Korean Guidelines for Diagnosis and Management of Chronic Heart Failure

Machine learning in heart failure diagnosis, prediction, and prognosis: review

Globally, cardiovascular diseases take the lives of over 17 million people each year, mostly through myocardial infarction, or MI, and heart failure (HF). This comprehensive literature review examines various aspects related to the diagnosis, prediction, and prognosis of HF in the context of machine learning (ML). The review covers an array of topics, including the diagnosis of HF with preserved ejection fraction (HFpEF) and the identification of high-risk patients with HF with reduced ejection fraction (HFrEF). The prediction of mortality in different HF populations using different ML approaches is explored, encompassing patients in the ICU, and HFpEF patients using biomarkers and gene expression. The review also delves into the prediction of mortality and hospitalization rates in HF patients with mid-range ejection fraction (HFmrEF) using ML methods. The findings highlight the significance of a multidimensional approach that encompasses clinical evaluation, laboratory assessments, and comprehensive research to improve our understanding and management of HF. Promising predictive models incorporating biomarkers, gene expression, and consideration of epigenetics demonstrate potential in estimating mortality and identifying high-risk HFpEF patients. This literature review serves as a valuable resource for researchers, clinicians, and healthcare professionals seeking a comprehensive and updated understanding of the role of ML diagnosis, prediction, and prognosis of HF across different subtypes and patient populations.

Expert recommendations for the management of iron deficiency in patients with heart failure in Asia

BACKGROUND

Iron deficiency is a common comorbidity in heart failure (HF) and is independently associated with a worse quality-of-life and exercise capacity, as well as increased risk of hospitalization, regardless of anemia status. Although international guidelines have provided recommendations for the management of iron deficiency in patients with HF, guidelines in Asia are less established, and practical use of guidelines for management of iron deficiency is limited in the region.

METHODS

A panel comprising cardiologists from China, Hong Kong, India, Japan, Malaysia, Pakistan, Philippines, Singapore, South Korea, Taiwan, and Thailand convened to share insights and provide guidance for the optimal management of iron deficiency in patients with HF, tailored for the Asian community.

RESULTS

Expert opinions were provided for the screening, diagnosis, treatment and monitoring of iron deficiency in patients with HF. It was recommended that all patients with HF with reduced ejection fraction should be screened for iron deficiency, and iron-deficient patients should be treated with intravenous iron. Monitoring of iron levels in patients with HF should be carried out once or twice yearly. Barriers to the management of iron deficiency in patients with HF in the region include low awareness of iron deficiency amongst general physicians, lack of reimbursement for screening and treatment, and lack of proper facilities for administration of intravenous iron.

CONCLUSIONS

These recommendations provide a structured approach to the management of iron deficiency in patients with HF in Asia.

Early Diagnosis of Cardiovascular Diseases in the Era of Artificial Intelligence: An In-Depth Review

Cardiovascular diseases (CVDs) are significant health issues that result in high death rates globally. Early detection of cardiovascular events may lower the occurrence of acute myocardial infarction and reduce death rates in people with CVDs. Traditional data analysis is inadequate for managing multidimensional data related to the risk prediction of CVDs, heart attacks, medical image interpretations, therapeutic decision-making, and disease prognosis due to the complex pathological mechanisms and multiple factors involved. Artificial intelligence (AI) is a technology that utilizes advanced computer algorithms to extract information from large databases, and it has been integrated into the medical industry. AI methods have shown the ability to speed up the advancement of diagnosing and treating CVDs such as heart failure, atrial fibrillation, valvular heart disease, hypertrophic cardiomyopathy, congenital heart disease, and more. In clinical settings, AI has shown usefulness in diagnosing cardiovascular illness, improving the efficiency of supporting tools, stratifying and categorizing diseases, and predicting outcomes. Advanced AI algorithms have been intricately designed to analyze intricate relationships within extensive healthcare data, enabling them to tackle more intricate jobs compared to conventional approaches.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Advanced and Acute Heart Failure

The Korean Society of Heart Failure (KSHF) Guidelines provide evidence-based recommendations based on Korean and international data to guide adequate diagnosis and management of heart failure (HF). Since introduction of 2017 edition of the guidelines, management of advanced HF has considerably improved, especially with advances in mechanical circulatory support and devices. The current guidelines addressed these improvements. In addition, we have included recently updated evidence-based recommendations regarding acute HF in these guidelines. In summary, Part IV of the KSHF Guidelines covers the appropriate diagnosis and optimized management of advanced and acute HF.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Advanced and Acute Heart Failure

The Korean Society of Heart Failure (KSHF) Guidelines provide evidence-based recommendations based on Korean and international data to guide adequate diagnosis and management of heart failure (HF). Since introduction of 2017 edition of the guidelines, management of advanced HF has considerably improved, especially with advances in mechanical circulatory support and devices. The current guidelines addressed these improvements. In addition, we have included recently updated evidence-based recommendations regarding acute HF in these guidelines. In summary, Part IV of the KSHF Guidelines covers the appropriate diagnosis and optimized management of advanced and acute HF.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Treatment

The Korean Society of Heart Failure (KSHF) guidelines aim to provide physicians with evidence-based recommendations for the management of patients with heart failure (HF). After the first introduction of the KSHF guidelines in 2016, newer therapies for HF with reduced ejection fraction, HF with mildly reduced ejection fraction, and HF with preserved ejection fraction have since emerged. The current version has been updated based on international guidelines and research data on Korean patients with HF. Herein, we present Part II of these guidelines, which comprises treatment strategies to improve the outcomes of patients with HF.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Treatment

The Korean Society of Heart Failure (KSHF) guidelines aim to provide physicians with evidence-based recommendations for the management of patients with heart failure (HF). After the first introduction of the KSHF guidelines in 2016, newer therapies for HF with reduced ejection fraction, HF with mildly reduced ejection fraction, and HF with preserved ejection fraction have since emerged. The current version has been updated based on international guidelines and research data on Korean patients with HF. Herein, we present Part II of these guidelines, which comprises treatment strategies to improve the outcomes of patients with HF.

Factors Related to Patients' Self-care and Self-care Confidence in Korean Patients With Heart Failure and Their Caregivers: A Cross-sectional, Correlational Study

BACKGROUND

The relationships of patient factors and caregiver contribution to patients' self-care to different types of self-care have been rarely examined in Korean patients with heart failure.

OBJECTIVE

The aim of this study was to examine patient (ie, age, depressive symptoms, and self-care confidence) and caregiver (ie, caregiver contribution to self-care maintenance and self-care management, and caregiver confidence in contributing to self-care) factors related to different types of self-care (ie, self-care maintenance, symptom perception, and self-care management) and self-care confidence in Korean patients with heart failure.

METHODS

In this cross-sectional, correlational study, data from 41 pairs of patients (mean age, 68.0 years) and caregivers (mean age, 54.1 years) were collected and analyzed using multiple regression.

RESULTS

Higher levels of self-care confidence in patients were related to higher levels of self-care maintenance in patients. Higher levels of self-care confidence in patients were related to higher levels of symptom perception. Higher levels of self-care confidence in patients and caregiver contribution to self-care maintenance were related to higher levels of self-care management. Less severe depressive symptoms in patients and higher levels of caregiver confidence in contributing to self-care were related to higher levels of self-care confidence.

CONCLUSION

Different patient and caregiver factors were related to different types of self-care and self-care confidence in Korean patients, but patients' self-care confidence was related to all types of self-care. Clinicians and researchers need to develop and deliver effective interventions to both patients and their caregivers to improve patients' self-care confidence and, in turn, self-care, considering different factors associated with each type of self-care.

Lifestyle Modification in Heart Failure Management: Are We Using Evidence-Based Recommendations in Real World Practice?

The heart failure (HF) guideline's purpose is to assist medical professionals while treating patients with HF in accordance with the best current research. Many cases of HF are both, avoidable and treatable thanks to scientific trials. Management is, therefore, based on lifestyle changes, also called non-pharmacological treatment. These, based on lifestyle changes, should be recommended in every patient at risk for HF or with diagnosed of HF, but evidence in itself is scarce. DASH Diet could be clearly beneficial while Mediterranean diet doesn't have enough evidence at the present moment. Smoking should be stopped, and excessive amounts of alcohol drinking avoided, but there is no clinical trial nor registry performed on these aspects. A moderate salt restriction is better than a strict reduction. Exercise and cardiac rehabilitation are beneficial but there are no clear recommendations about type, duration, etc. Most of the evidence that we have in HF patients with obesity is contradictory. Finally, due to the high number of aged frail patients in HF lifestyle changes should be individualized, but again available data is scant. Therefore, due to the lack of current evidence, these gaps need to be considered and need new efforts on investigation in the next future.

Treatment Strategies of Improving Quality of Care in Patients With Heart Failure

Heart failure (HF) is a global health problem closely related to morbidity and mortality. As the burden of HF increases, it is necessary to manage and treat this condition well. However, there are differences between real-world practice and guidelines for the optimal treatment for HF. Patient-related, healthcare provider-related, and health system-related factors contribute to poor adherence to optimal care. This review article aims to examine HF treatment patterns and treatment adherence in real-world practice, identify clinical gaps to suggest ways to improve the quality of care for HF and clinical outcomes for patients with HF. Although it is important to optimize treatment based on evidence-based guidelines to the greatest extent, it is known that there is still poor treatment adherence, and many patients do not receive guideline-directed medical therapy, especially at the early stages. To improve medication adherence, qualitative evaluation through performance measurement, as well as education of patients, caregivers and medical staff through a multidisciplinary approach are important.

Reviewing the Modern Therapeutical Options and the Outcomes of Sacubitril/Valsartan in Heart Failure

Sacubitril/valsartan (S/V) is a pharmaceutical strategy that increases natriuretic peptide levels by inhibiting neprilysin and regulating the renin-angiotensin-aldosterone pathway, blocking AT1 receptors. The data for this innovative medication are mainly based on the PARADIGM-HF study, which included heart failure with reduced ejection fraction (HFrEF)-diagnosed patients and indicated a major improvement in morbidity and mortality when S/V is administrated compared to enalapril. A large part of the observed favorable results is related to significant reverse cardiac remodeling confirmed in two prospective trials, PROVE-HF and EVALUATE-HF. Furthermore, according to a subgroup analysis from the PARAGON-HF research, S/V shows benefits in HFrEF and in many subjects having preserved ejection fraction (HFpEF), which indicated a decrease in HF hospitalizations among those with a left ventricular ejection fraction (LVEF) < 57%. This review examines the proven benefits of S/V and highlights continuing research in treating individuals with varied HF characteristics. The article analyses published data regarding both the safeness and efficacy of S/V in patients with HF, including decreases in mortality and hospitalization, increased quality of life, and reversible heart remodeling. These benefits led to the HF guidelines recommendations updating and inclusion of S/V combinations a key component of HFrEF treatment.

The effectiveness and usability of a novel mobile phone-based self-care intervention for patients with heart failure: A mixed-methods pilot study

AIM

To evaluate the preliminary effectiveness and usability of a novel mobile phone-based self-care intervention (named WithUs) for patients with heart failure (HF).

METHODS AND RESULTS

We conducted a mixed-methods pilot study with group pretest-posttest design and usability testing. Participants were 26 Korean HF patients (20 men; median age 62 years) who took part in this study after hospital discharge. Data were collected at baseline and after the 24-week intervention, using questionnaires and interviews. The outcome variables were eHealth literacy, disease knowledge, and self-care behaviours. The Wilcoxon signed-rank test was used to compare the pre- and post-intervention results. Thematic analysis was used for analysing qualitative data. The WithUs programme improved the eHealth literacy (p = .005), disease knowledge (p < .001), and self-care behaviours (p < .001) of patients with HF. The median score of total app usability was 4.1 out of 5 (interquartile range = 4.0-5.0). Four themes were identified which complemented the quantitative results. These were increased awareness of the importance of routine self-care behaviours, enhanced motivation toward self-care behaviours, challenges adapting to the new app, and suggestions for improving app adoption.

CONCLUSION

The app was effective in improving adherence to self-care behaviours, eHealth literacy, and disease knowledge in patients with HF. The usability evaluation results showed that the app is usable and has the potential to support HF patients in self-care. However, the app needs to be modified to improve its adoption.

Effects of educational intervention on mortality and patient-reported outcomes in individuals with heart failure: A randomized controlled trial

OBJECTIVE

To examine the effects of an educational intervention on patient-reported outcomes and all-cause mortality in heart failure (HF) patients METHODS: In this randomized controlled trial, we enrolled 122 hospitalized patients with HF. The intervention group (n = 60) received an individual nurse-led education session on HF self-management during hospitalization and three telephone calls after discharge. The control group (n = 62) received care as usual. Patient-reported outcomes were measured at baseline and at 3 and 6 months. Mortality status was determined using the National Death Records. Intervention effects were evaluated using the Cox proportional hazards regression model and linear mixed models.

RESULTS

During the follow-up (median: 568 days), 7 deaths (12%) in the intervention group and 15 deaths (24%) in the control group occurred (adjusted hazard ratio, 0.40; 95% confidence interval, 0.16-0.98; P = .046). From baseline to 3 and 6 months, the intervention group showed greater improvements in HF knowledge (difference=6.14, P = .03; difference=5.76, P = .02, respectively), self-care (difference=-6.08, P < .001; difference=-6.16, P < .001, respectively), and health-related quality of life (difference=-11.90, P = .01; difference=-14.57, P = .004, respectively) than the control group.

CONCLUSION

Educational intervention with telephone follow-up reduced all-cause mortality and improved patient-reported outcomes.

PRACTICE IMPLICATION

Educational intervention should be considered as part of routine care for HF patients.

Diagnostic value of cardiac magnetic resonance imaging for myocardial fibrosis in patients with heart failure and its predictive value for prognosis

OBJECTIVE

To determine the diagnostic value of cardiac magnetic resonance imaging (CMRI) for myocardial fibrosis (MF) in patients with heart failure (HF) and its predictive value for prognosis.

METHODS

A total of 180 patients with heart failure who were hospitalized in the Cardiology Department of The First People's Hospital of Shangqiu City from September 2019 to May 2021 were selected and assigned to Group B (n=80) given levosimendan and Group A (n=100) given levosimendan combined with ivabradine hydrochloride. The cardiac function indicators (left ventricular end-systolic volume (LVESV), left ventricular ejection fraction (LVEF), and left ventricular end-systolic diameter (LVESD) were measured by nuclear magnetic resonance (MRI). Myocardial fibrosis (MF)-related indicators (pyridinoline cross-linked carboxy-terminal telopeptide of type I collagen (ICTP), N-terminal propeptide of procollagen type III (PIIINP), connective tissue growth factor (CTGF), and hyaluronic acid (HA), inflammatory factors (Hs-CRP and IL-8) were measured using ELISA. Quality of life (QoL) and physical recovery (6-min walking test (6MWT), Fugl-Meyer Assessment (FMA), and Barthel index) of the two groups were compared. The late gadolinium enhancement (LGE) was used to analyze the occurrence of MF in patients. The patients were further divided into the LGE (+) group (cases) and LGE (-) group (cases). The changes of cardiac function indicators before treatment were analyzed, and their predictive value was analyzed.

RESULTS

Compared with Group B, Group A showed a lower incidence of complications, and presented a higher LVEF level and lower levels of LVESV, LVESD, ICTP, PIIINP, CTGF, HA, LN, and inflammatory factors. The area under the curves of LVESV, LVESD, and LVEF in predicting MF were all >0.7.

CONCLUSION

Levosimendan combined with ivabradine hydrochloride can effectively alleviate MF in patients with MF, and CMRI has a good predictive value for MF in such patients, which is worthy of clinical promotion.

Multidimensional Approach of Heart Failure Diagnosis and Prognostication Utilizing Cardiac Imaging with Biomarkers

Heart failure (HF) is a clinical syndrome caused by various etiologies that results in systolic and diastolic cardiac dysfunction with congestion. While evaluating HF and planning for treatment, physicians utilize various laboratory tests, including electrocardiography, diverse imaging tests, exercise testing, invasive hemodynamic evaluation, or endomyocardial biopsy. Among these, cardiac imaging modalities and biomarkers are the mainstays during HF diagnosis and treatment. Recent developments in non-invasive imaging modalities, such as echocardiography, computed tomography, magnetic resonance imaging, and nuclear imaging, have helped us understand the etiology, pathophysiology, and hemodynamics of HF, and determine treatment options and predict the outcomes. Due to the convenience of their use and potential impact on HF management, biomarkers are increasingly adopted in our clinical practice as well as research purpose. Natriuretic peptide is the most widely used biomarker for the diagnosis of HF, evaluation of treatment response, and prediction of future outcomes. Other cardiac biomarkers to evaluate the pathophysiological mechanisms of HF include myocardial injury, oxidative stress, inflammation, fibrosis, hypertrophy, and neurohormonal activation. Because HF results from complex cardiac disorders, it is essential to assess the disease status multidimensionally. The proper utilization of multimodality imaging and cardiac biomarkers can improve the quality of patient management and predict clinical outcomes in HF in the era of personalized medicine.

Development of Core Educational Content for Heart Failure Patients in Transition from Hospital to Home Care: A Delphi Study

Heart failure (HF) patients should be systematically educated before discharge on how to manage with standard written materials for patient self-management. However, because of the absence of readily available written materials to reinforce their learned knowledge, patients with HF feel inadequately informed in terms of the discharge information provided to them. This study aimed to develop core content to prepare patients with HF for transition from hospital to home care. The content was validated by expert panelists using Delphi methods. Nineteen draft items based on literature review were developed. We established a consensus on four core sections, including 47 categories and 128 subcategories through the Delphi survey: (1) understanding HF (five categories and 23 subcategories), (2) HF medication (19 categories and 45 subcategories), (3) HF management (20 categories and 47 subcategories), and (4) HF diary (three categories and 13 subcategories). Each section provided easy-to-understand educational contents using cartoon images and large or bold letters for older patients with HF. The developed core HF educational contents showed high consensus between the experts, along with clinical validity. The contents can be used as an educational booklet for both planning discharge education of patients with HF and for post-discharge management when transitioning from hospital to home. Based on this study, a booklet series for HF patients was first registered at the National Library of Korea. Future research should focus on delivering the core content to patients with HF in convenient and accessible format through various media.

Physician adherence and patient-reported outcomes in heart failure with reduced ejection fraction in the era of angiotensin receptor-neprilysin inhibitor therapy

This Korean nationwide, multicenter, noninterventional, prospective cohort study aimed to analyze physician adherence to guideline-recommended therapy for heart failure (HF) with reduced ejection fraction (HFrEF) and its effect on patient-reported outcomes (PROs). Patients diagnosed with or hospitalized for HFrEF within the previous year were enrolled. Treatment adherence was considered optimal when all 3 categories of guideline-recommended medications (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor-neprilysin inhibitors; beta-blockers; and mineralocorticoid receptor antagonists) were prescribed and suboptimal when ≤ 2 categories were prescribed. The 36-Item Short Form Survey (SF-36) scores were compared at baseline and 6 months between the 2 groups. Overall, 854 patients from 30 hospitals were included. At baseline, the optimal adherence group comprised 527 patients (61.7%), whereas during follow-up, the optimal and suboptimal adherence groups comprised 462 (54.1%) and 281 (32.9%) patients, respectively. Patients in the suboptimal adherence group were older, with a lower body mass index, and increased comorbidities, including renal dysfunction. SF-36 scores were significantly higher in the optimal adherence group for most domains (P < 0.05). This study showed satisfactory physician adherence to contemporary treatment for HFrEF. Optimal adherence to HF medication significantly correlated with better PROs.

Role of biomarkers in the heart failure clinic

Heart failure (HF) is a common cardiovascular disease that has a complex pathophysiology. Because it is the final stage of many cardiovascular diseases, proper diagnosis and treatment are crucial for prolonging patients’ survival and improving their well-being. Several biomarkers have been identified in HF, and their roles in diagnosis and prognostication have been widely investigated. Among them, natriuretic peptides are key for diagnosing HF, predicting its prognosis, and monitoring the effectiveness of HF treatment. Moreover, natriuretic peptides can also be used to treat HF. In addition to natriuretic peptides, several other biomarkers were included in the most recent HF management guidelines. Thus, we reviewed the role of the biomarkers included in these guidelines and discussed future perspectives.

Treatment of advanced heart failure

Background: The development of medical and device treatment of heart failure (HF) has improved the survival and quality of life in HF patients. However, not all HF patients respond well to these up-to-date HF treatments. We have termed these non-responders as advanced HF patients. The definition, diagnosis, and treatment of advanced HF are discussed in this review article.Current Concepts: After current guideline-directed treatments, advanced HF patients can experience aggravation and decompensation, usually resulting in hospitalization for the symptoms and volume control. Recurrent decompensation or hospitalization can cause a vicious cycle between the heart and other vital organs, such as the kidney and liver. Current and up-to-date guidelines recommend treatments, including heart transplant, left ventricular assist device (LVAD), and hospice care, for advanced HF. Given the limitation of heart transplant donors, LVAD can be used as a bridge to transplant, in addition to destination therapy. Updated LVAD system can reduce pump-related thrombosis, stroke, and bleeding.Discussion and Conclusion: Current guidelines suggest early recognition of advanced HF and referral to advanced HF specialists. Despite advances in the treatments of advanced HF, unmet needs for further improving clinical outcomes and quality of life exist.

Prognostic and Therapeutic Implications of Renal Insufficiency in Heart Failure

The heart and kidneys are closely related vital organs that significantly affect each other. Cardiorenal syndrome is the term depicting the various spectra of cardiorenal interaction mediated by the hemodynamic, neurohormonal, and biochemical cross-talk between these two organs. In patients with heart failure (HF), both the baseline and worsening renal function are closely related to prognosis. However, for both investigational and clinical purposes, the unified definition and classification of renal injury are still necessary. Renal insufficiency is caused by multiple factors, and categorizing them into monogenous subgroups of phenotype is difficult. Various clinical scenarios related to the chronicity of HF, progression of renal dysfunction, and issues related to pharmacologic therapies associated with the prognosis of patients with HF have been reviewed in this study.

Prognostic impact of chromogranin A in patients with acute heart failure

Background

Chromogranin A (CgA) levels have been reported to predict mortality in patients with heart failure. However, information on the prognostic value and clinical availability of CgA is limited. We compared the prognostic value of CgA to that of previously proven natriuretic peptide biomarkers in patients with acute heart failure.

Methods

We retrospectively evaluated 272 patients (mean age, 68.5±15.6 years; 62.9% male) who underwent CgA test in the acute stage of heart failure hospitalization between June 2017 and June 2018. The median follow-up period was 348 days. Prognosis was assessed using the composite events of 1-year death and heart failure hospitalization.

Results

In-hospital mortality rate during index admission was 7.0% (n=19). During the 1-year follow-up, a composite event rate was observed in 12.1% (n=33) of the patients. The areas under the receiver-operating characteristic curves for predicting 1-year adverse events were 0.737 and 0.697 for N-terminal pro-B-type natriuretic peptide (NT-proBNP) and CgA, respectively. During follow-up, patients with high CgA levels (>158 pmol/L) had worse outcomes than those with low CgA levels (≤158 pmol/L) (85.2% vs. 58.6%, p<0.001). When stratifying the patients into four subgroups based on CgA and NT-proBNP levels, patients with high NT-proBNP and high CgA had the worst outcome. CgA had an incremental prognostic value when added to the combination of NT-proBNP and clinically relevant risk factors.

Conclusion

The prognostic power of CgA was comparable to that of NT-proBNP in patients with acute heart failure. The combination of CgA and NT-proBNP can improve prognosis prediction in these patients.

Health schools as an organizational form of realization of the "life course health development" concept

This study was conducted to evaluate the effectiveness of health education in the Tatarstan Republic by establishing educational programs - Health Schools - for groups of patients with a high risk of developing potentially fatal cardiac and respiratory conditions. The concept of "Life Course Health Development" implies the development of mechanisms for personalized health management. The goal of the study is to explore the effectiveness of the specialized Health Schools in Tatarstan. For the comparative study of health education effects on the overall state of personal health, 590 patients were surveyed in a randomized controlled trial. The groups of patients were compared in relation to their health education; their health status was observed prior to and afterward undergoing the educative preventative programs and estimated in comparison between the two groups. Extrapolation of the data on Tatarstan's patient population was obtained through this study, taking into account the state of health of the Health Schools students, obtaining the regression equations of population mortality and the effects of training on it. The effectiveness of Health Schools for patients with cardiovascular pathology has been proven. However, additional efforts are required to involve a wider range of patients and increase learning effectiveness to critical levels of awareness by introducing new forms of education in Health Schools since it statistically significantly increased the awareness level regarding disease nature and preventive measures.

Comparative effectiveness of exercise training program in patients with heart failure: protocol for a systematic review of randomised controlled trials and network meta-analysis

INTRODUCTION

Heart failure (HF) is an end-stage of numerous heart diseases including hypertension, coronary heart disease and arrhythmia, in which the heart is unable to perform its circulatory function with sufficient efficiency due to structural or functional dysfunction (systolic or diastolic alterations). Strategies such as exercise rehabilitation may improve cardiac function, exercise capacity and health-related quality of life and reduce anxiety and depression in patients with HF. However, the relative effectiveness as well as the hierarchy of exercise interventions have not been well established, although various exercise options are available. Therefore, this protocol proposes to conduct a network meta-analysis (NMA) aiming to compare the effectiveness of different types of exercise training in patients with HF.

METHODS AND ANALYSIS

PubMed, Embase and the Cochrane Library will be searched from inception to March 2021 for relevant randomised controlled trials. Other resources, such as Google Scholar and Clinical Trials.gov will also be considered. Studies assessing exercise rehabilitation in patients with HF will be selected. Two independent reviewers will identify eligible trials. The PEDro risk of bias assessment tool will be used to assess the quality of the included studies. Bayesian NMA will be used when possible to determine the comparative effectiveness of the different exercise interventions. The mean ranks and surface will estimate the ranking probabilities for the optimal intervention of various treatments under the cumulative ranking curve. Subgroup, sensitivity and meta-regression will be conducted to explain the included studies' heterogeneity if possible. We will also use the Grading of Recommendations, Assessment, Development, and Evaluation system to assess the strength of evidence.

ETHICS AND DISSEMINATION

This systematic review and NMA will synthesise evidence on the effectiveness of the different exercises in patients with HF. The results will be submitted to a peer-reviewed journal. No ethical approval will be required because the data used for the review will be exclusively extracted from published studies.

PROSPERO REGISTRATION NUMBER

CRD42020165870.

Sodium-glucose Co-transporter 2 Inhibitors: a New Path for Heart Failure Treatment

Sodium-glucose co-transporter 2 inhibitors (SGLT2i) have been emerged as a powerful therapeutic option to reduce the risk of heart failure and hospitalization for heart failure (HFH) in patients with type II diabetes mellitus (T2DM), and to reduce cardiovascular mortality and HFH in heart failure with reduced ejection fraction (HFrEF) patients with or without T2DM. Ongoing study to evaluate the clinical effect of SGLTi for heat failure with preserved ejection fraction (HFpEF) may further widen the clinical implication of these novel cardiorenal protective drugs beyond their metabolic effects. In this review, we summarized the updated clinical evidences on SGLT2i (rather than basic and translational evidence) for reduction of HF risk in T2DM patients and favorable clinical outcomes in both HFrEF and HFpEF patients.

Results from cardiovascular outcome trials (CVOT) with 5 different sodium-glucose co-transporter 2 inhibitors (SGLT2i; empagliflozin, canagliflozin, dapagliflozin, ertugliflozin, sotagliflozin), initially developed for their glucose-lowering effect by blocking tubular glucose reabsorption in kidney, have been shown to decrease the risk of heart failure hospitalization (HFH) across a range of patients with and without atherosclerotic cardiovascular disease in patients with type 2 diabetes mellitus (T2DM). Following these CVOT results, SGLT2i (dapagliflozin, empagliflozin, sotagliflozin) also were reported to reduce HFH and cardiovascular death in patients with heart failure with reduced ejection fraction (HFrEF), regardless of existence or absence of T2DM. Ongoing studies have been conducted to evaluate the clinical benefit of SGLT2i (empagliflozin, dapagliflozin) in patients with heart failure with preserved ejection fraction (HFpEF). Although SGLT2i brought us to the entrance of a new era for prevention of HF incidence and worsening of HF, the search for pivotal mechanism of SGLT2i to improve our pharmacological armamentarium should continue in order to protect every HF patient from fatal progression of HF disease. In this review, we summarized the updated clinical evidences on SGLT2i (rather than basic and translational evidence) for reduction of HF risk in T2DM patients and favorable clinical outcomes in both HFrEF and HFpEF patients.

Prognostic Value of Leg Muscle Strength in Acute Heart Failure Syndrome

INTRODUCTION

Leg muscle strength (LMS) may be useful as a frailty index in patients with heart failure. However, LMS, until recently, has been indirectly estimated, and its prognostic value in acute heart failure syndrome (AHFS) is unclear. Therefore, we evaluated the prognostic value of direct LMS assessment and its relationship with proinflammatory mediators in patients with AHFS.

METHODS

We directly measured LMS at predischarge using a dynamometer in 110 prospectively and consecutively enrolled patients with AHFS (75 male; 60 ± 14 yr; mean ejection fraction, 29.9% ± 14.6%). The primary end point was cardiovascular (CV) events, defined as CV mortality, cardiac transplantation, or rehospitalization due to heart failure aggravation. Patients were divided into impaired and preserved LMS groups according to Contal and O'Quigley's method.

RESULTS

CV events occurred in 28 patients (25.5%) (including 5 CV deaths and 6 cardiac transplantations) during follow-up (median, 246 d; range = 11-888 d). Impaired LMS was associated with significantly higher levels of serum monokine induced by gamma interferon and poor clinical outcomes (P < 0.001). Multivariable Cox proportional hazard analysis (controlling for age, sex, body mass index, heart failure type, hemoglobin level, N-terminal pro-b-type natriuretic peptide level, and beta-blocker use) revealed LMS as an independent predictor of CV events (P = 0.017).

CONCLUSION

Impaired LMS, which might be used as a marker of frailty, is associated with increased levels of a proinflammatory chemokine and independently predicts clinical outcomes in patients with AHFS. The direct measurement of LMS is simple and feasible and might have important implications for the risk stratification of patients with AHFS.

Value of Galectin-3 assay in children with heart failure secondary to congenital heart diseases: a prospective study

BACKGROUND

Galectin-3 is a new biomarker, which plays an important role in tissue inflammation, cardiac remodeling, and fibrosis. It can be readily measured in the circulation to detect early heart failure (HF). This study aimed to assess the value of galectin-3 assay in early diagnosis of children with heart failure secondary to congenital heart disease (CHD) and correlate it with the patients' outcome.

METHODS

This prospective cohort study included 75 children diagnosed to have CHD; {Group A: 45 CHD children with HF symptoms and reduced ejection fraction (REF) and Group B: 30 CHD children with no HF symptoms and normal ejection fraction (NEF)}. They were compared to 40 age- and sex-matched controls (Group C). Children with CHD undergone history taking, Ross HF classification, Echocardiographic assessment and laboratory investigations including serum galactin-3 level.

RESULTS

Galectin-3 serum level increased in CHD children, and it showed significant increase in (Gp A) compared to Gp B or Gp C (p = ≤ 0.001). In addition, serum level of Galactin-3 was correlated positively with Ross classification (r = 0.68, p = 0.018) and negatively correlated to EF% (r= -0.61, p ≤ 0.001). Galactin-3 showed better diagnostic value than Ross HF classification in early diagnosis of HF in CHD children with a cut point (≥ 10.4), significantly had 96.7% sensitivity, 90% specificity, 91% positive predictive value, 93.2% negative predictive value, with area under the curve (AUC = 0.96) and 93% accuracy. While there was a significant correlation between Ross HF classification and HF outcome in (Gp A) children (p = 0.05), we did not find any significant correlation between serum galectin-3 level and HF mortality in same group (p = 0.08).

CONCLUSIONS

Galectin-3 assay is a promising marker for early diagnosis of HF in children with CHD; but it has no role in detecting HF mortality.

The Implication of Cardiac Injury Score on In-hospital Mortality of Coronavirus Disease 2019

BACKGROUNDS

The severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) has spread worldwide. Cardiac injury after SARS-CoV-2 infection is a major concern. The present study investigated impact of the biomarkers indicating cardiac injury in coronavirus disease 2019 (COVID-19) on patients' outcomes.

METHODS

This study enrolled patients who were confirmed to have COVID-19 and admitted at a tertiary university referral hospital between February 19, 2020 and March 15, 2020. Cardiac injury was defined as an abnormality in one of the following result markers: 1) myocardial damage marker (creatine kinase-MB or troponin-I), 2) heart failure marker (N-terminal-pro B-type natriuretic peptide), and 3) electrical abnormality marker (electrocardiography). The relationship between each cardiac injury marker and mortality was evaluated. Survival analysis of mortality according to the scoring by numbers of cardiac injury markers was also performed.

RESULTS

A total of 38 patients with COVID-19 were enrolled. Twenty-two patients (57.9%) had at least one of cardiac injury markers. The patients with cardiac injuries were older (69.6 ± 14.9 vs. 58.6 ± 13.9 years old, P = 0.026), and were more male (59.1% vs. 18.8%, P = 0.013). They showed lower initial oxygen saturation (92.8 vs. 97.1%, P = 0.002) and a trend toward higher mortality (27.3 vs. 6.3%, P = 0.099). The increased number of cardiac injury markers was significantly related to a higher incidence of in-hospital mortality which was also evidenced by Kaplan-Meier survival analysis (P = 0.008).

CONCLUSION

The increased number of cardiac injury markers is related to in-hospital mortality in patients with COVID-19.

The roles of health literacy and social support in improving adherence to self-care behaviours among older adults with heart failure

Aim

To describe the associations between health literacy, social support and self‐care behaviours in older adults with heart failure.

Design

A cross‐sectional descriptive study.

Methods

A total of 252 older adults were recruited from a tertiary care hospital from September 2018–February 2019. Structured questionnaires and medical record reviews were used for data collection. Two steps of hierarchical regression analysis were employed to determine the predictors of self‐care behaviours.

Results

Health literacy (β = 0.27, p < .001) and social support (β = 0.32, p < .001) were significant determinants of self‐care behaviours in older adults with heart failure. Together, they explained 22% of the variance in self‐care behaviours.

Conclusion

Health literacy and perceived social support were positively associated with self‐care behaviours among older heart failure patients. Our findings can help health professionals develop heart failure self‐care interventions to enhance health literacy skills and social support for older adults.

Characteristics, Outcomes, and Treatment of Heart Failure With Improved Ejection Fraction

Background

Many patients with heart failure (HF) with reduced ejection fraction (HFrEF) experience improvement or recovery of left ventricular ejection fraction (LVEF). Data on clinical characteristics, outcomes, and medical therapy in patients with HF with improved ejection fraction (HFiEF) are scarce.

Methods and Results

Of 5625 consecutive patients hospitalized for acute HF in the KorAHF (Registry [Prospective Cohort] for Heart Failure in Korea) study, 5103 patients had baseline echocardiography and 2302 patients had follow‐up echocardiography at 12 months. HF phenotypes were defined as persistent HFrEF (LVEF ≤40% at baseline and at 1‐year follow‐up), HFiEF (LVEF ≤40% at baseline and improved up to 40% at 1‐year follow‐up), HF with midrange ejection fraction (LVEF between 40% and <50%), and HF with preserved ejection fraction (LVEF ≥50%). The primary outcome was 4‐year all‐cause mortality from the time of HFiEF diagnosis. Among 1509 HFrEF patients who had echocardiography 1 year after index hospitalization, 720 (31.3%) were diagnosed as having HFiEF. Younger age, female sex, de novo HF, hypertension, atrial fibrillation, and β‐blocker use were positive predictors and diabetes mellitus and ischemic heart disease were negative predictors of HFiEF. During 4‐year follow‐up, patients with HFiEF showed lower mortality than those with persistent HFrEF in univariate, multivariate, and propensity‐score–matched analyses. β‐Blockers, but not renin–angiotensin system inhibitors or mineralocorticoid receptor antagonists, were associated with a reduced all‐cause mortality risk (hazard ratio: 0.59; 95% CI, 0.40–0.87; P=0.007). Benefits for outcome seemed similar among patients receiving low‐ or high‐dose β‐blockers (log‐rank, P=0.304).

Conclusions

HFiEF is a distinct HF phenotype with better clinical outcomes than other phenotypes. The use of β‐blockers may be beneficial for these patients.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01389843.

Phenotyping Heart Failure According to the Longitudinal Ejection Fraction Change: Myocardial Strain, Predictors, and Outcomes

Background

Many patients with heart failure (HF) experience changes in left ventricular ejection fraction (LVEF) during follow‐up. We sought to evaluate the predictors and outcomes of different HF phenotypes according to longitudinal changes in EF.

Methods and Results

A total of 2104 patients with acute HF underwent echocardiography at baseline and follow‐up. Global longitudinal strain was measured at index admission. HF phenotypes were defined as persistent HF with reduced EF (persistent HFrEF, LVEF ≤40% at baseline and follow‐up), heart failure with improved ejection fraction (LVEF≤40% at baseline and improved to >40% at follow‐up), heart failure with declined ejection fraction (LVEF>40% at baseline and declined to ≤40% at follow up), and persistent HF with preserved EF (persistent HFpEF, LVEF>40% at baseline and follow‐up). Overall, 1130 patients had HFrEF at baseline; during follow‐up, 54.2% and 46.8% had persistent HFrEF and heart failure with improved ejection fraction, respectively. Among 975 patients with HFpEF at baseline, 89.5% and 10.5% had persistent HFpEF and heart failure with declined ejection fraction at follow‐up, respectively. The 5‐year all‐cause mortality rates were 43.1%, 33.1%, 24%, and 17% for heart failure with declined ejection fraction, persistent HFrEF, persistent HFpEF, and heart failure with improved ejection fraction, respectively (global log‐rank P<0.001). In multivariable analyses, each 1% increase in global longitudinal strain (greater contractility) was associated with 10% increased odds for heart failure with improved ejection fraction among patients with HFrEF at baseline and 7% reduced odds for heart failure with declined ejection fraction among patients with HFpEF at baseline.

Conclusions

LVEF changed during follow‐up. Each HF phenotype according to longitudinal LVEF changes has a distinct prognosis. Global longitudinal strain can be used to predict the HF phenotype.

REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03513653.

Heart failure with preserved ejection fraction: insights from recent clinical researches

Heart failure (HF) with preserved ejection fraction (HFpEF) accounts for nearly half of the cases of HF and its incidence might be increasing with the aging society. Patients with HFpEF present with significant symptoms, including exercise intolerance, impaired quality of life, and have a poor prognosis as well as frequent hospitalization and increased mortality compared with HF with reduced ejection fraction. The concept of HFpEF is still evolving and may be a virtual complex rather than a real systemic disorder. Thus, beyond solely targeting cardiac abnormalities management strategies need to be extended, such as left ventricular diastolic dysfunction. In this review, we examine new diagnostic algorithms, pathophysiology, current management status, and ongoing trials based on heterogeneous pathophysiology and etiology in HFpEF.

Artificial intelligence for the diagnosis of heart failure

The diagnosis of heart failure can be difficult, even for heart failure specialists. Artificial Intelligence-Clinical Decision Support System (AI-CDSS) has the potential to assist physicians in heart failure diagnosis. The aim of this work was to evaluate the diagnostic accuracy of an AI-CDSS for heart failure. AI-CDSS for cardiology was developed with a hybrid (expert-driven and machine-learning-driven) approach of knowledge acquisition to evolve the knowledge base with heart failure diagnosis. A retrospective cohort of 1198 patients with and without heart failure was used for the development of AI-CDSS (training dataset, n = 600) and to test the performance (test dataset, n = 598). A prospective clinical pilot study of 97 patients with dyspnea was used to assess the diagnostic accuracy of AI-CDSS compared with that of non-heart failure specialists. The concordance rate between AI-CDSS and heart failure specialists was evaluated. In retrospective cohort, the concordance rate was 98.3% in the test dataset. The concordance rate for patients with heart failure with reduced ejection fraction, heart failure with mid-range ejection fraction, heart failure with preserved ejection fraction, and no heart failure was 100%, 100%, 99.6%, and 91.7%, respectively. In a prospective pilot study of 97 patients presenting with dyspnea to the outpatient clinic, 44% had heart failure. The concordance rate between AI-CDSS and heart failure specialists was 98%, whereas that between non-heart failure specialists and heart failure specialists was 76%. In conclusion, AI-CDSS showed a high diagnostic accuracy for heart failure. Therefore, AI-CDSS may be useful for the diagnosis of heart failure, especially when heart failure specialists are not available.

Development of Health-RESPECT: An Integrated Service Model for Older Long-Term Care Hospital/Nursing Home Patients Using Information and Communication Technology

BACKGROUND

Korea, as one of the fastest-aging countries worldwide, requires an improved healthcare service model for older adults. We evaluated the current healthcare system and developed a service model based on information and communication technologies (ICT) for use in older patients in long-term care facilities (LTCF).

METHODS

We conducted a qualitative literature review, focus group interviews (FGIs), and structured survey to identify the current technology use and status of healthcare systems. We then developed a web-based platform with necessary, high-priority, and usable content for the care of older patients in LTCF.

RESULTS

We reviewed 60 (23 hypertension, 18 diabetes, and 19 heart failure) articles on information and communication technologies (ICT)-based disease management for clinical effectiveness and improved patient satisfaction. FGIs and structured surveys were used to evaluate the inconvenience in patient and medical information transfer between hospitals and cost and time required for its process. Accordingly, we confirmed the unmet need for an ICT-based service model for management, monitoring, and consultation among older patients and developed the Health-RESPECT (integrated caRE Systems for elderly PatiEnts using iCT), a service platform for older patients residing in LTCF. The medical information exchange system was used to transfer medical information. Health-RESPECT includes an established algorithm for evidence-based comprehensive geriatric assessment and customized management; chronic disease management; management of potentially inappropriate medications; rehabilitation; and consultation and videoconferencing.

CONCLUSION

This study identified the current status and unmet needs of healthcare systems for older adults. We developed an ICT-based system to manage older institutionalized patients. However, the Health-RESPECT service model requires further validation.

Gender differences in the impact of health literacy on hospital readmission among older heart failure patients: A prospective cohort study

AIMS

To investigate the impact of limited health literacy on 1-year hospital readmission among both older men and women with heart failure.

DESIGN

Prospective cohort study.

METHODS

A total of 286 patients with heart failure (men = 144, women = 142) aged 65 years or older at baseline from two tertiary hospitals were enrolled from June-November 2017. Patients were followed up until November 2018. The Brief Health Literacy Screening Tool was used to assess baseline health literacy. One-year readmission after discharge was assessed via medical records or telephone interview. A hierarchical logistic regression was performed.

RESULTS

The prevalence rates of limited health literacy and 1-year hospital readmission among older women were 74.7% and 35.9%, respectively, compared with 48.6% and 27.1% in older men. Limited health literacy significantly increased the risk of 1-year hospital readmission in both older men and women with heart failure. More importantly, older women with limited health literacy had a much higher risk of hospital readmission (odds ratio: 10.17, 95% confidence interval: 2.19-47.14) than did older men with limited health literacy (odds ratio: 5.27, 95% confidence interval: 2.04-13.59).

CONCLUSIONS

Our findings highlight that a baseline assessment of health literacy would help prevent unplanned hospital readmissions after discharge in both older men and women with heart failure. Health professionals should recognize that women with limited health literacy are more vulnerable to re-hospitalization than are men with limited health literacy.

IMPACT

Few studies have addressed gender differences in the link between health literacy and hospital readmission among patients with heart failure. We found that older women with limited health literacy had a much higher risk of hospital readmission than did their male counterparts. Health professionals should be aware of gender differences in health literacy in discharge planning, including self-management counselling for older patients with heart failure.

Chinese herbal preparations for chronic heart failure: Study protocol for an umbrella review of systematic reviews and meta-analyses

BACKGROUND

Chinese herbal preparations (CHPs) have been reported to be effective in the management of chronic heart failure (CHF); they are beneficial in improving cardiac function, reducing hospital stays and readmission. However, the credibility of their effectiveness evidence has not been evaluated. We aim to summarize and evaluate current effectiveness evidence of traditional Chinese medicine in the management of CHF.

METHODS

We will search PubMed, Embase, the Cochrane Database of Systemic Review (CDSR), and Web of Science from inception to December 2019 for systematic reviews that assessing the effectiveness of CHPs for CHF. The search will be performed without language restriction. Experimental interventions will include any type of CHPs, and control interventions will include placebo, sham interventions, usual care, or no controls. The primary outcome will be the changes in heart function classification defined by the New York Heart Association. Secondary outcomes include left ventricular ejection fraction, Six Minute Walk Test, other efficacy outcomes, and adverse events. We will use I statistics to assess the between-study heterogeneity in each meta-analysis, Eager test to detect publication bias, and the ratio of observed versus expected number of trials with positive findings. We will summarize the evidence and classify them into convincing, highly suggestive, suggestive, or weak.

RESULTS

The results of this study will be published in a peer-reviewed journal.

ETHICS AND DISSEMINATION

No ethical approval and patient consent are required since this study data is based on published literature. The results of the study will be submitted to a peer-reviewed journal.

PROTOCOL REGISTRATION NUMBER

PROSPERO CRD 42019139649 (https://www.crd.york.ac.uk/PROSPERO/#joinuppage).

Efficacy and safety of spironolactone in the heart failure with mid-range ejection fraction and heart failure with preserved ejection fraction: A meta-analysis of randomized clinical trials

BACKGROUND

Recent studies have shown the efficacy for using spironolactone to treat heart failure with reduced ejection fraction (HFrEF), but the efficacy of spironolactone for heart failure with mid-range ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF) is unclear. This meta-analysis investigated the efficacy and safety of spironolactone in patients with HFmrEF and HFpEF.

METHODS AND RESULTS

We searched several databases including PubMed and the Cochrane Collaboration, for randomized controlled trials (RCTs) that assessed spironolactone treatment in HFmrEF and HFpEF. Eleven RCTs including 4539 patients were included. Spironolactone reduced hospitalizations (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.73-0.95; P = .006), improved New York Heart Association functional classifications (NYHA-FC) (OR, 0.35; 95% CI, 0.19-0.66; P = .001), decreased the levels of brain natriuretic peptide (BNP) (mean difference [MD], - 44.80 pg/mL; 95% CI, -73.44--16.17; P = .002), procollagen type I C-terminal propeptide (PICP) (MD, -27.04 ng/mL; 95% CI, -40.77--13.32, P < .001) in HFmrEF and HFpEF. Besides, it improved 6-minute walking distances (6-MWD) (standard weighted mean difference [SMD], 0.45 m; 95% CI, 0.27-0.64; P < .001), decreased amino-terminal peptide of procollagen type-III (PIIINP) (SMD, -0.37 μg/L; 95% CI, -0.59--0.15; P = .001) in HFpEF only. The risks of hyperkalemia (P<.001) and gynecomastia (P<.001) were increased.

CONCLUSION

Patients with HFmrEF and HFpEF could benefit from spironolactone treatment, with reduced hospitalizations, BNP levels, improved NYHA-FC, alleviated myocardial fibrosis by decreasing serum PICP in HFmrEF and HFpEF, decreased PIIINP levels and increased 6-MWD only in HFpEF. The risks of hyperkalemia and gynecomastia were significantly increased with the spironolactone treatment.

Real-World Eligibility for Sacubitril/Valsartan in Heart Failure with Reduced Ejection Fraction Patients in Korea: Data from the Korean Acute Heart Failure (KorAHF) Registry

Background and Objectives

Sacubitril/valsartan (SV, LCZ696), the first in class drug, called as angiotensin receptor-neprilysin inhibitor (ARNI) can reduce heart failure (HF) hospitalization and cardiovascular mortality. However, SV prescription rate remains still low despite current HF guideline recommendations. Considering the complex inclusion criteria of Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial, the real-world eligibility for SV remains uncertain in Asian heart failure with reduced ejection fraction (HFrEF) patients. Therefore, we aimed to assess real-world HF population eligibility for SV in a large Korean acute HF registry.

Methods

From March 2011 to February 2014, a total of 5,625 patients who were admitted for HF were enrolled in Korea. After excluding HF patients with left ventricular ejection fraction > 40% and in-hospital death, 2,941 patients were analyzed. Criteria for SV based on Korean Food and Drug Administration (KFDA) label and PARADIGM-HF were applied.

Results

Of 2,941 patients, KFDA label criteria excludes the absence of symptoms (New York Heart Association class I, 20%); PARADIGM-HF criteria excludes chronic kidney disease stage IV (9%), hyperkalemia (1%), hypotension (6%), and sub-optimal pharmacotherapy (52%, e.g. lower dose use of angiotensin converting enzyme inhibitor/angiotensin receptor blocker [ACEI/ARB], beta blocker use). When a daily requirement of ACEI/ARB ≥5 mg enalapril (instead of ≥10 mg) was used, the percent of eligibility for SV rose from 12% to 30% based on the PARADIGM-HF criteria.

Conclusions

Among the Korean hospitalized HFrEF patients, 80% met KFDA label criteria, while only 12% met the inclusion criteria of PARADIGM-HF trial for SV if requiring ≥10 mg enalapril. Sub-optimal pharmacotherapy could be the main reason for ineligible SV use based on the PARADIGM-HF criteria.

KSHF Guidelines for the Management of Acute Heart Failure: Part II. Treatment of Acute Heart Failure

The prevalence of heart failure (HF) is on the rise due to the aging of society. Furthermore, the continuous progress and widespread adoption of screening and diagnostic strategies have led to an increase in the detection rate of HF, effectively increasing the number of patients requiring monitoring and treatment. Because HF is associated with substantial rates of mortality and morbidity, as well as high socioeconomic burden, there is an increasing need for developing specific guidelines for HF management. The Korean guidelines for the diagnosis and management of chronic HF were introduced in March 2016. However, chronic and acute HF represent distinct disease entities. Here, we introduce the Korean guidelines for the management of acute HF with reduced or preserved ejection fraction. Part II of this guideline covers the treatment of acute HF.

KSHF Guidelines for the Management of Acute Heart Failure: Part III. Specific Management of Acute Heart Failure According to the Etiology and Co-morbidity

The prevalence of heart failure (HF) is on the rise due to the aging of society. Furthermore, the continuous progress and widespread adoption of screening and diagnostic strategies have led to an increase in the detection rate of HF, effectively increasing the number of patients requiring monitoring and treatment. Because HF is associated with substantial rates of mortality and morbidity, as well as high socioeconomic burden, there is an increasing need for developing specific guidelines for HF management. The Korean guidelines for the diagnosis and management of chronic heart failure (CHF) were introduced in March 2016. However, CHF and acute heart failure (AHF) represent distinct disease entities. Here, we introduce the Korean guidelines for the management of AHF with reduced or preserved ejection fraction. Part III of this guideline covers management strategies optimized according to the etiology of AHF and the presence of co-morbidities.

Update on heart failure management and future directions

Heart failure (HF) is an important cardiovascular disease because of its increasing prevalence, significant morbidity, high mortality, and rapidly expanding health care cost. The number of HF patients is increasing worldwide, and Korea is no exception. There have been marked advances in definition, diagnostic modalities, and treatment of HF over the past four decades. There is continuing effort to improve risk stratification of HF using biomarkers, imaging and genetic testing. Newly developed medications and devices for HF have been widely adopted in clinical practice. Furthermore, definitive treatment for end-stage heart failure including left ventricular assist device and heart transplantation are rapidly evolving as well. This review summarizes the current state-of-the-art management for HF and the emerging diagnostic and therapeutic modalities to improve the outcome of HF patients.

Sacubitril/Valsartan in Asian Patients with Heart Failure with Reduced Ejection Fraction

The Prospective comparison of Angiotensin Receptor-neprilysin inhibitor (ARNI) with Angiotensin converting enzyme inhibitor (ACEI) to Determine Impact on Global Mortality and morbidity in Heart Failure (HF) trial (PARADIGM-HF) showed that adding a neprilysin inhibitor (sacubitril) to a renin-angiotensin system blocker (and other standard therapy) reduced morbidity and mortality in ambulatory patients with chronic HF with reduced ejection fraction (HFrEF). In PARADIGM-HF, valsartan combined with sacubitril (a so-called ARNI) was superior to the current gold standard of an ACEI, specifically enalapril, reducing the risk of the primary composite outcome of cardiovascular (CV) death or first HF hospitalization by 20% and all-cause death by 16%. Following the results of PARADIGM-HF, sacubitril/valsartan was approved by American and European regulatory authorities for the treatment of HFrEF. The burden of HF in Asia is substantial, both due to the huge population of the region and as a result of increasing CV risk factors and disease. Both the prevalence and mortality associated with HF are high in Asia. In the following review, we discuss the development of sacubitril/valsartan, the prototype ARNI, and the available evidence for its efficacy and safety in Asian patients with HFrEF.

The Past, Present and Future of Cardiac Resynchronization Therapy

Cardiac resynchronization therapy (CRT) has revolutionized the care of the patients with heart failure with reduced ejection fraction and electrical dyssynchrony. The current guidelines for patient selection include measurement of left ventricular systolic function, QRS duration and morphology, and functional classification. Despite consistent and increasing evidence supporting CRT use in appropriate patients, CRT has been underutilized. Notwithstanding the heterogeneous definitions of non-response, more than one-third of patients demonstrate a lack of echocardiographic reverse remodeling or poor clinical outcome following CRT. Since the causes of this non-response are multifactorial, it will require multidisciplinary efforts to overcome including optimal patient selection, procedural strategies, as well as optimizing post-implant care in patients undergoing CRT. The innovations of novel pacing approaches combined with advanced imaging technologies may eventually offer a personalized CRT system uniquely tailored to each patient's dyssynchrony signature.

KSHF Guidelines for the Management of Acute Heart Failure: Part I. Definition, Epidemiology and Diagnosis of Acute Heart Failure

The prevalence of heart failure (HF) is on the rise due to the aging of society. Furthermore, the continuous progress and widespread adoption of screening and diagnostic strategies have led to an increase in the detection rate of HF, effectively increasing the number of patients requiring monitoring and treatment. Because HF is associated with substantial rates of mortality and morbidity, as well as high socioeconomic burden, there is an increasing need for developing specific guidelines for HF management. The Korean guidelines for the diagnosis and management of chronic HF were introduced in March 2016. However, chronic and acute heart failure (AHF) represent distinct disease entities. Here, we introduce the Korean guidelines for the management of AHF with reduced or preserved ejection fraction. Part I of this guideline covers the definition, epidemiology, and diagnosis of AHF.

Gender Differences in the Impact of Cognitive Function on Health Literacy among Older Adults with Heart Failure

Heart failure (HF)-related cognitive decline is a common condition and may be associated with health literacy. However, gender differences in this context have not been explored fully. This secondary data analysis aimed to identify gender differences in the impact of cognitive function on health literacy among older patients with HF. A total of 135 patients (75 men and 60 women) with a mean age of 73.01 ± 6.45 years were recruited. Older women with HF had higher cognitive impairment (15%) and inadequate health literacy (56.7%) compared to men. Cognitive function was the strongest predictor of health literacy in men (β = 3.668, p < 0.001) and women (β = 2.926, p = 0.004). Notably elderly women are likely to face double the burden of the influence of cognitive function on health literacy in comparison with men. It is necessary to assess cognitive function and health literacy during HF illness trajectories on a regular basis. Healthcare professionals working with patients with HF should be aware of gender differences in cognitive function and health literacy and the importance of assessing these factors.