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Background:\ud Patients admitted to hospital with heart failure will have had a chest X-ray (CXR), but little is known about their prognostic significance. We aimed to report the prevalence and prognostic value of the initial chest radiograph findings in patients admitted to hospital with heart failure (acute heart failure, AHF).\ud \ud Methods:\ud The erect CXRs of all patients admitted with AHF between October 2012 and November 2016 were reviewed for pulmonary venous congestion, Kerley B lines, pleural effusions and alveolar oedema. Film projection (whether anterior–posterior [AP] or posterior–anterior [PA]) and cardiothoracic ratio (CTR) were also recorded. Trial registration: ISRCTN96643197\ud \ud Results:\ud Of 1145 patients enrolled, 975 [median (interquartile range) age 77 (68–83) years, 61% with moderate, or worse, left ventricular systolic dysfunction, and median NT-proBNP 5047 (2337–10,945) ng/l] had an adequate initial radiograph, of which 691 (71%) were AP. The median CTR was 0.57 (IQR 0.53–0.61) in PA films and 0.60 (0.55–0.64) in AP films. Pulmonary venous congestion was present in 756 (78%) of films, Kerley B lines in 688 (71%), pleural effusions in 649 (67%) and alveolar oedema in 622 (64%).\ud \ud A CXR score was constructed using the above features. Increasing score was associated with increasing age, urea, NT-proBNP, and decreasing systolic blood pressure, haemoglobin and albumin; and with all-cause mortality on multivariable analysis (hazard ratio 1.10, 95% confidence intervals 1.07–1.13, p

Background: \ud Cachexia is common in patients with chronic heart failure and is associated with poor prognosis. How best to measure body composition is not clear.\ud \ud Methods and results: \ud We characterized body composition in 120 patients with chronic heart failure: mean (SD) age 70 (10) years, left ventricular ejection fraction 44 (10) %, and median (Q1–Q3) N-terminal pro B-type natriuretic peptide 845 (355–1368) ng/L. We measured body composition using dual-energy X-ray absorptiometry (DEXA) and a multi-frequency bioelectrical impedance analysis (BIA) device (Tanita BIA MC-180MA). Mean (SD) fat mass (FM) was 27.2 (11.7) kg by BIA and 32.3 (12.2) kg by DEXA (mean difference −5.1 kg, 95% limits of agreement: −11.7, 1.5; 4% of values outside limit of agreement); mean (SD) lean mass (LM) was 56.6 (10.9) kg by BIA and 51.1 (9.9) kg by DEXA (mean difference 5.5 kg, 95% limits of agreement: −1.3, 12.3; 6% of values outside limit of agreement); and mean (SD) bone mass (BM) was 3.0 (0.5) kg by BIA and 2.8 (0.6) kg by DEXA (mean difference 0.2 kg, 95% limits of agreement: −0.5, 0.8; 5% of values outside limit of agreement). There was a close correlation between DEXA and BIA for both LM and FM (LM: r = 0.95, P < 0.001; FM: r = 0.96, P < 0.001) but less so for BM (r = 0.84, P < 0.001). Both DEXA and BIA body composition measurements correlated well with other measures of body size (body mass index, hip circumference, and waist circumference).\ud \ud Conclusions: \ud There are differences in the measurements of FM, LM, and BM between the two techniques, which should not be used interchangeably.

No abstract available.

Heart failure (HF) does not occur in a vacuum and is commonly defined and exacerbated by its co-morbid conditions. Neurohormonal imbalance and systemic inflammation are some of the key pathomechanisms of HF but also commonly encountered co-morbidities such as arterial hypertension, diabetes mellitus, cachexia, obesity and sleep-disordered breathing. A cornerstone of HF management is neurohormonal blockade, which in HF with reduced ejection fraction has been tied to a reduction in morbidity and mortality. Pharmacological treatment effective in patients with HF with reduced ejection fraction did not show substantial effects in HF with preserved ejection fraction. Here, we review novel device-based therapies using neuromodulation of extra-cardiac targets to treat cardiometabolic disease.

Aim We explored the experiences and motivations of participants and staff who took part in the TRED-HF trial (Therapy withdrawal in REcovered Dilated cardiomyopathy). Methods We conducted a qualitative study, using semi-structured interviews, with participants (n=12) and the research team (n=4) from the TRED-HF trial. Interviews were carried out in 2019 and were audio-recorded and transcribed. Data were managed using NVivo and analysed using framework analysis. A patient representative provided guidance on the interpretation of findings and presentation of themes to ensure these remained meaningful, and an accurate representation, to those living with dilated cardiomyopathy. Results Three key themes emerged from the data: (1) perception of health; (2) experiences and relationships with healthcare services and researchers; and (3) perception of risk. Study participants held differing perceptions of their health; some did not consider themselves to have a heart condition or disagreed with the medical term ‘heart failure’. Relationships between participants, research staff and clinical management teams influenced participants’ experiences and decision-making during the trial, including following clinical advice. There were differences in participants’ perceptions of risk and their decisions to take heart failure medication after the trial was completed. Although the original TRED-HF trial did not provide the results many had hoped for, a strong motivator for taking part was the opportunity to withdraw medication in a safely monitored environment which had been previously considered by some participants before. Investigators acknowledged that the insights gained from the study can now be used to support evidence-based conversations with patients. Conclusion For people whose dilated cardiomyopathy is in remission, decisions to continue, reduce or stop their medication are influenced by perceptions of personal health, perceive risk and the important of work, employment, recreation, relationships and long-term plans. The unique relationship between patient and cardiologist provides opportunities to promote honest discussion about adherence to medication and personalised long-term management. Keywords Cardiomyopathy, Dilated; Feasibility Studies; Medication Adherence; Patient Participation; Physician-Patient Relations; Qualitative Research.

Background: \ud Loop diuretics (LD) relieve symptoms and signs of congestion due to heart failure (HF), but many patients prescribed LD do not have such a diagnosis.\ud \ud Aims and methods: \ud We studied the relationship between HF diagnosis, use of LD, and outcomes in four patient subgroups with type-2 diabetes mellitus (T2DM) in EMPA-REG OUTCOME; [i) investigator-reported HF on LD, ii) investigator-reported HF not on LD, iii] no HF on LD, and iv) no HF and not on LD], and assessed their risk of CV events.\ud \ud Results: \ud Of 7,020 participants, at baseline, 706 (10%) had a diagnosis of HF, of whom 334 were prescribed LD. However, 755 (11%) patients who did not have a diagnosis of HF were prescribed LD. Compared to those with neither HF nor prescribed LD (reference group; placebo), those with both HF and receiving LD had the highest rates for all-cause (hazard ratio [HR] [95% CI]: 3.19 [2.03-5.01]) and CV mortality (3.83 [2.28-6.44]), and HF hospitalisations (HHF) (9.51 [5.61-16.14]). Patients without HF but prescribed LD had higher rates for all three outcomes (1.62 [1.10-2.39]); 1.97 [1.26-3.08]); 3.20 [1.90-5.39]), which were similar to patients with HF who were not receiving LD (1.42 [0.78-2.57]; 1.56 [0.78-3.11]; 3.00 [1.40-6.40)]). Empagliflozin had similar benefits regardless of subgroup (p for interaction >0.1 for all outcomes).\ud \ud Conclusion: \ud Patients with T2DM prescribed LD are at greater risk of CV events even if they are not reported to have HF; this might reflect under-diagnosis. Empagliflozin was similarly effective in all subgroups investigated.

Background:\ud Gamma-glutamyltransferase (GGT) levels in the blood can be a sensitive marker of liver injury but the extent to which they give insight into risk across multiple outcomes in a clinically useful way remains uncertain.\ud \ud Methods:\ud Using data from 293,667 UK Biobank participants, the relationship of GGT concentrations to self-reported alcohol intake and adiposity markers were investigated. We next investigated whether GGT predicted liver-related, cardiovascular (CV) or all-cause mortality, and potentially improved CV risk prediction.\ud \ud Findings:\ud Higher alcohol intake and greater waist circumference (WC) were associated with higher GGT; the association was stronger for alcohol with evidence of a synergistic effect of WC. Higher GGT concentrations were associated with multiple outcomes. Compared to a GGT of 14.5 U/L (lowest decile), values of 48 U/L for women and 60 U/L for men (common upper limits of ‘normal’) had hazard ratios (HRs) for liver-related mortality of 1.83 (95% CI 1.60–2.11) and 3.25 (95% CI 2.38–4.42) respectively, for CV mortality of 1.21 (95% CI 1.14–1.28) and 1.43 (95% CI 1.27–1.60) and for all-cause mortality of 1.15 (95% CI 1.12–1.18) and 1.31 (95% CI 1.24–1.38). Adding GGT to a risk algorithm for CV mortality reclassified an additional 1.24% (95% CI 0.14–2.34) of participants across a binary 5% 10-year risk threshold.\ud \ud Interpretation:\ud Our study suggests that a modest elevation in GGT levels should trigger a discussion with the individual to review diet and lifestyle including alcohol intake and consideration of formal liver disease and CV risk assessment if not previously done.\ud \ud Funding:\ud British Heart Foundation Centre of Research Excellence Grant (grant number RE/18/6/34217), NHS Research Scotland (grant number SCAF/15/02), the Medical Research Council (grant number MC_UU_00022/2); and the Scottish Government Chief Scientist Office (grant number SPHSU17).

Background:\ud D‐dimer is a marker of fibrin degradation that reflects intra‐vascular coagulation. Therefore, plasma concentrations of D‐dimer might predict thromboembolic risk and rivaroxaban treatment effect.\ud \ud Aims:\ud To investigate the association between D‐dimer levels and the risk of stroke and other thrombotic, bleeding and fatal events, and whether D‐dimer concentrations could predict rivaroxaban 2.5mg/bd (vs. placebo) effect in patients enrolled in the COMMANDER‐HF trial who were in sinus rhythm, had HFrEF and coronary artery disease.\ud \ud Methods:\ud Survival models with treatment‐by‐plasma D‐dimer interaction. Baseline measurement of D‐dimer was available in 4,107 (82%) of 5,022 patients enrolled. Median (percentile25‐75) follow‐up was 21 (12.9‐32.8) months.\ud \ud Results:\ud The median (percentile25‐75) plasma concentration of D‐dimer was 360 (215‐665)ng/mL. The D‐dimer tertiles were: 1) ≤255; 2) 256‐515; 3) >515ng/mL. Patients within the tertile‐3 were older, and had lower BMI, blood pressure, hemoglobin, eGFR, and LVEF. Higher plasma D‐dimer concentrations were independently associated with higher rates of death, stroke, and venous thromboembolism. For example, the all‐cause death adjusted HR (95%CI) of tertile‐3 vs. tertile‐1 was 1.77 (1.48‐2.11), p

Heart failure is a major health and economic challenge in both developing and developed countries. Despite advances in pharmacological and device therapies for patients with a reduced left ventricular ejection fraction (LVEF) and heart failure (HFrEF), their quality of life (QoL) and exercise capacity are often persistently impaired, morbidity and mortality remain high and the health economic and societal costs are considerable. For patients with heart failure and preserved LVEF (HFpEF), diuretic management has an essential role for controlling congestion and symptoms even if no intervention has been convincingly shown to reduce morbidity or mortality.\ud \ud Remote monitoring might improve care delivery and clinical outcomes for patients regardless of LVEF. A great variety of innovative remote monitoring technologies and algorithms are being introduced, including patient self‐managed testing, wearable either as integrated into established clinically indicated therapeutic devices, such as pacemakers and defibrillators, or as stand‐alone are in development providing the promise of further improvements in service delivery and clinical outcomes. In this article, we will discuss unmet needs in the management of patients with HF, how remote monitoring might contribute to future solutions and provide an overview of current and novel remote monitoring technologies.

No abstract available.