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Patients residing in socioeconomically deprived neighborhoods experience higher hospital readmission rates after hospitalization for heart failure (HF). The role of medication access in the excessive readmissions in this group is poorly understood. This study explored patients' perspectives on medication access by individuals living in socioeconomically deprived neighborhoods who had experienced HF readmission. We conducted semistructured in-depth interviews with 25 patients (mean age 61 ± 9 years, 96% Black, 40% women) who were readmitted with acute HF at Emory Healthcare hospitals and were living in highly deprived neighborhoods (top decile of the Social Deprivation Index). Qualitative descriptive analyses of the interviews were performed by using a multilevel coding strategy. Most patients (84%) highlighted medications as a driver of HF readmission. Patients' reported reasons for lack of medication access included medication costs (60%), having access to refills only through an emergency department or hospitalization (36%), limited access to transportation (12%), and limited understanding of medications' role in disease management (12%). Lack of access to medications for patients with HF who live in socioeconomically distressed neighborhoods exacerbate excess hospitalizations in this vulnerable population. This study focuses on patients' perspectives and experiences and identifies some potentially high-value areas to focus on in trying to enhance access and adherence to evidence-based therapies. [ABSTRACT FROM AUTHOR]

Evidence-based medical therapy for heart failure with reduced ejection fraction (HFrEF) often entails substantial out-of-pocket costs that can vary appreciably between patients. This has raised concerns regarding financial toxicity, equity, and adherence to medical therapy. In spite of these concerns, cost discussions in the HFrEF population appear to be rare, partly because out-of-pocket costs are generally unavailable during clinical encounters. In this trial, out-of-pocket cost information is given to patients and clinicians during outpatient encounters with the aim to assess the impact of providing this information on medication discussions and decisions. Cost-informed decision-making will be facilitated by providing access to patient-specific out-of-pocket cost estimates at the time of clinical encounter. Integrating Cost into Shared Decision-Making for Heart Failure with Reduced Ejection Fraction (POCKET-COST-HF) is a multicenter trial based at Emory Healthcare and University of Colorado Health. Adapting an existing patient activation tool from the EPIC-HF trial, patients and clinicians are presented a checklist with medications approved for treatment of HFrEF with or without patient-specific out-of-pocket costs (obtained from a financial navigation firm). Clinical encounters are audio-recorded, and patients are surveyed about their experience. The trial utilizes a stepped-wedge cluster randomized design, allowing for each site to enroll control and intervention group patients while minimizing contamination of the control arm. This trial will elucidate the potential impact of robust cost disclosure efforts and key information regarding patient and clinician perspectives related to cost and cost communication. It also will reveal important challenges associated with providing out-of-pocket costs for medications during clinical encounters. Acquiring medication costs for this trial requires an involved process and outsourcing of work. In addition, costs may change throughout the year, raising questions regarding what specific information is most valuable. These data will represent an important step towards understanding the role of integrating cost discussions into heart failure care. NCT04793880. [ABSTRACT FROM AUTHOR]

The 14th Annual Report from The Society of Thoracic Surgeons (STS) Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) describes outcomes of 27,493 patients with a continuous-flow left ventricular assist device (LVAD) from the past decade (2013-2022). In 2022, 2517 primary LVADs were implanted, of which 2512 (99.8%) were fully magnetically levitated (Mag-Lev) devices. This shift to nearly exclusive use of a Mag-Lev device led us to examine its outcomes compared with contemporary (2018-2022) and historical (2013-2017) non–Mag-Lev cohorts. Patients supported by a Mag-Lev device (n = 10,920) had a higher 1- and 5-year survival of 86% (vs 79% and 81%, P <.0001) and 64% (vs 44% and 44%, P <.0001), respectively, than those receiving non–Mag-Lev devices during the contemporary and historical eras. Over 5 years, freedom from gastrointestinal bleeding (72% vs 60%, P <.0001), stroke (87% vs 67%, P <.0001), and device malfunction/pump thrombus (83% vs 54%, P <.0001), but not device-related infection (61% vs 64%, P =.93), was higher with Mag-Lev devices compared with non–Mag-Lev support during the contemporary era. In this large primacy cohort of real-world patients with advanced heart failure, this report underscores marked improvements in short- and intermediate-term survival and reduction of adverse events with a contemporary Mag-Lev LVAD. [Display omitted] [ABSTRACT FROM AUTHOR]

Some patients with heart failure (HF) have low natriuretic peptide (NP) levels. It is unclear whether specific populations are disproportionately excluded from participation in randomized clinical trials (RCT) with inclusion requirements for elevated NPs. We investigated factors associated with unexpectedly low NP levels in a cohort of patients hospitalized with HF, and the implications on racial diversity in a prototype HF RCT. We created a retrospective cohort of 31,704 patients (age 72 ± 16 years, 49% female, 52% Black) hospitalized with HF from 2010 to 2020 with B-type natriuretic peptide (BNP) measurements. Factors associated with unexpectedly low BNP levels (<50 pg/mL) were identified using multivariable logistic regression models. We simulated patient eligibility for a prototype HF trial using specific inclusion and exclusion criteria, and varying BNP cut-offs. Unexpectedly low BNP levels were observed in 8.9% of the cohort. Factors associated with unexpectedly low BNP levels included HFpEF (aOR 3.76, 95% CI: 3.36, 4.20), obesity (aOR 1.96, 95% CI: 1.73, 2.21), self-identification as Black (aOR 1.53, 95% CI: 1.36, 1.71), and male gender (aOR 1.45, 95% CI: 1.31, 1.60). Applying limited clinical inclusion and exclusion criteria from PARAGLIDE-HF disproportionately excluded Black patients, with impairment in renal function having the greatest impact. Adding thresholds for BNP of ≥35, ≥50, ≥67, ≥100, and ≥150 pg/mL demonstrated the risk of exclusion was higher for Black compared to non-Black patients (RR = 2.03 [95% CI: 1.73, 2.39], 1.90 [95% CI: 1.68, 2.15], 1.63 [95% CI: 1.48, 1.81], 1.38 [95% CI: 1.28, 1.50], and 1.23 [95% CI: 1.15, 1.31], respectively). Nearly 10% of patients hospitalized with HF have unexpectedly low BNP levels. Simulating inclusion into a prototype HFpEF RCT demonstrated that requiring increasingly elevated NP levels disproportionately excludes Black patients. [ABSTRACT FROM AUTHOR]

Heart failure (HF) remains a condition associated with high morbidity, mortality, and associated costs. Although the number of medical and device-based therapies available to treat HF are expanding at a remarkable rate, disparities in the risk for incident HF and treatments delivered to patients are also of growing concern. These disparities span across racial and ethnic groups, socioeconomic status, and apply across the spectrum of HF from stage A to stage D. The complexity of HF risk and treatment is further impacted by the number of patients who experience the downstream impact of social determinants of health. The purpose of this document is to highlight the known health care disparities that exist in the care of patients with HF and to provide a context for how clinicians and researchers should assess both biological and social determinants of HF risk in vulnerable populations. Furthermore, this document provides a framework for future steps that can be used to help diminish inequalities in access and clinical outcomes over time, and offer solutions to help decrease disparities within HF care. [ABSTRACT FROM AUTHOR]

The objective of this study was to investigate decisional regret among left ventricular assist device (LVAD) patients and their caregivers. This study was a single center, cross-sectional survey of patients after LVAD implantation and their caregivers. Subjects were recruited at their outpatient heart failure appointments. Patients and caregivers at least three months from LVAD implantation completed a 5-item, validated decisional regret scale. Summative scores on a 0–100 point scale were determined for patient and caregivers (0 = no regret). Subgroup analysis included gender, LVAD indication (bridge to transplant (BTT) or destination therapy (DT)), time from LVAD implantation, and caregiver relationship. Dyad discordance was defined as a patient-caregiver difference of ≥2 points on any regret scale question. Fifty patients were approached for participation. Thirty-three LVAD patient-caregiver dyads were enrolled in the study (19 male, 14 female patients; 8 male, 25 female caregivers). Patients had a mean age of approximately 50 years. Caregivers had a mean age of approximately 54 years. Patients had a median regret score of 10 (Interquartile range (IQR): 0–30), while caregivers had a median regret score of 20 (IQR: 0–25). Median regret scores of female patients were significantly higher than that of male patients (27.5 vs 0, p = 0.0038). BTT patients had numerically lower regret than DT patients, but this was not statistically significant. Patients who had been implanted for greater than three years had the highest regret scores. Discordance in at least one domain of the regret scale was present in 19 out of 33 (57.6%) dyads. While decisional regret was reasonably low in this population, comparatively, there was significantly increased decisional regret among female patients and patients further from LVAD implantation. Differences between patients and caregivers were also observed. These findings highlight the need for robust support and continual attention to expectations before and after LVAD implantation. [ABSTRACT FROM AUTHOR]

In chronic systolic heart failure, a proportional pulse pressure (PPP), defined as [systolic-diastolic blood pressure]/systolic blood pressure, ≤ 25% is highly predictive of cardiac index (CI) ≤ 2.2 L/min/m2, pulmonary capillary wedge pressure (PCWP) > 18 mmHg, and increased mortality. The utility of PPP in predicting CI in amyloid transthyretin cardiomyopathy (ATTR-CM) with systolic heart failure is unclear. A proportional pulse pressure ≤ 25% is highly sensitive and specific for a cardiac index ≤ 2.2 L/min/m2 in ATTR-CM with systolic heart failure, similar to other forms of chronic systolic heart failure. Retrospective chart review identified 26 patients with ATTR-CM who had systolic heart failure (EF ≤ 40%) and underwent right heart catheterization (RHC) off inotrope or mechanical support. The PPP at the time of catheterization was compared with the measured Fick cardiac index. An echocardiogram closest to the time of RHC was analyzed for additional non-invasive hemodynamic data. The correlations between hemodynamics and clinical measurements were assessed with linear regression and 2 × 2 tables to determine specificity and sensitivity. Of the 26 patients with ATTR-CM and systolic heart failure undergoing RHC, 23 (88%) were male, 25 (96%) had Hereditary Valine 122 Isoleucine ATTR-CM, and the median age was 73 (55 - 85) years. Three patients (12%) had previously been on inotrope support. The average echocardiographic ejection fraction was 23 ± 8% with mean left ventricular (LV) end-diastolic diameter 4.5 ± 0.6 cm and LV interventricular septum diameter 1.7 ± 0.4 cm. Average RHC hemodynamics recorded mean arterial pressure 92 ± 12 mmHg and pulse pressure 36 ± 13 mmHg for PPP 31 ± 8%, corresponding with average PCWP 21 ± 8 mmHg and Fick CI 1.67 ± 0.4 L/min/m2. 5 out of 6 patients with PPP ≤ 25% had CI ≤ 2.2 L/min/m2; however, only 2 of 20 patients with PPP > 25% had CI > 2.2 L/min/m2 (P=.256), correlating with a sensitivity of 22%, specificity of 67%, negative predictive value of 10%, and positive predictive value of 83% (Figure 1). Low PPP ≤ 25% was not sensitive or specific for reduced cardiac index ≤ 2.2 L/min/m2 in our ATTR-CM systolic heart failure cohort. However, there was a high positive predictive value for low PPP and reduced cardiac index. Patients in our cohort had low ejection fraction and increased LV thickness but did not have significant LV dilation, which may account for the lack of correlation with low PPP as seen in a more generalized systolic heart failure population. Non-invasive hemodynamic monitoring can be challenging in the ATTR-CM population. Further investigation may be required to determine more reliable markers of low cardiac output. [ABSTRACT FROM AUTHOR]

Patients listed for heart transplantation (HT) supported by intra-aortic balloon pump (IABP) or Impella (Abiomed, Danvers, MA) are accorded a higher waitlist status under the new 2018 heart allocation system. The effect of device duration of support on waitlist or post-transplant outcomes is unclear. The purpose of this study is to investigate the association of IABP or Impella duration of support with waitlist and post-transplant outcomes in patients listed for HT. The United Network for Organ Sharing database was queried for adults listed for HT who were supported with an IABP or Impella (2.5, 5.0, CP, or RP) between October 2018 and March 2020. Patients were stratified into tertiles according to duration of support by device type. Competing risks analysis was used to examine the risk of waitlist mortality or delisting, accounting for HT. One year post-HT stroke, dialysis, and acute rejection were analyzed using logistic regression models. Survival at 1-year was analyzed using Cox proportional hazards modeling. A total of 2823 listed patients were supported with an IABP (n=2494) or Impella (n=329) during the study period. The median [IQR] duration of device support was 9 [5, 17] days with IABP and 12 [6, 24.5] days with Impella. There were no differences in waitlist mortality/delisting by duration of support according to device type (IABP: >13 days ref., 6-13 days HR 1.18, 95% CI 0.41-3.40, <6 days HR 1.89, 95% CI 0.70-5.11; Impella: >18 days ref., 8-18 days HR 0.34, 95% CI 0.09-1.28; <6 days HR 0.26, 95% CI 0.06-1.20). Patients in the longest tertile of device support were less likely to receive transplant compared to patients in the shortest and middle tertiles (Figure, p<0.001 for IABP and Impella). Among those who successfully reached HT after support with an IABP (n=2418, 97%) or Impella (n=298, 90.6%), rates of stroke, need for dialysis, and acute rejection post-HT were similar between the IABP groups and the Impella groups. There were no differences in post-HT survival by duration of support at 1 year among patients with IABP (>13 days ref., 6-13 days HR 0.97, 95% CI 0.83 - 1.13, <6 days HR 0.94, 95% CI 0.80-1.10) or Impella (>18 days ref., 8-18 days HR 0.82, 95% CI 0.49-1.36, <6 days HR 0.86, 95% CI 0.49-1.52). Waitlist mortality and post-HT outcomes are comparable regardless of duration of support in patients supported by IABP, as well as those supported by Impella. [ABSTRACT FROM AUTHOR]

Acute kidney injury is common during support with microaxial percutaneous left ventricular assist devices (pLVAD) for cardiogenic shock. The effect of baseline renal function on outcomes in subjects listed for heart transplantation (HT) supported with pLVAD remains unknown. We investigated the association between baseline renal function and waitlist outcomes in listed patients supported with an Impella. We utilized de-identified data from the United Network for Organ Sharing database on adults listed for HT who were supported with an Impella 5.0 or Impella 5.5 (Abiomed, Denver, MA) for cardiogenic shock between October 2018 and March 2020. Patients were stratified into three groups based on their estimated glomerular filtration rate (eGFR) (< 30 vs. 30-60 vs. > 60 mL/min/1.73m2) at listing. Paired t-tests were used to assess the change in renal function from listing to the time of transplant for all 3 groups. The competing risks of waitlist mortality or transplantation were examined using the Fine-Grey sub-distribution hazard model. Of 272 patients (mean age 54±13) supported with an Impella while listed for HT during the study period, 37 (13.6%) had an eGFR < 30, 101 (37.1%) had an eGFR 30-60, and 134 (49.3%) had an eGFR > 60 at the time of listing. Duration of support was comparable between all groups (14 vs. 13 vs. 12 days; p=0.209). Median waitlist time was 15 (IQR 7, 43) days, with no significant difference between groups. At the time of transplant, the changes in eGFR [GFR group; delta: p value] were [GFR < 30; +13.3; <0.001], [GFR 30-60; +9.9; <0.001] and [GFR > 60; -10.5; <0.001]. Baseline renal function [ref: eGFR > 60] was not associated with waitlist mortality [eGFR 30-60: hazard ratio (HR) 3.57; 95% confidence interval (CI) 0.73-17.50, eGFR < 30: HR 1.73; 95% CI 0.39-7.70] or transplantation [eGFR 30-60: HR 0.98; 95% CI 0.75-1.26, eGFR < 30: HR 1.08; 95% CI 0.75-1.26]. In patients listed for HT who supported with an Impella for cardiogenic shock, baseline renal function had no impact on waitlist outcomes. Between listing and transplant, a significant improvement in eGFR was seen in patients listed with severely reduced eGFR. [ABSTRACT FROM AUTHOR]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2008.12.012 Byline: Michelle A. Albert, Guillaume Pare, Alanna Morris, Lynda Rose, Julie Buring, Paul M. Ridker, Robert Y.L. Zee Abstract: Although inflammation is a core element of atherogenesis and plasma levels of fibrinogen (FGB), homocysteine, and intercellular adhesion molecule-1 (ICAM-1) differ by race/ethnicity, little is known about the role of genetic polymorphisms in the FGB, methylenetetrahydrofolate reductase (MTHFR), and ICAM-1 genes in determining plasma levels of these biomarkers. We examined the relationship between specific polymorphisms in the FGB, homocysteine, and ICAM-1 genes and their respective inflammatory biomarker concentrations at baseline in women from different race/ethnic groups. Author Affiliation: Center for Cardiovascular Disease Prevention, Donald W. Reynolds Center for Cardiovascular Disease Research, Divisions of Cardiovascular Diseases and of Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston MA Article History: Received 15 July 2008; Accepted 15 December 2008

Abstract Objective It remains unclear whether left ventricular assist device (LVAD) implantation in non-inotrope dependent patients is of clinical benefit. This study sought to evaluate cause of death in patients listed for heart transplant (HT) to determine the relative risks and benefits of implanting LVAD into patients who are less sick than those included in the original clinical trials. Methods We examined death as the primary outcome in 23,098 patients listed for HT from 2006 to 2014 using proportional subdistribution hazards modeling. Cause of death was examined as a secondary outcome using χ2 tests. Results 1859 (8.1%) patients were removed from the wait list for death, including 229 (2.7%) status 1A, 349 (4.6%) status 1B, 246 (13.2%) status 2, and 1035 (26.0%) status 7 patients (P < 0.0001). Status 2 patients who received LVAD while listed had a higher risk of death compared to those who did not (adjusted HR 1.68; 95% CI 1.09–2.59; P = 0.02), while there was no increased risk of death in status 1A (HR 1.02; 95% CI 0.68–1.51; P = 0.9) and status 1B (HR 0.89; 95% CI 0.65–1.23; P = 0.5) who received LVAD. Status 2 patients who received LVAD were more likely to die cerebrovascular causes (0.6% vs. 0.1%, P = 0.009) and organ failure (70.6% vs. 29.4%, P = 0.003). Conclusions LVAD implantation in status 2 patients listed for HT is associated with a higher risk of death. More research is needed to determine the impact LVAD implantation will have on mortality in patients with ambulatory, non-inotrope dependent HF. [ABSTRACT FROM AUTHOR]

Transthyretin amyloid cardiomyopathy (ATTR-CM) is gaining recognition as a cause of heart failure (HF) in adults. The most common genetic mutation implicated in hereditary ATTR-CM (hATTR-CM), V142I, occurs in 3.4% of Black Americans. Although commonly associated with preserved ejection fraction (EF), patients with hATTR-CM may also present with reduced ejection fraction (<40%). The purpose of this study is to examine the relationship between EF and rates of mortality and hospitalization. Reduced EF in hATTR-CM is associated with greater rates of HF hospitalization and mortality. We conducted a retrospective chart review of patients diagnosed with ATTR-CM with V142I mutations enrolled in Emory University's Cardiac Amyloidosis Clinic between January 2014 and February 2022. Cox proportional hazard modeling was used to examine the association between EF, survival, and HF hospitalizations after confirmed TTR amyloidosis diagnosis. Models were adjusted for baseline patient characteristics including sex, body mass index (BMI), and echocardiogram measurements, as well as social/ecological factors (I.e., neighborhood social deprivation index). There were 111 patients (mean age 71.9 years, 71% male, 95% Black) with the V142I mutation in our cohort. Women presented with an EF > 40% more often than men (55% v 30%, p = 0.017). Patients with EF > 40% had higher scores on neighborhood social deprivation index (median [IQR] 81 [55, 92] v. 61 [42, 81], p=0.015), higher rates of diabetes (46.3% v. 32.2%, p=0.033), and higher body mass index (BMI) (29.2 [23.8, 28.8] v. 25.3 [26.0, 32.6], p=0.001). In adjusted Cox models, patients with an EF > 40% were as likely as patients with an EF < 40% to experience death (hazard ratio [HR] 0.73, 95% confidence interval [95% CI] 0.10-5.06) or heart failure (HF) hospitalization (HR 0.36, 95% CI 0.07-1.95). Ejection fraction was not a predictor of death or HF hospitalization in our hereditary amyloid cohort. Our analysis was limited by few events, perhaps due to the advent and increasingly common use of TTR stabilizing drugs to slow the progression of disease. [ABSTRACT FROM AUTHOR]

Val142Ile transthyretin cardiac amyloidosis is an underrecognized and undertreated cause of cardiomyopathy in the US, with 3-4% of African Americans being carriers of the mutation. Thought to be more common in males, there is little data regarding the role of sex on outcomes such as mortality and heart failure hospitalization in patients with Val122Ile CM. Men with Val142Ile ATTR-CM have higher rates of heart failure hospitalization and mortality as compared to women. Retrospective chart review identified a total of 111 patients with genetic confirmation of Val142Ile hATTR-CA and either positive technetium pyrophosphate (PYP) scanning or endomyocardial biopsy. Cohorts were divided based on sex and clinical data was collected from time of diagnosis. Cox proportional hazard modeling was used to compare and determine the association between gender, survival, and heart failure hospitalizations after adjusting for baseline patient characteristics, biomarkers, echocardiographic data, and social factors. Out of the 111 patients in our cohort, 79 (71%) were males and 32 (29%) were females. Women were significantly older than men at the time of diagnosis, 76 [72, 81] vs 71 [66, 76], p=0.003. NYHA classification was similar between sexes with the majority presenting with class II or III symptoms. Women had significantly higher rates of hypertension (28 [87.5%] vs 65 [68.4%], p=0.038), whereas men had significantly higher rates of coronary artery disease (18 [22.8%] vs 2 [6.3%], p=0.040). All other comorbidities and extracardiac manifestation were similar between the sexes. Troponin, BNP, pre-albumin, and estimated glomerular filtration rate were not significantly different. Electrocardiographic data, arrhythmia rates, and cardiac implantable device rates were similar between genders. Several echocardiographic variables at the time of diagnosis were significantly different: left ventricular ejection fraction (LVEF, %) was lower in men compared to women (30 [25,45] vs 45 [30,55], p=0.035), whereas left ventricular end-diastolic diameter (LVeDd, mm) and mass index (LVMI, g/m2) were both higher in men (44 [40,49] vs 40 [34, 42], p < 0.001 and 148 [122, 193] vs 122 [97,155], p = 0.002 respectively). On multivariate analysis, women were just as likely to experience death or heart failure hospitalizations as men. Women with Val142ile are older and present with a higher LVEF at the time of diagnosis as compared to men. Rates of death and heart failure hospitalizations were not significantly different between men and women. [ABSTRACT FROM AUTHOR]

Transthyretin cardiomyopathy (ATTR-CM) is a progressive disease characterized by the deposition of misfolded amyloid fibrils in the myocardium. The most common hereditary mutation associated with its development, V142I, is estimated to affect 3.4% of African Americans. ATTR-CM is typically described as a restrictive physiology presenting as heart failure with preserved ejection fraction (EF). However, patients with EF less than 40% have been increasingly reported. Furthermore, social characteristics in these patients have not been previously assessed. The purpose of this study is to evaluate clinical and social factors associated with reduced EF in patients with ATTR-CM with V142I mutation. ATTR-CM patients with reduced EF are more likely to have greater comorbidity burden and greater neighborhood social deprivation than ATTR-CM patients with preserved EF. We conducted a retrospective chart review of V142I patients enrolled in Emory University's Cardiac Amyloidosis Clinic between January 2014 and February 2022. Cohorts were divided based on EF (≤ 40% or >40%), and clinical, demographic, and echocardiographic data was collected from time of diagnosis. Social deprivation index (SDI), a composite measure of deprivation based on seven demographic characteristics including percent of a given population living in poverty, was collected based on patient zip codes. Chi-square tests and Mann-Whitney U tests were used to identify statistically significantly differences in categorical and continuous characteristics between groups respectively. There were 111 patients (mean age 71.9 years, 71% male, 95% Black, 61% EF≤40) with V142I mutation in our cohort. Compared to patients with preserved EF, patients with reduced EF were more often male (80% v. 59%, P=0.017), married (77% v. 51%, P=0.040), and had a lower neighborhood social deprivation index (SDI) score (median [IQR] 61 [42, 81] v. 81 [55, 92], P=0.015). Clinically, patients with reduced EF had lower body mass index (BMI) compared to preserved EF (25.3 [26.0, 32.6] v. 29.2 [23.8, 28.8], P=0.001), were less likely to have diabetes mellitus (23% v. 46%, P=0.033), and had greater BNP levels (844 [534, 1133] v. 396 [189, 705], P<0.001). On echocardiogram, patients with reduced EF had greater posterior wall diameters (mm) (16 [14, 19] v. 15 [13, 17], P=0.046), left ventricular end diastolic diameters (mm) (42 [40, 50] v. 41 [36, 44], P=0.021), and left ventricular mass indices (g/m2) (152 [125, 194] v. 118 [99, 162]). Diastolic dysfunction was worse in patients with reduced EF (92% v. 72%, P=0.024) and these patients were more likely to experience ventricular arrhythmias (58% v. 22%, P<0.001) and require an implantable cardiac defibrillator (ICD) (32% v. 5%, P=0.003). V142I-hATTR-CM patients with reduced EF had lower neighborhood social deprivation index scores, were more likely to be married, and had better or equivalent comorbidity profiles compared to those with preserved EF. Further studies are necessary to determine the cause of the lower EFs observed in certain ATTR-CM patients. [ABSTRACT FROM AUTHOR]

Recent randomized clinical trials (RCT) in heart failure (HF) have increasingly required elevated natriuretic peptide (NP) levels as an inclusion criteria. Some patients with HF have unexpectedly low NP levels (e.g., Black patients, obese patients, patients with HF with preserved ejection fraction [HFpEF]). Currently, it is unclear whether these populations are disproportionately excluded from RCT participation due to the requirement for elevated NPs, with some suggesting utilizing a 20-30% lower threshold for NPs under these circumstances. Here, we investigate demographic and clinical factors associated with unexpectedly low NP levels in a diverse cohort of patients hospitalized with HF, and the potential implications on inclusion of Black patients into a prototype HF RCT. We created a retrospective cohort of 31,704 patients (age 72 ± 16 years, 49% female, 52% Black, 53% HFpEF) hospitalized with acute HF at Emory Healthcare from 2010 to 2020 with B-type natriuretic peptide (BNP) measurements at admission. We quantified the prevalence of patients with unexpectedly low BNP levels (<50 pg/ml). Factors associated with low BNP levels were identified using multivariable logistic regression models, adjusted for age, gender, race, BMI, EF, eGFR, atrial fibrillation, and Social Deprivation Index. We simulated how many patients from our real-world cohort would be eligible for the PARAGON-HF trial using specific inclusion (age ≥ 55, EF ≥ 45 %) and exclusion (Hgb < 10, BMI > 40, SBP ≥ 180, SBP < 110, eGFR < 30, K > 5.2) criteria, as well as varying cut-offs for BNP. Unexpectedly low BNP levels were observed in 8.9% of the overall cohort, and Black patients were more likely than White patients to have low BNP levels (10.9% vs. 6.6%, p<.01). On multivariable analysis, factors associated with unexpectedly low BNP levels included HFpEF (aOR 3.76, 95% CI 3.36-4.20), BMI >30 kg/m2 (aOR 1.96, 95% CI 1.73 - 2.21), self-identification as Black (aOR 1.53, 95% CI 1.36 - 1.71), and male gender (aOR 1.45, 95% CI 1.31-1.60). Applying the limited inclusion and exclusion criteria from PARAGON-HF, n=3065 patients were eligible of which 1202 (39.2%) were Black. Adding a criteria of BNP > 50 , >100, and >150 pg/ml further decreased the total number (n=2616, 2177, and 1885) and the proportion of Black patients (36.1%, 35.5%, and 35.6%, all p≤.01) eligible, respectively. Unexpectedly low BNP levels were present in nearly 10% of a diverse cohort of patients hospitalized with acute HF. Simulating inclusion into a prototype RCT demonstrated that requiring increasingly elevated NP levels disproportionately excluded Black patients. [ABSTRACT FROM AUTHOR]

Although cardiovascular disease contributes outsized mortality in patients from underrepresented racial-ethnic groups, recruiting diverse patients for genomic research has been a challenge. Trust in medical researchers and knowledge of genetics may influence patients' decision to participate in genetic studies. Little is known about how trust in researchers varies by race and ethnicity among patients with dilated cardiomyopathy (DCM) and if it is associated with patients' knowledge of genome-sequencing. Understanding these may help identify barriers to research participation and develop strategies to educate patients about the role of genetics in cardiovascular disease. This study aimed to 1) assess racial and ethnic disparities in genome-sequencing knowledge and trust in researchers among patients with DCM and 2) determine the role of genome-sequencing knowledge in the association of trust with race and ethnicity. We hypothesize that better genetic knowledge may partially mitigate racial and ethnic differences in trust of researchers. A cross-sectional study was conducted by a consortium of 25 US heart failure programs. Participants included patients with DCM defined as left ventricular systolic dysfunction and left ventricular enlargement after excluding usual clinical causes. Enrollment occurred from June 7, 2016 to March 15, 2020. Knowledge of genome sequencing and trust in researchers were assessed by previously established questionnaires. Mixed effect models with a site random effect were used to estimate percentages, means, and associations of genome-sequencing knowledge scores and research trust scores for Hispanic, non-Hispanic White and non-Hispanic Black participants, after adjusting for confounding variables. Among 1,121 participants, mean age was 51.6 years (SD=13.6) with 41.4% non-Hispanic Black, 8.5% Hispanic, and 43.4% female. After accounting for multisite effect, the level of genome-sequencing knowledge was lower in non-Hispanic Black and Hispanic participants compared with non-Hispanic White participants [mean score difference: -2.9 (95% CI: -3.6 to -2.2) and -2.6 (95% CI: -3.9 to -1.2), respectively]. The level of trust in researchers was lowest in non-Hispanic Black participants (mean score: 27.7), followed by Hispanic participants (29.4) and non-Hispanic White participants (33.9) (P values <.001). Racial and ethnic disparities remained after adjusting for education, age at enrollment, duration of dilated cardiomyopathy, and health status. A higher level of genome-sequencing knowledge was associated with higher trust scores (mean difference: 4.4, 95% CI = 3.3 to 5.5) and mediated partially the association between trust scores and race and ethnicity. Large racial and ethnic disparities in levels of genome-sequencing knowledge and trust in medical researchers were observed. These findings suggest that patient education regarding genetic research may help enhance research trust, informing the recruitment process of diverse patient populations in future genetic studies. [ABSTRACT FROM AUTHOR]

One-third of patients hospitalized for heart failure with preserved ejection fraction (HFpEF) have premature HFpEF (age <65 years). Data on clinical outcomes in this population are scarce. In this analysis, we examine 30-day readmission rates by age in a diverse cohort of patients with premature HFpEF. We created a retrospective cohort of patients with premature HFpEF hospitalized for acute HF within Emory Healthcare from 2010 to 2020. Patients with HFpEF (ejection fraction [EF] ≥ 50% and B-type natriuretic peptide [BNP] ≥100 pg/mL on admission) were stratified by age group [18-40, 41-50, 51-64 years]. Differences in 30-day readmission rates by age group were tested using the Cochran-Armitage test. Multivariable logistic regression was used to adjust for covariates associated with 30-day readmission including gender, race-ethnicity, insurance, BMI, Charlson Comorbidity Index (CCI), eGFR, BNP, and discharging physician specialty. Of 12,017 patients hospitalized for HFpEF during the study period, 3,109 (25.9%) had premature HFpEF (63.2% Black, 54.2% women). There were 434 (14%) patients aged 18-40, 680 (21.9%) aged 41-50, and 1995 (64.2%) aged 51-65. Comorbidities increased with older age (CCI score for 18-40 yr olds 2.5±2.0, 41-50 yr olds 3.1±2.2, 51-65 yr olds 4.9±2.2, p<0.001). Thirty-day readmission rates were highest among 18-40 yr olds (17.7%) vs 41-50 yr olds (15.9%) vs 51-64 yr olds (11%, Figure 1A). Over the study period, 30-day readmissions decreased in those aged 41-50 (p for trend 0.002), but remained constant in the 18-40 (p for trend 0.99) and 51-65 year old (p for trend 0.39) groups (Figure 1B). After adjusting for covariates, the risk of 30-day readmission was higher among 18-40 year olds (OR:1.78, 95% CI: 1.29-2.46) and 41 - 50 year olds (OR: 1.45, 95% CI: 1.09-1.91) compared to 51-64 year olds. Other variables associated with higher 30-day readmission were discharging specialty as internal medicine (OR:1.80, 95% CI: 1.19-2.72) or other subspecialty (OR: 3.68, 95% CI 2.48-5.44) compared to cardiology, and higher BNP [OR: 1.27, 95% CI: 1.15-1.40]. In our cohort of hospitalized patients with HFpEF, one in four patients had premature HFpEF. 30-day Readmissions remained highest for 18-40 year olds despite a lower burden of comorbidities. [ABSTRACT FROM AUTHOR]

Although care of patients with heart failure (HF) has improved in the past decade, important disparities in HF outcomes persist based on race/ethnicity and gender. Age-adjusted HF-related HF hospitalization rates are highest for Black patients, particularly among young Black men and women compared to their White counterparts. The consequence of longstanding residential segregation is that Black and Latinx patients are more likely to reside in neighborhoods with limited opportunities for therapeutic lifestyle interventions to prevent the onset of HF. Growing income inequality in the United States also puts Black and Latinx patients, and women at higher risk of having limited access to healthcare and novel therapeutics. Limited conclusions can be made about populations including "Asians", because of an overall lack of data, and inappropriate grouping of a people with a heterogeneous risk of CVD (i.e. East Asians vs. South Asians). Moreover, recent data confirm that bias reduction training and diversification of the cardiovascular workforce will improve the quality of care for an increasingly diverse patient population. We propose a session to defining the most pressing needs to achieve health equity in HF prevention and treatment, and to delineate the role the HFSA has in promoting diversity within the society and the cardiovascular workforce at large. Learning Objective(s):• To redefine concepts related to definitions of race and ethnicity in research and clinical care.• To describe the importance of social determinants of health as a root cause for the growing burden of Stage A-B HF, and difficulty in treating Stage C-D HF• To define the role of HFSA in achieving health equity for patients with or at risk for HF [ABSTRACT FROM AUTHOR]

The demographics of patients undergoing heart transplantation in the United States have shifted over the last 10 years, with an increasing number of racial and ethnic minorities undergoing heart transplant. Multiple studies have shown that survival of African American patients after heart transplantation is lower compared with other ethnic groups. We review the data supporting the presence of this outcome disparity and examine the multiple mechanisms that contribute. With an increasingly diverse population in the United States, knowledge of these disparities, their mechanisms, and ways to improve outcomes is essential. [ABSTRACT FROM AUTHOR]

Background There is increasing recognition that the risk of stroke after left ventricular assist device (LVAD) implantation varies based on gender, with a higher risk in female patients. We reviewed our own data to determine gender differences in the risk of stroke. Methods Frequency of stroke, including intracranial hemorrhage and ischemic stroke, was retrospectively evaluated in 110 heart failure patients (mean age 49.6 ± 13.6 years, 32% women) discharged from the hospital after implantation of a HeartMate II ( N = 74) or HeartWare ( N = 36) LVAD. Competing outcomes analysis was used to determine which clinical risk factors were associated with the risk of stroke and death, with the primary end-point being time to first stroke event. Results During a median follow-up of 1.3 years, 26 patients had a stroke (23.6%, 0.14 case per person-year). The median time to first stroke was 0.7 (interquartile range 0.3 to 1.4) years. After adjusting for covariates, risk of stroke was higher for women than for men (hazard ratio 3.1, 95% confidence interval 1.4 to 6.9; p = 0.007). There was no difference in overall survival between men and women. Conclusion The risk of stroke after LVAD varies based on gender, with a higher risk in female patients. More research is needed to fully understand these differences, and whether device management strategies should be tailored based on gender. [ABSTRACT FROM AUTHOR]

BACKGROUND: Whether the routine use of continuous-flow left ventricular assist devices (LVAD) has affected gender differences in outcomes for patients listed for heart transplantation (HT) is unclear. METHODS AND RESULTS: We identified 20,468 adults (25% women) listed as status 1A or 1B for HT from 2000 to 2014. Sex differences in removal from the wait list during the first 365 days due to death or deterioration was assessed with the use of Kaplan-Meier survival analysis. Patients were stratified according to listing before (era 1) or after (era 2) Food and Drug Administration approval of the Heartmate II LVAD on April 22, 2008. Freedom from death or deterioration on the wait list was higher for men than for women (70% vs 64%; P < .001). After adjusting for risk factors, women had a higher risk of removal from the wait list at 365 days during both era 1 (hazard ratio [HR] 1.23, 95% confidence interval [CI] 1.10-1.36; P < .001) and era 2 (HR 1.15, 95% CI 1.01-1.31; P = .029). Further adjustment for LVAD use eliminated the higher risk for women in era 2 (HR 1.14, 95% CI 0.99-1.29; P = .053) and not in era 1 (HR 1.22, 95% CI 1.10-1.36; P < .001). CONCLUSIONS: The higher risk for death or deterioration in women waiting for HT has improved in the modern era. [ABSTRACT FROM AUTHOR]

Background Contemporary epidemiology of chronic graft failure (GF) after heart transplantation (HT) is not well described. Moreover, differences in the epidemiology of GF based on race/ethnicity remain poorly understood, despite clear evidence of inferior survival of ethnic minorities after HT. Methods The incidence of GF and the population-attributable risk (PAR) of independent risk factors for GF were assessed in 15,255 patients (76% men; mean age 52 ± 12 years) who underwent primary HT from 2004 to 2012. Results During a median follow-up of 4.7 years (interquartile range, 2.3–7.1 years), GF developed in 2,926 patients (19.2%), corresponding to an incidence rate of 39.8/1,000 person-years (95% confidence interval, 38.4–41.3). Blacks were more likely to develop GF than Hispanics or whites, with incidence rates of 55.1, 42.2, and 36.5/1,000 person-years, respectively. After multivariable adjustment, black race was associated with a higher risk of GF (hazard ratio, 1.4; 95% confidence interval, 1.2–1.6; p < 0.001). Blacks and Hispanics were more likely to have risk factors for GF, including low education, public insurance, allosensitization, higher human leukocyte antigen mismatch, non-adherence, and history of rejection requiring hospitalization (all p < 0.001). Rejection requiring hospitalization carried the highest population-attributable risk in all groups, with the highest fraction in blacks (25.8%) compared with whites (18.6%) and Hispanics (15.6%). Socioeconomic and donor risk factors conferred relatively less risk of GF. Conclusions Black HT recipients have the highest risk of GF, with immunologic factors conferring the greatest proportion of that risk. Racial differences in risk factors for GF after HT require further study. [ABSTRACT FROM AUTHOR]

Unlike traditional beta receptor antagonists, nebivolol activates nitric oxide. We hypothesized that therapy with nebivolol compared with metoprolol would improve arterial stiffness, increase levels of circulating progenitor cells (PC), and decrease oxidative stress (OS). In a randomized, double–blind, cross–over study, 30 hypertensive subjects received either once daily nebivolol or metoprolol succinate for 3 months each. Pulse wave velocity and augmentation index were measured using tonometry. Flow cytometry was used to measure circulating PC. OS was measured as plasma aminothiols. Measurements were performed at baseline, and repeated at 3 and 6 months. No significant differences were present between the levels of OS, arterial stiffness, and PC numbers during treatment with metoprolol compared with nebivolol. In subgroup analyses of beta–blocker naïve subjects (n = 19), nebivolol reduced pulse wave velocity significantly compared with metoprolol (−1.4 ± 1.9 vs. −0.1 ± 2.2; P = .005). Both nebivolol and metoprolol increased circulating levels of CD34+/CD133 + PC similarly ( P = .05), suggesting improved regenerative capacity. [ABSTRACT FROM AUTHOR]

1. To understand racial differences in receipt and timing of palliative care consultations among individuals who died from heart failure. 2. To consider precipitating factors for racial differences in receipt and timing of palliative care consultations among individuals who died from heart failure. Among heart failure (HF) decedents, Black individuals had greater odds of receiving a palliative care consultation (PCC) than whites. Median time from PCC to death was shorter among white than Black individuals. Findings suggest greater recognition of palliative needs among Black HF patients; however, most PCCs in HF occur late. Racially minoritized individuals experience greater heart failure incidence and mortality, yet it is unclear whether there are racial disparities in receipt of palliative care in heart failure. We sought to assess the association between race and receipt and timing of palliative care consultation among adults who died from heart failure. This retrospective cohort study used electronic medical records to identify adults who had a hospitalization at an academic health system in Georgia and died from heart failure between January 1, 2012 and December 31, 2018. Using multivariable logistic regression, we examined associations between decedent characteristics and receipt of palliative care consultation. Of 1,987 individuals who died with heart failure, 45.8% (n=911) received a palliative care consultation. Black individuals had 60% greater odds of receiving a palliative care consultation (OR = 1.60; 95% CI = 1.21-2.11) than white individuals. Median time from palliative care consultation to death was 38.5 days for all patients and was shorter among white than Black individuals (31.2 vs 51.5 days, p=.001). Mean age at death was younger among Black than white individuals (71.3 (14.8) vs. 81.8 (12.3) p<.001) and individuals of "other" race (71.3 (14.8) vs. 80.3 (10.4) p=.001). Relative to white individuals, Black individuals were more likely to receive inotropic therapy (42.3% vs. 54.4%, p<.001), to have a hospital admission in the last month of life (29.7% vs. 39.5%, p<.001), and have an ICU stay in the last month of life (18.3% vs. 30.3%, p<.001). Among adults who died from heart failure, a greater proportion of Black individuals received palliative care consultations compared to white individuals. Black individuals with heart failure died younger and had greater health care utilization near the end of life than whites, perhaps prompting palliative care consultations. Palliative care consultations in heart failure tend to occur late for all patient groups. Efforts to integrate palliative care earlier in the heart failure trajectory are needed. [ABSTRACT FROM AUTHOR]

Objectives: This study sought to investigate post-transplantation outcomes as a function of race and panel reactive antibody (PRA). Background: PRA screening is used to determine the presence of pre-formed antibodies to population-wide human leukocyte antigens (HLAs) in patients being evaluated for heart transplantation (HT). Racial/ethnic differences in long-term survival after HT have been described. However, whether there are significant racial/ethnic differences in PRA among adults awaiting HT is poorly characterized. Methods: We identified patients age ≥18 years in the Organ Procurement and Transplantation database with race/ethnicity of white, black, Hispanic, or Asian and listed for HT between 2000 and 2012 (N = 19,704). A PRA value of ≥10% was used to define clinically meaningful sensitization. Results: Blacks had a higher peak PRA than did all other groups and were more likely to be sensitized. Black HT recipients were more likely to experience graft failure than were Hispanic, white, and Asian recipients (31% vs. 27%, 26%, and 21%, respectively; p < 0.001). The median follow-up was 1,207 days (interquartile range: 373 to 2,364 days), with a trend toward a shorter median time to graft failure in the Asian group than in the black, Hispanic, and white groups (p = 0.065). Sensitized blacks had the lowest rate of allograft survival, whereas nonsensitized Asians had the highest survival. Using Cox proportional regression to adjust for other clinical variables, black race (HR: 1.3; 95% confidence interval [CI]: 1.2 to 1.5), Hispanic ethnicity (HR: 1.2; 95% CI: 1.0 to 1.5), and sensitization (HR: 1.2; 95% CI: 1.1 to 1.4) remained predictors of higher rates of graft failure. Conclusions: Race/ethnicity and level of sensitization are important predictors of graft survival. [Copyright &y& Elsevier]

The Impella (ABIOMED, Danvers, MA) is a temporary left ventricular support device, intended for short-term cardiac support for percutaneous procedures and cardiac shock. The Impella device is available in several sizes capable of producing different flows. It is FDA approved for up to 6 days of support. The device can provide significantly higher blood flow than an intra-aortic balloon pump and can be implanted percutaneously. We sought to describe potential complications and outcomes associated with extended Impella use for cardiogenic shock. We retrospectively evaluated patients who underwent implantation of either the Impella CP (Impella 3.5) or Impella 5.0 from September 1, 2017 to September 1, 2019 at our institution. Hemolysis was defined as plasma free hemoglobin level > 50 mg/dL, a lactate dehydrogenase (LDH) level > 500 units/L, and bilirubin increase > 1 mg/dL. 58 patients underwent percutaneous insertion of an Impella device, with the indication of cardiogenic shock in 32 patients (55%). In these 32 patients, only one had an Impella 2.5 device, 21 had an Impella CP (66%), and 10 (31%) had an Impella 5.0. The average age at time of implantation was 55 ± 17 years, and 25 patients were male (78%). Ejection fraction was 17 ± 11.7%. The average duration of Impella support was 5.5 days (1, 16 days). Complications included hematoma at the time of insertion (3 patients), leg ischemia (2 patients), improper positioning (7 patients), acute renal failure (28 patients), and hemolysis (20 patients). Hemolysis developed in 12 patients (57%) with the Impella CP and in 8 patients (80%) with the Impella 5.0, with an average LDH of 1452 units/L. 8 patients were transitioned to veno-arterial (VA) extracorporeal membrane oxygenation (ECMO), with the Impella utilized for left ventricular venting. 9 patients (28%) eventually underwent durable left ventricular assist device (LVAD) implantation on average 7 ± 6.1 days after Impella, and two patients underwent heart transplantation, both 9 days following Impella insertion. 23 patients (72%) did not survive past the initial hospitalization. The Impella is a percutaneous temporary left ventricular support device used to provide additional cardiac output in patients with cardiogenic shock. Serious complications can occur with extended support, including hemolysis, acute renal failure, and high mortality. Of our 28 patients who received an Impella, 11 were able to be successfully bridged to either LVAD or heart transplantation with the Impella. [ABSTRACT FROM AUTHOR]

Men have worse mortality in heart failure with reduced ejection fraction (HFrEF), even after accounting for traditional risk factors. A metabolomics risk score, capturing the end-effect of sex-dependent karyotypic, genetic, hormonal and environmental influences, will attenuate the increased residual risk of mortality observed in males. Metabolome-wide association study was performed in 187 HFrEF (EF <50%) patients in the Metabolomics, Oxidative Stress and Vascular Function in HF (MOV) study (Discovery Cohort (DC), mean age 54.0 ± 13.0 yrs, 49.2% male, 62.0% black) to determine unique endogenous metabolites associated with all-cause mortality (n=19). Metabolites that were significantly different between sexes, or had a significant metabolite*sex interaction (n=11) were further selected. Of these metabolites, those that attenuated the association of male sex with mortality were included in the metabolomics risk score (MS) (n=7). Association of male sex with mortality was determined in Cox proportional hazards models with and without inclusion of MS. Results were validated in an external validation cohort of 240 HFrEF patients in the The Atlanta Cardiomyopathy Consortium (TACC) study (Validation Cohort (VC), mean age 56.6 ± 12.0 yrs, 66.3% male, 45.4% black). There were 24 deaths (12.8%) during a median follow up of 782 [IQR 453, 1069] days in the DC. Males had a higher risk of mortality than females (adjusted HR: 3.84, 95% CI: 1.43-10.27; p=0.01). Metabolites that met aforementioned criteria for inclusion in the MS were: Bilirubin, Uric Acid, Hypoxanthine, L-Tyrosine, Phenylpyruvate, Oleoylcarnitine and Linoelaidyl carnitine (Table 1A). MS was higher in men than in women (0.90 ± 4.76 vs -0.66 ± 4.97, p=0.03) and associated with mortality in men (adjusted HR: 1.73, 95% CI: 1.20-2.29, p<0.001) but not in women (p=0.32) (p<0.001 for MS*sex interaction). Addition of MS to Cox models attenuated the association of male sex with mortality by 22.16%. The VC confirmed these findings: MS attenuated the association of male sex with mortality by 33.59% (Table 1B). The MS remained significantly associated with mortality (p≤0.01) in all models. A metabolomics risk score representing the cardio-hepatic axis, purine metabolism, phenylalanine metabolism and the carnitine shuttle contributes to the increased residual risk of mortality in males with HFrEF. [ABSTRACT FROM AUTHOR]

Use of heart transplant (HT) and left ventricular assist device (LVAD) are considered standard of care for eligible patients with end-stage heart failure (HF). In assessing eligibility, caregiver assistance is an important consideration in a patient's candidacy. While studies have shown that individuals without caregivers have worse survival outcomes, few studies have demonstrated how caregiver relationships differ based on sex and race, and whether that impacts eligibility for HT/LVAD. Women and Black patients are less likely than men and non-Black patients, respectively, to have a spouse listed as primary support, which may adversely affect eligibility for HT/LVAD. We identified all patients (N=534) evaluated at Emory University for HT/LVAD from 2011 to 2016. Stanford Integrated Psychological Assessment for Transplant (SIPAT) scores were compared by sex and race using Wilcoxon rank-sum tests. The outcome of HT/LVAD evaluation according to primary caregiver relationship was compared by sex and race using X2 analysis. Multivariable logistic regression was used to determine the association between primary caregiver and HT/LVAD eligibility according to sex and race, adjusted for age, HF etiology, insurance, inotrope dependence, bilirubin, albumin, allosensitization, CKD stage, and SIPAT score. The mean age of the cohort was 52 ± 13 years; 171 (32%) were women and 294 (55%) were black. Total SIPAT scores did not vary significantly between men and women or blacks and non-blacks, regardless of primary support person. Women were less likely to have a spouse as primary support, and were more likely to have a parent or child as primary support (Table). Black patients were less likely to have a spouse as primary support, and were more likely to have a parent as primary support. In sex-stratified multivariable models, the choice of primary caregiver did not affect eligibility for HT/LVAD for women (P=0.8) or men (P=0.4). In race-stratified multivariable models, blacks with a parent as primary caregiver were less likely to be eligible for HT/LVAD (OR=0.17, 95% CI 0.03 - 0.97, P=0.04), however the primary caregiver was not associated with eligibility for HT/LVAD in non-black patients (P=0.9). The choice of primary support person has a modest effect on decreasing eligibility for black patients being evaluated for advanced HF therapies, but not for women. More research is needed to determine unique barriers to advanced HF therapies for female and black patients. [ABSTRACT FROM AUTHOR]

The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) score assesses psychosocial and behavioral risk in patients who are undergoing evaluation for heart transplant. The SIPAT score is associated with adverse outcomes including increased rates of rejection, admissions and infections post-transplant. Many Stage D heart failure patients will undergo SIPAT testing, with some receiving an LVAD as bridge to transplant (BTT) and other as destination therapy (DT). However, the role of SIPAT scores in left ventricular assist devices (LVAD) patients remains unclear based on a limited number of studies. The objective of this study assesses whether SIPAT scores were associated with increased mortality. SIPAT scores were documented by a Licensed Master Social Worker for 137 LVAD patients (mean age: 50.0±13 years 35.8% female, 59.8% black)including BTT and DT (57.7%) implanted at Emory University Hospital from 2010 to 2018. The total SIPAT score is comprised of 4 subscales that represent different psychosocial domains: A - patient readiness and illness management, B - social support system, C - psychological stability and psychopathology, and D—lifestyle and substance abuse. Multivariable Cox regression models were used to examine the association of SIPAT scores with mortality. During a follow-up period of 1.58 years [IQR 0.8-2.87], 53 patients (38.7%) died. The mean total SIPAT score was 7.45 ±8.06, and 92.0% of patients classified as excellent-good candidates (total SIPAT score ≤20). There was no association between total SIPAT scores and mortality in the total cohort. However, the SIPAT B subscale was associated with mortality in men after adjusting for age, race, albumin, and renal function (SIPAT B *sex interaction P=0.009). Men who died had a higher mean score on the SIPAT B subscale than those who did not (2.00 ± 3.65 vs. 0.63 ± 1.63, p=0.05). Sex-stratified Cox models demonstrated that the SIPAT B subscale was associated with mortality in men (adjusted HR: 1.39, 95% CI 1.11-1.75, p=0.004); but not in women (p=0.4). In patients with LVAD, the SIPAT B subscale was associated with an increased risk of mortality in men. These findings suggest that social support may play an even greater role for male patients with LVAD as compared to females. More research is needed to determine which factors clearly define the association between social support and mortality in the LVAD population. [ABSTRACT FROM AUTHOR]

Endothelial dysfunction plays a key role in heart failure with reduced ejection fraction (HFrEF) pathogenesis, and is determined via the balance between oxidative stress (OS) and nitric oxide (NO) bioavailability. Higher cystine levels indicate increased OS. Nitrite is a major oxidative metabolite of NO. We sought to examine the relationship between OS, NO metabolism and vascular function, and their association with clinical outcomes in HFrEF patients. Cystine, nitrite and vascular function were measured in 130 HFrEF patients (mean age: 54.6 ± 12.7 yrs, 59.2% black, 48.5% female). Plasma cystine was quantified by high performance liquid chromatography. Plasma nitrite was determined by ion chromatography (ENO20 Analyzer, Eicom). Arterial stiffness was assessed as Augmentation index (Aix) using pulse wave analysis (SphygmoCor, AtCor Medical). Patients were categorized by median cystine (97.39 μM) and nitrite (0.26 μM) values. Linear regression was used to determine the association between cystine, nitrite and Aix, adjusting for age, gender, race, height, weight and mean arterial pressure. Cox regression was used to estimate the association of cystine, nitrite and Aix, with all-cause mortality, adjusting for age, gender, race, BNP and history of MI. Patients with higher levels of both cystine and nitrite (>median, n=31) had higher Aix (adjusted β =5.7, p=0.006, mean Aix= 27.6 ± 10.3) than those that had either elevated cystine (n=33) (p=0.1, mean Aix= 21.4 ± 7.9) or nitrite (n=33) (p=0.5, mean Aix= 18.9 ± 10.3), or neither (n=33) (P=0.9, mean Aix=22.1 ± 1.0). There were 14 deaths during a median follow up of 375 (IQR 188.5, 696) days. Patients with higher levels of both cystine and nitrite (>median) had a higher mortality (adjusted HR=15.2, 95% CI: 1.8-129.7, p=0.01) than those with elevation of either cystine or nitrite, or neither (Figure 1). Cystine did not correlate with BNP (p=0.2), while nitrite had a weak positive correlation with BNP (r=0.21, p=0.04). Higher Aix tended to be associated with mortality (adjusted HR: 1.2, 95% CI: 1.0-1.3, p=0.06), but was not a significant predictor when cystine and nitrite were added to the model (adjusted HR: 1.1, 95% CI: 0.9-1.2, p=0.5). Higher levels of OS and NO metabolites are synergistic determinants of arterial stiffness, and are independent determinants of mortality in HFrEF even after adjusting for BNP. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) and heart failure (HF) are common cardiovascular conditions that frequently coexist. Among patients with HF, more than one-half also have AF. Both are associated with significant morbidity and mortality. Moreover, the prevalence of each is increasing globally, and this trend is expected to continue owing to an aging population and increased life expectancy. Diagnosis of AF in a patient with HF is associated with greater symptom burden, more frequent hospitalizations, and a worse prognosis. Guideline-directed medical therapy (GDMT) for HF can affect the incidence of AF. Once present, AF can influence the efficacy of some components of GDMT for HF. In this review, we discuss the effect of GDMT for HF across the spectrum of ejection fraction on prevention of AF as well as the benefit of GDMT in patients with vs without AF. [Display omitted] • AF and HF commonly occur concurrently, and the combination is associated with worse prognosis than either condition alone. • GDMT for HF can reduce the incidence of AF. • Further research is needed to clarify the benefit of GDMT for HF in patients with concomitant AF across the range of left ventricular ejection fractions. [ABSTRACT FROM AUTHOR]