Aims
To examine the impact of COVID‐19 on acute heart failure (AHF) hospitalization rates, clinical characteristics and management of patients admitted to a tertiary Heart Failure Unit in London ...during the peak of the pandemic.
Methods and results
Data from King's College Hospital, London, reported to the National Heart Failure Audit for England and Wales, between 2 March–19 April 2020 were compared both to a pre‐COVID cohort and the corresponding time periods in 2017 to 2019 with respect to absolute hospitalization rates. Furthermore, we performed detailed comparison of patients hospitalized during the COVID‐19 pandemic and patients presenting in the same period in 2019 with respect to clinical characteristics and management during the index admission. A significantly lower admission rate for AHF was observed during the study period compared to all other included time periods. Patients admitted during the COVID‐19 pandemic had higher rates of New York Heart Association III or IV symptoms (96% vs. 77%, P = 0.03) and severe peripheral oedema (39% vs. 14%, P = 0.01). We did not observe any differences in inpatient management, including place of care and pharmacological management of heart failure with reduced ejection fraction.
Conclusion
Incident AHF hospitalization significantly declined in our centre during the COVID‐19 pandemic, but hospitalized patients had more severe symptoms at admission. Further studies are needed to investigate whether the incidence of AHF declined or patients did not present to hospital while the national lockdown and social distancing restrictions were in place. From a public health perspective, it is imperative to ascertain whether this will be associated with worse long‐term outcomes.
Objectives This study sought to compare catheter ablation with rate control for persistent atrial fibrillation (AF) in heart failure (HF). Background The optimal therapy for AF in HF is unclear. ...Drug-based rhythm control has not proved clinically beneficial. Catheter ablation improves cardiac function in patients with HF, but impact on physiological performance has not been formally evaluated in a randomized trial. Methods In a randomized, open-label, blinded-endpoint clinical trial, adults with symptomatic HF, radionuclide left ventricular ejection fraction (EF) ≤35%, and persistent AF were assigned to undergo catheter ablation or rate control. Primary outcome was 12-month change in peak oxygen consumption. Secondary endpoints were quality of life, B-type natriuretic peptide, 6-min walk distance, and EF. Results were analyzed by intention-to-treat. Results Fifty-two patients (age 63 ± 9 years, EF 24 ± 8%) were randomized, 26 each to ablation and rate control. At 12 months, 88% of ablation patients maintained sinus rhythm (single-procedure success 68%). Under rate control, rate criteria were achieved in 96%. The primary endpoint, peak oxygen consumption, significantly increased in the ablation arm compared with rate control (difference +3.07 ml/kg/min, 95% confidence interval: 0.56 to 5.59, p = 0.018). The change was not evident at 3 months (+0.79 ml/kg/min, 95% confidence interval: −1.01 to 2.60, p = 0.38). Ablation improved Minnesota score (p = 0.019) and B-type natriuretic peptide (p = 0.045) and showed nonsignificant trends toward improved 6-min walk distance (p = 0.095) and EF (p = 0.055). Conclusions This first randomized trial of ablation versus rate control to focus on objective exercise performance in AF and HF shows significant benefit from ablation, a strategy that also improves symptoms and neurohormonal status. The effects develop over 12 months, consistent with progressive amelioration of the HF syndrome. (A Randomised Trial to Assess Catheter Ablation Versus Rate Control in the Management of Persistent Atrial Fibrillation in Chronic Heart Failure; NCT00878384 )
Heart failure with preserved ejection fraction (HFpEF) involves multiple pathophysiological mechanisms, which result in the heterogeneous phenotypes that are evident clinically, and which have ...potentially confounded previous HFpEF trials. A greater understanding of the in vivo human processes involved, and in particular, which are the causes and which are the downstream effects, may allow the syndrome of HFpEF to be distilled into distinct diagnoses based on the underlying biology. From this, specific interventions can follow, targeting individuals identified on the basis of their biological phenotype. This review describes the biological phenotypes of HFpEF and therapeutic interventions aimed at targeting these phenotypes.
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This article updates the Heart Failure Association of the European Society of Cardiology (ESC) 2007 classification of advanced heart failure and describes new diagnostic and treatment options for ...these patients. Recognizing the patient with advanced heart failure is critical to facilitate timely referral to advanced heart failure centres. Unplanned visits for heart failure decompensation, malignant arrhythmias, co‐morbidities, and the 2016 ESC guidelines criteria for the diagnosis of heart failure with preserved ejection fraction are included in this updated definition. Standard treatment is, by definition, insufficient in these patients. Inotropic therapy may be used as a bridge strategy, but it is only a palliative measure when used on its own, because of the lack of outcomes data. Major progress has occurred with short‐term mechanical circulatory support devices for immediate management of cardiogenic shock and long‐term mechanical circulatory support for either a bridge to transplantation or as destination therapy. Heart transplantation remains the treatment of choice for patients without contraindications. Some patients will not be candidates for advanced heart failure therapies. For these patients, who are often elderly with multiple co‐morbidities, management of advanced heart failure to reduce symptoms and improve quality of life should be emphasized. Robust evidence from prospective studies is lacking for most therapies for advanced heart failure. There is an urgent need to develop evidence‐based treatment algorithms to prolong life when possible and in accordance with patient preferences, increase life quality, and reduce the burden of hospitalization in this vulnerable patient population.
Iron deficiency is an important comorbidity in patients with heart failure, occurring in around 40% of patients with chronic heart failure and 70% of patients with acute heart failure.1,2 Iron ...deficiency is associated with a reduction in both quality of life and exercise capacity, and an increase in hospital admissions for heart failure and mortality, irrespective of the presence of anaemia.3 Current European Society of Cardiology guidance for the treatment of iron deficiency in patients with heart failure is intravenous iron supplementation with ferric carboxymaltose.4 In The Lancet, Paul R Kalra and colleagues5 report the results of IRONMAN, the first large outcome trial using ferric derisomaltose in patients in the UK with heart failure. Two smaller randomised controlled trials in patients with chronic heart failure and reduced ejection fraction and iron deficiency showed improvements in quality of life and exercise capacity using a different iron preparation, ferric carboxymaltose.6,7 Subsequently, an individual patient data meta-analysis of trials using ferric carboxymaltose in patients with chronic heart failure showed a reduction in hospital admissions for heart failure, but not cardiovascular death.8 The large AFFIRM-AHF outcome trial, with ferric carboxymaltose, was done in patients admitted to hospital with heart failure, iron deficiency, and a left ventricular ejection fraction of less than 50% (encompassing patients with heart failure and reduced ejection fraction and patients with heart failure with mildly reduced ejection fraction). ...IRONMAN was open-label and did not mask the use of intravenous iron (a brown solution).
Aims
Admission rates for acute decompensated heart failure (HF) declined during the COVID‐19 pandemic. However, the impact of this reduction on hospital mortality is unknown. We describe temporal ...trends in the presentation of patients with acute HF and their in‐hospital outcomes at two referral centres in London during the COVID‐19 pandemic.
Methods and results
A total of 1372 patients hospitalized for HF in two referral centres in South London between 7 January and 14 June 2020 were included in the study and their outcomes compared with those of equivalent patients of the same time period in 2019. The primary outcome was all‐cause in‐hospital mortality. The number of HF hospitalizations was significantly reduced during the COVID‐19 pandemic, compared with 2019 (P < 0.001). Specifically, we observed a temporary reduction in hospitalizations during the COVID‐19 peak, followed by a return to 2019 levels. Patients admitted during the COVID‐19 pandemic had demographic characteristics similar to those admitted during the equivalent period in 2019. However, in‐hospital mortality was significantly higher in 2020 than in 2019 (P = 0.015). Hospitalization in 2020 was independently associated with worse in‐hospital mortality (hazard ratio 2.23, 95% confidence interval 1.34–3.72; P = 0.002).
Conclusions
During the COVID‐19 pandemic there was a reduction in HF hospitalization and a higher rate of in‐hospital mortality. Hospitalization for HF in 2020 is independently associated with more adverse outcomes. Further studies are required to investigate the predictors of these adverse outcomes to help inform potential changes to the management of HF patients while some constraints to usual care remain.
Temporal trends in heart failure admission and adjusted Kaplan–Meier curves for in‐hospital mortality during the COVID‐19 pandemic.
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