Hyponatraemia and changes in natraemia during hospitalization for acute heart failure and associations with in-hospital and long-term outcomes - from the ESC-HFA EORP Heart Failure Long-Term Registry

Prognostic Implications of Diabetes Insipidus in Heart Failure Hospitalizations: Insights from the U.S. National Readmissions Database 2016-2021

Background: Diabetes insipidus affects heart failure outcomes through its impact on volume status and electrolyte imbalance. However, previous data on its impact on heart failure hospitalizations are limited. This study aimed to evaluate the prognostic implications of diabetes insipidus in patients admitted with heart failure. We utilized the United States National Readmissions Database (NRD) from the years 2016 to 2021. Methods: Adult patients hospitalized with a primary diagnosis of heart failure were stratified based on the presence of diabetes insipidus. Propensity matching was used to balance the baseline characteristics. Multivariable logistic regression was used to estimate the association of heart failure with diabetes insipidus on clinical outcomes, complications, 30-day readmissions, and healthcare utilization. Results: Among 5,946,749 heart failure hospitalizations, 2846 (0.04%) had a secondary diagnosis of diabetes insipidus. Compared with matched control, patients with heart failure and diabetes insipidus had significantly higher in-hospital mortality (odds ratio [OR] 5.77 [95% CI, 4.78-6.97], p < 0.001). Patients with heart failure and diabetes insipidus were also associated with increased odds of acute kidney injury (OR 2.11 [95% CI, 1.86-2.39], p < 0.001), hypernatremia (OR 4.98 [95% CI, 1.86-2.39], p < 0.001), cardiogenic shock (OR 1.69 [95% CI, 1.32-2.15], p < 0.001), and cerebral edema (OR 22.28 [95% CI, 14.74-33.69], p < 0.001) compared with the matched controls. No difference was found in the all-cause readmission (OR 0.89 [95% CI, 0.76-1.04], p = 0.14), but patients with diabetes insipidus had a lower risk of heart failure readmissions (OR 0.47 [95% CI, 0.33-0.66], p < 0.001) and a higher risk of non-cardiac readmissions (OR 2.21 [95% CI, 1.48-3.9], p < 0.001). Conclusions: Diabetes insipidus was associated with worse outcomes in patients with primary heart failure hospitalizations, which was likely secondary to the risk of excessive diuresis.

2024 update in heart failure

In the last years, major progress has occurred in heart failure (HF) management. The 2023 ESC focused update of the 2021 HF guidelines introduced new key recommendations based on the results of the last years of science. First, two drugs, sodium-glucose co-transporter-2 (SGLT2) inhibitors and finerenone, a novel nonsteroidal, selective mineralocorticoid receptor antagonist (MRA), are recommended for the prevention of HF in patients with diabetic chronic kidney disease (CKD). Second, SGLT2 inhibitors are now recommended for the treatment of HF across the entire left ventricular ejection fraction spectrum. The benefits of quadruple therapy in patients with HF with reduced ejection fraction (HFrEF) are well established. Its rapid and early up-titration along with a close follow-up with frequent clinical and laboratory re-assessment after an episode of acute HF (the so-called 'high-intensity care' strategy) was associated with better outcomes in the STRONG-HF trial. Patients experiencing an episode of worsening HF might require a fifth drug, vericiguat. In the STEP-HFpEF-DM and STEP-HFpEF trials, semaglutide 2.4 mg once weekly administered for 1 year decreased body weight and significantly improved quality of life and the 6 min walk distance in obese patients with HF with preserved ejection fraction (HFpEF) with or without a history of diabetes. Further data on safety and efficacy, including also hard endpoints, are needed to support the addition of acetazolamide or hydrochlorothiazide to a standard diuretic regimen in patients hospitalized due to acute HF. In the meantime, PUSH-AHF supported the use of natriuresis-guided diuretic therapy. Further options and most recent evidence for the treatment of HF, including specific drugs for cardiomyopathies (i.e., mavacamten in hypertrophic cardiomyopathy and tafamidis in transthyretin cardiac amyloidosis), device therapies, cardiac contractility modulation and percutaneous treatment of valvulopathies, with the recent finding from the TRILUMINATE Pivotal trial, are also reviewed in this article.

Translating evidence into practice: Managing electrolyte imbalances and iron deficiency in heart failure

Mineral abnormalities are a common complication of heart failure (HF). In particular, dyskalaemia, hyponatraemia, and hypomagnesaemia are prevalent, with hypo- and hyperkalaemia observed in over 40 % of HF patients, hyponatraemia in 18-27 %, hypomagnesaemia in 7-52 %, and phosphate imbalance in 13 %. These abnormalities serve as indicators of the severity of HF and are strongly associated with an increased risk of morbidity and mortality. The neurohumoral activation, including the renin-angiotensin-aldosterone system (RAAS), the sympathetic nervous system, and vasopressin, HF medications such as diuretics and RAAS inhibitors, amd concomitant diseases such as chronic kidney disease, can disrupt mineral homeostasis. Iron deficiency (ID) is another of the most common mineral abnormalities, affecting up to 60 % of HF patients. ID is significantly associated with adverse clinical outcomes such as reduced quality of life and exercise capacity, HF re-hospitalization, and all-cause mortality. Various pathways contribute to the development of ID in HF, including reduced iron intake due to anorexia, increased hepcidin levels associated with chronic inflammation and hepatic congestion, and occult gastrointestinal bleeding due to the concomitant use of antithrombotic agents. The efficacy of iron replacement therapy has been demonstrated in clinical trials, particularly in heart failure with reduced ejection fraction (HFrEF), whilst more recently, it has also been shown to improve exercise capacity in patients with heart failure with preserved ejection fraction (HFpEF). This review focuses on potassium and phosphate abnormalities, hyponatraemia, hypomagnesaemia, and ID in HF, providing a comprehensive overview of the mechanisms, clinical significance, and intervention strategies with the latest findings.

[Consensus recommendations on the diagnosis and treatment of hyponatremia from the Austrian Society for Nephrology 2024]

Hyponatremia is a disorder of water homeostasis. Water balance is maintained by the collaboration of renal function and cerebral structures, which regulate thirst mechanisms and secretion of the antidiuretic hormone. Measurement of serum-osmolality, urine osmolality and urine-sodium concentration help to diagnose the different reasons for hyponatremia. Hyponatremia induces cerebral edema and might lead to severe neurological symptoms, which need acute therapy. Also, mild forms of hyponatremia should be treated causally, or at least symptomatically. An inadequate fast increase of the serum sodium level should be avoided, because it raises the risk of cerebral osmotic demyelination. Basic pathophysiological knowledge is necessary to identify the different reasons for hyponatremia which need different therapeutic procedures.