Right heart dysfunction and readmission risk across left ventricular ejection fraction status in patients with acute heart failure

Background

Right heart dysfunction (RHD) parameters, such as right ventricular to pulmonary artery uncoupling or significant tricuspid regurgitation (TR) are increasingly important in heart failure (HF), especially in patients with preserved ejection fraction. In this study, we aimed to evaluate the association of advanced RHD with the risk of recurrent admissions across the spectrum of left ventricular ejection fraction (LVEF).

Methods

We included 3,383 consecutive patients discharged for acute HF (AHF). Of them, in 1,435 (42.4%) pulmonary artery systolic pressure (PASP) could not be accurately measured, leaving a final sample size of 1,948 patients. Advanced RHD was defined as the combination of a ratio of tricuspid annular plane systolic excursion (TAPSE)/PASP<0.36 and a significant functional TR (n=196, 10.2%). Negative binomial regression analyses were used to evaluate the risk of recurrent admissions.

Results

At a median follow up of 2.2 years (IQR=0.63–4.71), 3,782 readmissions were registered in 1,296 patients (66.5%). Patients with advanced RHD showed higher rates of readmissions, but only if LVEF≥40% (p<0.001). In multivariable analyses, this differential association persisted for CV and HF recurrent admissions (p-value for interaction=0.016 and p=0.020; respectively). Advanced RHD was independently associated with the risk of recurrent CV and HF admissions if HF with LVEF≥40% (IRR: 1.99, 95% CI: 1.47–2.69, p<0.001; and IRR: 2.02, 95% CI: 1.45–2.81, p<0.001; respectively). In contrast, it was not associated with readmission risks if LVEF<40%.

Conclusion

Following an admission for AHF, advanced RHD was strongly associated with a higher risk of recurrent CV and HF admissions, but only in patients with LVEF≥40%.

Funding Acknowledgement

Type of funding sources: None.

Clinical applicability of echocardiographic strict negative criteria for suspected infective endocarditis

Introduction

Infective endocarditis (IE) is an uncommon but potentially lethal disease that requires a timely diagnosis. Echocardiography has a pivotal role in EI diagnosis, but this may lead to an overuse of this technology in clinical daily practice, and it is unclear which patients can benefit from a follow-up study if the initial transthoracic echocardiogram (TTE) shows no signs of IE. The strict negative criteria (good ultrasound quality and no high-risk features such as significant valvular regurgitations or stenosis, pericardial effusion or intracardiac devices) have been recently proposed to avoid unnecessary follow-up echocardiograms.

Purpose

The objective of this study is to review the contemporary, real-world use of echocardiography in patients with suspected IE and analyze the potential applicability of the strict negative criteria.

Methods

We retrieved all the echocardiograms that were performed in our center for suspected or confirmed IE between January 2014 and December 2018. We defined different groups according to the strict negative criteria and reviewed the electronic clinical history to check if a definitive diagnosis of IE was established or not.

Results

We included a total of 905 TTEs. 451 (49.8%) of them fulfilled the strict negativity criteria (Group 1). In this group, IE was seldom diagnosed (n=4, 0.9%). In 338 (37.4%) patients no signs of IE were evident but they didn't fulfill the strict negative criteria (Group 2). A follow-up echocardiogram and definitive diagnosis of IE were more frequent (n=48, 14.2% and n=20, 5.9%). Finally, in 116 (12.8%) patients the initial TEE showed typical or suggestive signs of IE, in whom the diagnosis was confirmed in 48 (41.4%). The independent predictors of follow-up echocardiography were the previous history of valvular heart disease (HR 2.38 [1.39–3.89], p=0.001) or cancer (HR 0.47 [0.27–0.84], p=0.01), positive blood cultures for Enterococcus (HR 5.01 [2.34–10.73], p<0.001), methicillin-sensitive Staphylococcus aureus (HR 2.8 [1.27–6.17], p=0.011) or Streptococcus (HR 2.36 [1.12–5], p=0.024), and the presence of typical or suggestive signs of infective endocarditis on initial TTE (HR 13.77 [8.6–22.05], p<0.001). A definitive diagnosis of IE was confirmed in a minority of the study population (n=72, 8%). Only one readmission for underdiagnosis of IE during index hospitalization was noted on Group 2.

Conclusions

In a real-life, observational setting only a minority of patients in whom IE was suspected had a definite diagnosis. An initial TTE for suspected IE fulfilling the strict negative criteria predicts both a low probability of requesting a follow-up study and of a definitive diagnosis of IE. Further research should be performed to rationalize echocardiogram requests for suspected IE.

Funding Acknowledgement

Type of funding sources: None.

Sex-related differences in mortality following an admission for acute heart failure across left ventricular ejection fraction spectrum

Background

Prognosis in heart failure (HF) may differ between women and men. However, data is conflicting and sex-related differences in prognosis may be determined by left ventricular ejection fraction (LVEF) status. We sought to evaluate the prognostic differences between women and men with HF following an admission for acute HF (AHF).

Methods

We included 4,812 patients consecutively admitted for AHF in a multicenter registry from 3 hospitals in Valencia (Spain). Study endpoints were all-cause, cardiovascular (CV), and HF-related mortality at 6-months follow-up. Multivariable Cox regression models were fitted to investigate sex-related differences across LVEF status.

Results

2,243 (46.6%) patients were women and 2,569 (53.4%) were men. 2,608 (54.2%) patients had HF with preserved ejection fraction. At 6-months follow-up, 645 patients died (13.4%), being 544 (11.3%) and 416 (8.6%) CV and HF-related deaths, respectively. LVEF was not independently associated to mortality risk (HR=1.02; 95% CI 0.99–1.05; p=0.135). After multivariate adjustment, we found no sex-related differences in all-cause mortality (p-value for interaction=0.168). However, a significant interaction between sex and the risk of CV and HF mortality was found across LVEF status (p-value for interaction= 0.030 and 0.007; respectively). Compared to men, women had a significant lower risk of CV-mortality and HF-mortality at LVEF<25% and <42%, respectively. On the contrary, women showed a higher risk of HF-mortality at the upper extreme of LVEF (>75%) (Figure, panel A and B).

Conclusions

Following an admission for AHF, no sex-related differences were found in the risk of all-cause mortality. However, compared to men, women showed a lower risk of CV and HF-mortality at the lower extreme of LVEF. On the contrary, they showed a higher risk of HF-death at the upper extreme.

Funding Acknowledgement

Type of funding sources: None.

P3543Rehospitalization burden in heart failure with mid-range ejection fraction and morbidity burden. Is it a distinct phenotype?

Methods

We prospectively included 2,961 consecutive patients discharged for acute HF in our institution from 2004 to 2017. Patients were categorized according to their ejection fraction (EF) obtained by an echocardiography during the index admission: HFmrEF (EF 41–49%), HFrEF (EF≤40%) and HFpEF (EF≥50%). Negative binomial regression method was used to evaluate the association between EF status and recurrent all-cause and HF-related admissions. Risk estimates were expressed as incidence ratio ratios (IRR).

Results

Mean age of the cohort was 73.9±11.1 years, 49% were women, and 46.0% had suffered from previous HF admissions. 472 patients (15.9%) had HFmrEF, 956 (32.3%) had HFrEF, and 1,533 (51.8%) had HFpEF. At a median (interquartile range) follow-up of 2.4 (4.4) years, 1,821 (61.5%) patients died and 6,035 all-cause readmissions were registered in 2,026 patients (68.4%), being 2,163 of them HF-related. Rates of all-cause readmission per 100 patients-years of follow-up were 43.4, 47.1 and 50.1 per HFrEF, HFmrEF and HFpEF categories, respectively. After multivariable adjustment, and compared to patients with HFrEF, HFmrEF status was not associated with a higher risk of all-cause or HF-related recurrent admissions (IRR=1.06; 95% confidence interval (CI), 0.93–1.20; p=0.89), and IRR=1.07; 95% CI, 0.91–1.26; p=0.389, respectively), whereas HFpEF status was associated with a non-significant increase in the risk of all-cause recurrent admissions but a similar risk of HF-related readmissions (IRR=1.10; 95% confidence interval (CI), 0.99–1.22; p=0.06, and IRR=1.01; 95% CI, 0.88–1.16; p=0.900, respectively)

Conclusion

Following an admission for acute HF, patients with HFmrEF have a similar all-cause and HF-related rehospitalization burden when compared to patients with HFrEF, by means of recurrent events analysis.