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Background The SGLT2 inhibitor empagliflozin has recently gained approval for treating heart failure (HF) across the entire spectrum of ejection fractions including heart failure with preserved ejection fraction (HFpEF). Bradycardia-induced HF, previously described in the literature as bradycardiomyopathy, is an uncommon cause of HFpEF. Case summary Herein, we describe a case of a young, 32-year-old woman with no prior medical history who was referred to the hospital due to progressive fatigue and exercise intolerance. She exhibited junctional bradycardia and sinus node dysfunction on electrocardiographic examination, was hypotensive, and had significantly elevated NT-proBNP levels at admission. Transthoracic echocardiographic examination (TTE) revealed preserved systolic function of the left ventricle with segmental abnormalities of contractility and reduced global longitudinal strain, indicative of HFpEF. Cardiac magnetic resonance imaging showed hypertrabeculations, suggesting noncompaction cardiomyopathy (NCCM), even though the definitive diagnostic criteria for NCCM were not met. The patient reported no recent episodes of fever and no chest pain. A comprehensive panel for cardiotropic viruses and Lyme disease were negative while infiltrative diseases such as sarcoidosis were clinically ruled out. Coronary angiography excluded coronary artery disease. Due to profound hypotension and bradycardia, we prescribed empagliflozin and theophylline. At the subsequent follow-up visit within 1 month, the patient reported that she was asymptomatic, with restored sinus rhythm, and complete normalization of NT-proBNP values. Discussion Bradycardia-induced HFpEF is a rare entity that can limit the use of most cardiovascular pharmacotherapies but can be successfully treated with empagliflozin and theophylline as demonstrated in our case. [ABSTRACT FROM AUTHOR]

The article discusses guideline-recommended medical therapy (GRMT) for heart failure with reduced ejection fraction (HFrEF). GRMT includes medications such as ACE inhibitors, beta-blockers, and SGLT2 inhibitors. The article emphasizes the importance of initiating GRMT promptly and titrating to target doses within the first 4 weeks following the index heart failure episode. It also discusses the concept of reverse remodeling, which is the process of improving the structure and function of the heart. The article presents a recent study that suggests the 90-day time frame for reassessing left ventricular function may be too short for substantial recovery in some patients. The study also highlights the importance of implementing and optimizing GRMT to unlock the full potential of reverse remodeling. The article concludes by suggesting that further research is needed to explore the impact of GRMT on the need for implantable cardioverter-defibrillator (ICD) devices. [Extracted from the article]

Background: The impact of sodium-glucose cotransporter-2 inhibitors (SGLT2is) in addition to optimal medical therapy (OMT) on the right ventricular (RV) systolic function using advanced echocardiographic analysis among outpatients with heart failure and a reduced ejection fraction (HFrEF) has thus far been poorly investigated. Methods: This was a single-center, prospective, single-blinded study in which an echocardiographic expert was blinded to the allocation of the treatment. A total of 36 outpatients with HFrEF were randomized to either OMT or OMT+SGLT2i. Both groups underwent an echocardiographic examination of the RV systolic function at the baseline and at the 3-month follow-up (3mFU). Results: The patients in both groups did not significantly differ with respect to the relevant baseline comorbidities, therapy, and clinical characteristics. The patients receiving OMT+SGLT2i showed a significant improvement from the baseline to the 3mFU in all the measured RV echocardiographic parameters, while for the OMT group, a significant improvement after the 3mFU was observed for TAPSE and s'. The mean percent change from the baseline to the 3mFU was significant when comparing OMT+SGLT2i to the OMT group concerning RV FWS (+91% vs. +28%, p = 0.039), TR maxPG (−27% vs. +19%, p = 0.005), and TR Vmax (−17% vs. +13%, p = 0.008), respectively. Conclusions: Adding SGLT2i to OMT in patients with HFrEF resulted in a greater improvement in the RV systolic function from the baseline to the 3mFU compared to the OMT alone. [ABSTRACT FROM AUTHOR]

Such therapy is also known as " I quadruple" i or " I four pillars i " therapy, and it consists of an angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin receptor-neprilysin inhibitor (ARNi), beta-blocker, mineralocorticoid receptor antagonist (MRA), and sodium-glucose co-transporter 2 (SGLT2) inhibitor. Equally so, accumulating data shows that early in-hospital initiation of these drugs can be a feasible and safe management strategy that should be employed on an individual patient basis and strongly considered at least before patient discharge from the hospital [[2]]. Similarly, Packer and McMurray provided a rapid sequencing algorithm that allows for patients with HFrEF to receive quadruple foundational therapy within 4 weeks in three flexible steps followed by the dose optimization [[8]]. Practical questions concerning the sequence, timing, initial doses, and subsequent titration strategies of foundational drugs constituting comprehensive disease-modifying therapy (CDMT) in patients with heart failure and reduced ejection fraction (HFrEF) remain unclear. [Extracted from the article]

The objectives of the study were to characterize and compare different acute heart failure (AHF) subgroups according to left-ventricular ejection fraction (LVEF) in terms of all-cause mortality and HF-related readmissions during the 1-year follow-up (FU). Three hundred and fifty-six AHF patients admitted to Cardiology ward and/or CCU were retrospectively included in the study and analyzed during the 1-year FU. Patients were stratified according to LVEF as those with preserved (HFpEF), midrange (HFmrEF) and reduced LVEF (HFrEF). During the FU period, 148 (43.3%) patients died, and 116 HF-related readmission events were recorded. HFmrEF group had significantly higher standardized all-cause mortality rate, unadjusted for age, compared to HFpEF group and significantly lower than HFrEF group (41 vs. 18 and 41 vs. 62.5 events per 100 patient-years; χ2 = 41.08, p < 0.001 and χ2 = 16.62, p < 0.001, respectively). A propensity score-matched analysis in which all HF groups were matched for age and other covariates confirmed that HFmrEF group had significantly higher all-cause mortality rate than HFpEF group (χ2 = 15.66, p < 0.001) while no significant differences in readmission rates were observed across all groups (p = NS). The hazard risk for a composite endpoint of death and readmission was highest in HFrEF group (HR 6.53, 95% CI 3.53-12.08, p < 0.001), followed by HFmrEF group (HR 3.30, 95% CI 1.86-5.87, p < 0.001) when compared to HFpEF group set as a reference. Among AHF patients, the HFmrEF phenotype was associated with significantly higher all-cause mortality compared to HFpEF, during the 1-year FU. This finding might implicate more stringent clinical approach towards this patient group. [ABSTRACT FROM AUTHOR]

Background: The initiation and titration of guideline-directed medical therapies for heart failure with reduced ejection fraction (HFrEF) are essential for improving prognosis. However, data from several global registries indicate suboptimal adherence to these guidelines.1,2 This study aims to assess the utilization of pharmacologic and device therapies at discharge for HFrEF patients at the University Hospital Centre Split (UHC Split) and compare it with prescription patterns documented in the robust U.S.-based hospital registry known as Get With The GuidelinesHF (GWTG-HF). Patients and Methods: We conducted a crosssectional observational study, comparing a consecutive sample of patients hospitalized with chronic HFrEF at the Cardiovascular Diseases Department of UHC Split in the year 2022-2023 with data published from the GWTG-HF Registry.³ Results: Figure 1 illustrates that the use of beta-blockers and ACE inhibitors/ARBs/ARNi medications was similar between the two registries, with the UHC Split HF registry reporting numerically higher prescription rates at discharge (95% vs. 89% and 78% vs. 68%, respectively). Significantly higher rates of MRAs and SGLT2 inhibitors were prescribed at discharge in the UHC Split HF Registry compared to GWTG-HF (80% vs. 41% and 78% vs. 20%, p<0.001). In terms of device therapies, cardiac resynchronization therapy was similarly utilized in both registries (13% vs. 10%, respectively), while a significantly greater rate of ICD implantations was observed in GWTG-HF compared to the UHC Split HF registry (23% vs. 8%, respectively). Conclusions: The use of fundamental pharmacologic therapies for HFrEF at UHC Split is high and appears to exceed what is reported in the contemporary GWTG-HF registry. Conversely, the utilization of device therapies for HFrEF is relatively low at UHC Split and should be improved in the coming years. [ABSTRACT FROM AUTHOR]

Introduction: Heart failure (HF) is a complex clinical syndrome associated with high mortality, morbidity, and healthcare expenditures.1,2 We sought to determine temporal trends concerning baseline characteristics and treatment modalities of patients enrolled at our Center during two periods: 2008- 2012 and 2018-2019 for which data were available. Patients and Methods: Patients admitted with the chief diagnosis of HF were stratified into two groups for the statistical analysis. The historic cohort comprised patients admitted during the period 2008- 2012 (N=356) while the contemporary cohort (2018-2019) consisted of 108 patients. Results: Patients in the contemporary cohort were younger, had a significantly higher prevalence of non-ischemic cardiomyopathy, diabetes mellitus, more preserved renal function, higher hemoglobin, higher uric acid, and lower potassium levels compared to the historic cohort. On the other hand, distribution of sex, blood pressure at admission, the prevalence of atrial fibrillation, NYHA functional class, left ventricular ejection fraction and left end-diastolic diameters were similar in both groups (Table 1). As shown in Figure 1A, we observed a significant decline in the prevalence of HF with midrange ejection fraction in a contemporary cohort compared to a historic one (p<0.001) along with a significant increase in the prevalence of HF with preserved ejection fraction and HF with reduced ejection fraction (p<0.001). Regarding treatment modalities, acetylsalicylic acid use significantly declined while the use of oral anticoagulants significantly increased among the contemporary cohort compared to the historic one. Likewise, the use of life-prolonging therapy such as beta-blockers increased by about 45%, and ACE-inhibitors or ARBs by about 11% accompanied by the slight decrease in the use of loop diuretics (Figure 1B). Conclusions: After the approximately 10-year timespan, we observed several changes in baseline characteristics of HF patients treated at our center. The most prominent change is the highest relative growth in the prevalence of HF with preserved ejection fraction. Likewise, the proportional use of life-prolonging pharmacotherapies and anticoagulation coverage (nowadays mostly direct oral anticoagulants) significantly improved over time. [ABSTRACT FROM AUTHOR]

Introduction: Previous studies showed an increased likelihood and risk of acute myocardial infarction (AMI) and hospitalizations for cardiovascular events among patients exposed to chronic use of proton pump inhibitors (PPIs). 1-3 In this study we aimed to compare parameters reflecting disease burden and cardiometabolic profile among patients treated for AMI with respect to the chronic exposure to PPIs. Patients and Methods: Data of 143 adult consecutive patients hospitalized for ST-elevation myocardial infarction (STEMI) or non-ST-segment elevation myocardial infarction (NSTEMI) during the 2019-2020 period were analyzed. All continuous variables had a normal distribution. Results: The mean age was 64.8 ± 11.3 years and 79.7% were men. Two-thirds (65.7%) of patients had STEMI while 34.3% had NSTEMI. The mean GRACE score in the whole cohort was 117 ± 26 points while 12.6% of patients were at high risk of in-hospital death, after adjustment for the ACS type. A total of 19 IPP+ patients were identified. Patients in the IPP+ group were significantly older and had a higher prevalence of NSTEMI compared to IPP- group while both groups did not significantly differ in terms of sex, body mass index, waist-to-hip ratio, the mean number of diseased vessels at angiography, and left ventricular ejection fraction. Patient IPP+ group had a significantly higher high-sensitivity cardiac troponin I rise from 1st to 2nd measurement compared to IPP- group (4726 ± 5938 vs. 2554 ± 3480 ng/L, p=0.025, Table 1). Furthermore, C-reactive protein, blood glucose, and serum creatinine levels at admission were significantly higher in IPP+ vs. the IPP- group. Finally, patients in the IPP+ group had a significantly higher risk of in-hospital and 6-month post-discharge death compared to IPP- group, as adjudicated by the GRACE score (132 ± 23 vs. 114 ± 26 points, p=0.008). Conclusions: Our study showed that AMI patients with chronic exposure to IPPs are older, mostly male, and tend to present with NSTEMI. These patients exhibit a larger magnitude of myocardial injury and systemic inflammation accompanied by worse renal function, and also seem to be at an increased risk of poor in-hospital and post-discharge outcomes. However, potential confounding of underlying comorbidities and age must be taken into account when interpreting these results. [ABSTRACT FROM AUTHOR]

The role of catestatin (CST) in acutely decompensated heart failure (ADHF) and myocardial infarction (MI) is poorly elucidated. Due to the implicated role of CST in the regulation of neurohumoral activity, the goals of the study were to determine CST serum levels among ninety consecutively enrolled ADHF patients, with respect to the MI history and left ventricular ejection fraction (LVEF) and to examine its association with clinical, echocardiographic, and laboratory parameters. CST levels were higher among ADHF patients with MI history, compared to those without (8.94 ± 6.39 vs. 4.90 ± 2.74 ng/mL, p = 0.001). CST serum levels did not differ among patients with reduced, midrange, and preserved LVEF (7.74 ± 5.64 vs. 5.75 ± 4.19 vs. 5.35 ± 2.77 ng/mL, p = 0.143, respectively). In the multivariable linear regression analysis, CST independently correlated with the NYHA class (β = 0.491, p < 0.001), waist-to-hip ratio (WHR) (β = −0.237, p = 0.026), HbA1c (β = −0.235, p = 0.027), LDL (β = −0.231, p = 0.029), non-HDL cholesterol (β = −0.237, p = 0.026), hs-cTnI (β = −0.221, p = 0.030), and the admission and resting heart rate (β = −0.201, p = 0.036 and β = −0.242, p = 0.030), and was in positive association with most echocardiographic parameters. In conclusion, CST levels were increased in ADHF patients with MI and were overall associated with a favorable cardiometabolic profile but at the same time reflected advanced symptomatic burden (CATSTAT-HF ClinicalTrials.gov number, NCT03389386). [ABSTRACT FROM AUTHOR]

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