Prevalence of American Heart Association Heart Failure Stages in Black and White Young and Middle-Aged Adults: The CARDIA Study

Proteomics of left ventricular structure in the Multi-Ethnic Study of Atherosclerosis

AIMS

Proteomic profiling offers an expansive approach to biomarker discovery and mechanistic hypothesis generation for LV remodelling, a critical component of heart failure (HF). We sought to identify plasma proteins cross-sectionally associated with left ventricular (LV) size and geometry in a diverse population-based cohort without known cardiovascular disease (CVD).

METHODS AND RESULTS

Among participants of the Multi-Ethnic Study of Atherosclerosis (MESA), we quantified plasma abundances of 1305 proteins using an aptamer-based platform at exam 1 (2000-2002) and exam 5 (2010-2011) and assessed LV structure by cardiac magnetic resonance (CMR) at the same time points. We used multivariable linear regression with robust variance to assess cross-sectional associations between plasma protein abundances and LV structural characteristics at exam 1, reproduced findings in later-life at exam 5, and explored relationships of associated proteins using annotated enrichment analysis. We studied 763 participants (mean age 60 ± 10 years at exam 1; 53% female; 19% Black race; 31% Hispanic ethnicity). Following adjustment for renal function and traditional CVD risk factors, plasma levels of 3 proteins were associated with LV mass index at both time points with the same directionality (FDR < 0.05): leptin (LEP), renin (REN), and cathepsin-D (CTSD); 20 with LV end-diastolic volume index: LEP, NT-proBNP, histone-lysine N-methyltransferase (EHMT2), chordin-like protein 1 (CHRDL1), tumour necrosis factor-inducible gene 6 protein (TNFAIP6), NT-3 growth factor receptor (NTRK3), c5a anaphylatoxin (C5), neurogenic locus notch homologue protein 3 (NOTCH3), ephrin-B2 (EFNB2), osteomodulin (OMD), contactin-4 (CNTN4), gelsolin (GSN), stromal cell-derived factor 1 (CXCL12), calcineurin subunit B type 1 (PPP3R1), insulin-like growth factor 1 receptor (IGF1R), bone sialoprotein 2 (IBSP), interleukin-11 (IL-11), follistatin-related protein 1 (FSTL1), periostin (POSTN), and biglycan (BGN); and 4 with LV mass-to-volume ratio: RGM domain family member B (RGMB), transforming growth factor beta receptor type 3 (TGFBR3), ephrin-A2 (EFNA2), and cell adhesion molecule 3 (CADM3). Functional annotation implicated regulation of the PI3K-Akt pathway, bone morphogenic protein signalling, and cGMP-mediated signalling.

CONCLUSIONS

We report proteomic profiling of LV size and geometry, which identified novel associations and reinforced previous findings on biomarker candidates for LV remodelling and HF. If validated, these proteins may help refine risk prediction and identify novel therapeutic targets for HF.

Impact of first-line antihypertensive drug class and intensity on NT-proBNP improvement and cardiovascular outcomes among hypertensive patients with pre-heart failure: findings from SPRINT trial

Five first-line classes of antihypertensive drugs are recommended for hypertension treatment. However, it is unclear which class should be chosen for hypertensive patients with pre-heart failure (pre-HF). The study aimed to investigate the association between antihypertensive drug classes and intensity with probability of NT-proBNP (N-terminal pro-B-type natriuretic peptide) improvement and risk of cardiovascular events among pre-HF hypertensive patients. Utilizing the data from SPRINT, we included pre-HF hypertensive patients, identified by NT-proBNP ≥125 pg/mL at baseline. NT-proBNP improvement is defined as a reduction of ≥50% to a level below 125 pg/mL. A total of 3293 patients (mean age: 71.9 years; female: 43.8%) were included. NT-proBNP improvement was observed in 415 patients (12.6%) over 1-year follow up. Thiazide-type diuretics users were associated with a higher likelihood of NT-proBNP improvement (odds ratio [OR], 1.33; 95% confidence interval [CI], 1.05-1.70), a lower risk of HF (hazard ratio [HR], 0.54; 95% CI, 0.37-0.78) and primary composite outcome (HR, 0.72; 95% CI, 0.57-0.89). ACEI/ARB users were only associated with a lower risk of primary composite outcome (HR, 0.80; 95% CI, 0.63-0.99). In contrast, beta-blockers users were associated with a lower likelihood of NT-proBNP improvement (OR, 0.43; 95% CI, 0.34-0.55), while a higher risk of HF (HR, 1.79; 95% CI, 1.21-2.64) and primary composite outcome (HR, 1.48; 95% CI, 1.18-1.87). These associations varied across subgroups of different drug intensities. This post hoc analysis supports the use of thiazide-type diuretics and ACEI/ARB for prevention of cardiovascular events. The use of beta-blockers is associated with an increased risk of HF and primary outcomes, which requires further validation. Association between antihypertensive drug classes and intensity with NT-proBNP improvement and long-term clinical outcome.

Racial disparities across multiple stages of the deceased organ donation process

Pervasive structural violence causes higher organ failure rates among Black Americans and excess Black potential deceased organ donors. Underuse of Black donors would exacerbate organ shortages that disproportionately harm Black transplant candidates. This study investigates racial differences in transit between distinct donation steps among 132 968 potential donors across 557 hospitals and 6 Organ Procurement Organizations (OPOs) from 2015 through 2021. Multilevel multistate modeling with patient covariates and OPO random effects shows adjusted likelihoods (95% confidence interval [CI]) of non-Black versus Black patients transitioning from OPO referral to approach: odds ratio (OR) 1.23 (95% CI 1.18, 1.27), approach to authorization: OR 1.64 (95% CI 1.56, 1.72), authorization to procurement: OR 1.08 (95% CI 1.02, 1.14), and procurement to transplant: OR 0.99 (95% CI 0.93, 1.04). Overall organ utilization rates for Black, Latino, White, and other OPO referrals were 5.88%, 8.17%, 6.78%, and 5.24%, respectively. Adjusting for patient covariates and hospital and OPO random effects, multilevel logistic models estimated that compared with Black patients, Latino, White, and other patients had ORs of organ utilization of 1.82 (95% CI 1.61, 2.04), 3.19 (95% CI 2.91, 3.50), and 1.25 (95% CI 1.06, 1.47), respectively. Nationwide in 2022, donor conversion disparities likely lost more than 1800 donors-70% of whom would have been Black. Achieving racial equity for transplant candidates will require reducing racial disparities in organ donation.

Electrocardiography changes and different stages of heart failure in central Iran: A cross-sectional study from Yazd Health Study

Background and Aims

Electrocardiography (ECG) is a widely accessible, noninvasive, and cost-effective diagnostic instrument used to evaluate patients with suspected heart failure (HF). The aim of this study is to investigate electrocardiographic changes in patients with different stages of HF in a random population of Yazd city.

Methods

This prospective cross-sectional study included 319 individuals, randomly selected, aged 40 years and more, registered in the Yazd Health Study was conducted from March 2022 to May 2023 at Afshar Hospitals. In accordance with the AHA/ACC guidelines, HF was classified into four stages (A, B, C, and D).

Results

The 159 individuals were classified in the stage 0 group, 77 were in Stage A, 65 were in Stage B, and 18 were in Stage C of HF. In the Stage 0, the PR interval (PRi) was 130.5 ± 18.1 ms, while in Stage C, it was 143.3 ± 21.9 ms, with a significant difference (p = 0.047). Similarly, the QRS interval (QRSi) increased with HF staging (p = 0.001). The frequency of diabetes mellitus (DM), hypertension (HTN), hyperlipidemia (HLP), chronic heart disease, alcoholism, and PRi, QRSi, QT interval levels were independent predictors of HF stage in multivariate regression analysis.

Conclusion

The prevalence of HF stages, as classified by the AHA/ACC guidelines, was observed, with significant correlations between ECG parameters and HF progression. abnormal rhythms, left bundle branch block, ischemia, hypertrophy, and left atrial enlargement increased with higher HF stages. Major risk factors like DM and HTN exhibited a heightened prevalence in advanced HF stages, accentuating their pivotal role in the progression of HF.

Preventing new-onset heart failure: Intervening at stage A

Heart failure (HF) prevention is an urgent public health need with national and global implications. Stage A HF patients do not show HF symptoms or structural heart disease but are at risk of HF development. There are no unique recommendations on detecting Stage A patients. Patients in Stage A are heterogeneous; many patients have different combinations of risk factors and, therefore, have markedly different absolute risks for HF. Comprehensive strategies to prevent HF at Stage A include intensive blood pressure lowering, adequate glycemic and lipid management, and heart-healthy behaviors (adopting Life's Essential 8). First and foremost, it is imperative to improve public awareness of HF risk factors and implement healthy lifestyle choices very early. In addition, recognize the HF risk-enhancing factors, which are nontraditional cardiovascular (CV) risk factors that identify individuals at high risk for HF (genetic susceptibility for HF, atrial fibrillation, chronic kidney disease, chronic liver disease, chronic inflammatory disease, sleep-disordered breathing, adverse pregnancy outcomes, radiation therapy, a history of cardiotoxic chemotherapy exposure, and COVID-19). Early use of biomarkers, imaging markers, and echocardiography (noninvasive measures of subclinical systolic and diastolic dysfunction) may enhance risk prediction among individuals without established CV disease and prevent chemotherapy-induced cardiomyopathy. Efforts are needed to address social determinants of HF risk for primordial HF prevention.Central illustrationPolicies developed by organizations such as the American Heart Association, American College of Cardiology, and the American Diabetes Association to reduce CV disease events must go beyond secondary prevention and encompass primordial and primary prevention.

Prevalence of heart failure stages in the general population and implications for heart failure prevention: reports from the China Hypertension Survey 2012-15

AIMS

There are no nationwide epidemiological data on heart failure (HF) stages in China. Knowledge of the prevalence of HF stages is crucial for planning HF prevention and management strategies. We aimed to evaluate the prevalence of HF stages in the general Chinese population and the specific prevalence by age, sex, and urbanity.

METHODS AND RESULTS

This is a cross-sectional study and national representative general population aged ≥ 35 years (n = 31 494, mean age 57.4 years, women 54.1%) were obtained from the China Hypertension Survey. Participants were divided into Stage A (at-risk for HF), Stage B (pre-HF), and Stage C (symptomatic HF). Survey weights were calculated based on the 2010 China population census data. The prevalence of Stage A was 35.8% (≈245.1 million), Stage B 42.8% (≈293.1 million), and Stage C 1.1% (≈7.5 million). The prevalence of Stages B and C increased with increasing age (P < 0.0001). Women had lower prevalence of Stage A (32.6% vs. 39.3%; P < 0.0001) but higher prevalence of Stage B (45.9% vs. 39.5%; P < 0.0001) than men. People from rural area had lower prevalence of Stage A (31.9% vs. 41.0%; P < 0.0001) but higher prevalence of Stage B (47.8% vs. 36.2%; P < 0.0001) than people from urban. The prevalence of Stage C was similar by sex and urbanity.

CONCLUSION

The burdens of pre-clinical and clinical HF are high and vary by age, sex, and urbanity in China. Targeted interventions are needed to reduce the high burden of pre-clinical and clinical HF.

Impact of a Nurse-Led Multidisciplinary Heart Failure Clinic in a Low-Resource Setting: Experience in a Latin American Public Healthcare System

Background

Nurse-led multidisciplinary heart failure clinics (MDHFCs) play an important role in patient care in developed countries, due to their proven benefits relating to mortality, hospitalization, and quality of life. However, evidence is limited regarding the role of MDHFCs in a limited-resource setting.

Methods

Patients with heart failure (HF) with reduced ejection fraction (n = 89) were enrolled in a prospective, longitudinal cohort, from January 2018 to January 2019. The following endpoints were collected at baseline and after 6 months of follow-up: (i) quality of life, measured using the Minnesota Living with Heart Failure Questionnaire; (ii) medication adherence using the Morisky Medication Adherence Scale, 8-item; (iii) titration of HF medications; (iv) self-care behavior using the European Heart Failure Self-care Behavior Scale; and (v) mortality and hospitalizations up to 12 months after.

Results

The questionnaire score was reduced from 66.5 (interquartile range [IQR], 46-86) at baseline to 26 (IQR, 13-45) at 6 months (P < 0.001). New York Heart Association (NYHA) functional class improved at 6 months (NYHA I: 41.9%; NYHA II: 39.5%; NYHA III: 17.2%), compared to baseline (NYHA I: 20%; NYHA II: 49%; NYHA III: 31%; P < 0.001). Medication adherence using the 8-item Morisky Medication Adherence Scale improved the score from 6 (IQR, 4-7) at baseline to 7 (IQR, 6.25-8; P = 0.001) at 6 months. Uptitration of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (25% vs 18% at target dose) and beta-blockers (25% vs 11% at target dose) was documented. After 6 months of follow-up, the European Heart Failure Self-care Behavior Scale was applied, showing a score of 18.5 (IQR, 15-22). The mortality reported at 12 months of follow-up was 9.7%, and the incidence of hospitalization was 44%.

Conclusion

An MDHFC is a feasible strategy to manage an HF clinic in a low-resource setting.

Effect of 2022 ACC/AHA/HFSA Criteria on Stages of Heart Failure in a Pooled Community Cohort

BACKGROUND

The 2022 American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America (HFSA) clinical practice guideline proposed an updated definition for heart failure (HF) stages.

OBJECTIVES

This study aimed to compare prevalence and prognosis of HF stages according to classification/definition originally described in 2013 and 2022 ACC/AHA/HFSA definitions.

METHODS

Study participants from 3 longitudinal cohorts (the MESA [Multi-Ethnic Study of Atherosclerosis], CHS [Cardiovascular Health Study], and the FHS [Framingham Heart Study]), were categorized into 4 HF stages according to the 2013 and 2022 criteria. Cox proportional hazards regression was used to assess predictors of progression to symptomatic HF and adverse clinical outcomes associated with each HF stage.

RESULTS

Among 11,618 study participants, according to the 2022 staging, 1,943 (16.7%) were healthy, 4,348 (37.4%) were in stage A (at risk), 5,019 (43.2%) were in stage B (pre-HF), and 308 (2.7%) were in stage C/D (symptomatic HF). Compared to the classification/definition originally described in 2013, the 2022 ACC/AHA/HFSA approach resulted in a higher proportion of individuals with stage B HF (increase from 15.9% to 43.2%); this shift disproportionately involved women as well as Hispanic and Black individuals. Despite the 2022 criteria designating a greater proportion of individuals as stage B, the relative risk of progression to symptomatic HF remained similar (HR: 10.61; 95% CI: 9.00-12.51; P < 0.001).

CONCLUSIONS

New standards for HF staging resulted in a substantial shift of community-based individuals from stage A to stage B. Those with stage B HF in the new system were at high risk for progression to symptomatic HF.

Prevalence and prognosis of frailty in older patients with stage B heart failure with preserved ejection fraction

AIMS

Frailty in older patients with stage B heart failure with preserved ejection fraction (HFpEF) has not been fully explored. We evaluated the prevalence and prognostic significance of frailty in older patients diagnosed with stage B HFpEF.

METHODS

Our prospective cohort study included inpatients aged ≥65 years who were followed up for 3 years. Stage B HFpEF was defined as cardiac structural or functional abnormalities with a left ventricular ejection fraction (LVEF) ≥ 50% without signs or symptoms. Frailty was assessed using the Fried phenotype. The primary outcome was 3-year all-cause mortality or readmission.

RESULTS

Overall, 520 older inpatients diagnosed with stage B HFpEF [mean ± standard deviation age: 75.5 ± 6.25 years, male: 222 (42.7%)] were included in the study. Of these, 145 (27.9%) were frail. Frail patients were older (78.5 ± 6.23 vs. 74.3 ± 6.22 years, P < 0.001), with a lower body mass index (24.6 ± 3.60 vs. 25.7 ± 3.27 kg/m² , P = 0.001), higher level of N-terminal pro-B-type natriuretic peptide [279 (interquartile range: 112.4, 596) vs. 140 (67.1, 266) pg/mL, P < 0.001], longer timed up-and-go test result (19.9 ± 9.71 vs. 13.3 ± 5.08 s, P < 0.001), and poorer performance in the short physical performance battery (4.1 ± 3.26 vs. 8.2 ± 2.62, P < 0.001), basic activities of daily living (BADL, 4.7 ± 1.71 vs. 5.7 ± 0.57, P < 0.001), and instrumental activities of daily living (IADL, 4.4 ± 2.73 vs. 7.4 ± 1.33, P < 0.001). Frail patients were more likely to have a Mini-Mental State Examination (MMSE) score <24 (55.9% vs. 28.8%, P < 0.001) and take more than five medications (64.1% vs. 47.2%, P = 0.001). Frail patients had a higher incidence of all-cause mortality or readmission (62.8% vs. 47.7%, P = 0.002), all-cause readmission (56.6% vs. 45.9%, P = 0.029), and readmission for non-heart failure (55.2% vs. 41.3%, P = 0.004) during the 3-year follow-up, with a 1.53-fold (95%CI 1.11-2.11, P = 0.009) higher risk of all-cause mortality or readmission, a 1.52-fold (95%CI 1.09-2.11, P = 0.014) higher risk of all-cause readmission, and a 1.70-fold (95%CI 1.21-2.38, P = 0.002) higher risk of readmission for non-clinical heart failure, adjusted for sex, age, polypharmacy, Athens Insomnia Scale, MMSE, LVEF, BADL, and IADL.

CONCLUSIONS

Frailty is common in elderly patients with stage B HFpEF. Physical frailty, particularly low physical activity, can independently predict the long-term prognosis in these patients.

Advanced Heart Failure: Definition, Epidemiology, and Clinical Course

Advanced heart failure (HF) is characterized by a progressive worsening of symptoms disabling for daily life, refractory to all therapies, and with high mortality. These patients may be candidates for life-prolonging therapies, such as heart transplantation (HT) or long-term (LT) mechanical circulatory support (MCS) or must just require palliative therapies. The 1-year survival after HT and/or LT-MCS is approaching 80% to 90%, being patient selection and timely referral to advanced HF centers critical for optimal outcomes. There is no single symptom, sign, or test that can identify these patients and different classifications are complementary and helpful for clinical decision-making.

Advanced Heart Failure Epidemiology and Outcomes: A Population-Based Study

OBJECTIVES

The goal of this study was to evaluate the prevalence, characteristics, and outcomes of patients with advanced heart failure (HF) in a geographically defined population.

BACKGROUND

Some patients with HF progress to advanced HF, characterized by debilitating HF symptoms refractory to therapy. Limited data are available on the epidemiology and outcomes of patients with advanced HF.

METHODS

This was a population-based cohort study of all Olmsted County, Minnesota, adults with and without HF from 2007 to 2017. The 2018 European Society of Cardiology advanced HF diagnostic criteria were operationalized and applied to all patients with HF. Hospitalization and mortality in advanced HF, overall and according to ejection fraction (EF) type (reduced EF <40% [HFrEF], mid-range EF 40%-49% [HFmrEF], and preserved EF ≥50% [HFpEF]) were examined using Andersen-Gill and Cox models.

RESULTS

Of 6,836 adults with HF, 936 (13.7%) met criteria for advanced HF. The prevalence of advanced HF increased with age and was higher in men. At advanced HF diagnosis, 396 (42.3%) patients had HFrEF, 134 (14.3%) had HFmrEF, and 406 (43.4%) had HFpEF. The median (interquartile range) time from advanced HF diagnosis to death was 12.2 months (3.7 months-29.9 months). The mean rate of hospitalization was 2.91 (95% CI: 2.78-3.06) per person-year in the first year after advanced HF diagnosis. There were no differences in risks of all-cause mortality or hospitalization by EF. Patients with advanced HFpEF were at lower risk for cardiovascular mortality compared with advanced HFrEF (HR: 0.79; 95% CI: 0.65-0.97).

CONCLUSIONS

In this population-based study, more than one-half of patients with advanced HF had mid-range or preserved EF, and survival was poor regardless of EF.

The Coronary Artery Risk Development In Young Adults (CARDIA) Study: JACC Focus Seminar 8/8

The CARDIA (Coronary Artery Risk Development in Young Adults) study began in 1985 to 1986 with enrollment of 5,115 Black or White men and women ages 18 to 30 years from 4 US communities. Over 35 years, CARDIA has contributed fundamentally to our understanding of the contemporary epidemiology and life course of cardiovascular health and disease, as well as pulmonary, renal, neurological, and other manifestations of aging. CARDIA has established associations between the neighborhood environment and the evolution of lifestyle behaviors with biological risk factors, subclinical disease, and early clinical events. CARDIA has also identified the nature and major determinants of Black-White differences in the development of cardiovascular risk. CARDIA will continue to be a unique resource for understanding determinants, mechanisms, and outcomes of cardiovascular health and disease across the life course, leveraging ongoing pan-omics work from genomics to metabolomics that will define mechanistic pathways involved in cardiometabolic aging.

Age-Related Development of Cardiac Remodeling and Dysfunction in Young Black and White Adults: The Coronary Artery Risk Development in Young Adults Study

BACKGROUND

Little is known about the timing of preclinical heart failure (HF) development, particularly among blacks. The primary aims of this study were to delineate age-related left ventricular (LV) structure and function evolution in a biracial cohort and to test the hypothesis that young-adult LV parameters within normative ranges would be associated with incident stage B-defining LV abnormalities over 25 years, independent of cumulative risk factor burden.

METHODS

Data from the Coronary Artery Risk Development in Young Adults study were analyzed. Participants (n = 2,833) had a mean baseline age of 30.1 years; 45% were black, and 56% were women. Generalized estimating equation logistic regression was used to estimate age-related probabilities of stage B LV abnormalities (remodeling, hypertrophy, or dysfunction) and logistic regression to examine risk factor-adjusted associations between baseline LV parameters and incident abnormalities. Cox regression was used to assess whether baseline LV parameters associated with incident stage B LV abnormalities were also associated with incident clinical (stage C/D) HF events over >25 years' follow-up.

RESULTS

Probabilities of stage B LV abnormalities at ages 25 and 60 years were 10.5% (95% CI, 9.4%-11.8%) and 45.0% (95% CI, 42.0%-48.1%), with significant race-sex disparities (e.g., at age 60, black men 52.7% [95% CI, 44.9%-60.3%], black women 59.4% [95% CI, 53.6%-65.0%], white men 39.1% [95% CI, 33.4%-45.0%], and white women 39.1% [95% CI, 33.9%-44.6%]). Over 25 years, baseline LV end-systolic dimension indexed to height was associated with incident systolic dysfunction (adjusted odds ratio per 1 SD higher, 2.56; 95% CI, 1.87-3.52), eccentric hypertrophy (1.34; 95% CI, 1.02-1.75), concentric hypertrophy (0.69; 95% CI, 0.51-0.91), and concentric remodeling (0.68; 95% CI, 0.58-0.79); baseline LV mass indexed to height2.7 was associated with incident eccentric hypertrophy (1.70; 95% CI, 1.25-2.32]), concentric hypertrophy (1.63; 95% CI, 1.19-2.24), and diastolic dysfunction (1.24; 95% CI, 1.01-1.52). Among the entire cohort with baseline echocardiographic data available (n = 4,097; 72 HF events), LV end-systolic dimension indexed to height and LV mass indexed to height2.7 were significantly associated with incident clinical HF (adjusted hazard ratios per 1 SD higher, 1.56 [95% CI, 1.26-1.93] and 1.42 [95% CI, 1.14-1.75], respectively).

CONCLUSIONS

Stage B LV abnormalities and related racial disparities were present in young adulthood, increased with age, and were associated with baseline variation in indexed LV end-systolic dimension and mass. Baseline indexed LV end-systolic dimension and mass were also associated with incident clinical HF. Efforts to prevent the LV abnormalities underlying clinical HF should start from a young age.

Frailty related all-cause mortality or hospital readmission among adults aged 65 and older with stage-B heart failure inpatients

BACKGROUND

Frailty increases the adverse outcomes of clinical heart failure; however, the relationship between frailty and stage-B heart failure (SBHF) remains unknown. We aimed to explore the epidemiology and predictive value of frailty in older adults with SBHF.

METHODS

A prospective cohort of SBHF inpatients aged 65 years or older who were hospitalized between September 2018 and February 2019 and were followed up for 6 months were included. SBHF was defined as systolic abnormality, structural abnormality (left ventricular enlargement, left ventricular hypertrophy, wall motion abnormalities, valvular heart disease), or prior myocardial infarction. Frailty was assessed by the Fried frailty phenotype. Multivariable Cox proportional hazards regression was used to explore the independent risk and prognostic factors.

RESULTS

Data of 443 participants (age: 76.1 ± 6.79 years, LVEF: 62.8 ± 4.92%, men: 225 [50.8%], frailty: 109 [24.6%]) were analyzed. During the 6-month follow-up, 83 (18.7%) older SBHF inpatients experienced all-cause mortality or readmission, and 29 (6.5%) of them developed clinical HF. Frail individuals had a 1.78-fold (95%CI: 1.02-3.10, P = 0.041) higher risk of 6-month mortality or readmission and a 2.83-fold (95%CI 1.24-6.47, P = 0.014) higher risk of developing clinical HF, independent of age, sex, left ventricular ejection fraction, and N-terminal pro-B-type natriuretic peptide level.

CONCLUSIONS

Frailty is common in older SBHF inpatients and should be considered to help identify individuals with an increased risk of mortality or readmission, and developing clinical HF.

TRIAL REGISTRATION

ChiCTR1800017204 .

Life-Course Implications of Pediatric Risk Factors for Cardiovascular Disease

The concept that origins of cardiovascular disease (CVD) begin in childhood is supported by substantial evidence. Prospective studies beginning in childhood report associations of childhood obesity, abnormal blood pressure (BP), dyslipidemia, diabetes, and tobacco use with intermediate CVD markers, including left ventricular hypertrophy and vascular stiffness in young adulthood. Trajectory analyses from longitudinal studies describe discrete BP pathways from childhood to young adult status of hypertension and prehypertension. Among individuals with familial hypercholesterolemia, abnormal low-density lipoprotein cholesterol levels are present in childhood. Some children are at risk for future CVD owing to hereditary factors, psychosocial stress, race, low birth weight, or other nonmodifiable exposures. Behavioural factors, including suboptimal diet, sedentary activity, and tobacco use, in childhood augment risk and can be modified to reduce risk. Pharmacologic treatments are reserved for those at high levels of the BP and cholesterol distributions and for those with diabetes and additional risk factors.

Risk-Based Approach for the Prediction and Prevention of Heart Failure

Targeted prevention of heart failure (HF) remains a critical need given the high prevalence of HF morbidity and mortality. Similar to risk-based prevention of atherosclerotic cardiovascular disease, optimal HF prevention strategies should include quantification of risk in the individual patient. In this review, we discuss incorporation of a quantitative risk-based approach into the existing HF staging landscape and the clinical opportunity that exists to translate available data on risk estimation to help guide personalized decision making. We first summarize the recent development of key HF risk prediction tools that can be applied broadly at a population level to estimate risk of incident HF. Next, we provide an in-depth description of the clinical utility of biomarkers to personalize risk estimation in select patients at the highest risk of developing HF. We also discuss integration of genomics-enhanced approaches (eg, Titin [TTN]) and other risk-enhancing features to reclassify risk with a precision medicine approach to HF prevention. Although sequential testing is very likely to identify low and high-risk individuals with excellent accuracy, whether or not interventions based on these risk models prevent HF in clinical practice requires prompt attention including randomized placebo-controlled trials of candidate therapies in risk-enriched populations. We conclude with a summary of unanswered questions and gaps in evidence that must be addressed to move the field of HF risk assessment forward.

Bi-directional association between depression and HF: An electronic health records-based cohort study

Objective:

To determine whether a bi-directional relationship exists between depression and HF within a single population of individuals receiving primary care services, using longitudinal electronic health records (EHRs).

Methods:

This retrospective cohort study utilized EHRs for adults who received primary care services within a large healthcare system in 2006. Validated EHR-based algorithms identified 10,649 people with depression (depression cohort) and 5,911 people with HF (HF cohort) between January 1, 2006 and December 31, 2018. Each person with depression or HF was matched 1:1 with an unaffected referent on age, sex, and outpatient service use. Each cohort (with their matched referents) was followed up electronically to identify newly diagnosed HF (in the depression cohort) and depression (in the HF cohort) that occurred after the index diagnosis of depression or HF, respectively. The risks of these outcomes were compared (vs. referents) using marginal Cox proportional hazard models adjusted for 16 comorbid chronic conditions.

Results:

2,024 occurrences of newly diagnosed HF were observed in the depression cohort and 944 occurrences of newly diagnosed depression were observed in the HF cohort over approximately 4–6 years of follow-up. People with depression had significantly increased risk for developing newly diagnosed HF (HR 2.08, 95% CI 1.89–2.28) and people with HF had a significantly increased risk of newly diagnosed depression (HR 1.34, 95% CI 1.17–1.54) after adjusting for all 16 comorbid chronic conditions.

Conclusion:

These results provide evidence of a bi-directional relationship between depression and HF independently of age, sex, and multimorbidity from chronic illnesses.

Prevalence and Prognostic Significance of Frailty in Gerontal Inpatients With Pre-clinical Heart Failure: A Subgroup Analysis of a Prospective Observational Cohort Study in China

Objective: To evaluate the prognostic value of frailty in gerontal pre-clinical heart failure (stage B heart failure, SBHF) inpatients.

Background: The association between frailty and SBHF remains unknown.

Methods: We conducted a subgroup analysis of a prospective observational cohort study on frailty. The previous study recruited 1,000 elderly inpatients who were consecutively admitted to a tertiary referral hospital in Beijing, China, from September 2018 to February 2019. The outcomes were all-cause death or readmission at 1-year follow-up. SBHF was diagnosed for asymptomatic cardiac structural or functional abnormalities. Frailty was assessed using the Comprehensive Geriatric Assessment-Frailty Index (CGA-FI).

Results: Overall, 531 inpatients aged ≥65 years were deemed to have SBHF and followed up for 1 year. Of them, 34.5% exhibited frailty. During the follow-up period, all-cause death or readmission occurred in 157 (29.5%) participants. Of these participants, 36.6% (67/183) and 25.9% (90/348) belonged to the frail and non-frail groups, respectively (χ² = 6.655, P = 0.010). Frailty, defined by the CGA-FI, rather than Fried frailty phenotype, could independently predict 1-year all-cause death or readmission (hazard ratio, 1.56; 95% confidence interval, 1.03–2.35; P = 0.034) and was more suitable for predicting all-cause death or readmission than N-terminal pro-B-type natriuretic peptide in female SBHF inpatients aged 80 years or over(AUC_CGA−FI vs. AUC_NT−proBNP 0.654 vs. 0.575, P = 0.017).

Conclusions: Frailty is highly prevalent even among SBHF inpatients aged ≥65 years. The CGA-FI can independently predict 1-year all-cause death or readmission, rather than Fried frailty phenotype. Frailty in gerontal SBHF inpatients deserves more attention.

Clinical Trial registration: ChiCTR1800017204; date of registration: 07/18/2018.

Trends in the Prevalence of Self-reported Heart Failure by Race/Ethnicity and Age From 2001 to 2016

Importance

Despite recent advances in therapies for heart failure (HF), deaths from HF are increasing, with persistent disparities between Black and White adults. Recent national trends in the prevalence of HF need to be clarified to appropriately allocate resources and develop effective preventive interventions.

Objectives

To examine the prevalence of ambulatory HF overall and by race/ethnicity and age and the temporal changes in HF prevalence between 2001 and 2016.

Design, Setting, and Participants

This cross-sectional study of nationally representative data collected biennially through the National Health and Nutrition Examination Survey (NHANES) from January 1, 2001, to December 31, 2016, assessed nonpregnant adults 35 years and older who self-identified as non-Hispanic Black, non-Hispanic White, or Mexican American. Data analysis was performed from November 16, 2019, to April 12, 2020.

Exposures

Survey period, race/ethnicity, and age group.

Main Outcomes and Measures

Age-standardized prevalence was calculated within 4-year survey periods (2001-2004, 2005-2008, 2009-2012, and 2013-2016) based on self-report of ambulatory HF overall and by race/ethnicity and age group (35-64 and ≥65 years). Weighted multivariable logistic regression was used to examine trends in ambulatory HF prevalence over time by race/ethnicity and age group.

Results

A total of 26 097 participants (mean [SD] age, 55.9 [10.7] years; 13 192 [52%] female; 6519 [12%] non-Hispanic Black; and 4906 [7%] Mexican American) were studied. Overall age-standardized prevalence (per 100 000 population) of ambulatory HF was 3184 (95% CI, 2641-3728) from 2001 to 2005 and 3045 (95% CI, 2651-3438) from 2013 to 2016. The prevalence of ambulatory HF was highest among non-Hispanic Black adults: from 2013 to 2016, HF prevalence (per 100 000 population) was 5017 (95% CI, 3755-6279) among non-Hispanic Black adults, 2746 (95% CI, 2313-3179) among non-Hispanic White adults, and 2508 (95% CI, 1154-3862) among Mexican American adults. Differences between White and Black adults in HF prevalence were also present in younger and middle-aged adults (eg, 35-64 years of age in 2013-2016: 3864 [95% CI, 2369-5359] for non-Hispanic Black adults vs 1297 [95% CI, 878-1716] for non-Hispanic White adults).

Conclusions and Relevance

This study found that a high burden of ambulatory HF persisted between 2001 and 2016 in the US. Disparities were most prominent by age group. Alongside prevention and aggressive management of risk factors, targeted efforts aimed at mitigating racial disparities are needed.