A combined clinical and biomarker approach to predict diuretic response in acute heart failure

Advancements in the Treatment of Diuretic Resistance in Congestive Heart Failure

This narrative evaluates the dynamic developments that have significantly transformed treatment strategies in the constantly evolving domain of diuretic resistance (DR) management in congestive heart failure (CHF). The discourse explores historical challenges and the current state of therapeutic approaches as it investigates the crucial matter of DR in patients with CHF. An introduction provides a synopsis of the pivotal function diuretics performed in the management of fluid excess and the intricacies associated with CHF. The narrative explores the progressive exposure of the constraints that traditional treatments face, thus underscoring the persistent issue of DR and the imperative for innovative methodologies. The text underscores advancements in pharmacotherapy that demonstrate efficacy in surmounting resistance, including innovative diuretics and combination therapies. Furthermore, it outlines the pivotal shift towards personalized medicine, an approach that transforms the results of treatments through the integration of genetic knowledge and individualized strategies. Furthermore, the text delves into nonpharmacological strategies, including ultrafiltration and renal denervation, that enhance the overall comprehension of the intricate battle against diuretic resistance. In summary, this narrative exemplifies resolute perseverance in the pursuit of solutions, presenting a promising future wherein various developments converge to restore hope in regard to the control of DR and the improvement of the health status of chronic heart failure patients.

Patient Selection and End Point Definitions for Decongestion Studies in Acute Decompensated Heart Failure: Part 1

Despite recent advances in the treatment of patients with chronic heart failure, acute decompensated heart failure remains associated with significant mortality and morbidity because many novel therapies have failed to demonstrate meaningful benefit. Persistent congestion in the setting of escalating diuretic therapy has been repeatedly shown to be a marker of poor prognosis and is currently being targeted by various emerging device-based therapies. Because these therapies inherently carry procedural risk, patient selection is key in the future trial design. However, it remains unclear which patients are at a higher risk of residual congestion or adverse outcomes despite maximally tolerated decongestive therapy. In the first part of this 2-part review, we aimed to outline patient risk factors and summarize current evidence for early recognition of high-risk profile for residual congestion and adverse outcomes. These factors are classified as relating to the following: (1) previous clinical course, (2) severity of congestion, (3) diuretic response, and (4) degree of renal impairment. We also aimed to provide an overview of key inclusion criteria in recent acute decompensated heart failure trials and investigational device studies and propose potential criteria for selection of high-risk patients in future trials.

Impact of the time-to-target rate of urine volume concept on the outcome of acute decompensated heart failure

BACKGROUND

Early decongestion with diuretics could improve clinical outcomes. This study aimed to examine the impact of the time-to-target rate of urine volume (T2TUV) concept on the outcome of acute decompensated heart failure (ADHF).

METHODS

This multicenter retrospective study included 1670 patients with ADHF who received diuretics within 24 h of admission. T2TUV was defined as the time from admission to the rate of urine volume of 100 ml/h. The primary outcomes were in-hospital death, mortality, and re-hospitalization for 1 year.

RESULTS

A total of 789 patients met the inclusion criteria (T2TUV on day 1, n = 248; day 2-3, n = 172; no target rate UV, n = 369). In-hospital mortality in the day 1 group was significantly lower (2.7% vs. 5.9% vs. 11.1%; p < 0.001) than that of other groups. The mortality and re-hospitalization for 1 year in the day 1 group was significantly lower (event-free rate: 67.7% vs. 54.1% vs. 56.9%; log-lank p = 0.004) than that of other groups. In multivariate analysis, predictors of T2TUV at day 1 were age (odds ratio [OR]: 1.02, 95% confidence interval [CI]: 1.01-1.04, p = 0.007), previous hospitalized heart failure (OR: 1.47, 95% CI: [1.03-2.12], p = 0.03), N-terminal-pro B type natriuretic peptide per 1000 pg/ml (OR: 1.02, 95% CI: 1.01-1.04, p = 0.007), carperitide (OR: 0.69, 95% CI: 0.48-0.99, p = 0.05), and early administration of tolvaptan (OR: 0.6, 95% CI: 0.42-0.85, p = 0.004).

CONCLUSIONS

T2TUV of less than day 1 was associated with lower in-hospital mortality and decreased mortality and re-hospitalization at 1 year.

Predictors of Poor Very Early Diuretic Response and Effectiveness of Early Tolvaptan in Symptomatic Acute Heart Failure

BACKGROUND

Diuretic response (DR) in patients with symptomatic acute decompensated heart failure (ADHF) has an impact on prognosis. This study aimed to identify predictive factors influencing acute 6 h poor DR and to assess DR after early administration of tolvaptan (TLV).

METHODS

This multicenter retrospective study included 1670 patients who were admitted for ADHF and received intravenous furosemide within 1 h of presentation in clinical scenario 1 or 2 defined based on initial systolic blood pressure ≥100 mmHg with severe symptoms (New York Heart Association class III or IV (n = 830). The score for the poor DR factors in the very acute phase was calculated in patients treated with furosemide-only diuretics (n = 439). The DR to TLV administration was also assessed in patients who received an additional dose of TLV within 6 h (n = 391).

RESULTS

The time since discharge from the hospital for a previous heart failure < 3 months (odds ratio [OR] 2.78, 95% confidence interval [CI] 1.34-5.83; p = 0.006), loop diuretics at admission (OR 3.05, 95% CI 1.74-5.36; p < 0.0001), and estimated glomerular filtration rate (eGFR) < 45 mL/min/1.73 m² (OR 2.99, 95% CI 1.58-5.74; p = 0.0007) were independent determinants of poor DR. The frequency of poor DR according to the risk stratification group was low risk (no risk factor), 18.9%; middle risk (one risk factor), 33.1%; and high risk (two to three risk factors), 58.0% (p < 0.0001). All risk groups demonstrated a significantly lower incidence of poor DR with early TLV administration: 10.7% in the early TLV group versus 18.9% in the loop diuretics group (p = 0.09) of the low-risk group; 18.4% versus 33.1% (p = 0.01) in the middle-risk group, and 20.2% versus 58.0% (p < 0.0001) in the high-risk group.

CONCLUSION

Early administration of TLV in patients with predicted poor DR contributed to a significant diuretic effect and suppression of worsening renal function.

Co-Administration of Albumin and Furosemide in Acute Heart Failure with Diuretics Resistance

Acute heart failure is a frequent cause of hospital admission in Portugal, and has an increasing tendency given the aging population. Although most admissions for acute heart failure are caused by congestive conditions, not all patients have a congestive phenotype, reflecting the complexity of a process with multiple pathophysiological pathways. The use of diuretics, usually loop diuretics, is the mainstay of treatment for congestion. However, many patients develop resistance, thus constituting a challenge with no consensual solution to date, despite extensive debate over the years. Despite its frequent use in clinical practice, the co-administration of albumin and furosemide remains controversial in the management of patients with acute heart failure, hypoalbuminemia, and diuretic resistance. This review addresses the pathophysiological mechanisms of congestion in patients with acute heart failure and explores the theoretical basis that supports the co-administration of albumin and furosemide in this clinical context. It is intended to clarify the potential benefit of the combined approach in this specific population and identify possible gaps in the literature that could be the subject of future studies.

Toward quantification of loop diuretic responsiveness for congestive heart failure

Diuretics, such as furosemide, are routinely administered to dogs with congestive heart failure (CHF). Traditionally, dose and determination of efficacy primarily are based on clinical signs rather than quantitative measures of drug action. Treatment of human CHF patients increasingly is guided by quantification of urine sodium concentration (uNa) and urine volume after diuretic administration. Use of these and other measures of diuretic responsiveness is associated with decreased duration of hospitalization, complication rates, future rehospitalization, and mortality. At their core, loop diuretics act through natriuresis, and attention to body sodium (Na) stores and handling offers insight into the pathophysiology of CHF and pharmacology of diuretics beyond what is achievable from clinical signs alone. Human patients with low diuretic responsiveness or diuretic resistance are at risk for difficult or incomplete decongestion that requires diuretic intensification or other remedial strategies. Identification of the specific etiology of resistance in a patient can help tailor personalized interventions. In this review, we advance the concept of loop diuretic responsiveness by highlighting Na and natriuresis. Specifically, we review body water homeostasis and congestion in light of the increasingly recognized role of interstitial Na, propose definitions for diuretic responsiveness and resistance in veterinary subjects, review relevant findings of recent studies, explain how the particular cause of resistance can guide treatment, and identify current knowledge gaps. We believe that a quantitative approach to loop diuretic usage primarily involving natriuresis will advance our understanding and care of dogs with CHF.

Diuretic Resistance Prediction and Risk Factor Analysis of Patients with Heart Failure During Hospitalization

Objectives

This study performed a prediction and risk factor analysis of diuretic resistance (DR) in patients with decompensated heart failure during hospitalization.

Methods

The data of patients with decompensated heart failure treated in 2010-2018 with DR (n = 3,383) or without DR (n = 15,444) were retrospectively collected from Chinese PLA General Hospital medical records. Statistical analysis of baseline was performed on two groups of people, and the risk factor of DR was analyzed through logic regression. Six machine learning models were built accordingly, and the adjustment of model super parameters was performed by using Bayesian optimization method. Finally, the optimal algorithm was selected according to prediction efficiency.

Results

The preliminary analysis of variance showed significant differences in the incidence of DR among patients with lung infection, hyperlipidemia, type 2 diabetes, and kidney disease. There were significant differences in estimated glomerular filtration rate (eGFR) (P < 0.001). In addition, some physical indicators like BMI were different, the laboratory results like mean red blood cell volume or C-reactive protein assay were also significantly different. The optimal classification model indicated that the best cutoff points for risk factors were vein carbon dioxide, 21 mmol/L and 29 mmol/L; total protein, 64 g/L; pro-brain natriuretic peptide (pro-BNP), 7,600 pg/mL; eGFR, 50 mL/(min ∙ 1.73 m2); serum albumin, 33 g/L; hematocrit, 0.32% and 0.56%; red blood cell volume distribution width, 13; and age, 59 years. The optimal area under the curve was 0.9512. The ranked features derived from the model were age, abnormal sodium level, pro-BNP level, serum albumin level, D-dimer level, direct bilirubin level, and eGFR.

Conclusions

The DR risk prediction model based on a gradient boosting decision tree created here identified its important risk factors. The model made very accurate predictions using simple indicators and simultaneously calculated cutoff values to help doctors predict the occurrence of DR.

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.

Efficacy of exogenous atrial natriuretic peptide in patients with heart failure with preserved ejection fraction: deficiency of atrial natriuretic peptide and replacement therapy

AIMS

Exogenous atrial natriuretic peptide (ANP) may be a logical treatment for heart failure (HF) patients with ANP deficiency. Lower ANP concentrations may result from HF with preserved ejection fraction (HFpEF), which also results in lower brain natriuretic peptide levels in HFpEF relative to HF with reduced ejection fraction (HFrEF), although clinical features regarding circulating ANP in HFpEF and HFrEF have not been fully investigated during acute HF. Here, we characterized the differential regulation of circulating ANP and the efficacy of exogenous ANP (carperitide) in patients with acute HF, especially HFpEF.

METHODS AND RESULTS

Serum ANP levels before treatment and the diuretic effect of 0.0125 μg/kg/min of carperitide alone for the first 6 h were prospectively evaluated in 113 patients with acute HF who were divided into two groups: HFpEF vs. HFrEF. We mainly analysed the impact of baseline ANP levels and the presence of HFpEF on the diuretic effect of exogenous ANP. There was an inverse relationship between ANP levels and the diuretic effect of exogenous ANP (r²  = 0.19, P < 0.001). Patients with HFpEF had lower ANP levels (P < 0.001) and a greater diuretic effect of exogenous ANP than patients HFrEF (P < 0.001). HFpEF was an independent predictor of greater diuretic effect of exogenous ANP (P = 0.003), as with a lower baseline ANP level (P = 0.004).

CONCLUSIONS

Patients with HFpEF might have an aspect of ANP deficiency and represent a promising therapeutic target for modulating circulating ANP.

Spot urinary sodium in acute decompensation of advanced heart failure and dilutional hyponatremia: insights from DRAIN trial

BACKGROUND

Diuretic resistance portends a poor prognosis in acute heart failure, especially in advanced stages. Early identification of a poor response to diuretics may help to improve treatment and outcomes. Spot natriuresis (UNa⁺) at 2 h from the start of intravenous furosemide has been proposed as an early indicator of diuretic response. Our paper aimed to determine the role of early natriuresis in patients hospitalized with advanced chronic heart failure (ACHF) and high risk of diuretic resistance.

METHODS AND RESULTS

We performed a sub-analysis of the DRAIN trial, a randomized clinical trial on 80 patients with acute decompensation of ACHF (NYHA IV, EF ≤ 30%) with low systolic blood pressure (≤ 110 mmHg) and dilutional hyponatremia (sodium ≤ 135 mMol/L) at admission. Patients were divided into two groups according to spot urinary sodium excretion (high: UNa⁺  > 50 or low: ≤ 50 mEq/L) at 2 h from furosemide administration. Twenty-eight patients (35%) showed a low natriuretic response. As compared to the other patients, this group showed lower daily urinary output (2275 ± 790 vs 3849 ± 2034 mL, p < 0.001), lower body weight reduction after 48 h (1.55 ± - 1.66 vs - 3.55 ± - 2.93 kg, p < 0.001), higher incidence of worsening renal function (32% vs 10%, p 0.02) and increasing rather than reducing NT-proBNP at 72 h (p 0.02).

CONCLUSIONS

In patients with ACHF and dilutional hyponatremia, low natriuresis after furosemide is an early marker of poor diuretic response and correlates with higher NT-proBNP and higher incidence of worsening renal function at 72 h.

Clinical value of pre-discharge bio-adrenomedullin as a marker of residual congestion and high risk of heart failure hospital readmission

AIMS

Recently, bio-adrenomedullin (bio-ADM) was proposed as a congestion marker in heart failure (HF). In the present study, we aimed to study whether bio-ADM levels at discharge from a hospital admission for worsening HF could provide additional information on (residual) congestion status, diuretic dose titration and clinical outcomes.

METHODS AND RESULTS

Plasma bio-ADM was measured in 1236 acute HF patients in the PROTECT trial at day 7 or discharge. Median discharge bio-ADM was 33.7 [21.5-61.5] pg/mL. Patients with higher discharge bio-ADM levels were hospitalised longer, had higher brain natriuretic peptide levels, and poorer diuretic response (all P < 0.001). Bio-ADM was the strongest predictor of discharge residual congestion (clinical congestion score > 3) (odds ratio 4.35, 95% confidence interval 3.37-5.62; P < 0.001). Oedema at discharge was one of the strongest predictors of discharge bio-ADM (β = 0.218; P < 0.001). Higher discharge loop diuretic doses were associated with a poorer diuretic response during hospitalisation (β = 0.187; P < 0.001) and higher bio-ADM levels (β = 0.084; P = 0.020). High discharge bio-ADM levels combined with higher use of loop diuretics were independently associated with a greater risk of 60-day HF rehospitalisation (hazard ratio 4.02, 95% confidence interval 2.23-7.26; P < 0.001).

CONCLUSION

In hospitalised HF patients, elevated pre-discharge bio-ADM levels were associated with higher discharge loop diuretic doses and reflected residual congestion. Patients with combined higher bio-ADM levels and higher loop diuretic use at discharge had an increased risk of rehospitalisation. Assessment of discharge bio-ADM levels may be a readily applicable marker to identify patients with residual congestion at higher risk of early hospital readmission.

Role of electrolyte concentrations and renin-angiotensin-aldosterone activation in the staging of canine heart disease

Background

Refractory congestive heart failure (CHF) and associated diuretic resistance are not well defined.

Objectives

To characterize renal function, electrolyte concentrations, indices of diuretic efficacy, and renin‐angiotensin‐aldosterone system (RAAS) activation in dogs with naturally occurring heart disease (HD) in American College of Veterinary Internal Medicine stages B1, B2, C, and D and to determine their usefulness in defining HD stages.

Animals

Group 1:149 dogs with HD stages B1, B2, C, and D. Group 2:22 dogs with HD stages C and D.

Methods

Group 1: Renal parameters, serum and urine electrolyte and diuretic concentrations, and urine aldosterone concentrations were measured. Medication dosages and measured variables were compared among stages. Correlation of furosemide dosages to serum concentrations was explored. Group 2: Angiotensin‐converting enzyme activity and RAAS components were measured and compared among CHF stages.

Results

Serum chloride concentration was the best differentiator of HD stage. Furosemide PO dosages (≤6 mg/kg/day) were weakly correlated with serum furosemide concentrations, whereas higher dosages were not significantly correlated. Angiotensin‐converting enzyme inhibitor dosage and RAAS inhibition were greater in stage D, compared to stage C dogs.

Conclusions and Clinical Importance

Hypochloremia is a useful marker for stage D HD in dogs. Poor furosemide dosage correlation to serum concentration may indicate variable and poor absorption, especially at higher dosages, advanced disease, or both. A small number of stage D dogs met proposed criteria for diuretic resistance. Greater RAAS inhibition in stage D versus stage C indicates effectiveness of RAAS‐suppressive treatments in this group of dogs with refractory CHF.

Diabetic patients need higher furosemide doses: a report on acute and chronic heart failure patients

INTRODUCTION

Diuretics are first-line drugs in symptomatic heart failure treatment. Diabetes mellitus has been suggested as a determinant of diuretic resistance. Studies comparing the dose and efficacy of diuretics in patients with and without diabetes are lacking. We aimed to study if furosemide dose differed according to diabetes status.

METHODS

We studied two cohorts of heart failure patients: a cohort of acute heart failure patients consecutively hospitalized with the primary diagnosis of heart failure and another of stable and optimized patients followed in a heart failure clinic. Data on comorbidities and medication were abstracted from patients' files. Use and doses of furosemide were compared between diabetic and nondiabetic patients. Regression analysis was used to determine the association of variables with diuretic dose. The independent association of diabetes with furosemide dose was assessed using multivariate models.

RESULTS

We studied 865 heart failure patients: 601 acute heart failure patients and 264 chronic stable heart failure patients. Acute heart failure patients with diabetes were more likely to need intravenous diuretic therapy and they were also more often discharged under higher doses of furosemide. They needed extra 6-mg furosemide at discharge in comparison with their nondiabetics counterparts and had an independent 26% higher odds of being discharged with at least 80-mg furosemide. Chronic patients were also more frequently prescribed with furosemide and on higher doses, although, diabetes was not independently associated with the use of higher furosemide doses.

CONCLUSION

Diabetic patients are more intensively treated with the loop diuretic furosemide. In acute heart failure, diabetes is an independent predictor of furosemide dose.

Acute heart failure and adverse events associated with the presence of renal dysfunction and hyperkalaemia. EAHFE- renal dysfunction and hyperkalaemia

OBJECTIVE

To study the outcomes of patients with acute heart failure (AHF) presenting renal dysfunction (RD) or hyperkalaemia (Hk) alone or in combination.

METHOD

We analysed the data of the EAHFE registry, a multicentre, non interventionist cohort with prospective follow-up of patients with AHF. Four groups were defined based on the presence or not of RD or Hk alone or in combination. The primary endpoint was 30-day all-cause mortality.

RESULTS

A total of 11,935 of the 13,791 patients included in the EAHFE registry were analysed. Of these, 5088 (42.6%) did not have RD or Hk (NoRD-NoHk), 150 (1.3%) had no RD but had Hk (NoRD-Hk), 6012 (50.4%) had RD but not Hk (RD-NoHk) and 685 (5.7%) had both RD and Hk (RD-Hk). Thirty-day all-cause mortality was greatest in the RD-Hk group with an adjusted Hazard Ratio (HR) of 2.44 (confidence interval 95% [CI95%] 1.67-3.55; p < 0.001) and in the RD-NoHk group with an adjusted HR of 1.34 (CI95% 1.04-1.71; p = 0.022). There were no significant differences in in-hospital mortality and reconsultation at 30 days for HF. For the combined endpoint of 30-day all-cause mortality the adjusted HR was 1.33 (CI95% 1.04-1.70); (p = 0.021) for the RD-Hk group.

CONCLUSIONS

The association of 30-day all-cause mortality with the presence of RD and Hk in patients presenting AHF at admission is greater than in those without this combination.

Serum and Urine Albumin and Response to Loop Diuretics in Heart Failure

BACKGROUND AND OBJECTIVES

Diuretic resistance can limit successful decongestion of patients with heart failure. Because loop diuretics tightly bind albumin, low serum albumin and high urine albumin can theoretically limit diuretic delivery to the site of action. However, it is unknown if this represents a clinically relevant mechanism of diuretic resistance in human heart failure.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In total, 208 outpatients with heart failure at the Yale Transitional Care Center undergoing diuretic treatment were studied. Blood and urine chemistries were collected at baseline and 1.5 hours postdiuretic administration. Urine diuretic levels were normalized to urine creatinine and adjusted for diuretic dose administered, and diuretic efficiency was calculated as sodium output per doubling of the loop diuretic dose. Findings were validated in an inpatient heart failure cohort (n=60).

RESULTS

Serum albumin levels in the outpatient cohort ranged from 2.4 to 4.9 g/dl, with a median of 3.7 g/dl (interquartile range, 3.5-4.1). Serum albumin had no association with urinary diuretic delivery (r=-0.05; P=0.52), but higher levels weakly correlated with better diuretic efficiency (r=0.17; P=0.02). However, serum albumin inversely correlated with systemic inflammation as assessed by plasma IL-6 (r=-0.35; P<0.001), and controlling for IL-6 eliminated the diuretic efficiency-serum albumin association (r=0.12; P=0.12). In the inpatient cohort, there was no association between serum albumin and urinary diuretic excretion (r=0.15; P=0.32) or diuretic efficiency (r=-0.16; P=0.25). In the outpatient cohort, 39% of patients had microalbuminuria, and 18% had macroalbuminuria. There was no correlation between albuminuria and diuretic efficiency after adjusting for kidney function (r=-0.02; P=0.89). Results were similar in the inpatient cohort.

CONCLUSIONS

Serum albumin levels were not associated with urinary diuretic excretion, and urinary albumin levels were not associated with diuretic efficiency.

Invasive hemodynamics and cardiac biomarkers to predict outcomes after percutaneous edge-to-edge mitral valve repair in patients with severe heart failure

BACKGROUND

Percutaneous mitral valve repair (PMVR) via MitraClip implantation is a therapeutic option for high-risk or non-surgical candidates with severe mitral regurgitation (MR) and advanced stages of heart failure (HF). However, these patients have a high mortality despite PMVR, and predictors for outcomes are not well established. Here, we evaluated invasive hemodynamics, echocardiography parameters, and biomarkers to predict outcomes after PMVR in severe HF patients.

METHODS

Patients with reduced ejection fraction (EF) and severe and moderate-to-severe MR undergoing PMVR at our centre between September 2009 and January 2016 were analysed retrospectively. Inclusion criteria were: left ventricular EF < 45%, preoperative right heart catheterization, successful MitraClip deployment ("technical success"), and follow-up for at least 1 year after the procedure. Data from preoperative right heart catheterization, echocardiography, and biomarkers were assessed. Primary endpoint was all-cause mortality at 1 year after PMVR. We performed univariate and multivariate Cox regression analyses and generated a risk score to predict outcomes.

RESULTS

Of 174 patients with PMVR and severe HF, 79.9% had functional MR. Mean EF was 25% (17.2; 30.7) and advanced New York Heart Association functional class was prevalent (class II: 13%; class III: 70%; and class IV: 17%). The cumulative incidences of all-cause death were 6.9% and 17.8% at 30 days and 1 year, respectively. In the Cox multivariate model, high-sensitive troponin T [hsTnT; hazard ratio (HR) 1.01; confidence interval (CI) 1.01-1.02; p < 0.0001] and mixed venous O₂-saturation (HR 0.92; CI 0.89-0.96; p < 0.0001) were found to significantly and independently predict outcomes. A simple risk score including these two parameters was sufficient to discriminate between low- and high-risk patients (HR 7.22; CI 3.4-15.5; p < 0.001).

CONCLUSION

In a cohort of patients with severe HF undergoing PMVR, patients with elevated hsTnT and reduced mixed venous O₂-saturation carried the worst prognosis. A simple risk score including these two parameters may improve patient selection and outcomes after PMVR.

Effects of early diuretic response to carperitide in acute decompensated heart failure treatment: A single-center retrospective study

Background

Diuretic response is a strong predictor of outcome for admitted patients of acute decompensated heart failure (ADHF). However, little is known about the effects of early diuretic response to carperitide.

Methods

We retrospectively analyzed records of 85 patients hospitalized for ADHF who received carperitide as initial treatment and <40 mg furosemide during the early period. The eligible patients were divided into good diuretic responder (GR) group and poor diuretic responder (PR) group on the basis of median urinary volume.

Results

The PR group demonstrated older age, lower body mass index (BMI), lower estimated glomerular filtration rate, and higher blood urea nitrogen (BUN) level, left ventricular ejection fraction, and β-blockers prescribed at baseline than the GR group. The incidence of worsening renal function (WRF) was significantly higher in the PR group than in the GR group. There was no correlation between early intravenous furosemide dose and urinary volume (Spearman correlation, ρ = 0.111, p = 0.312). Multivariate analysis showed that the statistically significant independent factors associated with poor diuretic response to carperitide were BMI (Odds ratio (OR) = 0.82, 95% confidence interval (CI) 0.68–0.94, p = 0.004) and BUN (OR = 1.07, 95%CI 1.01–1.15, p = 0.018). Kaplan–Meier analysis indicated a lower event-free rate in the PR group than in the GR group (log-rank, p = 0.007).

Conclusions

BMI and BUN levels on admission were significant determinants of early poor diuretic response to carperitide. Early poor diuretic response to carperitide was associated with future poor outcomes.

[Update on heart failure]

Heart failure is one of the leading diseases in internal medicine worldwide. Because of the increase in population aging, the incidence and prevalence of heart insufficiency is rising annually and is now the most frequent individual diagnosis among hospitalized patients in Germany. The mortality rate has recently been reduced, since new pharmacological options, especially the inhibition of neprilysin, have been developed; however, heart failure is still associated with a high mortality and morbidity rate. Thus, guideline-conform treatment is of crucial importance. This review highlights and summarizes the current scientific knowledge on heart failure from 2017 and 2018 based on the guidelines of the European Society of Cardiology. New aspects about heart failure with middle grade limitations of ejection fraction are firstly presented. Subsequently, innovative diagnostic and therapeutic strategies, new pharmacological developments and handling of frequent comorbidities in patients with heart failure are discussed.

Novel concept to guide systolic heart failure medication by repeated biomarker testing-results from TIME-CHF in context of predictive, preventive, and personalized medicine

Background

It is uncertain whether repeated measurements of a multi-target biomarker panel may help to personalize medical heart failure (HF) therapy to improve outcome in chronic HF.

Methods

This analysis included 499 patients from the Trial of Intensified versus standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME-CHF), aged ≥ 60 years, LVEF ≤ 45%, and NYHA ≥ II, who had repeated clinical visits within 19 months follow-up. The interaction between repeated measurements of biomarkers and treatment effects of loop diuretics, spironolactone, β-blockers, and renin-angiotensin system (RAS) inhibitors on risk of HF hospitalization or death was investigated in a hypothesis-generating analysis. Generalized estimating equation (GEE) models were used to account for the correlation between recurrences of events in a patient.

Results

One hundred patients (20%) had just one event (HF hospitalization or death) and 87 (17.4%) had at least two events. Loop diuretic up-titration had a beneficial effect for patients with high interleukin-6 (IL6) or high high-sensitivity C-reactive protein (hsCRP) (interaction, P = 0.013 and P = 0.001), whereas the opposite was the case with low hsCRP (interaction, P = 0.013). Higher dosage of loop diuretics was associated with poor outcome in patients with high blood urea nitrogen (BUN) or prealbumin (interaction, P = 0.006 and P = 0.001), but not in those with low levels of these biomarkers. Spironolactone up-titration was associated with lower risk of HF hospitalization or death in patients with high cystatin C (CysC) (interaction, P = 0.021). β-Blockers up-titration might have a beneficial effect in patients with low soluble fms-like tyrosine kinase-1 (sFlt) (interaction, P = 0.021). No treatment biomarker interactions were found for RAS inhibition.

Conclusion

The data of this post hoc analysis suggest that decision-making using repeated biomarker measurements may be very promising in bringing treatment of heart failure to a new level in the context of predictive, preventive, and personalized medicine. Clearly, prospective testing is needed before this novel concept can be adopted.

Clinical trial registration

isrctn.org, identifier: ISRCTN43596477

Electronic supplementary material

The online version of this article (10.1007/s13167-018-0137-7) contains supplementary material, which is available to authorized users.

Pharmacodynamic assessment of diuretic efficacy and braking in a furosemide continuous infusion model

INTRODUCTION

Diuretic failure is a potential life-ending event but is unpredictable and poorly understood. The objectives of this study were to evaluate pharmacodynamic markers of furosemide-induced diuresis and to investigate mechanisms of diuretic braking in dogs receiving constant rate infusion (CRI) of furosemide.

ANIMALS

Six healthy male dogs.

METHODS

Raw data and stored samples from one arm of a previously published study were further analyzed to mechanistically investigate causes of diuretic braking in these dogs. Urine volume was recorded hourly during a 5-h furosemide CRI. Urine and blood samples were collected hourly to measure serum and urine electrolytes, urine aldosterone, and plasma and urine furosemide. Serum electrolyte fractional excretion was calculated. Urine sodium concentration was indexed to urine potassium (uNa:uK) and urine furosemide (uNa:uFur) concentrations, plasma furosemide concentration was indexed to urine furosemide concentration (pFur:uFur), and urine aldosterone was indexed to urine creatinine (UAldo:C). Temporal change and the relationship to urine volume were evaluated for these measured and calculated variables.

RESULTS

Urine volume was significantly correlated with urine electrolyte amounts and with uNa:uK. The ratio of pFur:uFur decreased during the infusion, whereas furosemide excretion was unchanged.

CONCLUSIONS

There was a strong relationship between urine volume and absolute urine electrolyte excretion. Urine volume was strongly correlated to uNa:uK, giving it potential as a spot indicator of urine production during diuresis. The decrease in uNa:uK over time during the infusion is consistent with mineralocorticoid modification of urinary electrolyte excretion, supporting renin-angiotensin-aldosterone activation as a cause of diuretic braking in this model.

Pharmacologic Approaches to Electrolyte Abnormalities in Heart Failure

Electrolyte abnormalities are common in heart failure and can arise from a variety of etiologies. Neurohormonal activation from ventricular dysfunction, renal dysfunction, and heart failure medications can perturb electrolyte homeostasis which impact both heart failure-related morbidity and mortality. These include disturbances in serum sodium, chloride, acid-base, and potassium homeostasis. Pharmacological treatments differ for each electrolyte abnormality and vary from older, established treatments like the vaptans or acetazolamide, to experimental or theoretical treatments like hypertonic saline or urea, or to newer, novel agents like the potassium binders: patiromer and zirconium cyclosilicate. Pharmacologic approaches range from limiting electrolyte intake or directly repleting the electrolyte, to blocking or promoting their resorption, and to neurohormonal antagonism. Because of the prevalence and clinical impact of electrolyte abnormalities, understanding both the older and newer therapeutic options is and will continue to be necessity for the management of heart failure.

Effects of tolvaptan on urine output in hospitalized heart failure patients with hypoalbuminemia or proteinuria

Hypoalbuminemia is an independent prognostic factor in hospitalization for heart failure (HHF). Hypoalbuminemia or proteinuria is related to resistance to loop diuretics. Tolvaptan is an oral non-peptide, competitive antagonist of vasopressin receptor-2. It has been used for the treatment of volume overload in HHF patients in several Asian countries. Several studies have demonstrated marked improvement in congestion in HHF patients. However, whether tolvaptan is useful for HHF patients with hypoalbuminemia or proteinuria (both of which are related to resistance to loop diuretics) has not been clarified. We examined the diuretic response to tolvaptan in HHF patients with hypoalbuminemia or proteinuria. We defined hypoalbuminemia as a serum level of albumin < 2.6 g/dl. Fifty-one HHF patients who received additional tolvaptan upon therapies with loop diuretics were divided into the hypoalbuminemia group (n = 24) or control group (n = 27). The changes in urine output per day were not different between the two groups [610 (range 100–1032); 742 (505–1247) ml, P = 0.313]. There was no difference in diuretic responses between patients with and without proteinuria. The serum level of albumin did not correlate with changes in urine output per day after tolvaptan treatment (P = 0.276, r = 0.156). Thus, additional administration of tolvaptan elicited a good diuretic response in HHF patients with hypoalbuminemia or proteinuria. These data suggest that tolvaptan might be beneficial for such HHF patients.

Usefulness of the Combination of In-Hospital Poor Diuretic Response and Systemic Congestion to Predict Future Cardiac Events in Patients With Acute Decompensated Heart Failure

We aimed to (1) investigate the relation between diuretic response (DR) with or without systemic congestion and prognosis and (2) explore the potential predictors of poor DR for risk stratification in patients with acute decompensated heart failure (ADHF). We enrolled 186 consecutive patients hospitalized for ADHF. The DR was defined as (body weight at discharge - body weight at admission)/40 mg furosemide or equivalent loop diuretic dose. Systemic congestion on admission was simply evaluated by the presence of leg edema or jugular venous distention. All patients were divided into 4 groups based on the median of DR (-0.50 kg/40 mg) and the status of systemic congestion; GR/C (good DR with systemic congestion, n = 66), GR/N (good DR without systemic congestion, n = 27), PR/C (poor DR with systemic congestion, n = 48); and PR/N (poor DR without systemic congestion, n = 45). The composite outcome was defined as cardiac death and rehospitalization for worsening heart failure. In survival analysis, the cardiac event-free rate in PR/C was significantly lower than that in any other groups (log-rank, p <0.001), and PR/C was an independent predictor of cardiac events (hazard ratio 2.17, p = 0.016). In conclusion, the combination of in-hospital poor DR, characterized by previous ischemic heart disease, and prehospital dose of daily loop diuretics, and systemic congestion provides a risk stratification for future cardiac events in patients with ADHF.

Early treatment with tolvaptan improves diuretic response in acute heart failure with renal dysfunction

BACKGROUND

Poor response to diuretics is associated with worse prognosis in patients with acute heart failure (AHF). We hypothesized that treatment with tolvaptan improves diuretic response in patients with AHF.

METHODS

We performed a secondary analysis of the AQUAMARINE open-label randomized study in which a total of 217 AHF patients with renal impairment (eGFR < 60 mL/min/1.73 m²) were randomized to either tolvaptan or conventional treatment. We evaluated diuretic response to 40 mg furosemide or its equivalent based on two different parameters: change in body weight and net fluid loss within 48 h.

RESULTS

The mean time from patient presentation to randomization was 2.9 h. Patients with a better diuretic response showed greater relief of dyspnea and less worsening of renal function. Tolvaptan patients showed a significantly better diuretic response measured by diuretic response based both body weight [-1.16 (IQR -3.00 to -0.57) kg/40 mg vs. -0.51 (IQR -1.13 to -0.20) kg/40 mg; P < 0.001] and net fluid loss [2125.0 (IQR 1370.0-3856.3) mL/40 mg vs. 1296.3 (IQR 725.2-1726.5) mL/40 mg; P < 0.001]. Higher diastolic blood pressure and use of tolvaptan were independent predictors of a better diuretic response.

CONCLUSIONS

Better diuretic response was associated with greater dyspnea relief and less WRF. Early treatment with tolvaptan significantly improved diuretic response in AHF patients with renal dysfunction.

Associations of Body Mass Index With Laboratory and Biomarkers in Patients With Acute Heart Failure

BACKGROUND

Plasma concentrations of natriuretic peptides decline with obesity in patients with heart failure. Whether this is true for other biomarkers is unknown. We investigated a wide range of biomarker profiles in acute heart failure across the body mass index (BMI) spectrum.

METHODS AND RESULTS

A total of 48 biomarkers, assessing multiple pathophysiological pathways, were measured in 2033 patients included in PROTECT (Placebo-Controlled Randomized Study of the Selective A1 Adenosine Receptor Antagonist Rolofylline for Patients Hospitalized With Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function), a trial comparing the effects of rolofylline to placebo in patients with acute heart failure. Patients were classified into 4 groups according to BMI (<25, 25-30, 30-35, and >35 kg/m²). Of 2003 patients with known weight and height, mean age was 70±12 years and 67% were men. Patients with a higher BMI (>35 kg/m²) had higher blood pressures, were younger, and were more often women. Median levels of brain natriuretic peptide were 550 pg/mL in patients with a BMI <25 kg/m² and 319 pg/mL in patients with a BMI >35 kg/m² (P<0.001). Multivariable regression revealed that brain natriuretic peptide (β=-0.250; P<0.001) and receptor for advanced glycation endproducts (β=-0.095; P<0.007) were inversely correlated to BMI, whereas higher levels of uric acid (β=0.164; P<0.001), proadrenomedullin (β=0.171; P<0.001), creatinine (β=0.118; P=0.003), sodium (β=0.101; P=0.006), and bicarbonate (β=0.094; P=0.009) were associated with higher BMI. No significant interaction was seen between these 7 biomarkers and BMI on 180-day mortality.

CONCLUSIONS

The plasma concentrations of several biomarkers are either positively or negatively influenced by BMI. These findings suggest that these markers should be interpreted with caution in patients with obesity. Although concentrations differ, their prognostic value for mortality up to 180 days did not differ.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00354458.

Markers of diuretic resistance in emergency department patients with acute heart failure

Background

Loop diuretics are common therapy for emergency department (ED) patients with acute heart failure (AHF). Diuretic resistance (DR) is a term used to describe blunted natriuretic response to loop diuretics. It would be important to detect DR prior to it becoming clinically apparent, so early interventions can be initiated. However, several definitions have been proposed, and it is not clear if they identify similar patients. We compared these definitions and described the clinical characteristics of patients who fulfilled them.

Methods

To qualify for this secondary analysis of 1033 ED patients with AHF, all patients needed to receive intravenous diuretics in the ED and have urine available within 24 h of their ED evaluation. A poor diuretic response, suggesting DR, was characterized by (1) a fractional sodium excretion (FeNa) of less than 0.2%; (2) spot urinary sodium of less than 50 meq/L; and (3) a urinary Na/K ratio <1.0. McNemar’s test was used to compare the different cohorts identified by the three definitions. Secondary analyses evaluated associations between each DR definition and hospital length of stay (LOS), ED revisits and rehospitalizations for AHF, and mortality using the Wilcoxon rank-sum tests and linear regression or Pearson chi-square test and logistic regression, as appropriate.

Results

The median age of the 187 patients was 64, and 50% were African-American. There were 5.9% of patients with a FeNa less than 0.2%, 17.1% had urinary sodium less than 50 meq/L, and 10.7% had a urinary Na/K ratio <1.0. The three definitions identified significantly different patients with very little overlap (p < 0.02 for all comparisons). There were 37 (19.8%) patients who were readmitted to the ED or hospital or died within 30 days of ED evaluation. Patients with spot urinary sodium less than 50 meq/L were more likely to be readmitted (p = 0.03).

Conclusions

The patient proportion with poor natriuresis and DR varies depending on the definition used. Early ED therapy would be impacted at different rates if clinical decisions are made based on these definitions. These findings need to be further explored in a prospective ED-based study.

Trial registration

ClinicalTrials.gov, NCT00508638

Electronic supplementary material

The online version of this article (doi:10.1186/s12245-017-0143-x) contains supplementary material, which is available to authorized users.

Low circulating microRNA levels in heart failure patients are associated with atherosclerotic disease and cardiovascular-related rehospitalizations

OBJECTIVE

Circulating microRNAs (miRNAs) have been implicated in both heart failure and atherosclerotic disease. The aim of this study was to examine associations between heart failure specific circulating miRNAs, atherosclerotic disease and cardiovascular-related outcome in patients with heart failure.

METHODS

The levels of 11 heart failure-specific circulating miRNAs were compared in plasma of 114 heart failure patients with and without different manifestations of atherosclerotic disease. We then studied these miRNAs in relation to biomarkers associated to atherosclerosis and to cardiovascular-related rehospitalizations during 18 months of follow-up.

RESULTS

At least one manifestation of atherosclerotic disease was found in 70 (61%) of the heart failure patients. A consistent trend was found between an increasing number of manifestations of atherosclerosis (peripheral arterial disease in specific), and lower levels of miR-18a-5p, miR-27a-3p, miR-199a-3p, miR-223-3p and miR-652-3p (all P < 0.05). Target prediction and network analyses identified several interactions between miRNA targets and biomarkers related to inflammation, angiogenesis and endothelial dysfunction. Lower miRNA levels were associated with higher levels of these atherosclerosis-related biomarkers. In addition, lower miRNA levels were significantly associated with rehospitalizations due to cardiovascular causes within 18 months, with let-7i-5p as strongest predictor [HR 2.06 (95% CI 1.29-3.28), C-index 0.70, P = 0.002].

CONCLUSIONS

A consistent pattern of lower levels of circulating miRNAs was found in heart failure patients with atherosclerotic disease, in particular peripheral arterial disease. In addition, lower levels of miRNAs were associated with higher levels of biomarkers involved in atherosclerosis and an increased risk of a cardiovascular-related rehospitalization.

Serum Potassium Levels and Outcome in Acute Heart Failure (Data from the PROTECT and COACH Trials)

Serum potassium is routinely measured at admission for acute heart failure (AHF), but information on association with clinical variables and prognosis is limited. Potassium measurements at admission were available in 1,867 patients with AHF in the original cohort of 2,033 patients included in the Patients Hospitalized with acute heart failure and Volume Overload to Assess Treatment Effect on Congestion and Renal FuncTion trial. Patients were grouped according to low potassium (<3.5 mEq/l), normal potassium (3.5 to 5.0 mEq/l), and high potassium (>5.0 mEq/l) levels. Results were verified in a validation cohort of 1,023 patients. Mean age of patients was 71 ± 11 years, and 66% were men. Low potassium was present in 115 patients (6%), normal potassium in 1,576 (84%), and high potassium in 176 (9%). Potassium levels increased during hospitalization (0.18 ± 0.69 mEq/l). Patients with high potassium more often used angiotensin-converting enzyme inhibitors and mineralocorticoid receptor antagonists before admission, had impaired baseline renal function and a better diuretic response (p = 0.005), independent of mineralocorticoid receptor antagonist usage. During 180-day follow-up, a total of 330 patients (18%) died. Potassium levels at admission showed a univariate linear association with mortality (hazard ratio [log] 2.36, 95% confidence interval 1.07 to 5.23; p = 0.034) but not after multivariate adjustment. Changes of potassium levels during hospitalization or potassium levels at discharge were not associated with outcome after multivariate analysis. Results in the validation cohort were similar to the index cohort. In conclusion, high potassium levels at admission are associated with an impaired renal function but a better diuretic response. Changes in potassium levels are common, and overall levels increase during hospitalization. In conclusion, potassium levels at admission or its change during hospitalization are not associated with mortality after multivariate adjustment.