The Association Between On-treatment Ambulatory Central Blood Pressure and Left Ventricular Reverse Remodeling in Heart Failure With Reduced Ejection Fraction.

Background and Objectives: Compared to office blood pressure (OBP), central blood pressure (CBP) and ambulatory blood pressure (BP) are known to be better markers for predicting cardiovascular events. We evaluated the association between left ventricular reverse remodeling (LVRR) and ambulatory CBP in heart failure with reduced ejection fraction (HFrEF). Methods: This study retrospectively analyzed 93 patients who performed ambulatory CBP and brachial BP (BBP) monitoring from 2018 to 2020 within 1 year after diagnosis of HFrEF at a single tertiary center. We analyzed the association between on-treatment ambulatory BPs and LVRR on follow-up echocardiography. Results: The mean age of participants was 59 years; 65.6% were men; mean LVEF was 29%. Ambulatory BP and follow-up echocardiography were done at 143 days (interquartile range [IQR], 64-267) and 454 days (IQR, 281-600) after diagnosis of HF, respectively. Baseline OBP was not different between 2 groups, but ambulatory systolic CBP was significantly higher in the LVRR group than the non-LVRR group (p=0.005). Systolic OBP (odds ratio [OR], 1.029; confidence interval [CI], 1.004-1.055; p=0.026), 24-hour ambulatory systolic CBP (OR, 1.048; CI, 1.015-1.082; p=0.004), and 24-hour ambulatory systolic BBP (OR, 1.049; CI,1.017-1.082; p=0.003) were associated with LVRR. Compared to ambulatory systolic CBP of 110-119 mmHg, 90-99 mmHg showed lower OR for LVRR. Conclusions: Low on-treatment ambulatory systolic CBP was closely related to a lower likelihood of LVRR in HFrEF than the normal range. Ambulatory CBP measured during treatment of patients with HFrEF appears to be useful in predicting outcomes.

Association between frailty and physical performance in older patients with heart failure.

BACKGROUND: Frailty is an issue in patients with heart failure (HF). A Korean version of the frailty scale (K-FRAIL) has been developed. HYPOTHESIS: We aimed to analyze the relationship between the K-FRAIL scale and physical performance in patients with HF. METHODS: This study included 142 patients with HF aged ≥65 years from a single center. Muscular fitness was assessed using the handgrip test and knee extensor strength measurement. Aerobic capacity was assessed using the cardiopulmonary exercise test and 6-min walk test (6MWT). Frailty was assessed using the K-FRAIL questionnaire. RESULTS: Peak VO2 and 6MWT scores significantly decreased as frailty worsened, but handgrip and knee extensor strength did not. In the multivariate analysis, peak VO2 (ß = -.31; p = .002) and 6MWT score (ß = -.38; p < .001) showed significant inverse associations with the K-FRAIL score. Based on the receiver operating characteristic curve analysis, the cut-off values of peak VO2 (hazard ratio, 5.08; p = .023) and 6MWT (hazard ratio, 3.99; p = .020) were independent predictors of frailty. CONCLUSION: In older patients with HF, physical performance correlates with the degree of frailty. The K-FRAIL scale is correlated with the peak VO2 and 6MWT.

Prevalence and clinical characteristics of primary aldosteronism in a tertiary-care center in Korea.

Approximately 29% of Korean adults have hypertension; however, the prevalence of primary aldosteronism among the hypertensive population is largely unknown. The aim of our study was to evaluate the prevalence and clinical characteristics of primary aldosteronism in a tertiary-care center in Korea. We retrospectively analyzed 1173 patients with newly diagnosed or preexisting hypertension who were referred to our tertiary-care hospital between January 2013 and December 2018. Patients were screened for primary aldosteronism with the aldosterone-renin ratio and underwent a saline infusion test for diagnostic confirmation. Adrenal computed tomography and adrenal venous sampling were performed for subtype classification for primary aldosteronism. Among the 1173 patients (mean age, 51.8 years; women, 53.2%), 360 (30.7%) had positive screening-test results, of whom 71 (6.1%) were finally diagnosed with primary aldosteronism. Conclusive subtype differentiation was made in 55 patients, of whom 15 (27%) had an aldosterone-producing adenoma, 4 (7%) had unilateral adrenal hyperplasia, and 36 (66%) had bilateral adrenal hyperplasia. Patients with primary aldosteronism had a higher ambulatory blood pressure, left ventricular mass index, and urinary albumin-to-creatinine ratio than those without. Moreover, the primary aldosteronism group had a higher prevalence of left ventricular hypertrophy and albuminuria than the non-primary aldosteronism group. Primary aldosteronism may be more common (6.1%) among Korean patients with hypertension than generally recognized. Primary aldosteronism was associated with a higher degree and prevalence of target organ damage and a higher blood pressure level. Wide application of screening tests for primary aldosteronism may be beneficial in detecting this potentially curable cause of hypertension.

Comparison of the Association Between Arterial Stiffness Indices and Heart Failure in Patients With High Cardiovascular Risk: A Retrospective Study.

Objective: Study findings of the relationship of each arterial stiffness index with incident heart failure (HF) are conflicting. We aimed to compare the association between the indices of arterial stiffness and the risk of HF. Methods: We analysed 3,034 patients from a prospective cohort that enrolled patients with high cardiovascular risk. They underwent brachial-ankle pulse wave velocity (baPWV), brachial pulse pressure (PP), carotid-femoral pulse wave velocity (cfPWV), and central PP measurements. Results: Over a median follow-up of 4.7 years (interquartile range, 3.4-5.8 years), 65 HF events occurred. The incidence rate of HF was 4.7 per 1,000 person-years [95% confidence interval (CI), 3.7-6.0]. There was no difference in baPWV in those with and without HF events (1,561 ± 401 and 1,520 ± 321 cm/s, respectively, P = 0.415); however, there was a significant difference in brachial PP (63.2 ± 16.9 vs. 52.3 ± 11.5 mmHg, P < 0.001), cfPWV (11.0 ± 3.1 vs. 9.4 ± 2.4 m/s, P < 0.001) and central PP (56.6 ± 19.9 vs. 42.9 ± 13.8 mmHg, P < 0.001). In the multivariable-adjusted model, brachial PP [hazards ratio (HR) per standard deviation unit (SDU), 1.48; 95% CI, 1.19-1.84, P < 0.001], cfPWV (HR per SDU, 1.29; 95% CI, 1.02-1.63, P = 0.032) and central PP (HR per SDU, 1.44; 95% CI, 1.17-1.78; P < 0.001) were associated with incident HF, but baPWV was not (HR per SDU, 0.83; 95% CI, 0.63-1.10; P = 0.198). In the receiver operating characteristic analysis, the area under the curve (AUC) of brachial PP (P < 0.001), cfPWV (P = 0.003) or central PP (P = 0.001) was larger than that of baPWV, and there was no difference in the AUCs of brachial PP, cfPWV and central PP. Conclusion: Among arterial stiffness indices, brachial PWV was less associated with the risk of heart failure, and brachial PP and measures representing central hemodynamics were highly associated with incident HF.

Escalation of liPid-lOwering therapy in patientS wiTh vascular disease receiving HIGH-intensity statins: the retrospective POST-HIGH study.

In this retrospective study, we investigated whether lipid-lowering therapy (LLT) escalation has clinical benefits in patients with atherosclerotic cardiovascular disease (ASCVD) and low-density lipoprotein cholesterol (LDL-C) levels of 55-99 mg/dL (1.4-2.6 mmol/L), post high-intensity. Out of 6317 Korean patients screened in 2005-2018, 1159 individuals with ASCVD and LDL-C levels of 55-99 mg/dL after statin use equivalent to 40 mg atorvastatin were included. After 1:2 propensity score matching, 492 patients (164 with LLT escalation, 328 controls without LLT escalation) were finally analysed. Primary outcome variables were major adverse cardiovascular and cerebrovascular events (MACCE) and all-cause death. At median follow-up (1.93 years), the escalation group had a lower MACCE rate (1.72 vs. 3.38 events/100 person-years; hazard ratio [HR] 0.34, 95% confidence interval [CI] 0.14-0.83; p = 0.018) than the control group. The incidence of all-cause death (0.86 vs. 1.02 events/100 person-years; HR 0.58, 95% CI 0.15-2.19; p = 0.42) and each MACCE component did not differ between groups. Kaplan-Meier curves exhibited lower risk of MACCE in the escalation group (HR 0.36, 95% CI 0.12-0.97; p = 0.040) but a difference not statistically significant in all-cause death (HR 0.30, 95% CI 0.04-2.48; p = 0.26). LLT escalation was associated with reduced cardiovascular risk, supporting more aggressive LLT in this population.

Clinical evidence of initiating a very low dose of sacubitril/valsartan: a prospective observational analysis.

Sacubitril/valsartan is superior to enalapril in reducing the risks of cardiovascular death and preventing hospitalization in patients with heart failure and reduced ejection fraction (HFrEF). However, patients often do not receive sacubitril/valsartan because of concerns about hypotension. We examined the feasibility of initiating sacubitril/valsartan at a very low dose (VLD) in potentially intolerant patients with HFrEF and subsequent dose up-titration, treatment persistence and outcomes. We analyzed 206 patients with HFrEF grouped according to starting sacubitril/valsartan dose. The VLD group (n = 106) commenced 25 mg twice daily, and the standard-dose (SD) group (n = 100) started on ≥ 50 mg twice daily. Baseline systolic blood pressure was 103 ± 12 mmHg vs. 119 ± 14 mmHg in the SD group (P < 0.001). The maximal target dose achievement rate was higher in the SD group (27.0% vs 9.4%, p = 0.001) and the VLD group experienced more dose up-titrations and fewer down-titrations than the SD group. The VLD group had a decrease in N-terminal prohormone of brain natriuretic peptide (NT-proBNP) similar to the SD group and a similar increase in left ventricular ejection fraction. There were no significant differences in symptomatic hypotension, worsening renal function, hyperkalemia, cardiovascular mortality, and rehospitalization due to HF between the two groups during follow-up period. In patients considered by the treating physician likely to be intolerant of sacubitril/valsartan, initiation with 25 mg twice daily was generally possible and patients remained in therapy, with similar decreases in NT-proBNP and increases in left ventricular ejection fraction to those observed in patients receiving SD sacubitril/valsartan.

Sacubitril/valsartan in patients with heart failure with reduced ejection fraction with end-stage of renal disease.

AIMS: Sacubitril/valsartan (SV) reduced heart failure hospitalization and cardiovascular mortality compared with enalapril in the Prospective Comparison of ARNI with ACE-I to Determine Impact on Global Mortality and Morbidity in Heart Failure trial. However, this trial excluded patients with end stage of renal disease (ESRD); thus, the efficacy and safety of SV in heart failure with reduced ejection fraction (HFrEF) with ESRD remains uncertain. METHODS AND RESULTS: We retrospectively analysed the clinical and laboratory data of 501 HFrEF patients who administered with SV from March 2017 to April 2019 in a single tertiary university hospital. A total of 23 HFrEF patients with ESRD on dialysis [58.3% non-ischaemic heart failure; left ventricular ejection fraction (LVEF): 29.7 ± 4.4%] were included in this study. At baseline and follow-up visit, we evaluated cardiovascular biomarkers such as high-sensitive troponin T (hsTnT), soluble ST2 (sST2), echocardiographic parameters, and clinical and adverse events. The mean dose of SV was 90 ± 43 mg/day at baseline and 123 ± 62 mg/day at last follow-up (follow-up duration: median 132 days). The level of hsTnT was significantly reduced from 236.2 ± 355.3 to 97.0 ± 14.0 pg/mL (P = 0.002), and the sST2 level was significantly reduced from 40.4 ± 44.0 to 19.6 ± 14.1 ng/mL (P = 0.005). LVEF was significantly improved from 29.7 ± 4.4% to 40.8 ± 10.4% (P = 0.002). During the follow-up, up-titration, down-titration, and maintenance of SV dosing were observed in 7 (30%), 5 (21.7%), and 11 patients (47.8%), respectively. SV down-titration group had adverse events including symptomatic hypotension (systolic blood pressure <100 mmHg) (n = 4) and dizziness (n = 1), but they did not discontinue SV therapy. CONCLUSIONS: We found that SV could safely reduce the hsTnT and sST2 levels and improve LVEF in HFrEF patients with ESRD. As far as we know, this is the first study to show the efficacy and safety of SV in HFrEF with ESRD on dialysis. Larger prospective, long-term follow-up study should be warranted.