Socio-economic position, multimorbidity, and health care utilization among Danish left ventricular assist device patients.

AIMS: Increasing numbers of patients with advanced heart failure and significant comorbidity and social barriers are considered for left ventricular assist devices (LVADs). We sought to examine health care utilization post-LVAD implantation, including the influence of individual-level socio-economic position and multimorbidity. METHODS AND RESULTS: We conducted a Danish nationwide cohort study linking individual-level data from clinical LVAD databases, the Scandiatransplant Database, and Danish national medical and administrative registries. Socio-economic position included cohabitation status, educational level, and employment status. Multimorbidity was defined as two or more chronic conditions from at least two chronic disease groups. Health care utilization (hospital activity, general practice activity, and redeemed medical prescriptions) within 2 years post-discharge after LVAD implantation was evaluated using descriptive statistics at 0.5 year intervals. We identified 119 patients discharged alive with first-time LVAD implanted between 2006 and 2018. The median age of the patients was 56.1 years, and 88.2% were male. Patients were followed until heart transplantation, LVAD explantation, death, 31 December 2018, or for 2 years. The median follow-up was 0.8 years. The highest median use of health care services was observed 0-0.5 years post-LVAD discharge compared with the subsequent follow-up intervals: 0.5-1, 1-1.5, and 1.5-2 years, respectively. The median (interquartile range) number of hospitalizations was 10 (7-14), bed days 14 (9-28), outpatient visits 8 (5-12), telephone contacts with a general practitioner 4 (2-8), and total redeemed medical prescriptions 26 (19-37) within 0-0.5 years post-LVAD discharge compared with the median utilization within the consecutive follow-up periods [e.g. within 0.5-1 year: hospitalizations 5 (3-8), bed days 8 (4-14), outpatient visits 5 (3-8), telephone contacts 2 (0-5), and redeemed medical prescriptions 24 (18-30)]. The median use of health care services was stable from 0.5 years onwards. The median number of hospitalizations and bed days was slightly higher in patients living alone with a low educational level or low employment status within 0-0.5 years post-LVAD implantation. Finally, the median number of in-hospital days and redeemed prescriptions was higher among patients with pre-existing multimorbidity. CONCLUSIONS: Among patients who underwent LVAD implantation, health care utilization was high in the early post-LVAD discharge phase and was influenced by socio-economic position. Multimorbidity influenced the number of in-hospital days and redeemed prescriptions during the 2 year follow-up.

Long-Term Medical Treatment and Adherence in Patients With Left Ventricular Assist Devices: A Danish Nationwide Cohort Study.

The use of a left ventricular assist device (LVAD) in treating advanced heart failure has increased. However, data regarding medical treatment and adherence following LVAD implantation is sparse, particularly whether socioeconomic factors (cohabitation status, educational level, employment status, and income) and multimorbidity influence these aspects, which are known to impact adherence in heart failure patients. We performed a nationwide cohort study of 119 patients with LVAD implanted between January 1, 2006, and December 31, 2018, who were discharged alive with LVAD therapy. We linked individual-level data from clinical LVAD databases, the Scandiatransplant Database, and Danish medical and administrative registers. Medical treatment 90-day pre-LVAD and 720-day post-LVAD were assessed using descriptive statistics in 90-day intervals. Medication adherence (proportion of days covered ≥80%) was assessed 181- to 720-day post-LVAD. The proportions of patients using angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (88.7%), beta-blockers (67.0%), mineralocorticoid receptor antagonists (62.9%), warfarin (87.6%), and aspirin (55.7%) within 90-day post-LVAD were higher than pre-LVAD and were stable during follow-up. Medication adherence ranged from 86.7% (aspirin) to 97.8% (warfarin). Socioeconomic factors and multimorbidity did not influence medical medication use and adherence. Among LVAD patients, medical treatment and adherence are at high levels, regardless of socioeconomic background and multimorbidity.

Adherence to Pharmacotherapies After Heart Transplantation in Relation to Multimorbidity and Socioeconomic Position: A Nationwide Register-Based Study.

No studies have examined the impact of multimorbidity and socioeconomic position (SEP) on adherence to the pharmacological therapies following heart transplantation (HTx). Using nationwide Danish registers, we tested the hypothesis that multimorbidity and SEP affect treatment patterns and adherence to pharmacological therapies in first-time HTx recipients. Pharmacological management included cost-free immunosuppressants and adjuvant medical treatment (preventive and hypertensive pharmacotherapies; loop diuretics). We enrolled 512 recipients. The median (IQR) age was 51 years (38-58 years) and 393 recipients (77%) were males. In recipients with at least two chronic diseases, prevalence of treatment with antihypertensive pharmacotherapies and loop diuretics was higher. The overall prevalence of adherence to treatment with tacrolimus or mycophenolate mofetil was at least 80%. Prevalence of adherence to preventive pharmacotherapies ranged between 65% and 95% and between 66% and 88% for antihypertensive pharmacotherapies and loop diuretics, respectively. In socioeconomically disadvantaged recipients, both the number of recipients treated with and adherence to cost-free everolimus, lipid modifying agents, angiotensin-converting enzyme/angiotensin II inhibitors, calcium channel blockers, and loop diuretics were lower. In recipients with multimorbidity, prevalence of treatment with antihypertensive pharmacotherapies and loop diuretics was higher. Among socioeconomically disadvantaged recipients, both number of patients treated with and adherence to cost-free everolimus and adjuvant pharmacotherapies were lower.

Individual-Level Socioeconomic Position and Long-Term Prognosis in Danish Heart-Transplant Recipients.

Socioeconomic deprivation can limit access to healthcare. Important gaps persist in the understanding of how individual indicators of socioeconomic disadvantage may affect clinical outcomes after heart transplantation. We sought to examine the impact of individual-level socioeconomic position (SEP) on prognosis of heart-transplant recipients. A population-based study including all Danish first-time heart-transplant recipients (n = 649) was conducted. Data were linked across complete national health registers. Associations were evaluated between SEP and all-cause mortality and first-time major adverse cardiovascular event (MACE) during follow-up periods. The half-time survival was 15.6 years (20-year period). In total, 330 (51%) of recipients experienced a first-time cardiovascular event and the most frequent was graft failure (42%). Both acute myocardial infarction and cardiac arrest occurred in ≤5 of recipients. Low educational level was associated with increased all-cause mortality 10-20 years post-transplant (adjusted hazard ratio [HR] 1.95, 95% confidence interval [CI] 1.19-3.19). During 1-10 years post-transplant, low educational level (adjusted HR 1.66, 95% CI 1.14-2.43) and low income (adjusted HR 1.81, 95% CI 1.02-3.22) were associated with a first-time MACE. In a country with free access to multidisciplinary team management, low levels of education and income were associated with a poorer prognosis after heart transplantation.

Patient-reported outcome is associated with health care costs in patients with ischaemic heart disease and arrhythmia.

AIMS: Systematic use of patient-reported outcomes (PROs) have the potential to improve quality of care and reduce costs of health care services. We aimed to describe whether PROs in patients diagnosed with heart disease are directly associated with health care costs. METHODS AND RESULTS: A national cross-sectional survey including PROs at discharge from a heart centre with 1-year follow-up using data from national registers. We included patients with either ischaemic heart disease (IHD), arrhythmia, heart failure (HF), or valvular heart disease (VHD). The Hospital Anxiety and Depression Scale, the heart-specific quality of life, the EuroQol five-dimensional questionnaire, and the Edmonton Symptom Assessment Scale were used. The economic analysis was based on direct costs including primary, secondary health care, and medical treatment. Patient-reported outcomes were available from 13 463 eligible patients out of 25.241 [IHD (n = 7179), arrhythmia (n = 4322), HF (n = 987), or VHD (n = 975)]. Mean annual total direct costs in all patients were €23 228 (patients with IHD: €19 479, patients with arrhythmia: €21 076, patients with HF: €34 747, patients with VDH: €48 677). Hospitalizations contributed overall to the highest part of direct costs. For patients discharged with IHD or arrhythmia, symptoms of anxiety or depression, worst heart-specific quality of life or health status, and the highest symptom burden were associated with increased economic expenditure. We found no associations in patients with HF or VHD. CONCLUSION: Patient-reported outcomes at discharge from a heart centre were associated with direct health care costs in patients with IHD and arrhythmia. REGISTRATION: ClinicalTrials.gov: NCT01926145.

Evidence-Based Process Performance Measures and Clinical Outcomes in Patients With Incident Heart Failure With Reduced Ejection Fraction: A Danish Nationwide Cohort Study.

BACKGROUND: Data on the association between quality of heart failure (HF) care and outcomes among patients with incident HF are sparse. We examined the association between process performance measures and clinical outcomes in patients with incident HF with reduced ejection fraction. METHODS: Patients with incident HF with reduced ejection fraction (n=10 966) between January 2008 and October 2015 were identified from the Danish HF Registry. Data from public registries were linked. Multivariable regression analyses were used to assess the association between 6 guideline-recommended HF care processes (New York Heart Association assessment, use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, beta-blockers, and mineralocorticoid receptor antagonists, exercise training, and patient education) and all-cause and HF readmission, all-cause and HF hospital days, and mortality within 3 to 12 months after HF diagnosis. The associations were analyzed according to the percentages of all relevant performance measures fulfilled for the individual patient (0%-50% [reference group], >50%-75%, and >75%-100%) and for the individual performance measures. RESULTS: Fulfilling >75% to 100% of the performance measures (n=5341 [48.7%]) was associated with lower risk of all-cause readmission (adjusted hazard ratio, 0.78 [95% CI, 0.68-0.89]) and HF readmission (adjusted hazard ratio, 0.71 [95% CI, 0.54-0.92]), lower use of all-cause hospital days (adjusted mean ratio, 0.73 [95% CI, 0.70-0.76]) and HF hospital days (adjusted mean ratio, 0.79 [95% CI, 0.70-0.89]), and lower mortality (adjusted hazard ratio, 0.42 [95% CI, 0.32-0.53]). A dose-response relationship was observed between fulfilling more performance measures and mortality (adjusted hazard ratio, 0.62 [95% CI, 0.49-0.77] fulfilling >50%-75% of the measures). Fulfilling individual performance measures, except mineralocorticoid receptor antagonist therapy, was associated with lower adjusted all-cause readmission, lower adjusted use of all-cause and HF hospital days, and lower adjusted mortality. CONCLUSIONS: Fulfilling more process performance measures was associated with better clinical outcomes in patients with incident HF with reduced ejection fraction.

Influence of multimorbidity and socioeconomic factors on long-term cross-sectional health care service utilization in heart transplant recipients: A Danish cohort study.

BACKGROUND: Survival after heart transplantation has increased due to continuously refined and effective care management. Knowledge is sparse on the influence of multimorbidity and social vulnerability on management. We assessed the long-term influence of multimorbidity and socioeconomic factors on cross-sectional health care service utilization in heart transplant recipients. METHODS: First-time heart transplant recipients, from the Transplant Center at Aarhus University Hospital, were followed from transplant until December 31, 2018. We linked individual-level data from the Scandiatransplant Database to Danish national registers. We followed recipients for 15 years using descriptive statistic. RESULTS: We identified 325 recipients; 79% were male and 60% were between 41 and 60 years of age. The median (IQR) number of chronic conditions at baseline was 1.0 (1.0-2.0). The prevalence of recipients with ≥3 chronic conditions in the follow-up period 0 to 1 year was 10% and 65% within 10 to 15 years. The median use of cross-sectional health care services was higher in recipients with ≥3 chronic conditions compared to <3 chronic conditions during follow-up intervals. The median utilization of hospital outpatient visits and consultations in general practice were higher in recipients with low educational level, low employment status, or low income, respectively. We observed lower median number of redeemed prescriptions for medical therapies in recipients living alone or within the lowest income group. CONCLUSIONS: The use of cross-sectional health care services was higher in heart transplant recipients with increased incidence of comorbidities during follow-up intervals. A socioeconomic influence was observed in the utilization of services.

The Danish Heart Failure Registry: A Validation Study of Content.

Background: The Danish Heart Failure Registry (DHFR) is a clinical quality database established to monitor and improve the quality of heart failure (HF) care in Denmark. Objective: We examined the validity of the content of the DHFR. Methods: In a random sample of patients registered in DHFR between the 1st of January 2016 to the 31st of December 2018, we determined the agreement between the information entered in the database and information in the medical records regarding 1) content; 2) sensitivity; 3) specificity; 4) positive predictive values (PPV) as well as negative predictive values (NPV) of all patient characteristics and performance measures obtained in the DHFR. Results: The study population included 453 patients. In general, the content of the DHFR was accurate. Patient characteristics showed high PPV between 93.0% and 99.5% for all variables. Sensitivity ranged from 81.0% to 95.2%, specificity from 79.8% to 99.5% and NPV ranged from 81.4% to 99.0%. The pharmacological performance measures showed high agreement regarding sensitivity (77.4% to 98.6%) and PPV (84.0% to 94.0%). Further, the specificity ranged from 66.7% to 98.0% and NPP ranged from 90.1% to 96.5%. For the non-pharmacological performance measures, patient education showed high sensitivity (98.0%, 95% CI 96.1-99.1) and PPV (94.9% CI: 93.0-96.3), whereas referral to exercise training had a lower sensitivity of 77.8% (CI: 71.6-83.1) and a PPV of 74.5% (CI: 69.6-78.6). Conclusion: Overall, the Danish Heart Failure Registry have a high degree of completeness and validity, making it a valuable tool for clinical epidemiological research in HF.

Coronary Flow Velocity Reserve and Myocardial Deformation Predict Long-Term Outcomes in Heart Transplant Recipients.

BACKGROUND: After heart transplantation (HTx), invasive coronary angiography is the gold standard for surveillance of cardiac allograft vasculopathy (CAV). Noninvasive CAV surveillance is desirable. The authors examined left ventricular global longitudinal strain (LVGLS) and noninvasive coronary flow velocity reserve (CFVR) related to CAV and prognosis after HTx. METHODS: Doppler echocardiographic CFVR and LVGLS were evaluated in 98 HTx patients. All-cause mortality and major adverse cardiac events (MACE), including hospitalization for heart failure, cardiovascular death, and significant CAV progression, were recorded. RESULTS: Median follow-up duration was 3.3 years (range: 1.7-5.4 years). Patients with low CFVR (<2.0; n = 20) showed reduced MACE-free survival (hazard ratio, 4.3; 95% CI, 2.2-8.4; P < .0001) and increased all-cause mortality (hazard ratio: 4.7; 95% CI: 2.0-11.3; P < .0001) compared with patients with high CFVR (≥2.0; n = 78). Worsened LVGLS (≥-15.5%) was also a strong independent predictor of MACE and cardiovascular and all-cause mortality. Combined low CFVR and worsened LVGLS provided incremental prognostic value, even after adjustment for CAV and time since HTx. The prevalence of low CFVR increased significantly with CAV severity, and the prevalence of combined low CFVR and/or worsened LVGLS was high in patients with moderate CAV (86%) and those with severe CAV (83%). The negative predictive value of combined high CFVR and improved LVGLS to rule out significant CAV was 94.5% (95% CI, 86.2%-98.4%), whereas the positive predictive value was 39.0% (95% CI, 25.3%-54.3%). The model had sensitivity of 84.2% (95% CI, 63.6%-95.3%) and specificity of 67.5% (95% CI, 56.6%-77.2%) for one or more abnormal parameters. CONCLUSIONS: In HTx patients with severe CAV, a higher prevalence of low CFVR and worsened LVGLS was observed. Both measurements were strong independent predictors of MACE and all-cause mortality in HTx patients. Combined CFVR and LVGLS provided incremental prognostic value and showed an excellent ability to rule out significant CAV and may be considered as part of routine CAV surveillance of HTx patients.

A systematic approach to weaning from extracorporeal membrane oxygenation in patients with refractory cardiac failure.

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is commonly used to provide haemodynamic support for patients with severe cardiac failure. However, timing ECMO weaning remains challenging. We aimed to examine if an integrative weaning approach based on predefined haemodynamic, respiratory and echocardiographic criteria is associated with successful weaning. METHODS: All patients weaned from ECMO between April 2017 and April 2019 at Aarhus University Hospital, Denmark, were consecutively enrolled. Predefined haemodynamic, respiratory and echocardiographic criteria were assessed before and during ECMO flow reduction. A weaning attempt was commenced in haemodynamic stable patients and patients remaining stable at minimal flow were weaned from ECMO. Comparisons were made between patients who met the criteria for weaning at first attempt and patients who did not meet these criteria. Patients completing a full weaning attempt with no further need for mechanical support within 24 h were defined as successfully weaned. RESULTS: A total of 38 patients were included in the study, of whom 26 (68%) patients met the criteria for weaning. Among these patients, 25 (96%) could be successfully weaned. Successfully weaned patients were younger and had less need for inotropic support and ECMO duration was shorter. Fulfilling the weaning criteria was associated with successful weaning and both favourable 30-d survival and survival to discharge. CONCLUSION: An integrative weaning approach based on haemodynamic, respiratory and echocardiographic criteria may strengthen the clinical decision process in predicting successful weaning in patients receiving ECMO for refractory cardiac failure.

Cardiovascular risk and mortality in rheumatoid arthritis compared with diabetes mellitus and the general population.

OBJECTIVES: To compare risk of cardiovascular disease and mortality in patients with incident RA, diabetes mellitus (DM) and the general population (GP). METHODS: Patients diagnosed with incident RA were matched 1:5 by age, sex and year of RA diagnosis with the GP. In the same period, patients with incident DM were included. Outcomes were heart failure (HF), myocardial infarction (MI), coronary revascularization, stroke, major adverse cardiovascular events (MACE) and death up to 10 years after diagnosis. RESULTS: We included 15 032 patients with incident RA, 301 246 patients with DM and 75 160 persons from the GP. RA patients had an increased risk of HF [hazard ratio (HR) 1.51, 95% CI: 1.38, 1.64], MI (HR 1.58, 95% CI: 1.43, 1.74), percutaneous coronary intervention (PCI; HR 1.44, 95% CI: 1.27, 1.62), coronary artery bypass grafting (CABG; HR 1.30, 95% CI: 1.05, 1.62) and stroke (HR 1.22, 95% CI: 1.12-1.33) compared with the GP. However, the 10-year all-cause mortality was at the same level as observed in the GP. Cardiac death and MACE were increased in RA compared with the GP. When compared with patients with DM, RA patients had a lower adjusted risk of HF (HR 0.79, 95% CI: 0.73, 0.85), CABG (HR 0.62, 95% CI: 0.51, 0.76) and stroke (HR 0.82, 95% CI: 0.76, 0.89), and similar risk of MI and PCI. DM patients had the highest risk of 10-year mortality, cardiac death and MACE. CONCLUSION: This study demonstrates that RA is associated with an increased risk of HF, MI, stroke and coronary revascularization than found in the GP but without reaching the risk levels observed in DM patients.

Inequalities in heart failure care in a tax-financed universal healthcare system: a nationwide population-based cohort study.

AIMS: Data on socioeconomic-related differences in heart failure (HF) care are sparse. Inequality in care may potentially contribute to a poor clinical outcome. We examined socioeconomic-related differences in quality of HF care among patients with incident HF with reduced ejection fraction (EF) (HFrEF). METHODS AND RESULTS: We conducted a nationwide population-based cohort study among patients with HFrEF (EF ≤40%) registered from January 2008 to October 2015 in the Danish Heart Failure Registry, a nationwide registry of patients with a first-time primary HF diagnosis. Associations between individual-level socioeconomic factors (cohabitation status, education, and family income) and the quality of HF care defined by six guideline-recommended process performance measures [New York Heart Association (NYHA) classification, treatment with angiotensin-converting-enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB), beta-blockers and mineralocorticoid receptor antagonists, exercise training, and patient education] were assessed using multiple imputation and multivariable logistic regression controlling for potential confounders. Among 17 122 HFrEF patients included, 15 290 patients had data on all six process performance measures. Living alone was associated with lower odds of NYHA classification [adjusted OR (aOR) 0.81; 95% confidence interval (CI): 0.72-0.90], prescription of ACEI/ARB (aOR 0.76; 95% CI: 0.68-0.88) and beta-blockers (aOR 0.84; 95% CI: 0.76-0.93), referral to exercise training (aOR 0.75; 95% CI: 0.69-0.81), and patient education (aOR 0.73; 95% CI: 0.67-0.80). Compared with high-level education, low-level education was associated with lower odds of NYHA classification (aOR 0.93; 95% CI: 0.79-1.11), treatment with ACEI/ARB (aOR 0.99; 95% CI: 0.81-1.20) and beta-blockers (aOR 0.93; 95% CI: 0.79-1.09), referral to exercise training (aOR 0.73; 95% CI: 0.65-0.82), and patient education (aOR 0.86, 95% CI: 0.75-0.98). An income in the lowest tertile was associated with lower odds of NYHA classification (aOR 0.67; 95% CI: 0.58-0.79), prescription of ACEI/ARB (aOR 0.80, 95% CI: 0.67-0.95) and beta-blockers (aOR 0.88, 95% CI: 0.86-1.01), referral to exercise training (aOR 0.59, 95% CI: 0.53-0.64), and patient education (aOR 0.66; 95% CI: 0.59-0.74) compared with an income in the highest tertile. Overall, no systematic differences were seen when the analyses were stratified by sex and age groups. CONCLUSIONS: Living alone, low-level education, and income in the lowest tertile were associated with reduced use of recommended processes of HF care among Danish HFrEF patients with a first-time primary HF diagnosis. Efforts are warranted to ensure guideline-recommended HF care to all HFrEF patients, irrespective of socioeconomic background.

Platelet aggregation and response to aspirin therapy in cardiac allograft vasculopathy.

BACKGROUND: Long-term survival after heart transplantation (HTx) is compromised by cardiac allograft vasculopathy (CAV) characterized by coronary macro- and microvascular disease. The pathogenesis of CAV is unclear and may involve coronary thrombosis. We investigated whether HTx patients with CAV had higher platelet aggregation and turnover than HTx patients without CAV and healthy controls. Furthermore, we investigated the anti-platelet effect of low-dose aspirin in HTx patients. METHODS: We included 57 patients who had undergone HTx (median 8.3 years from HTx) and 57 healthy controls. Platelet aggregation was measured on-aspirin and off-aspirin using impedance aggregometry with adenosine diphosphate (ADP) and arachidonic acid (AA). We evaluated platelet turnover by flow cytometry, CAV burden by coronary angiography and echocardiography, and microvascular function by echocardiographic coronary flow velocity reserve (CFVR). RESULTS: Off-aspirin, HTx patients with CAV (n = 21) had higher ADP-induced platelet aggregation than healthy controls (p < 0.01) and HTx patients without CAV (n = 36) (p < 0.05). Aspirin treatment reduced AA-induced platelet aggregation in both HTx groups, but HTx patients with CAV had higher platelet aggregation on-aspirin than HTx patients without CAV (p < 0.05). Platelet turnover did not differ between HTx patients with CAV and HTx patients without CAV (p > 0.34). HTx patients with lower CFVR values had higher platelet aggregation than HTx patients with higher CFVR values (p < 0.05). CONCLUSIONS: Off-aspirin, platelet aggregation was higher in HTx patients with CAV than in HTx patients without CAV and healthy controls. On-aspirin, platelet aggregation was higher in HTx patients with CAV than in HTx patients without CAV. Aspirin monotherapy may not provide sufficient platelet inhibition in HTx patients with CAV.

Socioeconomic Factors and Clinical Outcomes Among Patients With Heart Failure in a Universal Health Care System.

OBJECTIVES: This study examined the associations between socioeconomic factors (SEF), readmission, and mortality in patients with incident heart failure (HF) with reduced ejection fraction (HFrEF) in a tax-financed universal health care system. BACKGROUND: Lack of health insurance is considered a key factor in health inequality, leading to poor clinical outcomes. However, data are sparse for the association between SEF and clinical outcomes among patients with HF in countries with tax-financed health care systems. METHODS: A nationwide population-based cohort study of 17,122 patients with incident HFrEF was carried out. Associations were assessed between individual-level SEF (cohabitation status, education, and income) and all-cause, HF, and non-HF readmission and mortality within 1 to 30, 31 to 90, and 91 to 365 days, as well as hospital bed days within 1 year after HF diagnosis. RESULTS: Low income was associated with a higher risk of all-cause readmission (adjusted hazard ratio [HR]: 1.24; 95% confidence interval [CI]: 1.08 to 1.43) and non-HF readmission (HR: 1.36; 95% CI: 1.17 to 1.58) within days 31 to 90 as well as with a higher risk of all-cause (HR: 1.27; 95% CI: 1.14 to 1.41), HF (HR: 1.26; 95% CI: 1.02 to 1.55) and non-HF readmission (HR: 1.25; 95% CI: 1.12 to 1.39) within days 91 to 365. Low-income patients also had a higher use of hospital bed days and risk of mortality during follow-up. CONCLUSIONS: In a tax-financed universal health care system, low income was associated with a higher risk of all-cause and non-HF readmission within 1 to 12 months after HF diagnosis and with HF readmission within 3 to 12 months among patients with incident HFrEF. Low-income patients also had a higher number of hospital bed days and a higher rate of mortality during follow-up.

Development of heart failure in patients with rheumatoid arthritis: A Danish population-based study.

BACKGROUND: To investigate the incidence of heart failure (HF) and ischaemic heart disease (IHD) in different time spans following incident rheumatoid arthritis (RA) and, furthermore, to investigate the impact of IHD on the development of HF and the impact of different treatment era of RA. MATERIALS AND METHODS: This matched cohort study used nationwide, prospectively collected data. From the total Danish population of approximately 5.7 million inhabitants, we identified 51 859 patients (between 1995 and July 2016) with incident RA and a sex- and age-matched cohort from the general population (256 653 persons). RESULTS: The hazard ratio (HR) for HF among RA patients compared with persons from comparison cohort was 2.28 within the first year of index date, 1.39 within the 1-5 years of index date and 1.38 within the 5-10 years of index date. No difference was identified regarding different treatment era of RA. For IHD, the subdistribution hazard ratio (sHR) was 1.93 within the first year of index date, 1.26 within the 1-5 years of index date and 1.31 within the 5-10 years of index date. Coronary revascularization was also more common within the first year after diagnosis of RA. An increased risk of percutaneous coronary intervention and coronary artery bypass grafting within 10 years following the RA diagnosis was observed. HR for new onset of HF in RA without IHD was 1.23, while the HR for new onset of HF in patients with RA and IHD was 2.06. CONCLUSIONS: Rheumatoid arthritis patients had higher rates of HF and IHD throughout the entire observation period compared to the comparison cohort. RA was associated with a larger risk of developing HF.

[Mechanical circulatory treatment of advanced heart failure]. / Mekanisk behandling af avanceret hjertesvigt.

Heart failure is one of the most common causes of morbidity and mortality worldwide. When patients cease to respond adequately to optimal medical therapy mechanical circulatory support has been promising. The advent of mechanical circulatory support devices has allowed significant improvements in patient survival and quality of life for those with advanced or end-stage heart failure. We provide a general overview of current mechanical circulatory support devices encompassing options for both short- and long-term ventricular support.

Left ventricular function in treatment-naive early rheumatoid arthritis.

BACKGROUND: The role of inflammation and anti-cyclic citrullinated peptide antibodies (anti-CCP) in the pathogenesis of cardiovascular disease in early rheumatoid arthritis (RA) remains unclear. Previous studies have suggested that both disease activity and disease duration are associated with atherosclerosis and a higher mortality rate caused primarily by coronary artery disease. OBJECTIVE: We investigated how disease activity, anti-CCP status and coronary calcium score in treatment-naive early RA impacts left ventricular (LV) systolic function. METHODS: Fifty-tree patients (30 women) with mean age 58.3±1.3 years and steroid- and disease-modifying antirheumatic drug (DMARD)-naive early RA were included. Disease activity was scored by the use of the Danish national DANBIO registry (number of swollen joints (NSJ (28)), number of tender joints (NTJ (28)), C-reactive protein (CRP) and Health Assessment Questionnaire (HAQ)). Pain, fatigue, patient and physician global assessment and a composite disease activity score (DAS28-CRP) were assessed by visual analog scales (VAS) 0-100. IgM rheumafactor (IgM-RF) and anti-CCP titers were evaluated by standardized techniques. Coronary calcium score was estimated by computed tomography by calculating the Agaston score. One experienced senior rheumatologist and one experienced cardiologist performed all the clinical assessments as well as all the transthoracic echocardiography (TTE) and coronary CT analysis. RESULTS: Disease activity scores before treatment at baseline were: NSJ (28) 7.1±2.7, NTJ (28) 8.5±3.5, CRP 11.7±12.9 mmol/l, HAQ 0.71±0.6, pain VAS 51.1±23.7, fatigue VAS 49.3±24.9, physician global assessment 54.2±15.0 and DAS28-CRP 4.8±0.7. Twenty-three (43%) patients were IgM-RF positive and 33 (62%) were anti-CCP positive. We found LV systolic function by conventional ejection fraction (EF) to be 54.1±9.2% and to be non-significant correlated to disease activity (CRP: r=0.07, p=0.64; baseline NSJ: r=-0.13, p=0.33; NTJ: r=-0.08, p=0.58; HAQ: r=0.23, p=0.1; pain VAS: r=-0.05, p=0.74; fatigue VAS: r=0.03, p=0,83; physician global assessment: r=-0.09, p=0.54 and DAS28: r=-0.03, p=0.84). However, using a more sensitive measurement of the LV function by global longitudinal systolic strain (GLS), we found a significant correlation: HAQ (r=0.29; p=0.037), patient global assessment by VAS (r=0.35; p=0.011), patient fatigue assessment by VAS (r=0.3; p=0.03) and DAS28-CRP (r=0.28; p=0.043); all corrected for relevant confounders (age, gender, pulse and blood pressure). Furthermore, anti-CCP was highly significantly correlated with GLS (r=-0.44; p=0.001) in univariate analysis. In multivariate analysis, it still remained significantly correlated (p=0.018), after correction for age, gender, pulse, and blood pressure. Using strain analysis of LV function, we found a significant difference in GLS in patients with high values of anti-CCP (titers ≥340) compared to patients with anti-CCP (titers <340); (-19.9±2.1% vs. -16.4±2.8%; p=0.0001). For patients with high IgM-RF, results were non-significant. CONCLUSIONS: We observed a significant correlation between increased disease activity and cardiac function in treatment-naive early RA.

Microvascular dysfunction is associated with plasma osteoprotegerin levels in patients with acute myocardial infarction.

OBJECTIVE: Osteoprotegerin (OPG) is a glycoprotein that inhibits nuclear factor-κB's regulatory effects on inflammation, skeletal, and vascular systems, and is a potential biomarker of atherosclerosis and seems to be involved in vascular calcifications. The objective of this study was to assess the relationship between OPG, left ventricular function, and microvascular function in patients with acute myocardial infarction (AMI). PATIENTS AND METHODS: After successful revascularization, noninvasive assessment of coronary flow reserve (CFR) was performed in the distal part of the left anterior descending artery in 183 patients with first AMI. We performed low-dose dobutamine stress echocardiography to assess viability and finally we assessed the ventriculoarterial coupling (VAC). Plasma OPG was determined by ELISA. RESULTS: Plasma OPG concentrations were higher in patients with impaired microcirculation (CFR<2) than in patients without [median (first; third quartile), 1.939 (1.366; 2.724) vs. 1.451 (0.925; 2.164) ng/l; P=0.001]. OPG was associated with CFR both in linear regression single-variable analysis (P=0.001) and in multivariable analysis adjusting for possible confounders (P=0.024).Eighty-seven patients had resting wall motion abnormalities and 28 patients fulfilled the criteria for viability. In the group with low OPG 20 patients had viability, and in patients with high OPG only eight patients had viability (P=0.03).Both the E/A ratio (1.22±0.65 vs. 1.06±0.39; P=0.04) and the E/e' ratio (10.4±3.1 vs. 12.2±4.6; P=0.002) indicated worse diastolic function in patients with increased levels of OPG.Overall, an increase in the VAC point was observed in the population (1.11±0.6). The VAC point was higher in patients with increased OPG compared with low OPG (1.01±0.51 vs. 1.2±0.67; P=0.03). CONCLUSION: This is the first study to show an association between OPG levels and CFR, decreased diastolic function, and increased VAC in the setting of AMI. Our results indicate a relationship between OPG and the degree of microvascular dysfunction.

Correlation between left ventricular global and regional longitudinal systolic strain and impaired microcirculation in patients with acute myocardial infarction.

OBJECTIVES: We investigated the correlation between left ventricular global and regional longitudinal systolic strain (GLS and LRS) and coronary flow reserve (CFR) assessed by transthoracic echocardiography (TTE) in patients with a recent acute myocardial infarction (AMI). Furthermore, we investigated if LRS and GLS imaging is superior to conventional measures of left ventricle (LV) function. METHODS: In a consecutive population of first time AMI patients, who underwent successful revascularization, we performed comprehensive TTE. GLS and LRS were obtained from the three standard apical views. Assessment of CFR by TTE was performed in a modified apical view using color Doppler guidance. RESULTS: The study population consisted of 183 patients (51 females) with a median age of 63 [54;70] years. Eighty-nine (49%) patients had a non-ST elevation myocardial infarction and 94 (51%) patients had a ST elevation myocardial infarction. The GLS was -15.2 [-19.3;-10.1]% in the total population of 183 patients. Total wall motion score index (WMSI) in the population was 1.19 [1;1.5]. Eighty-five patients suffered from culprit lesion in left anterior descending artery (LAD). The CFR in these patients was 1.86 [1.36;2.35] and the GLS was -14.3 [-18.9; -9.8]%. A significant difference was observed in the LRS in LAD territory in culprit LAD infarction patients with a CFR ≤ 2 (-9.6 [-13.77;-6.44]) compared with the LRS in LAD territory in culprit LAD infarction patients with a CFR > 2 (-19.33 [-21.1;-16.5]), P < 0.0001. We found no significant difference between WMSI in LAD territory in culprit LAD infarction patients with a CFR ≤ 2 (1.56 [1.06;2.23]) compared with WMSI in LAD territory in culprit LAD infarction patients with a CFR > 2 (1.37 [1.03;2.11]); P = 0.18. The same pattern was observed in both circumflex coronary artery (CX) and right coronary artery (RCA) territories. In the total population, we found a strong correlation between CFR and GLS (r = -0.85, P < 0.0001). This was also seen in the multivariate regression model adjusting for possible confounders including WMSI (P < 0.001). CONCLUSION: In this study, we have shown a close association between myocardial deformation in patients with a recent AMI and the degree of diminished microcirculation. We found that both GLS and LRS correlated with CFR. We conclude that GLS and LRS are significantly better tools to assess impaired CFR and LV function after a recent AMI, than conventional echocardiographic measurements.