Strategic multimodal non-invasive assessment of cardiac performance in patients with heart failure.

AIMS: Although various non-invasive cardiac examinations are known to be predictive of long-term outcomes in patients with heart failure (HF), combining them properly would provide synergism. We aimed to show that non-invasive cardiac assessments targeting left ventricular filling pressure (LVFP), left atrial remodelling, and exercise capacity would provide better prognostication in combination. METHODS AND RESULTS: This prospective observational study included consecutive hospitalized stage A-C HF patients evaluated with N-terminal pro-B-type natriuretic peptide (NT-proBNP), echocardiography including two-dimensional speckle tracking, and cardiopulmonary exercise testing. According to NT-proBNP and echocardiographic semi-quantitative LVFP grading (Echo-LVFP), patients were classified into three LVFP groups: normal range of both Echo-LVFP and NT-proBNP (Group 1), normal range of Echo-LVFP but elevated NT-proBNP (Group 2), and elevated Echo-LVFP and NT-proBNP (Group 3). The adverse outcome was defined as a composite of cardiovascular death, non-fatal acute coronary syndrome, acute stroke, or HF-related hospitalization. Among 224 HF patients (mean age of 63.8 ± 11.6 years, 158 men) analysed, 160 (71.4%) had ischaemic aetiology. During the follow-up of 18.6 ± 9.8 months, event-free survival in Group 2 (n = 56, age of 65.4 ± 12.4) was better than that in Group 3 (n = 45, age of 68.5 ± 11.5) but worse than that in Group 1 (n = 123, mean age of 61.4 ± 10.5) (log-rank P < 0.001). Mechanical left atrial dysfunction (peak longitudinal strain <28%) (adjusted hazard ratio 5.69, 95% confidence interval 1.06-4.48) and limited exercise capacity (peak VO2 per +5 mL/kg/min) (adjusted hazard ratio 0.63, 95% confidence interval 0.46-0.87) were also predictable adverse outcomes. Serial addition of peak VO2 and left atrial strain to the model incrementally enhanced the predictive power of LVFP-based risk stratification for adverse outcomes. CONCLUSIONS: The combination of NT-proBNP and Echo-LVFP could be used to predict adverse outcomes in patients with HF of various stages. Left atrial mechanics and exercise capacity are incremental to prognostication. Non-invasive test findings could be strategically combined to provide an integrative profile of cardiac performance.

Outcomes of Direct Oral Anticoagulants in Patients With Mitral Stenosis.

BACKGROUND: Patients with mitral stenosis and atrial fibrillation (AF) require anticoagulation for stroke prevention. Thus far, all studies on direct oral anticoagulants (DOACs) have excluded patients with moderate to severe mitral stenosis. OBJECTIVES: The aim of this study was to validate the efficacy of DOACs in patients with mitral stenosis. METHODS: The study population was enrolled from the Health Insurance Review and Assessment Service (HIRA) database in the Republic of Korea, and it included patients who were diagnosed with mitral stenosis and AF and either were prescribed DOACs for off-label use or received conventional treatment with warfarin. The primary efficacy endpoint was ischemic strokes or systemic embolisms, and the safety outcome was intracranial hemorrhage. RESULTS: A total of 2,230 patients (mean age 69.7 ± 10.5 years; 682 [30.6%] males) were included in the present study. Thromboembolic events occurred at a rate of 2.22%/year in the DOAC group, and 4.19%/year in the warfarin group (adjusted hazard ratio for DOAC: 0.28; 95% confidence interval: 0.18 to 0.45). Intracranial hemorrhage occurred in 0.49% of the DOAC group and 0.93% of the warfarin group (adjusted hazard ratio for DOAC: 0.53; 95% confidence interval: 0.22 to 1.26). CONCLUSIONS: In patients with AF accompanied with mitral stenosis, DOAC use is promising and hypothesis generating in preventing thromboembolism. Our results need to be replicated in a randomized trial.