Thibaud Damy

Aims: Sexual health is a cornerstone of well-being among the least explored aspects of heart failure (HF) care. Guidelines offer minimal, male-focused recommendations, leaving female sexual health underaddressed. The ROMANT'IC study investigated how HF affects intimacy and sexuality across sex, age and symptom burden. Methods and results: ROMANT'IC was a national descriptive questionnaire study including1,398 patients with HF (921 men, 477 women; age 18–93 years). Overall, 655 (46.9%) provided detailed responses:491 (53.3%) men, 164 (34.4%) women indicating a reluctance to disclose information on sexuality (p<0.001). 57.8% men, and 53.7% women reported no sexual activity in the previous three months. Sexual inactivity varied significantly across age groups (χ2=17.02, p=0.001): 52.9% at 18–40 years, 50.0% at 41–55 years, 48.3% at 56–65 years, and 65.5% at ≥66 years and increased markedly with dyspnea severity: 47.8% at Grade 1, 50.3% at Grade 2, and 79.0% at Grades 3–4 (χ2=40.96, p<0.001). Men reported erectile dysfunction (49.0%) and treatment side effects (39.5%); women reported loss of desire (65.4%), reduced sense of seductiveness (61.5%), and depression (42.3%). Severe dyspnea independently predicted sexual inactivity (OR=3.88 [2.26–6.64], p<0.001), whereas sex and age were not significant after adjustment. Overall, 72–80% had never discussed sexuality with their cardiologist, regardless of dyspnea severity or age. Conclusion: HF profoundly alters sexuality. Dyspnea severity is the dominant independent driver of sexual inactivity and represents a potentially modifiable therapeutic target. These findings call for systematic, gender- and age-sensitive, dyspnea-graded sexual counselling in routine HF care.

Background: Acoramidis, an oral transthyretin stabilizer that achieves near-complete (≥90%) transthyretin stabilization, demonstrated significant clinical benefit over placebo in participants with transthyretin amyloid cardiomyopathy (ATTR-CM) in the phase 3 ATTRibute-CM trial (NCT03860935). Methods: Post-hoc exploratory analyses of ATTRibute-CM were performed to evaluate associations between outpatient worsening heart failure (HF) (initiation/escalation of oral loop diuretics) and clinical outcomes, the impact of acoramidis on outpatient worsening HF, and the effect of acoramidis on clinical outcomes adjusting for time-dependent first outpatient worsening HF. Results: In the modified-intention-to-treat population, 287/611 participants (46.97%) experienced outpatient worsening HF, which was associated with an increased risk of all-cause mortality (ACM)/recurrent cardiovascular hospitalization (CVH) (hazard ratio [HR] 1.95, 95% confidence interval [CI] 1.51–2.51), first CVH (HR 2.78, 95% CI 1.95–3.95), ACM (HR 1.64, 95% CI 1.14–2.36), and cardiovascular mortality (HR 1.63, 95% CI 1.08–2.46) through month 30. Acoramidis was associated with a 41% risk reduction of first outpatient worsening HF versus placebo (HR 0.59, 95% CI 0.46–0.75); Kaplan–Meier curves separated early, nominal statistical significance was first reached at day 30 (HR 0.562, 95% CI 0.317–0.998; P = .0492), and sustained nominal statistical significance was achieved at day 134 through month 30. When adjusting for time-dependent first outpatient worsening HF over 30 months, acoramidis reduced the risk of ACM/recurrent CVH and first CVH versus placebo. Conclusions: Outpatient worsening HF was associated with clinical outcomes in ATTR-CM. Acoramidis reduced the risk of outpatient worsening HF; effects emerged early and persisted throughout follow-up.

To the EditorsHereditary transthyretin amyloidosis (ATTRv) is an autosomal dominant, multisystemic disease caused by pathogenic variants in the transthyretin (TTR) gene, associated with a poor prog...

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.

Background Although cardiac amyloidosis (CA) is often considered to be a cause of heart failure with preserved ejection fraction (HFpEF), many patients present with mildly reduced (HFmrEF) or reduced ejection fraction (HFrEF). Recognising CA across this spectrum is essential for diagnosis and risk stratification. Methods We studied 2244 patients with CA (557 light chain amyloidosis, 392 hereditary transthyretin amyloidosis, 1137 wild-type transthyretin amyloidosis) at the French national reference centre. Left ventricular ejection fraction (LVEF) was classified according to European Society of Cardiology guidelines. We evaluated the prognostic relevance of LVEF and its interaction with global longitudinal strain (GLS) and cardiac index (CIx). Survival was assessed with a Kaplan-Meier analysis, and a decision tree combined LVEF, GLS and CIx. Our findings were confirmed externally in an independent, French validation cohort. Results Although HFpEF was the most common phenotype, 39% of patients presented with HFmrEF or HFrEF. The survival time varied with the phenotype; the median was 30 months in HFrEF, 40 months in HFmrEF and was not reached in HFpEF. LVEF correlated moderately with GLS and weakly with CIx. A decision tree integrating LVEF, GLS and CIx identified four prognostic groups with HRs for 4-year mortality ranging from 1.6 to 3.7. Conclusions CA affects the full spectrum of LVEF phenotypes. The integration of LVEF, GLS and CIx improves prognostic stratification and argues in favour of a multimodal imaging approach for early diagnosis and individualised management.

Aims: Acoramidis is an oral transthyretin (TTR) stabilizer that achieves near-complete (≥90%) TTR stabilization. This post-hoc analysis evaluated response categories based on NT-proBNP concentration and 6-minute walk distance (6MWD) changes among participants with transthyretin amyloid cardiomyopathy (ATTR-CM) in the phase 3 ATTRibute-CM trial. Methods: Clinically meaningful improvement (CMI) was defined as a decrease from baseline to Month 30 in NT-proBNP of >700 ng/L and >30%, and separately, a 6MWD increase of >35 m. Results: Data from 611 participants were analysed (409: acoramidis; 202: placebo). Median baseline NT-proBNP and 6MWD values were 2273 ng/L and 365 m in the acoramidis group and 2274 ng/L and 352 m in the placebo group, respectively. A significantly higher proportion of participants in the acoramidis group reached CMI in NT-proBNP or 6MWD (22.7%) compared with the placebo group (8.9%; OR 3.0, 95% CI 1.8–5.1; P < .001). Conclusion: Acoramidis led to CMI from baseline in NT-proBNP concentration or 6MWD in a considerable proportion of participants with ATTR-CM. These findings suggest that the treatment paradigm of ATTR-CM may evolve from slowing disease progression to achieving improvement.