Patients with persistent heart failure (HF) with reduced ejection fraction (HFrEF) have a poorer prognosis than those with HF with improved ejection fraction (HFimpEF). However, data on the predictive value of echocardiographic parameters for persistent HFrEF are lacking. We retrospectively studied 443 patients who were diagnosed with HFrEF (EF ≤ 40%) during hospitalization and underwent echocardiography at the 1-year follow-up. We divided them into the 2 groups: HFimpEF (EF > 40%) and persistent HFrEF group at 1-year follow-up, and assessed the predictive value of echocardiographic parameters at discharge for persistent HFrEF. In total, 301/443 patients (68%) were diagnosed with persistent HFrEF and 142/443 (32%) with HFimpEF at the 1-year follow-up. Kaplan-Meier analysis revealed that the persistent HFrEF group had a poorer prognosis than the HFimpEF group (log-rank, P < 0.001). Receiver operating characteristic curve analysis revealed that left ventricular end-systolic diameter (LVESD) had the highest area under the curve (AUC) (0.70; 95% confidence interval [CI]: 0.64-0.75; cutoff value: 55 mm) among various echocardiographic parameters. LVESD was an independent predictor of persistent HFrEF at the 1-year follow-up (odds ratio: 1.07, 95%CI: 1.02-1.12) upon multivariable logistic regression analysis. The incidence of persistent HFrEF was higher in patients with an LVESD ≥ 55 mm than in those with an LVESD < 55 mm (81% versus 55%, Fisher's exact test, P < 0.001). In conclusion, an LVESD (≥ 55 mm) was associated with persistent HFrEF. Focusing on LVESD in daily practice may help clinicians with risk stratification for decision-making regarding management in patients with advanced HF refractory to guideline-directed medical therapy.
Abstract Deferral of percutaneous coronary intervention (PCI) for functionally insignificant stenosis, defined as fractional flow reserve (FFR) > 0.80, is associated with favorable long-term prognoses. The lower-the-better strategy for low-density lipoprotein cholesterol (LDL-C) management is an established non-angioplasty therapy to improve the clinical outcomes of patients undergoing PCI. We examined the optimal LDL-C management in cases of intermediate coronary stenosis with deferred PCI on the basis of FFR values. This observational study included 273 consecutive patients with a single target vessel and deferred PCI with an FFR > 0.80. Patients with an FFR of 0.81–0.85 (n = 93) and those with FFR > 0.85 (n = 180) were classified into the lower (< 100 mg/dL) and higher (≥ 100 mg/dL) LDL-C groups. The endpoint was major adverse cardiovascular and cerebrovascular events (MACCE), including death, non-fatal myocardial infarction, ischemic stroke, heart failure hospitalization, and unplanned revascularization. Patients with an FFR of 0.81–0.85 had a significantly higher MACCE rate than those with an FFR > 0.85 (log-rank, p = 0.003). In patients with an FFR of 0.81–0.85, the lower LDL-C group showed a significantly lower MACCE rate than the higher LDL-C group (log-rank, p = 0.006). However, the event rate did not differ significantly between the two groups in patients with FFR > 0.85 (log-rank, p = 0.84). Uncontrolled LDL-C levels were associated with higher MACCE rates in cases with deferred PCI due to an FFR of 0.81–0.85. This high-risk population for adverse cardiovascular events should receive strict LDL-C-lowering therapy.
Abstract Background The management of heart rate (HR) is crucial for improving the clinical prognosis of patients with heart failure (HF) and atrial fibrillation (AF). Tachycardia induced by AF can cause decompensation of HF and subsequent hospitalization, but guidelines do not mention a specific target HR for patients with HF and persistent AF. Indeed, the prognostic impact of HR at discharge for hospitalized patients with HF and AF is still unclear. Purpose The purpose of this study was to determine the optimal HR at discharge for improving the prognosis of hospitalized patients with HF and AF. Methods In this observational study, 334 patients with persistent AF were analyzed from a database of 1,930 consecutive patients hospitalized for HF. Patients with sinus rhythm or paroxysmal AF, those with cardiac pacemakers or other antiarrhythmic devices, and those whose HR was not recorded at discharge were excluded. Participants were divided into 4 groups based on HR at discharge, with every 10 beats per minute (bpm) increment: HR <60 bpm (N=79), 61 bpm < HR <70 bpm (N=89), 71 bpm < HR <80 bpm (N=101), and 81 bpm < HR (N=65). The association between HR at discharge and the incidence of composite death from any cause and rehospitalization due to HF was analyzed as the primary endpoint. Results The average age of participants was 78 years, and 60% were men. At discharge, the clinical profiles of patients in the 4 groups were comparable. During the median follow-up period of 356 days, the primary endpoint occurred in 133 patients (39.8%). Kaplan-Meier analysis showed a significantly higher incidence of the primary endpoint in patients with HR >81 bpm at discharge than in those with HR <60 bpm at discharge (log-rank test for trend: p=0.039, Figure A). After adjusting for diverse covariates, including the use of beta-blockers, multivariable Cox regression analysis revealed that HR >81 bpm at discharge was associated with the primary endpoint, with a hazard ratio of 1.75 (95% confidence interval: 1.03–2.98) compared to HR <60 bpm. Restricted cubic spline confirmed that HR >81 bpm at discharge was an independent predictor for the primary endpoint by a referred HR of 61 bpm (Figure B). Conclusions This observational study suggests that for better clinical outcomes, the HR at discharge for patients with HF and persistent AF should be controlled to less than 80 bpm.Figure AFigure B
Background: Hypochloremia is associated with a poor prognosis of heart failure (HF) patients. Serum chloride level is known to be affected by serum renin secretion; however, this relationship is one of the least investigated field in HF patients. Renin-angiotensin system inhibitor (RASi) is recommended as a first-line medication for HF patients with reduced left ventricular ejection fraction (LVEF), but its prognostic effect is still controversial in HF patients with preserved EF (HFpEF). Hypothesis: The prognostic benefit of RASi depends on the baseline serum chloride level in HFpEF patients. Methods: This observational study included 1,913 consecutive patients who admitted to hospital due to worsening of HF and discharged alive. After excluding patients who received regular hemodialysis and those whose LVEF <50%, 506 HFpEF patients were ultimately analyzed. They were divided into two groups by serum chloride levels at admission (Low-Chloride group: -101 mEq/L; High-Chloride group: 102- mEq/L), referred to prior reports. Death from any cause as the primary endpoint was compared between patients who received RASi at discharge and those who did not, in each chloride group. Results: During the observation period with 479 days of median follow-up, 77 (15%) died. Patients who received RASi had significantly lower mortality than those who did not, only in the Low-Chloride group (Log-rank: p=0.001, Figure ). In the multivariate Cox regression analysis with diverse covariates, the rate of risk reduction by RASi for the mortality was greater in patients in the Low-Chloride group than High-Chloride group (HR: 0.35 and 0.71, respectively). The prognostic advantages of RASi were evident in patients with low chloride level, but not in those with high chloride level at admission (P for interaction=0.027). Conclusion: In this observational study, the administration of RASi was associated with an improved prognosis of HFpEF patients only in low serum chloride level at admission.
With global aging, the number of patients with heart failure has increased markedly. Heart failure is a complex condition intricately associated with aging, organ damage, frailty, and cognitive decline, resulting in a poor prognosis. The relationship among frailty, sarcopenia, cachexia, malnutrition, and heart failure has recently received considerable attention. Although these conditions are distinct, they often exhibit a remarkably close relationship. Overlapping diagnostic criteria have been observed in the recently proposed guidelines and position statements, suggesting that several of these conditions may coexist in patients with heart failure. Therefore, a comprehensive understanding of these conditions is essential, and interventions must not only target these conditions individually, but also provide comprehensive management strategies. This review article provides an overview of the epidemiology, diagnostic methods, overlap, and prognosis of frailty, sarcopenia, cachexia, and malnutrition in patients with heart failure, incorporating insights from the FRAGILE-HF study data. Additionally, based on existing literature, this article discusses the impact of these conditions on the effectiveness of guideline-directed medical therapy for patients with heart failure. While recognizing these conditions early and promptly implementing interventions may be advantageous, further data, particularly from well-powered, large-scale, randomized controlled trials, are necessary to refine personalized treatment strategies for patients with heart failure.
Guideline-directed medical therapy (GDMT) including beta-blockers and renin-angiotensin system inhibitors is shown to reduce mortality risk in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF). However, there is little evidence about the efficacy of additional administration of mineralocorticoid receptor antagonists (MRAs) with GDMT in patients ≥80 years presenting with HF. We aimed to investigate the prognostic impact of GDMT with MRA in relation to the age of patients with HF.
