This study sought to report the prevalence of frailty, classification performance, and agreement among 3 frailty assessment tools and 3 screening tools in chronic heart failure (CHF) patients.
...Frailty is common in patients with CHF. There are many available frailty tools, but no standard method for evaluating frailty.
We used the following frailty screening tools: the clinical frailty scale (CFS); the Derby frailty index; and the acute frailty network frailty criteria. We used the following frailty assessment tools: the Fried criteria; the Edmonton frailty score; and the Deficit Index.
A total of 467 consecutive ambulatory CHF patients (67% male; median age: 76 years; interquartile range IQR: 69 to 82 years; median N-terminal pro–B-type natriuretic peptide: 1,156 ng/l IQR: 469 to 2,463 ng/l) and 87 control patients (79% male; median age: 73 years; IQR: 69 to 77 years) were studied. The prevalence of frailty using the different tools was higher in CHF patients than in control patients (30% to 52% vs. 2% to 15%, respectively). Frail patients tended to be older, have worse symptoms, higher N-terminal pro–B-type natriuretic peptide levels, and more comorbidities. Of the screening tools, CFS had the strongest correlation and agreement with the assessment tools (correlation coefficient: 0.86 to 0.89, kappa coefficient: 0.65 to 0.72, depending on the frailty assessment tools, all p < 0.001). CFS had the highest sensitivity (87%) and specificity (89%) among screening tools and the lowest misclassification rate (12%) among all 6 frailty tools in identifying frailty according to the standard combined frailty index.
Frailty is common in CHF patients and is associated with increasing age, comorbidities, and severity of heart failure. CFS is a simple screening tool that identifies a similar group using more lengthy assessment tools.
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Abstract
Aims
Plasma concentrations of high-sensitivity C-reactive protein (hsCRP) are often raised in chronic heart failure (CHF) and might indicate inflammatory processes that could be a ...therapeutic target. We aimed to study the associations between hsCRP, mode and cause of death in patients with CHF.
Methods and results
We enrolled 4423 patients referred to a heart failure clinic serving a local population. CHF was defined as relevant symptoms or signs with either a reduced left ventricular ejection fraction <40% or raised plasma concentrations of amino-terminal pro-B type natriuretic peptide (NT-proBNP >125 pg/mL). The median interquartile range (IQR) plasma hsCRP for patients diagnosed with CHF (n = 3756) was 3.9 (1.6–8.5) mg/L and 2.7 (1.3–5.1) mg/L for those who were not (n = 667; P < 0.001). Patients with hsCRP ≥10 mg/L (N = 809; 22%) were older and more congested than those with hsCRP <2 mg/L (N = 1117, 30%). During a median follow-up of 53 (IQR 28–93) months, 1784 (48%) patients with CHF died. Higher plasma hsCRP was associated with greater mortality, independent of age, symptom severity, creatinine, and NT-proBNP. Comparing a hsCRP ≥10 mg/L to <2 mg/L, the hazard ratio for all-cause mortality was 2.49 (95% confidence interval 2.19–2.84; P < 0.001), for cardiovascular (CV) mortality was 2.26 (1.91–2.68; P < 0.001), and for non-CV mortality was 2.96 (2.40–3.65; P < 0.001).
Conclusion
In patients with CHF, a raised plasma hsCRP is associated with more congestion and a worse prognosis. The proportion of deaths that are non-CV also increases with higher hsCRP.
Background
The recent AFFIRM-AHF trial assessing the effect of intravenous (IV) iron on outcomes in patients hospitalised with worsening heart failure who had iron deficiency (ID) narrowly missed its ...primary efficacy endpoint of recurrent hospitalisations for heart failure (HHF) or cardiovascular (CV) death. We conducted a meta-analysis to determine whether these results were consistent with previous trials.
Methods
We searched for randomised trials of patients with heart failure investigating the effect of IV iron vs placebo/control groups that reported HHF and CV mortality from 1st January 2000 to 5th December 2020. Seven trials were identified and included in this analysis. A fixed effect model was applied to assess the effects of IV iron on the composite of first HHF or CV mortality and individual components of these.
Results
Altogether, 2,166 patients were included (
n
= 1168 assigned to IV iron;
n
= 998 assigned to control). IV iron reduced the composite of HHF or CV mortality substantially OR 0.73; (95% confidence interval 0.59–0.90);
p
= 0.003. Outcomes were consistent for the pooled trials prior to AFFIRM-AHF. Whereas first HHF were reduced substantially OR 0.67; (0.54–0.85);
p
= 0.0007, the effect on CV mortality was uncertain but appeared smaller OR 0.89; (0.66–1.21);
p
= 0.47.
Conclusion
Administration of IV iron to patients with heart failure and ID reduces the risk of the composite outcome of first heart failure hospitalisation or cardiovascular mortality, but this outcome may be driven predominantly by an effect on HHF. At least three more substantial trials of intravenous iron are underway.
Graphic abstract
Aims
Psychosocial factors are rarely collected in studies investigating the prognosis of patients with heart failure (HF), and only time to first event is commonly reported. We investigated the ...prognostic value of psychosocial factors for predicting first or recurrent events after discharge following hospitalization for HF.
Methods and results
OPERA‐HF is an observational study enrolling patients hospitalized for HF. In addition to clinical variables, psychosocial variables are recorded. Patients provide the information through questionnaires that include social information, depression and anxiety scores, and cognitive function. Kaplan–Meier, Cox regression and the Andersen–Gill model were used to identify predictors of first and recurrent events (readmissions or death). Of 671 patients (age 76 ± 15 years, 66% men) with 1‐year follow‐up, 291 had no subsequent event, 34 died without being readmitted, 346 had one or more unplanned readmissions, and 71 patients died after a first readmission. Increasing age, higher urea and creatinine, and the presence of co‐morbidities (diabetes, history of myocardial infarction, chronic obstructive pulmonary disease) were all associated with increasing risk of first or recurrent events. Psychosocial variables independently associated with both the first and recurrent events were: presence of frailty, moderate‐to‐severe depression, and moderate‐to‐severe anxiety. Living alone and the presence of cognitive impairment were independently associated only with an increasing risk of recurrent events.
Conclusion
Psychosocial factors are strongly associated with unplanned recurrent readmissions or mortality following an admission to hospital for HF. Further research is needed to show whether recognition of these factors and support tailored to individual patients' needs will improve outcomes.
The management of heart failure has changed significantly over the last 30 years, leading to improvements in the quality of life and outcomes, at least for patients with a substantially reduced left ...ventricular ejection fraction (HFrEF). This has been made possible by the identification of various pathways leading to the development and progression of heart failure, which have been successfully targeted with effective therapies. Meanwhile, many other potential targets of treatment have been identified, and the list is constantly expanding. In this review, we summarise planned and ongoing trials exploring the potential benefit, or harm, of old and new pharmacological interventions that might offer further improvements in treatment for those with HFrEF and extend success to the treatment of patients with heart failure with preserved left ventricular ejection fraction (HFpEF) and other heart failure phenotypes.
Background
The inverse relationship between body mass index (BMI) and natriuretic peptide levels complicates the diagnosis of heart failure (HF) in obese patients. Assessment of congestion with ...ultrasound could facilitate HF diagnosis but it is unclear if any relationship exists amongst BMI, inferior vena cava (IVC) diameter and the number of B-lines.
Methods
We performed a comprehensive echocardiographic evaluation within 24 h from hospital admission in patients with HF, including lung B-lines and IVC diameter, and studied their relationship with BMI and outcome.
Results
216 patients (median age 81 (77–86) years) were enrolled. Median number of B-lines was 31 (IQR 26–38), median IVC diameter was 23 (22–25) mm and median BNP 991 (727–1601) pg/mL. BMI was inversely correlated with B-lines (
r
=
−
0.50,
p
< 0.001), but not with IVC diameter (
r
= − 0.04,
p
= 0.58). Compared to overweight patients (BMI 25–29.9 kg/m2;
n
= 100) or with a normal BMI (BMI < 25 kg/m2;
n
= 59), obese patients (BMI ≥ 30 kg/m2;
n
= 57) had lower B-lines 28 (24–33) vs 30 (26–35), and vs 38 (32–42), respectively;
p
< 0.001 but similar IVC diameter. During the first 60 days of follow-up, there were 53 primary events: 29 patients died and 24 had a HF-related hospitalisation. B-lines and IVC diameter were independently associated with an increased risk. However, B-lines were less likely to predict outcome in the subgroup of patients with a BMI ≥ 30 kg/m
2
.
Conclusions
Assessment of IVC diameter or B-lines in patients admitted with AHF identifies those at greater risk of death or HF readmission. However, assessment of B-lines might be influenced by BMI.
Graphic abstract
Background
Right ventricular (RV) dysfunction and RV–pulmonary artery (PA) uncoupling are associated with the development of pulmonary congestion during exercise. However, there is limited ...information regarding the association between these right-sided cardiac parameters and pulmonary congestion in acutely decompensated heart failure (HF).
Methods
We performed an individual patient meta-analysis from four cohort studies of hospitalized patients with HF who had available lung ultrasound (B-lines) data on admission and/or at discharge. RV function was assessed by tricuspid annular plane systolic excursion (TAPSE), RV–PA coupling was defined as the ratio of TAPSE to PA systolic pressure (PASP).
Results
Admission and discharge cohort included 319 patients (75.8 ± 10.1 years, 46% women) and 221 patients (77.9 ± 9.0 years, 47% women), respectively. Overall, higher TAPSE was associated with higher ejection fraction, lower PASP, b-type natriuretic peptide and B-line counts. By multivariable analysis, worse RV function or RV–PA coupling was associated with higher B-line counts on admission and at discharge, and with a less reduction in B-line counts from admission to discharge. Higher B-line counts at discharge were associated with a higher risk of the composite of all-cause mortality and/or HF re-hospitalization adjusted-HR 1.13 (1.09–1.16),
p
< 0.001. Furthermore, the absolute risk increase related to high B-line counts at discharge was higher in patients with lower TAPSE.
Conclusions
In patients with acutely decompensated HF, impaired RV function and RV–PA coupling were associated with severe pulmonary congestion on admission, and less resolution of pulmonary congestion during hospital stay. Worse prognosis related to residual pulmonary congestion was enhanced in patients with RV dysfunction.
Graphic abstract
TAPSE, tricuspid annular plane systolic excursion; PASP, pulmonary artery systolic pressure.
Immune responses play a significant role in hypertension, though the importance of key inflammatory mediators remains to be defined. We used a systematic literature review and meta-analysis to study ...the associations between key cytokines and incident hypertension.
We performed a systematic search of Pubmed/Medline, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL), for peer-reviewed studies published up to August 2022. Incident hypertension was defined as systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg and/or the use of antihypertensive medications. Random effects meta-analyses were used to calculate pooled hazard ratios (HRs)/risk ratios (RRs) and 95% confidence intervals by cytokine levels (highest vs. lowest quartile).
Only IL-6 and IL-1β levels have evidence allowing for quantitative evaluation concerning the onset of hypertension. Six studies (10406 participants, 2932 incident cases) examined the association of IL-6 with incident hypertension. The highest versus lowest quartile of circulating IL-6 was associated with a significant HR/RR of hypertension (1.61, 95% CI: 1.00 to 2.60; I2 =87%). After adjusting for potential confounders, including body mass index (BMI), HR/RR was no longer significant (HR/RR: 1.24; 95% CI, 0.96 to 1.61; I2 = 56%). About IL-1β, neither the crude (HR/RR: 1.03; 95% CI, 0.60 to 1.76; n = 2) nor multivariate analysis (HR/RR: 0.97, 95% CI, 0.60 to 1.56; n = 2) suggested a significant association with the risk of developing hypertension.
A limited number of studies suggest that higher IL-6, but not IL-1β, might be associated with the development of hypertension.
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Aims
Procollagen type I C‐terminal propeptide (PICP) and procollagen type III N‐terminal propeptide (PIIINP) are markers reflecting collagen synthesis in cardiac fibrosis. However, they may be ...influenced by the presence of non‐cardiac comorbidities (e.g. ageing, obesity, renal impairment). Understanding the associations between markers of collagen synthesis and abnormalities of cardiac structure and function is important to screen for myocardial fibrosis and monitor the antifibrotic effect of medications.
Methods and results
The HOMAGE (Heart ‘OMics’ in AGEing) trial showed that spironolactone decreased serum PICP concentrations and improved cardiac remodelling over 9 months in a population at risk of developing heart failure (HF). We evaluated the associations between echocardiographic variables, PICP, PIIINP and galectin‐3 at baseline and during the course of the trial. Among 527 individuals (74 ± 7 years, 26% women), median serum concentrations of PICP, PIIINP and galectin‐3 were 80.6 μg/L (65.1–97.0), 3.9 μg/L (3.1–5.0), and 16.1 μg/L (13.5–19.7), respectively. After adjustment for potential confounders, higher serum PICP was significantly associated with left ventricular hypertrophy, left atrial enlargement, and greater ventricular stiffness (all p < 0.05), whereas serum PIIINP and galectin‐3 were not (all p > 0.05). In patients treated with spironolactone, a reduction in serum PICP during the trial was associated with a decrease in E/e′ (adjusted‐beta = 0.93, 95% confidence interval 0.14–1.73; p = 0.022).
Conclusions
In individuals at high risk of developing HF, serum PICP was associated with cardiac structural and functional abnormalities, and a decrease in PICP with spironolactone was correlated with improved diastolic dysfunction as assessed by E/e′. In contrast, no such associations were present for serum PIIINP and galectin‐3.
In a population at risk of HF, independent of clinical confounders, higher serum concentration of procollagen type I C‐terminal propeptide (PICP) was associated with the presence of left ventricular (LV) hypertrophy and diastolic functional abnormalities (specifically, with greater left atrial LA volume indexed for body surface area and lower e′). In contrast, serum concentrations of procollagen type III N‐terminal propeptide (PIIINP) and galectin‐3 were not associated with abnormalities in any of the measures of cardiac structure or function. Additionally, in individuals treated with spironolactone, a decrease in serum PICP during a 9‐month period paralleled a decrease in E/e′.
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