Explore the vast range of titles available.

Cardiac resynchronization therapy (CRT) improves cardiac hemodynamics. Therefore, the maintenance dose of loop diuretic therapy might be reduced. Consecutive patients who underwent CRT (n = 648) were retrospectively evaluated. Loop diuretic dose was recorded at baseline before implantation and 6 months later with patients classified into 4 groups: (1) no loop diuretic, (2) down-titration, (3) unchanged dose, and (4) up-titration. Afterward total loop diuretic exposure was calculated. Renal function trajectories were evaluated as the difference between implantation and censoring serum creatinine (Cr) value. Clinical outcome was evaluated as the combined end point of heart failure readmissions and all-cause mortality. Independent predictors of successful loop diuretic down-titration were identified. Two hundred ninety-six patients (46%) received no loop diuretic at follow-up, 126 (19%) underwent down-titration, 137 (21%) remained on a stable dose, and 89 (14%) underwent up-titration. In comparison with the group that was free from loop diuretics (Cr = +0.06 mg/dl), renal function deteriorated faster during follow-up in patients on stable doses (Cr = +0.29 mg/dl; p = 0.045) and those underwent up-titration (Cr = +0.44 mg/dl; p = 0.009) but not in patients who were down-titrated (Cr = +0.13 mg/dl; p = 1.00). Patients receiving down-titration had a lower risk for the combined clinical end point (adjusted hazards ratio 0.43; confidence interval 0.22 to 0.83; p = 0.012). Factors associated with successful down-titration after 6 months of CRT included nonischemic cardiomyopathy, higher baseline dose of diuretics, higher ejection fraction at 6 weeks, and lower right ventricular systolic pressure at 6 weeks. In conclusion, after CRT, down-titration of loop diuretics is often feasible and associated with improved outcome and a slower rate of kidney function decline. Patients with nonischemic cardiomyopathy, treated with high doses of loop diuretics before implantation and beneficial left ventricular remodeling with CRT, are most likely to tolerate loop diuretic down-titration.

Iron deficiency is prevalent in heart failure with reduced ejection fraction and relates to symptomatic status, readmission, and all-cause mortality. The relation between iron status and response to cardiac resynchronization therapy (CRT) remains insufficiently elucidated. This study assesses the impact of iron deficiency on clinical response and reverse cardiac remodeling and outcome after CRT. Baseline characteristics, change in New York Heart Association functional class, reverse cardiac remodeling on echocardiography, and clinical outcome (i.e., all-cause mortality and heart failure readmissions) were retrospectively evaluated in consecutive CRT patients who had full iron status and complete blood count available at implantation, implanted at a single tertiary care center with identical dedicated multidisciplinary CRT follow-up from October 2008 to August 2015. A total of 541 patients were included with mean follow-up of 38 ± 22 months. Prevalence of iron deficiency was 56% at implantation. Patients with iron deficiency exhibited less symptomatic improvement 6 months after implantation (p value <0.001). In addition, both the decrease in left ventricular end-diastolic diameter (−3.1 vs −6.2 mm; p value = 0.011) and improvement in ejection fraction (+11% vs +15%, p value = 0.001) were significantly lower in patients with iron deficiency. Iron deficiency was significantly associated with an increased risk for heart failure admission or all-cause mortality (adjusted hazard ratio 1.718, 95% confidence interval 1.178 to 2.506), irrespectively of the presence of anemia (Hemoglobin <12 g/dl in women and <13 g/dl in men). In conclusion, iron deficiency is prevalent and affects both clinical response and reverse cardiac remodeling after CRT implantation. Moreover, it is a powerful predictor of adverse clinical outcomes in CRT.

BackgroundContemporary data on left ventricular function (LVF) recovery in patients with left ventricular dysfunction after ST-elevation myocardial infarction (STEMI) are scarce and to date, no comparison has been made with patients with a baseline normal LVF. This study examined predictors of LVF recovery and its relation to outcomes in STEMI. MethodsPatients presenting with STEMI between January 2010 and December 2016 were categorized in three groups after 3 months according to left ventricular ejection fraction (EF): (i) baseline normal LVF (EF ≥ 50% at baseline); (ii) recovered LVF (EF < 50% at baseline and ≥ 50% after 3 months); and (iii) reduced LVF (EF < 50% at baseline and after 3 months). Heart failure hospitalization, all-cause mortality and cardiovascular mortality were compared between the three groups.ResultsOf 577 patients, 341 (59%) patients had a baseline normal LVF, 112 (19%) had a recovered LVF and 124 (22%) had a reduced LVF. Independent correlates of LVF recovery were higher baseline EF, lower peak troponin and cardiac arrest. After median 5.8 years, there was no difference in outcomes between patients with LVF recovery and baseline normal LVF. In contrast, even after multivariate adjustment, patients with persistently reduced LVF had a higher risk for heart failure hospitalization (HR 5.00; 95% CI 2.17–11.46) and all-cause mortality (HR 1.87; 95% CI 1.11–3.16).ConclusionIn contemporary treated STEMI patients, prognosis is significantly worse in those with a persistently reduced LVF after 3 months, compared with patients with a baseline normal LVF and those with LVF recovery. Graphic abstract

Aims To investigate the outcomes and associated costs of haemodynamic‐guided heart failure (HF) management with a pulmonary artery pressure (PAP) sensor in a multicentre European cohort. Methods and results Data from all consecutive patients receiving a PAP sensor in Ziekenhuis Oost‐Limburg, University Hospital Zurich and Sheffield Teaching Hospitals NHS Foundation Trust before January 2021 were collected. Medication changes, total number of HF hospitalizations and HF related health care costs (composed of HF hospitalizations, outpatient cardiology visits and monitoring costs) were compared between the pre‐implantation and post‐implantation period at 3, 6, and 12 months. PAP evolution post‐implantation were grouped according to baseline mPAP ≥25 mmHg versus <25 mmHg and changes from baseline were analyzed via an area under the curve (AUC) analysis. A total of 48 patients received a PAP sensor (29 CardioMEMS and 19 Cordella devices) with a median follow‐up of 19 (13–30) months. Mean age was 71 ± 10 years, 25.0% were female, 68.8% had a left ventricular ejection fraction < 50%, median NT‐proBNP was 1801 (827–4503) pg/mL, and 89.6% were in NYHA class III. The number of diuretic therapy changes were non‐significantly increased after 3 months (49 vs. 82; P = 0.284) and 6 months (82 vs. 127; P = 0.093) with a significant increase noted after 12 months (118 vs. 195; P = 0.005). The mPAP AUC decreased by −1418 mmHg‐days for patients with a baseline mean PAP ≥ 25 mmHg. The number of HF hospitalizations was reduced for all patients after 6 (34 vs. 17; P = 0.014) and 12 months (48 vs. 29; P = 0.032). HF related health care costs were reduced from € 6286 to € 3761 at 6 months (P = 0.012) and from € 8960 to € 6167 at 12 months (P = 0.032). Conclusion Haemodynamic‐guided HF management reduces HF hospitalizations and HF related health care costs in selected HF patients amongst different European health care systems.

Background: Renin-angiotensin-aldosterone system (RAAS) activation in heart failure with reduced ejection fraction (HFREF) is detrimental through promotion of ventricular remodeling and salt and water retention. Aims: The aims of this article are to describe RAAS activity in distinct HFREF populations and to assess its prognostic impact. Methods: Venous blood samples were prospectively obtained in 76 healthy volunteers, 72 patients hospitalized for acute decompensated HFREF, and 78 ambulatory chronic HFREF patients without clinical signs of congestion. Sequential measurements were performed in patients with acute decompensated HFREF. Results: Plasma renin activity (PRA) was significantly higher in ambulatory chronic HFREF (7.6 ng/ml/h (2.2; 18.1)) compared to patients with acute decompensated HFREF (1.5 ng/ml/h (0.8; 5.7)) or healthy volunteers (1.4 ng/ml/h (0.6; 2.3)) (all p < 0.05). PRA was significantly associated with arterial blood pressure and renin-angiotensin system blocker dose. A progressive rise in PRA (+4 ng/ml/h (0.4; 10.9); p < 0.001) was observed in acute decompensated HFREF patients after three consecutive days of decongestive treatment. Only in acute HFREF were PRA levels associated with increased cardiovascular mortality or HF readmissions (p = 0.035). Conclusion: PRA is significantly elevated in ambulatory chronic HFREF patients but is not associated with worse outcome. In contrast, in acute HFREF patients, PRA is associated with cardiovascular mortality or HF readmissions.

In a randomized, placebo-controlled trial, patients with acute decompensated heart failure and volume overload who received intravenous acetazolamide plus a loop diuretic had a higher incidence of decongestion.

Purpose of review The number of cancer patients grows globally. An important subset may develop heart failure. Recent findings A paucity of data exists regarding outcomes and response to traditional intervention in cancer patients who develop heart failure. Advanced HF treatments in this population require special considerations. Since cancer treatment schedules are anticipated, emphasis should be placed on preventive interventions. Once left ventricular dysfunction ensues, early recognition and prompt treatment of heart failure may improve prognosis. Small studies have shown that guideline-directed medical therapies, cardiac resynchronization therapy, and implantable cardiac defibrillators are equally beneficial in cancer patients yet underutilized as a result of late recognition of heart failure and/or misconception of oncologic prognosis. Additionally, in carefully selected cancer survivors, clinical outcome after implantation of a left ventricular assist device and heart transplantation are comparable with other causes of heart failure. Summary Cancer survivors with acceptable prognosis should be evaluated for HF therapies in a timely manner. There remains an urgent need for larger-scale longitudinal studies to determine the best treatment strategies for heart failure in this population.

Incomplete relief of congestion in acute decompensated heart failure (HF) is related to poor outcomes. However, congestion can be difficult to evaluate, stressing the urgent need for new objective approaches. Due to its inverse correlation with tissue hydration, continuous bioimpedance monitoring might be an effective method for serial fluid status assessments. This study aimed to determine whether in-hospital bioimpedance monitoring can be used to track fluid changes (ie, the efficacy of decongestion therapy) and the relationships between bioimpedance changes and HF hospitalization and all-cause mortality. A wearable bioimpedance monitoring device was used for thoracic impedance measurements. Thirty-six patients with signs of acute decompensated HF and volume overload were included. Changes in the resistance at 80 kHz (R ) were analyzed, with fluid balance (fluid in/out) used as a reference. Patients were divided into two groups depending on the change in R during hospitalization: increase in R or decrease in R . Clinical outcomes in terms of HF rehospitalization and all-cause mortality were studied at 30 days and 1 year of follow-up. During hospitalization, R increased for 24 patients, and decreased for 12 patients. For the total study sample, a moderate negative correlation was found between changes in fluid balance (in/out) and relative changes in R during hospitalization (rs=-0.51, P<.001). Clinical outcomes at both 30 days and 1 year of follow-up were significantly better for patients with an increase in R . At 1 year of follow-up, 88% (21/24) of patients with an increase in R were free from all-cause mortality, compared with 50% (6/12) of patients with a decrease in R (P=.01); 75% (18/24) and 25% (3/12) were free from all-cause mortality and HF hospitalization, respectively (P=.01). A decrease in R resulted in a significant hazard ratio of 4.96 (95% CI 1.82-14.37, P=.003) on the composite endpoint. The wearable bioimpedance device was able to track changes in fluid status during hospitalization and is a convenient method to assess the efficacy of decongestion therapy during hospitalization. Patients who do not show an improvement in thoracic impedance tend to have worse clinical outcomes, indicating the potential use of thoracic impedance as a prognostic parameter.

ObjectiveTo determine the incremental value of implantable cardioverter defibrillators (ICD) in contemporary optimally treated patients with heart failure (HF) undergoing cardiac resynchronisation therapy (CRT).MethodsConsecutive patients with HF undergoing CRT-pacemaker (CRT-P) or CRT-defibrillator (CRT-D) implantation in a single tertiary care centre between October 2008 and August 2015 were retrospectively evaluated. For patients with a primary prevention indication of the CRT-D, no benefit of the ICD was defined as absence of appropriate therapy (device analysis) or lethal ventricular tachyarrhythmias (mode of death analysis) during follow-up.Results687 patients (CRT-P/CRT-D; n=361/326) were followed for 38±22 months. CRT-P recipients were older (75.7±9.1 vs 71.8±9.3 years; p<0.001) and had a higher comorbidity burden. Five patients with CRT-P (1%) experienced episodes of sustained ventricular-tachycardia vs 64 (20%) patients with CRT-D (p<0.001). Remote tele-monitoring detected the episodes of sustained ventricular tachycardia in four patients with CRT-P, allowing for elective upgrade to CRT-D. All-cause mortality was higher in patients with CRT-P versus CRT-D (21% vs 12%, p=0.003), even after adjusting for baseline characteristics (HR 2.5; 95% CI 1.36 to 4.60; p=0.003). However, mode of death analysis revealed a predominant non-cardiac mode of death in CRT-P recipients (n=47 (71%) vs n=13 (38%) in CRT-D, p=0.002). Multivariate analysis revealed that age >80 years, New York Heart Association class IV, intolerance to beta-blockers and underlying non-ischaemic cardiomyopathy were independently associated with little incremental value of a primary prevention ICD on top of CRT.ConclusionsThe majority of patients with contemporary HF as currently selected for CRT-P exhibit mainly non-cardiac-driven mortality. Weighing risk of ventricular-tachyarrhythmic death versus risk of all-cause mortality helps to address the incremental value of an ICD to CRT-P.

Abstract Background Amyloidosis is a systemic disorder characterized by the deposition of misfolded proteins in various organs. While cardiac transthyretin amyloidosis (ATTR) is well-recognized, pulmonary involvement is rare and often overlooked in clinical practice. Case summary We present a case of severe, and ultimately fatal, cardiac and pulmonary ATTR amyloidosis in a 67-year-old male. The patient’s initial complaints included dyspnoea and exercise intolerance. Echocardiography revealed isolated concentric left ventricular hypertrophy, and subsequent cardiac MRI suggested cardiac amyloidosis. Additional diagnostic steps, including bone scan and endomyocardial tissue biopsy, confirmed the diagnosis of ATTR amyloidosis. Intriguingly, this case also unveiled concurrent pulmonary involvement, characterized by ground-glass opacities, lymphadenopathy, and impaired lung function. Despite treatment with tafamidis, the patient’s condition deteriorated swiftly. He was admitted to the hospital four months after his initial presentation, and ultimately succumbed to therapy-resistant respiratory distress and heart failure. Post-mortem examination revealed extensive cardiac and pulmonary interstitial ATTR amyloidosis, with the lung exhibiting a fibrotic stage of diffuse alveolar damage. Discussion This case highlights pulmonary involvement as a potential contributor to the clinical picture of ATTR amyloidosis. It also emphasizes the necessity for a multidisciplinary approach, heightened awareness, and further research to enhance the detection and management of pulmonary involvement in ATTR amyloidosis. Video Abstract 10.1093/ehjcr/ytae568 Video Abstract ytae568media1 6364452816112