Circulation: Heart Failure最新文献

Background: Influenza contributes substantially to disease burden in individuals with heart failure (HF) and is an established trigger of cardiovascular and HF events. Standard-dose inactivated influenza vaccine (SD-IIV) is recommended for HF, though immune responses may be attenuated. High-dose inactivated influenza vaccine (HD-IIV) was developed to enhance immunogenicity, but its effectiveness compared with SD-IIV against hospitalization for influenza and cardiovascular disease by HF status remains uncertain.

Methods: This was a prespecified analysis of a pragmatic, prospective, individually randomized, open-label trial with registry-based end point-evaluation conducted in Denmark across the 2022/2023 to 2024/2025 influenza seasons. Citizens ≥65 years were randomized 1:1 to HD-IIV or SD-IIV. Outcomes included hospitalization for influenza-related illness, laboratory-confirmed influenza, any cardiovascular disease, cardio-respiratory disease, and HF, assessed by HF status. Effect of HD-IIV versus SD-IIV in reducing risk of outcomes assessed was expressed as risk ratios.

Results: The trial randomized 332 438 participants (48.6% female; mean age, 73.7±5.8 years), including 10 410 with HF at baseline (27.4% female; mean age, 76.0±6.3 years). Overall, HD-IIV was associated with a statistically significant lower incidence of hospitalization for influenza-related illness, laboratory-confirmed influenza, cardio-respiratory disease, cardiovascular disease, and HF compared with SD-IIV. In participants with HF, effect estimates were similar: risk ratio for influenza-related hospitalization was 0.48 (95% CI, 0.20-1.06; P_interaction=0.64), for laboratory-confirmed influenza hospitalization 0.55 (95% CI, 0.29-1.02; P_interaction=0.59), for cardio-respiratory hospitalization 0.89 (95% CI, 0.77-1.02; P_interaction=0.34), for cardiovascular hospitalization 0.86 (95% CI, 0.72-1.02; P_interaction=0.34), and for HF hospitalization 0.82 (95% CI, 0.61-1.11; P_interaction=0.83). Findings were consistent across HF subgroups by disease duration, recency of hospitalization, most recent NT-proBNP (N-terminal pro-B-type natriuretic peptide), and presence of device therapy.

Conclusions: In this prespecified exploratory analysis of the largest individually randomized influenza vaccine trial ever conducted, HD-IIV was associated with lower rates of influenza and cardiovascular hospitalizations compared with SD-IIV, with effect estimates similar across HF status at baseline and HF subgroups.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: https://clinicaltrials.gov/study/NCT05517174.

Background: There are currently no robust clinical markers for assessing prognosis in patients with heart failure (HF) with recovered left ventricular ejection fraction (LVEF). This study sought to investigate whether NT-proBNP (N-terminal pro-B-type natriuretic peptide) measured at the time of LVEF recovery is an independent predictor of prognosis among patients with HF with recovered LVEF.

Methods: This retrospective cohort study (2009-2024) included 3935 patients with HF with recovered LVEF (previous LVEF of ≤40% with subsequent improvement to ≥50%) and available NT-proBNP data at the time of LVEF recovery. Patients were categorized into 7 different NT-proBNP groups, which were compared using Kaplan-Meier analysis and multivariable Cox regression to evaluate the outcome of LVEF relapse (decrease in LVEF by ≥10% to <50%) and the composite outcome of HF hospitalization or all-cause death.

Results: The median value of NT-proBNP at the time of LVEF recovery was 1341 pg/mL (interquartile range, 400-4207). The probability of remaining free from LVEF relapse and the composite outcome decreased across NT-proBNP groups. After multivariable adjustment, NT-proBNP was an independent predictor of both LVEF relapse and the composite outcome, with higher NT-proBNP levels associated with higher risk of both outcomes in a dose-response manner. Even near-normal NT-proBNP levels (125-299 pg/mL) were associated with poorer prognosis relative to normal levels (<125 pg/mL), with a 46% higher risk of LVEF relapse and 82% higher risk of the composite outcome. This relationship was consistent and similar across age, sex, atrial fibrillation status, and renal function, but was modified by body mass index, with higher body mass index associated with higher risk. Notably, NT-proBNP was predictive of the composite outcome even when patients sustained LVEF recovery without experiencing LVEF relapse.

Conclusions: NT-proBNP is an independent and robust predictor of prognosis in patients with HF with recovered LVEF and may therefore be used to guide further optimization of pharmacotherapy.

Recent findings emphasize the potential role of invasive hemodynamic assessment in guiding transcatheter mitral and tricuspid valve percutaneous interventions. Right heart catheterization-derived parameters offer insights into hemodynamic changes associated with valvular heart diseases, pulmonary hypertension phenotyping, and right ventricular to pulmonary artery coupling. This might improve prognostic stratification for candidates to transcatheter therapies. This review provides a clinical overview of available data regarding the utility of preoperative right heart catheterization-derived parameters in patients undergoing mitral and tricuspid percutaneous repair or replacement.

Background: The 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America guidelines introduced elevated natriuretic peptide (NP) levels as a criterion for defining stage B heart failure (HF), or pre-HF, to identify individuals at greatest risk for future HF. Given the known NP deficiency in obesity, we aimed to assess whether a single NP cut point would disproportionately up-classify individuals with versus without obesity to stage B HF.

Methods: Participants free of HF from 5 community-based cohorts were included. We examined the reclassification of individuals to stage B HF using the 2022 versus 2013 guidelines, stratified by obesity class. Cox proportional hazards models were used to assess the association of NPs with incident HF across obesity classes.

Results: Among 32 735 participants, 35% had normal weight, 40% were overweight, 17% had obesity class 1, and 8% had obesity class 2/3. When applying the 2022 versus 2013 criteria, the proportion of individuals up-classified to stage B HF using the NP criterion was 62% among those with normal weight, 51% for those overweight, 47% for individuals with obesity class 1, and 42% for individuals with obesity class 2/3. Over a median follow-up of 13 years, 3077 HF events occurred. Both higher NP and body mass index were associated with greater HF risk, as expected (P<0.0001 for both). Importantly, body mass index modified the association of NP with HF risk, such that higher NP concentration was associated with greater HF risk among individuals with lower body mass index. The optimal NT-proBNP (N-terminal pro-B-type natriuretic peptide) cut point to predict future HF risk was lower among individuals with obesity (80 pg/mL; 95% CI, 53-121) compared with normal-weight individuals (109 pg/mL; 95% CI, 80-157).

Conclusions: The application of a single NP cut point resulted in fewer individuals with obesity being up-classified to stage B HF compared with normal-weight individuals. Adjusting NP cut points for individuals with obesity may improve the accuracy of HF risk stratification.

Background: Pulmonary hypertension (PH) is classified as precapillary, isolated postcapillary pulmonary hypertension (IpcPH), combined postcapillary and precapillary (CpcPH), or exercise PH. IpcPH associated with left heart disease can lead to pulmonary vascular remodeling and eventually CpcPH. Conversely, precapillary PH may be diagnosed in the presence of cardiovascular comorbidities, including left heart disease. Atrial functional impairment is a frequent finding in cardiopulmonary disease, reflecting both intrinsic atrial cardiomyopathy and congestion. Consequently, we sought to investigate this across the PH spectrum.

Methods: Patients referred to both right heart catheterization and cardiovascular magnetic resonance imaging were enrolled in this monocentric registry. Patients were classified by right heart catheterization according to current guideline recommendations. Cardiovascular magnetic resonance assessment included left/right ventricular and left atrial (LA)/right atrial volumes and deformation imaging.

Results: The study population consisted of N=209 patients (n=55 normal, n=72 precapillary, n=27 CpcPH, n=15 IpcPH, n=34 exercise, and n=6 unclassified PH). N=126 patients underwent additional exercise stress right heart catheterization. Median LA reservoir function was lowest and similar in IpcPH (10.0%) and CpcPH (10.0%), which were significantly impaired compared with normal hemodynamics (30.8%, both P<0.001), precapillary (28.2%, both P<0.001), and exercise PH (26.9%, IpcPH: P=0.039, CpcPH: P=0.048). LA reservoir function and left ventricular global longitudinal strain showed good diagnostic performance to identify patients with left cardiac involvement evident at rest (pulmonary capillary wedge pressure ≥15 mm Hg; area under the curve, 0.81 versus 0.77; P=0.20), whereas LA reservoir function emerged superior for identification of exercise stress induced pulmonary capillary wedge pressure ≥25 mm Hg (area under the curve, 0.79 versus 0.70, P=0.039).

Conclusions: LA functional impairment is a sign of left heart involvement in patients with PH. Left atrial reservoir function emerged superior for the identification of left heart disease unmasked during exercise stress compared with left ventricular global longitudinal strain. Consequently, LA strain may become an innovative method to detect early-stage left heart disease in PH.

Background: The performance of estimated glomerular filtration rate (eGFR) among patients with heart failure (HF) may be worse than in the general population due to a higher prevalence of confounding factors affecting creatinine and cystatin C. Studies in this area are scarce and not stratified by type of HF. We evaluated the performance of current creatinine and cystatin C equations (eGFRcr, eGFRcys, and eGFRcrcys) compared with measured GFR (mGFR) among patients with HF stratified by ejection fraction.

Methods: We pulled data on Mayo Clinic patients with an mGFR performed for clinical indications from 2011 to 2023, with serum creatinine and cystatin C measured within 7 days and an echocardiogram performed up to 1 year before the mGFR date. HF was identified by the presence of International Classification of Diseases codes within 1 year before the mGFR and subgrouped into ejection fraction (EF) ≥50% (HFEF≥50%, n=182) or <50% (HFEF<50%, n=115) and compared with no-HF controls (n=1871). CKD-EPI (and EKFC) eGFRcr, eGFRcys, and eGFRcrcys equations were calculated and compared for bias (mGFR minus eGFR) and accuracy (1-P30, proportion of people with ≥30% difference between eGFR and mGFR). CIs were generated by bootstrapping.

Results: The HF groups were characterized by older age, higher proportion of males, more diabetes, higher creatinine, and higher cystatin C than controls. In terms of bias, eGFRcr overestimated mGFR to a greater extent in both HF groups compared with controls, whereas eGFRcys and eGFRcrcys showed similar bias in both HF groups and controls. In the HF groups, cystatin C-based equations were more accurate than eGFRcr, particularly within HFEF<50% (1-P30 of 28% and 34% for CKD-EPI eGFRcys and eGFRcrcys, respectively, versus 60% for eGFRcr), whereas eGFRcrcys was more accurate in controls. The CKD-EPI and EKFC equations were overall convergent, showing similar results.

Conclusions: Among patients with HF, eGFRcr demonstrates inferior performance (more bias and less accuracy) compared with cystatin C-based eGFRs, with this effect being more pronounced in those with HFEF<50%.

The Get With The Guidelines-Heart Failure program was developed in 2005 with the goal of bringing evidence-based guidelines in heart failure management into widespread clinical practice. The program includes workshops, webinars, tool kits, chart abstraction, performance benchmarking, and achievement awards to drive quality improvement at participating hospitals. Two decades after its inception, the program has grown to include over 600 participating institutions across the United States. Linking registry data to Centers for Medicare and Medicaid Services claims has also allowed for the evaluation of longitudinal outcomes. Get With The Guidelines-Heart Failure has helped improve the quality of care for patients and has contributed substantially to the understanding of clinical science and optimal management of heart failure. This narrative review provides an overview of the indelible impact of the Get With The Guidelines-Heart Failure program on quality heart failure care over the past 20 years and highlights future challenges and directions.