Mode of Death After Acute Heart Failure Hospitalization - A Clue to Possible Mechanisms

Heart failure continues to be a leading cause of hospitalization worldwide, and acute heart failure (AHF) carries significant risk for short-term morbidity and mortality. Despite many trials of potential new therapies for AHF, there have been very few advances over the recent decades. In this review, we will examine mortality during and after AHF hospitalization, with an emphasis on available data on mode of death (MOD). We will also review data on the timing of different MOD after AHF and the effect of specific therapies, as well as what is known about the contribution of specific pathophysiological mechanisms. Finally, we discuss the potential utility of further study of MOD data for AHF and its application to drug development, risk stratification, and therapeutic tailoring to improve short- and long-term outcomes in AHF

Exercise Training in Patients With Chronic Heart Failure and Atrial Fibrillation

BACKGROUND: The safety and efficacy of aerobic exercise in heart failure (HF) patients with atrial fibrillation (AF) has not been well evaluated. OBJECTIVES: This study examined whether outcomes with exercise training in HF vary according to AF status. METHODS: HF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) randomized 2,331 ambulatory HF patients with ejection fraction ≤35% to exercise training or usual care. We examined clinical characteristics and outcomes (mortality/hospitalization) by baseline AF status (past history of AF or AF on baseline electrocardiogram vs. no AF) using adjusted Cox models and explored an interaction with exercise training. We assessed post-randomization AF events diagnosed via hospitalizations for AF and reports of serious arrhythmia caused by AF. RESULTS: Of 2,292 patients with baseline rhythm data, 382 (17%) had AF, 1,602 (70%) had sinus rhythm, and 308 (13%) had other rhythm. Patients with AF were older and had lower peak Vo CONCLUSIONS: AF in patients with chronic HF was associated with older age, reduced exercise capacity at baseline, and a higher overall rate of clinical events, but not a differential response to exercise training for clinical outcomes or changes in exercise capacity. (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training [HF-ACTION]; NCT00047437)

Relation of Angina Pectoris to Outcomes, Quality of Life, and Response to Exercise Training in Patients With Chronic Heart Failure (from HF-ACTION)

Angina pectoris (AP) is associated with worse outcomes in heart failure (HF). We investigated the association of AP with health-related quality of life (HRQoL), exercise capacity, and clinical outcomes and its interaction with exercise training in an HF population. We grouped 2,331 patients with HF with reduced ejection fraction in the Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION) trial of usual care ± exercise training according to whether they had self-reported AP by Canadian classification score. HRQoL and clinical outcomes were assessed by AP status. In HF-ACTION, 406 patients (17%) had AP at baseline (44% with Canadian classification score ≥II) with HF severity similar to those without AP. Patients with AP had similar baseline exercise capacity but worse depressive symptoms and HRQoL. AP was associated with 22% greater adjusted risk for all-cause mortality/hospitalizations, driven by hospitalizations. There was significant interaction between baseline AP and exercise training peak V

Patterns of Utilization and Clinical Adoption of 0.35 MR-Guided Radiation Therapy in the United States — Understanding the Transition to Adaptive, Ultra-Hypofractionated Treatments

Purpose/Objective(s): Magnetic resonance imaging-guided radiation therapy (MRgRT) utilization is rapidly expanding worldwide, driven by advanced capabilities including continuous intrafraction visualization, automatic triggered beam delivery, and on-table adaptive replanning. Our objective was to describe patterns of 0.35T-MRgRT utilization in the United States (US) among early adopters of this novel technology. Materials/Methods: Anonymized administrative data from all US 0.35T-MRgRT treatment systems were extracted for patients completing treatment from 2014-2020. Detailed treatment information was available for all 0.35T-MR Linac system and some cobalt system patients. Most cobalt patients were included in total only. Results: 17 systems at 16 centers treated 5,733 patients, delivering 40,171 fractions (fractions unavailable for 1,225 cobalt patients), of which 6,244 (15.5%) were adapted. Thirteen centers (81.3%) had treated for \u3e = 1 year, of which 9 treated \u3e 100 patients/year and 6 treated \u3e 150 patients/year. Ultra-hypofractionation (1-5 fractions) was delivered for 72.9% of all patients. The proportion of fractions adapted in patients receiving ultra-hypofractionation was 28.6%, with an average of 3.2 adapted fractions per course. The most commonly treated tumor types were pancreas (20.7%), liver (16.5%), prostate (12.5%), breast (11.5%), and lung (9.4%), respectively, with significantly increased number of fractions delivered from 2018-2020 compared to 2014-2017 for each (pancreas: 5,161 vs. 1,155; liver: 3,597 vs. 921; prostate: 5,795 vs. 1,398; breast: 2,221 vs. 1,876; lung: 2,589 vs. 660). The compound annual growth rate (CAGR) in the number of patients was 59.5%, growing from 111 in 2014 to 1,830 in 2020. Ultra-hypofractionation increased from 31.8% of all treated MR-Linac patients in 2014 to 87.0% in 2020 (n = 1,576/1,811). The proportion of adapted fractions in all patients and ultra-hypofractionation patients increased from 0% in the first two years to 24.3% (n = 3,071/12,639) and 33.8% (n = 2,677/7,911) respectively, by the end of 2020. No patient had adaptive treatment in 2014 although adaptive replanning steadily increased over time. For example, in 2020 vs. 2018 the proportion of adaptive fractions was highest for pancreas (60.6% vs. 50.8%), liver (17.8% vs. 9.9%), and lung (17.8% vs. 1.8%) cancers. Conclusion: This is the first comprehensive study reporting patterns of utilization among early adopters of a 0.35T-MRgRT system in the US. Intrafraction MR guidance, advanced motion management, and increasing adoption of adaptive RT has accelerated a transition to ultra-hypofractionation regimens. MRgRT has been predominantly used to treat abdominal and pelvic tumors, and increasingly with adaptive replanning, which is a radical departure from legacy radiotherapy practices