Heart failure 'the cancer of the heart': the prognostic role of the HLM score

Clinical phenotyping of cardiogenic shock at a glance: A rapid, costless, streamlined approach

AIMS

Cardiogenic shock (CS) is a heterogeneous syndrome in which recent guidelines have proposed clinical phenotyping based on the presence of hypoperfusion and/or congestion signs and symptoms. However, the impact of this clinical phenotype on outcomes remains poorly characterized.

METHODS AND RESULTS

FRENSHOCK is a prospective registry including 772 CS patients from 49 centres. Patients were categorized into multiple phenotypic groups based on three clinically assessed bedside criteria at admission: congestion, hypotension and skin mottling. The primary endpoint was 30-day all-cause mortality. Among 475 CS patients included, 69.7% were male, with a median age of 67.0 (59.0-78.0) years. Most patients presented with SCAI stage C (37.1%) or D (51.2%). At admission, 424 patients (89.3%) presented with congestion (50.7% on both sides, 39.2% left-sided, 10.1% right-sided), 343 (72.2%) with hypotension and 180 (37.9%) with mottling. At 30 days, 113 patients (23.8%) had died, spanning from 8.8% for patients with isolated hypotension (without congestion/mottling) to 26.5% for patients with hypotension and congestion, and 32.3% for patients with hypotension, congestion and mottling. The corresponding ORs for 30-day all-cause mortality remained significant even after adjustment for potential confounders, with 1.19 [(1.02-1.39), P = 0.03] for hypotension and congestion and 1.26 [(1.08-1.48), P < 0.01] for hypotension, congestion and mottling.

CONCLUSIONS

A simple clinical bedside evaluation of the CS phenotype based on hypotension, congestion and mottling allows for quick and costless stratification of 30-day mortality risk and can be used to guide the level of monitoring intensity and/or patient management.

Early in-hospital use of SGLT2i in heart failure patients with ischemic etiology

PURPOSE

SGLT2i role in the treatment of heart failure (HF) regardless of clinical presentation and left ventricular ejection fraction (LVEF) has been widely proven and real-world data regarding patients with HF and ischemic heart disease (IHD) and, in particular with recent acute coronary syndrome (ACS) and de novo HF, are lacking. We aim to evaluate the occurrence of the composite of cardiovascular death (CV)/ HF hospitalization (HFH), all-cause death, CV death and HFH at 6 months follow up, in patients with HF due to IHD as well as in recent ACS who introduced SGLT2i during the index hospitalization.

METHODS

The present is an observational, prospective, single center study, enrolling patients with a diagnosis of HF due to IHD as primary etiology. According to SGLT2i introduction timing, two groups were created: pre-discharge (G1) or post-discharge (G2) introduction. A sub-analysis in patients admitted due to ACS has been performed.

RESULTS

A total of 222 consecutive patients have been enrolled from April 2022 to April 2024 and were followed-up for a period of 6 months. At multivariate Cox regression analysis, statistically significant differences have been observed between the two groups in terms of the composite CV death/HFH (HR = 0.24; 95%CI [0.101-0.564]; p = 0.001), all-cause death (HR = 0.27; 95% CI [0.100-0.725]; p = 0.009), CV death (HR = 0.32; 95%CI [0.101-0.999] p = 0.045) and HFH (HR = 0.31; 95%CI [0.098-0.963]; p = 0.043). Patients with ACS treated with SGLT2i before discharge showed a reduced rate of CV death/HFH (log-rank p = 0.008), CV death (log-rank p = 0.015) and all-cause death (log-rank p = 0.005) compared to patients who were not treated with SGLT2i before discharge. In this subpopulation, no differences have been observed in terms of HFH (log-rank p = 0.155). Significant differences in term of CV death/HFH (log-rank p = 0.039) have been observed in de novo HF patients, but not in terms of the other study endpoints.

CONCLUSIONS

The early in-hospital introduction of SGLT2i reduced the occurrence of the composite CV death/HFH, all-cause death, CV death and HFH in patients with ischemic cardiomyopathy. In the subgroup analysis of patients admitted due to ACS, the introduction of SGLT2i during the index hospitalization resulted in a significant reduction of the composite CV death/HFH, CV death and all-cause death, but not in HFH. The same therapeutic strategy resulted in reduced rate of CV death/HFH in the de novo HF subpopulation.

The Early Pharmacological Strategy with Inodilator, bEta-blockers, Mineralocorticoid Receptor Antagonists, Sodium-glucose coTransporter-2 Inhibitors and Angiotensin Receptor-neprylisin Inhibitors in Acute Heart Failure (PENTA-HF)

PURPOSE

The management of acute heart failure (AHF) is crucial and challenging. Regarding the use of inotropes, correct patient selection and time of administration are of the essence. We hypothesize that the early use of Levosimendan favouring hemodynamic stabilization and enables rapid optimization of guideline-directed medical therapy (GDMT) in patients with HF, eventually impacting the patient's prognosis during the vulnerable phase.

METHODS

This prospective, observational study enrolled consecutive patients admitted due to AHF. Propensity score matching (PSM) analysis has been used to homogenize differences between groups. In group 1 (G1), patients were treated with early 24-h Levosimendan infusion followed by in-hospital introduction/up-titration of GDMT. In group 2 (G2), patients were treated with alternative inotropes/ vasopressors followed by in-hospital introduction/up-titration of GDMT. The comparison between the two groups has been performed at the 6-month follow-up in terms of cardiovascular (CV) mortality and HF hospitalizations (HFH).

RESULTS

233 patients were included in the present study, and after propensity match adjustments, 176 patients were analysed, 88 patients for each group. No differences in the baseline characteristics have been reported between the groups. At 6 months follow-up, no statistically significant differences were shown in terms of the composite endpoint of CV death and HFH (p = 0.445) and CV death (p = 0.62). Statistically significant differences between the two groups were reported in terms of HFH (p = 0.02). The Kaplan-Meier survival analysis showed that patients in G1 were significantly less hospitalized compared to G2 during the 6 months after the index hospitalization (log-rank p = 0.03).

CONCLUSION

Early 24-hour infusion of Levosimendan followed by rapid optimization of HF diseasemodifying therapies results in a significant reduction of HFH in the vulnerable post-discharge phase.

MicroRNA and Heart Failure: A Novel Promising Diagnostic and Therapeutic Tool

Heart failure (HF) has a multifaceted and complex pathophysiology. Beyond neurohormonal, renin-angiotensin-aldosterone system, and adrenergic hyperactivation, a role for other pathophysiological determinants is emerging. Genetic and epigenetic factors are involved in this syndrome. In many maladaptive processes, the role of microRNAs (miRNAs) has been recently demonstrated. MiRNAs are small endogenous non-coding molecules of RNA involved in gene expression regulation, and they play a pivotal role in intercellular communication, being involved in different biological and pathophysiological processes. MiRNAs can modulate infarct area size, cardiomyocytes restoration, collagen deposition, and macrophage polarization. MiRNAs may be considered as specific biomarkers of hypertrophy and fibrosis. MiRNAs have been proposed as a therapeutical tool because their administration can contrast with myocardial pathophysiological remodeling leading to HF. Antimir and miRNA mimics are small oligonucleotides which may be administered in several manners and may be able to regulate the expression of specific and circulating miRNAs. Studies on animal models and on healthy humans demonstrate that these molecules are well tolerated and effective, opening the possibility of a therapeutic use of miRNAs in cases of HF. The application of miRNAs for diagnosis, prognostic stratification, and therapy fits in with the new concept of a personalized and tailored approach to HF.

Identifying Demographic and Clinical Determinants of Ischemic Workup in Patients with Heart Failure

Background/Objectives: Coronary artery disease (CAD) is a common and treatable cause of heart failure (HF), but ischemic evaluation is often overlooked when evaluating patients with new-onset HF. Here, we sought to discern demographic and clinical predictors of ischemic workup in patients with newly diagnosed HF. Methods: A retrospective study of 200 consecutive patients with new-onset HF admitted to our safety-net hospital between 2011 and 2015 was performed. We developed a multivariate logistic regression model to analyze determinants of undergoing ischemic evaluation. Results: A total of 99 patients (49.5%) underwent ischemic workup, while 101 patients (50.5%) did not. The mean age of the cohort was 73.9 ± 16, with 50% as male and 51% as White. In total, 41.5% of patients had HF with reduced ejection fraction, and 37% of patients had HF with preserved ejection fraction. Among the patients who underwent ischemic evaluation, 63.6% received nuclear stress testing, 24.2% received cardiac catheterization, 9.1% received stress echocardiography, and 3% received computed tomography angiography. Demographic and clinical factors such as sex, age, race, presence of hypertension, hyperlipidemia, chronic kidney disease, diabetes, or obesity had no significant association with receiving ischemic workup (p > 0.05). Patients with known CAD (OR 2.816, p = 0.015) and a higher social deprivation index (SDI) (OR 1.022, p = 0.003) were significantly more likely to receive an ischemic evaluation. Atrial fibrillation was significantly negatively associated with receiving ischemic workup (OR: 0.24; p = 0.001). Conclusions: In our single-center safety-net hospital analysis, known CAD and higher SDI were significant predictors of ischemic evaluation in patients with newly diagnosed HF. Multiple demographic features, including age, sex, race, and clinical features, including HF type, hypertension, hyperlipidemia, and diabetes, had no significant correlation with ischemic workup.

Strategy for an early simultaneous introduction of four-pillars of heart failure therapy: results from a single center experience

INTRODUCTION

The 2021 European Society of Cardiology (ESC) Guidelines recommend the use of four different classes of drugs for heart failure with reduced ejection fraction (HFrEF): beta blockers (BB), sodium-glucose cotransporter-2 inhibitors (SGLT2i), angiotensin receptor/neprilysin inhibitor (ARNI), and mineralocorticoid receptor antagonists (MRAs). Moreover, the 2023 ESC updated Guidelines suggest an intensive strategy of initiation and rapid up-titration of evidence-based treatment before discharge, based on trials not using the four-pillars. We hypothesized that an early concomitantly administration and up-titration of four-pillars, compared with a conventional stepwise approach, may impact the vulnerable phase after hospitalization owing to HF.

METHODS

This prospective, single center, observational study included consecutive in-hospital patients with HFrEF. After performing propensity score matching, they were divided according to treatment strategy into group 1 (G1), with predischarge start of all four-pillars, with their up-titration within 1 month, and group 2 (G2) with the pre Guidelines update stepwise four-pillars introduction. HF hospitalization, cardiovascular (CV) death, and the composite of both were evaluated between the two groups at 6-month follow-up.

RESULTS

The study included a total of 278 patients who completed 6-month follow-up (139 for both groups). There were no differences in terms of baseline features between the two groups. At survival analysis, HF hospitalization risk was significantly lower in G1 compared with G2 (p < 0.001), while no significant differences were observed regarding CV death (p = 0.642) or the composite of CV death and HF hospitalization (p = 0.135).

CONCLUSIONS

In our real-world population, patients with HF treated with a predischarge and simultaneous use of four-pillars showed a reduced risk of HF hospitalization during the vulnerable phase after discharge, compared with  a conventional stepwise approach.

The Role of High-Sensitivity Troponin T Regarding Prognosis and Cardiovascular Outcome across Heart Failure Spectrum

Background: Cardiac troponin release is related to the cardiomyocyte loss occurring in heart failure (HF). The prognostic role of high-sensitivity cardiac troponin T (hs-cTnT) in several settings of HF is under investigation. The aim of the study is to assess the prognostic role of intrahospital hs-cTnT in patients admitted due to HF. Methods: In this observational, single center, prospective study, patients hospitalized due to HF have been enrolled. Admission, in-hospital peak, and discharge hs-cTnT have been assessed. Patients were followed up for 6 months. Cardiovascular (CV) death, HF hospitalization (HFH), and worsening HF (WHF) (i.e., urgent ambulatory visit/loop diuretics escalation) events have been assessed at 6-month follow up. Results: 253 consecutive patients have been enrolled in the study. The hs-cTnT median values at admission and discharge were 0.031 ng/mL (IQR 0.02-0.078) and 0.031 ng/mL (IQR 0.02-0.077), respectively. The risk of CV death/HFH was higher in patients with admission hs-cTnT values above the median (p = 0.02) and in patients who had an increase in hs-cTnT during hospitalization (p = 0.03). Multivariate Cox regression analysis confirmed that hs-cTnT above the median (OR: 2.06; 95% CI: 1.02-4.1; p = 0.04) and increase in hs-cTnT during hospitalization (OR:1.95; 95%CI: 1.006-3.769; p = 0.04) were predictors of CV death/HFH. In a subgroup analysis of patients with chronic HF, hs-cTnT above the median was associated with increased risk of CV death/HFH (p = 0.03), while in the subgroup of patients with HFmrEF/HFpEF, hs-cTnT above the median was associated with outpatient WHF events (p = 0.03). Conclusions: Inpatient hs-cTnT levels predict CV death/HFH in patients with HF. In particular, in the subgroup of chronic HF patients, hs-cTnT is predictive of CV death/HFH; while in patients with HFmrEF/HFpEF, hs-cTnT predicts WHF events.

Prognostic Assessment of HLM Score in Heart Failure Due to Ischemic Heart Disease: A Pilot Study

Background: Ischemic heart disease (IHD) represents the main cause of heart failure (HF). A prognostic stratification of HF patients with ischemic etiology, particularly those with acute coronary syndrome (ACS), may be challenging due the variability in clinical and hemodynamic status. The aim of this study is to assess the prognostic power of the HLM score in a population of patients with ischemic HF and in a subgroup who developed HF following ACS. Methods: This is an observational, prospective, single-center study, enrolling consecutive patients with a diagnosis of ischemic HF. Patients were stratified according to the four different HLM stages of severity, and the occurrence of CV death, HFH, and worsening HF events were evaluated at 6-month follow-up. A sub-analysis was performed on patients who developed HF following ACS at admission. Results: The study included 146 patients. HLM stage predicts the occurrence of CV death (p = 0.01) and CV death/HFH (p = 0.003). Cox regression analysis confirmed HLM stage as an independent predictor of CV death (OR: 3.07; 95% IC: 1.54-6.12; p = 0.001) and CV death/HFH (OR: 2.45; 95% IC: 1.43-4.21; p = 0.001) in the total population of patients with HF due to IHD. HLM stage potentially predicts the occurrence of CV death (p < 0.001) and CV death/HFH (p < 0.001) in patients with HF following ACS at admission. Conclusions: Pathophysiological-based prognostic assessment through HLM score is a potentially promising tool for the prediction of the occurrence of CV death and CV death/HFH in ischemic HF patients and in subgroups of patients with HF following ACS at admission.

Current Approaches to Worsening Heart Failure: Pathophysiological and Molecular Insights

Worsening heart failure (WHF) is a severe and dynamic condition characterized by significant clinical and hemodynamic deterioration. It is characterized by worsening HF signs, symptoms and biomarkers, despite the achievement of an optimized medical therapy. It remains a significant challenge in cardiology, as it evolves into advanced and end-stage HF. The hyperactivation of the neurohormonal, adrenergic and renin-angiotensin-aldosterone system are well known pathophysiological pathways involved in HF. Several drugs have been developed to inhibit the latter, resulting in an improvement in life expectancy. Nevertheless, patients are exposed to a residual risk of adverse events, and the exploration of new molecular pathways and therapeutic targets is required. This review explores the current landscape of WHF, highlighting the complexities and factors contributing to this critical condition. Most recent medical advances have introduced cutting-edge pharmacological agents, such as guanylate cyclase stimulators and myosin activators. Regarding device-based therapies, invasive pulmonary pressure measurement and cardiac contractility modulation have emerged as promising tools to increase the quality of life and reduce hospitalizations due to HF exacerbations. Recent innovations in terms of WHF management emphasize the need for a multifaceted and patient-centric approach to address the complex HF syndrome.