Data on the safety and tolerability of sacubitril/valsartan in patients with transthyretin amyloid cardiomyopathy (ATTR-CM) are limited.The REVIEW-HF registry was a nationwide, multicenter, retrospective study that investigated the characteristics and outcomes of patients with heart failure who were newly prescribed sacubitril/valsartan in Japan. We evaluated adverse events (AEs) related to sacubitril/valsartan within 3 months after initiation, defined as hypotension, worsening kidney function, hyperkalemia, and angioedema. The rates of AEs and sacubitril/valsartan discontinuation were compared between patients with and without ATTR-CM.Among the 995 patients enrolled, 17 were diagnosed with ATTR-CM. Patients with ATTR-CM had a significantly higher incidence of AEs (64.7% versus 21.7%, P < 0.001), which were all attributable to hypotension. The discontinuation rate of sacubitril/valsartan was also significantly higher in these patients (76.5% versus 21.7%, P < 0.001), with a median discontinuation time of 8 days (interquartile range, 7-16). In multivariable analysis, ATTR-CM remained significantly associated with a higher risk of AEs (adjusted odds ratio, 7.35; 95% confidence interval, 2.40-22.55; P < 0.001) and sacubitril/valsartan discontinuation (adjusted odds ratio, 8.05; 95% confidence interval, 2.47-26.20; P < 0.001).In conclusion, patients with ATTR-CM had a significantly higher incidence of hypotension and more frequent discontinuation of sacubitril/valsartan compared with those without ATTR-CM. Although the number of patients with ATTR-CM in this study was limited and the findings should be interpreted with caution, careful monitoring may be warranted after the initiation of sacubitril/valsartan in this population.

INTRODUCTION:To assess how national income level influences global variation in the diagnosis and management of heart failure with preserved ejection fraction (HFpEF). METHODS:A web-based survey on HFpEF diagnosis and treatment was distributed worldwide from May to July 2023 through email, scientific societies, and social networks. Respondents provided demographic information and details on diagnostic practices, resource availability, and treatment approaches. Countries were categorized according to the 2023 World Bank income classifications: high-income countries (HICs), upper-middle-income countries (UMICs), lower-middle-income countries (LMICs), and low-income countries (LICs). RESULTS:1459 physicians from 91 countries completed the survey (median age 42 years; 61% male). Income level influenced the type of clinician managing HFpEF, with cardiologists more frequently involved in UMICs and LMICs/LICs than HICs. Respondents in HICs reported a higher proportion of HFpEF among their HF patients (40% vs 30% elsewhere; P < .001). Use of natriuretic peptides varied significantly across settings, as did the availability of echocardiographic parameters required for HFpEF assessment, which was highest in HICs. Screening for coronary artery disease in new HFpEF cases ranged from 22% in LMICs/LICs to 40% in UMICs. Availability of ACE inhibitors, ARBs, MRAs, and loop diuretics showed clear income-related differences, while SGLT2 inhibitors were widely available across all groups (88%). Multi-disciplinary HF programmes were most common in HICs (62%) and least common in LMICs/LICs (24%; P < .001). CONCLUSION:National income level is associated with major differences in diagnostic testing, medication access, specialist involvement, and multi-disciplinary care for HFpEF. These disparities highlight the need for scalable, resource-adapted strategies to optimize HFpEF care globally.

BACKGROUND:Hypochloraemia has emerged as a prognostic marker in heart failure, although the mechanisms underlying chloride dysregulation remain incompletely understood. We evaluated the prognostic significance of serum chloride levels and explored clinical and biochemical correlates of hypochloraemia including circulating urocortin 2 (UCN2). METHODS:This multicentre prospective cohort study included 3941 patients discharged after hospitalisation for acute or worsening heart failure with available serum chloride measurements. Patients were categorised according to discharge chloride levels as hypochloraemia, normochloraemia or hyperchloraemia. Associations between chloride status and 2-year outcomes were assessed using multivariable Cox proportional hazards and competing risk models. Exploratory analyses of circulating UCN2 concentrations were performed in a predefined subset of 499 patients. RESULTS:Hypochloraemia was independently associated with adverse outcomes after multivariable adjustment, including all-cause mortality (adjusted HR, 2.09; 95% CI 1.64 to 2.67; p<0.001), cardiovascular mortality (adjusted HR, 2.29; 95% CI 1.64 to 3.20; p<0.001), heart failure rehospitalisation (adjusted HR, 1.30; 95% CI 1.02 to 1.67; p=0.04) and the composite outcome (adjusted HR, 1.46; 95% CI 1.20 to 1.78; p<0.001). Competing risk analyses demonstrated that the excess mortality risk associated with hypochloraemia was predominantly cardiovascular. In models including both serum chloride and sodium, chloride remained independently associated with all-cause mortality whereas sodium did not. In exploratory analyses, circulating UCN2 concentrations showed a modest inverse association with serum chloride levels after adjustment for sodium, renal function, nutritional status and clinical severity (B=-0.37; 95% CI -0.72 to -0.02; p=0.04). CONCLUSIONS:Hypochloraemia identified patients with heart failure at substantially increased cardiovascular risk independent of established prognostic markers. Exploratory analyses suggested a potential association between circulating UCN2 and chloride homeostasis that warrants mechanistic investigation.

BACKGROUND:The prognostic value of cardiopulmonary exercise testing (CPET) parameters, particularly peak oxygen consumption (VO2) and minute ventilation/carbon dioxide production (VE/VCO2) slope, in patients aged ≥80 years with heart failure (HF) remains unclear. OBJECTIVES:The study evaluated the age-stratified prognostic value of CPET parameters for adverse outcomes in patients with HF. METHODS:In this retrospective multicenter cohort study, we included 830 patients with HF who underwent CPET. The primary outcome was a composite of all-cause death or HF hospitalization within 3 years. CPET parameters were examined in 3 age groups: 20 to 64, 65 to 79, and ≥80 years. RESULTS:During a median follow-up time of 2.8 years, 176/830 patients experienced adverse outcomes. Peak VO2 was associated with adverse outcomes in patients 65 years or older (≥80 years: HR: 0.72; 95% CI: 0.62-0.85; 65-79 years: HR: 0.90; 95% CI: 0.84-0.96). VE/VCO2 slope was consistently associated across age groups (P < 0.05 for all). The area under the curves (95% CI) of peak VO2 tended to increase with age (20-64 years: 0.61 [0.53-0.69], 65-79 years: 0.74 [0.67-0.81], ≥80 years: 0.81 [0.70-0.91]), whereas VE/VCO2 slope was comparable across age groups (20-64 years: 0.64 [0.56-0.72], 65-79 years: 0.68 [0.60-0.76], ≥80 years: 0.68 [0.55-0.81]). CONCLUSIONS:Although CPET parameters were associated with adverse outcomes across age groups, the prognostic contribution of peak VO2 was most pronounced in older patients with HF, highlighting the importance of CPET-based risk stratification in this population.

Background Frail patients are considered to be at higher risk of bleeding than non-frail patients; however, the association between frailty and bleeding risk in patients with heart failure (HF) remains unclear. Therefore, this study aims to evaluate the prevalence of bleeding events, examine the relationship between frailty severity and bleeding risk, and assess the association between bleeding events and subsequent mortality in patients with HF receiving antiplatelet or anticoagulant therapy. Methods This post hoc analysis used data from the Japanese Registry of Acute Decompensated Heart Failure–Next, a prospective, multicentre, nationwide registry. Frailty was evaluated using the Clinical Frailty Scale (CFS). Bleeding events were defined as major or clinically relevant non-major bleeding, based on the International Society on Thrombosis and Haemostasis Bleeding Scale. Results Among 4016 patients, 3029 (75.4%) were discharged on antiplatelet or anticoagulant medication. After excluding 89 with missing CFS data, 2940 patients were analyzed (mean age: 75 ± 12 years; 64.0% male). Patients were grouped by CFS scores: 1-3 (n = 1033); 4-5 (n = 1364); and 6-9 (n = 543). At 2 years, 149 (5.0%) experienced bleeding. Higher CFS scores were associated with increased bleeding risk (CFS score 4-5: hazard ratio [HR]: 1.53, 95% confidence interval [CI]: 1.00-2.34; CFS score 6-9: HR: 1.75; 95% CI: 1.04-2.93). In addition, bleeding events were associated with a higher risk of mortality (HR: 2.80; 95% CI: 1.88-4.17, P < 0.001). Conclusions Frailty is associated with bleeding risk in patients with HF receiving antithrombotic therapy. Bleeding events were associated with a higher risk of subsequent death.

KEY POINTS:Intradialytic renal rehabilitation was associated with higher 3-year survival in patients on maintenance hemodialysis. This association was directionally consistent after multivariable adjustment and propensity score matching. The association seemed stronger in men with severe frailty; no rehabilitation-related adverse events were reported. BACKGROUND:Frailty and sarcopenia are increasingly common among patients undergoing maintenance hemodialysis. Globally, some countries, including Japan, have recently introduced insurance reimbursement for intradialytic renal rehabilitation, a supervised intradialytic exercise instruction plus nutritional and lifestyle guidance. However, the survival benefit has not been fully evaluated. METHODS:We evaluated 708 adult outpatients on dialysis (age, 69.8±11.2 years; men, 59%; and Clinical Frailty Scale ≥6, 13%) at ten institutions across Japan in January 2021 who were retrospectively assessed over a 3-year period, including 228 patients who received intradialytic renal rehabilitation, defined as supervised intradialytic exercise instruction plus nutritional and lifestyle guidance (≥1 session/wk for≥1 month), and 480 who did not receive this intervention. Cox regression models and propensity score matching were used to compare 3-year mortality after adjustment for the Clinical Frailty Scale, comorbidities, laboratory data, and other baseline characteristics. RESULTS:During the follow-up, deaths were observed in 14.9% of the rehabilitation group and 23.1% of the nonrehabilitation group ( P = 0.01). Three-year survival was higher with rehabilitation (84.6% versus 75.6%, P = 0.007), particularly among men and those with severe frailty. In Cox models, renal rehabilitation was consistently associated with lower mortality (crude hazard ratio [HR], 0.59 [95% confidence interval (CI), 0.40 to 0.87]; adjusted HR 0.66 [0.44 to 1.00]). After propensity score matching, the association remained directionally similar (HR, 0.65 [0.40 to 1.05]). Sex-stratified analyses suggested a stronger association among men (adjusted HR, 0.49 [0.27 to 0.89]) than among women (adjusted HR, 0.98 [0.54 to 1.77]), although the formal test for interaction was not statistically significant ( P for interaction = 0.13). Patients meeting exercise-habit criteria (≥2 sessions/wk, ≥30 minutes for ≥1 year) also showed better survival relative to the nonexercise-habit group (adjusted HR 0.60 [0.37 to 0.96], P = 0.03). No adverse events related to rehabilitation were reported. CONCLUSIONS:Intradialytic renal rehabilitation may be associated with better survival in patients on maintenance hemodialysis, particularly in men and in those with severe frailty.

BACKGROUND AND AIMS:Advances in therapeutics and interventions have enabled the comprehensive management of patients with heart failure (HF); however, real-world clinical practice remains poorly characterized. This study aimed to evaluate temporal changes in HF management and their impact on patient outcomes. METHODS:Two large-scale Japanese HF registries were compared: the JROADHF (2013, n = 13 238) and JROADHF-NEXT (2019-21, n = 4016). Propensity score matching (1:1) was performed to compare patient outcomes between cohorts and identify factors associated with outcome improvements. RESULTS:Propensity score matching yielded 2972 patients in each cohort. After matching, guideline-recommended therapy increased for renin-angiotensin system inhibitors (70.9% vs 73.1%), beta-blockers (74.9% vs 80.8%), mineralocorticoid receptor antagonists (54.2% vs 61.1%), cardiac rehabilitation (43.5% vs 88.8%), and nutritional guidance (2.9% vs 56.1%) in the 2013 and 2019-21 cohorts, respectively. The 2019-21 cohort demonstrated 26.7% and 52.1% reductions in 1-year mortality and HF readmission rate (P < .001 for both), respectively, compared with the 2013 cohort. Improved mortality was associated with pharmacotherapy [renin-angiotensin system inhibitors: hazard ratio (HR) .71, 95% confidence interval (CI) .64-.80, P < .001; beta-blockers: HR .85, 95% CI .75-.96, P = .012] and patient education (nutritional guidance: HR .76, 95% CI .64-.89, P = .001). The cohort effect was the strongest predictor of HF readmission (subdistribution HR .49, 95% CI: .43-.57, P < .001). CONCLUSIONS:Long-term outcomes of patients with HF improved between 2013 and 2019-21. Guideline-recommended therapy was associated with survival benefit, whereas marked reduction in HF readmission rates coincided with broader changes in post-discharge care and healthcare system.

Renal rehabilitation, particularly exercise therapy, plays a vital role in maintaining physical function and improving outcomes in patients undergoing hemodialysis. In April 2022, Japan introduced an insurance reimbursement policy for exercise instruction during hemodialysis. However, the clinical association with outcomes and broader impact of this policy remain unclear. This study aims to elucidate the real-world association between the implementation of renal rehabilitation, especially exercise therapy during dialysis, on clinical outcomes, including mortality and hospitalization, in Japanese patients undergoing hemodialysis. It also assesses secondary outcomes such as frailty, physical function, and nutritional status. A retrospective cohort study was conducted using data from 10 dialysis facilities across Japan between January 2021 and January 2024. Adult patients receiving outpatient hemodialysis were included. The exercise group received regular intradialytic exercise therapy, while a matched control group did not. Primary outcomes included death and hospitalization. Secondary outcomes included changes in physical function (e.g., grip strength, gait speed), serum albumin/creatinine levels, frailty scores, and care needs. Subgroup analyses were performed on the basis of the presence of reimbursement claims for exercise instruction. This multicenter study will provide the first large-scale real-world evaluation of exercise therapy during hemodialysis following the 2022 reimbursement policy. It will elucidate the association between the implementation clinical outcomes. The eventual findings from this study may clarify the role of structured exercise programs in dialysis care and have the potential to inform future health policy decisions in Japan and globally. These results could also help guide best practices in renal rehabilitation and optimize patient-oriented outcomes.

Background:Malnutrition is common in heart failure (HF) and is associated with poor outcomes; however, longitudinal changes in the nutritional status of patients with HF are poorly investigated. Objectives:To assess the prognostic impact of changes in Controlling Nutritional Status (CONUT) score and identify predictors of malnutrition improvement in hospitalized patients with HF. Methods:We analyzed data on 4,016 patients from a nationwide acute HF registry in Japan (UMIN ID: UMIN000036592). We identified 812 patients with moderate or severe malnutrition at admission (CONUT score ≥5) and stratified them into an improvement (IMP, n = 168) or non-improvement (Non-IMP, n = 644) group based on in-hospital change in CONUT score. The primary outcome was all-cause mortality; the secondary outcome was a composite endpoint of all-cause mortality and HF rehospitalization. Results:Over a median follow-up of 712 days (IQR, 392-768 days), all-cause mortality was significantly lower in the IMP group than in the Non-IMP group (11.90% vs. 30.12%; log-rank P < 0.0001). The composite endpoint was also lower in the IMP group (29.76% vs. 47.98%; log-rank P < 0.0001). After propensity score matching, the IMP group had consistently lower all-cause mortality and composite endpoints than the Non-IMP group (log-rank P = 0.0002; log-rank P = 0.041). Multivariable Cox proportional hazards model for all-cause mortality with overlap weighting demonstrated that CONUT improvement was associated with lower all-cause mortality (HR, 0.357; 95% CI, 0.205-0.624; P = 0.0003). Conclusion:In hospitalized patients with acute HF and moderate to severe malnutrition, improvement in CONUT score during hospitalization was associated with lower post-discharge mortality and rehospitalization.

Background Reported results indicate that implementation rates of guideline-directed medical therapy (GDMT) are associated with improved prognosis and cardiac function in heart failure (HF) patients. This study aimed to investigate the relationship between what we term a “simple GDMT score” calculated at discharge and subsequent cardiac reverse remodelling and long-term outcomes in patients hospitalized for acute decompensated HF, using data from the Japanese Registry of Acute Decompensated Heart Failure (JROADHF-NEXT) prospective registry. Methods We analyzed 2313 hospitalized patients with HFrEF or HFmrEF, stratifying them into high-score (≥ 5 points) and low-score (< 5 points) groups based on their discharge GDMT score. Results The high-score group demonstrated a significantly lower risk of the composite endpoint of cardiovascular death or HF rehospitalization (hazard ratio = 0.64, 95% confidence interval: 0.55-0.76), an association that remained significant following multivariable adjustment (adjusted model: hazard ratio = 0.70, 95% confidence interval: 0.56-0.88). Furthermore, the high-score group exhibited significantly greater improvements in echocardiographic indices, including absolute changes in left ventricular ejection fraction (P < 0.001), left ventricular end-diastolic volume index (P < 0.001), and left ventricular end-systolic volume index (P < 0.001), and showed significant reductions in brain natriuretic peptide (P = 0.005) and N-terminal pro brain natriuretic peptide levels (P < 0.001) at 1-year follow-up assessment. Conclusions A higher simple GDMT score at discharge is independently associated with better 2-year clinical outcomes and favourable cardiac reverse remodelling in this cohort of HFrEF/HFmrEF patients hospitalized for acute decompensated HF. These findings suggest that a simple assessment of GDMT at discharge may serve as a practical benchmark of discharge medical optimization in routine clinical care.

Key Points Intradialytic renal rehabilitation was associated with higher 3-year survival in patients on maintenance hemodialysis. This association was directionally consistent after multivariable adjustment and propensity score matching. The association seemed stronger in men with severe frailty; no rehabilitation-related adverse events were reported. Background Frailty and sarcopenia are increasingly common among patients undergoing maintenance hemodialysis. Globally, some countries, including Japan, have recently introduced insurance reimbursement for intradialytic renal rehabilitation, a supervised intradialytic exercise instruction plus nutritional and lifestyle guidance. However, the survival benefit has not been fully evaluated. Methods We evaluated 708 adult outpatients on dialysis (age, 69.8±11.2 years; men, 59%; and Clinical Frailty Scale ≥6, 13%) at ten institutions across Japan in January 2021 who were retrospectively assessed over a 3-year period, including 228 patients who received intradialytic renal rehabilitation, defined as supervised intradialytic exercise instruction plus nutritional and lifestyle guidance (≥1 session/wk for≥1 month), and 480 who did not receive this intervention. Cox regression models and propensity score matching were used to compare 3-year mortality after adjustment for the Clinical Frailty Scale, comorbidities, laboratory data, and other baseline characteristics. Results During the follow-up, deaths were observed in 14.9% of the rehabilitation group and 23.1% of the nonrehabilitation group ( P = 0.01). Three-year survival was higher with rehabilitation (84.6% versus 75.6%, P = 0.007), particularly among men and those with severe frailty. In Cox models, renal rehabilitation was consistently associated with lower mortality (crude hazard ratio [HR], 0.59 [95% confidence interval (CI), 0.40 to 0.87]; adjusted HR 0.66 [0.44 to 1.00]). After propensity score matching, the association remained directionally similar (HR, 0.65 [0.40 to 1.05]). Sex-stratified analyses suggested a stronger association among men (adjusted HR, 0.49 [0.27 to 0.89]) than among women (adjusted HR, 0.98 [0.54 to 1.77]), although the formal test for interaction was not statistically significant ( P for interaction = 0.13). Patients meeting exercise-habit criteria (≥2 sessions/wk, ≥30 minutes for ≥1 year) also showed better survival relative to the nonexercise-habit group (adjusted HR 0.60 [0.37 to 0.96], P = 0.03). No adverse events related to rehabilitation were reported. Conclusions Intradialytic renal rehabilitation may be associated with better survival in patients on maintenance hemodialysis, particularly in men and in those with severe frailty.

BACKGROUND:Sacubitril/valsartan (Sac/Val) reduces N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in acute heart failure (AHF), particularly in patients with reduced ejection fraction. However, whether estimated total blood volume (TBV), calculated using anthropometric equations, is associated with heterogeneity in biomarker response remains uncertain. METHODS:This post hoc exploratory sub-analysis of the PREMIER randomized trial evaluated whether baseline estimated TBV was associated with heterogeneity in NT-proBNP reduction after Sac/Val compared with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) therapy. Estimated TBV was calculated using validated anthropometric equations and dichotomized at the median (4.05 L). Patients were further stratified by left ventricular ejection fraction (LVEF <40% vs ≥40%). The primary endpoint was the proportional change in NT-proBNP from baseline to Week 8. RESULTS:Among 376 patients, 372 with baseline estimated TBV data were analyzed. In the high TBV group, Sac/Val was associated with greater NT-proBNP reduction than ACEI/ARB (-56% vs -32%; ratio of change, 0.67; 95% confidence interval, 0.53-0.84; P = .001), whereas no significant difference was observed in the low TBV group (P for heterogeneity = 0.063). In patients with LVEF <40%, Sac/Val was associated with greater NT-proBNP reduction in both TBV groups. In patients with LVEF ≥40%, Sac/Val was associated with greater NT-proBNP reduction in the high TBV group, whereas the point estimate in the low TBV group numerically favored ACEI/ARB. CONCLUSIONS:In this exploratory post hoc analysis, higher estimated TBV was associated with greater NT-proBNP reduction after Sac/Val, particularly among patients with LVEF ≥40%. These findings are hypothesis-generating and require external validation. TRIAL REGISTRATION:ClinicalTrials.gov, NCT05164653; Japan Registry of Clinical Trials, jRCTs021210046.

Background: Sacubitril/valsartan (Sac/Val) has been shown to reduce N-terminal pro-brain natriuretic peptide (NT-proBNP) levels in patients with acute heart failure (AHF), yet the therapeutic response may differ according to underlying cardiac phenotype. Hypothesis: We hypothesized that specific baseline echocardiographic parameters may modify the NT-proBNP-lowering effect of Sac/Val in this population. Aims: This study aimed to explore whether baseline echocardiographic markers could identify patients with AHF, who will experience greater reductions in NT-proBNP following Sac/Val therapy. Methods: This was a sub-analysis of the multicenter, physician-initiated, prospective, randomized, open-label PREMIER study (NCT05164653), in which the clinical effects of early initiation of Sac/Val, compared to the standard renin-angiotensin system inhibitor therapy (control), were evaluated in Japanese inpatients stabilized after hospitalization for AHF. Participants were stratified according to echocardiographic characteristics at baseline, including LVEDVI, LVESVI, LVMI, LVOT-VTI, E/e′, LAVI, and TRV. The proportional change in geometric mean NT-proBNP from baseline to 8 weeks was compared between the Sac/Val and control groups within each stratum. Results: Among 206 patients with echocardiographic data (median age, 76 years; 31% female; median left ventricular ejection fraction, 39%), 94 were assigned to the sacubitril/valsartan (Sac/Val) group and 112 to the control group. Overall, Sac/Val treatment led to a significantly greater reduction in NT-proBNP than control (group ratio 0.75; 95% CI, 0.60 to 0.93). Among the echocardiography-based subgroups, the treatment effect was more evident in subgroups with elevated LVMI (LVMI ≥123.7 g/m 2 ; group ratio, 0.56; 95% CI, 0.40 to 0.77) and reduced LVOT-VTI (LVOT-VTI <13 cm; group ratio, 0.59; 95% CI, 0.43 to 0.80), compared to each corresponding counterpart (P for interaction = 0.009 and 0.045, respectively) ( Figure ). In contrast, no significant between-group differences in the treatment effect were observed in subgroups stratified by other echocardiographic parameters (all P for interaction >0.1). Conclusions: Baseline LVMI and LVOT-VTI values may help identify the optimal patients who derive greater benefit from early initiation of Sac/Val therapy after an AHF episode, supporting a phenotype-guided approach to individualized treatment in this population.

BACKGROUND:Prognostic implications of mineralocorticoid receptor antagonist (MRA) initiation in the context of worsening renal function (WRF) in patients with acute heart failure (AHF) remain unknown. METHODS:This was a post hoc analysis using data from Japanese AHF registries (NARA-HF [Nara Registry and Analyses for Heart Failure], WET-HF [West Tokyo Heart Failure], REALITY-AHF [Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure]). MRA-naïve patients at baseline were included, comprising 1632 patients with HF with reduced ejection fraction (HFrEF) and 2407 with heart failure with mildly reduced or preserved ejection fraction (HFmr/pEF). They were divided into 3 groups: MRA initiated without WRF (HFrEF, n=590; HFmr/pEF, n=572), MRA initiated with WRF (HFrEF, n=74; HFmr/pEF, n=100), and no MRA initiation (HFrEF, n=968; HFmr/pEF, n=1735). WRF was defined as a 0.3 mg/dL increase from admission to discharge. The composite of death or HF hospitalization after discharge was assessed. RESULTS:During the 1-year follow-up, 369 and 593 events occurred in patients with HFrEF and HFmr/pEF, respectively. Overall, MRA initiation during hospitalization of AHF was independently associated with better prognosis (hazard ratio [HR], 0.81), mainly driven by HF hospitalization. Among patients with HFrEF, the groups with MRA with and without WRF showed a lower incidence of the outcome than the no-MRA group, even after adjusting for risk factors (HR, 0.75 and 0.49, respectively). Among patients with HFmr/pEF, MRA initiation without WRF was independently associated with better prognosis (HR, 0.78), but MRA initiation with WRF was not. CONCLUSIONS:Initiating an MRA during AHF hospitalization was associated with better postdischarge outcomes in HFrEF, irrespective of creatinine elevation, whereas no such consistent association was observed in HFmr/pEF.

Background: Functional tricuspid regurgitation (TR) develops in atrial fibrillation (AF), but its natural history after transcatheter aortic valve replacement (TAVR) remains unclear. Methods and Results: Of 981 patients from a single-center registry, AF/atrial flutter (AFL) was present in 169. Over 5 years, severe TR developed in 11.7% with AF/AFL vs. 0.8% without. AF/AFL independently predicted TR progression (sub-distribution hazard ratio 1.82, 95% confidence interval: 1.34-2.47). Conclusions: AF/AFL significantly increases TR progression risk post-TAVR, highlighting the importance of surveillance and preventive strategies.