BACKGROUND:The optimal duration of angiotensin receptor-neprilysin inhibitor (ARNI) exposure before implantable cardioverter-defibrillator (ICD) implantation remains undefined. In nonischemic dilated cardiomyopathy (NIDCM), reverse remodeling may continue beyond device implantation. However, predictors of post-implant latent left ventricular reverse remodeling (LVRR) remain unclear. OBJECTIVE:This study investigated the association between duration of pre-ICD ARNI therapy and latent LVRR in patients with NIDCM. METHODS:Seventy-five patients with NIDCM (69.3% male, mean age 61 years) with LVEF of ≤35% and prior ARNI treatment before primary prevention ICD implantation were retrospectively analyzed. Latent LVRR was defined as an absolute ≥10% increase in LVEF with a final LVEF of ≥40% at 1-year post-implant. Multivariable logistic regression identified the predictors of latent LVRR. RESULTS:At 1 year, 22 patients (29.3%) exhibited latent LVRR. Shorter duration from heart failure diagnosis (4.8 vs 30.1 months; odds ratio, 0.88, P = .007) and ARNI initiation (2.3 vs 7.2 months; odds ratio, 0.90, P = .029) to ICD implant were independently associated with latent LVRR. Cardiac magnetic resonance imaging analysis showed uniformly elevated fibrosis markers across groups, with no difference observed in native T1, T2, extracellular volume, or late gadolinium enhancement. Conventional variables, including age, sex, QRS duration, heart rate, and late gadolinium enhancement burden, were not predictive. Over a median follow-up of 33.8 months, ventricular arrhythmia incidence was comparable (9.1% vs 7.5%). CONCLUSION:Shorter ARNI exposure before ICD implantation was independently associated with latent LVRR, highlighting the need for sufficient guideline-directed medical therapy to optimize reverse remodeling, whereas residual arrhythmic risk warrants continued ICD protection.

Introduction Angiotensin receptor neprilysin inhibitor (ARNI) treatment for heart failure with mildly reduced ejection fraction (HFmrEF) has a class IIb recommendation in current guidelines, which limits its use in real-world practice. Furthermore, the effects of ARNI on left ventricular reverse remodeling (LVRR) including left ventricular global longitudinal strain (LVGLS) and left atrial reservoir strain (LASr) remain inadequately studied in HFmrEF. Research Question This study aims to investigate the effect of ARNI treatment on LVRR and improvements in LVGLS and LAS in patients with HFmrEF. Methods Patients with HFmrEF, defined as a LVEF between 40% and 50%, who had not received prior ARNI treatment at a single tertiary center were retrospectively enrolled. Baseline demographics and clinical characteristics were recorded. Echocardiograms were performed at baseline and during a 6- to 12-month follow-up. Changes in LVGLS, LASr were assessed using 2-dimensional speckle tracking analysis, with sufficient imaging quality for at both timepoints. LVRR was defined as an improvement in LVEF above 50%. Results A total of 103 patients (61.2% male, median age 61 years) were evaluated at baseline and followed up for a median of 330 days (IQR: 215-391 days). At the 1-year, 39.8% (N=41) achieved LVRR. ARNI treatment led to significant improvements in LVEF (46% to 48%, P<0.001) and LVGLS (-13.8% to -15.5%, P=0.001), along with a reduction in the LA volume index (LAVI) (36.5mL/m2 to 33.4mL/m2, P=0.043). Notably, patients without atrial fibrillation (AF) (N=65, 63.1%) demonstrated a greater reduction in NT-proBNP levels (121.5pg/mL to 99.5pg/mL, P=0.022), along with significant improvements in LASr (28.0% to 31.4%, P=0.030) and conduit strain (-12.9% to -14.8%, P=0.030) after ARNI treatment. Conclusion Despite the limited guideline recommendations, ARNI therapy in HFmrEF resulted in significant improvements in LVEF, LVGLS and LVRR. In particular, patients without AF experienced favorable changes in LASr, supporting the clinical efficacy of ARNI in real-world HFmrEF management.

BackgroundAcute heart failure (AHF) is a highly heterogeneous clinical syndrome, posing challenges for risk stratification and management. Phenotype-based classification using unsupervised clustering may provide insights beyond conventional approaches.MethodsWe analyzed a nationwide, prospective, multicenter registry of patients hospitalized with AHF. Baseline demographic characteristics, clinical variables, laboratory findings, and echocardiographic parameters obtained at index hospitalization were used for unsupervised clustering. K-means clustering was applied, and the optimal number of clusters was determined based on internal validation metrics and clinical interpretability. Clinical characteristics, treatment patterns, and outcomes were compared across clusters. Cox proportional hazards models were used to evaluate the association between cluster membership and clinical outcomes.ResultsA total of 7,351 patients were classified into five distinct clinical phenotypes. The clusters demonstrated marked differences in baseline characteristics, comorbidity burden, hemodynamic profiles, and cardiac function. Treatment patterns, including guideline-directed medical therapy and supportive interventions, varied significantly across clusters. During follow-up, all-cause mortality differed significantly among clusters (p < 0.001), with Clusters 2, 3, and 5 remaining independently associated with increased mortality compared with Cluster 1 after multivariable adjustment. Heart failure hospitalization also differed significantly across clusters (p < 0.001), although differences were less pronounced after multivariable adjustment. The composite endpoint of all-cause mortality or heart failure hospitalization showed clear separation across clusters (p < 0.001). In multivariable analysis, cluster membership remained independently associated with all-cause mortality and the composite endpoint.ConclusionIn this large, nationwide cohort of patients with AHF, unsupervised clustering identified five clinically distinct phenotypes with significantly different characteristics, management patterns, and outcomes. These findings support the clinical relevance of phenotype-based classification and highlight its potential to enhance risk stratification and inform more personalized management strategies in AHF.

Obesity is linked to adverse health effects, but paradoxically improves survival in heart failure (HF). Peak oxygen consumption (VO2), a measure of exercise capacity, is a key prognostic indicator in HF. We examined the interaction between obesity and peak VO2 in predicting survival in patients with HF with reduced ejection fraction (HFrEF). We retrospectively reviewed 18,879 patients who underwent maximal cardiopulmonary exercise testing using the modified Bruce ramp protocol between 2012 and 2020. The inclusion criteria were left ventricular ejection fraction <40

Background and Aims To evaluate differences in post-transplant outcomes by pre-transplant urgency status, focusing on early post-transplant infection and its contribution to mortality. Methods We retrospectively analysed 801 adult heart transplant recipients enrolled in the Korea Organ Transplant Registry (April 2014-December 2021). Recipients were classified as Status 0 (highest urgency; n = 287) and Status 1-3 (n = 514). Outcomes included all-cause mortality, post-transplant infection, acute allograft rejection, and cardiac allograft vasculopathy (CAV) up to 5 years. Mediation, landmark, and multivariable time-dependent Cox models assessed the impact and determinants of infection. Results During 5-year follow-up, 128 recipients (16.0%) died. Status 0 recipients had higher mortality than Status 1-3 recipients (28.0% vs. 13.5%; P < .001). Infection was the leading cause of death and was more frequent in Status 0 recipients at 1 and 6 months, whereas rejection and CAV rates were similar between groups. Infection at 1, 6, and 12 months was strongly associated with mortality and mediated the association between urgency status and mortality, accounting for 47.4%, 34.9%, and 34.2% of total effect, respectively. After adjustment for pre- and post-transplant organ support, urgency status was no longer independently associated with infection risk, whereas prolonged mechanical ventilation (>24 h) remained the strongest predictor. Conclusion Status 0 heart transplant recipients had higher mortality and early post-transplant infection risk than Status 1-3 recipients. Early infection, largely associated with greater clinical severity and prolonged mechanical ventilation, may explain the excess mortality in this high-urgency group.

Sacubitril/valsartan (Sac/Val) is associated with reverse cardiac remodeling in heart failure with reduced ejection fraction (HFrEF). However, the predictors of reverse cardiac remodeling after Sac/Val have not yet been fully established. We aimed to evaluate the predictors of reverse cardiac remodeling in patients with HFrEF, with a focus on HF duration and the dose of Sac/Val. In this retrospective, multicenter cohort study, 600 patients with HFrEF who received a Sac/Val prescription were enrolled at six tertiary hospitals in Korea between February 2017 and April 2019. After excluding patients without baseline or 12-month follow-up echocardiographic data, 294 patients were enrolled. Reverse cardiac remodeling was defined by comparing the baseline and follow-up echocardiographic data: an absolute increase in left ventricular ejection fraction (LVEF) ≥ 10% and a relative decrease in left ventricular end-diastolic volume index ≥ 10%. The average daily Sac/Val dose was calculated during the first 6 and 12 months after initiation. Among the 294 patients, 107 presented with reverse cardiac remodeling at 12 months. Patients with HF duration < 12 months at the time of Sac/Val initiation showed a higher proportion of reverse cardiac remodeling than patients with HF duration ≥ 12 months (46.1% vs. 25.7%; P < 0.001). Patients with an average daily Sac/Val dose ≥ 200 mg/day over 6 months also had a higher proportion of reverse cardiac remodeling than patients with Sac/Val < 200 mg/day (44.0% vs. 31.9%; P < 0.001). Multivariable logistic regression revealed low baseline LVEF, HF duration < 12 months, and higher Sac/Val dose as independent predictors of reverse cardiac remodeling. In conclusion, early initiation of Sac/Val following HF diagnosis and higher Sac/Val doses were associated with a higher likelihood of reverse cardiac remodeling in HFrEF.

Background:Chronic kidney disease (CKD) is prevalent among patients with heart failure with preserved ejection fraction (HFpEF), significantly affecting their outcomes. Although the prognostic risk factors remain unclear, peak oxygen consumption (peak VO2) may be used to objectively assess the risk of kidney damage due to overlapping factors affecting kidney function and aerobic exercise capacity. This study aimed to evaluate the association between peak VO2 levels and incident CKD risk among patients with HFpEF. Methods:A total of 342 patients with HFpEF and an estimated glomerular filtration rate (eGFR) >60 mL/min/1.73 m2 who underwent cardiopulmonary exercise testing between January 2012 and April 2021 were included. Aerobic exercise capacity was evaluated using the peak VO2 values. Incident CKD development was defined as two consecutive eGFR measurements <60 mL/min/1.73 m2 separated by ≥90 days. Results:The mean patient age was 62.9 ± 10.6 years, with 35.7% being male. Baseline left ventricular ejection fraction and eGFR were 66.7% ± 6.9% and 88.4 ± 12.6 mL/min/1.73 m2 , respectively. For over 940.0 person-years of follow-up (median, 2.9 years), 51 patients developed CKD. CKD incidence rate gradually increased with lower peak VO2 levels. Multivariable Cox analysis showed an association between a 1-standard-deviation peak VO2 increase and a 51% reduction in CKD risk. The adjusted hazard ratio (95% confidence interval) for the lowest peak VO2 tertile group was 3.29 (1.23-8.84) compared with the highest tertile group. Conclusion:Reduced aerobic exercise capacity, indicated by lower peak VO2 levels, is closely associated with an increased CKD risk in patients with HFpEF.

BACKGROUND AND OBJECTIVES:Postoperative bleeding requiring surgical re-exploration is a serious complication after cardiac surgery, yet its clinical impact in heart transplantation remains incompletely characterized. We assessed its clinical impact, predictors, and time-dependent risk profile. METHODS:We retrospectively analyzed 813 adult recipients in the Korean Organ Transplantation Registry (2014 to 2021). The primary outcome was all-cause mortality and the secondary outcome was infection-related mortality. Between-group effects were estimated using multivariable Cox proportional hazards and Fine-Gray subdistribution hazard models. Time dependence was examined with smoothing splines and a prespecified 3-month landmark analysis. Predictors of re-exploration were identified with multivariable logistic regression; discrimination was assessed by receiver operating characteristic analysis and the area under the curve (AUC), and the final model was presented as a nomogram. RESULTS:Sixty-two patients (7.6%) underwent re-exploration. Early mortality at 30 days, 90 days, and 1 year was higher in the re-exploration group. Re-exploration was associated with increased all-cause mortality (adjusted hazard ratio [HR], 2.11; 95% confidence interval [CI], 1.28-3.48) and infection-related mortality (adjusted subdistribution HR, 2.33; 95% CI, 1.06-5.14). The excess mortality risk was confined to the first 3 months, as shown by time-varying hazard and 3-month landmark analyses; thereafter the hazards were comparable. Cardiopulmonary bypass (CPB) time and preoperative renal replacement therapy independently predicted re-exploration. The prediction model showed acceptable discrimination (AUC=0.77) and was implemented as a nomogram. CONCLUSIONS:Re-exploration for postoperative bleeding markedly increases early mortality after heart transplantation. CPB time and renal replacement therapy may aid perioperative risk stratification and targeted prevention.

INTRODUCTION:This study aimed to determine whether the prognostic implications of body mass index (BMI) differ according to heart failure (HF) phenotype and sex. METHODS:From the Korean HF III registry (n = 7351), we analyzed 5271 patients hospitalized for acute heart failure (AHF) with available data. BMI was categorized as low (<18.5 kg/m²), normal (18.5-24.9), or high (≥25.0) using cut-off values consistent with Asia-Pacific criteria. The primary outcome was a composite of 2-year all-cause mortality or heart transplantation. Kaplan-Meier analyses and multivariable Cox proportional hazards models, including interaction terms for BMI, sex, and HF phenotype, were performed. RESULTS:In HF with reduced ejection fraction (HFrEF), lower BMI was consistently associated with worse outcomes in both men and women. In contrast, in HF with preserved ejection fraction (HFpEF), BMI was prognostic in women but not in men: survival differed by BMI category in Kaplan-Meier analyses for all subgroups except men with HFpEF. In multivariable analyses, higher BMI was independently associated with lower risk in women with HFrEF [hazard ratio (HR) 0.66, 95% confidence interval (CI) 0.45-0.96, P = .032], whereas lower BMI in women with HFpEF showed a borderline association with higher risk (HR 1.56, 95% CI 0.99-2.47, P = .057). CONCLUSION:The prognostic implications of BMI in AHF differ according to HF phenotype and sex. Lower BMI is a consistent adverse marker in HFrEF in both sexes and shows a borderline adverse association in women with HFpEF, whereas BMI is not prognostic in men with HFpEF. These findings highlight the importance of sex- and phenotype-specific interpretation of BMI in risk assessment.

Introduction Sacubitril/valsartan (Sac/Val) represents a cornerstone of heart failure (HF) with reduced ejection fraction (HFrEF) management. This systematic review provides a comprehensive overview of real-world evidence (RWE) regarding the implementation, clinical effectiveness, and safety of Sac/Val in patients with HFrEF.Methods A systematic literature search of PubMed was conducted through March 2024 following PRISMA guidelines.Results The review included 45 manuscripts from 30 different studies, primarily from Europe (44%) and the US (30%). RWE confirmed that Sac/Val was associated with a lower risk of cardiovascular mortality (10%-16%), HF hospitalization (10%-38%), and all-cause mortality (10%-25%). Sac/Val was significantly associated with cardiac reverse remodeling and lower-grade mitral regurgitation. Despite these benefits, implementation gaps persist, with only 15%-25% of patients achieving target doses in clinical practice. The most common reported adverse event with Sac/Val was hypotension (up to 17.6%), though severe hyperkalaemia and renal decline were similar when compared with traditional renin angiotensin system inhibitors.Conclusion Real-world data mirror the efficacy and safety profiles seen in randomized controlled trials, establishing Sac/Val as a cornerstone of HFrEF therapy. However, significant barriers remain, including delayed initiation and suboptimal dose titration. Enhancing clinician and patient awareness is needed to bridge these implementation gaps and fully realize the drug's potential to reduce the global healthcare burden of HF.

Background: Poor adherence to guideline-directed medical therapy (GDMT) in patients with heart failure (HF) with reduced ejection fraction is associated with higher mortality and hospitalization. However, its association with malignant arrhythmias and aborted sudden cardiac death (SCD) remains unclear. This study assessed the association between GDMT adherence and these outcomes in patients with an implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy with a defibrillator (CRT-D). Methods: Patients who had an ICD or CRT-D implanted for primary prevention were included. Those with sustained ventricular tachycardia (VT), ventricular fibrillation/flutter (VF/VFL), or an aborted SCD device before implantation were excluded. Adherence to renin-angiotensin system blockers (RASBs), beta blockers (BBs), and mineralocorticoid receptor antagonists (MRAs) was assessed and categorized as optimal, suboptimal, or poor. The primary outcome was a composite of all-cause mortality, sustained VT, VF/VFL, and aborted SCD. Results: Among 3,780 patients, the prescription rates were 87.5% for RASBs, 89.7% for BBs, and 74.2% for MRAs. Compared with optimal adherence, both suboptimal and poor adherence were associated with an increased risk of the primary outcome. The adverse effects of poor adherence were most evident in patients with ischemic HF. Although lower adherence was correlated with more arrhythmic events, these associations were inconsistent when clinical factors were considered. Conclusions: Lower GDMT adherence was independently associated with increased mortality despite device therapy, particularly in patients with ischemic HF. Although its relationship with arrhythmic outcomes was unclear, sustained adherence remains critical, underscoring the need for targeted interventions to enhance therapeutic continuity. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial None. ### Funding Statement None. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study protocol was approved by the Institutional Review Board for Human Research of Yonsei University Wonju Severance Christian Hospital (approval number: CR321358). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

BACKGROUND:The ventricular tachycardia (VT) substrate map is influenced by the rhythm during mapping. OBJECTIVE:This study aimed to elucidate the effects of different pacing sites on decrement-evoked potential (DEEP) mapping of scar-related VT in patients with cardiomyopathy. METHODS:Patients with ischemic cardiomyopathy or nonischemic cardiomyopathy who underwent substrate mapping and ablation for scar-related VT were included. DEEP mapping was performed during right ventricular apical (RVA) and left ventricular outflow tract (LVOT) pacing. We analyzed the characteristics of deceleration zones (DZs) from the DEEP maps obtained during RVA and LVOT pacing. RESULTS:A total of 20 patients (age 61.1 ± 17.7 years; 17 males; 11 with ischemic cardiomyopathy and 9 with nonischemic cardiomyopathy) were studied. The numbers of pacemap-matching DZs identified from the RVA S1, RVA S2, LVOT S1, and LVOT S2 maps were 0.74 ± 0.87, 1.28 ± 1.13, 1.00 ± 0.91, and 1.44 ± 1.20, respectively. 2 DZs were visible only during RVA pacing because they were parallel to the conduction direction. 7 DZs were visible only during LVOT pacing-5 DZs were parallel to the conduction direction, and 2 DZs were located at the wavefront collision area. S2 pacing and LVOT pacing were useful for finding more DZs in 41.2% and 41.2% of patients, respectively. During a mean follow-up of 10.9 ± 3.6 months, VT recurred in 30.0% of patients. CONCLUSION:A high number of pacemap-matching DZs can be identified using 2-site pacing DEEP mapping.

Background Guideline-directed medical therapy (GDMT) is fundamental in treating patients with heart failure (HF), and quantifying GDMT intensity is essential in HF care. GDMT is associated with left atrial reverse remodeling (LARR). However, the association between GDMT intensity score and LARR is uncertain. Methods This is a post-hoc analysis of the Korean Heart Failure III (KorHFIII) registry, a prospective, multicenter cohort study that analyzed acute HF patients across Republic of Korea between March 2018 and December 2022. Patients diagnosed with heart failure with reduced ejection fraction (HFrEF) were selected from the database. The GDMT intensity score was calculated using a method developed by the Heart Failure Collaboratory, based on the type and dosage of medication, one month after discharge from the hospital. The high GDMT intensity group was defined as having a GDMT intensity score of 6 or higher. Left atrial volume was examined by echocardiography, and LARR was defined as a reduction in the left atrial volume index by over 15% from baseline to 1 year after treatment. The primary endpoint was the achievement of LARR. Results A total of 675 patients were analyzed in this study. The median age was 64 years [Interquartile range: 53 - 74] and 66% were male. 267 patients (39.6%) were categorized as high GDMT group, and 408 patients were categorized as low GDMT group. Among those high GDMT Group, 193 patients (72.3%) achieved LARR, while 222 patients (54.4%) achieved LARR in low GDMT Group [Odds ratio 2.19, 95% CI 1.57 - 3.04, p <0.001]. Multivariate analysis also showed a significant association between high GDMT intensity score and LARR achievement [Odds ratio 2.42, 95% CI 1.60 - 3.65, p <0.001]. Conclusion Patients diagnosed with HFrEF who reached a high GDMT intensity score achieved more LARR than those who did not reach a sufficient GDMT intensity score. Even in the case of failing to administer all four drugs, reaching a high GDMT intensity score can lead to cardiac reverse remodeling.

Heart failure (HF) is a major cause of mortality and morbidity in South Korea, imposing substantial physical, emotional, and financial burdens on patients and society. Despite the high burden of symptom and complex care needs of HF patients, palliative care and hospice services remain underutilized in South Korea due to cultural, institutional, and knowledge-related barriers. This position statement from the Korean Society of Heart Failure emphasizes the need for integrating palliative and hospice care into HF management to improve quality of life and support holistic care for patients and their families. By clarifying the role of palliative care in HF and proposing practical referral criteria, this position statement aims to bridge the gap between HF and palliative care services in South Korea, ultimately improving patient-centered outcomes and aligning treatment with the goals and values of HF patients.

Introduction Clonal hematopoiesis of indeterminate potential (CHIP) has been largely studied in ischemic cardiomyopathy with reduced left ventricular ejection fraction (LV EF). However, its association with heart failure (HF) of non-ischemic etiology remains relatively unexplored. In this prospective study, we investigated the prevalence of CHIP and its associated changes in LV EF, as well as the presence of LV reverse remodeling (LV RR) in patients with non-ischemic HF. Methods The study enrolled patients diagnosed with non-ischemic HF with LV EF less than 40% of non-identifiable cause from November 2021 to January 2023. Error-corrected next generation sequencing was used to detect mutations with a variant allelic frequency greater than 1.5% in 89 CHIP driver genes. Baseline echocardiographic parameters were compared to those at one year after HF diagnosis, following maximally tolerated guideline-directed medical therapy (GDMT). The primary endpoint was the presence of LV RR, defined as LV EF greater than 40% and an absolute increase of more than 10% from baseline. Results Among the 95 patients included in the study, CHIP mutations were detected in 15 (15.8%) patients. These mutations were positively correlated with older age (67.6 vs. 57.4 years, P = 0.009) and elevated NT-proBNP levels (1105.0 vs. 175.5 pg/mL, P = 0.018), but were comparable in baseline EF (26.7% vs. 28.9%, P = 0.311) and LV end-diastolic diameter (26.7 mm vs. 31.0 mm, P = 0.110). The improvement in cardiac function, assessed by EF change, and the frequency of LV RR did not significantly differ regardless of CHIP status following GDMT. However, the CHIP group exhibited a lower absolute EF compared to the non-CHIP group (41.6% vs. 49.7%, P = 0.034), even after matching for age and sex in a ratio of 1:2. Conclusions CHIP mutations in patients with non-ischemic HF did not predict the incidence of LV RR, but they were associated with impaired recovery of overall LV EF after one year of GDMT. Extended follow-up is needed to ascertain if these findings are consistent or not.

Background and Objectives:In chronic heart failure (HF), natriuretic peptide (NP) levels are higher in atrial fibrillation (AF) compared to sinus rhythm (SR). However, due to the loss of atrial contraction, AF patients are prone to hemodynamic decompensation at earlier stages. Since NP levels reflect disease severity, acutely decompensated AF patients may exhibit lower NP levels compared to SR patients, who retain greater hemodynamic reserve. Methods:We analyzed 5,048 patients with acute HF from the Korea Acute Heart Failure registry with available NP data. NP levels and echocardiographic parameters were compared between AF and SR patients. The association of NP levels with in-hospital and one-year mortality was also assessed according to cardiac rhythm. Results:Brain natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were measured in 2,027 and 3,021 patients, respectively. NP levels were lower in AF than in SR (median BNP, 740 vs. 1,044 pg/mL; median NT-proBNP, 4,420 vs. 5,198 pg/mL), particularly in HF with reduced or mildly reduced ejection fraction. A similar trend was observed regardless of HF onset or etiology. AF patients had smaller left ventricular (LV) end-diastolic diameter and larger left atrial size compared to SR patients. Higher NP tertiles were associated with increased in-hospital and one-year mortality in both groups. Conclusions:In acute HF, NP levels are lower in AF than in SR. AF patients also exhibited smaller LV chamber sizes. Nevertheless, NP levels remain strong predictors of outcomes in both AF and SR patients. Trial Registration:ClinicalTrials.gov Identifier: NCT01389843.

The HFA-PEFF and H2FPEF scores were recently proposed to help diagnose heart failure (HF) with preserved ejection fraction (HFpEF). We aimed to evaluate HFpEF prevalence according to the 2021 European Society of Cardiology (ESC) HF guideline and the HFA-PEFF and H2FPEF scores in patients with unexplained dyspnea and to compare the concordance between these three algorithms in diagnosing HFpEF. We analyzed 992 patients with unexplained dyspnea suspected of having HFpEF, who underwent echocardiography, cardiopulmonary exercise testing, and N-terminal pro-brain natriuretic peptide measurement at a single tertiary center. Patients were classified as having confirmed, suspected, or no HFpEF on high, intermediate, or low scores according to HFA-PEFF or H2FPEF. Additionally, patients were classified into three categories according to elevated natriuretic peptide levels and echocardiographic parameters following the 2021 ESC HF guideline. Among the 992 patients included, confirmed prevalence HFpEF ranged from 28.5% (2021 ESC) to 21.1% (HFA-PEFF) and 4.7% (H2FPEF). Significant differences in the prevalence of hypertension, atrial fibrillation, number of antihypertensive medications, natriuretic peptide levels, and echocardiographic parameters of diastolic dysfunction were observed among the three HFpEF groups, with the highest burden in the group defined by the H2FPEF score. Comparing the HFA-PEFF and H2FPEF scores, 40.2% of patients were classified into different likelihood categories for HFpEF depending on the score used. The overlap of patients diagnosed with confirmed HFpEF according to the three algorithms was limited to 3.5%. HFpEF prevalence in patients with unexplained dyspnea varied significantly depending on the algorithm applied.

Background: Shortage of organ donors in the Republic of Korea has become a major problem. To address this, it has been questioned whether heart transplant (HTx) allocation should be modified to reduce priority of older patients. We aimed to evaluate post-HTx outcomes according to recipient age and specific pre-HTx conditions using a nationwide prospective cohort. Methods: We analyzed clinical characteristics of 628 patients from the Korean Organ Transplant Registry who received HTx from January 2015 to December 2020. Enrolled recipients were divided into three groups according to age. We also included comorbidities including ambulatory status. Non-ambulatory status was defined as pre-HTx support with either extracorporeal membrane oxygenation, continuous renal replacement therapy, or mechanical ventilation. Results: Of the 628 patients, 195 were < 50 years, 322 were 50-64 years and 111 were >= 65 years at transplant. Four hundred nine (65.1%) were ambulatory and 219 (34.9%) were non- ambulatory. Older recipients tended to have more comorbidities, ischemic cardiomyopathy, and received older donors. Post-HTx survival was significantly lower in older recipients (P = 0.025) and recipients with non-ambulatory status (P < 0.001). However, in contrast to non-ambulatory recipients who showed significant survival differences according to the recipient's age (P = 0.004), ambulatory recipients showed comparable outcomes (P = 0.465). Conclusion: Our results do not support use of age alone as an allocation criterion. Transplant candidate age in combination with some comorbidities such as non-ambulatory status may identify patients at a sufficiently elevated risk at which suitability of HTx should be reconsidered.