It is not clear to date whether a first admission in heart failure (HF) marks a worse evolution in patients not previously diagnosed with HF (“de novo HF”) than those already diagnosed as outpatients ...(“acutely decompensated HF”). The aim of the study was to analyze whether survival in patients admitted for de novo HF differs from the survival in those admitted for a first episode of decompensation but with a previous diagnosis of HF. This study includes an analysis of 1,728 patients admitted for decompensated HF during 9 years. Readmissions and patients with left ventricular ejection fraction ≥50% were excluded (finally, 524 patients analyzed). We compared de novo HF (n = 186) in patients not diagnosed with HF, although their structural heart disease was defined, versus acutely decompensated HF (n = 338). The clinical profiles in both groups were similar. The de novo HF group more frequently presented with normal right ventricular function, with less presence of severe tricuspid regurgitation. The probability of survival was low in both groups. Thus, the median life in the de novo HF group was 2.1 years and in the acutely decompensated HF group, 3.5 years. There was a lower probability of long-term survival in the de novo HF group (p = 0.035). The variables associated with mortality were age (p <0.0001), ischemic heart disease (p <0.0001), hypertension (p = 0.009), obesity (p = 0.025), diabetes (p = 0.001), and N-terminal pro-brain natriuretic peptide at admission (p <0.0001). A higher glomerular filtration rate was associated with better survival (p = 0.033). De novo HF was associated with a higher mortality than chronic HF with acute decompensation (hazard ratio 1.53, 95% confidence interval 1.03 to 2.27, p = 0.036). In conclusion, the first admission for HF decompensation in patients with no previous diagnosis of HF identifies a subgroup of patients with higher long-term mortality.
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Background
In Spain, listing for high‐urgent heart transplantation is allowed for critically ill candidates not weanable from temporary mechanical circulatory support (T‐MCS). We sought to analyse ...the clinical outcomes of this strategy.
Methods and results
We conducted a case‐by‐case, retrospective review of clinical records of 291 adult patients listed for high‐urgent heart transplantation under temporary devices from 2010 to 2015 in 16 Spanish institutions. Survival after listing and adverse clinical events were studied. At the time of listing, 169 (58%) patients were supported on veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO), 70 (24%) on temporary left ventricular assist devices (T‐LVAD) and 52 (18%) on temporary biventricular assist devices (T‐BiVAD). Seven patients transitioned from VA‐ECMO to temporary ventricular assist devices while on the waiting list. Mean time on T‐MCS was 13.1 ± 12.6 days. Mean time from listing to transplantation was 7.6 ± 8.5 days. Overall, 230 (79%) patients were transplanted and 54 (18.6%) died during MCS. In‐hospital postoperative mortality after transplantation was 33.3%, 11.9% and 26.2% for patients bridged on VA‐ECMO, T‐LVAD and T‐BiVAD, respectively (P = 0.008). Overall survival from listing to hospital discharge was 54.4%, 78.6% and 55.8%, respectively (P = 0.002). T‐LVAD support was independently associated with a lower risk of death over the first year after listing (hazard ratio 0.52, 95% confidence interval 0.30–0.92). Patients treated with VA‐ECMO showed the highest incidence rate of adverse clinical events associated with T‐MCS.
Conclusion
Temporary devices may be used to bridge critically ill candidates directly to heart transplantation in a setting of short waiting list times, as is the case of Spain. In our series, bridging with T‐LVAD was associated with more favourable outcomes than bridging with T‐BiVAD or VA‐ECMO.
Quadruple therapy (renin angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists and sodium/glucose cotransporter type 2 inhibitors SGLT2i) has become the current ...prognostic modifying treatment for heart failure (HF) with reduced ejection fraction (HFrEF). This study aimed to analyse the prescription´s evolution of this combination therapy, the analysis of each pharmacological group and the differences according to HF subgroups.
Retrospective analysis of consecutive patients admitted for cardiac decompensation. Inclusion period: from 1-1-2020 to 12-31-2022. Patients with left ventricular ejection fraction > 40% and deceased during admission were excluded. Finally, 602 patients were included. These were divided into: (a) de novo HF without previous heart disease (n:108), (b) de novo with previous heart disease (n:107), and (c) non-de novo (n:387).
Over the study time, all pharmacological groups experienced an increase in drugs prescription (p < 0.001). The group with the largest prescription rate increase was SGLT2i (2020:20%, 2021:42.9%, 2022:70.4%; mean increase 47.2%). The discharge rate prescription of quadruple therapy increased progressively (2020:7.4%, 2021:21.1%, 2022:32.5%; mean increase 21.9%). The subgroup with the highest combined prescription in 2022 was de novo with previous heart disease (43.9%).
The pharmacological group with the largest prescription´s rate increase was SGLT2i. The percentage of patients discharged on quadruple therapy has progressed significantly in recent years, although it remains low. The most optimised subgroup at discharge was that of de novo HF with previous heart disease.
The treatment of congestion in heart failure (HF) is a challenge despite the therapeutic arsenal available. The aim of this study was to analyze different combinations of diuretics used to resolve ...congestion in patients admitted for decompensated HF and to define clinical profiles according to these treatments.
Single-center study of 1,559 patients admitted for decompensated HF was done between 2016 and 2020. Patients were grouped according to the diuretic combination that led to clinical stabilization and discharge from the hospital: (1) Loop diuretic. (2) Loop diuretic + distal tubule (antialdosterone ± thiazides). (3) Loop diuretic + distal + proximal tubule (acetazolamide ± SGLT2 inhibitor). (4) Loop diuretic + distal tubule + collecting duct (tolvaptan). (5) Loop diuretic + distal + proximal + collecting duct. Based on these diuretic combinations, profiles with clinical, analytical, and echocardiographic differences were established.
There were more previous hospitalizations in groups 4 and 5 (p = 0.001) with a predominance of pulmonary congestion in profiles 1 and 2 and systemic congestion in 3, 4, and 5. Creatinine and CA125 were higher in profiles 4 and 5 (p = 0.01 and p = 0.0001), with no differences in NT-proBNP. Profiles 4 and 5 had a higher proportion of dilatation and depression of right ventricular (p = 0.0001) and left ventricular (p = 0.003) function. Diuretic therapy-defined groups showed difference in clinical characteristics.
The diuretic treatment used identifies five clinical profiles according to the degree of congestion, renal function, CA125, and right ventricular functionality. These profiles would guide the best diuretic treatment on admission.
Congestion profiles. Footnote: Profile 1: Pulmonary congestion. Profile 2: pulmonary congestion with moderate CA 125 elevation. Profile 3: systemic congestion with RV dysfunction. Profile 4: systemic congestion with RV and renal dysfunction. Profile 5: systemic congestion with renal dysfunction, RV dilatation, RV dysfunction, and severe elevation of CA 125. The last row represents the combination of treatments used to resolve each of the congestion pictures. Display omitted
Coronavirus disease 2019 (COVID-19) is a viral infectious disease caused by the severe acute respiratory syndrome coronavirus 2 virus that is affecting the entire world population. The objective of ...this study was to analyze the repercussion of the disease in a group of patients at risk such as heart transplant recipients.
From February 2020 to February 2021, heart transplant recipients diagnosed with COVID-19 were consecutively included. The total number of transplant recipients in outpatient follow-up at that time was 381. Three levels of infection were determined: group A: asymptomatic patients or with trivial symptoms without the need for hospital admission (6 patients); group B: patients admitted to the hospital for respiratory symptoms (12 patients); and group C: patients with severe symptoms and need for admission to the critical care unit (2 patients). At each risk level, medical performance was different: group A: close control, no therapeutic modification; group B: reduction of calcineurin inhibitor and substitution of mycophenolate mofetil for everolimus; group C: reduction of calcineurin inhibitor and withdrawal of mycophenolate mofetil.
The prevalence of infection in the series was 5.2%. Most patients admitted had a pathologic chest x-ray with fever, cough, dyspnea, or vomiting. The change in immunosuppression performed in patients in group 2 was well tolerated and there was no graft rejection. Antiviral treatment was little used. However, boluses of steroids and some antibiotics were used frequently. The need for supplemental oxygen was 50% in group 2 and 100% in group 3.
A significant number of transplant recipients will be affected by COVID-19 (5.3%). Management of the infection will depend on the severity of the infection and must be based on a balance between reduction and adjustment of immunosuppression, strict control of the cardiologic situation, and treatment of the infection.
Background In heart failure (HF), not all episodes of decompensation are alike. The study aimed to characterize the clinical groups of decompensation and perform a survival analysis. Methods A ...retrospective study was conducted on patients consecutively admitted for HF from 2018 to 2023. Patients who died during admission were excluded (final number 1,668). Four clinical types of HF were defined: low cardiac output ( n :83), pulmonary congestion ( n :1,044), mixed congestion ( n :353), and systemic congestion ( n :188). Results The low output group showed a higher prevalence of reduced left ventricular ejection fraction (93%) and increased biventricular diameters ( p < 0.01). The systemic congestion group exhibited a greater presence of tricuspid regurgitation with dilatation and right ventricular dysfunction ( p :0.0001), worse renal function, and higher uric acid and CA125 levels ( p :0.0001). Diuretics were more commonly used in the mixed and, especially, systemic congestion groups ( p :0.0001). The probability of overall survival at 5 years was 49%, with higher survival in pulmonary congestion and lower in systemic congestion ( p :0.002). Differences were also found in survival at 1 month and 1 year ( p :0.0001). Conclusions Mortality in acute HF is high. Four phenotypic profiles of decompensation differ clinically, with distinct characteristics and varying prognosis in the short, medium, and long term.
This study aims to analyse whether in acute heart failure (AHF) with iron deficiency (ID), the administration of ferric carboxymaltose (FCM) produces a greater benefit in renal dysfunction.
A total ...of 812 consecutive patients admitted for AHF and ID were studied. Untreated (n:272) and treated (n:540) patients were compared. The six-month prevalence of a combined event (readmission for HF, all-cause death, and emergency department visit for decompensation) was analysed. Three grades of renal dysfunction (KDIGO) were compared, Group 1 (grades 1 and 2), Group 2 (grades 3a and 3b), and Group 3 (grades 4 and 5).
There were differences in sex distribution (untreated group: males 39.7% vs. treated group: males 51.9%;
< 0.001). Sex-adjusted combined event analysis showed a greater benefit in Group 1 (OR: 0.31, 95% CI:0.19-0.5;
< 0.001) and Group 2 (OR: 0.23, 95% CI:0.14-0.38;
< 0.001), but not in Group 3 (OR: 0.51, 95% CI:0.17-0.55;
: 0.237).
The administration of FCM in patients with AHF and ID reduces the combined event analysed. The benefit is greater when renal dysfunction is present, except in very advanced degrees where no significant benefit is obtained.
•The rapid reduction of CA 125 corroborates its usefulness as a marker of congestion in heart failure.•CA 125 is not useful for predicting rejection.•In cases of very severe rejections that occur ...with systemic congestion, CA 125 could rise.
To analyze the relationship of the antigen carbohydrate 125 (CA125) biomarker with the cellular rejection of the heart graft during the first year after transplantation.
Retrospective study of consecutive heart transplant (HTx) patients for 1.5 years. The total number of patients included in the study was 23 with a total of 103 follow-ups. In all patients, CA125 was determined before HTx and determined post-HTx in every follow-up. These were performed during months 1, 2, 4, 6, 9, and 12. Endomyocardial biopsy was performed in all revisions to assess the degree of graft rejection in the pathologic study. The biopsy results were grouped into 1. absence of rejection and 2. presence of some degree of rejection.
The mean pretransplant CA125 value presented a median of 120 U/mL with an interquartile range of 28.8 U/mL. One month after transplantation, the value was reduced by 20% and at 2 months by 81%. In subsequent reviews, plasma values were always between 10 and 20 U/mL. When comparing the values by periods and according to the presence or absence of rejection, no significant differences were found other than a slight elevation at the 6-month checkup (P = .03) but without clinical relevance, because the CA125 value was slightly higher in biopsy results without rejection.
The rapid reduction of CA125 corroborates its usefulness as a marker of congestion in heart failure. This biomarker is not useful for predicting rejection. However, in cases of very severe rejections that occurred with systemic congestion, it could be raised. It would be necessary to corroborate this hypothesis in a larger study with a higher number of severe rejections.
Worsening heart failure (HF) is a vulnerable period in which the patient has a markedly high risk of death or HF hospitalization (up to 10% and 30%, respectively, within the first weeks after ...episode). The prognosis of HF patients can be improved through a comprehensive approach that considers the different neurohormonal systems, with the early introduction and optimization of the quadruple therapy with sacubitril–valsartan, beta‐blockers, mineralocorticoid receptor antagonists, and inhibitors. Despite that, there is a residual risk that is not targeted with these therapies. Currently, it is recognized that the cyclic guanosine monophosphate deficiency has a negative direct impact on the pathogenesis of HF, and vericiguat, an oral stimulator of soluble guanylate cyclase, can restore this pathway. The effect of vericiguat has been explored in the VICTORIA study, the largest chronic HF clinical trial that has mainly focused on patients with recent worsening HF, evidencing a significant 10% risk reduction of the primary composite endpoint of cardiovascular death or HF hospitalization (number needed to treat 24), after adding vericiguat to standard therapy. This benefit was independent of background HF therapy. Therefore, optimization of treatment should be performed as earlier as possible, particularly within vulnerable periods, considering also the use of vericiguat.
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