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The period following heart failure hospitalization (HFH) is a vulnerable time with high rates of death or recurrent HFH.OBJECTIVE To evaluate clinical characteristics, outcomes, and treatment response to vericiguat according to prespecified index event subgroups and time from index HFH in the Vericiguat Global Study in Subjects With Heart Failure With Reduced Ejection Fraction (VICTORIA) trial. DESIGN, SETTING, AND PARTICIPANTSAnalysis of an international, randomized, placebo-controlled trial. All VICTORIA patients had recent (<6 months) worsening HF (ejection fraction <45%). Index event subgroups were less than 3 months after HFH (n = 3378), 3 to 6 months after HFH (n = 871), and those requiring outpatient intravenous diuretic therapy only for worsening HF (without HFH) in the previous 3 months (n = 801). Data were analyzed between May 2, 2020, and May 9, 2020.INTERVENTION Vericiguat titrated to 10 mg daily vs placebo. MAIN OUTCOMES AND MEASURESThe primary outcome was time to a composite of HFH or cardiovascular death; secondary outcomes were time to HFH, cardiovascular death, a composite of all-cause mortality or HFH, all-cause death, and total HFH. RESULTS Among 5050 patients in the VICTORIA trial, mean age was 67 years, 24% were women, 64% were White, 22% were Asian, and 5% were Black. Baseline characteristics were balanced between treatment arms within each subgroup. Over a median follow-up of 10.8 months, the primary event rates were 40.9, 29.6, and 23.4 events per 100 patient-years in the HFH at less than 3 months, HFH 3 to 6 months, and outpatient worsening subgroups, respectively. Compared with the outpatient worsening subgroup, the multivariable-adjusted relative risk of the primary outcome was higher in HFH less than 3 months (adjusted hazard ratio, 1.48; 95% CI, 1.27-1.73), with a time-dependent gradient of risk demonstrating that patients closest to their index HFH had the highest risk. Vericiguat was associated with reduced risk of the primary outcome overall and in all subgroups, without evidence of treatment heterogeneity. Similar results were evident for all-cause death and HFH. Addtionally, a continuous association between time from HFH and vericiguat treatment showed a trend toward greater benefit with longer duration since HFH. Safety events (symptomatic hypotension and syncope) were infrequent in all subgroups, with no difference between treatment arms.CONCLUSIONS AND RELEVANCE Among patients with worsening chronic HF, those in closest proximity to their index HFH had the highest risk of cardiovascular death or HFH, irrespective of age or clinical risk factors. The benefit of vericiguat did not differ significantly across the spectrum of risk in worsening HF.

Aims: Because of the prognostic importance of LV dysfunction following an AMI and the increasing use of electrical and/or mechanical interventions in patients with LV systolic dysfunction, this retrospective analysis of EPHESUS patients with LVEF 30% at baseline was conducted to determine the value of eplerenone in this setting. Methods and results: In EPHESUS, 6632 patients with LVEF 40% and clinical heart failure (HF) post-AMI who were receiving standard therapy were randomized to eplerenone 25 mg/day titrated to 50 mg/day or placebo for a mean follow-up of 16 months. Treatment with eplerenone in the subgroup of patients with LVEF 30% (N = 2106) resulted in relative risk reductions of 21% versus placebo in both allcause mortality ( P = 0.012) and cardiovascular (CV) mortality/CV hospitalization ( P = 0.001), and 23% for CV mortality ( P = 0.008). The relative risk of sudden cardiac death (SCD) was reduced 33% ( P = 0.01) and HF mortality/HF hospitalization was reduced 25% ( P = 0.005) with eplerenone compared with placebo. Within 30 days of randomization, eplerenone resulted in relative risk reductions of 43% for all-cause mortality ( P = 0.002), 29% for CV mortality/CV hospitalization ( P = 0.006), and 58% for SCD ( P = 0.008). Conclusions: Treatment with eplerenone plus standard therapy in patients with post-AMI HF and LVEF 30% provided significant incremental benefits in reducing both early and late mortality and morbidity.

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SummaryIt was the aim of the study to develop a new surgical method to repair the so called rectovestibulum fistula (RVF) in the horse: In this context it was intended to combine and take up advantageous aspects of methods already established in plastic surgery for this traumatically caused defect. Known disadvantages of the different methods such as surgical transfer of the fistula to a third degree perineal laceration, difficult practicability and high incidence of recidives were minimized. The primary aspect of the new surgical method is the surgical transfer and inclusion of a second degree perineal laceration by which main parts of the perineal body and shincter ani in toto are maintained. After training phases for general feasability of the new procedure surgery was simulated on isolated pelvic organs (n = 15) and in straight before sacrified animals (n= 8) the operations were performed on 6 experimental and 4 client mares. The healing process until the removal of the sutures was without any clinical complications. On the average the clinical healing of the fistula operated was completed after two weeks. Complications such as intestinal constipation, tenesmus, excessive inflammatory reactions or general worsening of well-being of the mares did not show up in any case. In 8 of 10 cases the fistula was completely closed after a first surgery. In two (experimental mares) of the 10 cases there was a recidive of a now considerable smaller fistula which was in one mare closed and healed after a second surgery. In one of these two mares a second recidive occured demanding a third surgery session. Ultrasound measurements revealed a remarkable increase of the interrectovestibular tissue. After euthanasia of the experimental mares pathologicalanatomical and histological examinations of the rectal bottom and vestibulum roof within the area of the surgical site revealed similar results in all samples prooving a definite healing with scars which has to be regarded as stable. As a conclusion it can be stated that the new established plastic surgery of RVF can be recommended for practical use as it fulfilled the main aims of (1) durable and stable surgical closure of the RVF, (2) maintenance of integrity of the closing function of the anal sphincter, and (3) reliable external genital closure. Keywords:mare, rectovaginal fistula, plastic surgery, perineal integrity