95 % CI: 1.63 to 4.10). Among beta-blocker users, compared to patients treated before admission and who received their first dose within 48 h of admission, those who were not treated before admission but started after 48 h had a similar mortality risk (OR: 0.82; 95 % CI: 0.60 to 1.11; P = 0.202). However, patients previously treated with beta-blockers who initiated therapy after 48 h and those not treated before admission but started within 48 h had a lower risk of in-hospital mortality (OR: 0.44; 95 % CI: 0.30 to 0.64; P < 0.001, and OR: 0.65; 95 % CI: 0.48 to 0.86; P = 0.003, respectively).

CONCLUSION

The use of beta-blockers during hospitalization for AHF is associated with a reduced risk of in-hospital mortality, and withdrawal was associated with an increased risk of mortality. Initiating beta-blockers within 48 h for beta-blocker-naïve patients and after 48 h for those previously treated with beta-blockers before admission may further decrease mortality risk.

Predictors of Plasma Selenium Levels and Association with Prognosis in Outpatients with Heart Failure: a 36-Month Prospective Cohort Study

Selenium plays a role in the context of heart failure (HF), but still, there are gaps regarding the factors associated with selenium status, as well as its association with the prognosis of HF. We aimed to investigate predictors of plasma selenium and its association with hospitalization and all-cause mortality. This prospective cohort study included 80 outpatients with HF. Non-elective hospitalization and all-cause mortality were assessed during 36 months of follow-up. The associations between plasma selenium, dietary selenium intake, and sociodemographic, clinical, and biochemical parameters were evaluated by a multiple linear regression model. The risk of these clinical outcomes was assessed with multivariate Cox regression and cubic splines analysis. Albumin (β = 0.113, p < 0.001; R2 = 0.291) and triacylglycerol levels (β = 0.0002, p < 0.021, R2 = 0.376) were predictors of plasma selenium levels. No significant associations were found between dietary selenium intake and plasma selenium tertiles with hospitalization and all-cause mortality (all p > 0.05). The cubic splines analysis revealed that both low and high selenium concentrations influence these outcomes. The predictors of plasma selenium were related to the clinical conditions of HF. Selenium in plasma should be interpreted cautiously, considering that low and high levels may be associated with risks of adverse outcomes in HF.

Predictors of Cardiac Recovery in Adults With AML Who Develop Heart Failure During Treatment

PURPOSE

Heart failure is a leading cause of death in patients with AML, who face higher risks of cardiac complications than nonleukemic cancer patients treated with anthracyclines. This study examines factors associated with myocardial dysfunction and recovery occurring during treatment of AML.

METHODS

We retrospectively analyzed patients with AML who sustained reduced left ventricular ejection fraction (LVEF) during induction therapy at the University of Washington/Fred Hutchinson Cancer Center (2008-2022). Multivariable analysis compared characteristics between patients who eventually recovered LVEF and those who did not, with survival analysis performed by landmark censoring.

RESULTS

Of 86 patients with AML diagnosed with systolic dysfunction, 41 (48%) failed to recover LVEF. These patients were more frequently male, older than 60 years, had preexisting cardiovascular risk factors, and leukemias of higher risk. Ischemia-related systolic failure was associated with nonrecovery (B = -2.89, P = .005), whereas chemotherapy-related dysfunction was associated with eventual recovery (B = 1.15, P = .014). Frequent use and higher doses of guideline-directed medical therapy (GDMT) were found among patients who recovered LVEF. Failure to recover cardiac function was associated with a greater incidence of cardiac-specific mortality (51% v 23%, P = .042), although impact on overall survival was unclear.

CONCLUSION

Our retrospective single-center analysis suggests that approximately half of the patients with AML who experience LVEF decline during induction will not recover. Ischemic events during treatment were predictive of nonrecovery. The use of GDMT may improve prognosis for some patients. Given the impact of recovery, we propose the prospective verification and establishment of cardiac management algorithms in patients with AML.

Association of microRNA-210-3p with NT-proBNP, sST2, and Galectin-3 in heart failure patients with preserved and reduced ejection fraction: A cross-sectional study

BACKGROUND

Heart failure (HF) is a growing health problem and around two percent are affected in the general population. Accurate diagnostic markers that have the potential for early diagnosis of HF are lacking. This study aimed to compare the expression levels of microRNA-210-3p with biomarkers NT-proBNP, sST2, and galectin-3, in heart failure patients with preserved and reduced ejection fractions.

MATERIALS AND METHODS

The cross-sectional study was conducted on 270 hypertensive heart failure patients in the age group of 30 to 75 years of both genders. The participants with evidence of HF were recruited from the Department of Cardiology in a tertiary care hospital in Chennai, India. MicroRNA-210-3p was analyzed by qRT-PCR in a stratified sample of 80 HF patients and 20 apparently healthy individuals. Biomarkers were analyzed by ELISA. Institutional ethics committee approval and written informed consent were obtained. Statistical analysis was performed using R software (4.2.1). Based on the type of distribution of data, appropriate statistical tools were used. p-value ≤  0.05 was considered to be statistically significant.

RESULTS

All the biomarkers including microRNA-210-3p were significantly higher in HFrEF than in HFpEF. MAGGIC score showed a positive correlation with all the biomarkers. The cut-off of microRNA-210-3p was 5.03.

CONCLUSION

All the biomarkers were significantly elevated in HFrEF compared to HFpEF. However, microRNA-210-3p could be an early marker in the diagnosis of heart failure. The strategy of employing a multi-marker approach could help in the early diagnosis as well as in stratifying the HF patients.

Finerenone and New York Heart Association Functional Class in Heart Failure: The FINEARTS-HF Trial

BACKGROUND

The NYHA functional classification remains an important and widely used metric in heart failure (HF)-oriented clinical care and research.

OBJECTIVES

This study aims to evaluate whether the effect of finerenone varies according to NYHA functional class in HF with mildly reduced or preserved ejection fraction.

METHODS

In this prespecified analysis of the FINEARTS-HF trial, treatment effects of finerenone according to baseline NYHA functional class (II or III/IV) were examined on the primary endpoint (cardiovascular death and total HF events) and key secondary endpoints. Effects of finerenone on change in NYHA functional class were evaluated using ordinal logistic regression.

RESULTS

At baseline, 4,146 (69%) and 1,854 (31%) participants were NYHA functional class II and III/IV, respectively. Participants with baseline NYHA functional class III/IV vs II experienced a significantly higher rate of cardiovascular death and total HF events (adjusted rate ratio: 1.28 [95% CI: 1.11-1.46]; P < 0.001). Finerenone consistently reduced the primary endpoint irrespective of baseline NYHA functional class (Pinteraction = 0.54), with greater absolute benefits in NYHA functional class III/IV (absolute rate reduction [ARR]: 4.5 per 100 person-years) vs II (ARR: 2.0 per 100 person-years). Benefits of finerenone on Kansas City Cardiomyopathy Questionnaire-Total Symptom Score at 12 months were consistent irrespective of NYHA functional class (Pinteraction = 0.93). NYHA functional class improved similarly in the finerenone and placebo arms out to 12 months. The safety profile of finerenone was similar among participants with baseline NYHA functional class III/IV vs II.

CONCLUSIONS

In this FINEARTS-HF analysis, finerenone reduced clinical outcomes and improved patient-reported health status in HF with mildly reduced or preserved ejection fraction irrespective of baseline NYHA functional class. (Finerenone Trial to Investigate Efficacy and Safety Superior to Placebo in Patients with Heart Failure [FINEARTS-HF]; NCT04435626).

Management of Heart Failure With Improved Ejection Fraction: Current Evidence and Controversies

Heart failure with improved ejection fraction (HFimpEF) is defined by improved left ventricular ejection fraction (LVEF) among patients who previously had reduced LVEF. HFimpEF is associated with improved prognosis, albeit with persistent risk of relapse and adverse events in some patients. Current guidelines thus recommend sustained and indefinite guideline-directed medical therapy (GDMT) for all patients with HFimpEF. Emerging clinical experience suggests that heart failure arising from acute etiologies that fully resolve along with complete LVEF recovery may have a favorable prognosis with lower risk of relapse. Indeed, cohort and case series studies have demonstrated the feasibility of safe de-escalation of GDMT in select patients with specific etiologies, with multiple small trials ongoing. Future studies should investigate whether advanced imaging or blood biomarkers could aid in risk stratifying patients with recovered LVEF, whether partial de-escalation of GDMT could be safe and feasible, and whether implantable cardioverter-defibrillator therapy can be safely discontinued.

Blood pressure impact of dietary practices using the DASH method: a systematic review and meta-analysis

Background

In order to ascertain the impact of the Dietary Approach to Stop Hypertension (DASH) diet on blood pressure (BP), a systematic review and meta-analysis of randomized controlled trials were carried out. DASH is advised for lowering BP.

Methods

Scopus databases were searched from the beginning of 2024. A total of 579 articles from 2019 to 2023 from PubMed: 15, Scopus: 164 and Crossref: 400. There were 8 articles included in the meta-analysis.

Results

Systolic BP (1.29 mmHg to 4.6 mmHg, 95% CI, -2.17, -0.41; P < 0.005) and diastolic BP (0.76 mmHg to 1.1 mmHg, 95% CI, -1.39, -0.13; P < 0.005) were found to be significantly reduced by the DASH diet, while total cholesterol concentrations (5.2 mmol/L; P < 0.005), low-density lipoprotein (8.2 mmol/L; P = 0.03), and high-density lipoprotein increased by 8.2% (P < 0.005) were lowered by 0.9 points.

Conclusions

When followed consistently, the DASH diet can reduce BP's systolic and diastolic readings.

Trial Registration

PROSPERO Identifier: CRD42023494005.

Clinical studies in Myxomatous Mitral Valve Disease dogs: most prescribed ACEI inhibits ACE2 enzyme activity and ARB increases AngII pool in plasma

The hypertension patient population has doubled since 1990, affecting 1.3 billion globally and >75% live in low-and middle-income countries. Angiotensin Converting Enzyme Inhibitors (ACEI) and Angiotensin Receptor Blockers (ARB) are the most prescribed drugs (>160 million times in the US), but mortality increased >30% since 1990s globally. Clinical relevance of Myxomatous Mitral Valve Disease (MMVD) is directly linked to WHO group 2 pulmonary hypertension, with no disease specific therapies. Therefore, MMVD pet dogs with elevated systolic blood pressure treated with ACEI/ARB, were supplemented with oral ACE2 enzyme and Angiotensin1-7 (Ang1-7) bioencapsulated in plant cells. The oral ACE2/Ang1-7 was well tolerated by healthy and MMVD dogs with no adverse events and increased sACE2 activity by 670-755% with ARB (Telmisartan) than with ACEI (Enalapril) background therapy. In vitro rhACE2 activity was inhibited >90% by ACEIs enalapril/benazeprilat at higher doses but lisinopril inhibited at much lower doses. Membrane ACE2 activity evaluated in exosomes was 43-fold higher than the sACE2 and this was also inhibited 211% by ACEI, when compared to ARB. Background ACEI treatment reduced the Ang-II pool by 11-20-fold and proportionately decreased the abundance of Ang1-7 + Ang1-5 peptides. In contrast, ARB treatment increased Ang-II pool 11-20-fold and Ang1-7 + Ang1-5 by 160-260%. Systolic blood pressure was regulated by ARB better than ACEI, despite very high Ang-II levels. This first report on evaluation of metabolic pools in the RAS pathway identifies surprising interactions between ACEI/ARB/ACE2 and significant changes in key molecular dynamics. Affordable biologics developed in plant cells may offer potential new treatment options for hypertension.

A Machine Learning-derived Risk Score Improves Prediction of Outcomes After LVAD Implantation: An Analysis of the INTERMACS Database

BACKGROUND

Significant variability in outcomes after left ventricular assist device (LVAD) implantation emphasize the importance of accurately assessing patients' risk before surgery. This study assesses the Machine Learning Assessment of Risk and Early Mortality in Heart Failure (MARKER-HF) mortality risk model, a machine learning-based tool using 8 clinical variables, to predict post-LVAD implantation mortality and its prognostic enhancement over the Interagency Registry of Mechanically Assisted Circulatory Support (INTERMACS) profile.

METHODS

Analyzing 25,365 INTERMACS database patients (mean age 56.8 years, 78% male), 5,663 (22.3%) and 19,702 (77.7%) received HeartMate 3 and other types of LVAD, respectively. They were categorized into low, moderate, high, and very high-risk groups based on MARKER-HF score. The outcomes of interest were in-hospital and 1-year postdischarge mortality.

RESULTS

In patients receiving HeartMate 3 devices, 6.2% died during the index hospitalization. In-hospital mortality progressively increased from 4.4% in low-risk to 15.2% in very high-risk groups with MARKER-HF score. MARKER-HF provided additional risk discrimination within each INTERMACS profile. Combining MARKER-HF score and INTERMACS profile identified patients with the lowest (3.5%) and highest in-hospital mortality rates (19.8%). The postdischarge mortality rate at 1 year was 5.8% in this population. In a Cox proportional hazard regression analysis adjusting for both MARKER-HF and INTERMACS profile, only MARKER-HF score (hazard ratio 1.27, 95% confidence interval 1.11-1.46, P < .001) was associated with postdischarge mortality. Similar findings were observed for patients receiving other types of LVADs.

CONCLUSIONS

The MARKER-HF score is a valuable tool for assessing mortality risk in patients with HF undergoing HeartMate 3 and other LVAD implantation. It offers prognostic information beyond that of the INTERMACS profile alone and its use should help in the shared decision-making process for LVAD implantation.

Recognition of the Large Ambulatory C2D Stage of Advanced Heart Failure-A Call to Action

Importance

The advanced ambulatory heart failure (HF) population comprises patients who have progressed beyond the pillars of recommended stage C HF therapies but can still find meaningful life-years ahead. Although these patients are commonly encountered in practice, national databases selectively capture the small groups accepted for heart transplant listing or left ventricular assist devices. The epidemiology, trajectories, and therapies for other ambulatory patients with advanced HF are poorly understood.

Observations

In December 2022, the National Heart, Lung and Blood Institute convened a team of experts to identify knowledge gaps and research priorities for the ambulatory population with limiting daily symptoms and transition toward refractory end-stage D HF, designated as stage C2D. This article summarizes the findings from that 3-day workshop. Workshop participants surveyed the initial challenges and knowledge gaps for (1) recognition of ambulatory C2D HF, (2) estimation of the magnitude of the affected population and identifiable subpopulations, and (3) physiologic phenotypes, such as low cardiac output, right HF, cardiorenal syndromes, congestive hepatopathy and frailty, which offer distinct targets for existing and emerging therapies. Social drivers of HF and patient preferences for quality/length of survival were highlighted as essential modifiers for personalization of therapies.

Conclusions and Relevance

Ten key points summarized workshop findings, with target cohorts for study proposed as a crucial next step. This workshop summary is intended as a call for action to address knowledge gaps and develop new strategies to improve outcomes in the large ambulatory population with C2D HF.

The association of reduced ejection fraction with the outcomes of endovascular abdominal aortic aneurysm repair

OBJECTIVE

It is estimated that 20% of patients undergoing elective abdominal aortic aneurysm repair suffer from cardiomyopathy. This study examines the impact of reduced ejection fraction (EF) on the outcomes of endovascular aneurysm repair (EVAR) and compares the different types of cardiomyopathies causing reduction of EF. Our hypothesis is that reduction in EF is associated with higher mortality after EVAR.

METHODS

We examined the Vascular Quality Initiative database for EVAR from 2003 to 2020. Patients presenting with symptomatic abdominal aortic aneurysm or rupture were excluded. Patients were excluded if age, sex, mortality, and EF were not available. Patients were stratified into categories in two separate analyses. The first analysis examines differences between <30% EF, 30% to 50% EF, and EF >50%, and the second analysis examined differences between ischemic cardiomyopathy (ICM) and nonischemic cardiomyopathy in patients with reduced EF. Patients' demographics, comorbidities, operative characteristics, and outcomes were compared. Statistical comparisons were performed using χ2 analysis for categorical variables and analysis of variance for continuous variables. Multivariable comparison was performed to find characteristics impacting mortality.

RESULTS

There were 26,037 patients included and 20,127 (77.3%) had a normal EF (>50%), 4885 (18.7%) patients had a moderately reduced EF of 30% to 50%, and only 1025 (3.9%) patients had a severely reduced EF (<30%). The 30-day mortality was not significantly different between patients with very reduced (1.9%) and reduced EF (1.7%), but was significantly higher than patients with normal EF (0.8%) (P < .001). There was a nearly two-fold increase in 30-day mortality for ischemic cardiomyopathy (1.1% vs 2.0%; P = .024) compared with nonischemic cardiomyopathy, but there was no difference in long-term mortality between the two groups.

CONCLUSIONS

Elective EVAR in patients with reduced EF is associated with higher 30-day mortality compared with patients with a normal EF, but the overall mortality rate in the Vascular Quality Initiative falls within the acceptable range of Society for Vascular Surgery guidelines. Among patients with reduced EF, the type of cardiomyopathy seems to have a more important association with 30-day mortality than the severity of cardiomyopathy does.

Left ventricular function improvement during angiotensin receptor-neprilysin inhibitor treatment in a cohort of HFrEF/HFmrEF patients

AIMS

Heart failure (HF) patients may lack improvement of left ventricular (LV) ejection fraction (LVEF) despite optimal HF medication comprising an angiotensin receptor-neprilysin inhibitor (ARNI). Therefore, we aimed to identify key predictors for LV functional enhancement and prognostic reverse cardiac remodelling in HF patients on ARNI treatment.

METHODS

We retrospectively analysed 294 consecutive patients with HF with reduced (HFrEF) or mildly reduced (HFmrEF) ejection fraction in our 'EnTruth' patient registry. LVEF was determined by echocardiography at initiation of ARNI and at 12 months of follow-up. We assessed the predictive value of clinically relevant patient-, HF- and treatment-related parameters in regard to changes in LVEF and all-cause mortality using medoid clustering and the XGBoost machine learning algorithm.

RESULTS

Cluster analysis integrating clinically relevant patient characteristics unveiled four characteristic sub-phenotypes of patients with HFrEF and HFmrEF, respectively. Distinct clusters exhibit a strong (P < 0.05) therapeutic response to ARNI treatment and enhanced LV function. Key patient criteria, such as duration and aetiology of HF, renal function and de novo ARNI treatment, were significantly (P < 0.05) associated with change of LVEF and independently predicted cardiac remodelling. By training various machine learning models on relevant clinical parameters, stratification of LVEF improvement by XGBoost resulted in a high prediction accuracy. The stratification of patients with HFrEF [area under the receiver operating characteristic curve (AUC) = 0.77] and HFmrEF (AUC = 0.70) led to an increased diagnostic accuracy of LVEF improvement in the validation cohort. Using machine learning, the likelihood of cardiac remodelling following ARNI treatment, as indicated by our newly established EnTruth score, was directly associated with absolute LVEF improvement in both HFrEF (r = 0.51, P < 0.0001) and HFmrEF (r = 0.42, P = 0.001). Ultimately, patients with HFrEF and a high EnTruth score have a lower risk of all-cause mortality (P < 0.05 in survival analysis).

CONCLUSIONS

Recognition of essential clinical factors by integrating machine learning and cluster analyses may help to identify HF patients benefiting from improvement of LVEF following ARNI treatment. Early identification of those patients with a high response to ARNI treatment may allow a more refined selection of patients benefiting from an early escalation of HF treatment or interventional therapy.

PET Imaging for Cardiomyopathy Challenges Simplistic Notions of Ischemia and Viability

PET of the myocardium in patients with low ejection fraction has classically focused on identifying ischemic and viable myocardium. In this review, we use a case-based format to challenge these simplistic notions while integrating the results from recent clinical trials. The basic message is that, for most patients, severely reduced left ventricular function is due predominantly to nonischemic cardiomyopathy, not scar or ischemia. Consequently, we emphasize several practical pitfalls when using cardiac PET imaging in this population to improve its clinical value.

Effectiveness of home-based cardiac rehabilitation interventions delivered via mHealth technologies: a systematic review and meta-analysis

BACKGROUND

Centre-based cardiac rehabilitation (CBCR) is underused due to low referral rates, accessibility barriers, and socioeconomic constraints. mHealth technologies have the potential to address some of these challenges through remote delivery of home-based cardiac rehabilitation (HBCR). This study aims to assess the effects of mHealth HBCR interventions compared with usual care and CBCR in patients with heart disease.

METHODS

We conducted a systematic review and meta-analysis of randomised controlled trials of mHealth HBCR interventions. Four electronic databases (MEDLINE, CENTRAL, CINAHL, and Embase) were searched from inception to March 31, 2023, with no restrictions on language or publication type. Eligible studies were randomised controlled trials of adult patients (age ≥18 years) with heart disease, comparing mHealth interventions with usual care or CBCR. The primary outcome of interest was aerobic exercise capacity, assessed with VO2 peak or 6-min walk test (6MWT). Quality of evidence was assessed using the GRADE system. This review was registered with PROSPERO, CRD42024544087.

FINDINGS

Our search yielded 9164 references, of which 135 were retained for full-text review. 13 randomised controlled trials met eligibility criteria and were included in the systematic review, involving 1508 adults with myocardial infarction, angina pectoris, or heart failure, or who had undergone revascularisation. Intervention duration ranged from 6 weeks to 24 weeks. Random-effects meta-analysis showed that, compared with usual care, mHealth HBCR significantly improved 6MWT (mean difference 24·74, 95% CI 9·88-39·60; 532 patients) and VO2 peak (1·77, 1·19-2·35; 359 patients). No significant differences were found between mHealth HBCR and CBCR. Quality of evidence ranged from low to very low across outcomes due to risk of bias and imprecision (small sample size).

INTERPRETATION

mHealth HBCR could improve access and health outcomes in patients who are unable to attend CBCR. Further research is needed to build a robust evidence base on the clinical effectiveness and cost-effectiveness of mHealth HBCR, particularly in comparison with CBCR, to inform clinical practice and policy.

FUNDING

None.

Harnessing the Plasma Proteome to Predict Mortality in Heart Failure Subpopulations

BACKGROUND

We derived and validated proteomic risk scores (PRSs) for heart failure (HF) prognosis that provide absolute risk estimates for all-cause mortality within 1 year.

METHODS

Plasma samples from individuals with HF with reduced ejection fraction (HFrEF; ejection fraction <40%; training/validation n=1247/762) and preserved ejection fraction (HFpEF; ejection fraction ≥50%; training/validation n=725/785) from 3 independent studies were run on the SomaScan Assay measuring ≈5000 proteins. Machine learning techniques resulted in unique 17- and 14-protein models for HFrEF and HFpEF that predict 1-year mortality. Discrimination was assessed via C-index and 1-year area under the curve (AUC), and survival curves were visualized. PRSs were also compared with Meta-Analysis Global Group in Chronic HF (MAGGIC) score and NT-proBNP (N-terminal pro-B-type natriuretic peptide) measurements and further assessed for sensitivity to disease progression in longitudinal samples (HFrEF: n=396; 1107 samples; HFpEF: n=175; 350 samples).

RESULTS

In validation, the HFpEF PRS performed significantly better (P≤0.1) for mortality prediction (C-index, 0.79; AUC, 0.82) than MAGGIC (C-index, 0.71; AUC, 0.74) and NT-proBNP (PRS C-index, 0.76 and AUC, 0.81 versus NT-proBNP C-index, 0.72 and AUC, 0.76). The HFrEF PRS performed comparably to MAGGIC (PRS C-index, 0.76 and AUC, 0.83 versus MAGGIC C-index, 0.75 and AUC, 0.84) but had a significantly better C-Index (P=0.026) than NT-proBNP (PRS C-index, 0.75 and AUC, 0.78 versus NT-proBNP C-index, 0.73 and AUC, 0.77). PRS included known HF pathophysiology biomarkers (93%) and novel proteins (7%). Longitudinal assessment revealed that HFrEF and HFpEF PRSs were higher and increased more over time in individuals who experienced a fatal event during follow-up.

CONCLUSIONS

PRSs can provide valid, accurate, and dynamic prognostic estimates for patients with HF. This approach has the potential to improve longitudinal monitoring of patients and facilitate personalized care.

Association of nighttime very short-term blood pressure variability determined by pulse transit time with adverse prognosis in patients with heart failure

Long-term blood pressure (BP) variability (BPV) is associated with adverse prognosis in patients with heart failure. However, the clinical significance of very short-term (beat-to-beat) BPV is unclear. We collected data on nighttime pulse transit time-based continuous beat-to-beat BP measurement in patients with heart failure (n = 366, median age 72.0, male sex 53.3%). Coefficient of variation (CoV) of pulse transit time-based BP was considered as very short-term BPV. The primary outcome was a composite of heart failure hospitalization or cardiac death. Median values (25th and 75th percentiles) of systolic and diastolic BP CoV were 3.6% (2.8%, 4.5%) and 5.1% (3.8%, 6.5%), respectively. During a median follow-up period of 1084 days after BPV evaluation, 71 patients experienced the primary outcome. When the patients were divided into tertiles based on the systolic and diastolic BPV, the primary outcome occurred most frequently in the highest tertile of BPV. Multivariable Cox proportional hazard analysis revealed that systolic and diastolic BPV, as continuous variables, were independently associated with the primary outcome (hazard ratio 1.199 and 1.101, respectively). In conclusion, high nighttime very short-term BPV was associated with adverse prognosis in patients with heart failure.

Comparative Effectiveness and Safety of Torsemide Versus Furosemide in Older Adults With Heart Failure

PURPOSE

Evidence on the real-world comparative effectiveness and safety of commonly used loop diuretics for heart failure is mixed, particularly among older adults who are at a higher risk of adverse outcomes. Thus, we aimed to compare the outcomes and safety profiles of torsemide and furosemide.

METHODS

We conducted a new user, active comparator retrospective cohort study comparing torsemide to furosemide in Medicare fee-for-service beneficiaries with heart failure in claims data (2008-2020). Effectiveness outcomes were a composite of heart failure hospitalization or death and urgent outpatient visits requiring intravenous diuretics; safety outcomes included acute kidney injury, hypovolemia, and hypokalemia. We used 1:4 propensity score (PS) matching to adjust for confounding. We calculated PS-matched hazard ratios using Cox proportional hazard models.

RESULTS

Across 328 640 matched beneficiaries, compared with furosemide, torsemide was associated with a similar, though statistically significantly lower, risk of the composite effectiveness outcome (hazard ratio [HR] = 0.97, 95% CI:0.95,0.99; incidence rate difference (IRD) = -3.79, 95% CI:-9.38,1.81 events per 1000 person-years) and lower risk for urgent visits with intravenous loop diuretics (HR = 0.88, 95% CI:0.84,0.92; IRD = -7.03, 95% CI:-9.79,-4.26 events per 1000 person-years). Torsemide was also associated with an increased risk of acute kidney injury (HR = 1.12, 95% CI:1.10,1.15; IRD = 36.89, 95% CI:31.51,42.64 events per 1000 person-years) with no observed difference in hypokalemia (HR = 1.02, 95% CI:0.91,1.14; IRD = 0.46, 95% CI:-0.51,1.42 events per 1000 person-years) and hypovolemia (HR = 1.03, 95% CI:0.98,1.09; IRD = 2.36, 95% CI:0.15,4.56 events per 1000 person-years).

CONCLUSIONS

Compared with furosemide, initiation of torsemide was associated with a slightly lower risk of a composite of all-cause mortality or heart failure hospitalization and urgent visits with intravenous diuretics, but a slightly higher risk of acute kidney injury. In older adults, clinicians must balance torsemide's potential benefits with the acute kidney injury risk.

Necrosis-like cell death modes in heart failure: the influence of aetiology and the effects of RIP3 inhibition

Since cell dying in heart failure (HF) may vary based on the aetiology, we examined the main forms of regulated necrosis, such as necroptosis and pyroptosis, in the hearts damaged due to myocardial infarction (MI) or pressure overload. We also investigated the effects of a drug inhibiting RIP3, a proposed convergent point for both these necrosis-like cell death modes. In rat hearts, left ventricular function, remodelling, pro-cell death, and pro-inflammatory events were investigated, and the pharmacodynamic action of RIP3 inhibitor (GSK'872) was assessed. Regardless of the HF aetiology, the heart cells were dying due to necroptosis, albeit the upstream signals may be different. Pyroptosis was observed only in post-MI HF. The dysregulated miRNAs in post-MI hearts were accompanied by higher levels of a predicted target, HMGB1, its receptors (TLRs), as well as the exacerbation of inflammation likely originating from macrophages. The RIP3 inhibitor suppressed necroptosis, unlike pyroptosis, normalised the dysregulated miRNAs and tended to decrease collagen content and affect macrophage infiltration without affecting cardiac function or structure. The drug also mitigated the local heart inflammation and normalised the higher circulating HMGB1 in rats with post-MI HF. Elevated serum levels of HMGB1 were also detected in HF patients and positively correlated with C-reactive protein, highlighting pro-inflammatory axis. In conclusion, in MI-, but not pressure overload-induced HF, both necroptosis and pyroptosis operate and might underlie HF pathogenesis. The RIP3-targeting pharmacological intervention might protect the heart by preventing pro-death and pro-inflammatory mechanisms, however, additional strategies targeting multiple pro-death pathways may exhibit greater cardioprotection.

Canagliflozin and iron metabolism in the CREDENCE trial

BACKGROUND

Studies in patients with heart failure have indicated that sodium-glucose cotransporter 2 (SGLT2) inhibitors increase iron use and enhance erythropoiesis. In this post hoc analysis of the Canagliflozin and Renal Endpoints in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE) trial, we evaluated the effects of canagliflozin on iron metabolism in patients with chronic kidney disease (CKD) and whether the effects of canagliflozin on hemoglobin and cardiorenal outcomes were modified by iron deficiency.

METHODS

We measured serum iron, total iron binding capacity (TIBC), transferrin saturation (TSAT) and ferritin at baseline and 12 months. The effects of canagliflozin, relative to placebo, on iron markers were assessed with analysis of covariance. Interactions between baseline iron deficiency, defined as TSAT <20%, and the effects of canagliflozin on hemoglobin and cardiorenal outcomes were evaluated with mixed effect models and Cox regression models, respectively.

RESULTS

Of 4401 participants randomized in CREDENCE, 2416 (54.9%) had iron markers measured at baseline, of whom 924 (38.2%) were iron deficient. Canagliflozin, compared with placebo, increased TIBC by 2.1% [95% confidence interval (CI) 0.4, 3.8; P = .014] and decreased ferritin by 11.5% (95% CI 7.1, 15.7; P < .001) with no clear effect on serum iron or TSAT. Canagliflozin increased hemoglobin over the trial duration by 7.3 g/L (95% CI 6.2, 8.5; P < .001) and 6.7 g/L (95% CI 5.2, 8.2; P < .001) in patients with and without iron deficiency, respectively (P for interaction = .38). The relative effect of canagliflozin on the primary outcome of doubling of serum creatinine, kidney failure or death due to cardiovascular disease or kidney failure (hazard ratio 0.70, 95% CI 0.56, 0.87) was consistent regardless of iron deficiency (P for interaction = .83), as were effects on other cardiovascular and mortality outcomes (all P for interactions ≥0.10).

CONCLUSION

Iron deficiency is highly prevalent in patients with type 2 diabetes and CKD. Canagliflozin increased TIBC and decreased ferritin in patients with type 2 diabetes and CKD, suggesting increased iron utilization, and improved hemoglobin levels and clinical outcomes regardless of iron deficiency.

Impact of sodium-glucose cotransporter 2 inhibitor on recurrence and cardiovascular outcomes after catheter ablation for atrial fibrillation in patients with heart failure

BACKGROUND

The impact of sodium-glucose cotransporter 2 inhibitors (SGLT2i) on atrial fibrillation (AF) recurrence outcomes and adverse cardiovascular outcomes in heart failure (HF) patients after AF ablation is unknown.

OBJECTIVE

We investigated whether SGLT2i reduces the risk of AF recurrence and adverse cardiovascular outcomes in HF patients after AF ablation.

METHODS

HF patients with AF undergoing catheter ablation between January 2017 and December 2022 from the China-AF Registry were included. Patients were stratified into 2 groups on the basis of the use of SGLT2i at discharge and were 1:1 matched by propensity score, with SGLT2i using (n = 368) and non-SGLT2i using (n = 368) in each group. The primary outcome was AF recurrence after a 3-month blanking period.

RESULTS

During a total of 1315 person-years of follow-up, AF recurred in 83 patients (22.6%) in the SGLT2i group and 132 patients (35.8%) in the non-SGLT2i group. SGLT2i was associated with a lower risk of AF recurrence (adjusted hazard ratio, 0.56; 95% CI, 0.43-0.74; P < .001). The composite risk of cardiovascular death, thrombotic events, or cardiovascular hospitalization was significantly lower in the SGLT2i group compared with those without SGLT2i (adjusted hazard ratio, 0.58; 95% CI, 0.41-0.80; P = .001). Although there was a trend toward benefit, the differences in all-cause mortality, cardiovascular death, or thrombotic events were insignificant between the 2 groups.

CONCLUSION

The use of SGLT2i was associated with a lower risk of AF recurrence and the composite outcome of cardiovascular death, thrombotic events, or cardiovascular hospitalization after catheter ablation for AF in patients with HF.

Surgical Revascularization Decisions in Ischemia and Heart Failure

Coronary artery bypass grafting is the major modality of coronary revascularization in patients with ischemic cardiomyopathy as it provides surgical collateralization of the coronary bed protecting the functional myocardium. Myocardial viability testing does not have an established role in the surgical evaluation. Concomitant surgical ventricular restoration does not improve symptoms or survival, though patients with large aneurysms and significant reduction in ventricular size could benefit. Correction of functional mitral regurgitation does not improve survival, and severe functional mitral regurgitation should be addressed via mitral valve replacement. Temporary mechanical circulatory support can be used as a bridge to recovery.

Guidelines for treating heart failure

Optimal guideline-directed medical therapy for heart failure with reduced ejection fraction comprises the angiotensin receptor-neprilysin inhibitor (sacubitril/valsartan), an evidence-based beta-blocker (bisoprolol, carvedilol, or sustained-release metoprolol), a mineralocorticoid antagonist (spironolactone or eplerenone), and a sodium-glucose cotransporter-2 inhibitor (dapagliflozin or empagliflozin). Optimal guideline-directed medical therapy for heart failure with preserved ejection fraction comprises a sodium-glucose cotransporter-2 inhibitor with emerging evidence to support the use of a mineralocorticoid antagonist and glucagon-like peptide-1 receptor agonists. This review will summarize the evidence behind the guideline recommendations, the impact of newer trials on management of patients with HF, and strategies for implementation into clinical practice.