Acute heart failure and iron deficiency: a prospective, multicentre, observational study

Aims

The prevalence and the natural course of iron deficiency (ID) in acute heart failure (AHF) are still unclear. We investigated the prevalence of ID in unselected patients admitted with AHF on admission, at discharge and up to 3 months thereafter.

Methods and results

In this prospective, multicentre, observational study, 742 patients admitted with AHF were enrolled. The main study outcome was the percentage of patients with ID (ferritin <100 μg/L = absolute ID or ferritin 100–299 μg/L and transferrin saturation <20% = functional ID) at admission (T0), after clinical stabilization prior to discharge (T1), and 10 ± 6 weeks after discharge (T2). At T0, ID was present in 71.8% of the patients (44.1% absolute and 27.7% functional ID). At T1 and T2, ID was present in 56.4% (32.4% absolute and 24% functional ID) and 50.3% (36.8% absolute and 13.5% functional ID), respectively. Absolute ID persisted from T0 to T2 in 66% of the patients, while functional ID resolved in 56% of the patients. Ferritin (median [interquartile range] 124 μg/L [56–247] to 150 μg/L [73–277]), transferrin saturation (15% [10–20] to 18% [12–27]), and iron levels (9 μmol/L [6–13] to 11 μmol/L [8–16]) increased significantly (all P < 0.001) from T0 to T1. Transferrin saturation (to 21% [15–29]) and iron levels (to 13 μmol/L [9–17]) also increased significantly (both P < 0.01) from T1 to T2 without iron supplementation.

Conclusions

Iron deficiency is highly prevalent in patients with AHF, but resolves during treatment in some patients, even without iron supplementation. Absolute ID is more likely to persist over time, whereas functional ID often resolves during treatment of AHF, representing probably a reduced iron availability rather than a true deficiency.

The Prognostic Impact of Hospital Transfer after Admission due to Acute Heart Failure

The prognostic impact of transfer to another hospital among acute heart failure (AHF) patients has not been well elucidated.Of the 800 AHF patients analyzed, 682 patients were enrolled in this study for analysis. The subjects were divided into two groups according to their discharge location: discharge home (Group-H, n = 589) or transfer to another hospital for rehabilitation (Group-T, n = 93). The Kaplan-Meier curves revealed a poorer prognosis, including all-cause death and heart failure (HF) events (death, readmission-HF), in Group-T than that in Group-H (P < 0.001, respectively). A multivariate Cox regression model showed that Group-T was an independent predictor of 365-day all-cause death (hazard ratio: 2.618, 95% confidence interval [CI]: 1.510-4.538, P = 0.001). The multivariate logistic regression analysis showed that aging (per 1-year-old increase, odds ratio [OR]: 1.056, 95% CI: 1.028-1.085, P < 0.001), female gender (OR: 2.128, 95% CI: 1.287-3.521, P = 0.003), endotracheal intubation during hospitalization (OR: 2.074, 95% CI: 1.093-3.936, P = 0.026), and increased Controlling Nutritional Status score on admission (per 1.0-point increase, OR: 1.247, 95% CI: 1.131-1.475, P < 0.001) were associated with transfer to another hospital after AHF admission. The prognosis, including all-cause death, was determined to be significantly poorer in patients who were transferred to another hospital, as their activities of daily living were noted to lessen before discharge (n = 11) compared to others (n = 82).Elderly AHF patients suffering from malnutrition were difficult to discharge home after AHF admission, and transfer to another hospital only led to adverse outcomes. Appropriate rehabilitation during definitive hospitalization appears necessary for managing elderly patients in the HF pandemic era.

Sodium-based osmotherapy for hyponatremia in acute decompensated heart failure

Acute decompensated heart failure (ADHF) accounts for more than 1 million hospital admissions annually and is associated with high morbidity and mortality. Decongestion with removal of increased total body sodium and total body water are goals of treatment. Acute kidney injury (AKI) or chronic kidney disease (CKD) is present in two-thirds of patients with ADHF. The pathophysiology of ADHF and AKI is bidirectional and synergistic. AKI and CKD complicate the management of ADHF by decreasing diuretic efficiency and excretion of sodium and water. Among patients hospitalized with ADHF, hyponatremia is the most common electrolyte abnormality and is classically encountered with volume overload. ADHF represents an additional therapeutic challenge particularly when oligoanuria is present. Predilution continuous venovenous hemofiltration with sodium-based osmotherapy can safely increase plasma sodium concentration without deleteriously increasing total body sodium. We present a detailed methodology that addresses the issue of hypervolemic hyponatremia in patients with ADHF and AKI.

Inpatient versus outpatient intravenous diuresis for the acute exacerbation of chronic heart failure

BACKGROUND

We established an IV outpatient diuresis (IVOiD) clinic and conducted a quality improvement project to evaluate safety, effectiveness and costs associated with outpatient versus inpatient diuresis for patients presenting with acute decompensated heart failure (ADHF) to the emergency department (ED).

METHODS

Patients who were clinically diagnosed with ADHF in the ED, but did not have high-risk features, were either diuresed in the hospital or in the outpatient IVOiD clinic. The dose of IV diuretic was based on their home maintenance diuretic dose. The outcomes measured were the effects of diuresis (urine output, weight, hemodynamic and laboratory abnormalities), 30-90 day readmissions, 30-90 day death and costs.

RESULTS

In total, 36 patients (22 inpatients and 14 outpatients) were studied. There were no significant differences in the baseline demographics between groups. The average inpatient stay was six days and the average IVOiD clinic days were 1.2. There was no significant difference in diuresis per day of treatment (1159 vs. 944 ml, p = 0.46). There was no significant difference in adverse outcomes, 30-90 day readmissions or 30-90 day deaths. There was a significantly lower cost in the IVOiD group compared to the inpatient group ($839.4 vs. $9895.7, p=<0.001).

CONCLUSIONS

Outpatient IVOiD clinic diuresis may be a viable alternative to accepted clinical practice of inpatient diuresis for ADHF. Further studies are needed to validate this in a larger cohort and in different sites.

Effects of intravenous furosemide plus small-volume hypertonic saline solutions on markers of heart failure

AIMS

We sought to compare the effects of furosemide + hypertonic saline solution (HSS) treatment in patients with acute decompensated heart failure in comparison with furosemide alone and the response in a compensated state after an acute saline load with regard to serum levels of heart failure biomarkers.

METHODS AND RESULTS

We enrolled 141 patients with acute decompensated heart failure with reduced ejection fraction admitted to our Internal Medicine ward from March 2017 to November 2019. A total of 73 patients were randomized to treatment with i.v. high-dose furosemide plus HSS, whereas 68 patients were randomized to i.v. high-dose furosemide alone. Patients treated with furosemide plus HSS compared with controls treated with furosemide alone showed a comparable degree of reduction in the serum levels of interleukin (IL)-6, soluble suppression of tumorigenicity 2 (sST2), and N-terminal pro-brain natriuretic peptide (NT-proBNP) in the 'between-group' analysis. Nevertheless, patients treated with high-dose furosemide + HSS showed significantly higher absolute delta values of IL-6 (2.3 ± 1.2 vs. 1.7 ± 0.9, P < 0.0005, and 2.0 ± 0.8 vs. 1.85 ± 1.1, P = 0.034), sST2 (41.2 ± 8.6 vs. 27.9 ± 7.6, P < 0.0005, and 37.1 ± 6.6 vs. 28.4 ± 6.7, P < 0.0005), high-sensitivity troponin T (0.03 ± 0.02 vs. 0.02 ± 0.01, P = 0.001, and 0.03 ± 0.02 vs. 0.02 ± 0.01, P = 0.009), NT-proBNP (7237 ± 7931 vs. 3244 ± 4159, P < 0.005, and 5381 ± 4829 vs. 4466 ± 4332, P = 0.004), and galectin-3 (15.7 ± 3.2 ng/mL vs. 11.68 ± 1.9 ng/mL, P < 0.0005, and 16.7 ± 3.9 ng/mL vs. 11.8 ± 2.4 ng/mL, P < 0.0005) than patients treated with furosemide alone. After acute saline load, patients treated with i.v. furosemide + HSS in comparison with subjects treated with furosemide alone showed a significantly lower increase in the serum concentrations of IL-6 (-0.26 ± 0.42 pg/mL vs. -1.43 ± 0.86 pg/mL, P < 0.0005), high-sensitivity troponin T (0 vs. -0.02 ± 0.02 ng/mL, P < 0.0005), sST2 (-8.5 ± 5.9 ng/mL vs. -14.6 ± 6.2 ng/mL, P < 0.0005), galectin-3 (-2.1 ± 1.5 ng/mL vs. -7.1 ± 3.6 ng/mL, P < 0.0005), and NT-proBNP (77 ± 1373 vs. -1706 ± 2259 pg/mL, P < 0.0005).

CONCLUSIONS

Our findings concerning a comparable degree of reduction in the serum levels of three cardinal biomarkers indicate that a reduction in serum heart failure markers is not linked to the higher degree of congestion relief with a more rapid achievement of a clinical compensation state. This issue may have possible benefits on clinical practice concerning its therapeutic effects over and beyond the simple amelioration of clinical congestion signs and symptoms. Nevertheless, our findings of higher delta values after treatment with i.v. furosemide plus HSS indicate a possible higher efficacy by means of modulation of the stretching and fibrosis mechanisms.

Underweight Is Associated with Poor Prognosis in Heart Failure with Preserved Ejection Fraction

The obesity paradox states higher body mass index (BMI) is associated with better outcomes than normal weight in patients with heart failure with preserved ejection fraction (HFpEF). However, underweight was defined by BMI < 18.5 kg/m², and results have been inconclusive, in part due to small number of participants. The number of underweight patients with HFpEF is higher in Asian than in Western countries. In this study, we aim to determine the prognostic impact of underweight in patients with HFpEF in Asian population.We enrolled 846 consecutive patients from the PURSUIT-HFpEF registry. We then divided them into three groups by BMI, namely, underweight (BMI < 18.5 kg/m²), normal weight (18.5 ≤ BMI < 23), and overweight (23 ≤ BMI). The underweight group consisted of 187 patients (22%). Over a mean follow-up of 407 days, 105 deaths were reported as all-cause mortality. On multivariable Cox analysis, the underweight group was determined to be significantly associated with higher risk of all-cause mortality than the normal and overweight groups (Hazard ratios [HR]: 2.33; 95% confidence intervals [CI]: 1.45-3.75, P < 0.001; HR: 3.54; 95% CI: 1.99-6.29, P < 0.001, respectively), after adjustment for age, sex, vital signs, and comorbidities.Underweight is a useful predictor of poor prognosis in patients with HFpEF in Asian population.

Do we need a simplified model to predict outcomes in patients hospitalized with Acute Decompensated Heart Failure? Results from The Role of Sodium in Heart Failure Outcomes Prediction ('SHOUT-PREDICTION') study

Context

Hyponatremia is associated with high in-hospital mortality in patients with acute decompensated Heart Failure (ADHF) and is one of the components in various risk scores in heart failure (HF). However, some risk scores predict outcomes in these patients without using hyponatremia as its component.

Aim

The study was aimed to evaluate the relationship between serum sodium levels at admission and clinical outcomes during the in-hospital course and three months’ follow-up, in patients admitted in the intensive cardiac care unit (ICCU) with ADHF.

Methods and material

This was a single-center prospective, observational study in which 130 consecutive patients admitted with ADHF were observed for clinical characteristics and blood investigation at admission and their clinical outcomes during the in-hospital course and follow-up of 3 months.

Results

Hyponatremia and systolic blood pressure (SBP) both were found to be the independent predictor of in-hospital mortality. The SXS score (calculated as a product of SBP and serum sodium, divided by 1000) as a new prediction variable was significantly associated with in-hospital mortality and was compared with the Get with the guideline HF (GWTG-HF) score and ADHF national registry (ADHERE) score. The SXS score showed the best overall accuracy in predicting in-hospital mortality [area under the curve (AUC) = 0.899] as compared to the ADHERE (AUC = 0.780) and the GWTG (AUC = 0.815).

Conclusions

A score derived from the product of serum sodium and SBP (SXS score) had a significant association with in-hospital mortality, and better predictive value as compared to GWTG and ADHERE risk score in these patients.

Frailty in patients with acute decompensated heart failure in a super-aged regional Japanese cohort

AIMS

The aim of this study was to investigate clinical characteristics of frail patients based on a comprehensive frailty assessment in patients hospitalized for acute decompensated heart failure (HF) (ADHF) in super-aged regional Japanese cohort.

METHODS AND RESULTS

We established the Kochi Registry of Subjects with Acute Decompensated Heart Failure (Kochi YOSACOI) study, which was a prospective multicentre community-based cohort study in six participating hospitals in Kochi Prefecture, Japan. We enrolled 1061 patients (median age, 81 years; 50.0% men) hospitalized for ADHF between June 2017 and December 2019 in this registry. Patients were classified into the three groups by the severity of frailty using the Kihon Checklist: we identified frailty in 510 patients (53.7%), prefrailty in 293 patients (30.9%), and non-frailty in 146 patients (15.4%). Compared with prefrail and non-frail patients, frail patients were older (84 years interquartile range [IQR, 77-88] vs. 79 years [IQR, 69-86] and 72 years [IQR 65-81], P < 0.001) and more often had prior HF hospitalization (29.6% vs. 21.8% and 16.4%, P < 0.05), chronic kidney disease (81.6% vs. 71.7% and 61.0%, P < 0.01), anaemia (75.3% vs. 61.4% and 50.0%, P < 0.001), cerebrovascular accident (19.0% vs. 9.9% and 4.1%, P < 0.01). The proportion of patients with three or more comorbidities was larger in the frailty group than in the other groups (78.0% vs. 67.2% and 63.0%, P < 0.01). The frequency of functional decline in all domains increased with frailty status. Approximately 70% of frail patients were identified as functional decline in physical function and socialization domains. Fifty to sixty per cent of frail patients had functional decline in instrumental activities of daily living, cognitive function, and depression domains. The percentage of worsening walking ability during hospitalization was increasing with the frailty status (frailty, 27.5%; prefrailty, 21.8%; non-frailty, 8.9%). In multivariate logistic regression analysis, frailty was associated with age [odds ratio (OR) 1.031, 95% confidence interval (CI) 1.011-1.052, P = 0.003], prior HF hospitalization (OR 1.789, 95% CI 1.165-2.764, P = 0.008), brain natriuretic peptide level at discharge (OR 1.001, 95% CI 1.000-1.001, P = 0.020) and prior cerebrovascular accident (OR 2.549, 95% CI 1.484-4.501, P < 0.001).

CONCLUSIONS

More than half of patients with ADHF were frail and had functional decline across multiple domains, not only physical function domain. The Kihon Checklist provided useful and valuable information for easily identifying frail patients and comprehensive management of HF.

Clinical Significance of the Fibrosis-4 Index in Patients with Acute Heart Failure Requiring Intensive Care

The Fibrosis-4 (FIB4) index could indicate the liver fibrosis in patients with chronic hepatic diseases. It was calculated using the following formula: (age × aspartate aminotransferase [U/L]) / (platelet count [10³/μL] × √alanine aminotransferase [U/L]). However, the clinical impact of the FIB4 index in the acute phase of acute heart failure (AHF) has not been sufficiently investigated.A total 1,468 AHF patients were analyzed. The median FIB4 index was 2.71 [1.85-4.22]. The patients were divided into three groups according to the quartiles of their FIB4 index (low-FIB4 [Q1, ≤ 1.847], middle-FIB4 [Q2/Q3, 1.848-4.216], and high-FIB4 [Q4, ≥ 4.216] groups). A Kaplan-Meier curve analysis showed that the prognosis, such as all-cause mortality and HF events within 365 days, was significantly poorer in the high-FIB4 group than in the middle-FIB4 and low-FIB4 groups. A multivariate Cox regression model identified high FIB4 index as an independent predictor of 365-day all-cause death (hazard ratio (HR): 1.660, 95% CI: 1.136-2.427) and HF events (HR: 1.505, 95% CI: 1.145-1.978). The multivariate logistic regression analysis showed that the high plasma volume status (PVS) (Q4, odds ratio [OR]: 2.099, 95% CI: 1.429-3.082), low systolic blood pressure (SBP) (< 100 mmHg, OR: 3.825, 95% CI: 2.504-5.840), and low left ventricular ejection fraction (< 40%, OR: 1.321, 95% CI: 1.002-1.741) were associated with a high FIB4 index.A high FIB4 index can predict adverse outcomes in AHF patients, which indicate that congestive liver and liver hypoperfusion occur due to low cardiac output in the acute phase of AHF.

Impact of Atrial Fibrillation on the Prognosis of Acute Decompensated Heart Failure With and Without Mitral Regurgitation

Background: Atrial fibrillation (AF) and mitral regurgitation (MR) are frequently combined in patients with heart failure (HF). However, the effect of AF on the prognosis of patients with HF and MR remains unknown.

Methods and Results: We studied 867 patients (mean age 73 years; 42.7% female) with acute decompensated HF (ADHF) in the NARA-HF registry. Patients were divided into 4 groups based on the presence or absence of AF and MR at discharge. Patients with severe MR were excluded. The primary endpoint was the composite of cardiovascular (CV) death and HF-related readmission. During the median follow-up of 621 days, 398 patients (45.9%) reached the primary endpoint. In patients with MR, AF was associated with a higher incidence of the primary endpoint regardless of left ventricular function; however, in patients without MR, AF was not associated with CV events. Cox multivariate analyses showed that the incidence of CV events was significantly higher in patients with AF and MR than in patients with MR but without AF (hazard ratio 1.381, P=0.036). Similar findings were obtained in subgroup analysis of patients with AF and only mild MR.

Conclusions: The present study demonstrated that AF is associated with poor prognosis in patients with ADHF with mild to moderate MR, but not in those without MR.

Combined use of low T3 syndrome and NT-proBNP as predictors for death in patients with acute decompensated heart failure

BACKGROUND

In patients with established HF, low triiodothyronine syndrome (LT3S) is commonly present, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a useful marker for predicting death. This study was aimed to evaluate the prognostic value of LT3S in combination with NT-proBNP for risk of death in patients with heart failure (HF).

METHODS

A total of 594 euthyroid patients hospitalized with acute decompensated HF were enrolled by design. Of these patients, 27 patients died during hospitalization and 100 deaths were identified in patients discharged alive during one year follow-up. Patients were divided into 2 groups on the base of the reference ranges of free T3 (FT3) levels: LT3S group (FT3 < 2.3pg/mL, n = 168) and non-LT3S group (FT3 ≥ 2.3pg/mL, n = 426).

RESULTS

In multivariable Cox regression, LT3S was significantly associated with 1 year all-cause mortality (adjusted hazard ratio, 1.85; 95 % confidence interval [CI], 1.21 to 2.82; P = 0.005), but not significant for in-hospital mortality (adjusted hazard ratio, 1.58; 95 % CI, 1.58 to 2.82; P = 0.290) after adjustment for clinical variables and NT-proBNP. Addition of LT3S and NT-proBNP to the prediction model with clinical variables significantly improved the C statistic for predicting 1 year all-cause mortality.

CONCLUSIONS

In patients with acute decompensated HF, the combination of LT3S and NT-proBNP improved prediction for 1 year all-cause mortality beyond established risk factors, but was not strong enough for in-hospital mortality.

Early Goal-Directed Renal Replacement Therapy in Acute Decompensated Heart Failure Patients with Cardiorenal Syndrome

INTRODUCTION

The aim of this study was to clarify the efficacy of early goal-directed renal replacement therapy (GDRRT) for treatment of cardiorenal syndrome (CRS) patients after acute decompensated heart failure (ADHF).

METHODS

In the retrospective, observational study, we enrolled 54 patients in the early GDRRT group and 63 patients in the late GDRRT group. Baseline characteristics, clinical data at initiation renal replacement therapy time, and the clinical outcome were collected and several parameters were compared and analyzed between 2 groups.

RESULTS

The urine volume at GDRRT initiation time in the early group was higher than that in the late GDRRT group (1,060.3 ± 332.1 vs. 300.5 ± 148.3 mL, p < 0.001). Hemodynamic parameters such as mean artery pressure were higher (70.06 ± 32.99 vs. 54.34 ± 40.88 mm Hg, p = 0.012), the heart rate was slower (80.17 ± 15.26 vs. 99.21 ± 25.45 bpm, p = 0.002), and the diameter of inferior vena cava was narrower (22.00 ± 1.91 vs. 25.77 ± 5.5 mm, p = 0.04) in early GDRRT. Primary end point was inhospital all-cause mortality and cardiovascular mortality, which was obviously lower in the early GDRRT group (respectively 24.1 vs. 60.3%, p = 0.002 and 20.3 vs. 50.8%, p = 0.005). The second end point of kidney recovery in the early GDRRT group was much better than that in the latter GDRRT group (p = 0.018). Moreover, urine volume after GDRRT of the early group was more significant than that of the late group (1,432 ± 172 vs. 702 ± 183 mL, p = 0.005).

CONCLUSION

This study clarified the effectiveness of the early GDRRT strategy in ADHF patients suffered from CRS, which reduced inhospital mortality and improved the urine output and clinical kidney recovery outcome.

Predicting survival in patients with acute decompensated heart failure complicated by cardiogenic shock

Background

Acute decompensated heart failure (ADHF) complicated by cardiogenic shock (CS) has unique pathophysiological background requiring specific patient stratification, management and therapeutic targets. Accordingly, the aim of this study was to derive a simple stratification tool to predict survival in patients with ADHF complicated by CS.

Methods and results

Using logistic regression, univariable testing was performed to identify the variables potentially associated with 28-day mortality. We propose a new logistic model (ALC-Shock score) based on three easy parameters (age, serum creatinine and serum lactate at the ICU admission) as a powerful predictor of survival or successful bridge to heart replacement therapy at 28-day follow-up in this specific population. A multivariable analysis (logistic model) was performed to evaluate the association between selected variables and outcome (overall death at 28-day follow up). The score was then validated in a different cohort of 93 ADHF-CS patients and compared to a previous developed score (the Cardshock score).Overall, 28-day mortality was 34%. The ALC-shock score showed better discrimination (Area Under the Curve-AUC- 0.82; 95% CI 0.73-0.91) as compared to the Cardshock score (AUC 0.67; 95% CI 0.55-0.79) (p = 0.009) to predict 28-days overall mortality. In the validation cohort the AUC for the ALC-shock score was 0.66.

Conclusions

A simple score including age, lactates and creatinine on admission could be considered to predict short-term mortality in CS-ADHF patients in order to drive towards a treatment intensification.

Effect of government-issued state of emergency and reopening orders on cardiovascular hospitalizations during the COVID-19 pandemic

OBJECTIVE

Little is known about the effect of government-issued State of Emergency (SOE) and Reopening orders on health care behaviors. We aimed to determine the effect of SOE and Phase 1 of Reopening orders on hospitalizations for acute myocardial infarction (AMI) or acute decompensated heart failure (ADHF).

METHODS

Hospitalizations for AMI and ADHF in the UNC Health system, which includes 10 hospitals in both urban and rural counties, were identified. An interrupted time series design was used to compare weekly hospitalization rates for eight weeks before the March 10th SOE declaration, eight weeks between the SOE order and Phase 1 of Reopening order, and the subsequent eight weeks.

RESULTS

Overall, 3,792 hospitalizations for AMI and 7,223 for ADHF were identified. Rates before March 10th were stable. AMI/ADHF hospitalizations declined about 6% per week in both urban and rural hospitals from March 11th to May 5th. Larger declines in hospitalizations were seen in adults ≥65 years old (-8% per week), women (-7% per week), and White individuals (-6% per week). After the Reopening order, AMI/ADHF hospitalizations increased by 8% per week in urban centers and 9% per week in rural centers, including a significant increase in each demographic group. The decline and rebound in acute CV hospitalizations were most pronounced in the two weeks following the government orders.

CONCLUSIONS

AMI and ADHF hospitalization rates closely correlated to SOE and Reopening orders. These data highlight the impact of public health measures on individuals seeking care for essential services; future policies may benefit from clarity regarding when individuals should present for care.

Elevated urinary albumin concentration predicts worse clinical outcomes in hospitalized acute decompensated heart failure patients

Objective

To investigate the prognostic value of elevated urinary albumin concentration (UAC) in hospitalized acute decompensated heart failure (ADHF) patients.

Methods

We measured UAC at baseline in 1818 hospitalized ADHF patients who were admitted to our Heart Failure Center. All patients were followed up for a median period of 937.5 days. The primary endpoint was a composite of all‐cause death or heart transplantation (HTx) or left ventricular assist device (LVAD) implantation.

Results

In total, 41.5% of ADHF patients had albuminuria (UAC ≥ 20 mg/L). The median value of UAC was 15.5 mg/L. A total of 679 patients died or underwent HTx/LVAD during follow‐up. The median UAC was significantly lower in non‐HTx/LVAD survivors (14.3 mg/L) than in those who died or underwent HTx/LVAD (18.0 mg/L, P < 0.001). Compared with patients without albuminuria (reference, n = 1064), those with albuminuria had a 1.47‐fold higher risk of all‐cause death or HTx/LVAD (95% confidence interval [CI]:1.26–1.71, P < 0.001), with hazard ratios (HRs) of 1.42 (95% CI: 1.21–1.66) and 1.74 (95% CI: 1.33–2.26) in patients with microalbuminuria (20 mg/L ≤ UAC < 200 mg/L, n = 617) and macroalbuminuria (UAC ≥ 200 mg/L, n = 137), respectively (both P < 0.001). After adjustment for significant clinical risk factors, the albuminuria group had a higher risk of primary adverse events than the non‐albuminuria group (HR = 1.28, 95% CI: 1.09–1.50, P = 0.003), with HRs of 1.27 [95% CI: 1.07–1.49] and 1.36 [95% CI: 1.01–1.84] in patients with microalbuminuria and macroalbuminuria, respectively (P = 0.006 and P = 0.041). The adjusted risk of primary adverse events also increased with the degree of albuminuria in the test for trend (HR = 1.21, 95% CI: 1.06–1.37, P for trend = 0.004). In the subgroup analysis, albuminuria had a significantly greater prognostic value for patients with left ventricular ejection fraction ≥ 40%, eGFR ≥ 60 mL/min/1.73 m², BUN/creatinine ratio ≥ 20 or NT‐proBNP < 2098 pg/mL.

Conclusion

The presence of albuminuria evaluated by UAC predicts adverse clinical outcomes in hospitalized ADHF patients.

A new scoring system for predicting short-term outcomes in Chinese patients with critically-ill acute decompensated heart failure

Background

Acute decompensated heart failure (ADHF) contributes millions of emergency department (ED) visits and it is associated with high in-hospital mortality. The aim of this study was to develop and validate a multiparametric score for critically-ill ADHF patients.

Methods

In this single-center, retrospective study, a total of 1268 ADHF patients in China were enrolled and divided into derivation (n = 1014) and validation (n = 254) cohorts. The primary endpoint was any in-hospital death, cardiac arrest or utilization of mechanical support devices. Logistic regression model was preformed to identify risk factors and build the new scoring system. The assigning point of each parameter was determined according to its β coefficient. The discrimination was validated internally using C statistic and calibration was evaluated by the Hosmer-Lemeshow goodness-of-fit test.

Results

We constructed a predictive score based on six significant risk factors [systolic blood pressure (SBP), white blood cell (WBC) count, hematocrit (HCT), total bilirubin (TBIL), estimated glomerular filtration rate (eGFR) and NT-proBNP]. This new model was computed as (1 × SBP < 90 mmHg) + (2 × WBC > 9.2 × 10⁹/L) + (1 × HCT ≤ 0.407) + (2 × TBIL > 34.2 μmol/L) + (2 × eGFR < 15 ml/min/1.73 m²) + (1 × NTproBNP ≥ 10728.9 ng/ml). The C statistic for the new score was 0.758 (95% CI 0.667–0.838) higher than APACHE II, AHEAD and ADHERE score. It also demonstrated good calibration for detecting high-risk patients in the validation cohort (χ² = 6.681, p = 0.463).

Conclusions

The new score including SBP, WBC, HCT, TBIL, eGFR and NT-proBNP might be used to predict short-term prognosis of Chinese critically-ill ADHF patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02041-2.

Aortic pulsatility index predicts clinical outcomes in heart failure: a sub-analysis of the ESCAPE trial

AIMS

Aortic pulsatility index (API), calculated as (systolic-diastolic blood pressure)/pulmonary capillary wedge pressure (PCWP), is a novel haemodynamic measurement representing both cardiac filling pressures and contractility. We hypothesized that API would better predict clinical outcomes than traditional haemodynamic metrics of cardiac function.

METHODS AND RESULTS

The Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial individual-level data were used. Routine haemodynamic measurements, including Fick cardiac index (CI), and the advanced haemodynamic metrics of API, cardiac power output (CPO), and pulmonary artery pulsatility index (PAPI) were calculated after final haemodynamic-monitored optimization. The primary outcome was a composite endpoint of death or need for orthotopic heart transplant (OHT) or left ventricular assist device (LVAD) at 6 months. A total of 433 participants were enrolled in the ESCAPE trial of which 145 had final haemodynamic data. Final API measurements predicted the primary outcome, OR 0.47 (95% CI 0.32-0.70, P < 0.001), while CI, CPO, and PAPI did not. Receiver operator characteristic analyses of final advanced haemodynamic measurements indicated API best predicted the primary outcome with a cutoff of 2.9 (sensitivity 76.2%, specificity 55.3%, correctly classified 61.4%, area-under-the-curve 0.71), compared with CPO, CI, and PAPI. Kaplan-Meier analyses indicated API ≥ 2.9 was associated with greater freedom from the primary outcome (83.5%), compared with API < 2.9 (58.4%), P = 0.001. While PAPI was also significantly associated, CI and CPO were not.

CONCLUSIONS

The novel haemodynamic measurement API better predicted clinical outcomes in the ESCAPE trial when compared with traditional invasive haemodynamic metrics of cardiac function.

Clinical outcomes of levosimendan versus dobutamine in patients with acute decompensated heart failure with reduced ejection fraction and impaired renal function

To assess the clinical outcomes of levosimendan and dobutamine in patients with acute decompensated heart failure with reduced ejection fraction and impaired renal function in Indian scenario. Cardiac, renal, electrolytes and hepatic parameters as well as the clinical outcomes were assessed. Levosimendan and dobutamine improved ejection fraction significantly. Levosimendan in comparison to dobutamine, increased cardiac output (0.76 vs. −0.38 at 48 h, 1.15 vs. −0.31 day 7, -2.02 vs. −1.51 day 30), cardiac index (0.89 vs.-0.13 at 48 h, 1.16 vs. −0.07 at day 7 and 1.05 vs. −0.25 at day 30) and eGFR (−1.4 vs. −0.75 at day 30) significantly. Levosimendan reduced ICU stay (p = 0.038) significantly whereas dobutamine decreased the hospital stay duration (p = 0.015). There was no major difference in re-hospitalization and mortality between groups. Ventricular tachyarrhythmia was the main adverse event noted in Levosimendan arm. Levosimendan showed improved cardiac as well as renal outcomes within a month when compared to dobutamine and it is the first study to determine the renal parameters of Levosimendan in an Indian setting.

Clinical effectiveness and adverse events associated with tolvaptan in patients above 90 years of age with acute decompensated heart failure

With the aging society, the number of very-elderly (VE) patients with acute decompensated heart failure (ADHF) is increasing. Although tolvaptan is recommended for patients with ADHF in whom conventional diuretic therapy is ineffective, few reports exist on VE patients over 90 years of age. Therefore, we aimed to evaluate the clinical effectiveness and adverse events associated with tolvaptan in VE patients with ADHF. From January 2011 to December 2018, we retrospectively studied 180 patients with ADHF who were first administered tolvaptan during hospitalization. Patients were divided into two groups, namely, VE patients who were ≥ 90 years of age (n = 32) and not-VE patients (NVE) who were < 90 years of age (n = 148). The primary effective endpoints were the total urine volume and change in body weight. The safety endpoints evaluated were the incidence of hypernatremia (≥ 150 mEq/L) and worsening renal function (WRF) at any time during hospitalization. The median [interquartile range] patient age was 93 [91-94] years in the VE group and 80 [69-85] years in the NVE group. The mean dose of tolvaptan for the first week of administration was similar between groups (7.9 ± 5.0 mg, VE group; 7.3 ± 3.7 mg, NVE group; p = 0.52). There were no significant differences between the two groups in the total urine volume at 24 h (1901 ± 666 mL, VE group; 2101 ± 1167 mL, NVE group; p = 0.33) and that at 48 h (3707 ± 1274 mL, VE group; 4195 ± 1990 mL, NVE group; p = 0.19) and in the mean change in body weight (- 2.5 ± 2.0 kg, VE group; -2.7 ± 2.4 kg, NVE group; p = 0.70). The median duration of hospitalization was 24 [20-9] and 31 [20-42] days in the VE and NVE groups, respectively (p = 0.67). The incidence of hypernatremia (6.3% (2/32), VE group; 3.4% (5/148), NVE group; p = 0.61) and WRF (25.0% (8/32) VE group; 19.6% (29/148), NVE group; p = 0.31) was similar between the groups. In conclusion, tolvaptan has similar clinical effectiveness in increasing urine volume and decreasing body weight, without increased adverse events, in VE patients with ADHF who were ≥ 90 years of age compared to NVE patients with ADHF.

Prognostic value of impaired hepato-renal function and liver fibrosis in patients admitted for acute heart failure

AIMS

Cardiohepatic interactions have been a focus of attention in heart failure (HF). The model for end-stage liver disease excluding international normalized ratio (MELD-XI) score has been shown to be useful for predicting poor outcomes in patients with acute decompensated HF (ADHF). Furthermore, the fibrosis-4 (FIB-4) index, a simple marker to assess liver fibrosis, predicts adverse prognoses in patients with HF as well. However, there is little information available on the prognostic significance of the combination of the MELD-XI score and FIB-4 index in patients with ADHF and its association with left ventricular ejection fraction (LVEF) subgroup.

METHODS AND RESULTS

We prospectively studied 466 consecutive patients who were admitted for ADHF [HF with reduced LVEF (LVEF < 40%): n = 164, HF with mid-range LVEF (40% ≤ LVEF < 50%): n = 104, and HF with preserved LVEF (LVEF ≥ 50%): n = 198]. We calculated the MELD-XI score and FIB-4 indices at discharge. The primary endpoint was all-cause death (ACD). During the mean follow-up period of 2.8 years, 143 patients had ACD. In the multivariate Cox analysis, the MELD-XI score and FIB-4 index were independently associated with ACD. Patients were stratified into the following three groups according to the median value of MELD-XI score (=11) and FIB-4 index (=2.13): Group 1 had both a low MELD-XI score and a low FIB-4 index; Group 2 had either a high MELD-XI score (MELD-XI score ≥11) or a high FIB-4 index (FIB-4 index ≥2.13); and Group 3 had both a high MELD-XI score and a high FIB-4 index. Kaplan-Meier analysis revealed that Group 2 and Group 3 had a significantly greater risk of ACD than Group 1 [Group 2 vs. Group 1: adjusted hazard ratio, 2.48 (95% confidence interval: 1.75-3.53), P < 0.0001; Group 3 vs. Group 1: adjusted hazard ratio, 7.03 (95% confidence interval: 3.95-13.7), P < 0.0001]. In addition, the patients with both a higher MELD-XI score and FIB-4 index showed a significantly higher risk of ACD also in the patients with HF with reduced LVEF, HF with mid-range LVEF, and HF with preserved LVEF (all P < 0.0001).

CONCLUSIONS

The combination of MELD-XI score and FIB-4 index may be useful for stratifying patients at risk for ACD in patients with ADHF, irrespective of LVEF.

Incremental prognostic value of cardiac metaiodobenzylguanidine imaging over the co-morbid burden in acute decompensated heart failure

Aims

Co‐morbidities are associated with poor clinical outcomes in patients with chronic heart failure, while cardiac iodine‐123 (I‐123) metaiodobenzylguanidine (MIBG) imaging provides prognostic information in such patients. We sought to prospectively investigate the incremental prognostic value of cardiac MIBG imaging over the co‐morbid burden, in patients admitted for acute decompensated heart failure (ADHF).

Methods and results

In 433 consecutive ADHF patients with survival to discharge, we measured the co‐morbidity using age‐adjusted Charlson co‐morbidity index (ACCI), commonly employed to evaluate a weighted and scored co‐morbid condition, adding additional points for age. In cardiac MIBG imaging, the cardiac MIBG heart‐to‐mediastinum ratio (late HMR) was measured on the delayed image. Over a follow‐up period of 2.9 ± 1.5 years, 160 patients had a cardiac event (a composite of cardiac death and unplanned hospitalization for worsening heart failure). Patients with high ACCI (≥6: median value) had a significantly greater risk of a cardiac event. In multivariate Cox analysis, the ACCI and late HMR were significantly and independently associated with a cardiac event. In both high and low ACCI subgroups (ACCI ≥ 6 and <6, respectively), patients with low late HMR had a significantly greater risk of a cardiac event (high ACCI: 51% vs. 34% P = 0.0026, adjusted HR 1.74 [1.21–2.51]; low ACCI: 34% vs. 17%, P = 0.0228, adjusted HR 2.19 [1.10–4.37]).

Conclusions

Cardiac MIBG imaging could provide additional prognostic information over ACCI, which was also promoted to be a useful risk model, in patients admitted for ADHF.

Importance of the Corrected Calcium Level in Patients With Acute Heart Failure Requiring Intensive Care

Background: Serum calcium (Ca) concentrations in the acute phase of acute heart failure (AHF) have not been not sufficiently investigated. Methods and Results: This study enrolled 1,291 AHF patients and divided them into 3 groups based on original and corrected Ca concentrations: (1) hypocalcemia (both original and corrected Ca ≤8.7 mg/dL; n=651); (2) pseudo-hypocalcemia (original and corrected Ca ≤8.7 and >8.7 mg/dL, respectively; n=300); and (3) normal/hypercalcemia (both original and corrected Ca >8.7 mg/dL; n=340). AHF patients were also divided into 2 groups based on corrected Ca concentrations: (1) corrected hypocalcemia (corrected Ca ≤8.7 mg/dL; n=651); and (2) corrected normal/hypercalcemia (corrected Ca >8.7 mg/dL; n=640). Of the 951 patients with original hypocalcemia (≤8.7 mg/dL), 300 (31.5%) were classified as corrected normal/hypercalcemia after correction of Ca concentrations by serum albumin. The prognoses in the pseudo-hypocalcemia, low albumin, and corrected normal/hypercalcemia groups, including all-cause death within 730 days, were significantly poorer than in the other groups. Multivariate Cox regression analysis showed that classification into the pseudo-hypocalcemia, hypoalbumin, and corrected normal/hypercalcemia groups independently predicted 730-day all-cause death (hazard ratios [95% confidence intervals] of 1.497 [1.153-1.943], 2.392 [1.664-3.437], and 1.294 [1.009-1.659], respectively). Conclusions: Corrected normal/hypercalcemia was an independent predictor of prognosis because this group included patients with pseudo-hypocalcemia, which was affected by the serum albumin concentration.

Time-dependent changes in plasma xanthine oxidoreductase during hospitalization of acute heart failure

Aims

The aim of present study is to evaluate the clinical significance of the time‐dependent changes in xanthine oxidoreductase (XOR) activity during hospitalization for acute heart failure (AHF).

Methods and results

A total of 229 AHF patients who visited to emergency room were prospectively enrolled, and 187 patients were analysed. Blood samples were collected within 15 min of admission (Day 1), after 48–72 h (Day 3), and between Days 7 and 21 (Day 14). The AHF patients were divided into two groups according to the XOR activity on Day 1: the high‐XOR group (≥100 pmol/h/mL, n = 85) and the low‐XOR group (<100 pmol/h/mL, n = 102). The high‐XOR patients were assigned to two groups according to the rate of change in XOR from Day 1 to Day 14: the decreased group (≥50% decrease; n = 70) and the non‐decreased group (<50% decrease; n = 15). The plasma XOR activity significantly decreased on Days 3 and 14 [23.6 (9.1 to 63.1) pmol/h/mL and 32.5 (10.2 to 87.8) pmol/h/mL, respectively] in comparison with Day 1 [78.5 (16.9 to 340.5) pmol/h/mL]. A Kaplan–Meier curve indicated that the prognosis, including heart failure (HF) events (all‐cause death and readmission by HF) within 365 days, was significantly poorer in the low‐XOR patients than in the high‐XOR patients and was also significantly poorer in the non‐decreased group than in the decreased group.

Conclusions

The plasma XOR activity was rapidly decreased by the appropriate treatment of AHF. Although high‐XOR activity on admission was not associated with increased HF events in AHF, high‐XOR activity that was not sufficiently reduced during appropriate treatment was associated with increased HF events.

Acute decompensated heart failure in a non cardiology tertiary referral centre, Sarawak General Hospital (SGH-HF)

Background

Data on clinical characteristics of acute decompensated heart failure (ADHF) in Malaysia especially in East Malaysia is lacking.

Methods

This is a prospective observational study in Sarawak General Hospital, Medical Department, from October 2017 to September 2018. Patients with primary admission diagnosis of ADHF were recruited and followed up for 90 days. Data on patient’s characteristics, precipitating factors, medications and short-term clinical outcomes were recorded.

Results

Majority of the patients were classified in lower socioeconomic group and the mean age was 59 years old. Hypertension, diabetes mellitus and dyslipidaemia were the common underlying comorbidities. Heart failure with ischemic aetiology was the commonest ADHF admission precipitating factor. 48.6% of patients were having preserved ejection fraction HF and the median NT-ProBNP level was 4230 pg/mL. Prescription rate of the evidence-based heart failure medication was low. The in-patient mortality and the average length of hospital stay were 7.5% and 5 days respectively. 43% of patients required either ICU care or advanced cardiopulmonary support. The 30-day, 90-day mortality and readmission rate were 13.1%, 11.2%, 16.8% and 14% respectively.

Conclusion

Comparing with the HF data from West and Asia Pacific, the short-term mortality and readmission rate were high among the ADHF patients in our study cohort. Maladaptation to evidence-based HF prescription and the higher prevalence of cardiovascular risk factors in younger patients were among the possible issues to be addressed to improve the HF outcome in regions with similar socioeconomic background.

Delirium is associated with high mortality in older adult patients with acute decompensated heart failure

BACKGROUND

Delirium is associated with high mortality after cardiac surgery. However, evidence on the epidemiology of delirium in patients with acute decompensated heart failure (ADHF) is limited. This study aimed to assess the incidence and prognostic impact of delirium in patients with ADHF.

METHODS

This single-center prospective observational study enrolled 132 consecutive patients with ADHF. We utilized the Diagnostic and Statistical Manual of Mental Disorders, fifth edition and classified the patients into two groups according to the presence or absence of delirium. The primary endpoint was 90-day all-cause mortality. The prognostic impact and risk factors of delirium were evaluated using multivariable Cox and logistic regression analyses, respectively.

RESULTS

The median patient age was 83 (interquartile range, 75-87) years. Approximately 51.5% were men. Delirium occurred in 36 (27.3%) patients, and hyperactive delirium was the most frequent type (86.1%). The 90-day all-cause mortality was higher in the patients with delirium than in those without (21.6% versus 3.9%, log-rank p = 0.002). Delirium was associated with higher mortality with an adjusted hazard ratio of 6.8 (95% confidence interval, 1.1-42.6, p = 0.042). The risk factors associated with delirium included advanced age, male sex, higher clinical frailty scale score, and dementia.

CONCLUSIONS

Delirium was associated with a higher 90-day all-cause mortality in the older adult patients with ADHF. Hyperactive delirium was the most common subtype.