BACKGROUND:Ultrasound-guided puncture of the common femoral artery (CFA) is assumed to be more precise than conventional techniques without ultrasound. However, previous comparative studies have shown partly contradictory results with regard to success of ultrasound-guided puncture so that this method is not yet standard in transfemoral cardiac catheterization. AIMS:The PARFEM trial was performed to investigate whether an ultrasound-assisted in-plane technique using a needle guide could improve the precision of CFA puncture. METHODS:The study was conducted in 286 patients undergoing transfemoral cardiac catheterization. Patients were randomized 1:1, and femoral artery puncture was performed either using an ultrasound-guided in-plane technique with fluoroscopic marking of the center of the femoral head or a conventional approach. The primary endpoint was successful puncture of the CFA with the first attempt. In addition, the influence of the examiners' level of experience on puncture results was investigated. RESULTS:Primary successful puncture of the CFA was achieved more frequently in the ultrasound group than in the control group: 79.6% versus 55.6%, odds ratio 3.25 [95% CI: 1.92-5.23], p < 0.001. This favorable effect of ultrasound guidance was independent of the examiners' level of experience. The success rate of ultrasound-guided sheath placement within the CFA was 97.2%, compared to 77.8% in the control group (p < 0.01). CONCLUSIONS:The PARFEM trial demonstrated that in-plane ultrasound guidance can improve the precision of femoral puncture and reduce the occurrence of inadequate sheath placements. The results support the incorporation of this technique into standard practice for guiding transfemoral puncture. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT06065943.

Background: The pulmonary artery wedge pressure (PAWP) is regarded as a reliable indicator of left ventricular end-diastolic pressure (LVEDP), but this association is weaker in patients with left-sided heart disease (LHD). We compared morphological differences in cardiac magnetic resonance imaging (CMR) in patients with heart failure (HF) and a reduced left ventricular ejection fraction (LVEF), with or without elevation of PAWP or LVEDP. Methods: We retrospectively identified 121 patients with LVEF < 50% who had undergone right heart catheterization (RHC) and CMR. LVEDP data were available for 75 patients. Results: The mean age of the study sample was 63 ± 14 years, the mean LVEF was 32 ± 10%, and 72% were men. About 53% of the patients had an elevated PAWP (>15 mmHg). In multivariable logistic regression analysis, NT-proBNP, left atrial ejection fraction (LAEF), and LV end-systolic volume index independently predicted an elevated PAWP. Of the 75 patients with available LVEDP data, 79% had an elevated LVEDP, and 70% had concomitant PAWP elevation. By contrast, all but one patient with elevated PAWP and half of the patients with normal PAWP had concomitant LVEDP elevation. The Bland–Altman plot revealed a systematic bias of +5.0 mmHg between LVEDP and PAWP. Notably, LAEF was the only CMR variable that differed significantly between patients with elevated LVEDP and a PAWP ≤ or >15 mmHg. Conclusions: In patients with LVEF < 50%, a normal PAWP did not reliably exclude LHD, and an elevated LVEDP was more frequent than an elevated PAWP. LAEF was the most relevant determinant of an increased PAWP, suggesting that a preserved LAEF in LHD may protect against backward failure into the lungs and the subsequent increase in pulmonary pressure.

Background: Monitoring the vital signs of delirious patients in an intensive care unit (ICU) is challenging, as they might (un-)intentionally remove devices attached to their bodies. In mock-up scenarios, we systematically assessed whether a motion detector (MD) attached to the bed may help in identifying emergencies. Methods: We recruited 15 employees of the ICU and equipped an ICU bed with an MD (IRON Software GmbH, Grünwald, Germany). Participants were asked to replay 22 mock-up scenes of one-minute duration each: 12 scenes with movements and 10 without movements, of which 5 were emergency scenes (“lying dead-still, with no or very shallow breathing”). Blinded recordings were presented to an evaluation panel consisting of an experienced ICU nurse and a physician, who was asked to assess and rate the presence of motions. Results: Fifteen participants (nine women; 173 ± 7.0 cm; 78 ± 19 kg) joined the study. In total, 286 out of 330 scenes (86.7%) were rated correctly. Ratings were false negative (FN: “no movements detected, but recorded”) in 7 out of 180 motion scenes (3.9%). Ratings were false positive (FP: “movements detected, but not recorded”) in 37 out of 150 scenes (24.7%), more often in men than women (26 out of 60 vs. 11 out of 90, respectively; p < 0.001). Of note, in 16 of these 37 FP-rated scenes, a vibrating mobile phone was identified as a potential confounder. The emergency scenes were correctly rated in 64 of the 75 runs (85.3%); 10 of the 11 FP-rated scenes occurred in male subjects. Conclusions: The MD allowed for identifying motions of test subjects with high sensitivity (96%) and acceptable specificity (75%). Accuracy might increase further if activities are recorded continuously under real-world conditions.

Patienten mit akuter kardialer Dekompensation haben in der Fruhphase ein hohes Morbiditats- und Mortalitatsrisiko. Die oral verfugbaren antikongestiven Substanzen werden in der klinischen Praxis haufig nur langsam implementiert und nicht bis zur jeweiligen Zieldosis gesteigert - ein Vorgehen, mit dem Prognose-Chancen der Betroffenen verpasst werden, wie eine aktuelle prospektive multizentrische Studie zeigte.

BACKGROUND The randomized INH (Interdisciplinary Network Heart Failure) trial (N = 715) reported that 6 months' remote patient management (RPM) (HeartNetCare-HF) did not reduce the primary outcome (time to all-cause death/ rehospitalization) vs usual care (UC) in patients discharged after admission for acute heart failure, but suggested lower mortality and better quality of life in the RPM group. OBJECTIVES The Extended (E)-INH trial investigated the effects of 18 months' HeartNetCare-HF on the same primary outcome in an expanded population (N =1,022) and followed survivors up to 60 months (primary outcome events) or up to 120 months (mortality) after RPM termination. METHODS Eligible patients aged $18 years, hospitalized for acute heart failure, and with predischarge ejection fraction #40% were randomized to RPM (RPM+UC; n = 509) or control (UC; n = 513). Follow-up visits were every 6 months during RPM, and then at 36, 60, and 120 months. RESULTS The primary outcome did not differ between groups at 18 months (60.7% [95% CI: 56.5%-65.0%] vs 61.2% [95% CI: 57.0%-65.4%]) or 60 months (78.1% [95% CI: 74.4%-81.6%] vs 82.8% [95% CI: 79.5%-86.0%]). At 60 and 120 months, all-cause mortality was lower in patients previously undergoing RPM (41.1% [95% CI: 37.0%-45.5%] vs 47.4% [95% CI: 43.2%-51.8%]; P = 0.040 and 64.0% [95% CI: 59.8%-68.2%] vs 69.6% [95% CI: 65.6%-73.5%]; P = 0.019). At all visits, health-related quality of life was better in patients exposed to HeartNetCare-HF vs UC. CONCLUSIONS Although 18 months' HeartNetCare-HF did not significantly reduce the primary outcome of death or rehospitalization at 60 months, lower 120-month mortality in patients previously undergoing HeartNetCare-HF suggested beneficial longer-term effects, although the possibility of a chance finding remains. (J Am Coll Cardiol HF 2023;11:191-206) (c) 2023 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/).

Background & Aim: Longitudinal data on prescription rates (PR) of guideline-directed medical therapy (GDMT) in patients with acute heart failure (HF) are scarce. We investigated GDMT patterns in patients with reduced (HFrEF), mildly reduced (HFmrEF), and preserved (HFpEF) ejection fraction (EF) and determined mortality risk. Patients & Methods: 943 acute HF patients, consecutively recruited between 2015 and 2019, with EF measured while in hospital. PR of betablockers (BB), renin angiotensin system inhibitors (RASi), mineralocorticoid receptor antagonists (MRA), and diuretics were recorded on admission, at discharge, and 6-month follow-up. Results: Little more than one third of patients had HFrEF ( Table ). Patients with HFpEF were older and more often female. Irrespective of EF, comorbidity burden was high ( Table ). Mortality at 12 months was similar across HF phenotypes. The Figure shows that PR of all disease-modifying drug classes increased from admission to discharge irrespective of HF phenotype. PR of MRA were highest in HFrEF. After 6-months, in HFrEF patients, PR of BB (-9%), RASi (-8%), and diuretics (-10%) had decreased again to admission levels. Similar patterns were apparent in HFmrEF and HFpEF including PR of diuretics ( Figure ). Treatment discontinuation of one or more disease modifying drug classes after discharge was frequent (38% in HFrEF, 29% in HFmrEF, 39% in HFpEF). Post-discharge discontinuation was associated with an age-adjusted increase of 12-month mortality risk (OR 10.9, 95%CI 7.6–15.7): for BB 24.5 (16.0–37.5); for RASi 17.6 (11.1–28.0); for MRA 12.3 (6.9–22.1); for diuretics 27.7 (18.3–42.1), with comparable impact across HF phenotypes. Conclusion: In this cohort of patients with AHF, prescription patterns of GDMT were often changed along the HF trajectory, yet similar across HF phenotypes and time. Irrespective of HF phenotype, stopping GDMT was associated with a consistently increased mortality risk.

Intracavitary thrombi are an important differential diagnosis of cardiac masses. Cardiac magnetic resonance imaging (CMR) allows their non-invasive characterization. This case highlights extensive cardiac thrombi detected by CMR as solitary presentation of antiphospholipid syndrome.

The concept to utilize a multidisciplinary team approach in the care of patients with heart failure (HF) has been advocated for years by (inter-)national guidelines, but suffers from insufficient implementation. Up to now, in the German health care system, a guide for the composition of these teams has only been proposed for the highly specialized area (i.e., the so-called heart teams or HF teams), while respective blueprints do not exist for the outpatient sector. To improve the care situation of HF patients, the German Cardiac Society and the German Society of Thoracic and Heart Surgery had introduced in the year 2016 the concept of HF networks. However, these focussed on the cardiological-cardiosurgical intersectoral care areas. In order to integrate primary care providers into the network, this concept needs to be expanded and individually adjusted according to regional needs and care structures. For the interaction of the various care providers, a common communication platform including an electronic case file is indispensable. The currently planned "Disease Management Programme Heart Failure" could strengthen such structured interdisciplinary interaction by requesting it as an obligatory element and incentivize it appropriately.

Since publication of the European Society guidelines for the diagnosis and treatment of acute and chronic heart failure in 2016, numerous studies provided new evidence how to further optimize heart failure therapy.Besides recent device-based therapeutic options, promising new drug developments give a glimmer of hope that the prognosis of this progressive heart disease could be somehow more controlled in the near future. At the same time, the variety of therapeutic options as well as the number of concomitant comorbidities makes the complex therapy of chronic heart failure more difficult than ever. This review aims to provide an update and practical support on the recent pharmacotherapeutic options in chronic heart failure.

Heart failure (HF) has a high hospitalization and mortality rate. Specialized inpatient and outpatient Heart Failure Units (HFU) that cooperate amongst each other in the context of Heart Failure Networks (HF-NET) jointly focus on high-quality care of any disease severity level to improve HF prognosis and reduce HF hospitalizations. Additional, specialized physician-assistant staff is required to effectively manage the workload. An inpatient HFU needs a structured discharge management program as well as structures facilitating the post-discharge management. This involves general practitioners, resident cardiologists and other medical players as rehabilitation clinics to secure post-discharge treatment and improve overall quality of care.

Background: Epidemiologic studies on the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in heart failure are scarce, while one large intervention trial demonstrated a modest benefit. Methods: This is a secondary analysis from the Interdisciplinary Network Heart Failure (INH) program. Patients hospitalized for systolic heart failure were enrolled and followed for 36 months. At baseline, whole blood samples from 899 patients were analyzed for fatty acid composition using a standardized analytical procedure (HS-Omega-3 Index (R), O3-I). Associations of the O3-I with markers of heart failure severity, clinical characteristics, biomarkers, and mortality were analyzed. Results: The mean O3-I was 3.7 +/- 1.0%. Patient mean age was 68 +/- 12 years (72% male, 43% in New York Heart Association (NYHA) class III or IV, mean LVEF 30 +/- 8%). During follow-up 258 patients (28.7%) died. After adjustment for potential confounders, the O3-I showed weak associations with uncured malignancy, end-systolic diameter of the left atrium, left ventricular end-diastolic and end-systolic diameters, and blood lipids and other laboratory parameters (all p < 0.05), but not with NYHA class, left ventricular ejection fraction, and the underlying cause of heart failure. The O3-I did not predict the 3-year mortality risk. Conclusions: Our results show a marked depletion of omega-3 fatty acids in patients hospitalized for decompensated heart failure (suggested target range 8-11%). Although the O3-I was associated with a panel of established risk indicators in heart failure, it did not predict mortality risk.

Aim This study investigates the prevalence and prognostic impact of central and small airways obstruction (CAO and SAO) in patients with stable heart failure (HF).Methods & results Spirometry was performed in 585 outpatients (mean age 65 +/- 12 years, 75% male) six months after hospitalisation for acute decompensation secondary to HF with ejection fraction <40%. We assessed forced expiratory volume in the first second (FEV1), forced vital capacity (FVC) and mid-expiratory flow (MEF) at 50% of FVC. CAO was defined by FEV1/FVC <0.7. SAO was defined by FEV1/FVC >= 0.7 plus MEF <60% of predicted value. CAO and SAO were excluded in 359 patients (61% of all). MEF <60% predicted was found in 226 patients (39% of all), among those 88 with CAO (15% of all) and 138 (24% of all) with SAO. During a twelve month follow-up, 42 patients (7.2%) died. Mortality rates of patients with CAO and SAO were comparable (12.5% and 10.9%, respectively, p = 0.74), and both higher than in patients without airways obstruction (4.5%, both p < 0.01). In univariable Cox regression analysis, both CAO and SAO were associated with 2-fold increased all-cause mortality risk (hazard ratios [95% confidence intervals]: 2.78 [1.33-6.19], p = 0.007 and 2.51 [1.24-5.08], p = 0.010, respectively). Adjustment for determinants of CAO and SAO, prognostic markers of heart failure and comorbidities attenuated the association of mortality with CAO but not with SAO.Conclusions SAO is more common than CAO and indicates an increased mortality risk in HF. Thus, reduced MEF may be a feature of patients at risk and merits special attention in HF management.

Aims: Serumcortisol independently predicts mortality risk in patients with systolic heart failure. Salivary cortisol may provide advantages as it better reflects the biologically active free compound. Furthermore, sampling is non-invasive and may easily be performed in outpatients. We comparatively evaluated associations of morning (MSC) vs. evening salivary cortisol (ESC) and all-cause mortality risk.Methods and results: MSC (8 am) and ESC (9 pm) were determined in 229 patients with heart failure participating in the Interdisciplinary Network for Heart Failure program (66 +/- 13 years; 21% female; 37% New York Heart Association (NYHA) class III/IV, median left ventricular ejection fraction 33%). The association of cortisol with mortality risk was determined by univariate and Cox multivariable regression analyses adjusting for age, sex, NYHA class, and N-terminal pro-hormone B-type natriuretic peptide. Compared to ESC, MSC was significantly higher and exhibited a higher variance: median 0.59 ng/ml (interquartile range 0.41-0.93) vs. 0.25 ng/ml (0.15-0.48), p < 0.001. During 18 months of follow-up, 25 (11%) patients died. In univariate and multivariable models mortality risk was not increased in the highest MSC quartile: crude hazard ratio (HR) 1.81 (95% confidence interval 0.79-4.14, p=0.160), adjusted HR 1.26 (0.51-3.13, p=0.616). However, patients in the highest ESC quartile had a significantly increased mortality risk, suggesting that associations of high ESC and increased mortality were independent of disease severity: crude HR 3.33 (1.50-7.42, p = 0.003), adjusted HR 2.49 (1.01-6.14, p = 0.047). ESC alone proved the best predictor of mortality.Conclusion: High ESC but not MSC levels independently predict increased mortality risk in heart failure. (C) 2015 Elsevier Ireland Ltd. All rights reserved.

The importance of the co-existence of heart failure (HF) and COPD nowadays is widely accepted, and most physicians know that the 2012 ESC guidelines recommend beta-blockers in these patients with both diseases.1 An important conclusion of the study by Staszewsky et al. in this issue of the journal is that the prescription rate of beta-blockers significantly increased from 2002 to 2009.2 In those with HF without COPD, bisoprolol uptake increased from 1.4% to 51.2%, and that of carvedilol from 49.6% to 61.7%. In those with HF and COPD, the increase was from 0.4% to 46.4% for bisoprolol, and from 25.0% to 53.8% for carvedilol. This was one of the major changes in patient management between the cohorts from 2002 and 2009 derived from the same hospitals in Italy. The authors suggest that the improved uptake of beta-blockers could be one of the major reasons for a better prognosis of these HF patients, although they realize it was an observational study.2 Such real-life practice studies are important to confirm results from large randomized clinical trials (RCTs). Certainly for beta-blockers in patients with both HF and COPD, this is of utmost importance because the large landmark RCTs with beta-blockers in HF were selectively in those with a reduced EF (with the exception of the SENIORS trial), excluding patients known to have COPD.3–6 Therefore, RCT data on beta-blockers in patients with both HF and COPD are very scarce. There are also other interesting findings in this study of Staszewsky et al. Because the authors provide data on all types of HF, we may suspect that patients with HF and a normal EF may also benefit from beta-blockade, similarly as suggested in the SENIORS trial.7 Even more important is the finding that all-cause mortality

BackgroundHeart failure (HF) pharmacotherapy is often not prescribed according to guidelines. This longitudinal study investigated prescription rates and dosages of angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB), beta‐blockers, and mineralocorticoid receptor antagonists (MRA), and concomitant changes of symptoms, echocardiographic parameters of left ventricular (LV) function and morphology and results of the Short Form‐36 (SF‐36) Health Survey in participants of the Interdisciplinary Network Heart Failure (INH) programme.Methods and resultsThe INH study evaluated a nurse‐coordinated management, HeartNetCare‐HFTM (HNC), against Usual Care (UC) in patients hospitalized for decompensated HF [LV ejection fraction (LVEF) ≤40% before discharge). A total of 706 subjects surviving >18 months (363 UC, 343 HNC) were examined 6‐monthly. At baseline, 92% received ACEi/ARB, (HNC/UC 91/93%, P = 0.28), 86% received beta‐blockers (86/86%, P = 0.83), and 44% received MRA (42/47%, P = 0.07). After 18 months, beta‐blocker use had increased only in HNC (+7.6%, P < 0.001). Guideline‐recommended target doses were achieved more frequently in HNC for ACEi/ARB (HNC/UC: 50/25%, P < 0.001) and beta‐blockers (39/15%, P < 0.001). The following variables were more improved and/or better in subjects undergoing HNC compared with UC: LVEF (47 ± 12 vs. 44 ± 12%, P = 0.004, change +17/+14%, P = 0.010), LV end‐diastolic diameter (59 ± 9 vs. 61 ± 9.6 mm, P = 0.024, change −2.3/–1.4mm, P = 0.13), New York Heart Association class (1.9 ± 0.7 vs. 2.1 ± 0.7, P = 0.001, change −0.44/–0.25, P = 0.002) and SF‐36 physical component summary score (41.6 ± 11.2 vs. 38.5 ± 11.8, P = 0.004, change +3.3 vs. +1.1 score points, P < 0.02).ConclusionsPrescription rates and dosages of ACEi/ARB and beta‐blockers improved more in HNC than UC patients. Concomitantly, participation in HNC was associated with significantly better clinical outcomes and more favourable echocardiographic changes after 18 months.

We thank the authors for their comments on our paper "Reverse epidemiology in different stages of heart failure" [1,2]. There we showed that the phenomenon of a "reverse epidemiology" in the precursor stages of heart failure (stage A/B according to AHA/ACC criteria) is subject to significant selection bias [2].

Coincidence of COPD and heart failure (HF) is challenging as both diseases interact on multiple levels with each other, and thus impact significantly on diagnosis, disease severity classification, and choice of medical therapy. The current overview aims to educate caregivers involved in the daily management of patients with HF and (possibly) concurrent COPD in how to deal with clinically relevant issues such as interpreting spirometry, the potential role of extensive pulmonary function testing, and finally, the potential beneficial, but also detrimental effects of medication used for HF and COPD on either disease.