Relationship between left atrial functions and ambulatory blood pressure variability in patients with heart failure and preserved ejection fraction.

Aim    The aim of this study was to investigate the relationship between left atrial (LA) abnormalities and ambulatory blood pressure variability (BPV) in heart failure with preserved ejection fraction (HFpEF) patients.Material and methods    In this single-center, prospective study, we included 187 patients with HFpEF. Eighteen patients with poor image quality were excluded from the study. BPV was evaluated using 24-h ambulatory blood pressure (BP) monitoring. The standard deviation of systolic BP (SBP-SD) was calculated to assess BPV. The patients were classified into two groups according to median SBP-SD (10.5 mm Hg).Results    Overall, 169 HFpEF patients (69.2% women, mean age 69.2±11 yrs) were evaluated. There were 98 patients (57.9%) with a SBP-SD greater than 10.5 mm Hg. Patients with higher SPB-SD had significantly higher left atrial stiffness (LASt) and lower LA reservoir strain (LASr) than those with low SPB-SD. LASt was correlated with 24 hr SBP-SD in both sinus rhythm (r= 0.35, p= 0.015) and atrial fibrillation patients (r= 0.32, p= 0.005). There were significant correlations between night-time SBP-SD and LASr (r=-0.23, p=0.045) in HFpEF with sinus rhythm. For all HFpEF patients, multiple regression analyses showed that 24-hr SBP-SD was correlated with LASt (coeff.=0.40, 95%CI= 0.52-5.25, P= 0.017).Conclusions    High BPV is associated with impaired LA function, especially for LASt and LASr. This study may provide insight for larger multicenter studies to evaluate the effects on outcomes in HFpEF.

Thrombolysis in Myocardial Infarction Risk Index Predicts 1-Year Mortality in Patients with Heart Failure: An Analysis of the SELFIE-TR Study.

OBJECTIVE: Predicting outcomes is an essential part of evaluation of patients with heart failure (HF). While there are multiple individual laboratory and imaging variables as well as risk scores available for this purpose, they are seldom useful during the initial evaluation. In this analysis, we aimed to elucidate the predictive usefulness of Thrombolysis in Myocardial Infarction Risk Index (TIMI-RI), a simple index calculated at the bedside with three commonly available variables, using data from a multicenter HF registry. SUBJECTS AND METHODS: A total of 728 patients from 23 centers were included in this analysis. Data on hospitalizations and mortality were collected by direct interviews, phone calls, and electronic databases. TIMI-RI was calculated as heart rate × (age/10)2/systolic pressure. Patients were divided into three equal tertiles to perform analyses. RESULTS: Rehospitalization for HF was significantly higher in patients within the 3rd tertile, and 33.5% of patients within the 3rd tertile had died within 1-year follow-up as compared to 14.5% of patients within the 1st tertile and 15.6% of patients within the 2nd tertile (p < 0.001, log-rank p < 0.001 for pairwise comparisons). The association between TIMI-RI and mortality remained significant (OR: 1.74, 95% CI: 1.05-2.86, p = 0.036) after adjustment for other variables. A TIMI-RI higher than 33 had a negative predictive value of 84.8% and a positive predictive value of 33.8% for prediction of 1-year mortality. CONCLUSION: TIMI-RI is a simple index that predicts 1-year mortality in patients with HF; it could be useful for rapid evaluation and triage of HF patients at the time of initial contact.

Assesment of Cerebral Blood Flow Velocities with Transcranial Doppler Ultrasonography in Heart Failure Patients with Reduced Ejection Fraction.

BACKGROUND: Heart and brain interaction is a well-known entity in heart failure (HF) and left ventricular systolic dysfunction poses an increased risk for stroke and cognitive impairment. Transcranial Doppler (TCD) provides valuable information on cerebral blood flow velocities (CBFV). However, less is known about CBFV in HF patients with reduced EF. So, we aimed to evaluate CBFV by means of TCD in patients with HF and reduced ejection fraction (HFrEF). METHODS: This study included 46 HFrEF patients (mean age 65.2±11 years, mean EF 20.1±3.8%) who underwent to TCD examination. In addition, 26 healthy individuals with sinus rhythm and EF >50% were included in the study as a control group. Peak systolic, mean and end diastolic flow velocities of the both right and left middle cerebral artery (RMCA and LMCA) were analyzed. In subgroup analysis, HFrEF patients compared according to rhythm. Correlation analyses was performed in HFrEF group between EF and TCD velocities. RESULTS: The average of RMCA and LMCA peak systolic and mean flow velocities were significantly lower in HF patients than those in control group (76,06±23,7 cm/s and 48,49±16,4 cm/s in HF group vs 87,84±14,5 cm/s and 56,41±10,7 cm/s in control group, p=0,025 and p=0,016, respectively, for RMCA and 75,1±22,3 cm/s and 47,57±14.8 cm/s in HF group vs 88,73±17,7 cm/s and 57,15±12,4 cm/s in control group, p=0,009 and p=0,007, respectively, for LMCA). The average mean flow velocity of RMCA and LMCA was significantly lower in HFrEF patients with AF than HFrEF patients with sinus rhythm. (P=0.04 and P= 0.03, respectively) In correlation analysis, EF was significantly positively correlated with both LMCA and RMCA flow velocities in HFrEF group. CONCLUSION: This study showed that HFrEF patients have lower CBFV as compared to healthy controls and HFrEF patients with AF rhythm have lower CBFV compared to HFrEF with sinus rhythm which might be one of the explanations of the adverse interaction between heart and brain in HFrEF.

The association of exaggerated hypertensive response to exercise and beta-blockers use in hypertensives.

PURPOSE: An elevation in blood pressure (BP) during exercise is the normal physiological response, however an abnormally exaggerated rise in BP, in terms of hypertensive response to exercise (HRE), is seen as a prognostic factor for end-organ damage and mortality. HRE is more common in hypertensive (HT) patients and data are lacking on the effect of antihypertensive medication on HRE. In this study, we evaluated patients who underwent treadmill exercise testing (TET) to reveal the effect of antihypertensive medication on HRE. MATERIALS AND METHODS: A cohort of 2970 individuals underwent TET and data were evaluated for HRE development. HRE has been defined as a systolic BP>210 mmHg in males and >190 mmHg in females throughout the TET. To reveal the effects of antihypertensive medication on HRE, 992 HT patients were analyzed. RESULTS: HRE was observed in 11.4% (n = 113) of HT patients and 5.9% (n = 107) of non-HT individuals(p < .001). HRE was observed significantly more in males (57.6% vs. 67.3%;p = .033), and in patients with higher body mass index BMI (29.1 ± 4.5 vs. 30.3 ± 5.2;0.033). There was no significant association between medication and HRE development apart from beta-blockers. Also, gender (odds ratio:1.787; 95%CI:1.160-2.751;p = .008), BMI (odds ratio:1.070;95%CI:1.025-1.116;p = .002) and being under beta-blocker treatment (odds ratio:0.637;95%CI:0.428-0.949;p = .026) were found to be independent predictors of HRE in multivariate logistic regression analysis. CONCLUSION: HRE was associated with gender, BMI and beta-blocker use in hypertensive with male gender and higher BMI associated with higher HRE, while beta-blocker-based treatment, either mono- or combination therapy, associated with lower HRE.

Lymphocytopenia is associated with poor NYHA functional class in chronic heart failure patients with reduced ejection fraction.

OBJECTIVE: In heart failure (HF) patients, functional capacity has been demonstrated to be a marker of poor prognosis, independent of left ventricular ejection fraction (EF). Lymphocyte count is currently recognized in certain risk stratification scores for chronic HF, and severe HF is associated with lymphocytopenia. However, no data exists on the association between lymphocyte count and functional capacity in patients with stable HF. This study aimed to assess the relationship between lymphocyte count and New York Heart Association (NYHA) functional capacity in systolic HF outpatients. METHODS: The Turkish Research Team-HF (TREAT-HF) is a network which undertakes multi-center observational studies in HF. Data on 392 HF reduced ejection fraction (HFREF) patients from 8 HF centers are presented here. The patients were divided into two groups and compared: Group 1 comprised stable HFREF patients with mild symptoms (NYHA Class I-II), while Group 2 consisted of patients with NYHA Class III-IV symptoms. RESULTS: Patient mean age was 60±14 years. Lymphocyte count was lower in patients with NYHA functional classes III and IV than in patients with NYHA functional classes I and II, (0.9 [0.6-1.5]x1000 versus 1.5 [0.7-2.2]x1000, p<0.001). In multivariate logistic regression analysis, lymphocyte count (OR: 0.602, 95% CI: 0.375-0.967, p=0.036), advanced age, male gender, presence of hypertension, EF, left atrium size, systolic pulmonary artery pressure, neutrophil and basophil counts, creatinine level, and diuretic usage were associated with poor NYHA functional class in systolic HF outpatients. CONCLUSION: The present study demonstrated that in stable HFREF outpatients, lymphocytopenia was strongly associated with poor NYHA function, independent of coronary heart disease risk factors.

The use of low molecular weight heparin during pregnancy in patients with mechanical heart valves carries potential risk for valve thrombosis: a report of three cases.

Pregnancy is associated with an increased risk of valve thrombosis, hemorrhagic complications, and offspring complications in patients with metallic prosthetic heart valve (MHV). Warfarin treatment is the best regimen against thromboembolic complications, but its use in the first trimester can result in embryopathy. Low molecular weight heparin (LMWH) does not cross the placenta and has some potential advantages. However, the pharmacokinetics of LMWHs change during pregnancy, and serial monitoring of anti-Xa levels is strongly recommended. Despite this recommendation, LMWH therapy in a fixed dose is still used in pregnant women with MHV without monitoring anti-Xa activity in clinical practice. We present three cases of MHV thrombosis occurring while on therapy with LMWH during pregnancy. One of these patients showed cerebrovascular event, one presented with pulmonary edema, and one underwent reoperation for MHV thrombosis.

The Most Predictive Red Flags for Suspecting Cardiac Amyloidosis in Patients with Heart Failure with Preserved Ejection Fraction.

OBJECTIVE: Cardiac amyloidosis (CA) is a cardiomyopathy characterized by amyloid infiltration in the myocardium. Transthyretin cardiac amyloidosis (TTR-CA), commonly presenting as heart failure with preserved ejection fraction (HFpEF), was the focus of our study, which aimed to identify red flags that heighten suspicion of CA in HFpEF patients. METHODS: We prospectively included patients diagnosed with HFpEF. All patients were assessed for TTR-CA red flag features, cardiac and extra-cardiac, as outlined in the 'Diagnosis and Treatment of Cardiac Amyloidosis: A Position Statement of the European Society of Cardiology.' Technetium-99m pyrophosphate (99mTc-PYP) cardiac scintigraphy was performed in 167 HFpEF patients suspected of having TTR-CA. Patients testing positive and negative for TTR-CA were compared based on these red flag features. RESULTS: Out of 167 HFpEF patients, 19 (11.3%) were diagnosed with TTR-CA. In the TTR-CA group, 17 (89.5%) patients were 65 years or older. The presence of three or more red flags differentiated the TTR-CA positive and negative groups (P = 0.040). Features such as low voltage and pseudo infarct patterns were more prevalent in the TTR-CA group (P < 0.001 and P < 0.048, respectively). Left ventricular global longitudinal strain (LV-GLS) was lower in the TTR-CA positive group (P < 0.001). Multivariate analysis identified four variables-older age, pseudo infarct pattern, low/decreased QRS voltage, and LV-GLS-as strong, independent predictors of TTR-CA, with significant odds ratios (ORs) of 7.8, 6.8, 16.9, and 1.2, respectively. CONCLUSION: In this study, TTR-CA etiology occurs in approximately one in every ten HFpEF patients. The presence of three or more red flags increases the likelihood of TTR-CA. Older age, pseudo infarct pattern, low/decreased QRS voltage, and reduced LV-GLS are the most significant red flags indicating TTR-CA in HFpEF patients.

The 6-minute walk test and fall risk in patients with heart failure: A cross-sectional study.

BACKGROUND: Given the increased risk of falls in patients with heart failure (HF), there is limited information in the literature about the possible relationship between fall risk and functional capacity. OBJECTIVE: To investigate the relationship between functional capacity and fall risk in patients with HF and to determine whether there are differences in clinical parameters between patients with and without fall risk. METHODS: The study included 64 patients with HF. The Activity-Specific Balance Confidence Scale (ABC) determined the fall risk. Functional capacity was assessed with the 6-minute walk test (6MWT). The Berg Balance Scale (BBS), the timed up-and-go test (TUG), and the five times sit-to-stand (5-STS) test were used to evaluate functional balance and mobility. Comorbidities and dyspnea perception were assessed with the Charlson Comorbidity Index (CCI) and modified Medical Research Council (mMRC), respectively. RESULTS: The 6MWT was associated with fall risk in logistic regression with an odds ratio of 0.979 (0.970-0.989, p < 0.001). Furthermore, the 6MWT had a discriminative value for increased fall risk in patients with HF, with a cutoff value of 248 m. Patients with increased fall risk had lower 6MWT distance, BBS, and gait speed, and higher CCI and mMRC, number of falls, duration of TUG and 5STS compared to patients with no increased fall risk (p < 0.05). CONCLUSIONS: The study results demonstrated that 6MWT may be a clinically useful tool in quickly identifying potential balance problems and increased fall risk by providing insight into fall risk/balance confidence in addition to assessing functional capacity.

Association of Pan Immune-Inflammation Value with Long Term Outcomes of Acute Decompensated Heart Failure. / Associação do Valor Pan-Imune-Inflamatório com Desfechos de Longo Prazo na Insuficiência Cardíaca Agudamente Descompensada.

BACKGROUND: Although there have been significant improvements in the treatment of heart failure (HF) in recent decades, its prognosis remains poor. Although there are many biomarkers that can help predict the prognosis of patients with HF, there is a need for simpler, cheaper, and more easily available biomarkers. OBJECTIVE: To evaluate the predictive value of pan-immune-inflammation value (PIV) in patients with acute decompensated HF. METHODS: We analyzed 409 patients with HF with reduced ejection fraction who were hospitalized for acute decompensated HF. Patients were divided into 3 groups according to tertiles of PIV: tertile 1 (PIV < 357.25), tertile 2 (PIV ≥ 357.25 and < 834.55), and tertile 3 (PIV ≥ 834.55). P values < 0.05 were considered statistically significant. Kaplan-Meier curves and Cox proportional hazards regression models were used to evaluate the association between PIV and all-cause mortality. The primary outcome was 5-year all-cause mortality, and the secondary outcomes were in-hospital 30 days,, 180-day, and 1-year all-cause mortality. RESULTS: We showed that higher PIV value was associated with both primary and secondary outcomes. The Kaplan-Meier curve showed that patients with higher PIV values had an increased risk of short- and long-term all-cause mortality (log-rank p < 0.001). In the multivariate analysis, PIV was identified as an independent predictor of long-term all-cause mortality in patients with acute decompensated HF, and we observed a 1.96-fold increase in the hazard of an event (odds ratio: 1.96, 95% confidence interval: 1.330 to 2.908, p = 0.001). CONCLUSIONS: Our study showed that the novel biomarker PIV can be used as a predictor of prognosis in patients with acute decompensated HF.

FUNDAMENTO: Embora tenha havido melhorias significativas no tratamento da insuficiência cardíaca (IC) nas últimas décadas, seu prognóstico permanece desfavorável. Embora existam muitos biomarcadores que podem ajudar a prever o prognóstico de pacientes com IC, há necessidade de biomarcadores mais simples, menos dispendiosos e mais facilmente disponíveis. OBJETIVO: Avaliar o valor preditivo do valor pan-imune-inflamatório (PIV, do inglês pan-immune-inflammation value) em pacientes com IC agudamente descompensada. MÉTODOS: Analisamos 409 pacientes com IC com fração de ejeção reduzida internados por IC aguda descompensada. Os pacientes foram divididos em 3 grupos de acordo com os tercis de PIV: tercil 1 (PIV < 357,25), tercil 2 (PIV ≥ 357,25 e < 834,55) e tercil 3 (PIV ≥ 834,55). Foram considerados estatisticamente significativos valores de p < 0,05. Curvas de Kaplan-Meier e modelos de regressão de riscos proporcionais de Cox foram utilizados para avaliar a associação entre PIV e mortalidade por todas as causas. O desfecho primário foi mortalidade por todas as causas em 5 anos, e o desfecho secundário compreendeu a mortalidade por todas as causas intra-hospitalar em 30 dias, em 180 dias e em 1 ano. RESULTADOS: Mostramos que valores mais elevados de PIV estavam associados a desfechos primários e secundários. A curva de Kaplan-Meier mostrou que pacientes com valores mais elevados de PIV apresentaram risco aumentado de mortalidade por todas as causas em curto e longo prazo (log-rank p < 0,001). Na análise multivariada, o PIV foi identificado como um preditor independente de mortalidade por todas as causas em longo prazo em pacientes com IC aguda descompensada, e observamos um aumento de 1,96 vezes no risco de um evento (razão de chances: 1,96; intervalo de confiança de 95%: 1,330 a 2,908; p = 0,001). CONCLUSÕES: Nosso estudo mostrou que o novo biomarcador PIV pode ser usado como preditor de prognóstico em pacientes com IC aguda descompensada.

[Current Use of Sodium Glucose Co-transporter 2 Inhibitors in Heart Failure Therapy]. / Kalp Yetersizligi Tedavisinde Sodyum Glukoz Ko-transporter 2 Inhibitörlerinin Güncel Kullanimi.

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) inhibit urinary glucose and sodium reabsorption in the proximal tubule of the nephron and result in glucosuria, natriuresis and diuresis. In patients with T2DM who have atherosclerotic cardiovascular (CV) disease or CV risk factors, SGLT2is have been shown to reduce major CV events and heart failure (HF) hospitalization. The greatest and most consistent effect of SGLT2is in these trials was found to be reduction in HF hospitalization, which raised the possibility of clinical benefit of SGLT2i in HF patients. In DAPA-HF and EMPEROR-Reduced trials in HFrEF patients with or without T2DM, SGLT2is, dapagliflozin and empagliflozin treatment on top of standard HF therapy has been shown to have clear clinical benefit in reducing primary endpoint of CV mortality or HF hospitalization and improving quality of life. Recently published EMPEROR-Preserved and DELIVER trials showed that SGLT2is were also very effective in the treatment of HFpEF (EF >40%). Furthermore, SGLT2is have also been shown to have potential in improving clinical outcomes in hospitalized acute HF patients in EMPULSE and DICTATE-AHF trials. All of this evidence has changed guidelines recommended therapies, not only for HFrEF but also for HFpEF treatment. The aim of this article is to provide a comprehensive overview focused on the role of SGLT2i in the treatment of HF based on the recent evidence.

Patient Perception, Knowledge and Adaptation in The Management of Heart Failure: A Multicenter, Cross-Sectional, Observational, Questionnaire-Based Study: ADAPTATION HF.

OBJECTIVE: The aim of this study is to reveal the perception levels of heart failure (HF) patients about the disease, their adaptation to the disease process, their compliance with the treatment, and their knowledge and thoughts about the disease from the patient's perspective. METHOD: Patients with a diagnosis of HF for at least 6 months who applied to the cardiology clinics of 10 different centers were included in this cross-sectional, multicenter and questionnaire-based study. A questionnaire consisting of sections that included demographic information, evaluation of the patient's symptoms, knowledge and experience of clinical follow-up, knowledge of HF, compliance and awareness of treatment was applied to the patients. RESULTS: 504 patients with a mean age of 59.8 ± 14.9 years (M/F: 360/144, 71.4%/28.6%) were included in the study. 61.2% of the patients stated that they knew about HF disease before. Most of the patients knew that the complaints of shortness of breath, fatigue and palpitation could develop due to HF (95.4%; 92.7%; 89.7%, respectively). The patients reported that they were mostly worried about not being able to provide their own self-care without the support of another person (67.5%). While the majority of patients (37.6%) thought that the worst disease was to have a cerebrovascular disease; only 10.9% stated that HF was the worst disease. While 98.8% of the patients stated that they used HF drugs regularly, a relatively large part of the patients did not know that the drugs were effective on kidney functions (68.5%) and blood pressure (76.9%). In the daily practice of the patients, the rate of weight follow-up was 35.5%, the rate of blood pressure monitoring was 26.9%, and the rate of patients who exercised was 27%. Among the patients, 73.3% said that they pay attention to the amount of salt they take with diet, and 33.5% have a completely salt.free diet. There was no difference between the groups with low and high knowledge scores in terms of Pittsburgh Sleep Quality Index (P > 0.005). The knowledge level score was significantly higher in patients with previous myocardial infarction (P = 0.002). CONCLUSION: Most of the HF patients participating in the study are aware of the signs and symptoms of HF, follow the recommendations of their physicians, and use drugs regularly. These patients should have more information about blood pressure monitoring, weight monitoring, diet and sodium restriction, exercise, which are included in the non-pharmacological part of treatment management.

Current barriers and recommendations on the diagnosis of transthyretin amyloid cardiomyopathy: a Delphi study.

Objectives: This study has been conducted to investigate the non-invasive diagnostic journey of patients with a transthyretin amyloid cardiomyopathy (aTTR-CM) in Turkey, identify the challenges and uncertainties encountered on the path to diagnosis from the perspectives of expert physicians, and develop recommendations that can be applied in such cases. Methods: This study employed a three-round modified Delphi method and included 10 cardiologists and five nuclear medicine specialists. Two hematologists also shared their expert opinions on the survey results related to hematological tests during a final face-to-face discussion. A consensus was reached when 80% or more of the panel members marked the "agree/strongly agree" or "disagree/strongly disagree" option. Results: The panelists unanimously agreed that the aTTR-CM diagnosis could be established through scintigraphy (using either 99mTc-PYP, 99mTc-DPD, or 99mTc-HMPD) in a patient with suspected cardiac amyloidosis (CA) without a further investigation if AL amyloidosis is ruled out (by sFLC, SPIE and UPIE). In addition, scintigraphy imaging performed by SPECT or SPECT-CT should reveal a myocardial uptake of Grade ≥2 with a heart-to-contralateral (H/CL) ratio of ≥1.5. The cardiology panelists recommended using cardiovascular magnetic resonance (CMR) and a detailed echocardiographic scoring as a last resort before considering an endomyocardial biopsy in patients with suspected CA whose scintigraphy results were discordant/inconclusive or negative but still carried a high clinical suspicion of aTTR-CM. Conclusion: The diagnostic approach for aTTR-CM should be customized based on the availability of diagnostic tools/methods in each expert clinic to achieve a timely and definitive diagnosis.

Expert Recommendations to Bridge Gaps in Heart Failure Patient Support in the Middle East and Africa Region.

Heart failure (HF) remains a serious health and socioeconomic problem in the Middle East and Africa (MEA). The age-standardized prevalence rate for HF in the MEA region is higher compared to countries in Eastern Europe, Latin America, and Southeast Asia. Also cardiovascular-related deaths remain high compared to their global counterparts. Moreover, in MEA, 66% of HF readmissions are elicited by potentially preventable factors, including delay in seeking medical attention, nonadherence to HF medication, suboptimal discharge planning, inadequate follow-up, and poor social support. Patient support in the form of activation, counseling, and caregiver education has been shown to improve outcomes in patients with HF. A multidisciplinary meeting with experts from different countries across the MEA region was convened to identify the current gaps and unmet needs for patient support for HF in the region. The panel provided insights into the real-world challenges in HF patient support and contributed strategic recommendations for optimizing HF care.

Different Cardio-Selective ß-Blockers and the Prevention of Exaggerated Blood Pressure Response During Exercise: A Retrospective Cross-Sectional Study.

OBJECTIVE: The aim of this study was to analyze the role of various ß-blockers in managing exercise-induced blood pressure escalations, referred to as exaggerated blood pressure response (eBPR). Despite the importance of this phenomenon, there is limited data on the efficacy of ß-blockers in controlling eBPR. METHOD: Our retrospective cohort for this study comprised 2,803 individuals who underwent treadmill tests from January 2016 to February 2018. A further subgroup analysis of 1,258 patients receiving ß-blocker treatment was performed to evaluate the influence of different ß-blockers on eBPR. RESULTS: The results demonstrated that ß-blockers play a significant role in mitigating the occurrence of eBPR (P = 0.026), irrespective of the specific type of ß-blocker. Additionally, no significant variance was observed in the development of eBPR among the different ß-blocker groups (P = 0.532 for systolic blood pressure (BP); P = 0.068 for diastolic BP). This finding remained consistent even among the 992 hypertensive patients, where no notable association was found between the type of ß-blocker and the development of eBPR (P = 0.736 for systolic BP; P = 0.349 for diastolic BP). It is noteworthy that patients using ß-blockers had unique clinical and demographic attributes. CONCLUSION: Our study suggests that ß-blockers can potentially deter the development of eBPR during physical activity, a benefit that is consistent across all types of ß-blockers. The study sheds light on prospective randomized studies on the use of eBPR as a new treatment target.

Heart failure in Europe: Guideline-directed medical therapy use and decision making in chronic and acute, pre-existing and de novo, heart failure with reduced, mildly reduced, and preserved ejection fraction - the ESC EORP Heart Failure III Registry.

AIMS: We analysed baseline characteristics and guideline-directed medical therapy (GDMT) use and decisions in the European Society of Cardiology (ESC) Heart Failure (HF) III Registry. METHODS AND RESULTS: Between 1 November 2018 and 31 December 2020, 10 162 patients with acute HF (AHF, 39%, age 70 [62-79], 36% women) or outpatient visit for HF (61%, age 66 [58-75], 33% women), with HF with reduced (HFrEF, 57%), mildly reduced (HFmrEF, 17%) or preserved (HFpEF, 26%) ejection fraction were enrolled from 220 centres in 41 European or ESC-affiliated countries. With AHF, 97% were hospitalized, 2.2% received intravenous treatment in the emergency department, and 0.9% received intravenous treatment in an outpatient clinic. AHF was seen by most by a general cardiologist (51%) and outpatient HF most by a HF specialist (48%). A majority had been hospitalized for HF before, but 26% of AHF and 6.1% of outpatient HF had de novo HF. Baseline use, initiation and discontinuation of GDMT varied according to AHF versus outpatient HF, de novo versus pre-existing HF, and by ejection fraction. After the AHF event or outpatient HF visit, use of any renin-angiotensin system inhibitor, angiotensin receptor-neprilysin inhibitor, beta-blocker, mineralocorticoid receptor antagonist and loop diuretics was 89%, 29%, 92%, 78%, and 85% in HFrEF; 89%, 9.7%, 90%, 64%, and 81% in HFmrEF; and 77%, 3.1%, 80%, 48%, and 80% in HFpEF. CONCLUSION: Use and initiation of GDMT was high in cardiology centres in Europe, compared to previous reports from cohorts and registries including more primary care and general medicine and regions more local or outside of Europe and ESC-affiliated countries.

Left Bundle Branch Block-Induced Cardiomyopathy.

Left bundle branch block-induced cardiomyopathy is an increasingly recognized type of dilated cardiomyopathy identified in a minority but not negligible proportion of patients with newly diagnosed heart failure. However, it has not yet been included among the possible etiologies of dilated cardiomyopathies or among the unclassified cardiomyopathies. Although a few sets of diagnostic criteria have been proposed, currently there is a lack of universal consensus regarding diagnostic criteria. Some specific clinical features and electrocardiography, echocardiography, and cardiac magnetic resonance imaging findings are recommended to help physicians in the diagnosis of left bundle branch block-induced cardiomyopathy. In this review, prevalence, pathophysiological mechanisms, diagnostic criteria, diagnostic modalities, and specific features of left bundle branch block-induced cardiomyopathy have been addressed with attention to the differential diagnosis of other dilated cardiomyopathies.

Immunoadsorption therapy in refractory heart failure patients with dilated cardiomyopathy: a potential therapeutic option.

OBJECTIVE: Removal of cardiac autoantibodies by immunoadsorption might confer clinical improvement in dilated cardiomyopathy. In this pilot study, we investigated the efficacy and safety of immunoadsorption therapy in refractory heart failure patients with dilated cardiomyopathy. METHODS: This study consisted of 9 heart failure patients with dilated cardiomyopathy, NYHA III-IV, left ventricular ejection fraction <30%, unresponsive to heart failure therapy, and with cardiac autoantibodies. Patients underwent immunoadsorption therapy for five consecutive days using a tryptophan column. Changes in cardiac function (left ventricular ejection fraction, left ventricular end-diastolic diameter, left ventricular end-systolic diameter), exercise capacity (6-minute walk distance), neurohormonal (N-terminal pro-brain natriuretic peptide), proinflammatory (high-sensitive C-reactive protein), and myocardial (cardiac troponin-I), biochemical, and hematological variables were obtained at baseline and after 3 and 6 months of immunoadsorption therapy. RESULTS: Mean left ventricular ejection fraction and 6-minute walk distance significantly increased at 3 months (from 23.27±5.09 to 32.1±1.7%, p=0.01 for left ventricular ejection fraction and from 353±118 to 434±159 m, p=0.04 for 6-minute walk distance) and further increased at 6 months after immunoadsorption therapy (to 34.5±7.7%, p=0.02 for ejection fraction and to 441±136 m, p=0.04 for 6-minute walk distance). NT-proBNP level reduced from 1161(392.8-3034) to 385(116.1-656.5) ng/L (p=0.04), and high-sensitive C-reactive protein decreased from 9.74±0.96 to 4.3±5.8 mg/L (p=0.04) at 6 months. Left ventricular end-diastolic diameter (66.1±5.8 vs. 64.7±8.9 mm) and left ventricular end-systolic diameter (56.1±8.6 vs. 52.3±10.8 mm) tended to decrease but did not reach statistical significance. No significant worsening was observed in creatinine, cardiac troponin-I, and hemoglobin levels after the immunoadsorption procedure. CONCLUSION: In dilated cardiomyopathy patients with refractory heart failure, immunoadsorption may be considered a potentially useful therapeutic option to improve a patient's clinical status.

Left atrial structure and function: association with blood pressure variability in pregnant women.

BACKGROUND: The aim of this study was to investigate the relationship between left atrial (LA) abnormalities and ambulatory blood pressure variability (BPV) in pregnant women and their relationship with hypertension-related clinical outcomes in pregnancy. METHODS: This single-center, prospective study included 119 pregnant women. All participants underwent 24-h ambulatory blood pressure (BP) monitoring and echocardiographic examination before 20 weeks of gestation. BPV was evaluated using 24-h ambulatory BP monitoring. SD of the mean of SBP (SBP-SD) and DBP variability was calculated as 24-h, daytime and nighttime SBP and DBP. The patients were classified into two groups based on median 24-h SBP-SD (11.3 mmHg). LA features of the patients were compared according to the high and low BPV groups. RESULTS: One hundred and nineteen pregnant women (mean age, 28.6 ± 5.2 years) were included in the study. The mean office SBP and DBP were 108.7 ± 15.4 mmHg and 68.2 ± 10.2 mmHg, respectively. In pregnant women with high BPV, even though BP is normal, reservoir and conduit LA functions have decreased and LA stiffness has increased. Gestational hypertension and composite outcomes were more common in pregnant women with high BPV. Among the LA parameters, the most associated with composite outcome was conduit LA function. CONCLUSION: In pregnancy, higher BPV is associated with worse LA function. The LA conduit strain offers potential value in predicting hypertension-related clinical outcomes in pregnancy.

Usefulness of Age, Creatinine and Ejection Fraction - Modification of Diet in Renal Disease Score for Predicting Survival in Patients with Heart Failure. / Utilidade da Idade, Creatinina e Fração de Ejeção - Modificação da Dieta no Escore de Doença Renal para Prever a Sobrevivência em Pacientes com Insuficiência Cardíaca.

BACKGROUND: Central Illustration: Usefulness of Age, Creatinine and Ejection Fraction - Modification of Diet in Renal Disease Score for Predicting Survival in Patients with Heart Failure Summary of the study design and key findings. ACEF: Age, creatinine and ejection fraction, MDRD: Modified Diet in Renal Disease. While many risk models have been developed to predict prognosis in heart failure (HF), these models are rarely useful for the clinical practitioner as they include multiple variables that might be time-consuming to obtain, they are usually difficult to calculate, and they may suffer from statistical overfitting. OBJECTIVES: To investigate whether a simpler model, namely the ACEF-MDRD score, could be used for predicting one-year mortality in HF patients. METHODS: 748 cases within the SELFIE-HF registry had complete data to calculate the ACEF-MDRD score. Patients were grouped into tertiles for analyses. For all tests, a p-value <0.05 was accepted as significant. RESULTS: Significantly more patients within the ACEF-MDRD high tertile (30.0%) died within one year, as compared to other tertiles (10.8% and 16.1%, respectively, for ACEF-MDRD low and ACEF-MDRD med , p<0.001 for both comparisons). There was a stepwise decrease in one-year survival as the ACEF-MDRD score increased (log-rank p<0.001). ACEF-MDRD was an independent predictor of survival after adjusting for other variables (OR: 1.14, 95%CI:1.04 - 1.24, p=0.006). ACEF-MDRD score offered similar accuracy to the GWTG-HF score for predicting one-year mortality (p=0.14). CONCLUSIONS: ACEF-MDRD is a predictor of mortality in patients with HF, and its usefulness is comparable to similar yet more complicated models.

FUNDAMENTO: Figura Central: Utilidade da Idade, Creatinina e Fração de Ejeção - Modificação da Dieta no Escore de Doença Renal para Prever a Sobrevivência em Pacientes com Insuficiência Cardíaca Resumo do desenho do estudo e principais conclusões. ACEF: Idade, creatinina e fração de ejeção (Age, creatinine and ejection fraction) MDRD: Dieta Modificada em Doença Renal (Modified Diet in Renal Disease). Embora muitos modelos de risco tenham sido desenvolvidos para prever o prognóstico na insuficiência cardíaca (IC), esses modelos raramente são úteis para o clínico, pois incluem múltiplas variáveis que podem ser demoradas para serem obtidas, são geralmente difíceis de calcular e podem sofrer de overfitting estatístico. OBJETIVOS: Investigar se um modelo mais simples, nomeadamente o escore ACEF-MDRD, poderia ser usado para prever a mortalidade em um ano em pacientes com IC. MÉTODOS: 748 casos do registro SELFIE-HF tinham dados completos para calcular o escore ACEF-MDRD. Os pacientes foram agrupados em tercis para análise. Para todos os testes, um valor de p <0,05 foi aceito como significativo. RESULTADOS: Significativamente mais pacientes dentro do tercil ACEF-MDRD alto (30,0%) morreram dentro de um ano, em comparação com outros tercis (10,8% e 16,1%, respectivamente, para ACEF-MDRD baixo e ACEF-MDRD med , p<0,001 para ambas as comparações). Houve uma diminuição gradual na sobrevida em um ano à medida que o escore ACEF-MDRD aumentou (log-rank p<0,001). ACEF-MDRD foi preditor independente de sobrevida após ajuste para outras variáveis (OR: 1,14, IC95%:1,04 ­ 1,24, p=0,006). O escore ACEF-MDRD ofereceu precisão semelhante ao escore GWTG-HF para prever a mortalidade em um ano (p=0,14). CONCLUSÕES: ACEF-MDRD é um preditor de mortalidade em pacientes com IC e sua utilidade é comparável a modelos semelhantes, porém mais complicados.