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Objective: Acute heart failure (AHF) is a life-threatening clinical syndrome characterized by rapid onset of heart failure (HF) symptoms and signs and requires urgent therapy. The aim of the present study was to evaluate the overall clinical characteristics, management, and in-hospital outcomes of hospitalized patients with AHF in a large sample of Turkish population. Methods: The Journey HF-TR study is a cross-sectional, multicenter, non-invasive and observational trial. Patients who were hospitalized with a diagnosis of AHF in the intensive care unit (ICU)/coronary care unit and cardiology wards between September 2015 and September 2016 were included in our study. Results: A total of 1606 (male: 57.2%, mean age: 67.8±13 years) patients who were diagnosed with AHF were enrolled in the study. Seventeen percent of the patients were admitted to the hospital with a diagnosis of new onset AHF. Hypertension (67%) and coronary artery disease (CAD) (59.6%) were the most frequent underlying diseases. Acute coronary syndrome accompanying HF (14.7%), infection (29.3%), arrhythmia (25.1%), renal dysfunction (23%), and non-compliance with medication (23.8%) were the precipitating factors. The median length of stay in the ICU was 3 days (interquartile range, IQR 1–72) and 7 days (IQR 1–72) for in-hospital journey. The guideline recommended medications were less likely used in our patient population (<73%) before admission and were similar to European and US registers at discharge. The in-hospital mortality rate was 7.6%. Hypertension and CAD were the most frequent underlying diseases in our population similar to other European surveys. Although our study population was younger than other registers, in-hospital mortality was high. Conclusion: Analyses of such real-world data will help to prepare a national database and distinctive diagnosis and treatment algorithms and to provide observing compliance with the current European Society of Cardiology guidelines for more effective management of HF.

Introduction: Immune checkpoint inhibitor (ICI)-myocarditis is a new syndrome with estimated 50% mortality. Similar to acute cellular rejection (ACR), it is pathologically characterized by lymphocytic infiltration. We aimed to characterize the electrocardiograph features of ICI-myocarditis, compare them to ACR, and evaluate their association with adverse outcome. Methods: Presenting ECG of 130 cases of ICI-myocarditis were collected from a multicenter network spanning 12 countries and compared to 50 cases of ACR. ECG were quantified and interpreted by two blinded cardiologists. 53 patients with ICI-myocarditis had baseline ECG available for comparison via paired univariate analysis. Cox models correcting for age and sex determined association with a composite outcome of life-threatening arrhythmia or myocarditis-related death. Results: ICI-myocarditis patients had average age of 68(58-76), were 61.2% male, and 64.8% had prior cardiovascular disease. QRS prolongation (26% vs 13%, p=0.008), conduction disorders (67% vs 44%, p=0.007) such as left bundle branch block (LBBB) (18% vs 4% p=0.008), ST/T wave changes (50% vs 24%, p=0.004), and PVCs (16% vs 6%, p=0.020) were more prevalent on presenting ECG compared to baseline. ICI-myocarditis showed more PVCs (16% vs 2%, p=0.011) and less ST/T wave changes (41% vs 66%, p=0.002) when compared to ACR. On multivariate analysis, the combined outcome of life-threatening arrhythmia or myocarditis-related death was associated with pathological Q waves (HR=3.60 (1.78-7.27) p<0.001), QRS prolongation (HR=3.35 [1.00-11.21] p=0.05), LBBB (HR=2.24 [1.13-4.45] p=0.021), and supraventricular arrhythmia (HR=2.03 [1.05-3.91] p=0.035) on presenting EKG. Conclusions: ICI-myocarditis manifests as new conduction delays, ST/T-wave changes, and PVCs. QRS prolongation, LBBB, pathological Q waves, and supraventricular arrhythmias were associated with subsequent adverse outcomes.

Importance: Immune-checkpoint inhibitor (ICI)-myocarditis often presents with arrhythmias, but electrocardiographic (ECG) findings have not been well described. ICI-myocarditis and acute cellular rejection (ACR) following cardiac transplantation share similarities on histopathology; however, whether they differ in arrhythmogenicity is unclear. Objectives: To describe ECG findings in ICI-myocarditis, compare them to ACR, and evaluate their prognostic significance. Design: Cases of ICI-myocarditis were retrospectively identified through a multicenter network. Grade 2R or 3R ACR was retrospectively identified within one center. Two blinded cardiologists interpreted ECGs. Setting: 49 medical centers spanning 11 countries. Participants: 147 adults with ICI-myocarditis, 50 adults with ACR. Exposure: Myocarditis after ICI exposure per European Society of Cardiology criteria for clinically suspected myocarditis, grade 2R or 3R ACR per the International Society for Heart and Lung Transplantation working formulation for biopsy diagnosis of rejection. Outcomes: All-cause mortality, myocarditis-related mortality; and composite endpoint (defined as myocarditis-related mortality and life-threatening ventricular arrhythmia). Results: Of 147 patients, the median age was 67 years (58-77) with 92 (62.6%) men. At 30 days, ICI-myocarditis had an all-cause mortality of 39/146(26.7%), myocarditis-related mortality of 24/146(16.4%), and composite endpoint of 37/146(25.3%). All-cause mortality was more common in patients who developed complete heart block (12/25[48%] vs 27/121[22.3%], hazard ratio (HR)=2.62, 95% confidence interval [1.33-5.18],p=0.01) or life-threatening ventricular arrhythmias (12/22[55%] vs 27/124[21.8%], HR=3.10 [1.57-6.12],p=0.001) within 30 days after presentation. Compared to ACR, patients with ICI-myocarditis were more likely to experience life-threatening ventricular arrhythmias (22/147 [16.3%] vs 1/50 [2%];p=0.01) or third-degree heart block (25/147 [17.0%] vs 0/50 [0%];p=0.002). In ICI-myocarditis, overall mortality, myocarditis-related mortality, and composite outcome adjusted for age and sex were associated with pathological Q-waves on presenting ECG (hazard ratio by subdistribution model [HR(sh)]=5.98[2.8-12.79],p<.001; 3.40[1.38-8.33],p=0.008; 2.20[0.95-5.12],p=0.07; respectively) but inversely associated with Sokolow-Lyon Index (HR(sh)/mV=0.57[0.34-0.94],p=0.03; HR(sh)=0.54[0.30-0.97],p=0.04; 0.50[0.30-0.85],p=0.01; respectively). The composite outcome was also associated with conduction disorders on presenting ECG (HR(sh)=3.27[1.29-8.34],p=0.01). Conclusions: ICI-myocarditis has more life-threatening arrhythmias than ACR and manifests as decreased voltage, conduction disorders, and repolarization abnormalities . Ventricular tachycardias, complete heart block, low-voltage, and pathological Q-waves were associated with adverse outcomes.

Impact of uric acid on clinical outcomes Y. Niu et al.

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Impact of uric acid on clinical outcomes Y. Niu et al.