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The eligibility and potential benefit of transcatheter edge-to-edge repair (TEER) in addition to guideline-directed medical therapy to treat moderate-severe or severe secondary mitral regurgitation (MR) has not been reported in a contemporary heart failure (HF) population. In this study 50,841 adults with HF identified between 2013-2018 were screened for TEER eligibility based on the Food and Drug Administration (FDA) labeling. After applying the FDA eligibility criteria, 2,461 of these patients (4.8%) qualified for TEER (FDA+). These patients had higher natriuretic peptide levels and were more likely to have had a prior 1-year HF hospitalization. The estimated number needed to treat to prevent or postpone all-cause hospitalization was 4.4, 8.8 for HF hospitalization, and 5.3 for all-cause death at 24 months. The low prevalence of FDA eligibility for TEER treatment was primarily due to absence of moderate-severe or severe MR. Additional research is necessary to validate the scope of eligibility and comparative effectiveness of TEER.

Introduction:People living with HIV (PLWH) are at increased risk of incident heart failure (HF), but whether HIV status independently influences HF-related morbidity and mortality is unclear.Methods:In a 1:10 matched population of adults aged >21 years with (N=38,868) and without (N=386,586) HIV cared for in 3 large U.S. integrated healthcare systems, we identified all cases of incident HF from 2010-2016 using electronic heath records and followed these cases through December 2016 for all-cause death and HF hospitalization. Multivariable Cox regression was used to study the association between HIV status and HF-related outcomes.Results:Among 4,088 incident HF cases (483 PLWH; 3605 without HIV), PLWH vs. without HIV had significantly higher crude rates (per 100 person-years) of death (12.3 [95% CI: 10.8-14.0] vs. 8.6 [8.1-9.0], respectively, p<0.001) and HF hospitalizations (14.9 [13.3-16.8] vs. 13.4 [12.8-13.9], respectively, p=0.037). Of note, crude mortality was highest in PLWH with low (<200 cells/?L) CD4 counts (17.1 [13.4-21.8]). After adjustment for potential confounders, PLWH had a higher risk of death of borderline significance (adjusted Hazard Ratio [aHR] 1.25 [0.97-1.61]) but no excess risk of HF hospitalizations (aHR 1.00 [0.76-1.32]) (Figure). Compared to adults without HIV, PLWH with low CD4 counts had a significantly higher risk of death (aHR 1.65 [1.14-2.40]) but not HF hospitalization (aHR 1.07 [0.70-1.60]), while risks of death and HF hospitalization did not significantly differ for PLWH with 200-499 or >500 CD4 cells/?L.Conclusions:In a large U.S.-based cohort of incident HF, PLWH were at an increased risk of death that appeared modified by higher CD4 counts, but were not at increased risk of HF hospitalizations. Further research should identify additional modifiable factors contributing to excess mortality that help develop more accurate risk prediction models to better personalize care for PLWH and HF.

Introduction:Administrative claims data are often used for population management and quality reporting, but diagnosis codes for conditions such as valvular heart disease can be inaccurate and vary across health systems. Echocardiography (echo) data contain detailed clinical information but are generally unstructured and not feasible to extract manually in large scale.Methods:We developed and validated natural language processing (NLP) algorithms to identify aortic stenosis (AS) from echo reports in Kaiser Permanente Northern California (KPNC) and compared AS identification using NLP vs. administrative codes. Using NLP software (Linguamatics i2e), we initially developed algorithms to identify AS from a development set of >100 echo reports manually confirmed with AS, with iterative refinement using additional development sets (>100 echo reports each) until the NLP algorithm achieved positive and negative predictive values (PPV and NPV) of >95%. We then applied the NLP algorithm to all 2008-2018 echo reports (transthoracic, transesophageal or stress) in KPNC adults and compared results to ICD-9/10 diagnostic code-based definitions from 14 days before to 6 months after the echo date.Results:The NLP algorithm was developed and refined among >500 echo reports to achieve >95% PPV and NPV. Application of NLP to 957,505 echo reports (N=522,653 patients with mean age 63.3 years, 51% women, 8.5% black, 13.5% Asian/Pacific Islander, 12.9% Hispanic and median [interquartile range] 1 [1 to 2] echoes per person) yielded 104,090 echoes (10.9%) with AS (N=53,791 patients). Among echoes identified by NLP as positive for AS, 36,070 (34.7%) had diagnosis codes for AS between 14 days prior and 6 months after echo. Among echo?s without AS via NLP, 12,626 (1.5%) had diagnosis codes for AS between 14 days before to 6 months after the echo.Conclusions:An NLP algorithm applied to a large echo database was more accurate than using diagnosis codes for identifying AS and can facilitate more effective individual and population management than relying on administrative data alone. Future NLP development to characterize AS severity will further advance personalized and population-based care strategies for surveillance and treatment.

Introduction:Iron deficiency is common but infrequently tested for among older adults with heart failure (HF) and anemia. A low transferrin saturation (TSAT) and/or a reduced ferritin are suggestive of iron deficiency, but plasma concentrations of these proteins may be altered in response to inflammation and confound their interpretation in the setting of HF.Methods:We identified a multicenter cohort of adults age ?65 years with HF and incident anemia (hemoglobin <13 g/dL [men] or <12 g/dL [women]) between 2005-2012. Participants were required to have ferritin (ng/mL) and TSAT (%) evaluated within 90 days. Outcomes were ascertained from electronic health records.Results:Among 4,103 older adults with HF, incident anemia, and iron studies, 47% had TSAT <20% and median (IQR) ferritin was 126 (52.5, 256.0) ng/mL. Crude rates of HF hospitalization (Figure A) and all-cause death (Figure B) were higher for participants with a TSAT <20% vs. TSAT ?20% at any ferritin level. After adjustment for demographics, medical history, kidney function, proteinuria and medications, patients with TSAT <20% vs. TSAT ?20% were at increased risk of HF hospitalization for a corresponding ferritin <100 ng/mL (adjusted HR [aHR] 1.42, 95% CI 1.18-1.71) or 100-300 ng/mL (aHR 1.31, 95%CI:1.08-1.59). TSAT <20% (vs. >20%) was independently associated with an increased risk of death from any cause irrespective of baseline ferritin (<100 ng/mL: aHR 1.46, 95%CI:1.24-1.70; 100-300 ng/mL: aHR 1.21, 95%CI:1.03-1.42; >300 ng/mL: aHR 1.38, 95%CI:1.10-1.74).Conclusions:Among older adults with HF and incident anemia who had iron studies, ~50% had a TSAT <20%, which independently correlated with higher rates of morbidity and mortality across a wide range of ferritin levels. Additional research is required to clarify the role of routine evaluation and treatment of functional iron deficiency (impaired mobilization) based on an isolated low TSAT.

Introduction:Conflicting studies exist about whether the risk of developing atrial fibrillation (AF) varies by race, with even less known about whether race/ethnicity is associated with differential burden of AF (i.e., amount of time in AF).Methods:The Kaiser Permanente (KP) RHYTHM Study included all adult members of the KP Northern and Southern California integrated healthcare delivery systems who were prescribed 14-day continuous ambulatory ECG monitoring using the ZIO?XT Patch (iRhythm, Inc.) between October 2011-October 2016 and who were found to have any AF detected during monitoring. Self-reported race/ethnicity, other demographic characteristics and stroke risk factors were obtained from electronic medical records. We examined the multivariable association of race/ethnicity with log-transformed AF burden (ie, % of analyzable wear time spent in AF).Results:In 1069 eligible adults with any detected AF on continuous ambulatory ECG monitoring, mean age was 69.1 years, 45% were women, 4.2% black, 13.2% Asian/Pacific Islander, 10.5% Hispanic, and 2.2% other race. Median wear time (>13.3 days) did not vary by race/ethnicity. Overall, median AF burden was 4% (IQR:1-13%), with variation by race/ethnicity: white (3.6% [0.9-11.7%]), black (1.4% [0.2-6.5%], P=0.02), Asian/Pacific Islander (5.7% [1.4-19.2%], P=0.03) and Hispanic (2.5% [0.5-10.3%], P=0.18). After adjustment for age, gender, heart failure, hypertension, diabetes, eGFR, proteinuria, and prior stroke/TIA, compared with whites, black race was associated with a 54% lower burden of AF (adjusted relative estimate -54%, 95%CI:-77% to -19%), while Asian/Pacific Islander race was associated with a higher burden of AF that was of borderline significance (adjusted relative estimate 45%, 95%CI:-1% to 111%). Hispanic ethnicity was not associated with AF burden (adjusted relative estimate -26%, 95%CI:-51% to 13%).Conclusions:Among adults found to have AF on 14-day continuous, beat-to-beat ambulatory ECG monitoring, black race was independently associated with a >50% relatively lower burden of AF, while Asian/Pacific Islander race may be linked to a higher AF burden. These results support further investigation into potential pathways that may explain racial variation in AF burden.

Assessing fall risk is important for anticoagulation decision-making in adults with atrial fibrillation (AF). We investigated the prevalence of patient self-reported falls, and identified factors associated with falls and initiation of fall prevention programs in AF. The ATRIA2-CVRN study included adults with incident AF between 1/1/2006 - 6/30/2009 from Kaiser Permanente Northern and Southern California. We conducted surveys via mail and telephone to ascertain self-reported health and functional behaviors, including history of falls (fallen to the ground more than once in the past year), severe falls (falls requiring medical care), and initiation of fall prevention programs (physical therapy or exercise program) after a fall. Electronic health records provided clinical features. Associations between patient characteristics and falls and initiation of fall prevention programs were examined using multivariable logistic regression. Among 12,949 AF patients who completed the questionnaire (response rate = 55%; mean age 71y, 43% women), 56% were on anticoagulant therapy. Overall, 15% and 6% reported falls and serious falls, respectively (28% and 12% for ages ?85y). Older age, physical inactivity, disordered sleep pattern, unstable warfarin, and higher predicted risks of stroke and bleeds were associated with falls (Table). A minority of patients who experienced falls reported interactions with health care professionals about how to avoid falling (36%), behavior changes after the fall (30%), or initiation of fall prevention programs (22%). Experiencing severe falls, prior intracranial hemorrhage, and older age were significant factors for initiation of fall prevention programs.Falls were prevalent in older AF patients. Older adults who experienced severe falls were more likely to initiate fall prevention programs. Future research should consider the identified factors to develop effective fall assessment tools and fall prevention programs in AF.

Background:Patients with chronic kidney disease (CKD) often have heart failure with reduced left ventricular ejection fraction (HF-REF), and previous work has shown that the co-occurrence of those conditions confers a higher rate of poor outcomes than either condition alone. But few studies have examined whether CKD confers a clinically meaningful difference in outcomes among heart failure patients with preserved left ventricular ejection fraction (HF-PEF). Compared to previous work, our study uses more granular renal function estimates and a large, contemporary cohort.