Search

Abstract 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.

Abstract 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.

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.

Background: The Danish National Patient Registry (DNPR) is a valuable resource for population-based research, but the validity of routine registration of advanced heart failure (HF) treatments within the registry is unknown. We, therefore, investigated the validity of HF, advanced HF treatments, and HF readmissions in the DNPR., Methods: We randomly sampled patients registered at a Danish University Hospital during 2017-2021 from the DNPR. We identified 200 patients with first-time HF, 390 patients with one of eight advanced HF treatments, and 133 patients with HF admission after implantable cardioverter-defibrillator (ICD) or cardiac resynchronisation therapy (CRT). Compared with medical record reviews, we calculated positive predictive values (PPVs) with 95% confidence intervals (CIs)., Results: The PPV for first-time HF was 81% (95% CI: 74-86%). For advanced HF treatments, the PPV was 97% (95% CI: 91-99%) for ICD, 96% (95% CI: 86-100%) for CRT-pacemaker, 88% (95% CI: 76-95%) for CRT-defibrillator, 100% (95% CI: 83-100%) for left ventricular assist device, 43% (95% CI: 18-71%) for intra-aortic balloon pump, 38% (95% CI: 25-35%) for impella, 100% (95% CI: 93-100%) for cardiopulmonary support, and 100% (95% CI: 94-100%) for heart transplantation. The PPV for HF admission after ICD was 25% (95% CI: 16-37%) and 18% (95% CI: 9.2-30%) after CRT., Conclusions: The PPV of routine registrations in the DNPR was moderate for first-time HF, high for most advanced HF treatments, and low for HF admissions after ICD or CRT. Thus, the DNPR is a valuable data source for population-based research on first-time HF and many advanced HF treatments., Competing Interests: Conflict of interests: The authors declare that they have no competing interests.

Background: Some autoimmune diseases carry elevated risk for atherosclerotic cardiovascular disease (ASCVD), yet the underlying mechanism and the influence of traditional risk factors remain unclear., Objectives: This study sought to determine whether autoimmune diseases independently correlate with coronary atherosclerosis and ASCVD risk and whether traditional cardiovascular risk factors modulate the risk., Methods: The study included 85,512 patients from the Western Denmark Heart Registry undergoing coronary computed tomography angiography. A diagnosis of 1 of 18 autoimmune diseases was assessed. Adjusted OR (aOR) for any plaque, any coronary artery calcification (CAC), CAC of >90th percentile, and obstructive coronary artery disease as well as adjusted HR (aHR) for ASCVD were calculated., Results: During 5.3 years (Q1-Q3: 2.8-8.2 years) of follow-up, 3,832 ASCVD events occurred. A total of 4,064 patients had a diagnosis of autoimmune disease, which was associated with both presence of any plaque (aOR: 1.29; 95% CI: 1.20-1.40), any CAC (aOR: 1.28; 95% CI: 1.19-1.37), and severe CAC of >90th percentile (aOR: 1.53; 95% CI: 1.39-1.68), but not with having obstructive coronary artery disease (aOR: 1.04; 95% CI: 0.91-1.17). Patients with autoimmune diseases had a 46% higher risk (aHR: 1.46; 95% CI: 1.29-1.65) for ASCVD. Traditional cardiovascular risk factors were strongly associated with future ASCVD events, and a favorable cardiovascular risk factor profile in autoimmune patients was associated with ∼54% lower risk compared to patients with presence of risk factors (aHR: 0.46; 95% CI: 0.27-0.81)., Conclusions: Autoimmune diseases were independently associated with higher burden of coronary atherosclerosis and higher risk for future ASCVD events, with risk accentuated by traditional cardiovascular risk factors. These findings suggest that autoimmune diseases increase risk through accelerated atherogenesis and that cardiovascular risk factor control is key for improving prognosis in patients with autoimmune diseases., Competing Interests: Funding Support and Author Disclosures This study was funded by Aarhus University Hospital. The funding source had no influence on study design, conduct or reporting. Dr Blaha has received grants from the National Institutes of Health, U.S. Food and Drug Administration, American Heart Association, and Aetna Foundation; has received grants and personal fees from Amgen; and has received personal fees from Sanofi, Regeneron, Novartis, Bayer, and Novo Nordisk outside the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Advanced heart failure patients often have comorbidities of prognostic importance. However, whether total pretransplantation comorbidity burden predicts mortality in patients treated with heart transplantation (HTx) is unknown. We used population-based hospital and prescription data to examine the ability of the Danish Comorbidity Index for Acute Myocardial Infarction (DANCAMI), DANCAMI restricted to noncardiovascular diseases, Charlson Comorbidity Index, and Elixhauser Comorbidity Index to predict 30-d, 1-y, 5-y, and 10-y all-cause and cardiovascular mortality after HTx., Methods: We identified all adult Danish patients with incident HTx from the Scandiatransplant Database between March 1, 1995, and December 31, 2018 (n = 563). We calculated Harrell's C-Statistics to examine discriminatory performance., Results: The C-Statistic for predicting 1-y all-cause mortality after HTx was 0.58 (95% confidence interval [CI], 0.50-0.65) for a baseline model including age and sex. Adding comorbidity score to the baseline model did not increase the C-Statistics for DANCAMI (0.58; 95% CI, 0.50-0.65), DANCAMI restricted to noncardiovascular diseases (0.57; 95% CI, 0.50-0.64), Charlson Comorbidity Index (0.59; 95% CI, 0.51-0.66), or Elixhauser Comorbidity Index (0.58; 95% CI, 0.51-0.65). The results for 30-d, 5-y, and 10-y all-cause and cardiovascular mortality were consistent., Conclusions: After accounting for patient age and sex, none of the commonly used comorbidity indices added predictive value to short- or long-term all-cause or cardiovascular mortality after HTx., Competing Interests: The authors declare no funding or conflicts of interest., (Copyright © 2023 The Author(s). Transplantation Direct. Published by Wolters Kluwer Health, Inc.)

Background: Immune checkpoint inhibitor (ICI) induced myocarditis is a rare, severe, and often fatal adverse event. Evidence to guide appropriate immunosuppressive therapy is scarce. We present a case of ICI-induced myocarditis and a review of ICI-induced myocarditis cases to determine the most effective immunosuppressive therapeutic strategy for ICI-induced myocarditis., Methods: A systematic search of PubMed was carried out for treatment of ICI-induced myocarditis. Reference lists from identified articles were manually reviewed for additional cases., Results: A total of 87 cases with ICI-induced myocarditis were identified. The majority were melanoma (n = 39), lung cancer (n = 19), renal cell cancer (n = 10), and thymoma cancer patients (n = 4). In 38 (44%) cases, patients received high-dose steroid treatment only. A total of 49 (56%) cases were treated with immunosuppressive agents other than steroid; a total of 13 different immunosuppressive agents were used, including alemtuzumab or abatacept. The median time to onset of symptoms after initiation of ICI was 16 days (range, 1-196 days); cardiotoxic symptoms developed after 2 cycles of ICI (range, 1-13 cycles). A total of 48% of cases were fatal. In cases treated with high-dose steroids only vs. cases treated with other immunosuppressive agents, fatality was 55% and 43% respectively. In 64 out of the 87 cases, tumor control was not described. In patients treated with high-dose steroids only, two patients had stable disease as best tumor response; in patients treated with other immunosuppressive agents, one complete response, one partial response and seven stable disease were noted as best tumor response. Overall, 11 studies were at low risk of bias (12.6%), 38 at moderate risk of bias (43.7%) and 38 at high risk of bias (43.7%)., Conclusion: Immune checkpoint inhibitor induced myocarditis is a serious and often fatal adverse event. High-dose prednisolone, alemtuzumab or abatacept are all possible treatments options for ICI-induced myocarditis, whereas infliximab increases the risk of death from cardiovascular causes, and should be avoided. Further research is needed., (© 2021. The Author(s).)

Background: Statins have been shown to possess favourable effects on the cardiovascular system with stabilization of the vulnerable plaque. We sought to assess the effects of early aggressive statin treatment on plaque composition in patients with acute myocardial infarction (AMI), using serial assessment with coronary CT-angiography (CTA)., Methods: In a prospective randomized blinded endpoint trial patients with AMI were randomized to an intensive lipid lowering treatment receiving statin loading with 80 mg rosuvastatin followed by 40 mg daily or standard statin therapy according to current guidelines. Patients were assessed with CTA at baseline and after 12 months with evaluation of plaque volume and composition., Results: In total, 140 patients with AMI were randomized and plaque composition was assessed in 96 patients. In the intensive care group LDL-level was median 1.3 [0.9; 1.5] mmol/l at 12 months follow-up and 2.0 [1.7; 2.4] mmol/l in the usual care group, p < 0.001. Plaque volume increased over 12 months with 43.5 (±225.8) mm(3) in the intensive care group and 19.1 (±190.2) mm(3) in the usual care group, p = 0.57. Plaque composition changed over 12 months with an increase in total dense calcium volume by 11.1 (±39.6) mm(3), corresponding to a 23% increase, in the intensive care group and a decreased by -0.4 (±26.6) mm(3) in the usual care group, p < 0.001. Necrotic core volume increased 26.8 (±122.1) mm(3) in the intensive care group and 25.2 (±80.1) mm(3) in the usual care group, p = 0.94., Conclusions: Early aggressive lipid lowering therapy significantly increases dense calcium volume in patients with AMI., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)