Aims Patients with advanced heart failure (HF) with reduced left ventricular ejection fraction (HFrEF) and concurrent coronavirus disease 2019 (COVID-19) might have a higher risk of severe events. Methods and results We retrospectively studied 16 patients with advanced HFrEF who developed COVID-19 between 1 March and 29 May 2020. Follow-up lasted until 30 September. Ten patients previously hospitalized with decompensated HFrEF were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during hospitalization. Six patients undergoing ambulatory care at initiation of COVID-19 symptoms were hospitalized because of advanced HFrEF. All patients who experienced worsening of HFrEF due to COVID-19 required higher doses or introduction of additional inotropic drugs or intra-aortic balloon pump in the intensive care unit. The mean intravenous dobutamine dose before SARS-CoV-2 infection in previously hospitalized patients (n = 10) and the median (inter-quartile range) peak intravenous dobutamine dose during SARS-CoV-2 infection in all patients (n = 16) were 2 (0-7) μg/kg/min and 20 (14-20) (P < 0.001), respectively. During follow-up, 56% underwent heart transplantation (n = 2) or died (n = 7). Four patients died during hospitalization from mixed shock consequent to severe acute respiratory syndrome with inflammatory storm syndrome associated with septic and cardiogenic shock during COVID-19. After COVID-19 recovery, two patients died from mixed septic and cardiogenic shock and one from sustained ventricular tachycardia and cardiogenic shock. Five patients were discharged from hospital to ambulatory care. Four were awaiting heart transplantation. Conclusion Worsening of advanced HF by COVID-19 is associated with high mortality. This report highlights the importance of preventing COVID-19 in patients with advanced HF.
In randomized clinical trials, sodium-glucose cotransporter-2 inhibitors (SGLT2i) have been shown effective in reducing the risk of cardiovascular (CV) death and hospitalization for chronic heart failure (CHF), as well as renal outcomes, regardless of the presence of diabetes. Despite these findings in patients with heart failure (HF) with reduced ejection fraction (EF) (HFrEF), retrospective subanalyses of patients with type 2 diabetes have suggested that many of preventable events have occurred in patients with a left ventricular (LV) EF (LVEF) greater than 40%. 1 In this regard, the Empagliflozin Outcome Trial in Patients with Chronic Heart Failure with Preserved Ejection Fraction (EMPEROR-Preserved) was carried out to evaluate the safety and efficacy of empagliflozin in patients with HFpEF. A total of 5988 patients with LVEF > 40% were randomized (Empagliflozin or placebo) and followed up for a median of 26.2 months; 45% of participants were women, symptomatic, with class II-IV heart failure, one hospitalization in the last year and N-terminal pro-Btype natriuretic peptide (NT-proBNP) levels of more than 300 pg/mL if in sinus rhythm or > 900 pg/mL if in atrial fibrillation NT-PRO-BNP. The primary outcomecomposite outcome of CV death or hospitalization for heart failure (HF) -occurred in 13.8% in the empagliflozin group and in 17.1% in the placebo group, with a hazard ratio of 0.79; 95% confidence interval (CI) of 0.69 to 0.90; p<0.001. No significant difference was found in CV death (HR 0.91, 95%CI 0.76-1.09), but a significant difference was observed in hospitalization for HF (HR 0.71, 95%CI 0.60-0.83), regardless of the presence of diabetes. However, this beneficial effect of empagliflozin was not detected in patients with EF>60% (HR 0.87, 95%CI 0.69-1.1) in a subgroup analysis and its limitations. 2 When the outcomes were stratified by EF, 33% of patients had EF between 41 and 49% and the others an EF>50%. No difference in the effect of the medication was seen between patients with EF > 50% and patients with EF<60% or 41-49% (Table 1). Empagliflozin was superior to placebo in improving the combined outcome regardless of the presence of diabetes in patients with
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