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Chronic hepatitis C virus (HCV) infection has been associated with an increased risk for cardiovascular disease (CVD). The recommended Pooled Cohort atherosclerotic cardiovascular disease (ASCVD) risk equation for estimation of 10-year CVD risk has not been validated in HCV-infected populations. We examined the performance of the ASCVD risk score in HCV-infected persons, using the national Electronically Retrieved Cohort of HCV Infected Veterans to derive a cohort of HCV-infected and uninfected subjects without baseline ASCVD, hepatitis B, or HIV infection, and with low-density lipoprotein cholesterol level

BACKGROUND: Higher body mass index (BMI) is associated with improved heart failure (HF) survival, but the role of waist circumference (WC) in HF outcomes has not been studied. METHODS AND RESULTS: A total of 344 patients with advanced systolic HF had WC and BMI measured at presentation. High WC was defined as >=88 cm in women and >=102 cm in men, and high BMI as >=25 kg/m(2). Two-year urgent heart transplant (UT)-free survival in high vs normal WC groups was 77.9% vs 64.3% (P = .025) and in high vs normal BMI was 89.8% vs 58.2% (P < .001). After multivariable adjustment, normal WC compared with high WC was associated with higher all-cause mortality (risk ratio [RR] 2.76, 95% confidence interval [CI] 1.34-5.71) and higher risk of death/UT (RR 2.14, 95% CI 1.25-3.68). The best outcomes were seen in those with both high WC and high BMI. CONCLUSIONS: High WC, an alternative anthropometric index of obesity more specific to abdominal adiposity, high BMI, and the combination of high WC/high BMI were each associated with improved outcomes in this advanced HF cohort, lending further support for an obesity paradox in HF. The role of body composition in HF survival should be a focus of future investigation. [ABSTRACT FROM AUTHOR]

In patients with diabetes mellitus (DM) in the general population, elevated glycosylated hemoglobin (HbA(1c)) increases the risk for developing heart failure (HF). However, in patients with established HF, the association of HbA(1c) level with outcomes is not well established. The aim of this study was to investigate the relation between HbA(1c) and outcomes in patients with HF with and without DM. A total of 845 patients with advanced HF followed at the Ahmanson-UCLA Cardiomyopathy Center were studied, stratified by the presence (n = 358) or absence (n = 487) of DM and by DM-specific HbA(1c) quartiles (patients with DM: Q1 ≤6.4%, Q2 6.5% to 7.2%, Q3 7.3% to 8.5%, and Q4 ≥8.6%; patients without DM: Q1 ≤5.6%, Q2 5.7% to 6.0%, Q3 6.1% to 6.5%, and Q4 ≥6.6%). The primary outcomes analyzed were death and death or urgent heart transplantation. In the cohort with DM, 2-year event-free survival was 61% and 65% in Q3 and Q4 compared to 48% and 42% in Q1 and Q2 (p = 0.005). In the cohort without DM, there was no difference in outcomes by HbA(1c) quartile. Risk-adjusted analysis in the diabetic cohort showed significantly increased hazard ratios for death or urgent heart transplantation in Q1 and Q2 compared to Q4. For every unit HbA(1c) increase, there was a 15% decreased hazard ratio of death or urgent heart transplantation and all-cause mortality (p = 0.006 and p = 0.036, respectively). In the cohort without DM, multivariate models revealed similar hazard ratios among HbA(1c) quartiles. In conclusion, in this cohort of patients with advanced HF, higher HbA(1c) levels were associated with improved outcomes in patients with DM. This relation was not observed in patients without DM. Further investigations into mechanisms underlying the relation between HbA(1c), DM, and survival in advanced HF are warranted. [ABSTRACT FROM AUTHOR]

Background: Sex and racial disparities in the presentation and management of chest pain persist, however, the impact of coronavirus disease 2019 (COVID-19) on these disparities have not been studied. We sought to determine whether the COVID-19 pandemic contributed to pre-existing sex and racial disparities in the presentation, management, and outcomes of patients presenting to the emergency department (ED) with chest pain., Methods: We conducted an observational cohort study with retrospective data collection of patients between January 1, 2016, and May 1, 2022. This was a single study conducted at a quaternary academic medical center of all patients who presented to the ED with a complaint of chest pain or chest pain equivalent symptoms. Patient were further segregated into different groups based on sex (male, female), race, ethnicity (Asian, Black, Hispanic, White, and other), and age (18 - 40, 41 - 65, > 65). We compared diagnostic evaluations, treatment decisions, and outcomes during prespecified time points before, during, and after the COVID-19 pandemic., Results: This study included 95,764 chest pain encounters. Total chest pain presentations to the ED fell about 38% during the early pandemic months. Females presented significantly less than males during initial COVID-19 (48% vs. 52%, P < 0.001) and Asian females were least likely to present. There was an increase in the total number of troponins and echocardiograms ordered during peak COVID-19 across both sexes, but females were still less likely to have these tests ordered across all timepoints. The number of coronary angiograms did not increase during peak COVID-19, and females were less likely to undergo coronary angiogram during all timepoints. Finally, females with chest pain were less likely to be diagnosed with acute myocardial infarction (AMI) during all timepoints, while in-hospital deaths were similar between males and females during all timepoints., Conclusions: During COVID-19, females, especially Asian females, were less likely to present to the ED for chest pain. Non-White patients were less likely to present to the ED compared to White patients prior to and during the pandemic. Disparities in management and outcomes of chest pain encounters remained similar to pre-COVID-19, with females receiving less cardiac workup and AMI diagnoses than males, but in-hospital mortality remaining similar between groups and timepoints., Competing Interests: None to declare., (Copyright 2024, Hu et al.)

Background Social media is an effective channel for the advancement of women physicians; however, its use by women in cardiology has not been systematically studied. Our study seeks to characterize the current Women in Cardiology Twitter network. Methods and Results Six women-specific cardiology Twitter hashtags were analyzed: #ACCWIC (American College of Cardiology Women in Cardiology), #AHAWIC (American Heart Association Women in Cardiology), #ilooklikeacardiologist, #SCAIWIN (Society for Cardiovascular Angiography and Interventions Women in Innovations), #WomeninCardiology, and #WomeninEP (Women in Electrophysiology). Twitter data from 2016 to 2019 were obtained from Symplur Signals. Quantitative and descriptive content analyses were performed. The Women in Cardiology Twitter network generated 48 236 tweets, 266 180 903 impressions, and 12 485 users. Tweets increased by 706% (from 2083 to 16 780), impressions by 207% (from 26 755 476 to 82 080 472), and users by 440% (from 796 to 4300), including a 471% user increase internationally. The network generated 6530 (13%) original tweets and 43 103 (86%) amplification tweets. Most original and amplification tweets were authored by women (81% and 62%, respectively) and women physicians (76% and 52%, respectively), with an increase in original and amplification tweets authored by academic women physicians (98% and 109%, respectively) and trainees (390% and 249%, respectively) over time. Community building, professional development, and gender advocacy were the most common tweet contents over the study period. Community building was the most common tweet category for #ACCWIC, #AHAWIC, #ilooklikeacardiologist, #SCAIWIN, and #WomeninCardiology, whereas professional development was most common for #WomeninEP. Conclusions The Women in Cardiology Twitter network has grown immensely from 2016 to 2019, with women physicians as the driving contributors. This network has become an important channel for community building, professional development, and gender advocacy discussions in an effort to advance women in cardiology.

Background To determine whether differences in body composition contribute to sex differences in cardiovascular disease (CVD) mortality, we investigated the relationship between components of body composition and CVD mortality in healthy men and women. Methods and Results Dual energy x-ray absorptiometry body composition data from the National Health and Nutrition Examination Survey 1999-2004 and CVD mortality data from the National Health and Nutrition Examination Survey 1999-2014 were evaluated in 11 463 individuals 20 years of age and older. Individuals were divided into 4 body composition groups (low muscle mass-low fat mass-the referent; low muscle-high fat; high muscle-low fat, and high muscle-high fat), and adjusted competing risks analyses were performed for CVD versus non-CVD mortality. In women, high muscle/high fat mass was associated with a significantly lower adjusted CVD mortality rate (hazard ratio [HR], 0.58; 95% CI, 0.39-0.86; P =0.01), but high muscle/low fat mass was not. In men, both high muscle-high fat (HR, 0.74; 95% CI, 0.53-1.04; P =0.08) and high muscle-low fat mass (HR, 0.40; 95% CI, 0.21-0.77; P =0.01) were associated with lower CVD. Further, in adjusted competing risks analyses stratified by sex, the CVD rate in women tends to significantly decrease as normalized total fat increase (total fat fourth quartile: HR, 0.56; 95% CI, 0.34-0.94; P <0.03), whereas this is not noted in men. Conclusions Higher muscle mass is associated with lower CVD and mortality in men and women. However, in women, high fat, regardless of muscle mass level, appears to be associated with lower CVD mortality risk. This finding highlights the importance of muscle mass in healthy men and women for CVD risk prevention, while suggesting sexual dimorphism with respect to the CVD risk associated with fat mass.

Purpose: Intensive cardiac rehabilitation (CR) was recently approved by Medicare and includes more hours and more focus on nutrition, stress management, and group support than a traditional, exercise-focused CR. The purpose of this study was to compare changes in body composition and cardiovascular (CV) risk factors after intensive versus traditional CR programs in patients with coronary artery disease (CAD)., Methods: We studied 715 patients with CAD who completed a traditional versus intensive CR program at UCLA Medical Center between 2014 and 2018. Markers of CV health, including body composition using bioelectrical impedance analysis, were assessed pre- and post-program participation., Results: In both types of CR programs, body mass index, body fat percentage, blood pressure, and cholesterol levels (total cholesterol and low-density lipoprotein cholesterol) were significantly lower post- compared with pre-program. Exercise capacity was increased in both groups. Intensive CR patients had greater reductions in body mass index, body fat percentage, visceral adipose tissue, and diastolic blood pressure. Traditional CR patients demonstrated greater increases in high-density lipoprotein cholesterol and estimated lean mass., Conclusions: In patients with CAD, both traditional and intensive CR programs led to improvements in CV risk factors, though the magnitude of the effects of the program differed between the programs. Further studies, including studies analyzing CV outcomes, are needed to help determine optimal CR program choice for CAD patients based on their risk factor and body composition profile.

Cardiovascular disease (CVD) is a major cause of morbidity among people living with HIV (PLWH). Statins can safely and effectively reduce CVD risk in PLWH, but evidence-based statin therapy is under-prescribed in PLWH. Developed using an implementation science framework, INcreasing Statin Prescribing in HIV Behavioral Economics REsearch (INSPIRE) is a stepped-wedge cluster randomized trial that addresses organization-, clinician- and patient-level barriers to statin uptake in Los Angeles community health clinics serving racially and ethnically diverse PLWH. After assessing knowledge about statins and barriers to clinician prescribing and patient uptake, we will design, implement and measure the effectiveness of (1) educational interventions targeting leadership, clinicians, and patients, followed by (2) behavioral economics-informed clinician feedback on statin uptake. In addition, we will assess implementation outcomes, including changes in clinician acceptability of statin prescribing for PLWH, clinician acceptability of the education and feedback interventions, and cost of implementation., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Ventricular arrhythmias are challenging to manage in athletes with concern for an elevated risk of sudden cardiac death (SCD) during sports competition. Monomorphic ventricular arrhythmias (MMVA), while often benign in athletes with a structurally normal heart, are also associated with a unique subset of idiopathic and malignant substrates that must be clearly defined. A comprehensive evaluation for structural and/or electrical heart disease is required in order to exclude cardiac conditions that increase risk of SCD with exercise, such as hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy. Unique issues for physicians who manage this population include navigating athletes through the decision of whether they can safely continue their chosen sport. In the absence of structural heart disease, therapies such as radiofrequency catheter ablation are very effective for certain arrhythmias and may allow for return to competitive sports participation. In this comprehensive review, we summarise the recommendations for evaluating and managing athletes with MMVA., Competing Interests: Disclosure: JB has previously received honoraria from Abbott Medical and Biosense Webster. The other authors have no conflicts of interest to declare related to the topics discussed in this manuscript.

Background: Studies have shown that higher body mass index (BMI) is associated with improved prognosis in heart failure (HF), and this is often termed the obesity paradox., Hypothesis: Analysis of body composition may reveal that muscle mass rather than adipose tissue accounts for the obesity paradox., Methods: Bioelectrical impedance analysis of body composition in 359 outpatients with HF was performed using an In Body 520 body composition scale (Biospace Inc., California). Body fat and lean mass were indexed by height (m 2 ). The cohort was stratified by median fat and lean mass indexed by height., Results: The mean age of patients studied was 56 ± 14; mean left ventricular ejection fraction was 38 ± 16%. Patients with higher indexed body fat mass had improved 5-year survival over patients with lower indexed body fat mass (90.2% vs 80.1%, P = 0.008). There was also improved survival in patients with high vs low indexed lean body mass (89.3% vs 80.9%, P = 0.036). On multivariable analysis, higher indexed body fat mass, but not lean body mass, was independently associated with improved survival (HR 0.89, per kg/m 2 increase in indexed body fat mass, P = 0.044); however, this was attenuated after adjustment for diabetes. The combination of low lean with low-fat mass was independently associated with poor prognosis., Conclusions: Our data suggest that higher fat mass-and to a lesser extent higher lean mass-is associated with improved outcomes in HF. Further investigations of specific components of body composition and outcomes in HF are warranted., (© 2018 Wiley Periodicals, Inc.)

Obesity continues to be a public health problem in the general population, and also significantly increases the risk for the development of new-onset heart failure (HF). However, in patients with already-established, chronic HF, overweight and mild to moderate obesity is associated with substantially improved survival compared to normal weight patients; this has been termed the "obesity paradox". The majority of studies measure obesity by body mass index, but studies utilizing less-frequently used measures of body fat and body composition, including waist circumference, waist-hip ratio, skinfold estimates, and bioelectrical impedance analysis also confirm the obesity paradox in HF. Other areas of investigation such as the relationship of the obesity paradox to cardiorespiratory fitness, gender, and race are also discussed. Finally, this review explores various explanations for the obesity paradox, and summarizes the current evidence for intentional weight loss treatments for HF in context., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective The contribution of hepatitis C virus (HCV) infection to the risk of heart failure in human immunodeficiency virus (HIV)-coinfected persons is unknown. The objective was to characterize cardiac function and morphology in HIV-treated coinfected persons. Methods In a cross-sectional study, HIV-infected patients virologically suppressed on antiretroviral therapy without known cardiovascular disease or diabetes mellitus underwent cardiac magnetic resonance imaging and spectroscopy for measures of cardiac function, myocardial fibrosis, and steatosis. Results The study included 18 male patients with a median age of 44 years. Of these, 10 had untreated HCV coinfection and eight had HIV monoinfection. Global systolic and diastolic function in the cohort were normal, and median myocardial fat content was 0.48% (interquartile range 0.35-1.54). Left ventricular (LV) mass index and LV mass/volume ratio were significantly greater in the HIV/HCV-coinfected group compared with the HIV-monoinfected group. In the HIV-monoinfected group, there was more myocardial fibrosis as measured by extracellular volume fraction. Conclusions There were differences between HIV/HCV-coinfected and HIV-monoinfected patients in cardiac structure and morphology. Larger studies are needed to examine whether HIV and HCV independently contribute to mechanisms of heart failure.

The relation between high levels of psychosocial stress and the development of coronary artery disease (CAD) has been increasingly recognized, especially in women. We hypothesized that simple biomarkers of stress, urinary catecholamines/cortisol levels, are associated with more coronary artery calcium (CAC), an indicator of CAD, and that this relation is stronger in women compared with men. Using data from the Multi-Ethnic Study of Atherosclerosis Stress study, we examined the relation between urinary catecholamines/cortisol and CAC. The study cohort (n = 654) was 53% women, and 56.4% of the cohort had detectable CAC. Multivariable regression analyses assessed the relation between urinary catecholamines/cortisol and CAC (odds CAC >0 through logistic and ln CAC through Tobit model). There was an association between increased cortisol and increased CAC and an inverse association between dopamine and CAC. These relations were seen in men and women, with no difference between the genders. In conclusion, higher cortisol and lower dopamine levels are independently associated with higher CAC to a similar degree in men and women. These simple urinary biomarkers contribute to our understanding of the role of stress in the pathogenesis of CAD and may be incorporated into future strategies to prevent and treat CAD., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Aims: The effect of intentional weight loss on glomerular filtration rate (GFR) in overweight and obese patients with heart failure (HF), diabetes mellitus (DM) and/or metabolic syndrome (MS) has not been studied. The purpose of the present study is to assess the short term effects of intentional weight loss on renal function in this population., Materials and Methods: Fifty nine patients were recruited to participate in a 3-month intensive behavioral weight management intervention and received one of two standard structured energy-restricted meal plans (1200 or 1500kcal/day) based on their computed calorie deficit. Weight and renal function (serum creatinine, BUN and estimated glomerular filtration rate based on two formulas - Modification in Renal Disease Study (MDRD), and modified version of Cockcroft-Gault formula reported by Salazar Corcoran for obese patients (absolute and relative formulas) - were evaluated at baseline and at 3 months., Results: Participants had eGFR in the normal range at baseline and lost an average of 7.56±14.9 pounds (p<0.0001) over 3 months; however, there was no significant reduction in serum creatinine, BUN or eGFR., Conclusion: This study provides evidence that intentional weight loss in overweight and obese patients with HF along with DM, and/or MS and normal baseline renal function does not adversely affect renal function overtime., (Copyright © 2016 Diabetes India. Published by Elsevier Ltd. All rights reserved.)

Background: Noninvasive bioelectrical impedance analysis (BIA) has shown promise in acute heart failure (HF) management. To our knowledge, its use in predicting outcomes in outpatients with chronic HF patients has not been well described., Methods and Results: BIA assessment of edema index was performed in 359 outpatients with HF using the InBody 520 scale. Edema index was calculated by dividing extracellular by total body water. Patients were stratified into those with low (≤0.39) and high (>0.39) edema indices. The outcome of interest was death, urgent transplant, or ventricular assist device over 2-year follow up. Patients with a high edema index were older, had higher B-type natriuretic peptide values and New York Heart Association Class. Patients with a high edema index had poorer outcomes (unadjusted hazard ratio 1.90, 95% confidence intervals 1.05-3.56). However, in multivariate analyses, a high edema index was not an independent predictor of outcomes (adjusted hazard ratio 1.21, 95% confidence interval 0.51-2.90)., Conclusions: A high edema index using a bioimpedance scale in a HF clinic correlated with patient outcomes in unadjusted analyses, but was not a predictor of outcomes once other measures of HF severity are accounted for. As a noninvasive measure of volume status, use of BIA in a HF clinic may be beneficial in determining patient prognosis and treatment when other outcome predictors are not immediately available.

Aims: This study was conducted to examine the relationship between adiposity and functional status (i.e. peak oxygen consumption [VO 2 max]), and left ventricular (LV) structural characteristics (i.e., LV ejection fraction [LVEF], LV end diastolic dimension [LVEDD], LV posterior wall thickness [LVPWT]) in heart failure (HF) patients with diabetes mellitus (DM), and/or metabolic syndrome (MS). We hypothesize that excess weight and body fat are significantly related to cardiac functional status., Methods and Results: Ninety four patients' clinical characteristics were analyzed at baseline to examine the relationships of interest. Results show that weight was correlated with fat and lean mass and LVEF (all p's < 0.050). Novel findings from our data showed that weight, fat mass, and percent fat were inversely related to VO 2 max; weight, fat mass and lean mass were positively related with LVPWT. In a multivariate analysis, body mass index and fat mass accounted for 28.8% of the variance in VO 2 max, showing significantly higher predictive value than other covariates (P = 0.002)., Conclusions: Our findings show a possible relationship between body fat on functional status in this patient cohort and challenges existing research that supports that higher weight and increased fat are good in the setting of chronic HF (i.e. obesity paradox). Strategies to optimize weight and reduce adiposity warrants further investigation in this subgroup of patients., Competing Interests: Conflict of Interest: None declared

We evaluated the relation between components of body composition and mortality in patients with cardiovascular disease (CVD). Dual x-ray absorptiometry body composition data from the National Health and Nutrition Examination Survey 1999 to 2004 was linked to total and CVD mortality data 1999 to 2006 in 6,451 patients with CVD. Kaplan-Meier survival analysis for the end points of total and CVD mortality was plotted by quartiles of muscle mass, fat mass, and categories of body mass index (BMI). Subjects were stratified into 4 groups (low muscle/low fat mass, low muscle/high fat mass, high muscle/low fat mass, and high muscle/high fat mass). Adjusted Cox proportional hazards regression determined hazard ratios for total and CVD mortality. Rates of cardiovascular/total mortality were lower in higher quartiles of muscle mass, fat mass, and higher categories of BMI (p <0.001). The high muscle/low fat mass group had a lower risk of CVD and total mortality (risk-adjusted hazard ratios of 0.32, 95% confidence interval 0.14 to 0.73 and 0.38, 95% confidence interval 0.22 to 0.68, for CVD and total mortality, respectively). Thus, increasing fat mass, muscle mass, and BMI were all correlated with improved survival. The specific subgroup of high muscle and low fat mass had the lowest mortality risk compared with other body composition subtypes. This suggests the importance of body composition assessment in the prediction of cardiovascular and total mortality in patients with CVD., (Published by Elsevier Inc.)

Importance: Neighborhood environments may influence the risk for developing type 2 diabetes mellitus (T2DM), but, to our knowledge, no longitudinal study has evaluated specific neighborhood exposures., Objective: To determine whether long-term exposures to neighborhood physical and social environments, including the availability of healthy food and physical activity resources and levels of social cohesion and safety, are associated with incident T2DM during a 10-year period., Design, Setting, and Participants: We used data from the Multi-Ethnic Study of Atherosclerosis, a population-based cohort study of adults aged 45 to 84 years at baseline (July 17, 2000, through August 29, 2002). A total of 5124 participants free of T2DM at baseline underwent 5 clinical follow-up examinations from July 17, 2000, through February 4, 2012. Time-varying measurements of neighborhood healthy food and physical activity resources and social environments were linked to individual participant addresses. Neighborhood environments were measured using geographic information system (GIS)- and survey-based methods and combined into a summary score. We estimated hazard ratios (HRs) of incident T2DM associated with cumulative exposure to neighborhood resources using Cox proportional hazards regression models adjusted for age, sex, income, educational level, race/ethnicity, alcohol use, and cigarette smoking. Data were analyzed from December 15, 2013, through September 22, 2014., Main Outcomes and Measures: Incident T2DM defined as a fasting glucose level of at least 126 mg/dL or use of insulin or oral antihyperglycemics., Results: During a median follow-up of 8.9 years (37,394 person-years), 616 of 5124 participants (12.0%) developed T2DM (crude incidence rate, 16.47 [95% CI, 15.22-17.83] per 1000 person-years). In adjusted models, a lower risk for developing T2DM was associated with greater cumulative exposure to indicators of neighborhood healthy food (12%; HR per interquartile range [IQR] increase in summary score, 0.88 [95% CI, 0.79-0.98]) and physical activity resources (21%; HR per IQR increase in summary score, 0.79 [95% CI, 0.71-0.88]), with associations driven primarily by the survey exposure measures. Neighborhood social environment was not associated with incident T2DM (HR per IQR increase in summary score, 0.96 [95% CI, 0.88-1.07])., Conclusions and Relevance: Long-term exposure to residential environments with greater resources to support physical activity and, to a lesser extent, healthy diets was associated with a lower incidence of T2DM, although results varied by measurement method. Modifying neighborhood environments may represent a complementary, population-based approach to prevention of T2DM, although further intervention studies are needed.

We compared the Framingham risk score (FRS) for 10-year coronary heart disease (CHD) risk in age- and race-matched hepatitis C virus (HCV)-infected and HCV-uninfected persons: 114,073 HCV-infected (111,436 HCV-monoinfected and 2,637 HIV/HCV-coinfected) and 122,996 HCV-uninfected (121,380 HIV and HCV-uninfected and 1,616 HIV-monoinfected) males without cardiovascular disease, diabetes, or hepatitis B. In unadjusted analyses, FRS was similar between the HCV-infected and HCV-uninfected groups [median (interquartile range, IQR) risk points 13 (10-14) vs. 13 (10-14), p=0.192]. Cholesterol levels were lower and current smoking more prevalent in the HCV groups (both HCV and HIV/HCV) compared with the uninfected groups (p<0.001 for both). Prevalence of non-FRS CHD risk factors, such as substance abuse and chronic kidney disease, in the cohort was high, and differed by HCV and HIV status. Adjusting for age, race/ethnicity, body mass index, chronic kidney disease, drug and alcohol use, and HIV status, HCV infection was associated with minimally lower FRS (β=-0.095 risk points, p<0.001), suggesting a small but significant difference in 10-year CHD risk estimation in HCV-infected as compared to HCV-uninfected persons when measuring risk by FRS. Given the complex relationship between HCV, HIV, and CHD risk factors, some of which are not captured by the FRS, the FRS may underestimate CHD risk in HCV-monoinfected and HIV/HCV-coinfected persons. HCV- and HIV/HCV-specific risk scores may be needed to optimize CHD risk stratification.

Obesity has reached epidemic proportions in the general population and is associated with an increased risk for the development of new-onset heart failure (HF). However, in acute and chronic HF, overweight and mild to moderate obesity is associated with substantially improved survival compared with normal weight. This phenomenon has been termed the "obesity paradox" in HF. The majority of data pertaining to the obesity paradox identifies obesity with body mass index; however, the reliability of this method has been questioned. Newer studies have explored the use of other measures of body fat and body composition, including waist circumference, waist-to-hip ratio, skinfold thickness, and bioelectrical impedance analysis of body composition. The relationship between the obesity paradox and cardiorespiratory fitness in HF is also discussed in this review, and we explore the various potential explanations for the obesity paradox and summarize the current evidence and guidelines for intentional weight loss treatments for HF in the obese population., (Copyright © 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Although high body mass index (BMI) is associated with improved outcomes in established heart failure (HF), the impact of cardiorespiratory fitness on this obesity paradox is less clear. We studied 1,675 patients with systolic HF who underwent cardiopulmonary exercise testing at a single university center (77.4% men, mean age 52.2 ± 11.6 years, mean left ventricular ejection fraction 23.2 ± 7.1% and New York Heart Association class III or IV in 79.1%). We evaluated 2-year survival in patients stratified by both BMI (normal 18.5 to 24.9 kg/m(2)[reference], overweight 25 to 29.9 kg/m(2), obese ≥30.0 kg/m(2)) and by peak oxygen uptake (PKVO2; high >14 ml/kg/minute, low ≤14 ml/kg/minute). At 2 years, BMI category was significantly associated with outcomes for the low PKVO2 group (p <0.001) but not the high PKVO2 group (p = 0.1). In the low PKVO2 group, obese patients had decreased risk of death free from urgent status 1A heart transplant or ventricular assist device placement after multivariate adjustment compared with normal BMI (hazard ratio [HR] 0.64, 95% confidence interval [CI] 0.44 to 0.91, p = 0.01); no significant difference was observed for overweight patients (HR 0.91, 95% CI 0.66 to 1.25, p = 0.5). In the high PKVO2 group, no relation was seen (overweight BMI HR 0.75, 95% CI 0.43 to 1.32, p = 0.3; obese HR 0.87, 95% CI 0.43 to 1.75, p = 0.7). In conclusion, the obesity paradox was only observed in patients with lower cardiorespiratory fitness in this advanced systolic HF cohort, indicating that improved functional capacity may attenuate the obesity paradox., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Obesity is a growing public health problem in the general population, and significantly increases the risk for the development of new-onset heart failure (HF). However, in the setting of chronic HF, overweight and mild to moderate obesity is associated with substantially improved survival compared to normal-weight patients. Evidence exists for an "obesity paradox" in HF, with the majority of data measuring obesity by body mass index, but also across various less-frequently used measures of body fat (BF) and body composition including waist circumference, waist-hip ratio, skinfold estimates of percent BF, and bioelectrical impedance analysis of body composition. Other emerging areas of investigation such as the relationship of the obesity paradox to cardiorespiratory fitness are also discussed. Finally, this review explores various explanations for the obesity paradox, and summarizes the current evidence for intentional weight loss treatments for HF in context., (© 2014.)

Background: Risk stratification is an integral component of clinical decision making in heart failure (HF). Women with HF have unique characteristics compared with men, and it is unknown whether common prognostic factors are equally useful in both populations. We aimed to investigate whether sex-specific risk models are more accurate for risk prediction in patients with advanced HF., Methods and Results: Patients with advanced HF referred to University of California, Los Angeles (UCLA; n=2255), were stratified by sex into derivation (referred in 2000-2007) and validation (referred in 2008-2011) cohorts. Cox regression analysis was used to ascertain key variables predictive of the primary end point of death/urgent transplantation/ventricular assist device in the derivation cohorts and confirmed in the validation cohorts in men, women, and the total population. Women were younger, with higher ejection fraction and better event-free survival. Despite differences in baseline characteristics, the 4 strongest predictors of outcome in both women and men, as well as in the total cohort, were B-type natriuretic peptide, peak oxygen consumption by cardiopulmonary exercise testing (pkVO2), New York Heart Association (NYHA) classification, and use of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. In addition, the UCLA model performed better than the Seattle Heart Failure Model (SHFM) and the Heart Failure Survival Score (HFSS) in our cohort (c-indices of 0.791[UCLA] versus 0.758 [SHFM], 0.607 [noninvasive HFSS], and 0.625 [invasive HFSS])., Conclusions: A simple risk model assessing 4 clinical variables-B-type natriuretic peptide, pkVO2, NYHA, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use-is well suited to provide prognostic information in both men and women with advanced HF.

Oxidative stress and inflammation are hallmarks of the heart failure (HF) disease state. In the present study, we investigated the inflammatory/anti-inflammatory characteristics of high-density lipoproteins (HDL) in patients with HF. Ninety-six consecutive patients with systolic HF were followed in an advanced HF center, and 21 healthy subjects were recruited. Plasma was tested for HDL inflammatory index (HII) using a monocyte chemotactic activity assay, with HII >1.0 indicating proinflammatory HDL. We found significantly increased inflammatory properties of HDL in patients with HF (median HII 1.56 vs 0.59 in controls; p <0.0001). Serum amyloid A level was markedly elevated and the activity of paraoxonase-1, an HDL antioxidant enzyme, was significantly reduced in patients versus controls. HDL and albumin from patients with HF contained markedly elevated levels of oxidized products of arachidonic and linoleic acids. HDL function improved when plasma was treated in vitro with 4F, an apolipoprotein A-I mimetic peptide (40% reduction in HII, p <0.0001). There was no correlation found between HII level and ejection fraction or New York Heart Association functional class. In conclusion, HDL function is significantly impaired and oxidation products of arachidonic and linoleic acids are markedly elevated in patients with HF compared with non-HF controls., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Heart failure (HF) and obesity are commonly seen in the USA. Although obesity is associated with traditional cardiovascular disease, its relationship with HF is complex. Obesity is an accepted risk factor for incident HF. However, in patients with established HF, there exists a paradoxical correlation, with escalating BMI incrementally protective against adverse outcomes. Despite this relationship, patients with HF may desire to lose weight to reduce comorbidities or to improve quality of life. Thus far, studies have shown that intentional weight loss in obese patients with HF does not increase risk, with strategies including dietary modification, physical activity, pharmacotherapy, and/or surgical intervention.

Background: A skeletal myopathy, perhaps attributable to neuro-endocrine excitation or disuse, has been described in heart failure (HF) patients, and is thought to contribute to their exercise limitation. Our purpose was to assess biochemical and morphometric characteristics of skeletal muscles of HF patients on optimal HF therapy. A secondary purpose was to explore the effects of clonidine, which interrupts the neuro-endocrine excitation, on these same muscle characteristics., Methods and Results: Eleven HF patients (50.8 ± 3.4 years, peak VO2 11.6 ± 2.5 ml/kg/min) underwent two vastus lateralis biopsies (pre/post clonidine). Baseline values were compared to biopsies in 11 age-matched, healthy controls. Scatter plots of individual values for each mitochondrial enzyme revealed almost complete overlap between HF and control groups; mean values, although tending to be greater in controls versus HF patients, were not significantly different. The proportion of type 1 fibers was diminished in 10 of 11 patients. There was no difference in any of the variables after 3 months clonidine versus placebo., Conclusion: In HF patients treated with optimal medical and device therapy, characteristic abnormalities of mitochondrial enzyme activity are not found, but muscle fiber type shifts are present. The remaining severe impairment in exercise capacity cannot be attributed to mitochondrial abnormalities.

Background: Randomized trials have demonstrated the efficacy of several new therapies for heart failure (HF) with reduced ejection fraction over the preceding 2 decades. This study investigates whether these therapeutic advances have translated into improvement in outcomes for patients with advanced HF referred to a heart transplant center., Methods and Results: Patients with HF (n=2507) referred to a single university center were analyzed in three 6-year eras during which medical and device therapies were evolving: 1993 to 1998 (era 1), 1999 to 2004 (era 2), and 2005 to 2010 (era 3). Impaired hemodynamics and comorbidities were more frequent at time of referral in later eras, whereas other HF severity parameters where similar or improved. Successive eras had greater usage of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, aldosterone antagonists, implantable cardioverter defibrillators, and cardiac resynchronization therapy, consistent with evolving evidence and guideline recommendations over the study period. All-cause mortality and sudden death were significantly lower in era 2 and 3 compared with era 1. After multivariable risk adjustment, era 3 had significantly decreased 2- and 3-year all-cause mortality risk and significantly decreased 1- and 3-year sudden death risk compared with era 1. However, progressive HF death and the combined outcome of mortality/urgent transplant/ventricular assist device were modestly increased in the latter eras., Conclusions: Over the past 2 decades, patients with advanced HF referred to and managed at a tertiary university referral center have benefited from advances in HF medications and devices, as evidenced by improvements in overall survival and sudden death risk.

Background: In the failing human heart, abnormalities of Ca(2+) cycling have been described, but there is scant knowledge about Ca(2+) handling in the skeletal muscle of humans with heart failure (HF). We tested the hypothesis that in humans with HF, Ca(2+) cycling proteins in skeletal muscle are abnormal., Methods and Results: Ten advanced HF patients (50.4 ± 3.7 years), and 9 age-matched controls underwent vastus lateralis biopsy. Western blot analysis showed that sarco(endo)plasmic reticulum Ca(2+)-ATPase (SERCA)2a, which is responsible for Ca(2+) sequestration into the sarcoplasmic reticulum(SR), was lower in HF versus controls (4.8 ± 0.5 vs 7.5 ± 0.8 AU, P = .01). Although phospholamban (PLN), which inhibits SERCA2a, was not different in HF versus controls, phosphorylation (SER16 site) of PLN, which relieves this inhibition, was reduced (0.8 ± 0.1 vs 3.9 ± 0.9 AU, P = .004). Dihydropyridine receptors were reduced in HF, (2.1 ± 0.4 vs 3.6 ± 0.5 AU, P = .04). We tested the hypothesis that these abnormalities of Ca(2+) handling protein content and regulation were due to increased oxidative stress, but oxygen radical scavenger proteins were not elevated in the skeletal muscle of HF patients., Conclusion: In chronic HF, marked abnormalities of Ca(2+) handling proteins are present in skeletal muscle, which mirror those in failing heart tissue. This suggests a common mechanism, such as chronic augmentation of sympathetic activity and autophosphorylation of Ca(2+)-calmodulin-dependent-protein kinase II., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Obesity is common in heart failure (HF) and is associated with improved outcomes, a finding often termed the "obesity paradox." Although fat distribution varies by gender, the role of obesity in the outcomes of women compared to men with HF has not been well studied. In a cohort of patients with advanced systolic HF followed at a single university center, 2,718 patients had body mass indexes (BMIs) measured at baseline, and 469 patients with HF had waist circumferences (WCs) measured at baseline. Elevated BMI was defined as ≥25 kg/m(2). High WC was defined as ≥88 cm in women and ≥102 cm in men. The primary outcome was death, urgent heart transplantation, or ventricular assist device placement. The mean age was 53.0 ± 12.4 years, 25% of subjects were women, and the mean left ventricular ejection fraction was 22.9 ± 7.19%. In men, 2-year event-free survival was better for high versus normal BMI (63.2% vs 53.5%, p <0.001) and for high versus normal WC (78.8% vs 63.1%, p = 0.01). In women, 2-year event-free survival was better for elevated versus normal BMI (67.1% vs 56.6%, p = 0.01) but similar in the 2 WC groups. In multivariate analyses, normal BMI and normal WC were associated with higher relative risk for the primary outcome in men (BMI 1.34, WC 2.02) and women (BMI 1.38, WC 2.99). In conclusion, in patients with advanced HF, high BMI and WC were associated with improved outcomes in both genders. Further investigation of the interaction between body composition and gender in HF outcomes is warranted., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Exercise training (ET) in patients with heart failure (HF), as demonstrated in the Heart Failure: A Controlled Trial Investigating Outcomes of Exercise TraiNing (HF-ACTION), was associated with improved exercise tolerance and health status and a trend toward reduced mortality or hospitalization. The present analysis of the HF-ACTION cohort examined the effect of ET in overweight and obese subjects compared to normal weight subjects with HF. Of 2,331 subjects with systolic HF randomized to aerobic ET versus usual care in the HF-ACTION, 2,314 were analyzed to determine the effect of ET on all-cause mortality, hospitalizations, exercise parameters, quality of life, and body weight changes by subgroups of body mass index (BMI). The strata included normal weight (BMI 18.5 to 24.9 kg/m(2)), overweight (BMI 25.0 to 29.9 kg/m(2)), obese I (BMI 30 to 34.9 kg/m(2)), obese II (BMI 35 to 39.9 kg/m(2)), and obese III (BMI ≥40 kg/m(2)). At enrollment, 19.4% of subjects were normal weight, 31.3% were overweight, and 49.4% were obese. A greater BMI was associated with a nonsignificant increase in all-cause mortality or hospitalization. ET was associated with nonsignificant reductions in all-cause mortality and hospitalization in each weight category (hazard ratio 0.98, 0.95, 0.92, 0.89, and 0.86 in the normal weight, overweight, obese I, obese II, and obese III categories, respectively; all p >0.05). Modeled improvement in exercise capacity (peak oxygen consumption) and quality of life in the ET group was seen in all BMI categories. In conclusion, aerobic ET in subjects with HF was associated with a nonsignificant trend toward decreased mortality and hospitalization and a significant improvement in quality of life across the range of BMI categories., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Hydroxymethylglutaryl-coenzyme A reductase inhibitors (statins) have been shown to reduce sympathetic nervous system (SNS) activation in experimental heart failure (HF). However, this potential mechanism of action of statins in HF has not been well studied in humans., Methods and Results: Twenty-six patients with nonischemic systolic HF (left ventricular ejection fraction [LVEF] ≤35%) were randomized to atorvastatin (10 mg) or placebo for 3 months. Pre- and posttreatment testing included echocardiography, laboratory assays, quality of life (QOL) questionnaires, and peroneal nerve muscle sympathetic nerve activity (MSNA) via microneurography. Eighteen subjects had technically adequate MSNA tracings before and after treatment. The cohort was 65% male, 81% New York Heart Association functional class II, LVEF 26 ± 6%, and low-density lipoprotein cholesterol (LDL-C) 108 ± 26 mg/dL. Baseline MSNA was 41 ± 2 bursts/min. LDL-C significantly decreased in the atorvastatin (-36.8%) versus the placebo (-0.1%) group (P < .0001). However, there was no significant change in MSNA (-16.2% vs -2.5%), LVEF, B-type natriuretic peptide, or QOL score in the atorvastatin compared with the placebo group., Conclusions: Short-term statin therapy in patients with nonischemic HF does not result in a significant decrease in SNS activation as measured by MSNA. These findings are consistent with the neutral outcomes of large clinical trials of statins in HF., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Heart failure (HF) is a major public health issue, with a prevalence of over 5.8 million in the USA, and over 23 million worldwide, and rising. The lifetime risk of developing HF is one in five. Although promising evidence shows that the age-adjusted incidence of HF may have plateaued, HF still carries substantial morbidity and mortality, with 5-year mortality that rival those of many cancers. HF represents a considerable burden to the health-care system, responsible for costs of more than $39 billion annually in the USA alone, and high rates of hospitalizations, readmissions, and outpatient visits. HF is not a single entity, but a clinical syndrome that may have different characteristics depending on age, sex, race or ethnicity, left ventricular ejection fraction (LVEF) status, and HF etiology. Furthermore, pathophysiological differences are observed among patients diagnosed with HF and reduced LVEF compared with HF and preserved LVEF, which are beginning to be better appreciated in epidemiological studies. A number of risk factors, such as ischemic heart disease, hypertension, smoking, obesity, and diabetes, among others, have been identified that both predict the incidence of HF as well as its severity. In this Review, we discuss key features of the epidemiology and risk profile of HF.

B-type natriuretic peptide (BNP), peak oxygen consumption (VO(2)), blood urea nitrogen (BUN), systolic blood pressure (SBP), and pulmonary capillary wedge pressure are all established predictors of mortality or urgent transplantation in patients with advanced heart failure (HF). However, their comparative predictive ability in estimating prognosis has not been well studied. We analyzed 1,215 patients with advanced systolic HF referred to a university center from 1999 to 2009. BUN, BNP, VO(2), SBP, and pulmonary capillary wedge pressure were measured as a part of the initial evaluation. The patients were divided into groups according to the best cutoffs for predicting both 1- and 2-year mortality from the analysis of the receiver operating characteristic curves (BNP > or =579 pg/ml, peak VO(2) <14 ml/kg/min, BUN > or =53 mg/dl, SBP <118 mm Hg, and pulmonary capillary wedge pressure > or =21 mm Hg). During a 2-year follow-up, 234 patients (19%) died, and 208 (17%) required urgent transplantation. BNP (odds ratio 4.3, 95% confidence interval 3.3 to 5.5) and peak VO(2) (odds ratio 4.5, 95% confidence interval 2.6 to 7.8) were the strongest predictors for death or urgent transplantation. On multivariate analyses, BNP and peak VO(2) were the strongest predictors for both death or urgent transplantation and all-cause mortality. The c-statistic was 0.756 for BNP, 0.701 for VO(2), 0.659 for BUN, 0.638 for SBP, and 0.650 for pulmonary capillary wedge pressure. In conclusion, of the 5 established predictors of outcomes in advanced HF, BNP was the most robust discriminator of risk and thus could be useful, along with other more traditional prognostic variables, in patient counseling regarding prognosis and determining the timing for heart transplantation., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Although 25% to 44% of patients with heart failure (HF) have diabetes mellitus (DM), the optimal treatment regimen for HF patients with DM is uncertain. We investigated the association between metformin therapy and outcomes in a cohort of advanced, systolic HF patients with DM., Methods and Results: Patients with DM and advanced, systolic HF (n = 401) were followed at a single university HF center between 1994 and 2008. The cohort was divided into 2 groups based on the presence or absence of metformin therapy. The cohort had a mean age of 56 +/- 11 years, left ventricular ejection fraction (LVEF) of 24 +/- 7%, with 42% being New York Heart Association (NYHA) III and 45% NYHA IV. Twenty-five percent (n = 99) were treated with metformin therapy. The groups treated and not treated with metformin were similar in terms of age, sex, baseline LVEF, medical history, and baseline glycosylated hemoglobin. Metformin-treated patients had a higher body mass index, lower creatinine, and were less often on insulin. One-year survival in metformin-treated and non-metformin-treated patients was 91% and 76%, respectively (RR = 0.37, CI 0.18-0.76, P = .007). After multivariate adjustment for demographics, cardiac function, renal function, and HF medications, metformin therapy was associated with a nonsignificant trend for improved survival., Conclusion: In patients with DM and advanced, systolic HF who are closely monitored, metformin therapy appears to be safe. Prospective studies are needed to determine whether metformin can improve HF outcome., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Heart failure (HF) is common, results in poor clinical outcomes, and is associated with large health care costs. The incidence of HF continues to rise, with approximately 670,000 new cases per year and a 20% lifetime risk of HF for persons 40 years and older in the U.S. Risk factors for HF have been identified, and thus preventative strategies should have a positive effect on disease burden, morbidity, and mortality. Although coronary artery disease and hypertension have traditionally been considered among the most important modifiable risk factors for the development of HF, recent studies have highlighted the importance of increasingly prevalent metabolic risk factors: glucose, diabetes, obesity, and the metabolic syndrome. This report will present evidence for the link between glucose, diabetes, obesity, metabolic syndrome, and incident HF. Furthermore, we will discuss how risk factor modification and other preventive therapies may help curb the rising incidence of HF., (Copyright (c) 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Cardiopulmonary exercise testing (CPX) in patients with systolic heart failure (HF) is important for determining HF prognosis and helping guide timing of heart transplantation. Although approximately 20% to 30% of patients with HF are obese (body mass index [BMI] >30 kg/m(2)), the impact of BMI on CPX results is not well established. The objective of this study was to assess the relationship between BMI and CPX variables, including peak oxygen uptake (VO(2)) at ventilatory threshold, oxygen pulse, and ventilation-carbon dioxide production ratio., Methods: Consecutive patients with systolic HF (n = 2,324) enrolled in the Heart Failure and A Controlled Trial Investigating Outcomes of Exercise Training trial who had baseline BMI recorded were included in this study. Subjects were divided into strata based on BMI: underweight (BMI <18.5 kg/m(2)), normal weight (BMI 18.5-24.9 kg/m(2)), overweight (BMI 25.0-29.9 kg/m(2)), obese I (BMI 30-34.9 kg/m(2)), obese II (BMI 35-39.9 kg/m(2)), and obese III (BMI > or = 40 kg/m(2))., Results: Obese III, but not overweight; obese I; or obese II was associated with decreased peak VO(2) (mL kg(-1) min(-1)) compared to normal weight status. Increasing BMI category was inversely related to ventilation/carbon dioxide production (V(E)/V(CO2)) ratio (P < .0001). On multivariable analysis, BMI was a significant independent predictor of peak VO(2) (partial R(2) = 0.07, P < .0001) and V(E)/V(CO2) slope (partial R(2) = 0.03, P < .0001) in patients with chronic systolic HF., Conclusions: Body mass index is significantly associated with key CPX fitness variables in patients with HF. The influence of BMI on the prognostic value of CPX in HF requires further evaluation in longitudinal studies.

Background: Although hospital admissions during weekends have been associated with worse quality of care and worse outcomes in some but not all medical conditions, the impact of weekend versus weekday admission and discharge for heart failure (HF) has not been well studied. This study investigates the association of (1) weekend compared to weekday HF admissions and discharges with quality of care and (2) weekend versus weekday HF admissions with length of stay (LOS) and mortality in the hospital., Methods: Data were analyzed for 81,810 HF admissions at 241 sites participating in Get With the Guidelines (GWTG)-HF from January 2005 to September 2008. The cohort was stratified by weekend versus weekday admission and discharge. Generalized estimating equations adjusted for patient and hospital characteristics and clustering., Results: Mean age was 72 +/- 14 years; left ventricular ejection fraction (LVEF) was 39+/-17%. Inhospital mortality was 3.0% and median LOS 4 days. Weekend admission was associated with decreased odds of LVEF documentation. Weekend discharge was associated with decreased odds of LVEF documentation and completed discharge instructions. Weekend HF admission compared to weekday admission was associated with slightly higher risk-adjusted odds of longer inhospital LOS (1.03 [1.01-1.05] and increased inhospital mortality (1.13 [1.02-1.27])., Conclusions: Among GWTG-HF hospitals, weekend admission and discharge for HF were associated with similar quality of care in many but not all measures. Risk-adjusted LOS was slightly longer and mortality moderately higher for weekend HF admissions.

High systolic blood pressure (SBP) is a predictor of survival for patients with heart failure (HF). Whether SBP predicts survival in both ischemic and nonischemic HF has not been well examined. We analyzed 2,178 patients with advanced HF (47.3% ischemic etiology, 75.5% men, 93.5% New York Heart Association class III or IV, age 52 +/- 13, left ventricular ejection fraction 24 +/- 9%) referred to a university center between 1983 and 2006. SBP and invasive hemodynamic variables were recorded after optimization of medical therapy. Patients were divided into SBP quartiles (or=113 mm Hg) based on SBP frequency. Survival free from death or urgent transplant in ischemic versus nonischemic HF was 53.2% versus 61.1% at 2 years. Higher SBP quartile was associated with increased survival in the total cohort and in subgroups of both nonischemic and ischemic HF. On multivariate analysis adjusting for age, left ventricular ejection fraction, cholesterol, gender, diabetes mellitus, pulmonary capillary wedge pressure, cardiac index, New York Heart Association class, beta-blocker use, angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker use, statin use, and smoking history, relative risk (95% confidence interval) of death or urgent transplant at 2 years for quartile 1 compared with quartile 4 was 1.9 (1.4 to 2.6) in the total cohort, 1.6 (1.1 to 2.5) in nonischemic HF, and 2.4 (1.5 to 3.7) in ischemic HF. In conclusion, SBP predicts HF survival in both ischemic and nonischemic HF independent of other risk factors and invasive hemodynamic variables.

Adherence to treatment guidelines during hospital admissions for heart failure impacts readmissions and mortality. However, the relation between guideline adherence and heart failure hospital length of stay (LOS) has not been well studied. Whether quality of care delivered to patients with heart failure is impacted on by hospital LOS was assessed. Data were analyzed from 209 hospitals participating in the Get With the Guidelines heart failure program. From January 2005 to September 2006, a total of 36,078 admissions were recorded and stratified by a median heart failure hospitalization LOS of <5 or >or=5 days. Comparisons of baseline patient characteristics and quality measures were analyzed using generalized estimating equations. Patients with LOS >or=5 days were slightly older, more likely to be seen at a larger hospital, and had higher ejection fractions and increased rates of such co-morbidities as diabetes, anemia, renal insufficiency, and pulmonary disease. After adjustment, longer LOS was associated with an increased odds ratio (OR) per each additional day for providing discharge instructions (OR 1.027, 95% confidence interval [CI] 1.017 to 1.038) and left ventricular ejection fraction documentation (OR 1.049, 95% CI 1.031 to 1.067). However, LOS >or=5 days was independently associated with modestly decreased use of life-prolonging medications at hospital discharge for patients with left ventricular systolic dysfunction: angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (OR 0.977, 95% CI 0.967 to 0.987) and beta blockers (OR 0.990, 95% CI 0.982 to 0.997). In conclusion, in Get With the Guidelines participating institutions, hospital LOS had only a modest influence on quality-of-care measures. Overall, excellent adherence to guideline-based medical therapy was observed, even in patients with a shorter hospital LOS.