Sodium-Glucose Cotransporter-2 Inhibitor Use is Associated with a Reduced Risk of Heart Failure Hospitalization in Patients with Heart Failure with Preserved Ejection Fraction and Type 2 Diabetes Mellitus: A Real-World Study on a Diverse Urban Population

Background: Limited evidence-based therapies exist for the management of heart failure with preserved ejection fraction (HFpEF). Sodium-glucose cotransporter-2 inhibitor (SGLT2i) use in patients with systolic heart failure (HFrEF) and type-2-diabetes mellitus (T2DM) is associated with improved cardiovascular (CV) and renal outcomes. Objective: We sought to examine whether there is an association of SGLT2i use with improved CV outcomes in patients with HFpEF. Patients and methods: We conducted a single-center, retrospective review of patients with HFpEF and T2DM. The cohort was divided into two groups based on prescription of a SGLT2i or sitagliptin. The primary outcome was heart failure hospitalization (HFH); secondary outcomes were all-cause hospitalization and acute kidney injury (AKI). Results: After propensity score matching, there were 250 patients (89 in the SGLT2i group, 161 in the sitagliptin group), with a mean follow-up of 295 days. Univariate Cox regression analysis showed that the SGLT2i group had a reduced risk of HFH versus the sitagliptin group (hazard ratio (HR) 0.13; 95% confidence interval (CI) (0.05–0.36); p \u3c 0.001). The SGLT2i group had a decreased risk of all-cause hospitalization (HR 0.48; 95% CI (0.33–0.70); p \u3c 0.001) and SGLT2i had a lower risk of AKI (HR 0.39; 95% CI (0.20–0.74); p = 0.004). Conclusions: The use of SGLT2is is associated with a reduced incidence of HFH and AKI in patients with HFpEF and T2DM

ISSN 2347-954X (Print)

Abstract: Hypertriglyceridemia is a rare, but well known cause of acute pancreatitis. Presentation is often similar to other forms of acute pancreatitis, with lipemic serum usually the only distinguishing initial sign. Typically hypertriglyceridemia-induced pancreatitis occurs in a patient with a pre-existing lipid abnormality, along with the presence of a secondary precipitating factor e.g. poorly controlled diabetes, alcohol or medication. Secondary causes of hypertriglyceridemia have to be ruled out. Although the serum triglyceride threshold for considering hypertriglyceridemic pancreatitis is generally considered to be in the range of 1000mg/dl, the severity, clinical course and complication rate do not correlate with lipid levels. The mainstay of therapy is dietary restriction of fatty meal and fibric acid derivatives

Reflecting on the Advancements of HFrEF Therapies Over the Last Two Decades and Predicting What Is Yet to Come

What was once considered a topic best avoided, managing heart failure with reduced ejection fraction (HFrEF) has become the focus of many drug and device therapies. While the four pillars of guideline-directed medical therapies have successfully reduced heart failure hospitalizations, and some have even impacted cardiovascular mortality in randomized controlled trials (RCTs), patient-reported outcomes have emerged as important endpoints that merit greater emphasis in future studies. The prospect of an oral inotrope seems more probable now as targets for drug therapies have moved from neurohormonal modulation to intracellular mechanisms and direct cardiac myosin stimulation. While we have come a long way in safely providing durable mechanical circulatory support to patients with advanced HFrEF, several percutaneous device therapies have emerged, and many are under investigation. Biomarkers have shown promise in not only improving our ability to diagnose incident heart failure but also our potential to implicate specific pathophysiological pathways. The once forgotten concept of discordance between pressure and volume, the forgotten splanchnic venous and lymphatic compartments, have all emerged as promising targets for diagnosing and treating heart failure in the not-so-distant future. The increase in heart failure-related cardiogenic shock (CS) has revived interest in defining optimal perfusion targets and designing RCTs in CS. Rapid developments in remote monitoring, telemedicine, and artificial intelligence promise to change the face of heart failure care. In this state-of-the-art review, we reminisce about the past, highlight the present, and predict what might be the future of HFrEF therapies

Outcomes of Patients Transferred to Tertiary Care Centers for Treatment of Cardiogenic Shock: A Cardiogenic Shock Working Group Analysis: Outcomes of Patients Transferred for Treatment of Cardiogenic Shock

BACKGROUND: Consensus recommendations for cardiogenic shock (CS) advise transfer of patients in need of advanced options beyond the capability of \u27spoke\u27 centers to tertiary/ \u27hub\u27 centers with higher capabilities. However, outcomes associated with such transfers are largely unknown, beyond those reported in individual health networks. OBJECTIVES: To analyze a contemporary, multicenter CS cohort with an aim to compare characteristics and outcomes of patients between transfer (between spoke and hub center) and non-transfer cohorts (those primarily admitted to a hub center), for both acute myocardial infarction (AMI-CS) and heart failure related (HF-CS) shock. We also aim to identify clinical characteristics of the transfer cohort that are associated with in-hospital mortality. METHODS: The Cardiogenic Shock Working Group (CSWG) registry is a national, multicenter, prospective registry including high volume (mostly hub) CS centers. Fifteen U.S. sites contributed data for this analysis from 2016-2020. RESULTS: Of 1890 consecutive CS patients enrolled into the CSWG registry, 1028 (54.4%) patients were transferred. Of these, 528 (58.1%) had heart failure related CS (HF-CS) and 381 (41.9%) had CS related to acute myocardial infarction (AMI-CS). Upon arrival to the CSWG site, transfer patients were more likely to be in SCAI stage C and D, when compared to non-transfer patients. Transfer patients had higher mortality (37% vs. 29%, \u3c0.001) than non-transfer patients with the differences primarily driven by the HF-CS cohort. Logistic regression identified increasing age, mechanical ventilation, renal replacement therapy, and higher number of vasoactive drugs prior to, or within 24 hours after CSWG site transfer as independent predictors of mortality among HF-CS patients. Conversely, pulmonary artery catheter use prior to transfer, or within 24 hours of arrival was associated with decreased mortality. Among transfer AMI-CS patients BMI\u3e28 kg/m, worsening renal failure, lactate\u3e3 mg/dl and increasing number of vasoactive drugs were associated with increased mortality. CONCLUSION: More than half of CS patients managed at high volume CS centers were transferred from another hospital. Although transfer patients had higher mortality than those who were primarily admitted to hub centers, outcomes and their predictors varied significantly when classified by HF-CS versus AMI-CS

Nutritional status of adult patients with pulmonary tuberculosis in rural central India and its association with mortality.

Under-nutrition is a known risk factor for TB and can adversely affect treatment outcomes. However, data from India are sparse, despite the high burden of TB as well as malnutrition in India. We assessed the nutritional status at the time of diagnosis and completion of therapy, and its association with deaths during TB treatment, in a consecutive cohort of 1695 adult patients with pulmonary tuberculosis in rural India during 2004 - 2009.Multivariable logistic regression was used to obtain adjusted estimates of the association of nutritional status with deaths during treatment. At the time of diagnosis, median BMI and body weights were 16.0 kg/m(2)and 42.1 kg in men, and 15.0 kg/m(2)and 34.1 kg in women, indicating that 80% of women and 67% of men had moderate to severe under-nutrition (BMI<17.0 kg/m(2)). Fifty two percent of the patients (57% of men and 48% of women) had stunting indicating chronic under-nutrition. Half of women and one third of men remained moderately to severely underweight at the end of treatment. 60 deaths occurred in 1179 patients (5%) in whom treatment was initiated. Severe under-nutrition at diagnosis was associated with a 2 fold higher risk of death. Overall, a majority of patients had evidence of chronic severe under-nutrition at diagnosis, which persisted even after successful treatment in a significant proportion of them. These findings suggest the need for nutritional support during treatment of pulmonary TB in this rural population

Heart failure with preserved ejection fraction: recent concepts in diagnosis, mechanisms and management

International audienceIt is estimated that half of all patients with heart failure (HF) have HF with preserved ejection fraction (HFpEF). Yet this form of HF remains a diagnostic and therapeutic challenge. Differentiating HFpEF from other causes of dyspnoea may require advanced diagnostic methods, such as exercise echocardiography, invasive haemodynamics and investigations for ‘HFpEF mimickers’. While the classification of HF has relied heavily on cut-points in left ventricular ejection fraction (LVEF), recent evidence points towards a gradual shift in underlying mechanisms, phenotypes and response to therapies as LVEF increases. For example, among patients with HF, the proportion of hospitalisations and deaths due to cardiac causes decreases as LVEF increases. Medication classes that are efficacious in HF with reduced ejection fraction (HFrEF) have been less so at higher LVEF ranges, decreasing the risk of HF hospitalisation but not cardiovascular or all-cause death in HFpEF. These observations reflect the burden of non-cardiac comorbidities as LVEF increases and highlight the complex pathophysiological mechanisms, both cardiac and non-cardiac, underpinning HFpEF. Treatment with sodium-glucose cotransporter 2 inhibitors reduces the risk of composite cardiovascular events, driven by a reduction in HF hospitalisations; renin-angiotensin-aldosterone blockers and angiotensin-neprilysin inhibitors result in smaller reductions in HF hospitalisations among patients with HFpEF. Comprehensive management of HFpEF includes exercise as well as treatment of risk factors and comorbidities. Classification based on phenotypes may facilitate a more targeted approach to treatment than LVEF categorisation, which sets arbitrary cut-points when LVEF is a continuum. This narrative review summarises the pathophysiology, diagnosis, classification and management of patients with HFpEF

Distribution of pre-treatment and post-treatment body mass index (BMI) of adult patients with pulmonary tuberculosis treated successfully at JSS, 2004-2009.

<p>*BMI of 18.5 kg/m² is the cutoff separating under-nutrition (BMI<18.5 kg/m²) from normal range of BMI (18.5-24.99 kg/m²).</p

Distribution of body mass index (BMI) at diagnosis in adult patients with pulmonary Tuberculosis at JSS, 2004-9.

<p>*BMI of 18.5 kg/m² is the cutoff separating under-nutrition (BMI<18.5 kg/m²) from normal range of BMI (18.5-24.99 kg/m²).</p