Circulation: Heart Failure最新文献

Background: Up-titration of guideline-directed medical therapy (GDMT) is known to enhance left ventricular function in heart failure (HF) with reduced ejection fraction. However, data regarding its effect on right ventricular (RV) function remain sparse. We aimed to assess the impact of GDMT up-titration on the RV, especially RV to pulmonary artery coupling, and its prognostic value in these patients.

Methods: All consecutive patients (n=291) with left ventricular ejection fraction <50% followed for GDMT up-titration in a dedicated HF clinic in a tertiary center from January 2019 to June 2022 with an echocardiography at baseline (before up-titration) and at follow-up (end of up-titration) were included.

Results: The median age is 65 (55-74) years; 24% are female. Ischemic cardiomyopathy was the main cause of HF (47%), and left ventricular ejection fraction was 30% (22%-34%). After 2 years, 49 patients (17%) reached the primary end point (all-cause death or hospitalization for acute HF). RV size and function significantly improved after GDMT up-titration (all, P<0.001), including RV to pulmonary artery coupling assessed by tricuspid annular plane systolic excursion/systolic pulmonary artery pressure (0.62 versus 0.81 mm/mm Hg; P<0.001). Tricuspid annular plane systolic excursion/systolic pulmonary artery pressure <0.65 mm/mm Hg at follow-up remained associated with the primary end point after adjustment with comorbidities (hazard ratio, 5.9 [95% CI, 2.8-12.1]; P<0.001), clinical and biological severity (hazard ratio, 6.4 [95% CI, 2.4-17.8]; P<0.001), and echocardiography (hazard ratio, 3.6 [95% CI, 1.6-8.4]; P=0.002). In addition, tricuspid annular plane systolic excursion/systolic pulmonary artery pressure was associated with an incremental prognostic value (C-index improvement, P<0.01), over and above prognostic factors, including left ventricular ejection fraction.

Conclusions: This study highlights the independent and incremental prognostic value of tricuspid annular plane systolic excursion/systolic pulmonary artery pressure in HF with reduced ejection fraction during GDMT up-titration, suggesting to also consider RV to pulmonary artery coupling with echocardiography as a treatment goal.

Background: Biomarkers in heart failure (HF) provide mechanistic and prognostic insights, but their role in predicting treatment response is less understood. We evaluated whether multiple baseline biomarker profiles from the REHAB-HF trial (Rehabilitation Therapy in Older Acute Heart Failure Patients) could stratify functional improvement following a 12-week physical rehabilitation intervention (RI).

Methods: Participants ≥60 years hospitalized with heart failure were randomized to a 12-week outpatient RI or attention control. Functional outcomes included changes in the short physical performance battery and 6-minute walk distance. Blood collected at baseline and 12 weeks was analyzed for cardiac (cTnI and cTnT, NT-proBNP [N-terminal pro-brain natriuretic peptide]), renal (creatinine), and inflammatory (CRP [C-reactive protein]) biomarkers. Associations between baseline biomarker levels and 12-week functional gains by treatment group were evaluated using adjusted linear regression models and machine learning-based decision trees.

Results: Baseline biomarker data were available for 242 of 349 participants (69%). Using linear regression, higher cTnI and T were associated with greater 12-week gains in the short physical performance battery and 6-minute walk distance, respectively, among RI participants versus attention control (interaction P=0.040 and 0.032). In the decision tree, analyses combining all biomarkers, CRP emerged as the primary biomarker for both outcomes. Among participants with CRP ≥9.9 mg/L, RI was associated with a +2.4 point (95% CI, 1.8-3.1) greater increase in the short physical performance battery and a +79 m (95% CI, 50-109) greater increase in 6-minute walk distance compared with attention control. In contrast, for those with CRP <9.9 mg/L, the differential benefit of the RI was limited (+0.8 in short physical performance battery [95% CI, 0.1-1.6]; +30 m in 6-minute walk distance [95% CI, -1.0 to 61]). The biomarker levels (except for creatinine) decreased by 12 weeks posthospitalization, but with no differences based on treatment assignment.

Conclusions: Higher inflammation, measured by CRP, may identify older adults recently hospitalized for heart failure with the greatest functional benefit from a physical RI. Biomarker profiling may predict the benefits of this treatment.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02196038.

Background: Pregnant women with dilated cardiomyopathy (DCM) face high risks of complications and maternal death due to hemodynamic overload, withdrawal of teratogenic but essential therapies, and limited treatment options during pregnancy. To evaluate maternal and fetal outcomes in women with DCM during pregnancy and up to 12 months postpartum, across different etiologies, and identify predictors of maternal death.

Methods: Prospective cohort of pregnant women with confirmed DCM enrolled in the InCor Pregnancy and Heart Disease Registry. All received standardized cardio-obstetric care. Left ventricular ejection fraction was assessed by echocardiography; brain natriuretic peptide was evaluated when available. Treatment during pregnancy included β-blockers, hydralazine, diuretics, nitrates, enoxaparin, and hospitalization when needed. Guideline-directed therapy was resumed postpartum. Outcomes included maternal (heart failure, arrhythmias, thromboembolism, death) and obstetric/fetal complications. Logistic regression identified predictors of maternal mortality.

Results: Among 983 registry patients (2013-2023), 90 had DCM. Causes were peripartum (32), idiopathic (21), myocarditis (15), Chagas disease (11), and others (11). Maternal complications occurred in 51.1% during pregnancy, 36.0% in the early postpartum period (up to 6 weeks after delivery), and 38.6% in the late postpartum period (from 6 weeks to 12 months after delivery). All 9 maternal deaths (10%) occurred postpartum-mostly due to heart failure-at a mean of 8.8±3.1 months. Cesarean section was performed in 75%, with 10% fetal loss and 33.8% prematurity. Mean birth weight was 2606 g. Left ventricular ejection fraction improved from 32% at diagnosis to 39% during pregnancy and 42% at 12 months. Lower left ventricular ejection fraction (odds ratio, 0.87; P=0.006) and prior thromboembolism (odds ratio, 15.5; P=0.017) were independent predictors of death.

Conclusions: Pregnancy in women with DCM was associated with high morbidity and late mortality. Reduced left ventricular ejection fraction and a history of thromboembolism were independent predictors of maternal death.

Background: Although obesity and insulin resistance (IR) are established risk factors for left heart dysfunction, their clinical impact in group 1 pulmonary hypertension (PH) remains unclear. We sought to determine the impact of excess adiposity versus IR on biventricular hemodynamic and functional reserve in group 1 PH.

Methods: Homeostasis model of insulin resistance and adiposity indices (body mass index [BMI], fat mass, waist circumference) were measured among group 1 patients with PH recruited to PVDOMICS (Redefining Pulmonary Hypertension Through Pulmonary Vascular Disease Phenomics). Functional capacity, and dynamic pulmonary capillary wedge pressure (PCWP) and right atrial pressure responses were compared stratified by obesity (BMI≥30 kg/m²) and IR status (HOMA-IR≥2.6) using repeated-measure mixed models.

Results: Among patients with group 1 PH (n=418), 158 (38%) had BMI≥30 kg/m² (94 [60%] of whom had IR), and 260 (62%) had BMI<30 kg/m² (74 [28%] of whom had IR). Among those with waist circumference measurement (n=375), 287 (77%) had excess adiposity by elevated waist/height ratio, with 214 (57%) having elevated waist circumference. Patients with obesity had worse quality of life, exercise capacity and left heart remodeling, along with higher resting/dynamic PCWP, right atrial pressure and cardiac output (P<0.0001 for all). Higher PCWP response with obesity persisted after adjusting for IR (IR-adjusted PCWP+2.5 mm Hg [95% CI, +1.4 to +3.6]; P<0.0001). All adiposity indices were consistently associated with PCWP response, but IR was not. Similar associations were observed between adiposity indices with higher right atrial pressure and cardiac output. Greater visceral adiposity as measured by body shape index (hazard ratio, 2.01 [95% CI, 1.16-3.47]; P=0.01) or weight-adjusted waist index (hazard ratio, 1.64 [95% CI, 1.10-2.46]; P=0.01) was associated with worse survival.

Conclusions: Excess adiposity is common in group 1 PH, occurring in 4 out of 5 patients by the more sensitive waist/height ratio, in contrast to only 2 out of 5 patients having obesity by traditional BMI criteria. Excess adiposity is associated with higher biventricular filling pressures, cardiac output demand, worse functional status and reduced survival. These data support trials of adipose-reducing therapies in patients with group 1 PH and excess adiposity.

Background: Anecdotal evidence suggests that symptoms and physical activity levels in patients with heart failure (HF) fluctuate considerably, though empirical data to support this claim are sparse. We examined how stable psychosocial traits (eg, intrinsic motivation), situational psychosocial states (eg, vitality), and HF symptoms vary in stable patients with HF and their association with physical activity.

Methods: The MOVIN-HF study (Mobile Health Intervention to Increase Activity in Heart Failure) was a prospective, observational study of patients with symptomatic HF. We collected data on (1) psychosocial traits at baseline and (2) twice daily ecological momentary assessments for 28 days of participants' symptoms and current psychosocial states. Physical activity was measured by smartwatch step counts. We evaluated the association between baseline psychosocial states and mean daily step counts and between ecological momentary assessments of symptoms and psychosocial states and short-term step counts (12 hours after ecological momentary assessments). Mixed effects models quantified associations.

Results: Between February and June 2024, 30 participants enrolled in the study; the mean age was 59.7 (SD, 13.6) years, 53% were female, and most (63%) had New York Heart Association class 2 HF symptoms. Baseline psychosocial traits like motivational quality were significantly associated with daily step count. For example, each 1-point increase in intrinsic motivation was associated with 39% higher daily step count (95% CI, 3%-87%). There was also significant variability in ecological momentary assessment scores of symptoms and psychosocial states: 10 (33%) participants experienced a 50% or greater change in HF symptoms, and 18 (60%) a 50% or greater change in vitality. HF symptoms and psychosocial states (eg, vitality, competence) were significantly associated with 12-hour step count.

Conclusions: Baseline psychosocial traits are associated with daily physical activity. In addition, symptoms and psychosocial states fluctuate frequently among patients with HF and are associated with short term physical activity. These findings suggest tailored interventions may improve physical activity levels.

Background: Women with obstructive hypertrophic cardiomyopathy often present with a greater burden of disease and worse prognosis. Whether there are sex-related differences in response to aficamten is unknown.

Methods: We performed a prespecified subgroup analysis of sex differences in the double-blind, randomized-controlled SEQUOIA-HCM trial (Safety, Efficacy and Quantitative Understanding of Obstruction Impact of Aficamten in HCM) of aficamten versus placebo in patients with obstructive hypertrophic cardiomyopathy. Baseline characteristics were compared using the t test for continuous variables and the χ² test for categorical variables. Prespecified primary (change in peak oxygen uptake) and secondary end points from baseline to end of treatment (week 24) were analyzed using linear regression models, adjusted for baseline values, β-blocker use, and exercise mode.

Results: Of the 282 participants, women (n=115) were older (64 years in women versus 56 years in men) and had lower Kansas City Cardiomyopathy Questionnaire Clinical Summary Score, higher NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels, and lower peak oxygen uptake at baseline. Women had smaller left ventricular chamber sizes, higher E/e' ratios, and higher left ventricular outflow tract gradients. At 24 weeks, there was a significant treatment-related increase in peak oxygen uptake in women (+1.5 [+0.7 to +2.4]) and men (+2.0 [+0.9 to +3.0]). Both women and men had significant treatment-related decreases in left ventricular outflow tract gradients at rest and with Valsalva, with no sex-by-treatment interaction at week 24 (P_interaction≥0.13). There was a significant improvement in Kansas City Cardiomyopathy Questionnaire Clinical Summary Score in women (11 [6-15]) and men (6 [2-9]; P_interaction=0.08). Women had a greater reduction in lateral E/e' ratio (P_interaction=0.01). The geometric mean proportional reduction in NT-proBNP was similar in women and men (P_interaction=0.10).

Conclusions: Women enrolled in SEQUOIA-HCM were older with worse baseline health status, higher NT-proBNP, and higher left ventricular outflow tract gradients compared with men. Despite these differences, both men and women derived significant benefits in the primary and secondary end points following treatment with aficamten.