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Aims: The impact of frailty on outcomes in randomized heart failure with preserved ejection fraction (HFpEF) trials has not been previously reported. This analysis sought to characterize frailty in a large contemporary HFpEF clinical trial cohort and to evaluate its impact on patient relevant outcomes.Methods and Results: Using data from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial, a frailty index (FI) was constructed at baseline using 39 clinical, laboratory, and self-reported variables. The relationship between frailty and outcomes and the role of frailty in modulating the benefits of spironolactone were examined in a subset of 1767 TOPCAT patients. For the cohort as a whole (mean age 71.5 years, 49% female), the mean FI at baseline was 0.37 ± 0.11. Four frailty classes were defined ranging from FI < 0.3 to FI ≥ 0.5. Overall, 94% of subjects were considered frail (defined as a FI > 0.21). Mean age was lowest for the most frail class (69 ± 9 years for Class 4; 73 ± 10 years for Class 1; P < 0.001). Body mass index, systolic blood pressure, and pulse pressure all increased as FI increased. Both primary and secondary outcomes increased as frailty severity increased. There was no interaction between frailty class and treatment effect of spironolactone.Conclusions: Frailty was very common in TOPCAT HFpEF participants. Greater frailty was associated with a higher risk of cardiovascular outcomes and mortality. The benefit of spironolactone on outcomes in TOPCAT was not attenuated by frailty class. [ABSTRACT FROM AUTHOR]

Aims: Adjuvant heart failure (HF) drug therapy in patients undergoing chronic mechanical circulatory support (MCS) is often used in conjunction with a continuous-flow left ventricular assist device (LVAD), but its potential impact is not well defined. The objective of the present study was to examine the effects of conventional HF drug therapy on myocardial structure and function, peripheral organ function and the incidence of adverse events in the setting of MCS.Methods and Results: Patients with chronic HF requiring LVAD support were prospectively enrolled. Paired myocardial tissue samples were obtained prior to LVAD implantation and at transplantation for histopathology. The Meds group comprised patients treated with neurohormonal blocking therapy (concurrent beta-blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and aldosterone antagonist), and the No Meds group comprised patients on none of these. Both the Meds (n = 37) and No Meds (n = 44) groups experienced significant improvements in cardiac structure and function over the 6 months following LVAD implantation. The degree of improvement was greater in the Meds group, including after adjustment for baseline differences. There were no differences between the two groups in arrhythmias, end-organ injury, or neurological events. In patients with high baseline pre-LVAD myocardial fibrosis, treatment with HF drug therapy was associated with a reduction in fibrosis.Conclusions: Clinical and histopathological evidence showed that adjuvant HF drug therapy was associated with additional favourable effects on the structure and function of the unloaded myocardium that extended beyond the beneficial effects attributed to LVAD-induced unloading alone. Adjuvant HF drug therapy did not influence the incidence of major post-LVAD adverse events during the follow-up period. [ABSTRACT FROM AUTHOR]

The article discusses a study which investigated the differences on the impact of cardiac resynchronization therapy (CRT) in patients with moderately or severely prolonged QRS duration. Databases used for the randomized CRT trials were MEDLINE, SCOPUS and Cochrane. Findings showed a reduction in composite clinical trials with CRT in patients with prolonged QRS.

The author comments on a study which assessed the use of left ventricular assist devices and machines for the permanent treatment of advanced heart failure conducted by Slaughter and colleagues. He discusses the limitations in the study such as the failure to report the number of patients who had undergone screening to allow the enrollment of subjects who participated in the clinical trials. According to him, the lack of blinding may have affected the reporting of the adverse events which presented a trend in favor of the continuous-flow pump.

The article discusses devices that are both approved and investigational for the support of the acutely decompensated heart failure patient. These devices range in sophistication and expertise and target various features of the acute heart failure patient, such as circulatory failure, volume overload, renal insufficiency, and respiratory failure. These new devices may become a cornerstone of the management strategy in cardiac patients.

Background Although features of heart failure disease management programs are broadly outlined, little is known about which interventions are actually used in the outpatient setting or which patients are most likely to require interventions. Methods and Results Between September 2001 and June 2002, we enrolled 32 patients admitted to the Brigham and Women's Hospital Heart Failure Services, Boston, Mass, with decompensated heart failure. The intensity of care and outcomes of these patients were prospectively tracked for more than 90 days. During this time, there were 325 patient contacts (median 8.5 per patient), including 247 calls (median 7 per patient) and 78 clinic visits (median 2 per patient). Brigham and Women's Hospital clinicians adjusted diuretics a total of 109 times (median 2.5 times per patient). When frequency of diuretic adjustments was used to estimate the intensity of care, higher values of blood urea nitrogen at discharge predicted an increased intensity of care during the 90-day follow-up (relative risk [RR] 1.2, 95% confidence interval [CI] 1.0-1.3, P = .02). When frequency of clinic visits, telephone calls, and diuretic adjustments were used to estimate intensity of care, discharge creatinine (RR 1.03, 95% CI 0.99-1.06, P = .05), discharge blood urea nitrogen (RR 1.13, 95% CI 1.04-1.23, P = .004), and length of stay (RR 1.07, 95% CI 1.00-1.13, P = .04) were predictors of the composite end point. Conclusions Even after undergoing optimization of medications during admission for acute heart failure, patients in a comprehensive disease management program required frequent interventions to maintain clinical stability. Renal dysfunction was the strongest predictor of increased interventions and worse outcome. [ABSTRACT FROM AUTHOR]

Aim: The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.Methods: A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses. [ABSTRACT FROM AUTHOR]

Aim: The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.Methods: A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses. [ABSTRACT FROM AUTHOR]

Heart failure with preserved ejection fraction (HF-PELF) Is the clinical syndrome of heart failure associated with normal or near- normal systolic function. Because inhibition of the adrenergic and renin-anglotensin-aidosterone systems has been so effective in the treatment of systollc heart failure, these same therapies have been the subject of recent clinical trials of HF-PEF. in this review, we examine the current evidence about treatment of HF- PEF, with particular emphasis on reviewing the literature for large- scale randomized clinical studies. The lack of significant benefit with neuorhormonal antagonism in HF-PEF suggests that this condition might not involve neurohormonal activation as a critical pathophyslologic mechanism. Perhaps heart failure as we traditionally think of it Is the wrong paradigm to pursue as we try to understand this condition of volume overload known as HF-PEF. [ABSTRACT FROM AUTHOR]

Background: Studies have indicated differences between Asians and Whites in their propensity for stroke, coronary artery disease, heart failure, bleeding and thrombosis. We investigated whether Asian-Americans on durable left ventricular assist devices (LVADs) exhibit differential morbidity and mortality when compared to Whites.Methods: We analysed prospectively collected data from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database to compare the outcomes after LVAD implantation of Asians versus Whites.Results: In total, 7,018 patients were included, 130 were identified as Asian-Americans. Asian-Americans were younger, had lower body mass index, higher serum bilirubin and lower albumin levels. In a multivariable regression model, there was no difference in survival between the two groups. Asian-Americans had lower incidence of device malfunction and after adjusting for multiple factors this remained lower. The adjusted risk of a major safety composite outcome, including major bleeding, major infection, stroke and device malfunction, revealed no difference between the two groups.Conclusions: Although prior studies have reported worse cardiac surgery outcomes in Asians, in this INTERMACS analysis Asian-Americans appear to have similar survival and risk of adverse events as their White counterparts. The incidence of device malfunction was lower in the Asian-Americans, both in a univariate model and after adjusting for multiple clinical factors. Future, larger studies of Asian-Americans with end-stage heart failure and LVAD support are warranted to confirm these results. [ABSTRACT FROM AUTHOR]

Background: Physical activity (PA) is inversely associated with adverse cardiovascular outcomes in healthy populations, but the impact of physical activity in patients with heart failure (HF) with preserved ejection fraction is less well characterized.Methods: The baseline self-reported PA of 1751 subjects enrolled in the Americas region of the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) was categorized as poor, intermediate, or ideal PA with American Heart Association criteria. PA was related to the primary composite outcome (HF hospitalization, cardiovascular mortality, or aborted cardiac arrest), its components, and all-cause mortality with the use of multivariable Cox models.Results: The mean age at enrollment was 68.6±9.6 years. Few patients met American Heart Association criteria for ideal activity (11% ideal, 14% intermediate, 75% poor). Over a median follow-up of 2.4 years, the primary composite outcome occurred in 519 patients (397 HF hospitalizations, 222 cardiovascular deaths, and 6 aborted cardiac arrests). Compared with those with ideal baseline PA, poor and intermediate baseline PA was associated with a greater risk of the primary outcome (hazard ratio [HR], 2.05; 95% confidence interval [CI], 1.28-3.28; HR, 1.95; 95% CI, 1.15-3.33, respectively), HF hospitalization (HR, 1.93; 95% CI, 1.16-3.22; HR, 1.84; 95% CI, 1.02-3.31), cardiovascular mortality (HR, 4.36; 95% CI, 1.37-13.83; HR, 4.05; 95% CI, 1.17-14.04), and all-cause mortality (HR, 2.95; 95% CI, 1.44-6.02; HR, 2.05; 95% CI, 0.90-4.67) after multivariable adjustment for potential confounders.Conclusions: In patients with HF with preserved ejection fraction, both poor and intermediate self-reported PA were associated with higher risk of HF hospitalization and mortality.Clinical Trial Registration: URL: https://clinicaltrials.gov. Unique identifier: NCT00094302. [ABSTRACT FROM AUTHOR]