Improvement in left atrial strain following ferric carboxymaltose in heart failure: an analysis of the Myocardial-IRON trial.

AIMS: Iron deficiency (ID) is associated with an impaired cardiac function and remodelling in heart failure (HF). Treatment with ferric carboxymaltose (FCM) has been showed recently to improve biventricular systolic function and ventricular strain parameters in patients with HF with reduced ejection fraction and ID, but there is no evidence on the benefit of FCM on the left atrium (LA). In this study, we aimed to evaluate the effect of FCM on LA longitudinal strain (LA-LS). METHODS AND RESULTS: This is a post hoc subanalysis of a double-blind, placebo-controlled, randomized clinical trial that enrolled 53 ambulatory patients with HF, left ventricular ejection fraction (LVEF) < 50%, and ID [Myocardial-IRON trial (NCT03398681)], treated with FCM or placebo. Cardiac magnetic resonance-featured tracking (CMR-FT) strain changes were evaluated before and 7 and 30 days after randomization using linear mixed regression analysis. The median age of the sample was 68 years (interquartile range: 64-76), and 20 (69%) were men. Mean ± standard deviation of LVEF was 39 ± 11%, and most (97%) were in stable New York Heart Association class II. At baseline, mean LA-LS was -8.9 ± 3.5%. At 30 days, and compared with placebo, LA-LS significantly improved in those allocated to FCM treatment arm (LA-LS = -12.0 ± 0.5 and -8.5 ± 0.6, respectively; - ∆ 3.55%, P < 0.001). CONCLUSIONS: In patients with stable HF, LVEF < 50%, and ID, treatment with FCM was associated with short-term improvements in LA-LS assessed by CMR-FT. Future works should assess the potential benefit of iron repletion on LA function.

Kinesiophobia and associated variables in patients with heart failure.

AIM: Patients with heart failure (HF) can exhibit kinesiophobia, an excessive, debilitating, and irrational fear of movement. The study aimed to enhance the understanding of kinesiophobia in patients with HF by analyzing associations with the following variables: musculoskeletal pain, quality of life, quality of sleep, functional capacity, disability, frailty, sex and age. METHODS AND RESULTS: In this cross-sectional study, 107 participants were included, with ages ranging from 28 to 97 years [57% men, mean age 73.18 ± 12.68 years]. Multiple regression analyses were performed with all variables, including polynomial regressions for variables with a non-linear relationship. Kinesiophobia was significantly correlated (p < .01) with musculoskeletal pain, quality of life, quality of sleep, functional capacity, disability and being at risk of frailty, while age and sex were not statistically significant. Frailty disability and musculoskeletal pain intensity were variables linearly associated with kinesiophobia, whilst quality of sleep and disability had a non-linear relationship with kinesiophobia. CONCLUSIONS: Kinesiophobia needs to be evaluated and better understood in patients with HF to improve physical activity and exercise adherence. This study found that musculoskeletal pain intensity, quality of sleep, disability and frailty risk have a significant association with kinesiophobia in patients with HF. Our results suggest multidimensional associations of kinesiophobia in patients with HF which require further examination and understanding.

Technology Usage, Physical Activity, and Motivation in Patients With Heart Failure and Heart Transplantation.

The cross-sectional study enrolled 231 patients with heart failure (n = 115; 60.87% were men; mean age, 74.34 ± 12.70 years) and heart transplantation (n = 116; 72.41% were men; mean age, 56.85 ± 11.87 years) who self-reported their technology usage, physical activity, and source of motivation for exercise. Patients with heart failure were significantly older ( P = .0001) than patients with heart transplantation. Physical activity levels in patients with heart failure decreased as the New York Heart Association classification increased. Patients with heart failure reported significantly lower physical activity than patients with heart transplantation ( P = .0008). Smartphones were the most widely used electronic device to access the Internet in both groups. Patients with heart transplantation seemed to use more than one device to access the Internet. In both groups, patients reporting more technology usage also reported higher levels of physical activity. Patients who accessed the Internet daily reported lower levels of physical activity. Whereas patients with heart failure identified encouragement by family members as a source of motivation for exercise, patients with heart transplantation reported that they were likely to exercise if motivated by their healthcare provider. Patients with heart failure and heart transplantation have unique technological and motivational needs that need consideration for mobile health-driven interventions.

Correlates of musculoskeletal pain and kinesiophobia in older adults with heart failure: A structural equation model.

The study aimed to study the influence of musculoskeletal pain on kinesiophobia in patients with heart failure. This cross-sectional study recruited 107 heart failure patients aged 73.18±12.68 years (57% men) from an outpatient setting. Participants self-reported pain using the Musculoskeletal System Assessment Inventory and the Cornell Musculoskeletal Discomfort Questionnaire. Kinesiophobia was assessed with the Tampa Scale for Kinesiophobia-11. About 62% reported musculoskeletal pain, with knees (16.8%) and lower back (12.%) being the most painful locations. About 31% reported moderate levels and 24% indicated high levels of kinesiophobia. There were positive and significant associations between the indicators of pain and kinesiophobia. Results showed an adequate structural equation model fit to the data with musculoskeletal pain factors explaining 22.09% of the variance in kinesiophobia. Assessment of kinesiophobia in patients with heart failure with musculoskeletal pain is essential to improve self-care and overall quality of life.

Repetitive ambulatory levosimendan as a bridge to heart transplantation.

INTRODUCTION AND OBJECTIVES: Repetitive ambulatory doses of levosimendan are an option as a bridge to heart transplantation (HT), but evidence regarding the safety and efficacy of this treatment is scarce. The objective of the LEVO-T Registry is to describe the profile of patients on the HT list receiving levosimendan, prescription patterns, and clinical outcomes compared with patients not on levosimendan. METHODS: We retrospectively reviewed all patients listed for elective HT from 2015 to 2020 from 14 centers in Spain. RESULTS: A total of 1015 consecutive patients were included, of whom 238 patients (23.4%) received levosimendan. Patients treated with levosimendan had more heart failure (HF) admissions in the previous year and a worse clinical profile. The most frequent prescription pattern were fixed doses triggered by the patients' clinical needs. Nonfatal ventricular arrhythmias occurred in 2 patients (0.8%). No differences in HF hospitalizations were found between patients who started levosimendan in the first 30 days after listing and those who did not (33.6% vs 34.5%; P=.848). Among those who did not, 102 patients (32.9%) crossed over to levosimendan after an HF admission. These patients had a rate of 0.57 HF admissions per month before starting levosimendan and 0.21 afterwards. Propensity score matching analysis showed no differences in survival at 1 year after listing between patients receiving levosimendan and those who did not (HR, 1.03; 95%CI, 0.36-2.97; P=.958) or in survival after HT (HR, 0.97; 95%CI, 0.60-1.56; P=.958). CONCLUSIONS: Repetitive levosimendan in an ambulatory setting as a bridge to heart transplantation is commonly used, is safe, and may reduce HF hospitalizations.

What motivates heart transplantation patients to exercise and engage in physical activity? A network analysis.

AIMS: After heart transplantation (HTx), increments in physical activity are strongly recommended. However, participation rates in exercise-based cardiac rehabilitation and engagement in physical activity (PA) are insufficient in many patients. Hence, this study aimed to explore the central factors and the interconnections among distinct types of motivation to exercise, PA, sedentary time, psychosomatic, diet and activity limitation characteristics in patients post-HTx. METHODS AND RESULTS: Cross-sectional study involving 133 patients post-HTx [79 men, mean age 57±13 years, mean time from transplantation 55±42 months] recruited from an outpatient clinic in Spain. The patients were asked to fill in questionnaires measuring self-reported PA, motivation to exercise, kinesiophobia, musculoskeletal pain, quality of sleep, depression, functional capacity, frailty, sarcopenia risk and diet quality. Two network structures were estimated: one network including PA and one network including sedentary time as nodes. The relative importance of each node in the network structures was determined using centrality analyses. According to the strength centrality index, functional capacity and identified regulation (sub-types of motivation to exercise) are the two most central nodes of the network (strength: z-score = 1.35-1.51). Strong and direct connections emerged between frailty and PA and between sarcopenia risk and sedentary time. CONCLUSION: Functional capacity and autonomous motivation to exercise are the most promising targets of interventions to improve PA levels and sedentary time in patients post-HTx. Furthermore, frailty and sarcopenia risk were found to mediate the effect of several other factors on PA and sedentary time.

Physical Activity Readiness in Patients with Heart Failure.

The aim of this study was to explore the readiness for physical activity (PA) and its related factors in patients with heart failure. This cross-sectional study included 163 patients with heart failure (mean age 66 ± 16, 50% female). The ability to safely engage in PA was assessed with the PA Readiness Questionnaire (PAR-Q). Psychological readiness was measured using two questionnaires, namely: Exercise Self-efficacy Scale and the Motivation for PA and Exercise/Working Out. A multivariate analysis of covariance was conducted to test the effect of background variables on readiness for PA. 64% (n = 105) of patients reported not being able to safely engage in PA, 80% (n = 129) reported low self-efficacy, and 45% (n = 74) were extrinsically motivated indicating external factors drove their motivation. Factors that positively influenced the PA readiness included lower age (p < 0.01), being male (p < 0.01), being married (p < 0.01), having higher education (p < 0.01), being in NYHA-class I compared with II (p < 0.01), less time since diagnosis (p < 0.01), lower BMI (p = 0.02), and not suffering from COPD (p = 0.02). Prior to recommending exercise, assessment of safety to engage in PA along with self-efficacy and motivation in patients with heart failure is essential.

Physical activity enjoyment, exercise motivation, and physical activity in patients with heart failure: A mediation analysis.

OBJECTIVE: To determine whether physical activity enjoyment mediated the association between motivation and physical activity in patients with heart failure. DESIGN AND SETTING: A cross-sectional study at the cardiology clinic in the university hospital in Valencia, Spain. SUBJECTS: A total of 134 patients with heart failure. MAIN MEASUREMENTS: Physical activity was assessed with the International Physical Activity Questionnaire, motivation was assessed with the Exercise Motivation Index and Physical Activity Enjoyment was assessed with the Physical Activity Enjoyment Scale. ANALYSIS: Mediation analysis using Hayes' PROCESS macro (Model 4) for SPSS. RESULTS: The mean age of the sample was 70 ± 14 years, 47 patients were female (35%), and 87 patients were in New York Heart Association I/II (67%). A positive relationship was found between exercise motivation and physical activity (t = 4.57, p < .01) and physical activity enjoyment (t = 11.52, p < .01). Physical activity enjoyment was found to positively affect physical activity (t = 3.50, p < .01). After controlling for physical activity enjoyment, the effect of exercise motivation on physical activity changed from a significant to non-significant (t = 1.33, p = .89), indicating that enjoyment completely mediated the relationship between motivation and physical activity. Overall, 25% of the variation in physical activity was explained by the mediation model. CONCLUSIONS: Physical activity enjoyment mediates the relationship between exercise motivation and physical activity in patients with heart failure. This means that even highly motivated heart failure patients may not be physically active if they do not enjoy the physical activity.

Cardiac Allograft Rejection Induces Changes in Nucleocytoplasmic Transport: RANGAP1 as a Potential Non-Invasive Biomarker.

The non-invasive diagnosis of acute cellular rejection (ACR) is a major challenge. We performed a molecular study analyzing the predictive capacity of serum RanGTPase AP1 (RANGAP1) for diagnosing ACR during the first year after heart transplantation (HT). We included the serum samples of 75 consecutive HT patients, extracted after clinical stability, to determine the RANGAP1 levels through ELISA. In addition, various clinical, analytical, and echocardiographic variables, as well as endomyocardial biopsy results, were collected. RANGAP1 levels were higher in patients who developed ACR (median 63.15 ng/mL; (inter-quartile range (IQR), 36.61-105.69) vs. 35.33 ng/mL (IQR, 19.18-64.59); p = 0.02). Receiver operating characteristic (ROC) curve analysis confirmed that RANGAP1 differentiated between patients with and without ACR (area under curve (AUC), 0.70; p = 0.02), and a RANGAP1 level exceeding the cut-off point (≥90 ng/mL) was identified as a risk factor for the development of ACR (OR, 6.8; p = 0.006). Two independent predictors of ACR identified in this study were higher RANGAP1 and N-terminal pro-brain natriuretic peptide levels. The analysis of the ROC curve of the model showed a significant AUC of 0.77, p = 0.001. Our findings suggest that RANGAP1 quantification facilitates risk prediction for the occurrence of ACR and could be considered as a novel non-invasive biomarker of ACR.

Short-Term Changes in Left and Right Ventricular Cardiac Magnetic Resonance Feature Tracking Strain Following Ferric Carboxymaltose in Patients With Heart Failure: A Substudy of the Myocardial-IRON Trial.

Background The mechanisms explaining the clinical benefits of ferric carboximaltose (FCM) in patients with heart failure, reduced or intermediate left ventricular ejection fraction, and iron deficiency remain not fully clarified. The Myocardial-IRON trial showed short-term cardiac magnetic resonance (CMR) changes suggesting myocardial iron repletion following administration of FCM but failed to find a significant increase in left ventricular ejection fraction in the whole sample. Conversely, the strain assessment could evaluate more specifically subtle changes in contractility. In this subanalysis, we aimed to evaluate the effect of FCM on the short-term left and right ventricular CMR feature tracking derived strain. Methods and Results This is a post hoc subanalysis of the double-blind, placebo-controlled, randomized clinical trial that enrolled 53 ambulatory patients with heart failure and left ventricular ejection fraction <50%, and iron deficiency [Myocardial-IRON trial (NCT03398681)]. Three-dimensional left and 2-dimensional right ventricular CMR tracking strain (longitudinal, circumferential, and radial) changes were evaluated before, 7 and 30 days after randomization using linear mixed-effect analysis. The median (interquartile range) age of the sample was 73 years (65-78), and 40 (75.5%) were men. At baseline, there were no significant differences in CMR feature tracking strain parameters across both treatment arms. At 7 days, the only global 3-dimensional left ventricular circumferential strain was significantly higher in the FCM treatment-arm (difference: -1.6%, P=0.001). At 30 days, and compared with placebo, global 3-dimensional left ventricular strain parameters significantly improved in those allocated to FCM treatment-arm [longitudinal (difference: -2.3%, P<0.001), circumferential (difference: -2.5%, P<0.001), and radial (difference: 4.2%, P=0.002)]. Likewise, significant improvements in global right ventricular strain parameters were found in the active arm at 30 days (longitudinal [difference: -3.3%, P=0.010], circumferential [difference: -4.5%, P<0.001], and radial [difference: 4.5%, P=0.027]). Conclusions In patients with stable heart failure, left ventricular ejection fraction <50%, and iron deficiency, treatment with FCM was associated with short-term improvements in left and right ventricular function assessed by CMR feature tracking derived strain parameters. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03398681.

Influence on kinesiophobia by disability, physical, and behavioural variables after a heart transplantation.

BACKGROUND: From clinical experience, kinesiophobia represents a barrier to being physically active after a heart transplantation (HTx), but studies in this field are lacking. Identifying the factors associated with kinesiophobia is essential to determine preventive interventions to avoid negative consequences for health. AIMS: To study the influence of disability, physical, and behavioural variables on kinesiophobia in patients with an HTx. METHODS: A total of 117 patients with an HTx [51 women; mean age 56 (SD 12.1) years] were recruited at an outpatient clinic. These patients were asked to fill in questionnaires measuring kinesiophobia, self-reported physical activity (PA), exercise self-efficacy, motivation for PA, and disability. A multiple regression analysis was conducted to examine the statistical prediction of kinesiophobia as a dependent variable, with the questionnaires, gender and education as independent variables. RESULTS: The independent variables explained 70% of the variance in kinesiophobia. The prediction model was significant (F = 32.1, P < 0.001). The time from transplantation (standardised coefficient, beta; -0.17), the total exercise self-efficacy (-0.16), extrinsic motivation (-0.23), and the disability total score (0.63) were significant predictors of kinesiophobia, while the independent variables of gender, education, intrinsic motivation, and the PA total score were not significant. CONCLUSIONS: This study highlights that a short time from transplantation, low self-efficacy, low extrinsic motivation, and a high level of disability explained high levels of kinesiophobia in patients after an HTx. These results suggest that an increased awareness of the biopsychosocial health perspective is essential in order to maximising patient outcomes after an HTx.

Depression mediates physical activity readiness and physical activity in patients with heart failure.

AIMS: Although physical activity (PA) and exercise are essential for patients with heart failure (HF), adherence to the recommended guidelines is low. Not much is known about the mediating effect of HF patients' mental state with their readiness for PA and reported activity levels. The purpose of this study is to investigate the mediatory effect of depression on PA readiness (physical limitation and psychological readiness) and self-reported PA in patients with HF. METHODS AND RESULTS: In this cross-sectional study, 163 New York Heart Association Class I and II HF patients, during their clinic visit, reported on their physical limitation (PAR-Q) and psychological readiness [self-efficacy (ESES) and motivation (RM 4-FM)] for PA, depression (HADS-D), and PA (s-IPAQ). Mediation analysis was performed to test the mediating effect of depression on PA readiness (physical limitation and psychological readiness) and self-reported PA following the steps described by Baron and Kenny (1986). Hierarchical regression models were tested for their effects. The Self-Efficacy Theory and Self-Determination theory provided the theoretical platform for the study. Depression completely mediated the effect of physical limitation (ßdep  = 268.57; P < 0.0001) and partially mediated the effect of self-efficacy on PA (ßdep  = 344.16; P < 0.0001). Both intrinsic (P < .0001) and extrinsic motivation (P < .0001) for PA had an independent and significant effect on PA, not mediated by depression. CONCLUSIONS: Patients with HF should be screened for depression throughout the trajectory of the disease as it can impact their physical and psychological readiness to perform PA.

Impact of Circulatory Assistance in the Early Evolution After Heart Transplantation. Unicentric Experience.

BACKGROUND: Heart transplantation (HT) is the reference treatment for patients with terminal heart failure. In recent years there has been a progressive increase in HT procedures in patients who have a circulatory support (CS). METHODS: This is a retrospective single-center study of 293 consecutive patients who underwent HT from 2009 to 2018, analyzing the evolution of the 2 cohorts: patients with and without CS as a bridge to HT. Baseline and evolutionary clinical data collected following the usual follow-up protocol were recorded, including clinical events observed during the follow-up 1 year after the procedure. RESULTS: The subgroup of patients transplanted with CS showed a higher incidence of primary graft failure, frequent infection, and mortality. A tendency toward lower cardiac allograft vasculopathy was observed in this subgroup. Mechanical ventilation added to the CS resulted in a higher incidence of primary graft failure, infection, and renal dysfunction. The CS variable as a bridge to HT was shown to be predictive of 1-year mortality in both univariate (odds ratio, 1.84; 95% confidence interval, 1.03-3.3; P = .038) and multivariate (odds ratio, 2.1; 95% confidence interval, 1.01-4.3; P = .047) analyses. CONCLUSIONS: In our experience, CS as a bridge to HT results in a higher incidence of primary graft failure, frequent infection, and mortality at 1-year follow-up. Mechanical ventilation added to CS has a clear unfavorable prognostic impact. CS as a bridge to HT was shown to be predictive of 1-year mortality in both univariate and multivariate analyses.

Iron deficiency and short-term adverse events in patients with decompensated heart failure.

BACKGROUND: For patients with heart failure (HF), iron deficiency (ID) is a common therapeutic target. However, little is known about the utility of transferrin saturation (TSAT) or serum ferritin for risk stratification in decompensated HF (DHF) or the European Society of Cardiology's (ESC) current definition of ID (ferritin < 100 µg/L or TSAT < 20% if ferritin is 100-299 µg/L). We evaluated the association between these potential markers of ID and the risk of 30-day readmission for HF or death in patients with DHF. METHODS: We retrospectively included 1701 patients from a multicenter registry of DHF. Serum ferritin and TSAT were evaluated 24-72 h after hospital admission, and multivariable Cox regression was used to assess their association with the composite endpoint. RESULTS: Participants' median (quartiles) age was 76 (68-82) years, 43.8% were women, and 51.7% had a left ventricular ejection fraction > 50%. Medians for NT-proBNP, TSAT, and ferritin were 4067 pg/mL (1900-8764), 14.1% (9.0-20.3), and 103 ug/L (54-202), respectively. According to the current ESC definition, 1,246 (73.3%) patients had ID. By day 30, there were 177 (10.4%) events (95 deaths and 85 HF readmission). After multivariable adjustment, lower TSAT was associated with outcome (p = 0.009) but serum ferritin was not (HR 1.00; 95% confidence interval 0.99-1.00, p = 0.347). CONCLUSIONS: Lower TSAT, but not ferritin, was associated with a higher risk of short-term events in patients with DHF. Further research is needed to confirm these findings and the utility of serum ferritin as a marker of ID in DHF.

Validation of the usefulness of 2-dimensional strain parameters to exclude acute rejection after heart transplantation: a multicenter study.

INTRODUCTION AND OBJECTIVES: Two-dimensional speckle-tracking echocardiography has emerged as a promising alternative to endomyocardial biopsy to rule out acute cellular rejection after orthotopic heart transplantation (OHT) in single center studies. In an original cohort, 15.5% and 17% of cutoff points for left ventricular global longitudinal strain (LVGLS) and free-wall right ventricular longitudinal strain, respectively, achieved 100% negative predictive value to exclude moderate or severe acute cellular rejection (ACR ≥ 2R). Our objective was to demonstrate the usefulness of speckle-tracking and validate these cutoff points in an external cohort. METHODS: A prospective, multicenter study that included patients who were monitored during their first year after OHT was conducted. Echocardiographic studies analyzed by local investigators were compared with simultaneous paired endomyocardial biopsies samples. RESULTS: A total of 501 endomyocardial biopsy-echocardiographic studies were included in 99 patients. ACR≥2R was present in 7.4% of samples. LVGLS and free-wall right ventricular longitudinal strain were significantly reduced during ACR≥2R on univariate analysis. On multivariate analysis, LVGLS was independently associated with the presence of ACR≥2R. The original cutoff points demonstrated a negative predictive value of 94.3% to exclude ACR≥2R. CONCLUSIONS: This study maintained a strong negative predictive value to exclude ACR≥2R after OHT and LVGLS was independently associated with the presence of ACR≥2R. We propose the use of speckle-tracking, especially LVGLS, as part of the noninvasive diagnosis and management of ACR.

Short-term changes in left and right systolic function following ferric carboxymaltose: a substudy of the Myocardial-IRON trial.

AIMS: The mechanisms underlying the beneficial effect of ferric carboxymaltose (FCM) in patients with heart failure (HF) and iron deficiency (ID) have not been completely characterized. The Myocardial-IRON trial was a double-blind, randomized trial that evaluated myocardial iron repletion following FCM vs. placebo in 53 patients with HF and ID. In this post hoc analysis, we evaluated whether treatment with FCM was associated with cardiac magnetic resonance changes in left and right ventricular function (LVEF and RVEF, respectively) at different points of systolic dysfunction. METHODS AND RESULTS: We included patients from the Myocardial-IRON trial with left and right ventricular systolic dysfunction (LVSD and RVSD, respectively) at enrolment. Linear mixed regression models were used to evaluate changes at 7 and 30 days on LVEF and RVEF at cardiac magnetic resonance. At enrolment, 27 (50.9%) and 38 (71.7%) patients had LVEF < 40% (LVSD1 ) or <45% (LVSD2 ), respectively, and 10 (18.9%) and 17 (32.1%) patients had RVEF < 45% (RVSD1 ) or <51% in women and <52% in men (RVSD2) , respectively. Treatment with FCM was associated with a significant improvement in LVEF at 30 days (LVSD1 : Δ2.3%, P < 0.001; LVSD2 : Δ4.1, P = 0.014). FCM was also associated with a significant and early improvement in RVEF at 7 days (RVSD1 : Δ6.9%, P = 0.003; RVSD2 : Δ3.2%, P = 0.003) that persisted at 30 days (RVSD1 : Δ8.1%, P < 0.001; RVSD2 : Δ4.7%, P < 0.001). CONCLUSIONS: In patients with HF and systolic dysfunction with ID, FCM was associated with short-term improvement in LVEF and, especially, in RVEF.

Gender Differences in Health-Related Quality of Life in Patients with Systolic Heart Failure: Results of the VIDA Multicenter Study.

Previous studies have shown that heart failure is associated with worse health-related quality of life (HRQoL). The existence of differences according to gender remains controversial. We studied 1028 consecutive outpatients with heart failure and reduced ejection fraction (HFrEF) from a multicentre cross-sectional descriptive study across Spain that assessed HRQoL using two questionnaires (KCCQ, Kansas City Cardiomyopathy Questionnaire; and EQ-5D, EuroQoL 5 dimensions). The primary objective of the study was to describe differences in HRQoL between men and women in global scores and domains of health status of patients and explore gender differences and its interactions with heart failure related factors. In adjusted analysis women had lower scores in KCCQ overall summary scores when compared to men denoting worse HRQoL (54.7 ± 1.3 vs. 62.7 ± 0.8, p < 0.0001), and specifically got lower score in domains of symptom frequency, symptoms burden, physical limitation, quality of life and social limitation. No differences were found in domains of symptom stability and self-efficacy. Women also had lower scores on all items of EQ-5D (EQ-5D index 0.58 ± 0.01 vs. 0.67 ± 0.01, p < 0.0001). Finally, we analyzed interaction between gender and different clinical determinants regarding the presence of limitations in the 5Q-5D and overall summary score of KCCQ. Interestingly, there was no statistical significance for interaction for any variable. In conclusion, women with HFrEF have worse HRQoL compared to men. These differences do not appear to be mediated by clinical or biological factors classically associated with HRQoL nor with heart failure severity.

Changes in REVEAL risk score in patients with pulmonary arterial hypertension treated with macitentan in clinical practice: results from the PRACMA study.

BACKGROUND: Macitentan is a dual endothelin receptor antagonist indicated for the long-term treatment of pulmonary arterial hypertension (PAH). We evaluated the change over time in REVEAL risk score in incident and prevalent patients receiving macitentan for the first time. METHODS: Retrospective, observational study including adult patients with idiopathic/heritable PAH or PAH associated with connective tissue disorders or congenital heart disease treated with macitentan for ≥6-month follow-up in Spain. The REVEAL risk score and risk strata were computed at the start of macitentan and after ≥6-month in patients with ≥7 out of 12 valid REVEAL components. RESULTS: Overall, 81 patients (57 for the REVEAL score) were analysed, 77.8% women. The mean age was 57.2 years and 50.6% of patients had idiopathic/heritable PAH. Prevalent patients were 59.3 and 40.7% were incident. Main therapies for PAH included macitentan monotherapy (42.0%) and macitentan in combination with phosphodiesterase type 5 inhibitor (44.4%). With a median time of macitentan treatment of 10.5 months, the mean REVEAL score was 8.7 points at baseline and was 7.2 points after ≥6-month follow-up. The mean change (95% CI) in REVEAL risk score was - 1.4 (- 2.0, - 0.9) points (p < 0.0001), being - 1.8 (- 3.0, - 0.7) points (p = 0.0040) and - 1.2 (- 1.8, - 0.5) points (p = 0.0010), in incident and prevalent patients, respectively. The reduction was also significant by risk stratum (36.8% of patients in the high-very high risk strata at baseline versus 14.0% after ≥6-month, p < 0.05) and therapy group. The REVEAL components that significantly improved were WHO functional class (FC) (63.9% FC III at macitentan initiation and 23.6% after ≥6-month, p < 0.0001), 6-min walk test (mean change: 41.8 m, p < 0.01), brain natriuretic peptide (BNP) or N-terminal proBNP (NT-proBNP) (mean change of - 157.6 pg/mL and - 530.0 pg/mL, respectively, p < 0.05 both), and pulmonary vascular resistance (PVR) (mean change: - 3.4 WU, p < 0.01). CONCLUSIONS: In this study, treatment with macitentan improved the REVEAL risk strata and score in both incident and prevalent PAH patients, and in all patients regardless of the therapy strategy. Macitentan significantly improved some of REVEAL components including WHO FC, BNP/NT-proBNP, PVR, and 6-min walk test after at least 6-month follow-up.

Consenso de expertos en la asistencia multidisciplinaria y el abordaje integral de la insuficiencia cardiaca. Desde el alta hospitalaria hasta la continuidad asistencial con primaria / Expert consensus on multidisciplinary management and integrated approaches in heart failure. Continuity of care from hospital discharge to primary care

La insuficiencia cardiaca es una enfermedad que precisa un tratamiento multidisciplinario, dadas la diversidad de causas y entornos clínicos implicados que las tratan y las diferentes estrategias terapéuticas que precisan la participación indispensable de diversas disciplinas. La presencia en los servicios de cardiología de unidades de insuficiencia cardiaca centradas en el tratamiento de los pacientes con esta afección y unidades de rehabilitación cardiaca que, entre sus indicaciones para la reducción de la morbimortalidad, también están implicadas en la atención de esos mismos pacientes puede causar dificultades de coordinación y pérdida de una atención integral centrada en el paciente. Por estos motivos, en el presente documento se plantea una estrategia de coordinación entre las diferentes unidades implicadas en el tratamiento de los pacientes dentro de los servicios de cardiología y la continuidad asistencial con atención primaria, tanto tras haber conseguido la estabilidad como la interrelación para una coordinación posterior más efectiva

Heart failure is a condition that requires a multidisciplinary approach to treatment because of the wide range of causes and clinical contexts that may be involved and because the diverse treatment strategies used necessitate the participation of multiple disciplines. In cardiology departments, the presence of both heart failure units that focus on the treatment of affected patients and cardiac rehabilitation units that, as well as targeting reductions in morbidity and mortality, are also involved in caring for the same patients can create difficulties for coordination and can result in the loss of comprehensive patient-centered care. For these reasons, this paper presents a strategy for coordinating the different units involved in patient management in cardiology departments and for ensuring continuity of care in primary care, both immediately after achieving stabilization and subsequently, when these interactions are important for effective coordination

Chondrocostal grafting for lateral osteochondral injury of the metacarpal head.

Osteochondral injuries of the metacarpal head require anatomical restoration to prevent limitations in range of motion and osteoarthritis. Osteochondral bone grafting is a viable option, especially in younger patients. Central injuries allow for different types of grafting, but when the injured area is on the lateral portion of the metacarpal head, the graft must include both a cortical and a cartilaginous portion. We present here the pearls and pitfalls in the surgical technique of chondrocostal grating from the 6th rib and an example of its use within a case of comminuted fracture of the metacarpal head. This technique provides a graft with cortical bone that allows for a stable fixation, with few complications during its harvesting. The graft is viable in the long-term and shows similar magnetic resonance intensities in comparison to hand cartilage.