[The IN-HF Registry: the history and the scientific production for the Italian cardiology community]. / Il programma IN-HF: la storia e la produzione scientifica a favore della comunità cardiologica italiana.

The Italian Network on Congestive Heart Failure (IN-CHF) project, later known as IN-HF Online, was launched in 1995 to provide the Italian cardiology community with a digital tool, standardized across the country, for managing outpatients with heart failure (HF), that enabled the creation of a database for clinical, educational and scientific purposes. During its almost three decades of activity, this observational research program has achieved highly positive scientific results. Indeed, IN-HF fostered professional relationships among individuals working in different centers, established a cultural network for the care of HF patients, periodically updated on the scientific advances, and allowed the assessment of several clinical, epidemiological, and prognostic features. These findings have been published in numerous national and international journals, as summarized in the present overview.

Simple scores to predict 1-year mortality in atrial fibrillation.

BACKGROUND: Traditional scores as CHADS2 and CHA2DS2-Vasc are suitable for predicting stroke and systemic embolism in patients with atrial fibrillation (AF) and have shown to be also associated with mortality. Other more complex scores have been recommended for survival prediction. The purpose of our analysis was to test the performance of different clinical scores in predicting 1-year mortality in AF patients. MATERIAL AND METHODS: CHADS2 and CHA2DS2-Vasc scores were calculated for AF patients of the BLITZ-AF register and compared to R2-CHADS2, R2-CHA2DS2-Vasc and CHA2DS2VASc-RAF scores in predicting 1-year survival. Scores including renal function were calculated both with glomerular filtration rate (GFR) and creatinine clearance. RESULTS: One-year vital status (1960 alive and 199 dead) was available in 2159 patients. Receiver-operating characteristic curves displayed an association of each score to all-cause mortality, with R2(ClCrea)-CHADS2 being the best [area under the curve (AUC) 0.734]. Differences among the AUCs of the eight scores were not so evident, and a significant difference was found only between R2(ClCrea)-CHADS2 and CHADS2, CHA2DS2VASc, (ClCrea)-CHA2DS2-VASC-RAF.All the scores showed a similar performance for cardiovascular (CV) mortality, with CHA2DS2VASc-RAF being the best (AUC 0.757), with a significant difference with respect to CHADS2, CHA2DS2VASc, and (ClCrea)CHA2DS2Vasc-RAF. CONCLUSIONS: More complex scores, even if with better statistical performance, do not show a clinically relevant higher capability to discriminate alive or dead patients at 12 months. The classical and well known CHA2DS2VASc score, which is routinely used all around the world, has a high sensitivity in predicting all-cause mortality (AUC 0.695; Sensit. 80.4%) and CV mortality (AUC 0.691; Sensit. 80.0%). GRAPHICAL ABSTRACT: http://links.lww.com/JCM/A632.

Clinical characteristics, treatment, trajectories and outcome of patients with dilated cardiomyopathy in a national heart failure registry.

BACKGROUND: Available data on the clinical characteristics and prognosis of patients with heart failure (HF) due to dilated cardiomyopathy (DCM) derive mainly from tertiary care centres for cardiomyopathies or from drug trial sub-studies, which may entail a referral bias. METHODS: From 2008 to 2021, we enrolled in a nationwide HF Registry 1886 DCM patients and 3899 with ischemic heart disease (IHD). RESULTS: Patients with DCM were younger, more often female, had more commonly recent onset HF, left bundle branch block, and showed higher LV end-diastolic volume and lower LVEF than IHD. With respect to IHD, DCM patients received more often mineralocorticoid receptor antagonists, renin angiotensin system inhibitors and betablockers, the latter more commonly at doses ≥50% of target, and triple guideline-directed medical therapy (GDMT) (adjusted OR 1.411, 95% CI 1.247-1.595, p < .0001). During one-year follow-up, 819 patients (14.2%) died or were hospitalized for HF [187 (9.9%) DCM, 632 (16.2%) IHD]; DCM was associated with lower risk of the combined end-point (adjusted HR 0.745, 95% CI 0.625- 0.888, p = .0011). Among the 1954 patients with 1-year echocardiograms available, 1483 had LVEF≤40% at baseline; of these,166 (30.6%) DCM and 165 (17.5%) IHD improved their LVEF to >40% (p < .0001). DCM aetiology was associated with higher likelihood of LVEF improvement (adjusted OR 1.722, 95% CI 1.328 -2.233, p < .0001). CONCLUSIONS: DCM patients have a different clinical profile, greater uptake of GDMT and better outcomes than IHD subjects. A comprehensive management approach is needed to further address the risk of unfavorable outcomes in DCM.

Acute pulmonary embolism and cancer: findings from the COPE study.

BACKGROUND: Patients with acute venous thromboembolism associated with cancer have an increased risk of recurrences and bleeding in the long term. RESEARCH QUESTION: To describe the clinical features and short-term course of patients with acute pulmonary embolism (PE) and active cancer, previous cancer or no cancer. STUDY DESIGN AND METHODS: Patients with acute PE included in COPE-prospective, multicentre study of adult patients with acute, symptomatic, objectively diagnosed PE-were classified as having active cancer, previous cancer, or no cancer. RESULTS: Overall, 832 patients had active cancer, 464 with previous cancer and 3660 patients had no cancer at the time of acute PE. The most prevalent primary sites of active cancer were urogenital (23.0%), gastrointestinal (21.0%), and lung (19.8%), with a high prevalence of metastatic disease (57.6%) and ongoing anticancer treatment (16.2%). At discharge, a direct oral anticoagulant was used in 43.1%, 78.8%, and 82.0% of patients with active cancer, previous cancer, and no cancer, respectively. Rates of death in-hospital and at 30 days were higher in patients with active cancer compared to patients with previous cancer and no cancer (7.9% vs. 4.3% vs. 2.2% and 13.8% vs. 5.2% vs. 2.6%, respectively). Rates of major bleeding were 4.8%, 2.6%, and 2.4%, respectively. Among patients with active cancer, lung or metastatic cancer were independent predictors of death; brain, hematological or gastrointestinal cancer had the highest risk of major bleeding. INTERPRETATION: Among patients with acute PE, those with active cancer have high risks for death or major bleeding within 30 days. These risks vary based on primary site of cancer. CLINICAL TRIAL REGISTRATION: clinicaltrial.gov identifier: NCT03631810.

Prevalence and predictive role of hypertriglyceridemia in statin-treated patients at very high risk: Insights from the START study.

BACKGROUND AND AIM: Elevated triglyceride (TG) levels seem to identify subjects at increased cardiovascular risk, independent of LDL-C levels. We sought to evaluate the predictive role of hypertriglyceridemia, defined as TG levels ≥150 mg/dl, in very high risk (VHR) patients with chronic coronary syndromes (CCS) treated with statins. METHODS AND RESULTS: Using the data from the STable Coronary Artery Diseases RegisTry (START) study, an Italian nationwide registry, we assessed the association between the TG levels and baseline clinical characteristics, pharmacological treatment and major adverse cardio-cerebrovascular events (MACCE) at 1 year in a large cohort of statin-treated patients at VHR. Of the 4751 consecutive patients with CCS enrolled in the registry and classified as VHR, 2652 (55.8%) had TG values available (mean 120.6 ± 54.9) and were treated with at least a statin at baseline: 2019 (76.1%) with TG < 150 and 633 (23.9%) with TG ≥ 150 mg/dl. At 1 year from enrolment, MACCE occurred in 168 (6.3%) patients, without differences between the two groups of TG (5.9 vs 7.6%; p = 0.14). At multivariable analysis, hypertriglyceridemia did not result as independent predictor of the MACCE (hazard ratio: 1.16; 95% confidence intervals: 0.82-1.64; p = 0.42). CONCLUSIONS: In the present large, nationwide cohort of consecutive CCS patients at VHR with statin-controlled LDL-C levels, hypertriglyceridemia was present in around 24% of cases and did not result as predictor of MACCE at 1 year. Further studies with a longer follow-up and larger sample size are needed to better define the prognostic role of TG levels when intensive LDL lowering therapies are used.

Is there a reduced confidence towards direct oral anticoagulants compared to vitamin K antagonists in patients scheduled for an elective electrical cardioversion? The results of the BLITZ-AF study.

OBJECTIVE: To study the confidence of cardiologists in performing an electrical cardioversion in patients on oral anticoagulation (OA) with or without transoesophageal echocardiography (TOE). METHODS: Data about atrial fibrillation (AF) patients admitted to cardiology wards for elective cardioversion (ECV) were extrapolated from the BLITZ-AF study. Percentage of vitamin K antagonists (VKAs), direct oral anticoagulants (DOAC) and heparin prescription were analysed in relation to the use of TOE before ECV. RESULTS: Overall rate of TOE was 33.7% (240/713); it was used before ECV in 124/313 (39.6%) of DOACs patients and in 96/372 (25.8%) of the patients on VKAs, showing a significant reduced resort to TOE in VKAs patients (p = 0.0001). Among non-valvular patients TOE was more frequently performed in males, at younger ages and in patients on heparin when compared to patients treated with OA. TOE was also more frequently performed in tertiary hospitals and in hospitals with cardiology wards and electrophysiology labs, when compared to hospital provided only with cardiology wards. At multivariable analysis there was a significant less recourse to TOE in patients on VKAs (OR 0.47; 95% CI: 0.33-0.67) and higher recourse in the heparin group (OR: 3.85; 95% CI:1.59-9.28) with respect to patients on DOACs; a higher recourse to TOE was observed also in tertiary hospitals (OR 4.25; 95% CI 2.69-6.69) and in hospitals with cardiology wards and electrophysiology (EP) labs (OR 1.87; 95% CI 1.23-2.82). CONCLUSION: our study shows the reluctance in cardioverting patients on DOACs respect to VKAs without a previous TOE, despite adequate anticoagulant treatment.

DAPA-HF applicability: the point of view of a cardiology setting.

Randomised clinical trials, observational studies, and meta-analyses have shown that sodium-glucose cotransporter 2 inhibitors (SGLT2-i) reduce the risk of hospitalisation for heart failure (HF), chronic kidney disease (CKD) progression, and mortality in patients with HF, irrespective of the presence of type 2 diabetes mellitus. However, real-world epidemiology may differ from clinical trial populations, thereby limiting generalisability and delaying the introduction of novel treatments in clinical practice.The aim of the present study was to assess the prevalence of DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure) inclusion criteria in a population of HF with reduced ejection fraction (HFrEF) patients enrolled in the Italian Network on Heart Failure (IN-HF) registry.Overall, 3415 IN-HF patients matched the 4744 patients in DAPA-HF, overlapping for most baseline characteristics (e.g. similar average ejection fraction), with a slightly lower prevalence of type 2 diabetes and of HF ischaemic aetiology and a higher percentage of NYHA class II patients. The theoretical eligibility to DAPA-HF in a cardiology setting resulted to be 73%.The availability of an easily accessible database from a large nationwide prospective registry allows to provide insights to clinicians and policy makers on the applicability of the DAPA HF findings to a contemporary population of HFrEF patients followed by cardiologists. It is reasonable to assume that the results of this analysis can be applicable to the entire SGLT2-ir class of drugs.

Combined Neuro-Humoral Modulation and Outcomes in Patients with Chronic Heart Failure and Mildly Reduced or Preserved Ejection Fraction.

Pharmacotherapy of chronic heart failure with mildly reduced (HFmrEF) and preserved ejection fraction (HFpEF) remains challenging. We aimed to assess whether combined neuro-humoral modulation (NHM) (renin−angiotensin system inhibitors, betablockers, mineralocorticoid receptor antagonists) was differentially associated with outcome according to phenotype and age groups. Between 1999 and 2018 we recruited in a nationwide cardiology registry 4707 patients (HFmrEF n = 2298, HFpEF n = 2409) from three age groups: <65, 65−79 and 80+ years old. We analyzed clinical characteristics and 1 year all-cause mortality/cardiovascular hospitalization according to none/single, any double, or triple NHM. Prescription rates of no/single and triple NHM were 25.1% and 26.7% for HFmrEF; 36.5% and 17.9% for HFpEF patients, respectively. Older age was associated with higher prescription of no/single NHM in HFmrEF (ptrend = 0.001); the reverse was observed among HFpEF (ptrend = 0.005). Triple NHM increased over time in both phenotypes (all p for trend < 0.0001). Compared to no/single NHM, triple, but not double, NHM was associated with better outcomes in both HFmrEF (HR 0.700, 95%CI 0.505−0.969, p = 0.032) and HFpEF (HR 0.700, 95%CI 0.499−0.983, p = 0.039), with no interaction between NHM treatment and age groups (p = 0.58, p = 0.80, respectively). In a cardiology setting, among HF outpatients with EF > 40%, triple NHM treatment increased over time and was associated with better patient outcomes.

Impact of eGFR rate on 1-year all-cause mortality in patients with stable coronary artery disease.

BACKGROUND: Coronary artery disease (CAD) is a leading cause of mortality and is often complicated by chronic kidney disease. We sought to investigate the prevalence of different degree of estimated glomerular filtration rate (eGFR) reduction, the clinical and bio-humoral correlates, its relationship with therapeutic management, and its predictive role on 1-year all-cause mortality, in patients with stable CAD. METHODS: We studied 4,130 patients with stable CAD recruited in a prospective, observational, nationwide study (START, STable coronary Artery diseases RegisTry) in Italy. Baseline clinical characteristics, pharmacological treatment, and all-cause 1-year mortality were evaluated according to groups of eGFR (<30; 30-59; 60-89; ≥90 ml/min/1.73 m2) at baseline. RESULTS: The presence and the degree of chronic kidney disease entailed an unfavorable risk profile, since it was gradually associated with more comorbidities. Furthermore, progressively lower eGFR values were associated to lower diastolic blood pressure and hemoglobin values. As eGFR lowers, optimal medical treatment and its persistence overtime is reduced. Multivariate analysis showed that progressively lower eGFR significantly correlated with all-cause 1-year mortality [hazard ratio (HR): 1.02; 95% confidence intervals (CI): 1.01-1-03; p = 0.0001]. CONCLUSIONS: Low eGFR is associated with an increasing risk of all-cause mortality in patients with stable CAD. Chronic kidney disease may hamper the optimization of treatment limiting the use of drugs which may favorably impact cardiovascular and renal outcomes.

Temporal trends in characteristics, treatment, and outcomes of heart failure in octogenarians over two decades.

INTRODUCTION AND OBJECTIVES: Octogenarians represent the most rapidly expanding population segment in Europe. The prevalence of heart failure (HF) in this group exceeds 10%. We assessed changes in clinical characteristics, therapy, and 1-year outcomes over 2 decades in chronic HF outpatients aged ≥ 80 years enrolled in a nationwide cardiology registry. METHODS: We included 2520 octogenarians with baseline echocardiographic ejection fraction measurements and available 1-year follow-up, who were recruited at 138 HF outpatient clinics (21% of national hospitals with cardiology units), across 3 enrolment periods (1999-2005, 2006-2011, 2012-2018). RESULTS: At recruitment, over the 3 study periods, there was an increase in age, body mass index, ejection fraction, the prevalence of obesity, diabetes, dyslipidemia, pre-existing hypertension, and atrial fibrillation history. The proportion of patients with preserved ejection fraction rose from 19.4% to 32.7% (P for trend <.0001). Markers of advanced disease became less prevalent. Prescription of beta-blockers and mineralocorticoid receptor antagonists increased over time. During the 1-year follow-up, 308 patients died (12.2%) and 360 (14.3%) were admitted for cardiovascular causes; overall, 591 (23.5%) met the combined primary endpoint of all-cause mortality or cardiovascular hospitalization. On adjusted multivariable analysis, enrolment in 2006 to 2011 (HR, 0.70; 95%CI, 0.55-0.90; P=.004) and 2012 to 2018 (HR, 0.61; 95%CI, 0.47-0.79; P=.0002) carried a lower risk of the primary outcome than recruitment in 1999 to 2005. CONCLUSIONS: Among octogenarians, over 2 decades, risk factor prevalence increased, management strategies improved, and survival remained stable, but the proportion hospitalized for cardiovascular causes declined. Despite increasing clinical complexity, in cardiology settings the burden of hospitalizations in the oldest old with chronic HF is declining.

Clinical Impact and Prognostic Role of Triglyceride to High-Density Lipoprotein Cholesterol Ratio in Patients With Chronic Coronary Syndromes at Very High Risk: Insights From the START Study.

Background: Several studies have reported that the combination of high TG and low HDL-C, as simplified by the TG/HDL-C ratio, was a predictor of cardiovascular disease independent of LDL-C level. Nevertheless, poor data are available on the predictive role of TG/HDL-C ratio in very high risk (VHR) patients with chronic coronary syndromes (CCS). Methods: Using the data from the STable Coronary Artery Diseases RegisTry (START) study, an Italian nationwide registry, we assessed the association between the TG/HDL-C ratio and baseline clinical characteristics, pharmacological treatment, and major adverse cardio-cerebrovascular events (MACCE) at 1 year in a large cohort of CCS patients at VHR. Results: VHR patients with both TG and HDL-C levels available were grouped in tertiles of TG/HDL-C ratio: low (TG/HDL-C ratio <2, n = 967), middle (TG/HDL-C ratio 2-3.3, n = 1,071) and high (TG/HDL-C ratio >3.3, n = 1,028). At 1 year from enrolment, 232 (7.6%) patients presented a MACCE, with a higher incidence in the higher tertile, even though not statistically significant (6.0, 8.2, and 8.4% in the low, middle and high tertile, respectively; p = 0.08). At multivariable analysis, the TG/HDL-C ratio in tertiles did not result an independent predictor of the MACCE (p = 0.29) at 1-year follow-up (HR: 1.30; 95% CI: 0.93-1.82; p = 0.12 middle vs. lower tertile, and HR: 1.22; 95% CI: 0.87-1.72; p = 0.25 higher vs. lower). Conclusions: In the present large, nationwide cohort of CCS patients at VHR a high TG/HD ratio did not emerge as independent predictor of MACCE at 1 year. Further studies with a longer follow-up are needed to better define the prognostic role of TG/HDL ratio in CCS.

Age-related changes in clinical characteristics and outcomes of chronic heart failure outpatients in a cardiology setting. A report from the Italian Network on Heart Failure.

AIMS: Ageing and comorbidities are increasing frailty/complexity of heart failure (HF) patients globally. We assessed evolving trends over two decades according to patients' age and time of recruitment in a nationwide cardiology setting in Italy. METHODS AND RESULTS: Chronic HF outpatients recruited between 1999 and 2018 (N = 14,823) were divided into 3 cohorts: 1999-2005 (N = 5404); 2006-2011 (N = 3971); 2012-2018 (N = 5448). We analyzed temporal changes in clinical characteristics, therapies, and outcome (1-year all-cause mortality/cardiovascular hospitalization), overall and by age group: <65 (n = 5465); 65-79 (n = 6838); ≥80 (n = 2520) years old. Across enrolment epochs, comorbidities (atrial fibrillation, hypertension, obesity) increased by both epoch/age groups (p < 0.001), whereas the prevalence of ischemic etiology declined among patients ≥65 years (p = 0.05). Accordingly, the preserved LVEF phenotype (HFpEF) increased in all age categories (p < 0.001) over time. Moreover, the use of betablockers, mineralocorticoid-receptor antagonists and loop-diuretics rose by enrolment epoch in all age groups (p < 0.05). In parallel with these epidemiologic/treatment changes, age-adjusted survival free from cardiovascular hospitalization improved over time (p < 0.0001). However, divergent trends in the end-point components were apparent according to age groups: mortality decreased in patients<80 years, although hospitalizations remained stable in the youngest group, while subjects ≥65 years were less likely to be admitted for cardiovascular causes (all p < 0.005). CONCLUSIONS: Over two decades in a cardiology outpatient setting, the prevalence of comorbid HFpEF increased in all age categories. Mortality improved among patients<80 years and cardiovascular hospitalizations decreased in patients≥65 years. These findings point to the value of cardiologist' input in the management of adult chronic HF patients at all ages.

Comparing the Prognostic Impact of Prediabetes with Diabetes in a Nationwide Cohort of Patients with Chronic Coronary Syndromes: An Analysis of the START Registry.

AIMS: Using data from the nationwide prospective START registry that enrolled a large cohort of patients with chronic coronary syndromes (CCS), we aimed to investigate whether the presence of diabetes mellitus (DM) and pre-DM independently affected the risk of cardiovascular events at 1-year follow-up. METHODS: We assessed the impact of DM and pre-DM on all-cause mortality and a composite of all-cause mortality and hospitalization for cardiovascular causes at 1-year follow-up. RESULTS: Among the 3,778 patients with available fasting plasma glucose data at study entry, 37% were classified as DM, 25% as pre-DM, and 38% as no DM. At 1 year, patients with DM had higher rates of all-cause death (p = 0.004) and death/cardiovascular hospitalization (p = 0.003) than those with pre-DM or without DM. Conversely, no significant differences in the adverse event rate were found between patients with pre-DM and those without DM. At unadjusted Cox analysis, DM resulted as a predictor of both death for any cause (hazard ratio [HR]: 2.41; 95% confidence intervals [CI]: 1.34-4.34; p = 0.003) and all-cause death/hospitalization for cardiovascular causes (HR: 1.29; 95% CI: 1.02-1.62; p = 0.03). However, DM did not result as an independent predictor of either endpoint at multivariate analysis. CONCLUSIONS: The risk of 1-year major events among patients with CCS and pre-DM is comparable to that of patients with CCS and normoglycemic status and is lower than that of patients with DM.

Post-discharge antithrombotic management and clinical outcomes of patients with new-onset or pre-existing atrial fibrillation and acute coronary syndromes undergoing coronary stenting: Follow-up data of the MATADOR-PCI study.

BACKGROUND: . Patients with concomitant atrial fibrillation (AF) and acute coronary syndromes (ACS) do not seem to receive proper antithrombotic therapies and present high rates of adverse clinical events. METHODS: . We analyzed the follow-up data of the prospective, nationwide MATADOR-PCI registry. We assessed the use of antithrombotic strategies and the incidence of major adverse cardiovascular events (MACE) and net adverse clinical events (NACE) at 6 months, in patients with new-onset or pre-existing AF admitted for ACS and treated with percutaneous coronary intervention (PCI). RESULTS: . Out of the 588 patients enrolled in the registry and discharged alive (287 with pre-existing and 301 with new-onset AF), data at 6 months were obtained for 579 (98.5%) patients. Compared to hospital discharge, the rate of triple antithrombotic therapy was significantly reduced (from 76.4% to 23.6% and from 53.8% to 23.6%; both p<0.0001) while dual antithrombotic therapy (DAT) increased (from 11.8% to 56.3% and from 5.8% to 30.9%; both p<0.0001) at follow-up, in patients with pre-existing and new-onset AF, respectively. Among patients with a class IA indication to receive oral anticoagulation therapy (OAT), it was prescribed in 91% and 88% of patients with pre-existing and 64% and 62% of new-onset AF, at discharge and follow-up, respectively. At 6 months from discharge the overall rate of MACE was 8.4% and 7.6% (p=0.75), while NACE occurred in 10.8% vs 10.0% (p=0.74) of patients with pre-existing or new-onset AF, respectively. CONCLUSIONS: . At follow-up, DAT was the most used antithrombotic strategy for both patients with pre-existing and new-onset AF with concomitant ACS. These two groups of patients presented comparable rates of MACE and NACE at 6 months.

Prevalence, clinical impact and costs of hyperkalaemia: Special focus on heart failure.

BACKGROUND: Hyperkalaemia is a potential life-threatening electrolyte abnormality. Although renin-angiotensin-aldosterone system inhibitors (RAASi) are potentially life-saving, they may contribute to hyperkalaemia. METHODS: The prevalence, comorbidities, comedications and 1-year outcomes of patients admitted or treated for hyperkalaemia were investigated in a large healthcare administrative database including 12 533 230 general population inhabitants. A similar analysis was performed in the Italian Network on Heart Failure (IN-HF), a cardiology registry of 1726 acute and 7589 chronic HF patients, stratified by serum potassium. General practice healthcare costs related to hyperkalaemia were also assessed. Hyperkalaemia was defined by hospital coding, potassium-binder prescription or serum levels (mild: 5-5.4, moderate-severe: ≥5.5 mmol/L). RESULTS: In the general population, the prevalence of hyperkalaemia was 0.035%. After excluding patients on haemodialysis, hyperkalaemia in the community (n = 2314) was significantly and directly associated with diabetes, chronic kidney disease, HF, RAASi prescriptions, 1-year hospitalisations and threefold annual healthcare costs, compared to age- and sex-matched non-hyperkalaemic subjects (n = 2314). In the IN-HF registry, hyperkalaemia affected 4.3% of acute and 3.6% of chronic patients and was significantly associated with diabetes, kidney disease and lesser use of RAASi, compared to normokalaemic patients. Among patients hospitalised for acute HF, those with hyperkalaemia at entry had significantly higher 1-year all-cause mortality compared with normokalaemic patients, even after adjustment for available confounders. CONCLUSIONS: Hyperkalaemia in the general population, although uncommon, was associated with increased hospitalisations and tripling of healthcare costs. Among HF patients, hyperkalaemia was common and associated with underuse of RAASi; in acutely decompensated patients, it remained independently associated with 1-year all-cause mortality.

Impact of history of depression on 1-year outcomes in patients with chronic coronary syndromes: An analysis of a contemporary, prospective, nationwide registry.

BACKGROUND: Depression is common in patients with acute cardiovascular conditions and it is associated with adverse clinical events. METHODS: Using the data from a nationwide, prospective registry on patients with chronic coronary syndromes (CCS), we assessed the impact of depression on major adverse cardiovascular events (MACE), a composite of all-cause death and hospitalization for myocardial infarction, revascularization, heart failure or stroke, and quality of life (QoL) at 1-year follow-up. RESULTS: From the 5070 consecutive CCS patients enrolled in the registry, 531 (10.5%) presented a history of depression and the remaining 4539 (89.5%) did not. At 1 year (median 369; IQR 362-378 days) from enrolment, the incidence of the primary composite outcome was 9.8% for patients with a history of depression and 7.2% for non-depressed patients (p = 0.03). Patients with history of depression had a significantly higher rate of all-cause mortality (3.0% vs 1.4%; p = 0.004) and hospital admission for heart failure (3.4% vs 1.3%; p = 0.0002) compared to the group without depression. However, history of depression did not result as an independent predictor of MACE at multivariable analysis [hazard ratio 1.17, 95% confidence interval (0.87-1.58), p = 0.31]. Depressed patients had worse QoL according to all domains of the EQ. 5D-5L questionnaire as compared to non-depressed patients (all p < 0.001), at both enrolment and follow-up. CONCLUSIONS: In this contemporary, large cohort of consecutive patients with CCS, patients with a history of depression experienced a two-fold rate of mortality, a higher incidence of MACE and a worse QoL at 1-year follow-up, compared to non-depressed patients.

Risk stratification and secondary prevention post-myocardial infarction: insights from the EYESHOT Post-MI study.

AIMS: Clinical management of patients more than 1 year after acute myocardial infarction (MI) is challenging. Patient risk stratification may help to establish therapeutic priorities. We aimed to describe the comprehensive risk profile and management of patients with prior MI. METHODS: We analyzed data from the EYESHOT Post-MI study, which evaluated the management of patients 1-3 years after MI. The risk profile of participants was defined according to the qualifying high-risk features of the PEGASUS-TIMI 54 trial (history of diabetes, history of recurrent MI, angiographic evidence of multivessel coronary disease, chronic kidney disease with estimated glomerular filtration rate <60 ml/min, age ≥65 years). Patients were classified into five subgroups according to the presence of zero, one, two, three, or more than three features. RESULTS: Of the 1633 patients in the EYESHOT Post-MI study, 1008 could be stratified according to PEGASUS-TIMI 54 high-risk features. About 22% of patients had no high-risk features, whereas 25% showed at least three features. The prevalence of patients with specific clinical severity indicators was progressively higher with the increasing number of high-risk features. Dual antiplatelet therapy and oral anticoagulation were more frequently used in patients with an increasing number of high-risk features (P for trend <0.0001). Lipid-lowering therapies were less frequently prescribed in patients with a higher number of features (P for trend 0.006 for statins; P for trend 0.007 for ezetimibe). CONCLUSION: Higher-risk post-MI patients, identified by PEGASUS-TIMI 54 high-risk features, showed an increased prevalence of major clinical severity indicators. Secondary prevention therapies were not adequately implemented in higher-risk patients.

Temporal Trends in Invasive Management and In-Hospital Mortality of Patients With Non-ST Elevation Acute Coronary Syndromes and Chronic Kidney Disease.

We analyzed data from 4 nationwide prospective registries of consecutive patients with acute coronary syndromes (ACS) admitted to the Italian Intensive Cardiac Care Unit network between 2005 and 2014. Out of 26 315 patients with ACS enrolled, 13 073 (49.7%) presented a diagnosis of non-ST elevation (NSTE)-ACS and had creatinine levels available at hospital admission: 1207 (9.2%) had severe chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] <30), 3803 (29.1%) mild to moderate CKD (eGFR 31-59), and 8063 (61.7%) no CKD (eGFR > 60 mL/min/1.73 m2). Patients with severe CKD had worse clinical characteristics compared with those with mild-moderate or no kidney dysfunction, including all the key predictors of mortality (P < .0001) which became worse over time (all P < .0001). Over the decade of observation, a significant increase in percutaneous coronary intervention rates was observed in patients without CKD (P for trend = .0001), but not in those with any level of CKD. After corrections for significant mortality predictors, severe CKD (odds ratio, OR: 5.49; 95% CI: 3.24-9.29; P < .0001) and mild-moderate CKD (OR: 2.33; 95% CI: 1.52-3.59; P < .0001) remained strongly associated with higher in-hospital mortality. The clinical characteristics of patients with NSTE-ACS and CKD remain challenging and their mortality rate is still higher compared with patients without CKD.