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Abstract Introduction Persons with diabetes are at risk for developing a cardiomyopathy through several pathophysiological mechanisms independent of traditional risk factors for heart failure. Among those with diabetic cardiomyopathy (DbCM), the relationship between natriuretic peptides, cardiac structural abnormalities and functional capacity is largely unknown. Methods In this prespecified subgroup analysis of the Aldose Reductase Inhibition for Stabilization of Exercise Capacity in Heart Failure (ARISE-HF) trial, 685 participants with asymptomatic DbCM underwent baseline echocardiography data, laboratory investigations, and functional assessments. Participants were stratified by N-terminal pro-B type natriuretic peptide (NT-proBNP) quartiles, and correlation with echocardiographic and functional parameters were assessed using Spearman correlation test. Results The median NT-proBNP was 71 (Q1, Q3: 33, 135) ng/L. No association was observed between NT-proBNP concentrations and echocardiographic parameters of either diastolic or systolic dysfunction including global longitudinal strain, left ventricular ejection fraction, left ventricular mass index, left atrial volume index, E/E’, or right ventricular systolic pressure. In contrast, NT-proBNP was significantly correlated with overall Kansas City Cardiomyopathy Questionnaire score (rho = − 0.10; p = 0.007), the Physical Activity Scale in the Elderly (rho = − 0.12; p = 0.004), duration of cardiopulmonary exercise testing (rho = − 0.28; p 95 for females or > 115 for males or E/e’ >13 or left atrial volume index > 34. †Normal ECHO is defined as the absence of these abnormalities. Low NT-proBNP is defined as

Abstract Artificial intelligence-enabled electrocardiogram (ECG) algorithms are gaining prominence for the early detection of cardiovascular (CV) conditions, including those not traditionally associated with conventional ECG measures or expert interpretation. This study develops and validates such models for simultaneous prediction of 15 different common CV diagnoses at the population level. We conducted a retrospective study that included 1,605,268 ECGs of 244,077 adult patients presenting to 84 emergency departments or hospitals, who underwent at least one 12-lead ECG from February 2007 to April 2020 in Alberta, Canada, and considered 15 CV diagnoses, as identified by International Classification of Diseases, 10th revision (ICD-10) codes: atrial fibrillation (AF), supraventricular tachycardia (SVT), ventricular tachycardia (VT), cardiac arrest (CA), atrioventricular block (AVB), unstable angina (UA), ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), pulmonary embolism (PE), hypertrophic cardiomyopathy (HCM), aortic stenosis (AS), mitral valve prolapse (MVP), mitral valve stenosis (MS), pulmonary hypertension (PHTN), and heart failure (HF). We employed ResNet-based deep learning (DL) using ECG tracings and extreme gradient boosting (XGB) using ECG measurements. When evaluated on the first ECGs per episode of 97,631 holdout patients, the DL models had an area under the receiver operating characteristic curve (AUROC) of 90% for 4 diagnoses (AVB, HCM, MS, STEMI). DL models outperformed XGB models with about 5% higher AUROC on average. Overall, ECG-based prediction models demonstrated good-to-excellent prediction performance in diagnosing common CV conditions.

Abstract Background Diabetic cardiomyopathy (DbCM) is a form of Stage B heart failure (HF) at high risk for progression to overt disease. Using baseline characteristics of study participants from the Aldose Reductase Inhibition for Stabilization of Exercise Capacity in Heart Failure (ARISE-HF) Trial we sought to characterize clinical characteristics of individuals with findings consistent with DbCM. Methods Among study participants meeting inclusion criteria, clinical characteristics, laboratory testing, imaging, Kansas City Cardiomyopathy Questionnaire (KCCQ), Physical Activity Scale of the Elderly (PASE) and cardiopulmonary exercise testing (CPET) results were tabulated. Cluster phenogroups were identified. Results Among 691 study participants (mean age 67.4 years; 50% were female), mean duration of type 2 diabetes mellitus (T2DM) was 14.5 years. The median (Q1, Q3) N-terminal pro-B type natriuretic peptide and high sensitivity cardiac troponin T were 71 (35, 135) ng/L and 9 [6, 12] ng/L. The most common echocardiographic abnormalities were reduced global longitudinal strain in 25.3% and impaired diastolic relaxation in 17.7%. Despite rather well-preserved KCCQ scores the average PASE score was markedly impaired at 155 accompanied by an average maximal oxygen consumption of 15.7 mL/Kg/minute on CPET. In K-means clustering, 4 phenogroups were identified including a higher-risk group with more advanced age, greater elevation of cardiac biomarkers, and more prevalent evidence for diastolic dysfunction and left ventricular hypertrophy. Conclusions Baseline data from the ARISE-HF Trial provide clinical characterization of individuals with T2DM and features of stage B HF, and may help clarify the diagnosis of DbCM. Trial Registration ARISE-HF, NCT04083339.

Background: Pulmonary hypertension is common among patients with heart failure (HF). Right ventricular systolic pressure (RVSP) is frequently used to assess its presence and severity. Although RVSP has been associated with adverse outcomes, the importance of serial measurements has not been studied. We evaluated associations between serial RVSP measurements and cardiovascular events in patients with HF. Methods: Patients with HF and 2 echocardiograms performed ≥ 6 months apart were included. RVSP was categorized, using the second echocardiogram, as follows: normal (< 40 mm Hg); severely elevated (≥ 60 mm Hg); moderately elevated (50-59 mm Hg); or mildly elevated (40-49 mm Hg). Patients also were classified according to change in RVSP categories between echocardiograms. The primary outcome was time to HF hospitalization (HFH) or all-cause mortality (ACM) after the second echocardiogram. Results: In total, 4319 patients were included (median age: 78 years; 52.1% female). During a median follow-up period of 19.4 months, HFH/ACM occurred in 2714 patients (62.8%). In multivariable analysis, baseline RSVP that was mildly elevated (1069 patients, hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.12-1.54), moderately elevated (797 patients, HR 1.54, 95% CI 1.30-1.82), or severely elevated (837 patients, HR 1.92, 95% CI 1.60-2.31) was independently associated with HFH/ACM. Additionally, improving RVSP was associated with increased HFH/ACM in both categorical (HR 1.16, 95% CI 1.01-1.33) and continuous analyses. Conclusions: RVSP measurements identify patients at increased risk who may require more-aggressive monitoring and medical therapy. Our study raises the hypothesis that, in addition to the absolute value of RVSP, improving RVSP category may identify higher-risk patients, but further study is needed to elucidate the underlying reasons. Résumé: Contexte: L’hypertension pulmonaire est fréquente chez les patients atteints d’insuffisance cardiaque. La pression systolique ventriculaire droite (PSVD) est souvent utilisée pour évaluer la présence et la gravité de l’hypertension pulmonaire. Bien que la PSVD ait été associée à des complications, l’importance de mesures répétitives n’a pas été étudiée. Nous avons évalué les liens entre des mesures répétitives de la PSVD et des événements cardiovasculaires chez des patients atteints d’insuffisance cardiaque. Méthodologie: Ont été inclus des patients atteints d’insuffisance cardiaque pour lesquels on disposait de deux échocardiogrammes réalisés dans un intervalle ≥ 6 mois. La PSVD a été catégorisée comme suit, au moyen du deuxième échocardiogramme : normale (

Abstract Background Acute myocardial infarction (AMI) research is challenging as it requires enrollment of acutely ill patients. Patients are generally in a suboptimal state for providing informed consent. Patients’ understanding to verbal assents have not been previously examined in AMI research. Patients Acceptance and Comprehension to Written and Verbal Consent (PAC–VC) compared patients’ understanding and attitudes to verbal and written consents in AMI RCTs. Methods PAC–VC recruited patients from 3 AMI trials using both verbal N = 12 and written N = 6 consents. We compared patients’ understanding using two survey questionnaires. The first questionnaire used open-ended questions with multiple choice answers. The second questionnaire used a 5-point Likert scale to measure patients understanding and attitudes to the consent process. Overall answers average scores were categorized into three groups: Adequate understanding (71–100) %, Partial understanding (41–70)% and Inadequate understanding (0–40)%. Results Responses showed patients with verbal assent had adequate understanding to most components of informed consent, close to those of written consent. Most patients did not read written information entirely and believed that it is not important to make a final decision. Patients favoured to have written information be part of the consent but not necessarily presented during the initial consent process. Patients felt less pressured in the verbal assent arm than those of written consent. Conclusion Patients had adequate understanding to most components of verbal assent and comparable to those of written consent. Utilizing verbal assents in the acute care setting should be further assessed in larger trials.

Background: Guideline-directed medical therapy (GDMT) improves clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF). Despite its proven efficacy, GDMT is underutilized in clinical practice. The current study examines GDMT utilization after incident hospitalization for HF to promote medication initiation, and titration to target dosing within a reasonable time period. Methods: This observational study identified 66,372 patients with HFrEF who were aged ≥ 65 years and had an incident HF hospitalization, using administrative health data (2013-2018). GDMT (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor-neprilysin inhibitors, β-blockers (BB), and mineralocorticoid receptor antagonists ) received within the 6 months after hospitalization was evaluated by monitoring therapy combinations, optimal dosing (proportion receiving ≥ 50% of the target dose for these inhibitors and blockers, and any dose of MRA), and maximal and last dose assessed, and by use of a GDMT intensity score. Results: Among patients with HFrEF, 4768 (7.2%) were on no therapy, 17,184 (25.9%), were on monotherapy, 30,912 (46.6%) were on dual therapy, and 13,508 (20.4%) were on triple therapy. Only 8747 (13.2%) and 5484 (8.3%) achieved optimal GDMT based on the maximum dose and the last dispensed dose, respectively, within 6 months postdischarge. Finally, 38,869 (58.6%) achieved < 50% of the maximum intensity score, 23,006 (34.7%) achieved between 50% and 74% of the maximum intensity score, and 4497 (6.8%) achieved a score that was ≥ 75% of the maximum intensity score. Conclusions: Current pharmacologic management for patients with HFrEF does not align with the Canadian guidelines. Given this gap in care, innovative strategies to optimize care in patients with HFrEF are needed. Résumé: Introduction: Les traitements médicamenteux préconisés dans les lignes directrices (TMPLD) permettent d’améliorer les résultats cliniques des patients atteints d’insuffisance cardiaque à fraction d’éjection réduite (ICFER). En dépit des preuves de leur efficacité, les TMPLD sont sous-utilisés dans la pratique clinique. La présente étude porte sur l’utilisation des TMPLD après une hospitalisation incidente en raison d’une IC afin de favoriser l’amorce de la médication, et l’ajustement de la posologie en vue d’atteindre la dose cible dans un délai raisonnable. Méthodes: Cette étude observationnelle portait sur 66 372 patients atteints d’ICFER qui avaient ≥ 65 ans et une hospitalisation incidente en raison d’une IC, et reposait sur les données administratives sur la santé (2013-2018). Nous avons évalué les TMPLD (inhibiteurs de l’enzyme de conversion de l’angiotensine, bloqueurs des récepteurs de l’angiotensine, β-bloquants [BB] et antagonistes des récepteurs des minéralocorticoïdes [ARM]) reçus dans les six mois après l’hospitalisation par la surveillance des combinaisons de traitement, la posologie optimale (proportion recevant ≥ 50 % de la dose cible pour ces inhibiteurs et ces bloquants, et toute dose d’ARM), la dose maximale et la dernière dose évaluées, et par l’utilisation d’un score d’intensité des TMPLD. Résultats: Parmi les patients atteints d’ICFER, 4 768 (7,2 %) n’avaient reçu aucun traitement, 17 184 (25,9 %), avaient reçu une monothérapie, 30 912 (46,6 %) avaient reçu une bithérapie et 13 508 (20,4 %) avaient reçu une trithérapie. Seuls 8 747 (13,2 %) et 5 484 (8,3 %) avaient obtenu les TMPLD optimaux en fonction de la dose maximale et de la dernière dose administrée, et ce, respectivement, dans les six mois après la sortie de l’hôpital. Enfin, 38 869 (58,6 %) avaient obtenu < 50 % du score d’intensité maximale, 23 006 (34,7 %) avaient obtenu entre 50 % et 74 % du score d’intensité maximale, et 4 497 (6,8 %) avaient obtenu un score qui était ≥ 75 % du score d’intensité maximale. Conclusions: La prise en charge pharmacologique actuelle des patients atteints d’ICFER va à l’encontre des lignes directrices canadiennes. Compte tenu de cette lacune dans les soins, des stratégies novatrices pour optimiser les soins aux patients atteints d’ICFER sont nécessaires.

Background: The suboptimal implementation of guideline-directed medical therapy (GDMT) for heart failure (HF) patients has been linked with poor clinical outcomes. Little is known about the potential role of cardiology residency training programs in improving trainees’ (ie, future cardiologists’) ability to utilize GDMT. Methods: In this survey-based study, we examined the degree of exposure to ambulatory HF patient management among cardiology trainees in Canada. All cardiology residency program directors (n = 15; 100% response rate) completed our survey. Results: Although 9 programs (60%) mandated ≥ 3 ambulatory cardiology rotations, only 3 (20%) required ≥ 2 ambulatory HF rotations. When HF rotations were provided, only 7 programs (47%) offered moderate or higher exposure to ambulatory nontransplant HF patients (defined as ≥ 5 clinics/rotations). This element was independent of program- and institution-specific characteristics. All institutions had a multidisciplinary HF clinic, and the majority (13 [87%]) had access to an inpatient HF service, a consultative HF service, and/or a specialist pharmacist. Furthermore, 13 program directors (87%) agreed on the importance of adopting HF training curriculum and their program’s readiness to implement such a module. Conclusions: The current state of HF training among cardiology residencies is suboptimal and in need of improvement. Most programs have access to a HF clinic, a specialist pharmacist, or an inpatient consultative service, which would facilitate adoption of a HF management curriculum that focuses on practical and experiential aspects of GDMT optimization. This program, which is under development, will be offered to training programs nationwide, to enable trainees to manage this growing and increasingly complex patient population. Résumé: Contexte: Une mise en application sous-optimale des traitements médicaux recommandés dans les lignes directrices (TMRLD) dans les cas de patients atteints d’insuffisance cardiaque (IC) a été associée à des issues cliniques défavorables. On en sait peu sur le rôle éventuel des programmes de résidence en cardiologie sur l’amélioration des capacités des stagiaires (c.-à-d. des futurs cardiologues) à mettre en œuvre les TMRLD. Méthodologie: Notre étude s’appuyant sur un sondage a permis d’examiner le niveau d’exposition des stagiaires en cardiologie au Canada à la prise en charge des patients ambulatoires atteints d’IC. La direction de tous les programmes de résidence en cardiologie (n = 15; taux de réponse de 100 %) a participé à notre sondage. Résultats: Alors que neuf programmes (60 %) exigeaient ≥ trois stages en cardiologie ambulatoire, seulement trois d’entre eux (20 %) exigeaient ≥ deux stages en IC ambulatoire. Parmi les programmes offrant des stages en IC, seulement sept (47 %) offraient une exposition modérée à élevée à des patients ambulatoires atteints d’IC et n’ayant pas reçu de greffe (cette exposition était établie à cinq cliniques par stage ou plus); le niveau d’exposition à ces patients ne dépendait pas des caractéristiques du programme ou de l’établissement. Dans tous les établissements, une clinique multidisciplinaire spécialisée en IC était présente, et la majorité d’entre eux (13 [87 %]) bénéficiaient également d’un service pour les patients hospitalisés atteints d’IC, d’un service de consultation en IC et/ou de la présence d’un pharmacien spécialisé. De plus, la direction de 13 programmes (87 %) se disait en accord avec l’importance d’adopter un curriculum de formation portant sur l’IC et considérait que leur programme était prêt à intégrer un tel module. Conclusions: L’état actuel de la formation en IC dans les programmes de résidence en cardiologie n’est pas optimal, et des améliorations sont nécessaires. La plupart des programmes ont accès à une clinique en IC, un pharmacien spécialisé ou un service de consultation pour les patients hospitalisés, ce qui pourrait faciliter l’adoption d’un curriculum de prise en charge de l’IC portant sur l’expérience concrète de l’optimisation des TMRLD. Ce module, qui est en cours d’élaboration, sera offert à tous les programmes de formation à travers le Canada, pour permettre aux stagiaires de mieux prendre en charge cette population de patients qui gagne en nombre et en complexité.

Background: Heart failure (HF) is a leading complication of nonvalvular atrial fibrillation (NVAF), and the presence of both conditions worsens prognosis. Sex-specific associations between NVAF and outcomes focus on stroke; less is known about HF. We evaluated sex differences in incident HF in NVAF. Methods: We identified adults age ≥ 65 years hospitalized for incident NVAF without prior HF from April 2010 to March 2018 in Canada. The primary outcome was incident HF hospitalization, with a secondary composite outcome of incident HF hospitalization or all-cause mortality at 1 year. Cox proportional hazard regression models were constructed for the association between sex and outcomes, adjusting for age, comorbidities, socioeconomic status, cardioversion, and medications. Results: Of 68,909 NVAF patients, 53.8% were women. Women had a higher rate of the primary outcome (30.0% vs 25.6%, P < 0.001) and the composite outcome (39.5% vs 36.6%, P < 0.001) than men. In multivariable analysis without adjusting for medications, there was an 8% increase risk of HF (95% confidence interval [CI] 1.05-1.11, P < 0.001) for women, which was attenuated when accounting for medication (hazard ratio [HR] 1.01, 95% CI 0.98-1.04). After full adjustment, women age ≥ 75 years were at higher risk of the primary outcome (HR 1.10, 95% CI 1.06-1.13, P < 0.001) and the composite outcome (HR 1.04, 95% CI 1.01-1.07, P < 0.001), compared with men, whereas there was a significantly lower risk for those age 65-75 years. Conclusions: In this nationwide study of incident NVAF without HF, women age ≥ 75 years were more likely to develop HF or die than men. Strategies to prevent HF in older women with NVAF are needed. Résumé: Contexte: L’insuffisance cardiaque (IC) est une complication majeure de la fibrillation auriculaire non valvulaire (FANV), et la présence des deux affections assombrit le pronostic. Les associations entre la FANV et ses complications en fonction du sexe ont surtout porté sur l’AVC; on en connaît moins sur l’IC. Nous avons évalué les différences entre les sexes pour l’IC fortuite dans la FANV. Méthodologie: Nous avons identifié des adultes de ≥ 65 ans, sans antécédents d’IC, hospitalisés pour une FANV fortuite entre avril 2010 et mars 2018 au Canada. L’hospitalisation à la suite d’une IC fortuite constituait le critère d’évaluation principal, le critère d’évaluation secondaire composé comprenait les hospitalisations pour un épisode d’IC fortuite ou le décès toutes causes confondues à un an. Des modèles de régression à risques proportionnels de Cox ont servi à évaluer l’association entre le sexe et les résultats, après correction en fonction de l’âge, des comorbidités, de la situation socio-économique, de la cardioversion et de la médication. Résultats: Le groupe étudié comptait 68 909 patients atteints de FANV dont 53,8 % étaient des femmes. Les femmes étaient plus nombreuses à répondre au critère d’évaluation principal (30,0 % vs 25,6 %, p < 0,001) et au critère d’évaluation composé (39,5 % vs 36,6 %, p

Abstract Aims Heart failure with mildly reduced ejection fraction (HFmrEF) is associated with a favourable prognosis compared with heart failure (HF) with reduced ejection fraction (EF). We assessed whether left ventricular ejection fraction (LVEF) trajectory can be used to identify groups of patients with HFmrEF who have different clinical outcomes in a large retrospective study of patients with serial imaging. Methods and results Patients with HF and ≥2 echocardiograms performed ≥6 months apart were included if the LVEF measured 40–49% on the second study. Patients were classified as HFmrEF‐Increasing if LVEF had increased ≥10% (n = 450), HFmrEF‐Decreasing if LVEF had decreased ≥10% (n = 512), or HFmrEF‐Stable if they did not meet other criteria (n = 389). The primary outcome was all‐cause mortality or cardiovascular hospitalization after the second echocardiogram. Associations with time to first event were assessed with multivariable Cox analyses adjusted for age, co‐morbidities, and medications. In total, 1351 patients with HFmrEF (median age 74, 64.2% male) were included with 28.8% exhibiting stable LVEF. During median follow‐up of 15.3 months, the composite outcome occurred in 811 patients. During follow‐up, patients with HFmrEF‐Increasing were less likely to experience the primary outcome [adjusted hazard ratio (HR) 0.72, 95% confidence interval (CI) 0.60–0.88, P

Background Oral anticoagulation (OAC) therapy prevents morbidity and mortality in nonvalvular atrial fibrillation; whether location of diagnosis influences OAC uptake or adherence is unknown. Methods and Results Retrospective cohort study (2008–2019), identifying adults with incident nonvalvular atrial fibrillation across health care settings (emergency department, hospital, outpatient) at high risk of stroke. OAC uptake and adherence via proportion of days covered for direct OACs and time in therapeutic range for warfarin were measured. Proportion of days covered was categorized as low (0–39%), intermediate (40–79%), and high (80–100%). Warfarin control was defined as time in therapeutic range ≥65%. All‐cause mortality was examined at a 3‐year landmark. Among 75 389 patients with nonvalvular atrial fibrillation (47.0% women, mean 77.4 years), 19.7% were diagnosed in the emergency department, 59.1% in the hospital, and 21.2% in the outpatient setting. Ninety‐day OAC uptake was 51.6% in the emergency department, 50.9% in the hospital, and 67.9% in the outpatient setting (P

Background: Heart failure (HF) with preserved ejection fraction (HFpEF) carries high morbidity and mortality. Compared with HF with reduced ejection fraction (HFrEF), HFpEF is difficult to diagnose, and lacks evidence-based treatments. In this survey we assessed perceptions of cardiologists, internists, and primary care physicians (PCPs) regarding HFpEF diagnosis and management. Methods: In total, 159 cardiologists, 89 internists, and 200 PCPs from across Canada completed an online survey, with response rates of 14%-17%. Results: The perceived prevalence of HFpEF vs HFrEF was similar across physician types (58% HFrEF, 42% HFpEF). Thirty-seven percent of PCPs did not differentiate HF on the basis of ejection fraction. All physician types ranked symptom and mortality reduction as treatment priorities. Ninety-two percent of specialists believed that HFpEF is best comanaged by PCPs and specialists, whereas one-fifth of PCPs suggested PCP management alone. Compared with specialists, PCPs were more likely to underestimate HFpEF mortality and less aware of sex differences in the prevalence of HFpEF vs HFrEF (all P < 0.001). Fewer PCPs use natriuretic peptides for diagnosis (P < 0.001). All physician types listed cost and availability as barriers to natriuretic peptide use. Ninety-one percent of PCPs incorrectly identified various therapies as effective for improving HFpEF outcomes. Most of all physicians expressed a strong desire to increase knowledge of diagnostic and treatment algorithms for HFpEF. Conclusions: There are substantial knowledge gaps in the diagnosis and management of HFpEF, particularly among PCPs. Because of the prevalence of HFpEF in primary care, strategies are required to reduce these gaps. Résumé: Introduction: L’insuffisance cardiaque (IC) à fraction d’éjection préservée (ICFEP) entraîne des taux élevés de morbidité et de mortalité. Comparativement à l’IC à fraction d’éjection réduite (ICFER), il est difficile de poser le diagnostic de l’ICFEP et de trouver des traitements fondés sur des données probantes. Dans cette enquête, nous avons évalué la perception des cardiologues, des internistes et des médecins de premier recours (MPR) concernant le diagnostic et la prise en charge de l’ICFEP. Méthodes: Au total, 159 cardiologues, 89 internistes et 200 MPR du Canada ont rempli l’enquête en ligne. Le taux de réponse a été de 14 % à 17 %. Résultats: Tous les types de médecins percevaient une prévalence similaire entre l’ICFEP et l’ICFER (58 % ICFER, 42 % ICFEP). Trente-sept pour cent des MPR ne différenciaient pas l’IC en fonction de la fraction d’éjection. Tous les types de médecins donnaient la priorité de traitement à la réduction des symptômes et de la mortalité. Quatre-vingt-douze pour cent des spécialistes croyaient que la prise en charge commune de l’ICFEP par les MPR et les spécialistes était préférable, tandis qu’un cinquième des MPR suggéraient une prise en charge par le MPR seul. Comparativement aux spécialistes, il était plus probable que les MPR sous-estiment la mortalité liée à l’ICFEP et qu’ils soient moins au fait des différences entre les sexes dans la prévalence de l’ICFEP vs l’ICFER (toutes les valeurs p < 0,001). Un plus petit nombre de MPR utilisent les peptides natriurétiques pour le diagnostic (P < 0,001). Tous les types de médecins ont considéré les coûts et la disponibilité comme des obstacles à l’utilisation des peptides natriurétiques. Quatre-vingt-onze pour cent des MPR ont considéré à tort que les diverses thérapies étaient efficaces pour améliorer les résultats de l’ICFEP. La plupart des médecins ont fait part de leur profond désir de rehausser leurs connaissances sur les algorithmes diagnostiques et thérapeutiques de l’ICFEP. Conclusions: Il existe des lacunes substantielles dans les connaissances en matière de diagnostic et de prise en charge de l’ICFEP, particulièrement des lacunes dans les connaissances des MPR. En raison de la prévalence de l’ICFEP dans les soins primaires, des stratégies sont nécessaires pour combler ces lacunes.

Background Clinical prediction models have been developed for hospitalization for heart failure in type 2 diabetes. However, a systematic evaluation of these models’ performance, applicability, and clinical impact is absent. Methods and Results We searched Embase, MEDLINE, Web of Science, Google Scholar, and Tufts’ clinical prediction registry through February 2021. Studies needed to report the development, validation, clinical impact, or update of a prediction model for hospitalization for heart failure in type 2 diabetes with measures of model performance and sufficient information for clinical use. Model assessment was done with the Prediction Model Risk of Bias Assessment Tool, and meta‐analyses of model discrimination were performed. We included 15 model development and 3 external validation studies with data from 999 167 people with type 2 diabetes. Of the 15 models, 6 had undergone external validation and only 1 had low concern for risk of bias and applicability (Risk Equations for Complications of Type 2 Diabetes). Seven models were presented in a clinically useful manner (eg, risk score, online calculator) and 2 models were classified as the most suitable for clinical use based on study design, external validity, and point‐of‐care usability. These were Risk Equations for Complications of Type 2 Diabetes (meta‐analyzed c‐statistic, 0.76) and the Thrombolysis in Myocardial Infarction Risk Score for Heart Failure in Diabetes (meta‐analyzed c‐statistic, 0.78), which was the simplest model with only 5 variables. No studies reported clinical impact. Conclusions Most prediction models for hospitalization for heart failure in patients with type 2 diabetes have potential concerns with risk of bias or applicability, and uncertain external validity and clinical impact. Future research is needed to address these knowledge gaps.

Background Although safety and tolerability of vericiguat were established in the VICTORIA (Vericiguat Global Study in Subjects With Heart Failure With Reduced Ejection Fraction) trial in patients with heart failure with reduced ejection fraction, some subgroups may be more susceptible to symptomatic hypotension, such as older patients, those with lower baseline systolic blood pressure (SBP), or those concurrently taking angiotensin receptor neprilysin inhibitors. We described the SBP trajectories over time and compared the occurrence of symptomatic hypotension or syncope by treatment arm in potentially vulnerable subgroups in VICTORIA. We also evaluated the relation between the efficacy of vericiguat and baseline SBP. Methods and Results Among patients receiving at least 1 dose of the study drug (n=5034), potentially vulnerable subgroups were those >75 years old (n=1395), those with baseline SBP 100–110 mm Hg (n=1344), and those taking angiotensin receptor neprilysin inhibitors (n=730). SBP trajectory was plotted as mean change from baseline over time. The treatment effect on time to symptomatic hypotension or syncope was evaluated overall and by subgroup, and the primary efficacy composite outcome (heart failure hospitalization or cardiovascular death) across baseline SBP was examined using Cox proportional hazards models. SBP trajectories showed a small initial decline in SBP with vericiguat in those >75 years old (versus younger patients), as well as those receiving angiotensin receptor neprilysin inhibitors (versus none), with SBP returning to baseline thereafter. Patients with SBP

Background: Implantable cardioverter defibrillator (ICD) therapy is lifesaving; however, real-world data regarding the proportion of patients eligible for a primary prevention ICD and subsequent use remain sparse. This study evaluated rates of primary prevention ICD eligibility and use among patients in heart function clinics (HFCs) and to identify reasons for nonimplantation. Methods: A retrospective study was performed of patients seen at HFCs in Alberta, Canada, from 2013 to 2015. Demographics, comorbidities, clinical indications, and reasons for nonimplantation were abstracted. Eligibility was defined according to the 2008 American College of Cardiology/American Heart Association/Heart Rhythm Society ICD, 2012 American College of Cardiology/American Heart Association/Heart Rhythm Society Focused Update, and 2013 Canadian Cardiovascular Society Cardiac Resynchronization Therapy guidelines. Logistic regression was used to calculate an odds ratio (OR) and 95% confidence interval (CI) for predictors of nonimplantation. Results: Among 1239 patients in HFCs, the median age was 70 years (interquartile range, 59-80), 67% were male, and the median left ventricular ejection fraction was 0.40 (interquartile range, 0.28-0.53). Overall, 45% of patients (n = 553) met guideline criteria for an ICD, and of those, 36% (n = 198) received a device. Among device nonrecipients, 52% (n = 185) had no documented reason for nonimplantation. The most common reason for nonimplantation among nonrecipients was patient preference (48%). Predictors associated with nonimplantation were age more than 75 years (OR, 1.92; 95% CI, 1.31-2.82) and history of cancer (OR, 2.26; 95% CI, 1.07-4.78). At 3 years follow-up, 27% of nonrecipients were deceased. Conclusions: We found that one-third of patients who met guideline criteria received an ICD and that documentation for nonimplantation was poor. Résumé: Contexte: Le défibrillateur cardioverteur implantable (DCI) sauve des vies. Or, les données recueillies dans la pratique réelle concernant le pourcentage de patients admissibles à l’implantation d’un tel dispositif en prévention primaire et l’utilisation subséquente de ce dispositif sont très limitées. Cette étude a évalué le taux de patients admissibles à la pose d’un DCI en prévention primaire et le taux d’utilisation de ce dispositif chez des patients traités en clinique de cardiologie. Elle a également recensé les motifs de non-implantation. Méthodologie: Une étude rétrospective a été réalisée chez des patients traités de 2013 à 2015 dans plusieurs cliniques de cardiologie de l’Alberta, au Canada. Les données relatives aux caractéristiques démographiques, aux comorbidités, aux indications cliniques et aux motifs de la non-implantation ont été extraites. L’admissibilité était définie en fonction des lignes directrices de 2008 de l’American College of Cardiology, de l’American Heart Association et de la Heart Rhythm Society sur le DCI, de leur mise à jour ciblée en 2012 et des lignes directrices de 2013 de la Société canadienne de cardiologie sur la thérapie de resynchronisation cardiaque. Une régression logistique a été utilisée pour calculer le risque relatif approché (RRA) et l’intervalle de confiance (IC) à 95 % associés aux facteurs de prédiction de la non-implantation. Résultats: L’âge médian des 1 239 patients traités en clinique de cardiologie était de 70 ans (plage interquartile : 59 – 80 ans); 67 % d’entre eux étaient des hommes, et la fraction d’éjection ventriculaire gauche médiane était de 0,40 (plage interquartile : 0,28 – 0,53). D’une manière générale, 45 % des patients (n = 553) répondaient aux critères énoncés dans les lignes directrices pour la pose d’un DCI, et 36 % d’entre eux (n = 198) ont reçu un dispositif. Parmi les patients qui n’ont pas reçu de dispositif, aucun motif justifiant la non-implantation n’a été documenté chez 52 % des patients (n = 185); chez les 48 % des patients restants, le motif le plus courant pour justifier la non-implantation a été la préférence du patient. Les facteurs de prédiction associés à la non-implantation ont été l’âge (plus de 75 ans; RRA : 1,92; IC à 95 % : 1,31 – 2,82) et les antécédents de cancer (RRA : 2,26; IC à 95 % : 1,07 – 4,78). Après 3 ans de suivi, 27 % des patients qui n’avaient pas reçu de dispositif étaient décédés. Conclusions: Nous avons constaté que le tiers des patients qui répondaient aux critères énoncés dans les lignes directrices ont reçu un DCI et que les motifs justifiant la non-implantation étaient mal documentés.

Background NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) is a prognostic biomarker in heart failure (HF) with reduced ejection fraction. However, it is unclear whether there is a sex difference in NT‐proBNP response and whether the therapeutic goal of NT‐proBNP ≤1000 pg/mL has equivalent prognostic value in men and women with HF with reduced ejection fraction. Methods and Results In a secondary analysis of the GUIDE‐IT (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment) trial we analyzed trends in NT‐proBNP and goal attainment by sex. Differences in clinical characteristics, HF treatment, and time to all‐cause death or HF hospitalization were compared. Landmark analysis at 3 months determined the prognostic value of early NT‐proBNP goal achievement in men and women. Of the 286 (32%) women and 608 (68%) men in the GUIDE‐IT trial, women were more likely to have a nonischemic cause and shorter duration of HF. Guideline‐directed medical therapy was less intense over time in women. The absolute NT‐proBNP values were consistently lower in women; however, the change in NT‐proBNP and clinical outcomes were similar. After adjustment, women achieving the NT‐proBNP goal had an 82% reduction in death or HF hospitalization compared with a 59% reduction in men. Conclusions Men and women with HF with reduced ejection fraction had a similar NT‐proBNP response despite less intensive HF treatment among women. However, compared with men, the early NT‐proBNP goal of ≤1000 pg/mL had greater prognostic value in women. Future efforts should be aimed at intensifying guideline‐directed medical therapy in women, which may result in greater NT‐proBNP reductions and improved outcomes in women with HF with reduced ejection fraction. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01685840.

Background: Patients with heart failure (HF) experience a major symptom burden and an overall reduction of quality of life. However, supportive care (SC) remains an under-utilized resource for these patients. Among the many existing barriers to integrating SC into routine care, identifying patients with SC needs remains challenging. The Kansas City Cardiomyopathy Questionnaire (KCCQ) is an important predictor of SC needs in patients with HF.Methods and Results: We used the shortened version KCCQ-12 as a screening tool for SC need in our ambulatory HF patient population using a KCCQ-12 summary score of

Heart failure (HF) with preserved ejection fraction (HFpEF) is increasingly recognized as an important clinical entity. Preclinical studies have shown differences in the pathophysiology between HFpEF and HF with reduced ejection fraction (HFrEF). Therefore, we hypothesized that a systematic metabolomic analysis would reveal a novel metabolomic fingerprint of HFpEF that will help understand its pathophysiology and assist in establishing new biomarkers for its diagnosis.Ambulatory patients with clinical diagnosis of HFpEF (n = 24), HFrEF (n = 20), and age-matched non-HF controls (n = 38) were selected for metabolomic analysis as part of the Alberta HEART (Heart Failure Etiology and Analysis Research Team) project. 181 serum metabolites were quantified by LC-MS/MS and 1H-NMR spectroscopy. Compared to non-HF control, HFpEF patients demonstrated higher serum concentrations of acylcarnitines, carnitine, creatinine, betaine, and amino acids; and lower levels of phosphatidylcholines, lysophosphatidylcholines, and sphingomyelins. Medium and long-chain acylcarnitines and ketone bodies were higher in HFpEF than HFrEF patients. Using logistic regression, two panels of metabolites were identified that can separate HFpEF patients from both non-HF controls and HFrEF patients with area under the receiver operating characteristic (ROC) curves of 0.942 and 0.981, respectively.The metabolomics approach employed in this study identified a unique metabolomic fingerprint of HFpEF that is distinct from that of HFrEF. This metabolomic fingerprint has been utilized to identify two novel panels of metabolites that can separate HFpEF patients from both non-HF controls and HFrEF patients.ClinicalTrials.gov NCT02052804.