Pathophysiology of acute heart failure syndrome: a knowledge gap

Difference Analysis of N-Terminal B-Type Natriuretic Peptide, High-Sensitivity Troponin I, and Endothelin-1 Levels in Patients With Normotensive and Hypertensive Acute Heart Failure

Background

Acute heart failure (AHF) is a condition commonly affecting elderly patients. Heart failure is classified based on systolic blood pressure (SBP) into hypertensive (SBP ≥ 140 mm Hg), and normotensive (SBP < 140 mm Hg) categories. Differences in the pathophysiological mechanisms associated with each type of AHF may result in varying levels of biomarkers released by the heart during the episode, including N-terminal B-type natriuretic peptide (NT-proBNP), high-sensitivity (hs)-troponin I, and endothelin-1. Currently, there are no studies comparing the levels of cardiac biomarkers between normotensive and hypertensive AHF. Therefore, this study aimed to compare the levels of NT-proBNP, hs-troponin I, and endothelin-1 in patients with hypertensive and normotensive AHF.

Methods

A cross-sectional study was conducted in 104 patients with AHF (40 hypertensive, 64 normotensive) at M. Djamil General Hospital from August 2021 to November 2022. Clinical characteristics, hemodynamic parameters, and cardiac biomarker levels were assessed and compared between groups.

Results

Patients with hypertensive AHF had significantly higher sodium and chloride levels with lower urea levels. Echocardiographic assessment showed higher left ventricular ejection fraction (LVEF) (35.72% vs. 35.25%, P = 0.857), cardiac output (3.0 vs. 2.9 L/min, P = 0.669), and systemic vascular resistance (SVR) (2,276 vs. 2,200, P = 0.693), with lower tricuspid annular plane systolic excursion (TAPSE) (1.7 vs. 1.8 cm, P = 0.717), and estimated right atrial pressure (eRAP) > 8 (87.5% vs. 92.6%, P = 0.517) in normotensive AHF patients compared to hypertensive group, although there was no statistically significant difference between the two groups. The biomarkers test showed higher hs-troponin I levels (281 vs. 72.8 ng/L, P = 0.039) in normotensive AHF than those in hypertensive group. No significant differences were observed in endothelin-1 (12.12 vs. 12.02 pg/L, P = 0.510) and NT-proBNP levels (5,410 vs. 4,712 pg/mL, P = 0.122) between groups.

Conclusions

In patients with normotensive AHF, higher levels of hs-troponin I were observed, with no significant differences in other cardiac biomarkers. A higher proportion of males and a lower prevalence of hypertension as a risk factor were also noted in normotensive AHF, although these differences were not statistically significant.

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.

The impact of platelet-to-lymphocyte ratio on clinical outcomes in heart failure: a systematic review and meta-analysis

BACKGROUND

Inflammation has been suggested to play a role in heart failure (HF) pathogenesis. However, the role of platelet-to-lymphocyte ratio (PLR), as a novel biomarker, to assess HF prognosis needs to be investigated. We sought to evaluate the impact of PLR on HF clinical outcomes.

METHODS

English-published records in PubMed/Medline, Scopus, and Web-of-science databases were screened until December 2023. Relevant articles evaluated PLR with clinical outcomes (including mortality, rehospitalization, HF worsening, and HF detection) were recruited, with PLR difference analysis based on death/survival status in total and HF with reduced ejection fraction (HFrEF) patients.

RESULTS

In total, 21 articles (n = 13,924) were selected. The total mean age was 70.36 ± 12.88 years (males: 61.72%). Mean PLR was 165.54 [95% confidence interval (CI): 154.69-176.38]. In total, 18 articles (n = 10,084) reported mortality [either follow-up (PLR: 162.55, 95% CI: 149.35-175.75) or in-hospital (PLR: 192.83, 95% CI: 150.06-235.61) death rate] and the mean PLR was 166.68 (95% CI: 154.87-178.50). Further analysis revealed PLR was significantly lower in survived HF patients rather than deceased group (152.34, 95% CI: 134.01-170.68 versus 194.73, 95% CI: 175.60-213.85, standard mean difference: -0.592, 95% CI: -0.857 to -0.326, p < 0.001). A similar trend was observed for HFrEF patients. PLR failed to show any association with mortality risk (hazard ratio: 1.02, 95% CI: 0.99-1.05, p = 0.289). Analysis of other aforementioned outcomes was not possible due to the presence of few studies of interest.

CONCLUSION

PLR should be used with caution for prognosis assessment in HF sufferers and other studies are necessary to explore the exact association.

Acute heart failure: mechanisms and pre-clinical models-a Scientific Statement of the ESC Working Group on Myocardial Function

While chronic heart failure (CHF) treatment has considerably improved patient prognosis and survival, the therapeutic management of acute heart failure (AHF) has remained virtually unchanged in the last decades. This is partly due to the scarcity of pre-clinical models for the pathophysiological assessment and, consequently, the limited knowledge of molecular mechanisms involved in the different AHF phenotypes. This scientific statement outlines the different trajectories from acute to CHF originating from the interaction between aetiology, genetic and environmental factors, and comorbidities. Furthermore, we discuss the potential molecular targets capable of unveiling new therapeutic perspectives to improve the outcome of the acute phase and counteracting the evolution towards CHF.

Endothelitis profile in acute heart failure and cardiogenic shock patients: Endocan as a potential novel biomarker and putative therapeutic target

Aims: Inflammation-driven endothelitis seems to be a hallmark of acute heart failure (AHF) and cardiogenic shock (CS). Endocan, a soluble proteoglycan secreted by the activated endothelium, contributes to inflammation and endothelial dysfunction, but has been scarcely explored in human AHF. We aimed to evaluate serum (S-Endocan) and urinary endocan (U-Endocan) profiles in AHF and CS patients and to correlate them with biomarkers/parameters of inflammation, endothelial activation, cardiovascular dysfunction and prognosis.

Methods: Blood and spot urine were collected from patients with AHF (n = 23) or CS (n = 25) at days 1–2 (admission), 3-4 and 5-8 and from controls (blood donors, n = 22) at a single time point. S-Endocan, U-Endocan, serum IL-1β, IL-6, tumour necrosis factor-α (S-TNF-α), intercellular adhesion molecule-1 (S-ICAM-1), vascular cell adhesion molecule-1 (S-VCAM-1) and E-selectin were determined by ELISA or multiplex immunoassays. Serum C-reactive protein (S-CRP), plasma B-type natriuretic peptide (P-BNP) and high-sensitivity troponin I (P-hs-trop I), lactate, urea, creatinine and urinary proteins, as well as prognostic scores (APACHE II, SAPS II) and echocardiographic left ventricular ejection fraction (LVEF) were also evaluated.

Results: Admission S-Endocan was higher in both patient groups, with CS presenting greater values than AHF (AHF and CS vs. Controls, p < 0.001; CS vs. AHF, p < 0.01). Admission U-Endocan was only higher in CS patients (p < 0.01 vs. Controls). At admission, S-VCAM-1, S-IL-6 and S-TNF-α were also higher in both patient groups but there were no differences in S-E-selectin and S-IL-1β among the groups, nor in P-BNP, S-CRP or renal function between AHF and CS. Neither endocan nor other endothelial and inflammatory markers were reduced during hospitalization (p > 0.05). S-Endocan positively correlated with S-VCAM-1, S-IL-6, S-CRP, APACHE II and SAPS II scores and was positively associated with P-BNP in multivariate analyses. Admission S-Endocan raised in line with LVEF impairment (p = 0.008 for linear trend).

Conclusion: Admission endocan significantly increases across AHF spectrum. The lack of reduction in endothelial and inflammatory markers throughout hospitalization suggests a perpetuation of endothelial dysfunction and inflammation. S-Endocan appears to be a biomarker of endothelitis and a putative therapeutic target in AHF and CS, given its association with LVEF impairment and P-BNP and its positive correlation with prognostic scores.

The association between platelet-to-lymphocyte ratio with mortality among patients suffering from acute decompensated heart failure

Background

Platelet-to-lymphocyte ratio (PLR) is an inflammation index suggested to have the prognostic capability in heart failure (HF). We sought to investigate the association of PLR with cardiovascular disease (CVD) mortality and creatinine (Cr) rise among Iranian individuals suffering from acute decompensated HF (ADHF).

Methods

This retrospective cohort study was in the context of the Persian Registry Of cardioVascular diseasE/Heart Failure (PROVE/HF) study. 405 individuals with ADHF admitted to the emergency department were recruited from April 2019 to March 2020. PLR was calculated by division of platelet to absolute lymphocyte counts and categorized based on quartiles. We utilized the Kaplan–Meier curve to show the difference in mortality based on PLR quartiles. Cr rise was defined as the increment of at least 0.3 mg/dl from baseline. Cox proportional hazard ratio (HR) was used to investigate the association of PLR with CVDs mortality.

Results

Mean age of participants was 65.9 ± 13.49 years (males: 67.7%). The mean follow-up duration was 4.26 ± 2.2 months. CVDs mortality or re-hospitalization was not significantly associated with PLR status. Multivariate analysis of PLR quartiles showed a minimally reduced likelihood of CVDs death in 2nd quartile versus the first one (HR 0.40, 95% confidence interval (CI) 0.16–1.01, P = 0.054). Cr rise had no remarkable relation with PLR status in neither model.

Conclusion

PLR could not be used as an independent prognostic factor among ADHF patients. Several studies are required clarifying the exact utility of this index.

Adaptive anti-myocardial immune response following hospitalization for acute heart failure

Aims

It has been hypothesized that cardiac decompensation accompanying acute heart failure (AHF) episodes generates a pro‐inflammatory environment boosting an adaptive immune response against myocardial antigens, thus contributing to progression of heart failure (HF) and poor prognosis. We assessed the prevalence of anti‐myocardial autoantibodies (AMyA) as biomarkers reflecting adaptive immune responses in patients admitted to the hospital for AHF, followed the change in AMyA titres for 6 months after discharge, and evaluated their prognostic utility.

Methods and results

AMyA were determined in n = 47 patients, median age 71 (quartiles 60; 80) years, 23 (49%) female, and 24 (51%) with HF with preserved ejection fraction, from blood collected at baseline (time point of hospitalization) and at 6 month follow‐up (visit F6). Patients were followed for 18 months (visit F18). The prevalence of AMyA increased from baseline (n = 21, 45%) to F6 (n = 36, 77%; P < 0.001). At F6, the prevalence of AMyA was higher in patients with HF with preserved ejection fraction (n = 21, 88%) compared with patients with reduced ejection fraction (n = 14, 61%; P = 0.036). During the subsequent 12 months after F6, that is up to F18, patients with newly developed AMyA at F6 had a higher risk for the combined endpoint of death or rehospitalization for HF (hazard ratio 4.79, 95% confidence interval 1.13–20.21; P = 0.033) compared with patients with persistent or without AMyA at F6.

Conclusions

Our results support the hypothesis that AHF may induce patterns of adaptive immune responses. More studies in larger populations and well‐defined patient subgroups are needed to further clarify the role of the adaptive immune system in HF progression.

Chrysophanol Protects Against Acute Heart Failure by Inhibiting JNK1/2 Pathway in Rats

BACKGROUND Acute heart failure (AHF) usually requires urgent therapy. Myocardial damage, oxidative stress, and inflammation are major components in the pathology of AHF. This study was designed to investigate the effects of chrysophanol on AHF. MATERIAL AND METHODS Sprague-Dawley rats were injected with isoprenaline hydrochloride to construct AHF rat models. AHF rats were treated with normal saline (negative control), chrysophanol, the combination of chrysophanol and SP600125, or benazepril (positive control) using sham rats as blank controls. Echocardiography, histological staining, and enzyme activity analysis were performed to assess the heart functions and myocardial damage. Effects on apoptosis, oxidative stress (OS), and inflammation were evaluated by biochemical analysis, TUNEL staining, and ELISA. RESULTS Chrysophanol improved the parameters of cardiac functions and alleviated the myocardial damage accompanied by the reduction of creatine kinase and lactate dehydrogenase activity. Meanwhile, chrysophanol inhibited the myocardial apoptosis along with the upregulation of Bcl-2 and downregulation of Bax and cleaved caspase-3. AHF-induced abnormal changes of OS parameters (MDA, GPx, CAT, SOD) and inflammatory markers (IL-6, IL-1ß, TNF-alpha, IFN-γ) were alleviated by chrysophanol. Benazepril treatment showed similar results with chrysophanol, while the addition of SP600125 enhanced the chrysophanol-mediated protection effects in AHF rats. Western blot analysis demonstrated that chrysophanol inhibited the phosphorylation of JNK1/2 and its upstream/downstream factors. CONCLUSIONS Chrysophanol improved cardiac functions and protected against myocardial damage, apoptosis, OS, and inflammation by inhibiting activation of the JNK1/2 pathway in AHF rat models. These finding indicate that chrysophanol may be a promising approach for treatment of AHF.

Mode of Death Among Japanese Adults With Heart Failure With Preserved, Midrange, and Reduced Ejection Fraction

IMPORTANCE

Despite intensive treatment, hospitalized patients with acute decompensated heart failure (ADHF) have a substantial risk of postdischarge mortality. Limited data are available on the possible differences in the incidence and mechanisms of death among patients with heart failure with reduced ejection fraction (HFrEF), heart failure with midrange ejection fraction (HFmrEF), and heart failure with preserved ejection fraction (HFpEF).

OBJECTIVES

To examine the incidences and mode of postdischarge mortality among patients with ADHF and to compare the risk profile among patients with HFrEF, HFmrEF, and HFpEF.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study of 4056 patients hospitalized for ADHF analyzed data from 3717 patients who were discharged from October 1, 2014, to March 31, 2016. Data analysis was performed from April 1 to August 31, 2019.

EXPOSURES

Death among patients with ADHF after hospital discharge.

MAIN OUTCOMES AND MEASURES

All-cause death and cause of postdischarge mortality after the index hospitalization by left ventricular ejection fraction (LVEF) subgroup.

RESULTS

A total of 3717 patients (mean [SD] age, 77.7 [12.0] years; 2049 [55.1%] male) were included in the study. The mean (SD) LVEF at baseline was 46.4% (16.2%). Among 3717 enrolled patients, 1383 (37.2%) were categorized as having HFrEF (LVEF, <40%), 703 (18.9%) as having HFmrEF (LVEF, 40%-49%), and 1631 (43.9%) as having HFpEF (LVEF, ≥50%). The incidence and causes of death were evaluated after discharge from the index hospitalization. The median follow-up period was 470 days (interquartile range, 357-649 days), and the 1-year follow-up rate was 96%. During follow-up, all-cause death occurred in 848 patients (22.8%; HFrEF group: 298 [21.5%; 95% CI, 19.5%-23.8%]; HFmrEF group: 158 [22.5%; 95% CI, 19.5%-25.7%]; and HRpEF group: 392 [24.0%; 95% CI, 22.0%-26.2%]; P = .26), cardiovascular deaths occurred in 523 patients (14.1%; HFrEF group: 203 [14.7%; 95% CI, 12.9%-16.6%]; HFmrEF group: 97 [13.8%; 95% CI, 11.4%-16.5%]; and HFpEF group: 223 [13.7%; 95% CI, 12.1%-15.4%]; P = .71), and sudden cardiac death occurred in 98 patients (2.6%; HFrEF group: 44 [3.2%; 95% CI, 2.4%-4.2%]; HFmrEF group: 14 [2.0%; 95% CI, 1.2%-3.3%]; and HFpEF group: 40 [2.5%; 95% CI, 1.8%-3.3%]; P = .23). The risks of causes of death were similar among the subtypes.

CONCLUSIONS AND RELEVANCE

The mode of death was similar among the heart failure subtypes. Given the nonnegligible incidence of sudden cardiac death in patients with HFpEF found in this study, further studies appear to be warranted to identify a high-risk subset in this population.

Clinical Characteristics of De Novo Heart Failure and Acute Decompensated Chronic Heart Failure: Are They Distinctive Phenotypes That Contribute to Different Outcomes?

Heart failure is currently one of the leading causes of morbidity and mortality. Patients with heart failure often present with acute symptoms and may have a poor prognosis. Recent evidence shows differences in clinical characteristics and outcomes between de novo heart failure (DNHF) and acute decompensated chronic heart failure (ADCHF). Based on a better understanding of the distinct pathophysiology of these two conditions, new strategies may be considered to treat heart failure patients and improve outcomes. In this review, the authors elaborate distinctions regarding the clinical characteristics and outcomes of DNHF and ADCHF and their respective pathophysiology. Future clinical trials of therapies should address the potentially different phenotypes between DNHF and ADCHF if meaningful discoveries are to be made.

Acutely decompensated versus acute heart failure: two different entities

Heart failure (HF) has been classified in chronic HF (CHF) and acute HF (AHF). The latter has been subdivided in acutely decompensated chronic HF (ADCHF) defined as the deterioration of preexisting CHF and de novo AHF defined as the rapid development of new symptoms and signs of HF that requires urgent medical attention. However, ADCHF and de novo AHF have fundamental pathophysiological differences. Most importantly, the typical illness trajectory of HF, which is similar to that of other chronic organ diseases including lung, renal, and liver failure, features a gradual decline, with acute episodes usually related to disease evolution followed by partial recovery. Thus, ADCHF should be considered part of the natural history of CHF and renamed CHF exacerbation (CHFE) in accordance with the appropriate terminology used in chronic obstructive pulmonary disease. AHF, in turn, should include only acute de novo HF. The clinical implications of this paradigm shift will be in CHFE the change in focus from in-hospital to optimal ambulatory CHF management aiming at primary and secondary CHFE prevention, while in AHF, the institution of measures for in-hospital limitation of cardiac injury and prevention or retardation of symptomatic CHF development.

Efficacy of urapidil for the treatment of patients with senile hypertension and acute heart failure

BACKGROUND

Previous clinical studies have reported that urapidil can effectively treat patients with senile hypertension (SH) and acute heart failure (AHF). However, no studies have systematically assessed the efficacy and safety of urapidil for patients with SH and AHF. Thus, this study will investigate the efficacy and safety of urapidil for SH and AHF.

METHODS

In this study, we will search the following electronic databases from inception to the June 30, 2019: MEDLINE, EMBASE, Cochrane Library, Google scholar, Springer, WANGFANG, and China Knowledge Resource Integrated Database. We will search all these electronic databases without language limitations. We will also search grey records to avoid missing potential literature. In this study, only randomized controlled trials on assessing efficacy and safety of urapidil for SH and AHF will be considered. We will use RevMan 5.3 software and STATA 15.0 software to carry out statistical analysis.

RESULTS

This study will evaluate the efficacy and safety of urapidil for SH and AHF by assessing all-cause mortality, change in body weight, urine output, change in serum sodium; and incidence of all adverse events.

CONCLUSION

This study will provide latest evidence of the efficacy and safety of urapidil for patients with SH and AHF.

DISSEMINATION AND ETHICS

This study will only analyze published data; therefore, no ethical approval is needed. The findings of this study will be published at peer-reviewed journals.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019139344.

Evaluation of Neutrophil-lymphocyte and Platelet-lymphocyte Ratios as Predictors of 30-day Mortality in Patients Hospitalized for an Episode of Acute Decompensated Heart Failure

BACKGROUND

To investigate the association between both neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) and 30-day mortality in patients hospitalized for an episode of acute decompensated heart failure (ADHF).

METHODS

439 patients admitted to emergency department (ED) for an episode of ADHF. Clinical history, demographic, clinical and laboratory data recorded at ED admission and then correlated with 30-day mortality.

RESULTS

45/439 (10.3%) patients died within 30 days from ED admission. The median values of NLR (4.1 vs 11.7) and PLR (159.1 vs 285.9) were significantly lower in survivors than in patients who died. The area under the ROC curve of NLR was significantly higher than that of the neutrophil count (0.76 vs 0.59; p<0.001), whilst the AUC of PLR was significantly better than that of the platelet count (0.71 vs 0.51; p<0.001). In univariate analysis, both NLR and PLR were significantly associated with 30-day. In the fully-adjusted multivariate model, NLR (odds ratio, 3.63) and PLR (odds ratio, 3.22) remained independently associated with 30-day mortality after ED admission.

CONCLUSIONS

Routine assessment of NLR and PLR at ED admission may be a valuable aid to complement other conventional measures for assessing the medium-short risk of ADHF patients.