Does high sensitivity troponin add prognostic value to validated risk scores to predict in-hospital mortality in patients with acute heart failure?

Troponin elevation correlates with an increased short and long-term mortality in patients with acute decompensated heart failure (AHF). However, it has not been included in the development of multiple validated predictive models of mortality. We aim to  determine whether the addition of high-sensitivity troponin T (hs-TnT) to clinical risk scores improves the prediction of in-hospital mortality in patients with AHF. A retrospective analysis of a prospective and consecutive cohort was performed. Adult patients hospitalized between 2015 and 2019 with a primary diagnosis of AHF were included. Hs-TnT was measured on admission. OPTIMIZE-HF, GWTG-HF, and ADHERE risks score were calculated for each patient. The primary endpoint was all-cause in-hospital mortality. Discrimination of isolated hs-TnT and the risk scores with and without the addition of hs-TnT were evaluated using the area under the ROC curve (AUC-ROC). A subanalysis was performed according to left ventricular ejection fraction (LVEF). Of 712 patients, 562 (79%) had hs-TnT measurement upon admission, and was elevated in 91%. In-hospital mortality was 8.7% (n = 49). The AUC-ROC was 0.70 (95% CI 0.63-0.77) for isolated hs-TnT, and 0.80 (0.74-0.87), 0.79 (0.72 -0.86) and 0.79 (0.71-0.86) for the OPTIMIZE-HF, GWTG-HF and ADHERE scores, respectively. The addition of hs-TnT to the models did not increase the AUC: 0.72 (0.66-0.79) for the OPTIMIZE-HF + hs-TnT score (difference between AUC - 0.08 p = 0.04), 0.74 (0.68-0.80) for GWTG-HF (difference between AUC-0.04, p = 0.2) and 0.7 (0.63-0.77) for ADHERE (difference between AUC - 0.085 p = 0.07). The models presented good calibration (p > 0.05). In the sub-analysis, no differences were found between risk scores with the addition of hs-TnT in the population with LVEF < 40% and ≥ 40%. Elevated hs-TnT on admission was frequent and its incorporation into the validated risk scores did not prove an incremental prognostic benefit in patients hospitalized for AHF, regardless of LVEF. Isolated hs-TnT had a modest ability to predict hospital mortality. Additional prospective studies are needed to validate these findings.

Evolución a mediano plazo de pacientes con diagnóstico de cardiopatía amiloidótica por transtiretina / Mid-term Outcome of Patients with Diagnosis of Transthyretin Cardiac Amyloidosis

RESUMEN Introducción: El compromiso cardíaco es la principal causa de morbimortalidad en la amiloidosis, independientemente de la patogenia productora del amiloide subyacente. La amiloidosis por transtiretina (TTR) es una de las variantes más frecuentes, por lo cual el objetivo de este trabajo fue evaluar las características de una cohorte de pacientes con diagnóstico de cardiopatía amiloidótica por TTR (CA-TTR) Material y métodos: Se recabaron datos de los estudios basales, de la metodología diagnóstica y de la evolución de 49 pacientes en seguimiento en la Clínica de Miocardiopatías de nuestra institución. Resultados: La mediana del tiempo de seguimiento fue de 1258 días (410-2004) y la edad promedio de 79 ± 9 años. Al inicio del seguimiento, el 57% de los pacientes estaban en clase funcional I, el 26%, en II y el 16%, en III-IV. El diagnóstico se basó en centellograma con difosfonatos en el 92%; en el 24% requirió biopsia. La mortalidad global fue del 19%, con 15% de muerte cardiovascular. La tasa de internación por insuficiencia cardíaca fue 29%; el 63% de los pacientes empeoró su clase funcional. Conclusiones: El seguimiento de nuestros pacientes con CA-TTR expresa los cambios que ha sufrido el proceso diagnóstico, con una reducción de estudios invasivos y tiempo para la caracterización. El diagnóstico de pacientes en etapas "tempranas" de la enfermedad parece impactar en los resultados a mediano plazo.

ABSTRACT Background: Cardiac involvement is the main cause of morbidity and mortality in amyloidosis, regardless of the underlying pathogenesis of amyloid production, and transthyretin (TTR) amyloidosis is one of the most frequent variants. Objective: The aim of this study was thus to assess the characteristics of a cohort of patients with diagnosis of TTR cardiac amyloidosis (ATTR-CA). Methods: Baseline data and diagnostic and follow-up methodology were collected from 49 patients treated at the cardiomy-opathy clinic of our institution. Results: Median follow-up was 1,258 days (410-2004). Mean age was 79±9 years, and 57% of patients were in functional class (FC) I, 26% in FC II and 16% in FC III-IV at follow-up onset. Diagnosis was made with diphosphonate scintigraphy in 92% of patients and 24% required a biopsy. Overall mortality was 19%, with 15% of cardiovascular death. The rate of hospitalization for heart failure was 29% and 63% of patients worsened their FC. Conclusions: Follow-up of patients with ATTR-CA expresses the changes undergone by the diagnostic process, with a reduction of invasive studies and time to characterization. The diagnosis of patients at "early stages of the disease" seems to have an impact on mid-term outcomes.

Atrial Fibrillation in Heart Failure Patients with Preserved or Reduced Ejection Fraction. Prognostic significance of Rhythm control strategy with Catheter Ablation.

INTRODUCTION: Atrial fibrillation (AF) and heart failure (HF) often coexist with an increase in morbidity and mortality. AF catheter ablation (CA) has proved to be a safe and efficient option for HF patients, but long-term evolution and prognosis remain uncertain. The aim is to assess the efficacy and safety of CA in HF patients with AF, and analyze HF long-term evolution. METHODS: We prospectively analyzed consecutive patients with AF and congestive HF or left ventricular ejection fraction (EF) less than 45%, who underwent CA of AF between 2011 and 2016. We excluded patients who did not complete one year of follow-up. RESULTS: Seventy-nine patients were included. Mean age was 62.1 years, 72.4% were men, 67.2% had hypertension and 8.6% were diabetics. Mean EF was 49%, left atrial area was 26.5 cm2 and mean CHA2DS2-VASc score was 2. 70.6% were on NYHA FC II-III.The recurrence rate of AF was 60%, and after a second CA the rate decreased to 27.8%. Only persistent AF prior to the procedure was identified as independent predictor of recurrence. There was a significant NYHA FC improvement in the sinus rhythm (SR) group vs those with recurrence (63.6% vs 36.4%; p=0.047). None of the patients in SR were hospitalized, whereas six with recurrence were hospitalized due to HF (0% vs. 18.2%; p = 0.07). The rate of complications was 9.1%. CONCLUSIONS: Catheter ablation of atrial fibrillation in heart failure presents an adequate success rate, improving symptoms and reducing rehospitalizations due to heart failure.