Circulation: Heart Failure最新文献

Background: The tenet of cardiac amyloidosis (CA) as a paradigm of heart failure with restrictive ventricular physiology and preserved systolic function has come under scrutiny. We aimed to evaluate the prevalence and clinical significance of left ventricular (LV) systolic dysfunction versus restriction in a large real-world cohort with CA, assessed at the time of diagnosis.

Methods: We retrospectively analyzed 540 TTR (transthyretin)-CA and 280 AL (light chain)-CA. Patients were divided into 3 LV phenotypes: (1) preserved LV function: LV ejection fraction >40% associated with grade I diastolic dysfunction; (2) restriction: LV ejection fraction >40% associated with grade II/III diastolic dysfunction; (3) systolic dysfunction: LV ejection fraction ≤40% irrespective of diastolic function. We analyzed the progression from preserved LV function towards the other 2 LV phenotypes and survival free from the composite end point of all-cause mortality and heart transplantation.

Results: In TTR-CA, the prevalence of preserved LV function was 32.0%, restriction was 56.1%, and systolic dysfunction was 11.9%. Among patients with preserved LV function, at the last evaluation, the conversion rate to restriction was 16.3% and to systolic dysfunction was 1.8%. The 3-year freedom from the composite end point was 75%, 61%, and 44%, respectively. In AL-CA, the prevalence of preserved LV function was 32.9%, restriction was 58.6%, and systolic dysfunction was 8.5%. Among patients with preserved LV function, at the last evaluation, the conversion rate to restriction was 12.9%, and to systolic dysfunction was none. The 3-year freedom from the composite end point was 46%, 32%, and 21%, respectively.

Conclusions: Restriction was the most common presenting phenotype, while preserved LV function represented approximately one-third. The rate of progression from preserved LV function towards restriction was high, whereas it was limited towards systolic dysfunction. Although patients with preserved LV function presented the best event-free survival, considering all-cause mortality and heart transplantation, compared with restriction or systolic dysfunction, these phenotypes are not independent predictors of this composite end point.

Background: ECG-based artificial intelligence may enable efficient prediction of incident heart failure (HF) risk to facilitate preventive efforts. Prior models are proprietary, with modest or inconsistent accuracy. We sought to develop and validate a generalizable and publicly available convolutional neural network to predict incident HF using the 12-lead ECG waveform (ECG-to-HF [ECG2HF]).

Methods: We developed ECG2HF in 94 636 patients receiving longitudinal ambulatory care at Massachusetts General Hospital (MGH), and validated it in 3 test sets: MGH, Brigham and Women's Hospital (BWH), and Beth Israel Deaconess Medical Center (BIDMC), among 93 868 individuals aged 30 to 79 years without HF. HF events at 10 years were identified using a validated electronic health record-based natural language processing model. Discrimination was quantified using the area under the receiver operating characteristic curve. We then compared discrimination and net reclassification (at <10%, 10% to 20%, ≥20% 10-year risk categories) using ECG2HF versus the 15-component Pooled Cohorts Equations to Prevent HF score.

Results: The test sets comprised MGH (13 954 individuals, 441 events, age 57±13 years, 48% women), BWH (54 396 individuals, 1809 events, age 57±13 years, 55% women), and BIDMC (25 457 individuals, 901 events, age 57±13 years, 53% women). Over 10 years, the cumulative risk of HF was 4.6% (95% CI, 4.1-5.0) in MGH, 5.0% (4.8-5.2) in BWH, and 4.4% (4.1-4.7) in BIDMC. ECG2HF discriminated 10-year incident HF in each test set (area under the receiver operating characteristic curve: MGH 0.86 [0.84-0.87]; BWH 0.85 [0.84-0.86]; BIDMC 0.84 [0.83-0.86]). Compared with the Pooled Cohorts Equations to Prevent HF, ECG2HF provided favorable discrimination (improvement in area under the receiver operating characteristic curve MGH/BWH 0.061 [0.025-0.097]; BIDMC 0.038 [-0.0096 to 0.086]) and net reclassification (NRI MGH/BWH 0.16 [0.077-0.24]; BIDMC 0.23 [0.10-0.35]) of 10-year HF risk.

Conclusions: ECG2HF is a publicly available 12-lead ECG-based artificial intelligence model that discriminates the risk of future HF with favorable and consistent performance across 3 large health care samples from the northeastern United States. ECG2HF may enable efficient prioritization of high-risk individuals for HF-related preventive measures.

Kidney dysfunction after heart transplantation (HT) is associated with significant morbidity and mortality. Recipient and perioperative factors may all influence the risk of kidney injury. Furthermore, data suggest that the incidence of kidney dysfunction, both acute and chronic, is increasing after the implementation of the United States' 2018 allocation system due to increasing use of temporary mechanical circulatory support and changing recipient characteristics. While data are robust regarding nephroprotective therapies such as renin-angiotensin-aldosterone system inhibition and SGLT2 (sodium-glucose cotransporter 2) inhibitors to minimize the progression of chronic kidney disease in patients with heart failure, data in HT recipients are beginning to emerge. This state-of-the-art review will critically examine the existing literature regarding the epidemiology of kidney dysfunction after HT, mitigation strategies for acute kidney injury and chronic kidney disease, including pharmacotherapeutics, the need for kidney transplantation after HT, and practical next steps for the larger HT community.

Background: Guidelines acknowledge that discordant low-gradient (LG) aortic stenosis (AS) may be severe, but verifying this can be challenging. Right heart catheterization during exercise is considered the gold standard for evaluating ventricular hemodynamics. No invasive studies have compared the hemodynamic response of discordant LG and severe AS during exercise. The aim of this observational study was to describe exercise hemodynamics in patients with asymptomatic discordant AS and left ventricular ejection fraction ≥50%.

Methods: Patients with aortic valve area ≤1.5 cm² underwent right heart catheterization at rest and during maximal exercise, measuring pulmonary capillary wedge pressure (PCWP), cardiac output (CO), and the PCWP/CO-slope. Patients were stratified into 3 groups: discordant LG AS (aortic valve area ≤1.0 cm² and mean gradient <40 mm Hg); moderate AS (aortic valve area >1.0 cm²); and high-gradient (HG) severe AS (aortic valve area ≤1.0 cm² and mean gradient ≥40 mm Hg).

Results: Among 86 patients, 17 (20%) had discordant LG, 49 (57%) moderate, and 20 (23%) HG severe AS. The median PCWP/CO-slope was significantly steeper in discordant LG (3.3 [interquartile range, 2.1-4.3] mm Hg/L/min) and HG severe AS (2.7 [1.9-3.4] mm Hg/L per minute) compared with moderate AS (1.9 [0.7-2.8] mm Hg/L per minute), P=0.004. In a regression model adjusted for age, sex, and rest PCWP, systemic arterial compliance and AS severity were significantly associated with the PCWP/CO-slope. Furthermore, patients with discordant LG AS had a leftward-upward shift in the PCWP/CO-curve.

Conclusions: Discordant LG and HG severe AS had similar hemodynamic responses to exercise with steeper PCWP/CO-slope than in moderate AS, suggesting that discordant LG AS is a severe form of AS. In addition, the left upwards shift in PCWP/CO-curve for discordant LG compared with HG severe AS indicates that this group also has heart failure with preserved ejection fraction physiology.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04913870 and NCT02395107.

Background: There are limited data on the etiology, management, and outcomes of Society for Cardiovascular Angiography and Interventions (SCAI) B cardiogenic shock.

Methods: From 2017 to 2022, adult patients (≥18 years) admitted to the medical, intermediate, and critical care units in a 6-hospital system were evaluated. SCAI B cardiogenic shock was defined as hypotension (systolic ≤90/mean ≤65 mm Hg) or hypoperfusion (lactate 2-5 mEq/L). Cardiac arrest, use of circulatory support, and noncardiac etiologies were excluded. The composite primary end point included transfer to a higher level of care, SCAI stage escalation, or in-hospital mortality. Multivariable analysis and mixed-effects regression models were used.

Results: During this period, 500 patients (median age, 76 years; 56% men; 79% White) developed SCAI B cardiogenic shock (hypotension 18%, hypoperfusion 82%). The most common etiologies were heart failure (37%), arrhythmia (23%), and acute myocardial infarction (13%). The primary composite end point was noted in 135 patients (deterioration cohort). The deterioration cohort had comparable baseline characteristics to those who recovered, but before the primary outcome, had lower blood pressures, higher rates of renal (60% versus 33%) and hepatic (15% versus 4%) injury, less negative fluid balance (-0.30 versus -0.68 L), and greater diuretic resistance (21% versus 2%; P<0.001). In a multivariable analysis, acute kidney injury-adjusted odds ratio 2.17 (95% CI, 1.11-4.22); P=0.02-and diuretic resistance-adjusted odds ratio 9.55 (95% CI, 2.61-34.89); P=0.001-were independently predictive of clinical deterioration. Patients with isolated hypotension had worse outcomes compared with those with isolated hypoperfusion.

Conclusions: Among patients with SCAI B cardiogenic shock, a quarter of the population experienced clinical deterioration. Acute kidney injury and diuretic resistance in the preceding 24 hours were independently predictive of developing the primary end point.

Inhibiting SGLT2 (sodium-glucose cotransporter 2) has recently transformed the medical care of patients with left heart disease. Right ventricular failure is a major predictor for patients suffering from pulmonary hypertension of various causes, including those with postcapillary pulmonary hypertension due to left heart disease. Similar to how SGLT2 inhibition benefits patients with left heart failure, recent studies have suggested utilizing these molecules to enhance right ventricular function in pulmonary hypertension. In this review, we summarize the current knowledge on the use of SGLT2is (SGLT2 inhibitors) in pulmonary hypertension. Further dedicated trials are necessary to establish their role in right ventricular pulmonary vascular disease.