Tag: heart failure

Categories : Cardiovascular Disease Surgeries & ProceduresTags :

Post-operative AF Linked to Risk of Hospitalisation for Heart Failure

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Associations between post-operative atrial fibrillation and incident heart failure hospitalisations. Credit: European Heart Journal

A study of over three million patients found that people who develop an atrial fibrillation (AF) after undergoing surgery have an increased risk of subsequent hospitalisation for heart failure.

The study, which is published in the European Heart Journal, showed that the risk of hospitalisation for heart failure among patients who developed AF after surgery increased regardless of whether or not the surgery was for a heart condition.

Among 76 536 patients who underwent heart surgery, 18.8% developed post-operative AF and the risk of hospitalisation for heart failure increased by a third compared to patients who did not develop AF. Among 2 929 854 patients without a history of heart disease who had surgery for non-heart-related conditions, 0.8% developed AF and the risk of hospitalisation for heart failure doubled.

The study’s first author, Dr Parag Goyal, Associate Professor of Medicine at Weill Cornell Medicine, said: “Our study, which to our knowledge is the largest study to date, shows that post-operative atrial fibrillation is associated with future heart failure hospitalisations. This could mean that atrial fibrillation is an important indicator of underlying but not yet detected heart failure; or it could mean that atrial fibrillation itself contributes to the future development of heart failure. While this study could not specifically address which of these mechanisms are at play, our hope is that this study will inspire future work into exploring the underlying mechanism seen in our important findings.

“Regardless of the mechanism, our study shows that post-operative atrial fibrillation is clearly an important entity that merits attention and incorporation into decision making. Most importantly, patients and doctors need to be more vigilant about heart failure symptoms among patients who develop post-operative atrial fibrillation. Those who do develop the condition may require more aggressive treatments for other risk factors for heart failure, such as high blood pressure, diabetes and narrowing of the arteries.”

Post-operative AF occurs in up to 40% of patients undergoing heart surgery and 2% of patients undergoing non-cardiac surgery. Doctors have tended to view it as a benign event, triggered by the stress of the surgery – but evidence is emerging that post-operative AF is linked to longer term problems such as stroke and death from any cause. Until now, there has been limited evidence regarding its association with subsequent heart failure.

For the current, retrospective study, the researchers collected data on hospital health claims from 2016 to 2018, adjusting for factors that could affect the results such as age, sex, race, insurance status, medical history and body mass index.

Study limitations include its observational nature which can only establish association, not causation. The study relies on administrative claims data and medical codes to identify medical conditions; it lacks more detailed information like management strategies for post-operative AF, and on the function and size of the left ventricle, which could affect the likelihood of developing AF.

The researchers hope to conduct further studies to understand the underlying mechanism and to investigate ways of preventing future hospitalisations for heart failure among patients who develop post-operative AF.

The researchers wrote in the conclusion that “In the meantime, clinicians should be aware that POAF [post-operative AF] may be a harbinger of HF.”

In an accompanying editorial, Dr Melissa Middeldorp and Professor Christine Albert, both from the Smidt Heart Institute at Cedars-Sinai, California, USA, write: “These data add to a growing body of literature suggesting that POAF is not just a transient response to surgery but may be reflective of underlying atrial and myocardial structural changes that not only predispose to the acute AF event but to other potentially related adverse cardiovascular events, such as HF hospitalisation.”

They write that further studies are needed for a better understanding of the mechanisms involved in placing people at greater risk of AF and post-operative heart failure is needed in order to reduce hospitalisation and deaths after surgery.

“With a greater understanding of patients’ full risk factor profile, we may advocate for early aggressive intervention at the initial manifestation of POAF, to improve outcomes and reduce rehospitalisation following cardiac and non-cardiac surgery,” they concluded.

Source: European Society of Cardiology

Categories : Cardiovascular Disease Metabolic DisordersTags :

New SGLT-2 Inhibitors Could Reduce Heart Failure Risk in Diabetes

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Diabetes - person measures blood glucose
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A study published in Annals of Internal Medicine has suggested that the new SGLT-2 inhibitors may be viable as a first-line treatment in patients with type 2 diabetes, with reduced odds of hospitalisation for heart failure compared to those receiving metformin.

In cardiovascular outcome trials among adults with type 2 diabetes (T2D), sodium-glucose co-transporter 2 inhibitors (SGLT-2i) have shown therapeutic promise, including reduced risk of hospitalisation for heart failure compared to placebo. However, SGLT-2i have mainly been evaluated as a second-line treatment – metformin is generally given as a first-line, antidiabetic treatment.

In this new study, researchers from the Brigham and Women’s Hospital compared cardiovascular outcomes among adults with T2D who initiated first-line treatment with either metformin or SGLT-2i. For the study, 8613 patients receiving SGLT-2i were matched to 17 226 patients receiving metformin.

The researchers reported that that patients receiving SGLT-2i showed a similar risk for myocardial infarction, stroke, and all-cause mortality, and a lower risk for hospitalisation for heart failure compared with patients who received metformin. The risk for adverse events was similar except for an increased risk for genital infections compared with those receiving metformin.

“Our results suggest that SGLT-2i may be considered as first-line treatment for patients with T2D and cardiovascular disease or who are at increased risk for cardiovascular events,” said lead author HoJin Shin, BPharm, PhD, of the Division of Pharmacoepidemiology and Pharmacoeconomics. “However, more evidence from randomised clinical trials or observational studies will help us to identify patients who would benefit most from using SGLT-2i as first-line type 2 diabetes treatment.”

Source: EurekAlert!

Categories : Cardiovascular Disease VaccinesTags :

In Flu Season, Vaccine Reduces Cardiovascular Events in Heart Failure

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Woman sneezing
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A randomised controlled trial showed that people with heart failure receiving an annual flu shot had lower rates of pneumonia and hospitalisation on a year-round basis and a reduction in major cardiovascular events during peak flu season – but not year-round.

The study, presented at the American College of Cardiology’s 71st Annual Scientific Session, is the first randomised controlled trial to assess the benefits of the flu vaccine in people with heart failure, who face a high risk of cardiovascular events. It was conducted in countries across Asia, Africa and the Middle East where getting a flu shot is not commonplace.

Lead author Mark Loeb, MD, said: “Although our prespecified endpoints were not significant, our data suggest that there’s a clinical benefit [to getting a flu shot] given the clear reduction in pneumonia, moderate reduction in hospitalisation and reduction in vascular events and deaths during periods of peak influenza. When taken together with previous trials and observational studies, the collective data demonstrate there is a substantial benefit to receiving a flu vaccine for people with heart failure.”

Heart failure is a condition in which the heart becomes too weak or stiff to pump blood effectively. Previous studies have shown that people with heart disease or cardiovascular risk factors face an elevated risk of complications when they contract influenza, but there has been a lack of evidence on whether flu vaccines can help to mitigate this risk specifically in people with heart failure.

The trial enrolled 5129 patients with heart failure in 10 countries where flu vaccines are not common. Participants did not routinely get flu shots and had previously received a flu shot no more than once during the three years preceding the trial. Participants were randomised to receive a flu shot or a placebo annually for up to three years, though they could still get a flu shot outside of the trial. Researchers tracked health outcomes for a median of 2.9 years. The trial’s primary endpoint was a composite of death from cardiovascular causes, non-fatal heart attack or non-fatal stroke. Its co-primary endpoint included a composite of any of these events plus hospitalisation for heart failure.

Overall, the composite primary endpoint occurred in 691 participants and 1470 experienced the composite co-primary endpoint. When analysed on a year-round basis there was no significant difference in the rates of these events between those who had received a flu vaccine and those who had not.

Separate analyses of hospitalisation, pneumonia and other respiratory outcomes however found that rates of pneumonia were 42% lower and hospitalisations were down 15% among those who received a flu shot.

The flu vaccine arm showed a significant reduction in the first primary endpoint, as well as reductions in all-cause death and cardiovascular death, when the analysis was limited to periods of peak influenza circulation. When influenza circulation was low, no significant difference was seen.

The researchers accounted for the differences in influenza circulation seasons. Based on these results, researchers said the flu vaccine did help to protect patients from influenza complications, including cardiovascular events.

“Many of the effects we found during peak flu circulation disappeared outside of it,” Dr Loeb said. “There’s no biological explanation for that other than influenza infections.”

While the study was conducted in countries where the flu vaccine is either not widely available or not common to receive, Dr Loeb said the results could likely be generalisable even in countries where flu vaccine uptake is higher. Study participants were allowed to get a flu vaccine outside of the study, but Dr Loeb said that there was no impact on the findings as very few did so. He added that the study was stopped early in four countries due to the COVID pandemic.

Loeb said that additional trials and large-scale observational studies could further clarify the health benefits of influenza vaccination in people with cardiovascular disease.

“I think this study offers an important message about vaccines generally – that it is important to do randomised controlled trials in populations that historically haven’t had a very high uptake of vaccines,” Dr Loeb said. “These types of [research] gaps have to be filled.”

Source: American College of Cardiology

Categories : Cardiovascular DiseaseTags :

Micronutrients Could Replenish Mitochondria in Cardiac Cells

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There is convincing evidence that micronutrients, such as iron, selenium, zinc, copper, and coenzyme Q10, can impact the function of cardiac cells’ energy-producing mitochondria to contribute to heart failure according to a review published in the Journal of Internal Medicine.

Research has established a relationship between poor cardiac performance and metabolic perturbations, including deficits in substrate uptake and utilisation, reduction in mitochondrial oxidative phosphorylation and excessive reactive oxygen species production. Together, these disturbances result in depletion of cardiac adenosine triphosphate (ATP) and loss of cardiac energy. Delivering more energy substrates such as fatty acids to the mitochondria will be worthless if the mitochondria can’t turn them into fuel. 

Micronutrients are required to efficiently convert macronutrients to ATP. However, studies have shown that up to 50% of patients with heart failure have deficiencies in one or more micronutrients. “Micronutrient deficiency has a high impact on mitochondrial energy production and should be considered an additional factor in the heart failure equation,” the authors argued. Their findings suggest that micronutrient supplementation could represent an effective treatment for heart failure.

“Micronutrient deficiency has a high impact on mitochondrial energy production and should be considered an additional factor in the heart failure equation, moving our view of the failing heart away from ‘an engine out of fuel’ to ‘a defective engine on a path to self-destruction’,” said co–lead author Nils Bomer, PhD, of the University Medical Center Groningen, in The Netherlands.

An accompanying editorial suggests a large trial to see if there is indeed a clinical benefit.

Source: Wiley

Categories : Cardiovascular Disease Metabolic DisordersTags :

A Surprising Benefit of Dapagliflozin in Patients with Heart Failure

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Dapagliflozin, widely used to treat type 2 diabetes, was shown to improve symptoms and physical limitations in patients with heart failure with preserved ejection fraction, according to clinical trial results reported in Nature Medicine.

Heart failure with preserved ejection fraction (HFpEF) occurs when the heart’s lower left chamber is unable to fill with blood properly. The condition accounts for approximately half of all heart failure cases and disproportionally affects older individuals. Patients with HFpEF can experience a host of debilitating symptoms linked to cardiometabolic abnormalities, including physical limitations, impaired cognition and poor quality of life. Life expectancy is also reduced for patients with this diagnosis, with 50% of patients with the diagnosis not expected to survive more than five years.

Finding ways to improve patients’ health and developing or identifying therapeutic interventions that not only reduce hospitalisation but also improve patient survival is key, the researchers said, but at present there are no available treatments that improve patient survival for patients with HFpEF.

Previous studies have shown that sodium glucose cotransporter 2 (SGLT2) inhibitors – which inhibit SGLT2 receptor proteins produced by the kidneys and are used to treat type 2 diabetes – reduces risk of cardiovascular death and heart failure-related hospitalisation in patients with HFpEF.

For this trial, the researchers measured patient-reported symptoms, physical limitations and function in patients with HFpEF who were taking dapagliflozin, an SGLT2 inhibitor drug.

A total of 324 patients with HFpEF, 56.8% women, were randomised to receive either dapagliflozin or placebo for 12 weeks and at the end of the trial were evaluated using the Kansas City Cardiomyopathy Questionnaire Clinical Summary Score, a measure of heart failure-related health status.
“It’s important to note the percentage of women that were enrolled in this study because usually women are under-enrolled in clinical trials,” pointed out study co-author Professor Sadiya Khan.

Compared to the placebo group, an overall improvement in patient-reported symptoms, physical limitations and exercise function was seen in the dapagliflozin group. Adverse events were also similar between both groups, the authors reported.

“It was definitely surprising and very exciting to see such a stark difference between the treatment group and the placebo group, that there was this clear separation that happened even over a short period of time,” Prof Khan said, adding that next steps will be to investigate dapagliflozin’s precise molecular mechanisms that enable its effectiveness.

Source: Northwestern University

Categories : Cardiovascular DiseaseTags :

Heart Failure Risk Further Increased by Aspirin Use

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Aspirin may increase heart failure risk in at-risk people
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Aspirin use is associated with a 26% higher risk of heart failure in people with at least one risk factor for it, according to a study published today in ESC Heart Failure. Risk factors included smoking, obesity, hypertension, high cholesterol, diabetes, and cardiovascular disease.

“This is the first study to report that among individuals with a least one risk factor for heart failure, those taking aspirin were more likely to subsequently develop the condition than those not using the medication,” said study author Dr. Blerim Mujaj of the University of Freiburg, Germany. “While the findings require confirmation, they do indicate that the potential link between aspirin and heart failure needs to be clarified.”

The influence of aspirin on heart failure is controversial, and so the study sought to investigate its association with heart failure incidence in people with and without heart disease and assess whether it is related to a new heart failure diagnosis in at-risk individuals.

The analysis included 30 827 individuals at risk for developing heart failure who were enrolled from Western Europe and the US into the HOMAGE study. The definition of “at risk” included one or more of the following: smoking, obesity, hypertension, high cholesterol, diabetes and cardiovascular disease. Participants were aged 40 years and older and were free of heart failure at baseline. Aspirin use was recorded at enrolment and participants were classified as users or non-users. Participants were followed-up for the first incidence of fatal or non-fatal heart failure requiring hospitalisation.

Average participant age was 67, 34% were women, and at baseline, a total of 7,698 participants (25%) were taking aspirin. During the 5.3-year follow-up, 1330 participants developed heart failure.

The investigators assessed the association between aspirin use and incident heart failure after adjusting for factors including demographic variables, medical history and medication. Taking aspirin was independently associated with a 26% raised risk of a new heart failure diagnosis.

For consistency, the researchers repeated the analysis after matching aspirin users and non-users for heart failure risk factors. In this matched analysis, aspirin was associated with a 26% raised risk of a new heart failure diagnosis. After excluding patients with a history of cardiovascular disease, in 22 690 participants (74%) without cardiovascular disease, aspirin use was still associated with a 27% increased risk of incident heart failure.

Dr Mujaj noted that “this was the first large study to investigate the relationship between aspirin use and incident heart failure in individuals with and without heart disease and at least one risk factor. Aspirin is commonly used – in our study one in four participants were taking the medication. In this population, aspirin use was associated with incident heart failure, independent of other risk factors.”

He concluded that “large multinational randomised trials in adults at risk for heart failure are needed to verify these results. Until then, our observations suggest that aspirin should be prescribed with caution in those with heart failure or with risk factors for the condition.”

Source: European Society of Cardiology

Categories : Cardiovascular DiseaseTags :

A Year of Exercise Reverses Heart Failure Signs

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In a small study, a year of exercise training helped to maintain or increase the youthful elasticity of the heart muscle among people in late middle age showing early signs of heart failure.

Published in Circulation, the research reinforces the notion that “exercise is medicine,” an important shift in approach, according to the researchers.

The study focused on heart failure with preserved ejection fraction, which is characterised by stiffening of the heart muscle and high pressures inside the heart during exercise. Once established, the condition is largely untreatable and causes fatigue, excess fluid in the lungs and legs, and shortness of breath.

“It is considered by some to be one of the most important virtually untreatable diseases in cardiovascular medicine,” said senior author Dr Benjamin Levine,  professor of internal medicine at UT Southwestern and director of the Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Dallas. “So, of course, if there are no therapies, then the most important thing to do is to figure out how to prevent it from happening in the first place.”

In previous studies, prolonged exercise training was shown to improve heart elasticity in younger people, but was ineffective for heart stiffness in people 65 and older. The researchers decided to see if committed exercise could improve heart stiffness in healthy, sedentary men and women ages 45 to 64.

The study recruited 31 participants who showed some thickening of the heart muscle and an increase in blood biomarkers associated with heart failure, even though they had no other symptoms such as shortness of breath.

Eleven were randomly assigned to a control group and prescribed a program of yoga, balance and strength training three times a week. The rest were assigned to an individually tailored exercise regimen that gradually ramped up until the participants were doing intensive aerobic interval training for at least 30 minutes at least twice a week, plus two to three moderate-intensity training sessions and one to two strength training sessions each week. 

After one year, the group assigned vigorous exercise training showed a physiologically and statistically significant improvement in measures of cardiac stiffness and cardiorespiratory fitness, compared to no change in the control group.

The results suggest late middle age may be a “sweet spot” for using exercise to prevent heart failure with preserved ejection fraction, before the heart gets too stiff, Prof Levine said. He compared the heart muscle to an elastic band: a new one stretches easily and snaps right back.

“That’s a youthful cardiovascular system,” he said. “Now, stick it in a drawer and come back 30 years later—it doesn’t stretch, and it doesn’t snap back. And that’s one of the things that happens to the circulation, both the heart and the blood vessels as we age, particularly with sedentary aging.”

However, the study cannot determine if the participants will still go on to develop heart failure. This question will have to be addressed by larger studies. Furthermore, it is difficult for people to adhere to an exercise program, and the intensive intervention studied may be difficult and expensive to replicate on a large scale.

Source: American Heart Association

Categories : Cardiovascular DiseaseTags :

New Approach to Address Cardiac Disease in Rheumatoid Arthritis

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A new approach to address cardiac disease in rheumatoid arthritis (RA) patients has been developed.

Currently patients suffering from RA are also particularly susceptible to diastolic dysfunction, a type of cardiac deficiency which may lead to heart failure, resulting in a higher mortality rate among such patients.
To address this unmet clinical need, researchers from Queen Mary’s William Harvey Research Institute (WHRI) responded by developing an experimental model of cardiomyopathy in inflammatory arthritis.

After several attempts, the researchers finally hit upon the right model by characterising experimental animals with arthritis. The animals developed cardiac diastolic dysfunction, recapitulating the symptoms presented by RA patients. Diastolic dysfunction means the heart is able to contract as normal but unable to dilate properly, ultimately leading to heart failure over time.

Professor Mauro Perretti, lead study author and Professor of Immunopharmacology at Queen Mary University of London said, “As is often the case, the description of a valid model of disease can open new vistas on pathogenic mechanisms as well as on novel therapeutic approaches. At present, the cardiomyopathy of patients affected by rheumatoid arthritis is not treated, and on top of this, current anti-rheumatic drugs (eg biologics or steroids) may even worsen it. As such there is an urgent therapeutic need to intervene and treat, if not cure, the cardiomyopathy of patients affected by rheumatoid arthritis.”

“The broad area of cardiac inflammation is largely unexplored. At the WHRI we have several groups addressing experimental and translational work on several syndromes of the heart. Thus, there is work on myocarditis, on diabetes-induced cardiomyopathy and now with this study, the cardiomyopathy of inflammatory arthritis. The WHRI at Queen Mary University of London is a place of excellence to study cardiac inflammation in all its multiple faces, thanks also to our partnership with the Barts Heart Centre at Barts Health NHS Trust.”

The study was published in PNAS.

Source: EurekAlert!

Categories : Cardiovascular Disease Neurodegenerative DiseasesTags :

Unexpected Cognitive Effect of ARNI Therapy in Heart Failure

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Despite fears about cognitive decline in heart failure patients taking angiotensin receptor-neprilysin inhibition (ARNI), an observational study found that the drug instead had a protective effect.

Adults with systolic heart failure taking sacubitril/valsartan (Entresto) starting from 2015–2019 had fewer neurocognitive diagnoses up to 5 years later compared with a those staying on angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) alone.

  • Alzheimer’s disease: 1.11% on ARNI vs 1.24% on ACE inhibitors/ARBs
  • Dementia: 4.18% vs 6.49%
  • Cognitive decline: 11.82% vs 14.53%

On the basis of the PARAGON-HF trial,  sacubitril/valsartan won a broad heart failure indication, reaching into the normal ejection fraction range, for prevention of cardiovascular death and hospitalisation.

“Experimental studies with sacubitril/valsartan have fueled theoretical concerns about neurocognitive side effects, but long-term clinical data are scarce,” noted Prabhjot Grewal, MD, of Stony Brook University Hospital in New York, who reported the findings for the Heart Failure Society of America annual virtual meeting.

She explained that neprilysin inhibition by sacubitril could theoretically inadvertently interfere with the degradation of beta amyloid in the central nervous system, where neprilysin is expressed, in addition to the kidneys where it is most abundant.

However there are many factors in cognitive decline in heart failure, such as the circulatory deficit itself; vascular dementia resulting from comorbidities such as hypertension and vascular disease; and Alzheimer’s disease or Lewy body dementia. By ameliorating heart failure and improving blood pressure, drugs such as ACE inhibitors and sacubitril/valsartan could protect cognition, according to Mandeep Mehra, MBBS, MSc, of Brigham and Women’s Hospital and Harvard Medical School in Boston.

“Thus, even if a drug like sacubitril may cause worsening of one type of cognitive decline, it may be counterbalanced by positive effects on other domains since the reasons for cognitive decline in such patients are almost always multi-factorial and the signals may therefore be obfuscated in general analyses,” explained Mehra, who was not involved in the study.

The authors acknowledged that the observational study lacked systematic characterisation, and also leaves room for residual confounding despite propensity matching.

“This is why we require a prospective study that includes mechanistic end points (degree of beta amyloid protein deposition) in concert with functional outcomes (sensitive measures of cognitive decline) while ensuring that sufficient time is allowed to be evaluated since these are slow and subtle effects,” Mehra said, adding that the PERSPECTIVE trial will likely publish findings in 2022.

Source: MedPage Today

Categories : Cardiovascular DiseaseTags :

Study Evaluates Efficacy and Tolerability of Ultrafiltration

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A new study evaluates the efficacy and renal tolerability of ultrafiltration in acute decompensated heart failure.

Acute decompensated heart failure (ADHF) is a life-threatening and costly disease. Controversy remains regarding the efficacy and renal tolerability of ultrafiltration for treating ADHF. This article by Yajie Liu and Xin Yuan from the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China, and published in Cardiovascular Innovations and Applications, evaluated this clinical issue.

After searching databases for relevant trials, their quality and outcomes were evaluated with the use of the risk of the bias assessment tool and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, respectively. Risk ratio and the standardised or weighted mean differences were computed and pooled with fixed-effects or random-effects models.

The 19-study meta-analysis, involving 1281 patients, found that ultrafiltration was superior to control for weight loss (1.24kg) and fluid removal (1.55L) and was associated with a significant increase in serum creatinine level compared with the control treatments (0.15 mg/dL).
No significant effects were found for serum N-terminal prohormone of brain natriuretic peptide level, length of hospital stay, all-cause mortality, or all-cause rehospitalisation in the ultrafiltration group.

Overall, the meta-analysis found that use of ultrafiltration in patients with ADHF is superior to control treatments for weight loss and fluid removal but has adverse renal effects and lacks significant effects on long-term prognosis.

Source: News-Medical.Net