Heart Failure Therapies and Renal Effects: A Critical Reevaluation of Clinical Data

Guideline-directed medical therapy of heart failure (HF) primarily targets neurohormonal activation. However, GH has emerged as a potential treatment for the multiple hormonal deficiency syndrome, which is associated with worse outcomes in HF. This study evaluates the efficacy and safety of GH therapy in HF. A systematic search was conducted in PubMed, Cochrane Library, and ClinicalTrials.gov, according to PRISMA guidelines. Randomized, placebo-controlled trials studying GH therapy in adult HF patients were included. Of the 1184 initially identified records, 17 studies (1.4%) met the inclusion criteria. Two independent authors conducted the search, with any disagreements resolved by a third author. Study quality was assessed using predefined criteria, including randomization, blinding, and the presence of a placebo group. A random-effects model was applied due to heterogeneity across studies. GH therapy significantly improved left ventricular ejection fraction (+3.34%; 95% CI, 1.09-5.59; P = .0037), peak oxygen consumption (+2.84 mL/kg/min; 95% CI, 1.32-4.36; P = .0002), and New York Heart Association class (-0.44; 95% CI, -0.08 to -0.81; P = .023). GH therapy also reduced the composite of death, worsening HF or ventricular tachycardia by 41% (RR = .59; 95% CI, 0.39-0.90; P = .013). Subgroup analyses indicated that patients with ischemic cardiomyopathy, baseline ejection fraction ≥30%, and longer treatment duration experienced greater benefits. GH therapy demonstrated improvements in cardiac function, exercise capacity, and HF symptoms, along with a statistically significant trend toward improvements in hard endpoints. Event-driven trials are needed to validate these findings.

Finerenone—A New Frontier in Renin-Angiotensin-Aldosterone System Inhibition in Diabetic Kidney Disease

Background Heart failure (HF) is associated with an increased incidence of cancer independently of shared risk factors. The mechanism behind this link is not entirely clear. Purpose We aimed to test the hypothesis that cardiac extracellular vesicles (cEVs) contribute to the link between HF and cancer. In addition, we aimed to determine if heart failure (HF) therapy will reduce the tumour-promoting effects of HF. Methods We used a mouse model of heterotopic lung cancer tumours and post-myocardial infarction (MI) HF. To determine the role of cEVs in tumour growth, we focused on cardiac mesenchymal stromal cells (cMSCs). First, we isolated cMSCs from mice hearts 10d after MI or sham MI and purified cMSC-EVs from the conditioned medium using size exclusion chromatography. Then, we analyzed cMSC-EV characteristics, cargo, and neoplastic effects on lung cancer cells. We also used cMSC-EV transfer to assess EV biodistribution and its effect on tumour growth. Next, we tested the effects of EV depletion on tumour growth. Finally, we used spironolactone to determine if HF therapy would attenuate the harmful interaction between HF and cancer. Results Mice with HF developed larger lung tumours than sham-MI mice during 28 days of follow-up. Failing hearts, particularly cMSCs, produced twice more EVs with neoplastic properties than non-failing hearts (Fig-A). Proteomics analysis revealed unique protein profiles of cMSC-EVs from failing hearts (Fig-B). cMSC-EVs from the failing hearts harbored higher quantities of tumour-promoting cytokines such as periostin, osteopontin, vascular endothelial growth factor, interleukin-6 and tumour necrosis factor-alpha; and tumorigenic microRNAs (miR) such as miR-221 and mir-21. Transfer of labeled cMSC-EVs from the failing heart into the systemic circulation of tumour-bearing mice targeted tumour cells and accelerated tumour growth (Fig-C). Moreover, EV depletion reduced the tumour-promoting effects of HF, and adoptive transfer of cMSC-EVs from failing hearts accelerated tumour growth in mice during systemic EV depletion (Fig-D). Finally, we used spironolactone to determine if HF therapy would inhibit the tumour trophic effects of HF. Spironolactone attenuated LV dilatation and improved global longitudinal strain following MI. Subsequently, spironolactone treatment reduced the number of EVs secreted by cMSCs from failing hearts by 26% and reduced the accelerated tumour growth after MI and HF (Fig E). Notably, spironolactone treatment did not reduce the volume of the tumours in sham-MI mice, indicating that the anti-tumour effects of spironolactone were related to its effects on the faling heart. Conclusions Our results provide new insight into the link between heart failure and cancer. We show, for the first time, that cardiac extracellular vesicles promote tumour growth independently of other secreted factors. Moreover, heart failure therapy reduces the tumour-promoting effects of heart failure.

In patients with heart failure, chronic kidney disease is common and associated with a higher risk of renal events than in patients without chronic kidney disease. We assessed the renal effects of angiotensin/neprilysin inhibition in patients who have heart failure with preserved ejection fraction enrolled in the PARAGON-HF trial (Prospective Comparison of ARNI With ARB Global Outcomes in HF With Preserved Ejection Fraction). In this randomized, double-blind, event-driven trial, we assigned 4822 patients who had heart failure with preserved ejection fraction to receive sacubitril/valsartan (n=2419) or valsartan (n=2403). Herein, we present the results of the prespecified renal composite outcome (time to first occurrence of either: ≥50% reduction in estimated glomerular filtration rate (eGFR), end-stage renal disease, or death from renal causes), the individual components of this composite, and the influence of therapy on eGFR slope. At randomization, eGFR was 63±19 mL·min-1·1.73 m-2. At study closure, the composite renal outcome occurred in 33 patients (1.4%) assigned to sacubitril/valsartan and 64 patients (2.7%) assigned to valsartan (hazard ratio, 0.50 [95% CI, 0.33-0.77]; P=0.001). The treatment effect on the composite renal end point did not differ according to the baseline eGFR (<60 versus ≥60 mL·min-1·1.73 m-2 (P-interaction=0.92). The decline in eGFR was less for sacubitril/valsartan than for valsartan (-2.0 [95% CI, -2.2 to -1.9] versus -2.7 [95% CI, -2.8 to -2.5] mL·min-1·1.73 m-2 per year). In patients with heart failure with preserved ejection fraction, sacubitril/valsartan reduced the risk of renal events, and slowed decline in eGFR, in comparison with valsartan. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01920711.

BackgroundAlthough contemporary guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (HFrEF) and heart failure with mildly-reduced ejection fraction (HFmrEF) has been shown to significantly improve prognosis, patients with these conditions still face considerable residual risk, and their quality of life (QoL) remains severely compromised. ShengXian-QuYu (SXQY) Decoction is a widely prescribed complementary and alternative medicine (CAM) therapy for HF in clinical practice. However, there is currently no robust evidence supporting its efficacy in HFrEF and HFmrEF, and its potential adverse effects have yet to be fully elucidated.MethodsPatients with chronic HF, New York Heart Association (NYHA) class II–IV symptoms, elevated plasma natriuretic peptide levels, and a left ventricular ejection fraction (LVEF) of ≤50 % were enrolled in the ShengXian-QuYu Decoction in the Treatment of Heart Failure with Reduced and mildly reduced Ejection Fraction (SHINE-HF) trial. Patients eligibility entered a run-in period, followed by randomization in a 1:1 ratio to double-blind treatment with either 30 ml of SXQY or 30 ml of placebo, administered twice daily. The primary endpoint was the change from baseline in the Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (KCCQ-CSS) at week 12. Key secondary endpoints included the change from baseline in the Traditional Chinese Medicine Syndrome Score Scale (TCMSSS) and the 6-min walk test (6MWT) distance at week 12. Additionally, a safety analysis will be conducted.ConclusionSHINE-HF will determine the effects of SXQY on patient-reported outcomes (PROs) and symptom burden in patients with HFrEF and HFmrEF. This will shed light on the potential of SXQY as a novel treatment option in improving QoL of patients with HFrEF and HFmrEF.

Foundational therapies in heart failure improve clinical outcomes in heart failure with a reduced ejection fraction (HFrEF). Underuse of these life-prolonging heart failure therapies, such as sacubitril-valsartan, is common in older adults and has been associated with worse clinical outcomes. Characterizing the early benefits seen with these therapies might help increase their uptake in older adults. We applied several methods to estimate the time to benefit of an HFrEF therapy, using sacubitril-valsartan as a case study. PARADIGM-HF was a randomized controlled study on sacubitril-valsartan versus enalapril in stable, ambulatory HFrEF patients (n = 8399). The primary endpoint, a composite of death from cardiovascular causes or a first hospitalization for heart failure, was significantly reduced (sacubitril-valsartan (21.8%) versus enalapril (26.5%), hazard ratio (HR) 0.80 (95% confidence interval [CI] 0.73-0.87). We extracted and tabulated the Kaplan-Meier (KM) curves of the primary endpoint. An individual patient dataset was then reconstructed. The following methods were applied to explore the time to benefit of sacubitril-valsartan versus enalapril: visual estimation of the point of divergence of the KM curves, statistical process control (SPC), unadjusted landmark analyses using Cox proportional hazards analysis with 30-day increments until significance was persistently achieved, and comparing the survival probabilities of the extracted life tables. Six raters visually estimated the time to benefit at a median of 60 days (interquartile range 38-10 days). Using SPC we found an early benefit from 28 days on, using the longest predefined control period of 28 days. An absolute risk reduction of 1 and 2% was found after 59 and 250 days, respectively. The reconstructed dataset provided a similar HR of 0.8004 (95% CI 0.7331-0.8739). Landmark analyses persistently showed statistical significance from 390 days and later. Survival probabilities differed from 35 days onward. Using multiple approaches, the earliest benefit of sacubitril-valsartan compared to enalapril in stable HFrEF was found at about 1 month after initiation.

Background Clinical trials like STRONG emphasize the importance of optimizing heart failure (HF) therapy by titrating medications to maximum doses. However, real-world data suggests that achieving maximum doses across all HF drug classes is rare. Additionally, the initiation of comprehensive HF therapy during hospitalization appears to be a critical determinant for long-term therapeutic adherence. This study evaluates the discharge treatment patterns and subsequent uptitration in patients with de novo HF and reduced ejection fraction (HFrEF) from our registry. Methods We analyzed patients from a prospective registry of de novo HFrEF (LVEF ≤ 40%) admitted to two tertiary hospitals between March 2021 and October 2023. We assessed the distribution of treatments by drug classes and the number of drug classes prescribed at discharge, as well as changes after a mean follow-up period of 97 days. Uptitration success was measured by the percentage of patients achieving maximum doses in each drug class. Results Among 370 patients at discharge, 91.3% were prescribed beta-blockers, 61.9% ARNI, 77.6% MRAs, and 81.6% SGLT2i. Quadruple therapy was achieved in 58.1%, with limited changes after uptitration (63.7% at follow-up). Despite efforts, only 16.0% of patients on beta-blockers, 27.0% on RASi, 54.0% on MRAs, and 100% on SGLT2i reached maximum doses. Notably, 3.5% of patients receiving quadruple therapy achieved maximum doses across all drug classes. Uptitration primarily benefited those already initiated on foundational HF therapies during hospitalization, as the addition of new drug classes post-discharge was rare. Conclusion Our real-world data highlight a significant gap between guideline-recommended HF management strategies and clinical practice. Initiating optimal HF therapy during hospitalization is critical, as post-discharge uptitration or the addition of missing drug classes is infrequent. These findings emphasize the importance of comprehensive HF management during the initial hospitalization to maximize long-term therapeutic outcomes.

Introduction: In patients with noncompaction cardiomyopathy (NCC) no heart failure (HF) therapy has been shown to improve the left ventricle ejection fraction (LVEF). Sudden cardiac death (SCD) or need for heart transplantation (HTx) or left ventricle assist device (LVAD) implantation have been described. The effect of novel HF therapy, such as angiotensin receptor and neprilysin inhibitor (ARNI) and sodium glucose co-transporter 2 inhibitors (SGLT2i) remains unclear. Hypothesis: We sought to analyze a potential recovery of cardiac function in patients with NCC after introducing the novel HF therapy. Methods: We have prospectively enrolled 41 (33 male, 8 female) patients with NCC, confirmed by cardiac MRI from 2018 to 2021. The average age was 49±16.3 years. At inclusion, echocardiography was performed to determine the left ventricle end-diastolic diameter and volume (EDD and EDV) and LVEF; serum levels of NT-proBNP have also been obtained. ARNI and SGLT2i have been introduced into patients’ therapy and up titrated to maximal tolerated dose. After 1 year follow up investigations, performed at patients' inclusion, have been repeated. Results: Of 41 patients enrolled 23 patients (56%) had echocardiographic evidence of myocardial recovery (Group A), defined by improvement of LVEF above 40% (LVEF increased from 31±6.6% to 48±5.2%. 9 patients (22%) showed no significant LVEF improvement (Group B, LVEF increased from 26±8.0% to 33±2.6%). 9 patients were excluded (2 due to SCD, 7 had HTx or LVAD implantation performed). The two groups did not differ in sex (male 41% vs. 39% in Group B, P=0.51), age (51±17.2 years vs. 46±15.2 years, P=0.72), sodium (140±2.6mEq/L vs. 138±1.8mEq/mL, P=0.22), creatinine (82±24μmol/L vs. 87±18 μmol/L, P=0.51) or bilirubin levels (17±12μmol/L vs. 21±12μmol/L, P=0.42). When compared to Group B at inclusion, Group A had significantly higher LVEF (31,6±6,6% vs. 26,5±8,0% in Group B, P=0.033) and lower NTproBNP levels (1619±1505pg/mL vs. 4902±3795pg/mL, P&lt;0.001). Conclusions: In patients with NCC, the introduction of novel HF therapy seems to be connected with significant reverse remodelation of the myocardium. The improvement has been shown to be more pronounced in NCC patients with better LVEF and lower neurohormonal activation.

Treatment of Diabetes in People with Heart Failure

Congestive heart failure in the elderly is recognized as a national public health priority; however, clinical diagnosis can be problematic in elderly persons, many of whom have a history of heart failure in the presence of normal or only minimally decreased ejection fraction. Findings of the Cardiovascular Health Study have underscored the common substrate and predictors underlying heart failure both with decreased ejection fraction and with normal ejection fraction (i.e., diastolic heart failure). Coronary heart disease, systolic blood pressure, and C-reactive protein (a measure of inflammation) are predictive of heart failure independent of ejection fraction. Left atrial size, arguably a marker of the effects of impaired diastolic filling over time, is increased in both systolic and diastolic heart failure of the elderly, as is atrial natriuretic peptide. The outcome of heart failure in elderly persons is poor both for systolic and diastolic heart failure. Moreover, many community-dwelling elderly persons have decreased ejection fraction without heart failure. In these persons the chance of death is similar to that of participants with diastolic heart failure. Since most clinical trials have studied younger patients with predominantly systolic heart failure, the appropriate therapy for heart failure in elderly persons remains to be determined.

Aims: Patients with heart failure are at increased risk of hyperkalemia, particularly when treated with renin-angiotensin-aldosterone system inhibitor (RAASi) agents. This study developed a model to quantify the potential health and economic value associated with sustained potassium management and optimal RAASi therapy in heart failure patients.Materials and methods: A patient-level, fixed-time increment stochastic simulation model was designed to characterize the progression of heart failure through New York Heart Association functional classes, and predict associations between serum potassium levels, RAASi use, and consequent long-term outcomes. Following internal and external validation exercises, model analyses sought to quantify the health and economic benefits of optimizing both serum potassium levels and RAASi therapy in heart failure patients. Analyses were conducted using a UK payer perspective, independent of costs and utilities related to pharmacological potassium management.Results: Validation against multiple datasets demonstrated the predictive capability of the model. Compared to those who discontinued RAASi to manage serum potassium, patients with normokalemia and ongoing RAASi therapy benefited from longer life expectancy (+1.38 years), per-patient quality-adjusted life year gains (+0.53 QALYs), cost savings (£110), and associated net monetary benefit (£10,679 at £20,000 per QALY gained) over a lifetime horizon. The predicted value of sustained potassium management and ongoing RAASi treatment was largely driven by reduced mortality and hospitalization risks associated with optimal RAASi therapy.Limitations: Several modeling assumptions were made to account for a current paucity of published literature; however, ongoing refinement and validation of the model will ensure its continued accuracy as the clinical landscape of hyperkalemia evolves.Conclusions: Predictions generated by this novel modeling approach highlight the value of sustained potassium management to avoid hyperkalemia, enable RAASi therapy, and improve long-term health economic outcomes in patients with heart failure.

We evaluated the effect of pimobendan, a positive inotropic agent, in elderly patients with frequent readmission as a result of heart failure despite conventional therapy. Pimobendan was given to five male patients with severe chronic heart failure (New York Heart Association class III-IV) (age range 69-89 years; mean 78 ± 8 years; ischemic cardiomyopathy in three cases, dilated cardiomyopathy in two cases) who required repeated admission for heart failure despite conventional therapy with angiotensin inhibitors, beta-blockers, diuretics and anti-arrhythmic agents. After the addition of pimobendan at a dose of 1.25-3.75 mg/day, we evaluated serum levels of brain natriuretic peptide (BNP), left ventricular ejection fraction (LVEF), septal e' and left ventricular end-diastolic diameter (LVDD) by echocardiography, as well as readmission rates for more than 2 years. The serum level of BNP significantly decreased after treatment with pimobendan, although its level returned to pretreatment levels after 2 years. LVEF significantly improved after the treatment, with the improvement continuing beyond the 2 years, although LVDD did not change after treatment. Septal e' significantly improved after the treatment, although its level returned to pretreatment levels at 2 years after the treatment. Readmission rates significantly decreased for 2 years after the treatment, although one patient required cardiac resynchronization therapy for severe heart failure, and another patient required cardiac pacemaker implantation for sick sinus syndrome 2 years after adding pimobendan. Pimobendan in conjunction with conventional therapy for heart failure decreases the readmission rate in elderly patients with severe heart failure for at least 2 years.

The mechanism of decrease in dynamic mitral regurgitation during heart failure treatment: importance of reduction in the regurgitant orifice size.

(919) - Beyond 35% Ejection Fraction: Choosing Resynchronization Pacing for Congenital Heart Patients as a Bridge to Transplant

AimThe sodium–glucose cotransporter 2 (SGLT2) inhibitor empagliflozin improved clinical outcomes in patients hospitalized for acute heart failure. In patients with chronic heart failure, SGLT2 inhibitors cause an early decline in estimated glomerular filtration rate (eGFR) followed by a slower eGFR decline over time than placebo. However, the effects of SGLT2 inhibitors on renal function during a hospital admission for acute heart failure remain largely unknown.Methods and resultsBetween 1 and 5 days after a hospitalization for acute heart failure, 530 patients with an eGFR >20 ml/min/1.73 m2 were randomized to 10 mg of empagliflozin or placebo and treated for 90 days. Renal function and electrolytes were measured at baseline, and after 15, 30 and 90 days. We evaluated the effect of empagliflozin on eGFR over time and the impact of baseline eGFR on the primary hierarchical outcome of death, worsening heart failure events and quality of life. Mean baseline eGFR was 52.4 ml/min/1.73 m2 in the empagliflozin group and 55.7 ml/min/1.73 m2 in the placebo group. Empagliflozin caused an initial decline in eGFR (−2 ml/min/1.73 m2 at day 15 compared to placebo). At day 90, eGFR was similar between empagliflozin and placebo. Investigator‐reported acute renal failure occurred in 7.7% of empagliflozin versus 12.1% of placebo patients. The overall clinical benefit (hierarchical composite of all‐cause death, heart failure events and quality of life) of empagliflozin was unaffected by baseline eGFR.ConclusionIn patients hospitalized for acute heart failure, empagliflozin caused an early modest decline in renal function which was no longer evident after 90 days. Acute renal events were similar in both groups. The clinical benefit of empagliflozin was consistent regardless of baseline renal function.