Damien Logeart

Background: Current stroke prevention strategies in hypertrophic cardiomyopathy (HCM) rely on the detection of atrial fibrillation (AF), although thromboembolic events may occur before arrhythmia is documented. These observations support atrial cardiomyopathy as the substrate for thrombogenesis and highlight the need for imaging-guided risk stratification. Left atrial reservoir strain (LARS), derived from speckle-tracking echocardiography, detects atrial dysfunction earlier than left atrial enlargement and has been associated with AF and thromboembolic events. The LA-HCM trial evaluates whether rivaroxaban reduces thromboembolic events in patients with HCM, sinus rhythm, no documented AF, and impaired LARS. LA-HCM is a prospective, multicentre, randomized, open-label trial with blinded endpoint adjudication (PROBE design), sponsored by Rennes University Hospital and conducted in 17 French centres. A total of 532 adults with HCM, sinus rhythm, no documented AF, and core-laboratory-confirmed LARS ≤20% are randomized 1:1 to rivaroxaban or standard care. Participants are followed for 24 months. The primary endpoint is the composite of all-cause death, myocardial infarction, ischemic stroke—including newly detected silent cerebral infarction on paired baseline and 24-month brain MRI—and systemic embolism at 24 months. LA-HCM tests whether rivaroxaban improves outcomes in a population with HCM, no documented AF, and impaired LARS. It evaluates a LARS-based treatment-allocation strategy but is not designed to validate the predictive utility or optimal threshold of LARS.

Aims: Cardiac magnetic resonance (CMR) has a central role in the management of patients with acute heart failure (AHF), but timely access remains heterogeneous. We investigated real-world CMR use in patients hospitalized for AHF and its associations with demographic, clinical, and institutional characteristics. Methods and results: In the nationwide prospective OFICA2 cohort, conducted from March to April 2021 across 80 centres, we included 906 patients hospitalized for AHF, discharged alive, and without contraindications to CMR (mean age 74.7 years, 42.1% women). CMR use was identified through national billing codes during hospitalization and within 1 year using linked national administrative data. Analyses assessed CMR use across patient subgroups, hospital types, and care settings. Overall, 116 patients (12.8%) underwent CMR during hospitalization or within 1 year. CMR use was more frequent in younger patients, those without myocardial infarction, those with reduced LVEF, and patients with dilated rather than hypertensive or valvular cardiomyopathy. Among patients hospitalized for a first AHF episode, male sex was also associated with higher referral rates. CMR use varied across hospital types and care settings, with higher rates in university hospitals and intensive care units. Among patients with potential CMR indications according to the 2016 ESC Heart Failure guidelines, only 10.9% (class I) and 15.0% (class II) underwent the examination. Conclusion: In this nationwide AHF cohort, real-world use of CMR remained limited, even among patients with potential guideline-based indications, with marked patient- and institution-level disparities. These findings support coordinated efforts to improve timely access to CMR in heart failure care.

Background: Real-life data is very useful for gaining a better understanding of care in practice and identifying areas for improvement. This study aimed to assess changes in the clinical characteristics, care and outcomes of patients hospitalised with acute heart failure (HF). Methods: Two multicentre snapshot surveys were conducted in 2009 and 2021 following the same methodology and enrolled 1658 and 1513 patients, respectively. Clinical characteristics, hospitalisation pathways, in-hospital management and short-term outcomes during a 6-month follow-up were collected. Results: While the age of patients and the proportion in each left ventricular ejection fraction (LVEF) category remained largely unchanged (76 years and 53% with reduced LVEF in the two surveys), there was a rise in the prevalence of most comorbidities. Emergency department was the predominant and increasing route for hospitalisation (64–71%), and admission to critical care units remained frequent and stable (40%). In patients with reduced LVEF, the prescription rate of ACE inhibitors, angiotensin receptor blockers or angiotensin receptor-neprilysin inhibitors (ARNis) decreased from 77.8% to 70.6%, while the use of beta-blockers and mineralocorticoid receptor antagonists increased (67.7–74.2% and 26.6–35.5%, respectively) at discharge. Mortality at 1 and 6 months declined from 8.9% to 7.6% and from 24.7% to 21.3%, respectively. This difference was also significant after matching the two cohorts (HR 0.78 (0.66–0.94)). This improvement in mortality was observed in most patients except in the most elderly and those with preserved LVEF. Conclusions: A comparison of two cross-sectional surveys of acute HF, conducted 12 years apart, reveals an increasing burden of comorbidities, as well as a lack of dedicated admission pathways and a significant shortcoming in the prescription of evidence-based HF drugs on discharge. However, there has been a significant decrease in short-term mortality. Trial registration number: NCT01080937 and NCT05232058 .

Background: Despite significant advances in heart failure (HF) management, mortality and readmission rates remain persistently high. Low adherence has been recognised as a contributing factor, although supporting data remain limited. Objective: This study aimed to evaluate the impact of medication adherence on outcome following a HF hospitalisation. Methods: Patients who were discharged after HF hospitalisation were included in the study from a national multicentre HF cohort, and their records were matched with the National Healthcare System database, which includes all health-related claims and clinical events. Adherence to beta blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists were measured using the proportion of days covered (PDC). Low adherence was defined by PDC < 80% for at least one of the three HF drug classes. We then analysed the relationship between the PDC and outcome during a two-year follow-up period. Results: A total of 448 patients (median age: 73 years; 67% male; mean ejection fraction: 40%) were included. Of these patients, 152 (34%) were classified as having low adherence. The two-year mortality rate was comparable between the two groups (16.9% vs. 19.1% in adherent and low-adherent groups, respectively, p = 0.6). However, the rates of all-cause and HF rehospitalisations at two years were lower in the adherent group than in the group with low adherence (85.9% vs. 92.8%, p ≤ 0.01; 48.5% vs. 58.2%, p = 0.04, respectively). Conclusions: In patients discharged after acute HF, low adherence to HF drugs is frequent and worsens outcome, particularly the risk of rehospitalisation.