Search

Previous studies have shown that pulmonary hypertension is a predictor of mortality in patients with systolic heart failure (SHF). Persistent pulmonary hypertension after a reactivity test is associated with a worse outcome after transplantation. Recent studies have shown the utility of different haemodynamic parameters.To define best haemodynamic parameters for risk stratification in patients with advanced systolic heart failure.We included 425 consecutive patients who underwent a right heart catheterization with an inotropic challenge if indicated.During a median (interquartile range) follow-up of 1.67 (0.49-4.49) years, there were 151 major cardiac events (126 cardiovascular deaths and 25 postoperative deaths after ventricular assist device implantation or heart transplantation). The most powerful independent predictors of major cardiac events were baseline right atrial pressure (RAP) (hazard ratio [HR]: 1.09, 95% confidence interval [CI]: 1.06-1.12; P0.0001) and baseline pulmonary vascular resistance (PVR) (HR: 1.10; 95% CI: 1.03-1.17; P=0.002). After inotropic challenge, the only independent predictor was mean pulmonary arterial pressure (mPAP) (HR: 1.06; 95% CI: 1.03-1.09; P0.0001). The combination of PVR (≤or3 Wood units), RAP (or≥9mmHg) and mPAP after the inotropic challenge (≤or30mmHg) was the best predictor of major events.We suggest using a simple algorithm based on baseline PVR, baseline RAP and mPAP after the inotropic challenge for the risk stratification of stable patients with advanced systolic heart failure.

Summary Background Transfemoral percutaneous transcatheter aortic valve implantation (TF-TAVI) is a safe, reproducible and established procedure, mainly performed under local anaesthesia, which is mostly administered and monitored by a dedicated anaesthesia team (regular approach). Our centre has developed a standardized pathway of care, and eligible patients are selected for a minimalist TF-TAVI, entirely managed by operators without the presence of the anaesthesia team in the operating room, like most interventional coronary procedures (“percutaneous coronary intervention-like” approach [PCI approach]). Aim To compare the safety and efficacy of TF-TAVI performed with the PCI approach versus the regular approach. Methods The analysis population comprised all patients who underwent TF-TAVI with the PCI or regular approach in our institution from November 2016 to July 2019. The two co-primary endpoints were early safety composite and early efficacy composite at 30 days as defined by the Valve Academic Research Consortium-2. The PCI (n = 137) and Regular (n = 221) approaches were compared using the propensity score based method of inverse probability of treatment weighting. Results No differences were observed after comparison of TAVI performed with the PCI or regular approach regarding the composite safety endpoint (7.3% vs. 11.3%; odds ratio 0.63, 95% confidence interval 0.37 to 1.07; P = 0.086) or the composite efficacy endpoint (4.4% vs. 6.3%; odds ratio 0.78, 95% confidence interval 0.41 to 1.49; P = 0.45). Conclusions This study suggests that the efficacy and safety of TF-TAVI entirely managed by a PCI approach for selected patients are not different to those when TF-TAVI is performed with the attendance of a full anaesthesia care team. The PCI approach appears to be a safe and efficient clinical pathway, providing an appropriate and rational utilization of anaesthesiology resources, and could be used for the majority of TF-TAVI procedures.

International audience

Physical activity is important in heart failure to improve functional capacity, quality of life and prognosis, and is a class IA recommendation in the European Society of Cardiology guidelines (Ponikowski et al., 2016). The benefits of exercise training are widely recognized. Cardiac rehabilitation centres offer tailored exercise training to patients with heart failure, as part of specialized multidisciplinary care, alongside pharmacological treatment optimization and patient education. After cardiac rehabilitation, maintenance of regular physical activity long term is essential, as the benefits of exercise training vanish within a few weeks. Unfortunately, only 10% of patients benefit from a cardiac rehabilitation programme after hospitalization for acute heart failure, and the majority of patients do not pursue long-term physical activity. In this paper, two Working Groups of the French Society of Cardiology (the heart failure group [Groupe Insuffisance Cardiaque et Cardiomyopathies; GICC] and the cardiac rehabilitation group [Groupe Exercice Readaptation Sport et Prevention; GERS-P]) discuss the obstacles to broader access to cardiac rehabilitation centres, and propose ways to improve the diffusion of cardiac rehabilitation programmes and encourage long-term adherence to physical activity.

Summary Background Coronary artery disease (CAD) is the leading cause of systolic heart failure (HF). Cardiac magnetic resonance imaging (CMR) is a non-invasive technique that detects a myocardial infarction scar as subendocardial or transmural late gadolinium enhancement (st-LGE). Aim We sought to evaluate whether a lack of st-LGE could rule out CAD in new-onset systolic HF of unknown aetiology. Methods We included 232 consecutive patients with new-onset HF and left ventricular ejection fraction ≤ 35% who underwent both coronary angiography and CMR to assess HF aetiology. CAD was defined as the presence of coronary artery stenosis ≥ 50% on a coronary angiogram. We assessed sensitivity, specificity, and positive and negative likelihood ratios (PLR and NLR) of the presence of st-LGE to detect underlying CAD. A complementary meta-analysis of 11 studies (including ours) was also performed. Results In our study, 49 (21.1%) patients had CAD. The sensitivity and specificity of the presence of st-LGE to detect CAD were 69 and 92%, respectively. PLR and NLR were 8.47 and 0.33, respectively. In the meta-analysis, 1227 patients were included, and the prevalence of CAD ranged from 19.2 to 68.3%. Sensitivity, specificity, PLR and NLR were 87% (95% confidence interval [CI] 0.80–0.92), 93% (95% CI 0.89–0.96), 12.91 (95% CI 7.70–21.64) and 0.14 (95% CI 0.09–0.22), respectively. Altogether, 55 patients presented CAD with no st-LGE; inversely, 75 patients presented st-LGE with no CAD. Conclusion With a CMR specificity of 93%, the absence of st-LGE rules out significant underlying CAD in patients with systolic HF of unknown aetiology in most cases.

SummaryOver the past two decades, the use of multiple biomarkers has changed cardiovascular disease management. Recently, several trials have assessed the diagnostic and prognostic performances of copeptin, especially in patients with heart failure or acute coronary syndromes. Primary results are interesting, with copeptin looking promising for: the management of patients who present at emergency departments early after chest pain onset and the risk stratification of patients with heart failure. The purpose of this article is to review the data on the place of copeptin in the management of patients with chest pain or heart failure.

Low-density lipoprotein cholesterol (LDL-C) reduction is an integral part of the management of patients with coronary artery disease (CAD).To assess attainment of LDL-C goals during long-term treatment of patients with stable CAD, and to determine predictors of goal attainment and the prognostic impact of reaching LDL-C70mg/dL (1.8mmol/L) in a real-life setting.Data were obtained for 4080 outpatients with stable CAD included in the multicentre CORONOR study. Five-year follow-up was achieved for 3991 (97.8%) patients.At inclusion, a recent (1 year) measurement of LDL-C was available in 3757 (92.1%) patients. LDL-C70mg/dL was reached by 885 (23.6%) patients. Independent predictors of LDL-C70mg/dL were diabetes mellitus, statin treatment, treatment with renin-angiotensin system inhibitors, previous myocardial infarction and short time since last coronary event. The adjusted hazard ratio (HR) for the composite endpoint (cardiovascular death, myocardial infarction, ischemic stroke or coronary revascularization) during the 5-year follow-up was 1.31 (95% confidence interval [CI]: 1.09-1.58; P=0.004) for LDL-C≥70mg/dL versus70mg/dL. When compared with patients with LDL-C70mg/dL, the adjusted HRs for LDL-C 70-99mg/dL and ≥100mg/dL (2.6mmol/L) were 1.27 (95% CI: 1.05-1.55; P=0.016) and 1.38 (95% CI: 1.12-1.70; P=0.003), respectively. When LDL-C was used as a continuous variable, the adjusted HRs for increases of 10mg/dL (0.3mmol/L) and 1mmol/L were 1.05 (95% CI: 1.03-1.08) and 1.21 (95% CI: 1.10-1.33), respectively.In this observational study, only a minority of stable CAD patients had LDL-C70mg/dL. The patients who reached their LDL-C goal had the lowest risk of cardiovascular events.

Summary Background Limited recent data are available in the literature on whether the presence of left ventricular systolic dysfunction (LVSD) affects the therapeutic management of patients with stable coronary artery disease (CAD). Aims The objectives of this study were to analyse prevalence, effect on therapeutics and prognosis of LVSD in stable CAD. Methods We prospectively included 4184 CAD outpatients free from any myocardial infarction or coronary revascularization for > 1 year. Left ventricular ejection fraction (EF) was available for 4124 (98.6%) patients. Follow-up was performed at 2 years. All events were adjudicated blindly. Results The mean EF was 57.5 ± 10.8%, and 201 (4.9%) patients had an EF ≤ 35%. The prescription of renin–angiotensin system inhibitors and beta-blockers was inversely related to EF, and reached > 90% in patients with EF ≤ 35%. Seventy-five (37.3%) of the patients with EF ≤ 35% received a mineralocorticoid receptor antagonist. Eighty-five (42.3%) of the patients with EF ≤ 35% had an implantable cardioverter defibrillator. Clinical follow-up data were obtained for 4090 patients (99.2%). Event rates were higher in patients with low EF (adjusted hazard ratio [95% confidence interval] for EF ≤ 35%, with EF ≥ 60% as reference: 3.93 [2.60–5.93] and 7.12 [3.85–13.18], for all-cause death and cardiovascular death, respectively). Conclusions In patients with stable CAD, LVSD is well taken into account by cardiologists, with extensive use of evidence-based medications and interventions. Despite this, LVSD remains a major prognostic indicator in this population.

Background In patients with coronary artery disease (CAD), non-optimal use of evidence-based medications is associated with an increased risk of adverse outcome. Aims To assess the prevalence and correlates of non-optimal secondary medical prevention in patients with stable CAD. Methods We included 4184 consecutive outpatients with stable CAD. Treatment at inclusion was classified as optimal/non-optimal regarding the four major classes of secondary prevention drugs: antithrombotics; statins; angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs); and beta-blockers. For each treatment, the prescription was considered non-optimal if the drug was missing despite a class IA indication according to international guidelines. To assess the information globally, non-optimal secondary prevention was defined as at least one major treatment missing. Results The proportions of patients with non-optimal treatment were 0.7%, 7.8%, 12.9% and 10.3% for antithrombotics, statins, ACE inhibitors/ARBs and beta-blockers, respectively. Non-optimal secondary medical prevention was observed in 16.8% of cases. By multivariable analysis, the correlates of non-optimal secondary medical prevention were long time interval since last coronary event (P

SummaryBackgroundLeft ventricular systolic function is a useful indicator of in-hospital prognosis in patients with acute myocardial infarction. For long-term risk stratification, however, the variable degree of recovery that may occur during the ensuing period has also to be taken into account.AimsTo analyse the prevalence, time course, determinants and correlates of late left ventricular function recovery after myocardial infarction, from hospital discharge to 1-year follow-up, using systematic serial assessment of left ventricular function.MethodsData from 512 patients with a first anterior myocardial infarction included in two prospective studies on left ventricular remodelling (REVE and REVE-2) were analysed. Serial echocardiographic studies were performed before discharge, at 3 months and at 1 year after myocardial infarction. Left ventricular volumes, ejection fraction, and Wall Motion Score Index were determined at a core echocardiographic laboratory.ResultsIn both cohorts, there was a significant decrease in Wall Motion Score Index between discharge and 1 year (from 1.87±0.15 to 1.71±0.21 [P

SummaryBackgroundLeft atrial (LA) volume is an important predictor of mortality and morbidity after myocardial infarction (MI). However, the process of LA remodelling has not been extensively investigated.AimsOur purpose was to analyse the incidence, determinants and consequences of LA remodelling in a cohort of patients with a first anterior MI enrolled in the modern era of MI management.MethodsWe used data from 246 patients with a first anterior MI who were included in a prospective study on left ventricular (LV) remodelling (REVE-2). Serial echocardiographic studies were performed before discharge and at 3 months and 1 year after MI.ResultsLA volume increased from 20.5±5.9mL/m2 at baseline to 24.6±7.4mL/m2 at 3 months (P

Background Severe pulmonary hypertension is a usual contraindication to heart transplantation. A few studies have found that sildenafil has a favourable effect on haemodynamic variables in patients with severe left ventricular systolic dysfunction. Aim To report our clinical experience of sildenafil in patients with left ventricular systolic dysfunction and severe pulmonary hypertension. Methods All patients underwent echocardiography, radionuclide angiography, a cardiopulmonary exercise test and right heart catheterization before and after treatment with sildenafil. All patients were clinically stable and were receiving maximal tolerated doses of recommended drugs. Results We included 18 patients, with a mean ± standard deviation age of 47 ± 13 years. After a median of 8.7 months (interquartile range, 4.4–13.5 months) on sildenafil, there was a significant improvement in New York Heart Association classification (P = 0.02) and mean right ventricular ejection fraction (from 26 ± 7% to 30 ± 9%; P = 0.008), with a decrease in the VE/VCO2 slope (from 52 ± 11 to 44 ± 11; P = 0.009) and in pulmonary vascular resistance (from 5.3 ± 1.9 Wood units to 3.3 ± 1.8 Wood units; P = 0.01). During follow-up, three patients had urgent heart transplantation, two had non-urgent transplantation and six had left ventricular assist device implantation. All patients with pulmonary vascular resistance