2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC

[Implantable sensors for outpatient assessment of ventricular filling pressure in advanced heart failure : Which telemonitoring design is optimal?]

INTRODUCTION

Patients with advanced heart failure suffer from frequent hospitalizations. Non-invasive hemodynamic telemonitoring for assessment of ventricular filling pressure has been shown to reduce hospitalizations. We report on the right ventricular (RVP), the pulmonary artery (PAP) and the left atrial pressure (LAP) sensor for non-invasive assessment of the ventricular filling pressure.

METHODS

A literature search concerning the available implantable pressure sensors for noninvasive haemodynamic telemonitoring in patients with advanced heart failure was performed.

RESULTS

Until now, only implantation of the PAP-sensor was able to reduce hospitalizations for cardiac decompensation and to improve quality of life. The right ventricular pressure sensor missed the primary endpoint of a significant reduction of hospitalizations, clinical data using the left atrial pressure sensor are still pending.

CONCLUSION

The implantation of a pressure sensor for assessment of pulmonary artery filling pressure is suitable for reducing hospitalizations for heart failure and for improving quality of life in patients with advanced heart failure.

Incidence, Mortality and Positive Predictive Value of Type 1 Cardiorenal Syndrome in Acute Coronary Syndrome

OBJECTIVES

To determine whether the risk of cardiovascular mortality associated with cardiorenal syndrome subtype 1 (CRS1) in patients who were hospitalized for acute coronary syndrome (ACS) was greater than the expected risk based on the sum of its components, to estimate the predictive value of CRS1, and to determine whether the severity of CRS1 worsens the prognosis.

METHODS

Follow-up study of 1912 incident cases of ACS for 1 year after discharge. Cox regression models were estimated with time to event (in-hospital death, and readmission or death during the first year after discharge) as the dependent variable.

RESULTS

The incidence of CRS1 was 9.2/1000 person-days of hospitalization (95% CI = 8.1-10.5), but these patients accounted for 56.6% (95% CI = 47.4-65.) of all mortality. The positive predictive value of CRS1 was 29.6% (95% CI = 23.9-36.0) for in-hospital death, and 51.4% (95% CI = 44.8-58.0) for readmission or death after discharge. The risk of in-hospital death from CRS1 (RR = 18.3; 95% CI = 6.3-53.2) was greater than the sum of risks associated with either acute heart failure (RR = 7.6; 95% CI = 1.8-31.8) or acute kidney injury (RR = 2.8; 95% CI = 0.9-8.8). The risk of events associated with CRS1 also increased with syndrome severity, reaching a RR of 10.6 (95% CI = 6.2-18.1) for in-hospital death at the highest severity level.

CONCLUSIONS

The effect of CRS1 on in-hospital mortality is greater than the sum of the effects associated with each of its components, and it increases with the severity of the syndrome. CRS1 accounted for more than half of all mortality, and its positive predictive value approached 30% in-hospital and 50% after discharge.

Galectin-3 Reflects Mitral Annular Plane Systolic Excursion Being Assessed by Cardiovascular Magnetic Resonance Imaging

Background. This study investigates whether serum levels of galectin-3 may reflect impaired mitral annular plane systolic excursion (MAPSE) in patients undergoing cardiac magnetic resonance imaging (cMRI). Methods. Patients undergoing cMRI during routine clinical care were included prospectively within an all-comers design. Blood samples for biomarker measurements were collected within 24 hours following cMRI. Statistical analyses were performed in all patients and in three subgroups according to MAPSE (MAPSE I: ≥11 mm, MAPSE II: ≥8 mm–<11 mm, and MAPSE III: <8 mm). Patients with right ventricular dysfunction (<50%) were excluded. Results. 84 patients were included in the study. Median LVEF was 59% (IQR 51–64%). Galectin-3 correlated significantly with NT-proBNP (r = 0.42, p = 0.0001). Galectin-3 increased significantly according to the different stages of impaired MAPSE (p = 0.006) and was able to discriminate both patients with impaired MAPSE <11 mm (area under the curve (AUC) = 0.645, p = 0.024) and <8 mm (AUC = 0.733, p = 0.003). Combining galectin-3 with NT-proBNP improved discrimination of MAPSE <8 mm (AUC 0.803, p = 0.0001). In multivariable logistic regression models galectin-3 was still associated with impaired MAPSE (MAPSE < 11 mm: odds ratio (OR) = 3.53, p = 0.018; MAPSE < 8 mm: OR = 3.18, p = 0.06). Conclusions. Galectin-3 reflects MAPSE being assessed by cardiac MRI.

Clinical characteristics and prognostic impact of atrial fibrillation in patients with chronic heart failure

AIM

To assess the prevalence, clinical characteristics and independent prognostic impact of atrial fibrillation (AF) in chronic heart failure (CHF) patients, and the potential protective effect of disease-modifying medications, particularly beta-blockers (BB).

METHODS

We retrospectively reviewed the charts of patients referred to our center since January 2004, and collected all clinical information available at their first visit. We assessed mortality to the end of June 2015. We compared patients with and without AF, and assessed the association between AF and all-cause mortality by multivariate Cox regression and Kaplan-Meyer analysis, particularly accounting for ongoing treatment with BB.

RESULTS

A total of 903 patients were evaluated (mean age 68 ± 12 years, 73% male). Prevalence of AF was 19%, ranging from 10% to 28% in patients ≤ 60 and ≥ 77 years, respectively. Besides the older age, patients with AF had more symptoms (New York Heart Association II-III 60% vs 44%), lower prevalence of dyslipidemia (23% vs 37%), coronary artery disease (28% vs 52%) and left bundle branch block (9% vs 16%). On the contrary, they more frequently presented with an idiopathic etiology (50% vs 24%), a history of valve surgery (13% vs 4%) and received overall more devices implantation (31% vs 21%). The use of disease-modifying medications (i.e., BB and ACE inhibitors/angiotensin receptor blockers) was lower in patients with AF (72% vs 80% and 71% vs 79%, respectively), who on the contrary were more frequently treated with symptomatic and antiarrhythmic drugs including diuretics (87% vs 69%) and digoxin (51% vs 11%). At a mean follow-up of about 5 years, all-cause mortality was significantly higher in patients with AF as compared to those in sinus rhythm (SR) (45% vs 34%, P value < 0.05 for all previous comparisons). However, in a multivariate analysis including the main significant predictors of all-cause mortality, the univariate relationship between AF and death (HR = 1.49, 95%CI: 1.15-1.92) became not statistically significant (HR = 0.98, 95%CI: 0.73-1.32). Nonetheless, patients with AF not receiving BB treatment were found to have the worst prognosis, followed by patients with SR not receiving BB therapy and patients with AF receiving BB therapy, who both had similarly worse survival when compared to patients with SR receiving BB therapy.

CONCLUSION

AF was highly prevalent and associated with older age, worse clinical presentation and underutilization of disease-modifying medications such as BB in a population of elderly patients with CHF. AF had no independent impact on mortality, but the underutilization of BB in this group of patients was associated to a worse long-term prognosis.

Established and novel treatment options in acute myocarditis, with or without heart failure

INTRODUCTION

Acute myocarditis is a disorder characterized by an unpredictable clinical course which ranges from asymptomatic, incidentally discovered forms, to cases with fulminant course and adverse outcome. The most challenging issues in the context of acute myocarditis are the appearance of difficult to treat heart failure in the acute phase and the potential progression in the long-term to dilated cardiomyopathy. Areas covered: With respect to available treatment options in acute myocarditis, in the absence of specific guidelines, management is supportive and overall empirical, especially for the oligo- or asymptomatic patients with preserved ejection fraction. Haemodynamically instable patients should be treated in referral centers with capability of advanced cardiopulmonary support. Patients with heart failure but without haemodynamic impairment should be treated according to the heart failure guidelines. Endomyocardial biopsy may be performed in an individualized basis both for diagnostic purposes and to guide treatment, based on the detection or not of viral genome. Expert commentary: Apart from the already established treatments, novel therapies against several targets are currently investigated and are expected to contribute to a more efficacious management options in the future. Increased awareness among medical professionals is essential for the early diagnosis and best care of acute myocarditis patients.

Patients with HFpEF and HFrEF have different clinical characteristics but similar prognosis: a retrospective cohort study

BACKGROUND

Globally, heart failure (HF) has been recognized as one of the major cardiovascular disorder with high morbidity, mortality and considerable social impact. In Sub Saharan African countries, HF has turned out as a leading form of cardiovascular diseases, and has considerable socioeconomic impact. However, there are differences in clinical characteristics and survival status among patients with preserved (HFpEF) and reduced (HFrEF) ejection fraction. The aim of this study is to outline the clinical characteristics and medication profile, assess the survival status and prognostic factors of Ethiopian HF patients with HFrEF and HFpEF.

METHODS

A retrospective cohort study was carried out and we employed medical records of patient's, admitted as a result of HF to the University of Gondar Referral Hospital in the period between December 02, 2010 and December 01, 2015 due to HF. Kaplan Meier curve was used to analyze the survival status and log rank test was used to compare the curves. Cox regression was used to analyze independent predictors of mortality in all HF patients.

RESULTS

Of the 850 patients who were admitted due to HF, 311 patients met the inclusion criteria. Majority of the patients had HFpEF (52.73%) and tend to be women (76.22%). They predominantly had etiologies of valvular and hypertensive heart diseases, and took calcium channel blockers and anticoagulants. Conversely, patients with HFrEF had etiologies of ischemic heart disease and dilated cardiomyopathy and were prescribed angiotensine converting inhibitors (ACEI) and beta blockers. Kaplan Meier curves and Log rank test (p = 0.807) showed that there was no statistically significant difference in the mortality difference among patients with HFpEF and HFrEF. On the other hand, Cox regression analysis showed advanced age, lower sodium level, higher creatinine level and absence of medications like ACEI, spironolactone and statins independently predicted mortality in all HF patients.

CONCLUSIONS

Different clinical characteristics were found in both groups of HF patients. There was no difference in survival outcome between patients with HFrEF and HFpEF.

Association of chronic kidney disease with impaired left atrial reservoir function: A community-based cohort study

Background Chronic kidney disease (CKD) is an independent risk factor for atrial fibrillation, although the pathophysiological mechanisms remain unclear. This study investigated the relationship between CKD and left atrial (LA) volume and function in a sample of the general population without overt cardiac disease. Design and methods We examined 358 participants from the Cardiovascular Abnormalities and Brain Lesions study. The LA minimum volume index (LAVI_min), LA maximum volume index (LAVI_max), and LA emptying fraction (LAEF) were assessed by real-time three-dimensional echocardiography. Based on their estimated glomerular filtration rate (eGFR), the participants were divided into a CKD group (eGFR <60 ml/min/1.73 m²) and a non-CKD group (eGFR ≥60 ml/min/1.73 m²). Results Of the 358 participants, 69 (19%) were classified as having CKD and 289 (81%) as non-CKD. Participants with CKD were older, had a greater prevalence of hypertension and use of antihypertensive drugs, a larger left ventricular (LV) mass index, and a higher prevalence of diastolic dysfunction than those without CKD (all p < 0.05). There was no significant difference in LAVI_max between the CKD and non-CKD groups (23.4 ± 7.1 vs. 22.8 ± 5.8 ml/m², p = 0.47), whereas significant differences were observed for LAVI_min (13.6 ± 5.5 vs. 12.0 ± 4.6 ml/m², p = 0.01) and LAEF (42.7 ± 11.4 vs. 47.8 ± 11.5%, p = 0.001). Multivariate regression analysis revealed that the eGFR was significantly associated with LAEF independent of age, LV mass index, and diastolic dysfunction (all p < 0.05). Conclusions Participants with CKD in an unselected community-based cohort had significantly impaired LA reservoir function. Assessment of LA function may add important information in the prognostic assessment of patients with CKD even in the absence of overt cardiac disease.

Heart Failure: Diagnosis, Severity Estimation and Prediction of Adverse Events Through Machine Learning Techniques

Heart failure is a serious condition with high prevalence (about 2% in the adult population in developed countries, and more than 8% in patients older than 75 years). About 3-5% of hospital admissions are linked with heart failure incidents. Heart failure is the first cause of admission by healthcare professionals in their clinical practice. The costs are very high, reaching up to 2% of the total health costs in the developed countries. Building an effective disease management strategy requires analysis of large amount of data, early detection of the disease, assessment of the severity and early prediction of adverse events. This will inhibit the progression of the disease, will improve the quality of life of the patients and will reduce the associated medical costs. Toward this direction machine learning techniques have been employed. The aim of this paper is to present the state-of-the-art of the machine learning methodologies applied for the assessment of heart failure. More specifically, models predicting the presence, estimating the subtype, assessing the severity of heart failure and predicting the presence of adverse events, such as destabilizations, re-hospitalizations, and mortality are presented. According to the authors' knowledge, it is the first time that such a comprehensive review, focusing on all aspects of the management of heart failure, is presented.

Advances in the management of heart failure: the role of ivabradine

A high resting heart rate (≥70–75 b.p.m.) is a risk factor for patients with heart failure (HF) with reduced ejection fraction (EF), probably in the sense of accelerated atherosclerosis, with an increased morbidity and mortality. Beta-blockers not only reduce heart rate but also have negative inotropic and blood pressure-lowering effects, and therefore, in many patients, they cannot be given in the recommended dose. Ivabradine specifically inhibits the pacemaker current (funny current, I_f) of the sinoatrial node cells, resulting in therapeutic heart rate lowering without any negative inotropic and blood pressure-lowering effect. According to the European Society of Cardiology guidelines, ivabradine should be considered to reduce the risk of HF hospitalization and cardiovascular death in symptomatic patients with a reduced left ventricular EF ≤35% and sinus rhythm ≥70 b.p.m. despite treatment with an evidence-based dose of beta-blocker or a dose below the recommended dose (recommendation class “IIa” = weight of evidence/opinion is in favor of usefulness/efficacy: “should be considered”; level of evidence “B” = data derived from a single randomized clinical trial or large nonrandomized studies). Using a heart rate cutoff of ≥ 75 b.p.m., as licensed by the European Medicines Agency, treatment with ivabradine 5–7.5 mg b.i.d. reduces cardiovascular mortality by 17%, HF mortality by 39% and HF hospitalization rate by 30%. A high resting heart rate is not only a risk factor in HF with reduced EF but also at least a risk marker in HF with preserved EF, in acute HF and also in special forms of HF. In this review, we discuss the proven role of ivabradine in the validated indication “HF with reduced EF” together with interesting preliminary findings, and the potential role of ivabradine in further, specific forms of HF.

Specificity of B-Type Natriuretic Peptide Assays: Cross-Reactivity with Different BNP, NT-proBNP, and proBNP Peptides

BACKGROUND

B-type natriuretic peptides (BNPs) are used clinically to diagnose and monitor heart failure and are present in the circulation as multiple proBNP-derived fragments. We investigated the specificity of BNP immunoassays with glycosylated and nonglycosylated BNP, N-terminal proBNP (NT-proBNP), and proBNP peptides to probe the cross-reactivity of each assay.

METHODS

Nine B-type natriuretic peptides were studied,including synthetic and recombinant BNP (Shionogi, Scios, Mayo), human and synthetic glycosylated and nonglycosylated NT-proBNP (HyTest, Roche Diagnostics), and human glycosylated and nonglycosylated proBNP (HyTest, Scios). Five BNP [Abbott, Abbott POC, Alere, Beckman Coulter, Siemens (Centaur)], 9 NT-proBNP [Ortho-Clinical Diagnostics, Roche, Response, bioMerieux, Siemens (Dimension, Immulite, Stratus CS), Mitsubishi] and 3 research-use-only proBNP immunoassays [Biosite (Alere), Bio-Rad, Goetze] were evaluated. Specificity was assessed by calculating the recovery between baseline and peptide-spiked human plasma pools at target concentrations of 100 ng/L BNP, 300 ng/L proBNP, or 450 ng/L NT-proBNP. All assays were performed in duplicate.

RESULTS

BNP and NT-proBNP assays demonstrated substantial cross-reactivity with proBNP peptides. NT-proBNP assays do not detect glycosylated forms of either NT-proBNP or proBNP. proBNP assays preferentially detect the BNP 1-32 peptide and have minimal cross-reactivity with BNP peptides and glycosylated proBNP.

CONCLUSIONS

BNP or NT-proBNP results are not transferable among the current existing immunoassays owing to their differences in cross-reactivity and ability to detect various glycosylated forms of proBNP-derived fragments. Opportunities remain to standardize and harmonize BNP and NT-proBNP assays, as well as to develop specific proBNP assays, to widen their clinical scope of use.

Optimized management of heart failure patients aged 80 years or more improves outcomes versus usual care: The HF80 randomized trial

BACKGROUND

The prevalence and incidence of heart failure (HF) in elderly patients are increasing worldwide. Management of HF with reduced ejection fraction (HF-REF) in patients aged 80 years or more follows international guidelines, despite the lack of a dedicated study in this frail population.

AIMS

To determine whether optimized management of HF-REF in patients aged 80 years or more can improve quality of life at 6 months.

METHODS

Patients aged 80 years or more hospitalized for acute HF-REF were randomized prospectively into an optimized group or a control group (usual care). All patients benefitted from the same in-hospital management. Optimized group patients were also managed at 3, 6 and 9 weeks, and 3, 6, 9 and 12 months after initial hospitalization, to optimize HF-REF treatment. The primary endpoint was quality of life at 6 months.

RESULTS

The trial was stopped prematurely, according to prespecified rules and an independent data monitoring board, after 34 patients were included (n=17 in each group). There was no difference in quality of life at baseline and at 6 months between the two groups (P=0.14 and 0.64, respectively), although a significant improvement was observed between baseline and 6 months in the optimized group compared with the control group: -20.2±25.2 (P=0.01) versus -9.9±19.0 (P=0.19). Mortality at 12 months was lower in the optimized group (17.7% vs 47.1%; P=0.03). There was no increase in acute renal failure, hyperkalaemia or falls in the optimized group (P=0.49, 1 and 1, respectively).

CONCLUSIONS

Optimizing the management of HF-REF in patients aged 80 years or more, according to the modalities of the HF80 study, seems to be both effective and safe.

Myocarditis in Paediatric Patients: Unveiling the Progression to Dilated Cardiomyopathy and Heart Failure

Myocarditis is a challenging and potentially life-threatening disease associated with high morbidity in some paediatric patients, due to its ability to present as an acute and fulminant disease and to ultimately progress to dilated cardiomyopathy. It has been described as an inflammatory disease of the myocardium caused by diverse aetiologies. Viral infection is the most frequent cause of myocarditis in developed countries, but bacterial and protozoal infections or drug hypersensitivity may also be causative agents. The prompt diagnosis in paediatric patients is difficult, as the spectrum of clinical manifestation can range from no myocardial dysfunction to sudden cardiac death. Recent studies on myocarditis pathogenesis have revealed a triphasic nature of this disease, which influences the diagnostic and therapeutic strategies to adopt in each patient. Endomyocardial biopsy remains the gold standard for diagnosing myocarditis, and several non-invasive diagnostic tools can be used to support the diagnosis. Intravenous immunoglobulin has become part of routine practice in the treatment of myocarditis in paediatric patients at many centres, but its true effect on the cardiac function has been the target of many studies. The aim of this review is to approach the recently discovered facets of paediatric myocarditis regarding its progression to dilated cardiomyopathy.

Non-vitamin K antagonist oral anticoagulants and heart failure

Thromboembolism contributes to morbidity and mortality in patients with heart failure (HF), and atrial fibrillation (AF) is one of the main factors promoting this complication. As they share many risk factors, HF and AF frequently coexist, and patients with both conditions are at a particularly high risk of thromboembolism. Non-vitamin K antagonist oral anticoagulants (NOACs) are direct antagonists of thrombin (dabigatran) and factor Xa (rivaroxaban, apixaban and edoxaban), and were designed to overcome the limitations of vitamin K antagonists. Compared with warfarin in non-valvular AF, NOACs demonstrated non-inferiority with better safety, most particularly for intracranial haemorrhages. Therefore, the European Society of Cardiology guidelines recommend NOACs for most patients with non-valvular AF. Subgroups of patients with both AF and HF from the pivotal studies investigating the safety and efficacy of NOACs have been analysed and, for each NOAC, results were similar to those of the total analysis population. A recent meta-analysis of these subgroups has confirmed the better efficacy and safety of NOACs in patients with AF and HF - particularly the 41% decrease in the incidence of intracranial haemorrhages. The prothrombotic state associated with HF suggests that patients with HF in sinus rhythm could also benefit from treatment with NOACs. However, in the absence of clinical trial data supporting this indication, current guidelines do not recommend anticoagulant treatment of patients with HF in sinus rhythm. In conclusion, recent analyses of pivotal studies support the use of NOACs in accordance with their indications in HF patients with non-valvular AF.

Impact of chronic obstructive pulmonary disease on clinical course after an episode of acute heart failure. EAHFE-COPD study

OBJECTIVE

To study if the coexistence of chronic obstructive pulmonary disease (COPD) in patients diagnosed with acute heart failure (AHF) at the emergency department (ED) has an impact on short- and long-term outcomes.

METHOD

The EAHFE-COPD study included patients who attended in 34 Spanish EDs for AHF. We compared patients with AHF plus COPD with patients with AHF in whom COPD was neither diagnosed nor excluded by functional respiratory tests (FRT). Outcome analysis included all-cause mortality, prolonged hospitalization, and ED revisit. Crude results were adjusted by differences between patients with and without COPD.

RESULTS

We included 8099 patients with AHF, 2069 having COPD (25.6%; AHF-COPD-known). Compared with AHF-COPD-unknown, AHF-COPD-known differed in 20 variables. After adjusting for differences between the two groups, AHF-COPD-known patients showed no significant differences in 30-day mortality (OR=0.89; 95% CI=0.71-1.11), prolonged hospitalization in general wards (OR=1.04; 95% CI=0.89-1.22) or SSU (OR=1.38; 95% CI=0.97-1.97), and 1-year mortality (HR: 1.02; 95% CI=0.89-1.17), but showed a higher 30-day revisit rate (OR=1.32; 95% CI=1.13-1.54).

CONCLUSIONS

In patients attending the ED for AHF, the coexistence of COPD is only associated with an increased risk of short-term ED revisit, but not prolonged hospitalization and short- or long-term mortality.

The effects of resistance training on muscle strength, quality of life and aerobic capacity in patients with chronic heart failure - A meta-analysis

BACKGROUND

Resistance training (RT) has been utilised to target muscle dysfunction associated with Chronic Heart Failure (CHF). However, there is limited meta-analysis evidence to support its use as a standalone therapy. This meta-analysis examined the effects of RT on muscle strength (one repetition maximum, 1RM and Peak Torque), aerobic capacity (VO_2peak and 6min walk distance) and quality of life (QoL) in patients with CHF.

METHODS

We searched Medline, EMBASE, Cochrane and CINAHL for studies published up to July 2016, combining terms related to the population (eg, heart failure, CHF) with terms for the intervention (eg, resistance, strength training) and the outcomes (eg, QoL, VO₂peak_,strength, aerobic capacity).

RESULTS

Ten studies including 240 participants were included in our meta-analysis (aged 48-76years, Ejection Fraction 18-37%). Training duration ranged from 8 to 24weeks and intensity up to 80% of 1RM. RT increased 1RM (standardised change score=0.60; 95% Confidence Interval: 0.43, 0.77) but not strength measured via peak torque at 60°/s^-1 and 180°/s^-1. RT increased VO_2peak (CSMD: 2.71ml/kg/min; 1.96, 3.45) and QoL (CSMD: -5.71; -9.85, -1.56).

CONCLUSION

RT as a single intervention can increase muscle strength, aerobic capacity and QoL in patients with CHF and may offer an alternative approach, particularly for those unable to participate in aerobic training. The effect of RT on muscle strength is mainly during slow controlled movements and not during rapid movements. Older adults and patients with advanced CHF are underrepresented in RT trials and future studies should seek to optimise their inclusion.

Obstructive Ventilatory Disorder in Heart Failure-Caused by the Heart or the Lung?

Heart failure (HF) is a clinical syndrome frequently associated with airway obstruction, either as a respiratory comorbidity or as a direct consequence of HF pathophysiology. Recognizing the relative contribution of an underlying airway disease as opposed to airway obstruction due to volume overload and left atrial pressure elevation is of importance for the appropriate management of patients affected by HF. This review focuses on "les liaisons dangereuses" between the heart and the lungs, outlying recent advances linking in a vicious circle of chronic obstructive lung disease (COPD) and obstructive sleep apnea (OSA) on one side and HF on the other side. It also discusses the role of pivotal diagnostic tools such as pulmonary function tests and cardiopulmonary exercise test to determine the contribution of HF and COPD to symptoms and clinical status. Treatment implications are discussed as well.

Sacubitril/valsartan in heart failure: latest evidence and place in therapy

Despite significant therapeutic advances, patients with chronic heart failure (HF) remain at high risk for HF progression and death. Sacubitril/valsartan (previously known as LCZ696) is a first-in-class medicine that contains a neprilysin (NEP) inhibitor (sacubitril) and an angiotensin II (Ang-II) receptor blocker (valsartan). NEP is an endopeptidase that metabolizes different vasoactive peptides including natriuretic peptides, bradykinin and Ang-II. In consequence, its inhibition increases mainly the levels of both, natriuretic peptides (promoting diuresis, natriuresis and vasodilatation) and Ang-II whose effects are blocked by the angiotensin receptor blocker, valsartan (reducing vasoconstriction and aldosterone release). Results from the 8442 patient PARADIGM-HF study showed in patients with New York Heart Association (NYHA) class II-IV and reduced ejection fraction treated with LCZ696 (versus enalapril), the following benefits: reduction of the risk of death from cardiovascular causes by 20%; reduction of HF hospitalizations by 21%; reduction of the risk of all-cause mortality by 16%. Overall there was a 20% risk reduction on the primary endpoint, composite measure of cardiovascular (CV) death or time to first HF hospitalization. PARADIGM-HF was stopped early after a median follow up of 27 months. Post hoc analyses of PARADIGM-HF as well as the place in therapy of sacubitril/valsartan, including future directions, are included in the present review.

Changing the treatment of heart failure with reduced ejection fraction: clinical use of sacubitril-valsartan combination

Despite significant therapeutic advances, patients with chronic heart failure (HF) remain at high risk of morbidity and mortality. Sacubitril valsartan (previously known as LCZ696) is a new oral agent approved for the treatment of symptomatic chronic heart failure in adults with reduced ejection fraction. It is described as the first in class angiotensin receptor neprilysin inhibitor (ARNI) since it incorporates the neprilysin inhibitor, sacubitril and the angiotensin II receptor antagonist, valsartan. Neprilysin is an endopeptidase that breaks down several vasoactive peptides including natriuretic peptides (NPs), bradykinin, endothelin and angiotensin II (Ang-II). Therefore, a natural consequence of its inhibition is an increase of plasmatic levels of both, NPs and Ang-II (with opposite biological actions). So, a combined inhibition of these both systems (Sacubitril / valsartan) may enhance the benefits of NPs effects in HF (natriuresis, diuresis, etc) while Ang-II receptor is inhibited (reducing vasoconstriction and aldosterone release). In a large clinical trial (PARADIGM-HF with 8442 patients), this new agent was found to significantly reduce cardiovascular and all cause mortality as well as hospitalizations due to HF (compared to enalapril). This manuscript reviews clinical evidence for sacubitril valsartan, dosing and cautions, future directions and its considered place in the therapy of HF with reduced ejection fraction.

[Optimization of the management of acute heart failure. New concept of fast-track]

The acute heart failure generates a very important number of hospitalizations for a high cost. A recent reflection on optimizing its management is ongoing, based on the fastest management in the emergency department, with a distinction between which patient should remain and who returns at home, and under what conditions, allowing to limit the number of hospitalizations. It will require a reorganization of emergency department and updating of decision algorithms and new guidelines of care.

The Role of Cardiovascular Magnetic Resonance Imaging in Heart Failure

Cardiovascular imaging is key for the assessment of patients with heart failure. Today, cardiovascular magnetic resonance imaging plays an established role in the assessment of patients with suspected and confirmed heart failure syndromes, in particular identifying aetiology. Its role in informing prognosis and guiding decisions around therapy are evolving. Key strengths include its accuracy; reproducibility; unrestricted field of view; lack of radiation; multiple abilities to characterise myocardial tissue, thrombus and scar; as well as unparalleled assessment of left and right ventricular volumes. T2* has an established role in the assessment and follow-up of iron overload cardiomyopathy and a role for T1 in specific therapies for cardiac amyloid and Anderson-Fabry disease is emerging.

Muscle wasting in heart failure : The role of nutrition

Muscle wasting and malnutrition are common complications in patients with advanced heart failure (HF); however, both remain underdiagnosed and undertreated although they both play relevant roles in the progression of HF. The risk of muscle wasting in patients with HF increases in those patients with malnutrition or at risk of malnutrition. Muscle wasting and malnutrition are thought to be positively influenced by adequate therapeutic interventions such as physical activity and nutritional support. Consequently, early detection of malnutrition in patients with HF is recommended. This review discusses muscle wasting and nutritional status, describing the effects of malnutrition on muscle wasting in patients with HF. We review specific issues related to muscle wasting and nutritional status in patients with HF; however, no established strategies currently exist to focus on patients suffering from muscle wasting with malnutrition.

Coronary artery disease prevalence and outcome in patients hospitalized with acute heart failure: an observational report from seven Middle Eastern countries

OBJECTIVES

The purpose of this study was to report prevalence, clinical characteristics, precipitating factors, management and outcome of patients with coronary artery disease (CAD) among patients hospitalized with heart failure (HF) in seven Middle Eastern countries and compare them to non-CAD patients.

METHODS

Data were derived from Gulf CARE (Gulf aCute heArt failuRe rEgistry), a prospective multicenter study of 5005 consecutive patients hospitalized with acute HF during February-November 2012 in 7 Middle Eastern countries.

RESULTS

The prevalence of CAD among Acute Heart Failure (AHF) patients was 60.2% and varied significantly among the 7 countries (Qatar 65.7%, UAE 66.6%, Kuwait 68.0%, Oman 65.9%, Saudi Arabia 62.5%, Bahrain 52.7% and Yemen 49.1%) with lower values in the lower income countries. CAD patients were older and more likely to have diabetes, hypertension, dyslipidemia and chronic kidney disease. Moreover, CAD patients were more likely to have history of cerebrovascular and peripheral vascular disease when compared to non-CAD patients. In-hospital mortality rates were comparable although CAD patients had more frequent re-hospitalization and worse long-term outcome. However, CAD was not an independent predictor of poor outcome.

CONCLUSION

The prevalence of CAD amongst patients with HF in the Middle East is variable and may be related to healthcare sources. Regional and national studies are needed for assessing further the impact of various etiologies of HF and for developing appropriate strategies to combat this global concern.

Development of guidance on the timeliness in response to acute kidney injury warning stage test results for adults in primary care: an appropriateness ratings evaluation

OBJECTIVES

Tackling the harm associated with acute kidney injury (AKI) is a global priority. In England, a national computerised AKI algorithm is being introduced across the National Health Service (NHS) to drive this change. The study sought to maximise its clinical utility and minimise the potential for burden on clinicians and patients in primary care.

DESIGN

An appropriateness ratings evaluation using the RAND/UCLA Appropriateness Method.

SETTING

Clinical scenarios were developed to test the timeliness in (1) communication of AKI warning stage test results from clinical pathology services to primary care, and (2) primary care clinician response to an AKI warning stage test result.

PARTICIPANTS

A 10-person panel was purposively sampled with representation from clinical biochemistry, acute and emergency medicine and general practice. General practitioners (GPs) represented typical practice in relation to rural and urban practice, out of hours care, GP commissioning and those interested in reducing the impact of medicalisation and 'overdiagnosis'.

RESULTS

There was agreement that delivery of AKI warning stage test results through interruptive methods of communication (ie, telephone) from laboratories to primary care was the appropriate next step for patients with an AKI warning stage 3 test result. In the context of acute illness, waiting up to 72 hours to respond to an AKI warning stage test result was deemed an inappropriate action in 62 out of the 65 (94.5%) cases. There was agreement that a clinician response was required within 6 hours, or less, in 39 out of 40 (97.5%) clinical cases relating AKI warning stage test results in the presence of moderate hyperkalaemia.

CONCLUSIONS

The study has informed national guidance to support a timely and calibrated response to AKI warning stage test results for adults in primary care. Further research is needed to support effective implementation, with a view to examine the effect on health outcomes and costs.

Targeting acetaldehyde dehydrogenase 2 (ALDH2) in heart failure-Recent insights and perspectives

Heart failure is one of the major causes of the ever-rising mortality globally. ALDH2 rs671 polymorphism is proven to be closely related to the prevalence of CAD, hypertension, diabetes mellitus and alcoholism, which are etiological factors of heart failure. In addition, growing evidence supports a possible role for ALDH2 in different forms of heart failure. In this mini-review, we will review the recent insights regarding the effects of ALDH2 polymorphism on etiological factors of heart failure and underlying mechanisms involved. In addition, we will also discuss the booming epigenetic information in this field which will greatly improve our understanding of the cardiovascular effect of ALDH2. This article is part of a Special Issue entitled: Genetic and epigenetic control of heart failure edited by Dr. Jun Ren & Yingmei Zhang.

Upregulation of Soluble HLA-G in Chronic Left Ventricular Systolic Dysfunction

Left ventricular systolic dysfunction (LVSD) defined by ejection fraction (EF) <40% is common, serious but treatable, and correct diagnosis is the cornerstone of effective treatment. Biomarkers may help to diagnose LVSD and give insight into the pathophysiology. The immune system is activated in LVSD, and the immunomodulatory molecule human leukocyte antigen-G (HLA-G) may be involved. The primary aim was to measure soluble HLA-G (sHLA-G) in the blood in different stages of LVSD (<30% and 30–40%), in the midrange EF 40–50%, and in preserved EF ≥ 50% and to validate sHLA-G as a LVSD biomarker. The secondary aim was to examine associations between HLA-G gene polymorphisms influencing expression levels and LVSD. The 260 study participants were ≥75 years old, many with risk factors for heart disease or with known heart disease. Soluble HLA-G was significantly and uniformly higher in the groups with EF < 50% (<30, 30–40, and 40–50%) compared to EF > 50% (p < 0.0001). N-terminal fragment-pro-B-type natriuretic peptide (NT-proBNP) and uric acid values were inversely related to EF. According to Receiver Operating Characteristic (ROC) curves NT-proBNP outperformed both sHLA-G and uric acid as biomarkers of LVSD. Soluble HLA-G in blood plasma was elevated in LVSD regardless of EF. A novel finding was that a combined 14 bp ins-del/+3142 SNP HLA-G haplotype was associated with EF < 40%.

Heart Failure Therapy in 2016

Heart failure (HF) continues to afflict millions of Americans, resulting in substantial clinical and economic burden to our society. Recent literature has highlighted the role of 2 novel therapies (an angiotensin receptor blocker/neprilysin inhibitor and ivabradine) in further reducing residual disease in HF. Simultaneously, evidence has mounted suggesting that older therapies like digoxin are not effective in contemporary practice and, in fact, may be harmful. This editorial summarizes the most recently published articles pertaining to both new and old HF therapies and provides a call to action to pharmacists on how to shift patients toward effective drug regimens.