Acute heart failure management in the USA and Japan: overview of practice patterns and review of evidence

Novel enhancers of guanylyl cyclase-A activity acting via allosteric modulation

BACKGROUND AND PURPOSE

Guanylyl cyclase-A (GC-A), activated by endogenous atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP), plays an important role in the regulation of cardiovascular and renal homeostasis and is an attractive drug target. Even though small molecule modulators allow oral administration and longer half-life, drug targeting of GC-A has so far been limited to peptides. Thus, in this study we aimed to develop small molecular activators of GC-A.

EXPERIMENTAL APPROACH

Hits were identified through high-throughput screening and optimized by in silico design. Cyclic GMP was measured in QBIHEK293A cells expressing GC-A, GC-B or chimerae of the two receptors using AlphaScreen technology. Binding assays were performed in membrane preparations or whole cells using 125 I-ANP. Vasorelaxation was measured in aortic rings isolated from Wistar rats.

KEY RESULTS

We have identified small molecular allosteric enhancers of GC-A, which enhanced ANP or BNP effects in cellular systems and ANP-induced vasorelaxation in rat aortic rings. The mechanism of action appears novel and not mediated through previously described allosteric binding sites. In addition, the selectivity and activity depend on a single amino acid residue that differs between the two similar receptors GC-A and GC-B.

CONCLUSION AND IMPLICATIONS

We describe a novel allosteric binding site on GC-A, which can be targeted by small molecules to enhance ANP and BNP effects. These compounds will be valuable tools in further development and proof-of-concept of GC-A enhancement for the potential use in cardiovascular therapy.

Natriuretic Peptides: It Is Time for Guided Therapeutic Strategies Based on Their Molecular Mechanisms

Natriuretic peptides (NPs) are the principal expression products of the endocrine function of the heart. They exert several beneficial effects, mostly mediated through guanylate cyclase-A coupled receptors, including natriuresis, diuresis, vasorelaxation, blood volume and blood pressure reduction, and regulation of electrolyte homeostasis. As a result of their biological functions, NPs counterbalance neurohormonal dysregulation in heart failure and other cardiovascular diseases. NPs have been also validated as diagnostic and prognostic biomarkers in cardiovascular diseases such as atrial fibrillation, coronary artery disease, and valvular heart disease, as well as in the presence of left ventricular hypertrophy and severe cardiac remodeling. Serial measurements of their levels may be used to contribute to more accurate risk stratification by identifying patients who are more likely to experience death from cardiovascular causes, heart failure, and cardiac hospitalizations and to guide tailored pharmacological and non-pharmacological strategies with the aim to improve clinical outcomes. On these premises, multiple therapeutic strategies based on the biological properties of NPs have been attempted to develop new targeted cardiovascular therapies. Apart from the introduction of the class of angiotensin receptor/neprilysin inhibitors to the current management of heart failure, novel promising molecules including M-atrial natriuretic peptide (a novel atrial NP-based compound) have been tested for the treatment of human hypertension with promising results. Moreover, different therapeutic strategies based on the molecular mechanisms involved in NP regulation and function are under development for the management of heart failure, hypertension, and other cardiovascular conditions.

Relationship between instrumental activities of daily living decline during hospitalization and one-year mortality in elderly patients with heart failure: A multi-center prospective cohort study

BACKGROUND

It remains unclear whether instrumental activities of daily living (IADL) decline during hospitalization is related to mortality rates. This study examined the relationship between IADL decline during hospitalization and the one-year mortality rate in elderly heart failure (HF) patients.

METHODS

Five hundred seventy-six consecutive patients who were hospitalized for acute decompensated HF and underwent rehabilitation were divided into groups based on changes in IADL during hospitalization: IADL maintained and IADL decline. IADL was assessed by the National Center for Geriatrics and Gerontology-Activities of Daily Living Scale (NCGG-ADL). IADL decline was defined as Δ NCGG-ADL ≤ -1 point. The primary outcome was one-year all-cause mortality rate after discharge. Outcomes were examined using the Kaplan-Meier method with the log-rank test and Cox proportional hazards models using the existing prognostic risk factors for HF.

RESULTS

Of 576 patients, 20% (n = 113) had IADL decline during hospitalization, and 9.2% (n = 35) and 6.0% (n = 18) died of all-cause and cardiovascular disease within one year after discharge, respectively. The IADL-decline group had significantly higher one-year all-cause mortality rates after adjusting for risk factors (hazard ratio: 1.923, 95% confidence interval 1.085-3.409; P = 0.023). Among the IADL subcategories, outdoor activity items such as "go out by oneself," "take a bus or train," and "shop for necessities" were more likely to change from independent to dependent during hospitalization.

CONCLUSION

IADL decline during hospitalization was associated with an increased all-cause mortality rate at one-year after discharge in elderly HF patients.

Diagnostic utility of lung echography for congestive heart failure performed by junior resident doctors

Background

Dyspnea is a high priority symptom in the emergency department, with heart failure (HF) as one of its leading causes. Recently, the “comet tail sign (CTS),” a pulmonary ultrasonographic sign, has been proposed as an efficacious tool for detecting pulmonary edema. However, to the best of our knowledge, there have been no published data regarding its utility when performed by non‐experts, including junior residents.

Methods

Between September 2017 and December 2018, patients with dyspnea, who were admitted to the ER, were enrolled. CTS was evaluated by junior residents at the ER. All patients were evaluated by cardiologists independently, and clinical HF was defined as requiring pharmacological intervention by a cardiologist. At the end of this study, we investigated the results of CTS, laboratory data, and available radiological images.

Results

A total of 95 patients were enrolled in the current study, wherein 42 patients were treated by cardiologists as those with clinical HF. Our results showed that CTS could identify clinical HF with a sensitivity of 71.4% and a specificity of 81.1%. The sensitivity of CTS against brain natriuretic peptide (BNP) (cut‐off value, 100 pg/ml) was calculated at 92.5%. Furthermore, when evaluated together with peripheral edema, CTS identified clinical HF with a sensitivity of 96%. False positives for CTS included bilateral pneumonia, hypoalbuminemia, and interstitial pneumonitis.

Conclusions

Our results indicate that CTS is a simple and effective tool for the use of non‐experts, including junior residents.

Efficacy and safety of intravenous OPC-61815 compared with oral tolvaptan in patients with congestive heart failure

AIMS

This multicentre, randomized, controlled, double-blind, parallel-group Phase III study was conducted to confirm the non-inferiority of OPC-61815 (tolvaptan sodium phosphate) intravenous injections to oral tolvaptan tablets in patients with congestive heart failure and volume overload despite receiving diuretics other than vasopressin antagonists.

METHODS AND RESULTS

Congestive heart failure patients with volume overload despite receiving diuretics other than vasopressin antagonists were randomly assigned (1:1) to receive OPC-61815 (16-mg injection; n = 149) or oral tolvaptan (15-mg tablet; n = 145) once daily for 5 days. Most patients were male; the mean age and weight were 74.7 years and 62.1 kg, respectively; other demographic and clinical characteristics were similar between groups. In this study, the primary endpoint was the change in body weight from baseline to the day after the last dose. Secondary endpoints included improvement from baseline in congestive findings and New York Heart Association classification. The change in body weight was -1.67 kg [95% confidence interval (CI): -1.93, -1.41] and -1.36 kg (95% CI: -1.62, -1.10) in the OPC-61815 group and tolvaptan group, respectively; the difference in the least squares mean between the groups was -0.31 kg (95% CI: -0.68, 0.06). Given the upper CI did not exceed the pre-specified limit of 0.48, this confirmed the non-inferiority of injectable OPC-61815 to oral tolvaptan. Daily urine volume and daily fluid intake increased, and daily fluid balance was negative throughout the treatment period; changes were similar for both groups. All evaluated congestive symptoms and New York Heart Association classifications showed improvement and safety findings were similar between the groups. The incidence of hyperkalaemia was higher in the OPC-61815 group, and the incidence of thirst and dry mouth was higher in the tolvaptan group. Most treatment-emergent adverse events were mild to moderate; one serious treatment-emergent adverse event of hyperkalaemia in the OPC-61815 group was considered treatment related.

CONCLUSIONS

OPC-61815 (16-mg injection) was confirmed as non-inferior to oral tolvaptan (15-mg tablet) in patients with congestive heart failure and inadequate response to diuretics; no new safety concerns were observed.

Clinical implication of initial intravenous diuretic dose for acute decompensated heart failure

Although intravenous diuretics is a cornerstone of acute heart failure treatment (AHF), its optimal initial dose is unclear. This is a post-hoc analysis of the REALITY-AHF, a prospective multicentre observational registry of AHF. The initial intravenous diuretic dose used in each patient was categorised into below, standard, or above the recommended dose groups according to guideline-recommended initial intravenous diuretic dose. The recommended dose was individualised based on the oral diuretic dose taken at admission. We compared the study endpoints, including 60-day mortality, diuretics response within six hours, and length of hospital stay (HS). Of 1093 patients, 429, 558, and 106 were assigned to the Below, Standard, and Above groups, respectively. The diuretics response and HS were significantly greater in the Below group than in the Standard group after adjusting for covariates. Kaplan–Meier analysis indicated a significantly higher incidence of 60-day mortality in the Above group than the Standard group. This difference was retained after adjusting for other prognostic factors. Treatment with a lower than guideline-recommended intravenous diuretic dose was associated with longer HS, whereas above the guideline-recommended dose was associated with a higher 60-day mortality rate. Our results reconfirm that the guideline-recommended initial intravenous diuretic dose is feasible for AHF.

Ultrafiltration in Japanese critically ill patients with acute kidney injury on renal replacement therapy

A recent worldwide survey indicates an international diversity in net ultrafiltration (UF^NET) practices for the treatment of fluid overload in critically ill patients with acute kidney injury (AKI) requiring renal replacement therapy (RRT). The sub-analysis of the survey has demonstrated that maximum doses of furosemide used before determination of diuretic resistance are lower in Japan than those prescribed worldwide and UF^NET is lower but is initiated earlier. In contrast, the interval during which practitioners evaluate fluid balance is longer. The characterization of RRT in critically ill patients in Japan should unveil more appropriate approaches to the successful treatment of AKI.

Temporal changes and prognostic value of plasma ghrelin level in patients with acute heart failure: a prospective study

BACKGROUND

Plasma ghrelin levels can be elevated in patients with acute heart failure (AHF). This study aimed to analyze the temporal changes and prognostic value of ghrelin levels in patients with AHF.

METHODS

This prospective study included patients with AHF at the Cardiology Department, Weifang People's Hospital (May 2018-October 2019), and age- and sex-matched healthy controls. Plasma ghrelin levels were measured. Multivariable logistic regression and receiver operating characteristic (ROC) curve analyses were used to evaluate whether ghrelin levels could predict major cardiac adverse events (MACEs) during a 1-year follow-up.

RESULTS

Finally, 92 patients with AHF and 50 healthy controls were enrolled. Ghrelin levels were higher in patients with AHF at 1, 3, 12, and 24 h compared with controls (all P < 0.01). Ghrelin levels in the AHF group were higher at 3 and 12 h than at 1 and 24 h (P < 0.001). Ghrelin level at 3 h in patients with AHF was negatively correlated with the left ventricular end-diastolic diameter and left ventricular ejection fraction (both P < 0.05). MACEs occurred in 48 patients with AHF. Ghrelin levels were higher in the MACE group than in the non-MACE group at 1 (P = 0.011) and 3 h (P = 0.034). Multivariable regression showed that ghrelin level at 3 h was independently associated with MACEs [OR = 0.629, 95% confidence interval (CI): 0.515-0.742, P = 0.010], but the area under the ROC curve was only 0.629 (95% CI 0.515-0.742).

CONCLUSIONS

Plasma ghrelin levels are elevated in AHF and patients with MACEs during follow-up.

Pathophysiology and Therapeutic Approaches to Acute Decompensated Heart Failure

Acute decompensated heart failure (ADHF) is one of the leading admission diagnoses worldwide, yet it is an entity with incompletely understood pathophysiology and limited therapeutic options. Patients admitted for ADHF have high in-hospital morbidity and mortality, as well as frequent rehospitalizations and subsequent cardiovascular death. This devastating clinical course is partly due to suboptimal medical management of ADHF with persistent congestion upon hospital discharge and inadequate predischarge initiation of life-saving guideline-directed therapies. While new drugs for the treatment of chronic HF continue to be approved, there has been no new therapy approved for ADHF in decades. This review will focus on the current limited understanding of ADHF pathophysiology, possible therapeutic targets, and current limitations in expanding available therapies in light of the unmet need among these high-risk patients.

Disease Management and Outcomes in Patients Hospitalized for Acute Heart Failure in Japan

Introduction

This study described patients hospitalized for acute heart failure (AHF) in Japan who received intravenous (IV) diuretics and/or vasodilators as the initial therapy.

Methods

The Japan Medical Data Vision database was used to identify adult patients hospitalized for AHF during 2013–2017, who were hemodynamically stable at presentation and treated with IV diuretics and/or IV vasodilators as initial therapy. Treatment patterns and use of cardiac rehabilitation, as well as outcomes (e.g., length of stay [LOS], in-hospital mortality, HF-readmission) were reported overall and by year of AHF hospitalization.

Results

Of 30,360 patients (mean age = 80.0 years; 52.2% male), 87.0% were treated during the hospitalization with IV diuretics, 63.9% with IV vasodilators, and 13.8% with intensified therapies. On average, the duration of IV therapy was 10.6 days. In-hospital cardiac rehabilitation was utilized by 51.7% of the patients for 11.7 days on average. Mean LOS was 23.3 days, while in-hospital mortality and 30-day HF readmission post-discharge were 13.2 and 9.5%, respectively. Hospitalization outcomes remained stable between 2013 and 2017 despite important changes in AHF management such as a decrease in carperitide use (55.9–40.0% in 2017), and increases in use of tolvaptan (from 14.2% in 2013 to 31.3% in 2017) and of cardiac rehabilitation (from 43.2% in 2013 to 56.1% in 2017). Patients with intensified therapies had the longest IV therapy duration (mean 23.8 days vs. 5.5–9.9 days), the highest cardiac rehabilitation services use (60.2 vs. 38.3–57.0%), the longest LOS (mean 36.7 vs. 16.3–22.2 days), and the highest in-hospital mortality (37.4 vs. 3.1–12.4%) compared to the other treatment groups.

Conclusions

Contemporary treatment for AHF hospitalization in Japan comprises a long duration of IV therapy followed by extended use of oral medications and in-hospital cardiac rehabilitation prior to discharge. Patients requiring intensified therapies had much longer LOS and higher in-hospital mortality.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40119-021-00212-y.

Early rehabilitation in older patients hospitalized with acute decompensated heart failure: A retrospective cohort study

Although hospitalized patients with acute decompensated heart failure (ADHF) have severe physical dysfunction, little data are available on the comparative effectiveness of early versus late rehabilitation. This study examined the relationship between early compared to late rehabilitation and physical function among older patients hospitalized for ADHF.

METHODS

In a retrospective cohort study, independent patients aged ≥65 years at baseline who were hospitalized for ADHF from 2012 to 2014 and underwent inpatient rehabilitation were identified using Emergency Department visit data and electronic medical records at two hospitals. Patients were classified into those who underwent early rehabilitation (initiated within 72 hours of admission) and late rehabilitation (after 72 hours). Primary outcome was length of time from admission until the patient was able to walk independently. Multivariable competing-risk regression with death as the competing event was used to adjust for potential confounding factors, and multiple imputation (MI) analysis was performed.

RESULTS

Of 259 individuals, 30 (11.6%) commenced rehabilitation within 72 hours after admission while 229 (88.4%) did so 72 hours after admission. Patients who received early rehabilitation had a higher rate of unassisted walking for at least 40 m by 30 days after admission (hazard ratio: 8.03; 95% confidence interval: 2.15 to 29.98; P = .002 in the multivariable adjusted model) than those who received late rehabilitation. Similar findings were observed on MI analysis.

CONCLUSION

Early rehabilitation therapy commenced within 72 hours of admission was associated with a higher rate of recovery of an activity of daily living (independent walking on a level surface).

Safety of Outpatient Milrinone Infusion in End-Stage Heart Failure: ICD-Level Data on Atrial Fibrillation and Ventricular Tachyarrhythmias

BACKGROUND

Milrinone infusion is one of a few select "non-device" therapies for patients with New York Heart Association (NYHA) class IV, stage D heart failure, which has been associated with an increase in ventricular tachyarrhythmia and atrial fibrillation. Milrinone improves hemodynamics and provides symptomatic relief. Many patients with end-stage heart failure die from cardiac pump failure, and the impact of ventricular tachyarrhythmia and atrial fibrillation on their mortality is unclear.

METHODS

This is a retrospective study of 98 consecutive patients receiving outpatient milrinone in a single center from 2008 to 2016. The primary endpoint of the study was overall survival on milrinone. Secondary endpoints were incidence of post-milrinone implantable cardioverter defibrillator (ICD) shocks and development of ventricular tachyarrhythmia or atrial fibrillation.

RESULTS

Median survival was 581 ± 96 days with no difference between those with prior ventricular tachyarrhythmia and those without at 1 month (92% vs 97%, P = 0.34), 6 months (67% vs 73%, P = 0.75), and 12 months (67% vs 61%, P = 0.88). Seven out of 12 (58%) patients with prior ventricular tachyarrhythmia had ICD shocks, as compared to 5 out of 78 (6.4%) (P <0.001). Thirty-five patients had atrial fibrillation prior to starting milrinone, which decreased to 72% (P <0.05) by the third follow-up time period (7-9 months). Amiodarone use was protective against new onset atrial fibrillation.

CONCLUSIONS

Patients with stage D heart failure with a history of ventricular tachyarrhythmia have similar survival on outpatient milrinone compared to those without. However, those with prior ventricular tachyarrhythmia received more ICD shocks for more ventricular tachyarrhythmias. Milrinone remains a viable therapy for patients with stage D heart failure with limited therapeutic options.

Circulating galectin-3 on admission and prognosis in acute heart failure patients: a meta-analysis

Changes of serum galectin-3 have been associated with the pathogenesis of many cardiovascular diseases. The aim of the study was to evaluate the prognostic role of serum galectin-3 in patients with acute heart failure (AHF) in a meta-analysis. Follow-up studies evaluating the association between serum galectin-3 on admission and clinical outcomes in AHF patients were identified via search of PubMed and Embase databases. A random effects or a fixed effects model was applied to pool the results depending on the heterogeneity. Subgroup analysis was used to evaluate the influences of study characteristics on the outcomes. Overall, 7057 AHF patients from eighteen follow-up studies were included. Higher serum galectin-3 was associated with higher risks of all-cause mortality (adjusted risk ratio [RR], 1.58; p < 0.001), mortality/HF rehospitalization (RR, 1.68; p < 0.001), and cardiovascular mortality (RR, 1.29; p = 0.04), but not HF rehospitalization (RR, 1.24; p = 0.25) in AHF patients. Subgroup analyses showed that study characteristics including study design, sample size, age, gender, left ventricular ejection fraction, galectin-3 variable type, follow-up duration, and adjustment of type B natriuretic peptide did not significantly impact the results. Significant heterogeneities were detected for the outcomes of all-cause mortality and mortality/HF rehospitalization. However, trim-and-fill analyses by including the imputed studies to generate symmetrical funnel plots showed similar significant meta-analysis results. These results suggested that higher serum galectin-3 may be associated with poor prognosis in AHF patients. Further studies are needed to determine the mechanisms underlying the potential prognostic role of galectin-3 in AHF.

Acute heart failure management in the USA and Japan: overview of practice patterns and review of evidence

Globally, acute heart failure (AHF) remains an ongoing public health issue with its prevalence and mortality increasing in the east and the west. Effective treatment strategies to stabilize AHF are important to alleviate clinical symptoms and to improve clinical outcomes. However, despite the progress in the management of stable and chronic heart failure, no single agent has been proven to play a definitive role in the management of AHF. As a consequence, contemporary treatment strategies for patients with AHF vary greatly by region. This manuscript reviews the medical treatment options for AHF, with an emphasis on the differences between the treatment strategies in the USA and Japan. This information would provide a framework for clinicians to evaluate and manage patients with AHF and highlight the remaining questions to improve clinical outcomes.