Carcinoid Heart Disease Management: A Multi-Disciplinary Collaboration.

Carcinoid heart disease (CaHD) is an important complication among patients with metastatic neuroendocrine tumors and carcinoid syndrome (CS). CS patients (25%-65%) eventually develop CaHD; these patients face a significantly increased risk of morbidity and mortality. Guidance papers (eg, clinical practice guidelines, consensus guidelines, and expert statements) have been established by major organizations across the disciplines of cardiology and oncology; however, these recommendations are not routinely implemented. The aim of this article is to encourage the integration of current recommendations from national societies into clinical practice. Early screening upon recognition of CS and prior to the development of CaHD symptoms is paramount, as no existing therapies are approved to reverse the fibrotic damage to the heart once it occurs. Valvular replacement is the only definitive treatment for CaHD once it has developed. When patients are noted to have urinary 5-hydroxyindoleacetic acid (5-HIAA) levels ≥300 µmol/24 h and/or serum N-terminal pro B-type natriuretic peptide (NT-proBNP) levels >260 pg/mL, echocardiography is recommended. Systemic approaches to control tumor growth and hormonal secretion include somatostatin analogs (SSAs), followed by options including peptide receptor radiotherapy (PRRT), everolimus and liver embolization. Telotristat is the primary choice for control of diarrhea refractory to SSA. Diuretics are the mainstay of heart failure symptom management for patients who develop CaHD. Considerations for future research are discussed, including the ongoing TELEHEART (TELotristat Ethyl in a HEART biomarker study) trial involving telotristat and not yet activated CHARRT (Carcinoid Heart disease And peptide Receptor Radiotargetted Therapy) study involving PRRT with lutetium 177 (177Lu) dotatate.

Anemia in Cardiovascular Disease: Marker of Disease Severity or Disease-modifying Therapeutic Target?

PURPOSE OF THE REVIEW: In this review paper, we examine the latest evidence regarding the use of iron supplementation, erythropoiesis-stimulating agents (ESAs), and blood transfusions as therapeutic targets for anemia to mitigate morbidity and mortality in patients with cardiovascular disease. RECENT FINDINGS: Intravenous ferric carboxymaltose (FC) injections in heart failure (HF) have resulted in improved self-reported patient symptoms; higher exercise capacity, as measured by 6-min walk test distance in anemic patients; and lower re-hospitalization rates in iron deficient patients. Darbepoetin alfa has shown evidence of improved Kansas City Cardiomyopathy Questionnaire scores. No mortality benefits have been noted thus far with FC injections or darbepoetin in HF, with an increase in adverse events with darbepoetin. Aggressive transfusions (Hg < 10 g/dL) are not associated with improved outcomes in cardiovascular disease. Quality of life metrics, rather than mortality, appear to improve with IV FC and ESA use in HF. More studies are required to see if these treatments have a role in coronary artery disease. Current evidence suggests that anemia is a marker of underlying disease severity, with a limited role in disease modification. Further studies are required to solidify our understanding of this topic.

Interventional Strategies in Cancer-induced Cardiovascular Disease.

PURPOSE OF REVIEW: To highlight the range of illnesses and procedures that the interventional onco-cardiologists face in their daily practice, along with the recent additions to anti-cancer therapies and their related cardiotoxicity. RECENT FINDINGS: Immune checkpoint inhibitors (ICI) are not devoid of cardiotoxicity as thought earlier and lead to an increased incidence of myocarditis. Transcatheter valve replacement has been shown to be a safer alternative to surgical replacement in cancer patients. Interventional onco-cardiology is a novel field that addresses cardiovascular diseases in the setting of cancer. Traditionally excluding cancer patients from clinical trials has led to a dearth of information needed to tackle cardiac conditions like Takotsubo cardiomyopathy, malignant pericardial effusions, and radiation-induced vascular diseases encountered either exclusively or predominantly in this high-risk population. This review discusses the various treatment options available in the interventional armamentarium with a particular focus on ICI-myocarditis and transcatheter aortic valve replacement in cancer patients.

Prevalence of pulmonary hypertension in myelofibrosis.

Pulmonary hypertension (PH) has been described in myelofibrosis (MF), but it is rare and typically found in advanced disease. Although the etiology of PH in MF is unclear, early predictors may be detected by echocardiogram. The goals of our study were to evaluate the prevalence of PH as determined by echocardiography in a cohort of MF patients and to identify clinical risk factors for PH. We performed a retrospective review of MF patients from October 2015 to May 2017 at MD Anderson Cancer Center in the ambulatory clinic, and those with echocardiogram were included. Clinical, echocardiographic, and laboratory data were reviewed. Patients with and without PH were compared using a chi-square or Fisher's exact test, and logistic regression was performed with an outcome variable of PH. There were 143 patients with MF who underwent echocardiogram, and 20 (14%) had echocardiographic findings consistent with PH. Older age, male gender, hypertension, hyperlipidemia, coronary artery disease, dyspnea, hematocrit, brain natriuretic peptide (BNP), and N-terminal prohormone BNP (NT-proBNP) were significantly different between those without PH and those with PH (p < 0.05). Female gender was protective (OR 0.21, 95% CI 0.049-0.90, p = 0.035), and NT-proBNP was a significant clinical predictor of PH (OR 1.07, CI 1.02 = 1.12, p = 0.006). PH in MF is lower than previously reported in our MF cohort, but many patients had cardiac comorbidities. PH due to left-sided heart disease may be underestimated in MF. Evaluation of respiratory symptoms and elevated NT-proBNP should prompt a baseline echocardiogram. Early detection of PH with a multidisciplinary approach may allow treatment of reversible etiologies.

Cardiovascular manifestations of Erdheim-Chester disease.

INTRODUCTION: Erdheim-Chester disease is a rare, multisystem hematologic disease. Cardiovascular involvement is seen in patients with Erdheim-Chester disease and can lead to increased morbidity and mortality. In this series, we report various cardiovascular manifestations of patients with Erdheim-Chester disease. METHODS: This study includes patients with Erdheim-Chester disease who were referred to our institution from 12/3/2009 through 12/13/2017. All patients had biopsy-proven Erdheim-Chester disease. Clinical data, multimodality imaging, and cardiac tests were reviewed. RESULTS: Cardiovascular findings in 24 patients with Erdheim-Chester disease were included in the study. We reviewed available transthoracic echocardiograms, whole body PET/CT scans, and CMR studies. Most patients were male and mean age at the time of diagnosis was 58 years. Pericardial involvement (13%), myocardial infiltration (25%), endocardial involvement (4%), valvular disease (17%), aortic/vascular disease (17%), conduction system infiltration (8%), and coronary artery disease (25%) were present. At a median follow-up of 5.5 years, mortality was 17%. CONCLUSIONS: Erdheim-Chester disease can involve various cardiovascular structures and is frequently diagnosed on an imaging modality. Some patients had asymptomatic involvement, but others presented with ischemic heart disease, heart failure, valvular disease, and conduction system abnormalities. Early recognition of cardiovascular involvement of Erdheim-Chester disease is needed because of high morbidity and mortality.

Carcinoid Heart Disease: a Comprehensive Review.

PURPOSE OF REVIEW: Carcinoid heart disease is a rare disorder that is associated with significant morbidity and mortality. In this review of the literature, we will present current concepts in diagnosis and management of carcinoid heart disease. RECENT FINDINGS: Recent expert consensus guidelines highlight the role of echocardiography and screening with NT-proBNP for the evaluation of carcinoid heart disease. Advances in medical therapy along with better surgical outcomes highlight the experience and expertise that has been gained in the treatment of carcinoid heart disease. Carcinoid heart disease occurs in patients with neuroendocrine tumors who have carcinoid syndrome. Serotonin appears to play a central role in the development of carcinoid heart disease. Cardiac biomarkers and multimodality imaging can be used to aid in screening and diagnosis. The mainstay of treatment of carcinoid heart disease is surgery.

Chemotherapeutic Agents and the Risk of Ischemia and Arterial Thrombosis.

PURPOSE OF REVIEW: Numerous chemotherapeutic agents have been associated with the development of ischemia and arterial thrombosis. As newer therapies have been developed to treat cancer, some of these chemotherapy drugs have been implicated in the development of vascular disease. In this review, we will summarize the most common chemotherapeutic drug classes that may play a role in the development of ischemic heart disease. RECENT FINDINGS: Angiogenesis inhibitors, alkylating agents, antimetabolites, antimicrotubules, and proteasome inhibitors have a number of cardiovascular toxicities. The possible mechanisms of action of these drugs leading to ischemic complications are varied but include endothelial dysfunction, platelet aggregation, reduced levels of nitrous oxide (NO), and elevated levels of reactive oxygen species (ROS), and vasospasm. While some drugs act through multiple pathways that result in the development of ischemic heart disease, others such as the antimetabolites and antimicrotubules appear to primarily cause vasospasm. Furthermore, while aromatase inhibitors increase the risk of heart disease in comparison to tamoxifen in large studies, this finding likely occurs because of a protective role of tamoxifen on cardiovascular risk factors rather than a direct effect of aromatase inhibitors. Angiogenesis inhibitors, alkylating agents, antimetabolites, antimicrotubules, and proteasome inhibitors can lead to ischemic complications in patients with cancer. Many of these drugs have proven to be effective in improving cancer prognosis, but their possible cardiovascular effects have to be carefully monitored and treated. Treatment of ischemic complications in the setting of cancer therapy should focus on the optimal medical management of known cardiovascular risk factors and follow an evidence-based approach.

Radiation-Induced Cardiovascular Disease.

PURPOSE OF REVIEW: Thoracic radiation therapy is an effective treatment for several malignancies, such as Hodgkin's lymphoma and breast cancer. Over the years, however, the incidence of cardiovascular events has increased in these patients, notably in younger survivors who do not have traditional risk factors. This review summarizes the pathology, incidence, clinical presentation, and management of cardiac events after radiation therapy. RECENT FINDINGS: Mediastinal radiation therapy accelerates the atherosclerosis process, resulting in early onset coronary artery disease. Valvular disease due to radiation therapy typically affects the left-sided valves, with aortic regurgitation being the most common. Rarely, it may lead to aortic stenosis requiring surgical interventions. Pericardial involvement includes acute and chronic pericardial disease and pericardial effusion. New studies are investigating the prevalence and pathogenesis of autonomic dysfunction in cancer survivors who have undergone mediastinal and neck radiation. Radiation therapy itself causes vascular endothelial dysfunction, resulting in clinical cardiovascular events, manifesting many years after completion of therapy. There remains little guidance regarding screening and therapies to prevent cardiovascular events in this population.

Predictors of left ventricular systolic function recovery in the setting of sinus tachycardia in patients with cancer.

OBJECTIVES: To identify unique echocardiographic features that could be used to reliably predict LVEF recovery upon resolution of sinus tachycardia in patients with cancer. BACKGROUND: Sinus tachycardia may be a manifestation of underlying cardiomyopathy or can lead to a reversible form of dilated cardiomyopathy known as tachycardia-mediated cardiomyopathy. While distinguishing the two can be challenging, predicting recovery regardless of cause can be of significant clinical importance in the cancer population. METHODS: Results of echocardiograms performed were collected. Patients with a repeat echocardiogram within 6 months of the initial echocardiogram were included. Patients with structural heart disease, acute coronary syndrome, sepsis, and pericardial disease were excluded. A comparison between baseline echocardiogram and subsequent echocardiogram was made to determine whether specific echocardiographic parameters predicted LVEF recovery. Two groups of patients were defined at the outset of the study. The recovered group was comprised of patients with reduced LVEF in the setting of sinus tachycardia and normal LVEF with resolution of tachycardia to normal sinus rhythm (NSR). The unrecovered group was comprised of subjects with low LVEF in the setting of both sinus tachycardia and NSR. RESULTS: A total of 40 patients were included in the study. LVEF in the recovered group (n=18) was 42.8% with sinus tachycardia and increased to 58.3% with NSR. Average LVEF in the unrecovered group (n=22) was 35.1% with tachycardia and improved to 38.5% with NSR. Medial TDI (E') was significantly greater in the recovered group with both tachycardia (7.95 cm/s versus 4.56 cm/s, P<.001) and NSR (8.11 cm/s versus 5.13 cm/s, P<.001). Similarly, lateral TDI (E') was significantly greater in the recovered group than in the unrecovered group during tachycardia (8.97 cm/s versus 5.13 cm/s, P<.001) and NSR (9.05 cm/s versus 5.13 cm/s, P<.001). Multivariable logistic regression analysis showed that medial TDI >6.5 cm/s (OR=30.9, P=.001) and lateral TDI >7.8 cm/s (OR=52.5, P=.002) are positively associated with the probability of LVEF recovery. CONCLUSIONS: In conclusion, TDI (medial E'>6.5 cm/s; lateral E'>7.8 cm/s) appears to predict LVEF recovery in patients with sinus tachycardia upon resolution of the tachycardia in patients with cancer.

Extensive Painless Aortic Dissection in a Patient With Breast Cancer.

This case illustrates the unusual clinical presentation and natural progression of type A aortic dissection, found incidentally on echocardiogram in a patient with breast cancer. Possible association of tyrosine kinase inhibitor with aortic dissection is reviewed in the light of this case.

Predictors of Recurrence and Survival in Cancer Patients With Pericardial Effusion Requiring Pericardiocentesis.

Aim: This study investigated the factors predicting survival and the recurrence of pericardial effusion (PE) requiring pericardiocentesis (PCC) in patients with cancer. Materials and Methods: We analyzed the data of patients who underwent PCC for large PEs from 2010 to 2020 at The University of Texas MD Anderson Cancer Center. The time to the first recurrent PE requiring PCC was the interval from the index PCC with pericardial drain placement to first recurrent PE requiring drainage (either repeated PCC or a pericardial window). Univariate and multivariate Fine-Gray models accounting for the competing risk of death were used to identify predictors of recurrent PE requiring drainage. Cox regression models were used to identify predictors of death. Results: The study cohort included 418 patients with index PCC and pericardial drain placement, of whom 65 (16%) had recurrent PEs requiring drainage. The cumulative incidences of recurrent PE requiring drainage at 12 and 60 months were 15.0% and 15.6%, respectively. Younger age, anti-inflammatory medication use, and solid tumors were associated with an increased risk of recurrence of PE requiring drainage, and that echocardiographic evidence of tamponade at presentation and receipt of immunotherapy were associated with a decreased risk of recurrence. Factors predicting poor survival included older age, malignant effusion on cytology, non-use of anti-inflammatory agents, non-lymphoma cancers and primary lung cancer. Conclusion: Among cancer patients with large PEs requiring drainage, young patients with solid tumors were more likely to experience recurrence, while elderly patients and those with lung cancer, malignant PE cytology, and non-use of anti-inflammatory agents showed worse survival.

Acute coronary syndrome in patients with cancer.

INTRODUCTION: Improvement in cancer survival has led to an increased focus on cardiovascular disease as the other major determinant of survivorship. As a result, there has been an increasing interest in managing cardiovascular disease during and post cancer treatment. AREAS COVERED: This article reviews the current literature on the pathogenesis, risk factors, presentation, treatment and clinical outcomes of acute coronary syndrome (ACS) in patients with cancer. EXPERT OPINION: There is growing evidence that both medical therapy and invasive management of ACS improve outcomes in patients with cancer. Appropriate patient selection, risk stratification and tailored therapy represents the cornerstone of management in these patients.

Characteristics of infective endocarditis in a cancer population.

BACKGROUND: Infective endocarditis (IE) is more common in patients with cancer as compared with the general population. Due to an immunocompromised state, the need for invasive procedures, hypercoagulability and the presence of indwelling catheters, patients with cancer are particularly predisposed to the development of IE. OBJECTIVES: Limited information exists about IE in patients with cancer. We aimed to evaluate the characteristics of patients with cancer and IE at our tertiary care centre, including a comparison of the microorganisms implicated and their association with mortality. METHODS: A retrospective chart review of patients with cancer who had echocardiography for suspicion of endocarditis was conducted. A total of 56 patients with a confirmed diagnosis of cancer and endocarditis, based on the modified Duke criteria, were included in the study. Baseline demographics, risk factors for developing IE, echocardiography findings, microbiology and mortality data were analysed. RESULTS: Following the findings of vegetations by echocardiography, the median survival time was 8.5 months. Staphylococcus aureus was the most common organism identified as causing endocarditis. The mitral and aortic valves were the most commonly involved sites of endocarditis. Patients with S. aureus endocarditis (SAE) had a significantly poorer survival when compared with patients without SAE (p=0.0217) over the 12-month period from diagnosis of endocarditis. CONCLUSIONS: Overall survival of patients with cancer and endocarditis is poor, with a worse outcome in patients with SAE.

Delayed bolus-tracking trigger at CT correlates with cardiac dysfunction and suboptimal portovenous contrast phase.

OBJECTIVE: To assess whether delayed trigger during bolus-tracking for CT correlates with reduced heart function and suboptimal portovenous contrast phase. METHODS AND MATERIALS: Patients who underwent portovenous abdominal CT using bolus-tracking and echocardiography within 2 weeks were included and excluded if there was a non-standard contrast injection. The bolus trigger time (BTT) at 100 Hounsfield units in the abdominal aorta, patient age, congestive heart failure (CHF) history, and ejection fraction were recorded. Two radiologists scored the liver contrast phase (1-5, 5 being an optimal portovenous phase). When applicable, the BTT and contrast score of the most recent comparison examination with equivalent technical parameters were also recorded. Simple linear regression (univariate) was used to test for associations with trigger time. RESULTS: 114 patients with a mean age of 61 ± 15 years fulfilled criteria. The mean trigger time was 18 ± 6 s (range: 6-38 s) and the mean ejection fraction was 52 ± 12% (range: 19-69%). A longer bolus trigger had a significant correlation with reduced ejection fraction (P = 0.0018), lower hepatic contrast score (P < 0.0001), history of CHF (P = 0.0212), and older age (P = 0.0223). Contrast score differences between the study exam and available prior exams revealed score differences of 0 (n = 73), 1 (n = 15) and 2 (n = 5); these were associated, respectively, with a mean bolus trigger time difference between exams of 2 s (range, 0-6 s), 6 s (range, 1-15 s), and 11 s (range, 5-13). The P-value comparing bolus trigger time and contrast score differences was less than 0.0001. A lower ejection fraction also significantly correlated with suboptimal PV contrast phase (P < 0.0001). CONCLUSION: Delayed time to trigger during bolus-tracking for CT can indicate cardiac dysfunction and may not adequately adjust to provide an optimal portovenous contrast phase.

Rate of Progression of Aortic Stenosis in Patients With Cancer.

Patients with cancer and aortic stenosis (AS) are exposed to several factors that could accelerate the progression of AS. This study aimed to determine the cumulative incidence of AS progression and associated factors in these patients. This retrospective cohort study included patients with cancer, mild or moderate AS and at least two echocardiograms 6 months apart between 1996 and 2016 at MD Anderson Cancer Center. AS progression was defined by an increase in mean gradient of 20 mmHg or peak velocity of 2 m/s by spectral Doppler echocardiography or as requiring aortic valve replacement. Univariate and multivariable Fine-Gray models to account for the competing risk of death were used. One hundred and two patients were included and median follow-up was 7.3 years. Overall, 30 patients (29%) developed AS progression, while 48 (47%) died without it. Yearly rate of mean gradient change was 4.9 ± 3.9 mmHg and yearly rate of peak velocity change was 0.23 ± 0.29 m/s for patients who developed AS progression. In the univariate analysis, coronary artery disease (CAD), dyspnea, prevalent cyclophosphamide and beta-blocker use were associated with AS progression. In multivariable analysis, CAD and prevalent cyclophosphamide use for the time interval of more than 3 years of follow-up remained significantly associated with increased cumulative incidence of AS progression. In conclusion, patients with mild or moderate AS and cancer are more likely to die before having AS progression. AS progression is associated with CAD and prevalent cyclophosphamide use.

Detection of subclinical cardiotoxicity in sarcoma patients receiving continuous doxorubicin infusion or pre-treatment with dexrazoxane before bolus doxorubicin.

BACKGROUND: Continuous infusion of doxorubicin or dexrazoxane pre-treatment prior to bolus doxorubicin are proven strategies to protect against doxorubicin-induced cardiotoxicity. Recently, global longitudinal peak systolic strain (GLS) measured with speckle tracking echocardiography (STE) and high-sensitivity troponin T (hs-TnT) have been validated as sensitive indicators of doxorubicin-induced cardiotoxicity. Here, we asked whether changes in hs-TnT and/or GLS can be detected in patients who were treated with continuous infusion of doxorubicin or pre-treated with dexrazoxane followed by bolus doxorubicin. METHODS: Twenty-nine patients with newly diagnosed sarcoma were assigned to receive either 72-h doxorubicin infusion or dexrazoxane pre-treatment before bolus doxorubicin. Eight patients received dexrazoxane pre-treatment; eleven patients received continuous doxorubicin infusion; ten patients crossed over from continuous infusion to dexrazoxane. Bloods were collected for hs-TnT at baseline, 24 h or 72 h after initiation of doxorubicin treatment in each chemotherapy cycle. All blood samples were assayed in batch using hs-TnT kit from Roche diagnostics. 2D Echo and STE were performed before doxorubicin, after cycle 3, and at the end of chemotherapy. RESULTS: Seven patients in the cross-over group have at least one hs-TnT measurement between 5 ng/L to 10 ng/L during and after chemotherapy. Ten patients have at least one hs-TnT measurement above 10 ng/ml during and after chemotherapy (six in dexrazoxane group, three in continuous infusion group, one in cross-over group). The average hs-TnT level increases with each additional cycle of doxorubicin treatment. Eight patients had a more than 5% reduction in LVEF at the end of chemotherapy (four in dexrazoxane group, three in continuous infusion group, and one in cross-over group). Four out of these eight patients had a change of GLS by more than 15% (three in the dexrazoxane group). CONCLUSION: Elevation in hs-TnT levels were observed in more than 59% of patients who had received either continuous doxorubicin infusion or dexrazoxane pre-treatment before bolus doxorubicin. However, changes in LVEF and GLS were less frequently observed. Thus, continuous doxorubicin infusion or dexrazoxane pre-treatment do not completely ameliorate subclinical doxorubicin-induced cardiotoxicity as detected by more sensitive techniques.

Targeted Cancer Therapies With Pericardial Effusions Requiring Pericardiocentesis Focusing on Immune Checkpoint Inhibitors.

Case reports have reported immune checkpoint inhibitors (ICI), especially nivolumab, are associated with recurrent pericardial effusions. Our objective was to determine how often patients being treated with ICI develop hemodynamically significant pericardial effusion requiring pericardiocentesis compared with other cancer therapeutics and whether the survival of patients who underwent pericardiocentesis differs according to ICI use versus standard cancer therapeutics. Our institutional review board approved catheterization laboratory data collection for all pericardiocenteses performed and all patients receiving ICI from January 1, 2015 to December 31, 2017. Retrospective review of the electronic medical record was performed to identify cancer therapeutics given preceding pericardiocentesis. Log-rank analysis was performed to compare survival in patients requiring pericardiocentesis between those on ICI and those not on ICI. Overall, 3,966 patients received ICI of which only 15 pericardiocenteses were required, including 1 repeat pericardiocentesis in a patient on nivolumab. The prevalence of pericardiocentesis among patients on ICI was 0.38% (15/3,966). Eleven pericardiocenteses were performed after nivolumab infusion, 3 after pembrolizumab, and 1 after atezolizumab, with pericardiocentesis prevalences for each agent of 0.61% (11/1,798), 0.19% (3/1,560), and 0.32% (1/309), respectively. One hundred and twenty pericardiocentesis were performed on patients receiving other cancer therapeutics although no therapeutic agent was associated with more pericardiocenteses than nivolumab. In conclusion, the prevalence of hemodynamically significant pericardial effusions and ICI administration is uncommon, and survival durations after pericardiocentesis for patients receiving ICI and those not receiving ICI are similar, suggesting that frequent echocardiographic monitoring for pericardial effusions is not necessary.

The metabolic syndrome and mortality in an ethnically diverse heart failure population.

BACKGROUND: In the general population, 27% of adults have the metabolic syndrome (MetS) and is associated with increased mortality. Similar data are not available for a heart failure (HF) population. This study sought to determine the prevalence of the MetS and its effect on mortality in a HF population. METHODS AND RESULTS: Patients (n = 886) discharged from the hospital with a primary diagnosis of HF were retrospectively identified. Demographic, clinical, and laboratory data were extracted by chart review. The MetS was defined according to National Cholesterol Education Program Expert Panel criteria with a body mass index >or=30 kg/m(2) substituted for increased waist circumference. Mortality data were acquired by query of the National Death Index, with a median follow-up of 856 days. Data were available to evaluate for the presence or absence of MetS in 71% (n = 625). The prevalence of MetS in this cohort was 68%. MetS was most common in Hispanics (79%) compared with whites (70%) and blacks (61%, P = .003). Mortality was lower in those with MetS (44%) compared with those without (58%, unadjusted HR 0.67 [95% CI, 0.53-0.85]). In a fully adjusted model, there was still a significantly lower risk of mortality in those with MetS (adjusted HR 0.73 [95% CI, 0.56-0.94]). CONCLUSIONS: In a cohort hospitalized with HF, the prevalence of MetS exceeds that of the general population, and unlike the general population, MetS is associated with a lower mortality.