Prognostic impact of intestinal wall thickening in hospitalized patients with heart failure

Associations of Obesity and Prognostic Nutritional Index on 1-Year Mortality in Patients with Acute Heart Failure

Background

Increased BMI is paradoxically associated with improved survival among patients with acute heart failure (AHF). However, the impact of different nutritional status on this obesity paradox on 1-year mortality is underreported. The prognostic nutritional index is a simple tool to assess nutrition status.

Methods

From 10,027 emergency department admissions at the Amager and Hvidovre Hospital, Copenhagen University Hospital in Denmark, all patients with AHF were identified. Patients were categorised by BMI (normal: 18.5-24.9 kg/m2, overweight: 25-29.9 kg/m2, obese: ≥30 kg/m2) and nutritional status using the prognostic nutritional index (malnourished: <38, well-nourished: ≥38). Kaplan- Meier curves analysed cumulative survival, and Cox regression examined associations between BMI, nutritional status and outcomes, expressed as HR and 95% CI.

Results

Among 383 AHF patients (median age 76 years), 41.3% were malnourished and 58.7% well nourished. In the well-nourished group, obesity was inversely associated with 1-year mortality (adjusted HR 0.48; 95% CI [0.24-0.95]; p=0.035). However, this correlation disappeared in the malnourished group (adjusted HR 1.08; 95% CI [0.59-2.00]; p=0.798). Mortality rates were significantly lower in the well-nourished group among patients with overweight and obesity.

Conclusion

Obesity was associated with reduced 1-year mortality only in AHF patients with good nutritional status, while in malnourished patients, obesity was not associated with 1-year mortality. The prognosis in patients with AHF depends on both the presence of obesity and their nutritional status, highlighting the need for nutritional assessment for risk stratification.

Development and validation of a multifactorial nomogram to predict 48 month mortality in decompensated heart failure

BACKGROUND AND AIMS

As the incidence of heart failure (HF) increases, the need for practical tools to evaluate the long-term prognosis in these patients remains critical. Our study aimed to develop a 48 month prediction model for all-cause mortality in decompensated HF patients using available clinical indicators.

METHODS

HF patients (n = 503), 60 years or older, were divided into a training cohort (n = 402) and a validation cohort (n = 101). Data on demographics, comorbidities, laboratory results and medications were gathered. Prediction models were developed using the Prognostic Nutritional Index (PNI), cholinesterase (ChE) and a multifactorial nomogram incorporating clinical variables. These models were constructed using the least absolute shrinkage and selection operator algorithm and multivariate logistic regression analysis. The performance of the model was assessed in terms of calibration, discrimination and clinical utility.

RESULTS

The mean age was 77.11 ± 8.85 years, and 216 (42.9%) were female. The multifactorial nomogram included variables of ChE, lymphocyte count, albumin, serum creatinine and N-terminal pro-brain natriuretic peptide (all P < 0.05). In the training cohort, the nomogram's C-index was 0.926 [95% confidence interval (CI) 0.896-0.950], outperforming the PNI indices at 0.883 and ChE at 0.804 (Z-tests, P < 0.05). The C-index in the validation cohort was 0.913 (Z-tests, P < 0.05). Calibration and decision curve analysis confirmed model reliability, indicating a more significant net benefit than PNI and ChE alone.

CONCLUSIONS

Both the ChE- and PNI-based prediction models effectively predict the long-term prognosis in patients over 60 years of age with decompensated HF. The multifactorial nomogram model shows superior performance, improving clinical decision-making and patient outcomes.

Predictive value of the prognostic nutritional index combined with serum chloride levels for the prognosis of patients with acute decompensated heart failure

BACKGROUND

The prognostic nutritional index (PNI) and serum chloride level are related to adverse outcomes in patients with heart failure. However, little is known about the relationship between the PNI and serum chloride level in predicting the poor prognosis of patients with acute decompensated heart failure (ADHF).

METHODS AND RESULTS

We reviewed 1221 consecutive patients with ADHF admitted to the First Affiliated Hospital of Kunming Medical University from January 2017 to October 2021. After excluding patients with in hospital death, missing follow-up data, missing chloride data, missing lymphocyte (LYM) count data, or missing serum albumin data, 805 patients were included. PNI was calculated using the formula: serum albumin (ALB) (g/L) + 5 × LYM count (10^9/L). Patients were divided into 4 groups according to the quartiles of the PNI, and the highest PNI quartile (PNI Q4: PNI ≥ 47.3) was set as the reference group. The patients in the lowest PNI quartile (PNI Q1: PNI < 40.8) had the lowest cumulative survival rate, and mortality risk decreased progressively through the quartiles (log-rank χ2 142.283, P < 0.0001). Patients with ADHF were divided into 8 groups by quartiles of PNI and median levels of serum chloride. After adjustment, the hazard ratio (HR) for all-cause mortality in ADHF patients in Group 1 was 8.7 times higher than that in the reference Group 8. Furthermore, the addition of serum chloride level and PNI quartile to the Cox model increased the area under the Receiver operating characteristic (ROC) curve by 0.05, and the area under the ROC curve of the new model was higher than that of the original model with traditional risk factors.

CONCLUSIONS

Both the lowest PNI quartiles and low chloride level indicate a higher risk of all-cause death in patients with ADHF.

Prognostic Implication of Intestinal Wall Edema in Patients with Aortic Stenosis Receiving Trans-Catheter Aortic Valve Replacement

BACKGROUND

A recently proposed mechanism, the intestinal-cardiovascular relationship, serves as a framework to elucidate the interplay between these two systems. In our investigation, we assessed the prognostic implications of colon wall thickness, a marker correlated with intestinal congestion and dysfunction, in patients diagnosed with severe aortic stenosis undergoing transcatheter aortic valve replacement (TAVR).

METHODS

Patients diagnosed with severe aortic stenosis who underwent TAVR at our institution during the period spanning 2015 to 2022 were retrospectively enrolled. As part of the institutional protocol, patients underwent abdominal computed tomography upon admission, preceding TAVR. Our analysis aimed to assess the influence of colon wall thickness on the occurrence of either all-cause mortality or readmission due to heart failure within a two-year period.

RESULTS

A total of 345 patients were included. The median age was 85 (82, 88) years, and 99 patients were male. Baseline colon wall thickness was distributed widely, with a median value of 2.2 (2.0, 2.5) mm. Patients with thicker colon walls tended to have lower pulmonary artery pulsatility index values, indicating more impaired right ventricular function and more advanced malnutrition. A thicker colon wall was independently associated with 2-year death or heart failure readmission with a hazard ratio of 2.02 (95% confidence interval 1.01-14.07), adjusted for hemoglobin, age, and plasma B-type natriuretic peptide levels (p = 0.049), and significantly stratified the primary endpoint at a cutoff of 2.7 mm (25% versus 10%, p = 0.005).

CONCLUSIONS

Our initial observation revealed that a thicker baseline colon wall correlated with increased rates of mid-term mortality and readmission due to heart failure subsequent to TAVR. Developing a comprehensive understanding of the underlying causality necessitates further in-depth investigations through subsequent studies.

Clinical Presentation and Diagnostic Approach to Hypoglycemia in Adults Without Diabetes Mellitus

OBJECTIVE

To review the clinical presentation, causes, and diagnostic approach to spontaneous hypoglycemia in adults without diabetes mellitus.

METHODS

A literature review was performed using the PubMed and Google Scholar databases.

RESULTS

Hypoglycemia is uncommon in people who are not on glucose-lowering medications. Under normal physiologic conditions, multiple neural and hormonal counterregulatory mechanisms prevent the development of abnormally low levels of plasma glucose. If spontaneous hypoglycemia is suspected, the Whipple triad should be used to confirm hypoglycemia before pursuing further diagnostic workup. The Whipple criteria include the following: (1) low levels of plasma glucose, (2) signs or symptoms that would be expected with low levels of plasma glucose, and (3) improvement in those signs or symptoms when the level of plasma glucose increases. Spontaneous hypoglycemia can be caused by conditions that cause endogenous hyperinsulinism, including insulinoma, postbariatric hypoglycemia, and noninsulinoma pancreatogenous hypoglycemia. Spontaneous hypoglycemia can also be seen with critical illness, hepatic or renal dysfunction, hormonal deficiency, non-diabetes-related medications, and non-islet cell tumors. The initial diagnostic approach should begin by obtaining a detailed history of the nature and timing of the patient's symptoms, medications, underlying comorbid conditions, and any acute illness. A laboratory evaluation should be conducted at the time of the spontaneous symptomatic episode. Supervised tests such as a 72-hour fast or mixed-meal test may be needed to recreate the situation under which the patient is likely to experience symptoms.

CONCLUSION

We provide an overview of the physiology of counterregulatory response to hypoglycemia, its causes, and diagnostic approaches to spontaneous hypoglycemia in adults.

Correlation between the prognostic nutritional index and outcomes in older patients aged ≥ 60 years with chronic heart failure

BACKGROUND

Nutritional status is related to clinical outcomes in patients with chronic heart failure (CHF). The prognostic nutritional index (PNI) is a simple tool to assess nutrition.

AIM

To evaluate the association between the PNI score and clinical outcomes in patients (60 years and older) hospitalized due to an acute exacerbation of CHF.

METHOD

This was a retrospective observational study. Patients hospitalized for acute CHF exacerbation between July 2015 and May 2020 were analyzed. Patients were followed until January 31, 2021. The primary end point was cardiovascular-related readmissions and all-cause mortality after hospital discharge. Secondary outcomes were factors associated with all-cause mortality. Patients were divided into normal nutrition (PNI > 38), moderate malnutrition (PNI = 35-38), and severe malnutrition (PNI < 35) groups.

RESULTS

The study included 355 patients (mean age 78 ± 9 years). The median follow-up was 769 days. Compared to survivors (n = 214), patients who expired (n = 133) were (1) older; (2) had lower PNI scores, lymphocyte counts, hemoglobin, albumin, total cholesterol, and serum sodium level; but (3) had higher serum creatinine levels, log(N-terminal-pro-B-type natriuretic peptide), and cardiac troponin I (P < 0.05). Multivariate analyses revealed that PNI was independently associated with all-cause mortality. The hazard ratio (HR) for moderate malnutrition versus normal nutrition was 1.624 (95% confidence interval [CI] 1.011-2.609, P = 0.045), while HR for severe malnutrition versus normal nutrition was 1.892 (95%CI 1.119-3.198, P = 0.017). Malnourished patients had significantly higher rates of cardiovascular readmissions and all-cause mortality.

CONCLUSION

Lower PNI (malnutrition) was associated with worse clinical outcomes and was independently associated with all-cause mortality in patients with CHF.

Association between intestinal oedema and oral loop diuretic resistance in hospitalized patients with acute heart failure

AIMS

Intestinal oedema is one of the manifestations associated with right-sided heart failure (HF), which is known to be associated with poorer patient outcomes. We attempted to reveal the association between intestinal oedema and diuretic resistance in hospitalized patients with acute HF.

METHODS AND RESULTS

Among 213 hospitalized patients with acute HF, abdominal ultrasonography was performed under clinically stable conditions after initial HF treatments. The association among abdominal ultrasonographic parameters, maintenance doses of loop diuretics, and responsiveness to initial loop diuretic treatment was evaluated. Higher mean colon wall thickness (CWT) independently correlated with a higher dose of loop diuretics at enrolment (adjusted β = 0.198, P = 0.0004). Increased mean CWT also correlated with poor response to oral loop diuretics as an initial treatment, whereas it did not correlate with the response to intravenous loop diuretics. Discrimination of non-responders to initial oral loop diuretics resulted in a sensitivity of 0.772 and a specificity of 0.733 using a mean CWT cut-off value of ≥3 mm.

CONCLUSIONS

In hospitalized patients with acute HF, a strong correlation was identified among the severity of intestinal oedema, required quantities as maintenance loop diuretic doses, and poor responsiveness to oral loop diuretics at admission.

Assessment of organ congestion in patients with heart failure by ultrasonography

In recent years, there has been a growing interest in assessing congestion of organs (e.g., liver, kidneys, lungs, intestines) in patients with heart failure (HF). HF involves an increased risk of mortality, thereby making it important to evaluate organ congestion. Ultrasonography is a useful tool for noninvasive and repeatable evaluation of patients with HF. Noninvasive evaluation of organ congestion can also be used to assess hemodynamics. It may further be useful for elucidating organ cross-talk in patients with HF. This review discusses the clinical implications of evaluating organ congestion by ultrasonography.

Impaired intestinal function is associated with lower muscle and cognitive health and well-being in patients with congestive heart failure

BACKGROUND

Small- and large-intestinal perturbations have been described as prevalent extracardiac systemic manifestations in congestive heart failure (CHF), but alterations in protein digestion and absorption and plasma short-chain fatty acid (SCFA) concentrations and the potential link with other systemic effects (muscle and cognitive health) have not been investigated in CHF.

METHODS

We analyzed protein digestion and absorption with dual stable tracer method in 14 clinically stable, noncachectic CHF outpatients (mean left ventricular ejection fraction: 35.5% [95% CI, 30.9%-40.1%]) and 15 controls. Small-intestinal non-carrier-mediated permeability and active carrier-mediated glucose transport were quantified by sugar permeability test. Plasma SCFA (acetate, propionate, butyrate, isovalerate, valerate) concentrations were measured as intestinal microbial metabolites. Muscle function was assessed by isokinetic dynamometry, cognition by a battery of tests, and well-being by questionnaire.

RESULTS

Protein digestion and absorption were impaired by 29.2% (P = .001) and active glucose transport by 38.4% (P = .010) in CHF. Non-carrier-mediated permeability was not altered. Whereas plasma propionate, butyrate, and isovalerate concentrations were lower in CHF (P < .05), acetate and valerate concentrations did not differ. Overall, intestinal dysfunction was associated with impaired leg muscle quality, emotional distress, and cognitive dysfunction (P < .05).

CONCLUSIONS

We identified impaired protein digestion and absorption and altered SCFA concentrations as additional intestinal dysfunctions in CHF that are linked to reduced muscle and cognitive health and well-being. More research is needed to implement strategies to improve intestinal function in CHF and to investigate the mechanisms underlying its link with other systemic manifestations.

Point of Care Ultrasonography for Objective Assessment of Heart Failure: Integration of Cardiac, Vascular, and Extravascular Determinants of Volume Status

BACKGROUND

Lingering congestion portends poor outcomes in patients with heart failure (HF) and is a key target in their management. Studies have shown that physical exam has low yield in this setting and conventional methods for more precise assessment and monitoring of volume status (e.g., body weight, natriuretic peptides, and chest radiography) have significant inherent shortcomings.

SUMMARY

Point of care ultrasonography (POCUS) is a noninvasive versatile bedside diagnostic tool that enhances the sensitivity of conventional physical examination to gauge congestion in these patients. It also aids in monitoring the efficacy of decongestive therapy and bears prognostic significance. In this narrative review, we discuss the role of focused sonographic assessment of the heart, venous system, and extravascular lung water/ascites (i.e., the pump, pipes, and the leaks) in objective assessment of fluid volume status. Key Messages: Since each of the discussed components of POCUS has its limitations, a combinational ultrasound evaluation guided by the main clinical features would be the key to reliable assessment and effective management of congestion in patients with HF.

Small bowel wall edema induced by regorafenib is associated with regorafenib intolerance and shorter survival in patients with metastatic colorectal cancer: A retrospective study

INTRODUCTION

Regorafenib, a receptor tyrosine kinase inhibitor, is a routinely used targeted agent in the current treatment of patients with refractory metastatic colorectal carcinoma (mCRC). The aims of this study were to detect the presence of bowel wall edema during regorafenib treatment via computed tomography (CT) and to assess the relationship between survival and regorafenib-induced bowel wall edema in patients with mCRC receiving regorafenib.

PATIENTS AND METHODS

We retrospectively evaluated the presence of bowel wall edema on CT of 25 mCRC patients who received regorafenib and analyzed its relationship with progression free survival (PFS) and overall survival (OS).

RESULTS

Among the 25 patients, 25 had small bowel wall edema (SBWE) and 14 had large bowel wall edema (LBWE) on at least one CT examination. The median SBWE value was 4.85 milimeters (mm). Of the 25 patients, 14 had SBWE ≤4.85 mm and 11 had SBWE >4.85 mm. Regorafenib intolerance was significantly higher at SBWE >4.85 mm patients (p = 0.03). The median PFS was 4.6 months (95% CI: 2.4-6.8) and median OS was 9.3 months (95% CI: 3.1-15.4). Median PFS and OS were shorter in patients with SBWE > 4.85 mm than in those with ≤4.85 mm, but not statistically significant (median PFS: 3.9 vs 4.6 months, p: 0.523; median OS: 5.6 vs 9.3 months, p: 0.977).

CONCLUSIONS

Regorafenib caused SBWE in patients with mCRC. Patients who developed more SBWE had a higher regorafenib intolerance and a shorter survival. Further studies are needed to confirm the predictor value of SBWE on the survival outcomes of patients with mCRC receiving regorafenib.

Potential Risk of Hypoglycemia in Patients with Heart Failure

The properties of glucose changes in patients with chronic heart failure remain elusive. In the present study, we investigated the sequential changes of interstitial glucose concentrations in patients with chronic heart failure and heart disease who were not undergoing antidiabetic therapy.A glucose monitoring device (FreeStyle Libre Pro) was attached to the backside of an upper arm and the interstitial glucose concentration was monitored every 15 minutes for 1 week. Eleven patients with chronic heart failure (Heart failure (+) ) and 7 patients with chronic heart diseases but not with heart failure (Heart failure (-) ) were enrolled. The average level and peak value of interstitial glucose concentrations, and the duration of hyperglycemia (≥ 140 mg/dL) were not significantly different between Heart failure (+) and Heart failure (-). The duration of hypoglycemia (< 80 mg/dL) was significantly longer and the trough value was significantly lower in Heart failure (+) compared with Heart failure (-). Most of the patients in Heart failure (+) were exposed to a long duration of hypoglycemia from midnight to morning. Importantly, none of the patients who showed hypoglycemia complained of any subjective symptoms during hypoglycemia. Malabsorption may be one of the mechanisms of hypoglycemia.In summary, patients with chronic heart failure are at risk of developing hypoglycemia even if they do not undergo any antidiabetic therapy.

Ultrasonographic assessment of organs other than the heart in patients with heart failure

The number of patients with heart failure has been dramatically increasing in Japan in association with aging of the society. This phenomenon is referred to as a heart failure pandemic. The fundamental origin of heart failure is cardiac dysfunction. Echocardiography is widely used to assess cardiac function, as well as to diagnose heart diseases that cause cardiac dysfunction. However, the severity of heart failure is not necessarily correlated with that of cardiac dysfunction. This is partly explained by the fact that heart failure induces dysfunction of organs other than the heart through hemodynamic deterioration and neurohumoral changes. In addition, one of the characteristics of patients with heart failure, particularly elderly patients, is the presence of numerous comorbidities. Symptoms of heart failure are not specific, and assessment of cardiac function, particularly left ventricular diastolic function, has not been established. Thus, ultrasonographic assessment of organs other than the heart helps the diagnosis of heart failure, assessment of the severity of heart failure, and development of our understanding of the pathophysiology in each patient. This review summarizes current knowledge about the usefulness of ultrasonographic assessment of organs other than the heart in heart failure.

Hydrogen- and Methane-Based Breath Testing and Outcomes in Patients With Heart Failure

BACKGROUND

Recent evidence endorses gut microbiota dysregulation in the pathophysiology of heart failure (HF). Small intestinal bacterial overgrowth (SIBO) might be present in HF and associated with poor clinical outcomes. Lactulose breath testing is a simple noninvasive test that has been advocated as a reliable indicator of SIBO. In patients with HF, we aimed to evaluate the association with clinical outcomes of the exhaled hydrogen (H₂) and methane (CH₄) concentrations through the lactulose breath test.

METHODS AND RESULTS

We included 102 patients with HF in which lactulose SIBO breath tests were assessed. Cumulative gas was quantified by the area under the receiver operating characteristic curve of CH₄ (AUC-CH₄) and H₂ (AUC-H₂). Clinical end points included the composite of all-cause death with either all-cause or HF hospitalizations, recurrent all-cause hospitalizations, and recurrent HF hospitalizations. Medians (interquartile ranges) of AUC-H₂ and AUC-CH₄ were 1290 U (520-2430) and 985 U (450-2120), respectively. In multivariable analysis, AUC-H₂ (per 1000 U) was associated with all-cause death/all-cause hospitalization (hazard ratio [HR] 1.21, 95% CI 1.04-1.40; P = .012), all-cause death/HF hospitalization (HR 1.20, 95% CI 1.03-1.40; P = .021), and an increase in the rate of recurrent all-cause (incidence rate ratio [IRR] 1.31, 95% CI 1.14-1.51; P < .001) and HF (IRR 1.41, 95% CI 1.15-1.72; P = .001) hospitalizations. AUC-CH₄ was not associated with any of these end points.

CONCLUSIONS

AUC-H₂, a safe and noninvasive method for SIBO estimation, is associated with higher risk of long-term adverse clinical events in patients with HF. In contrast, AUC-CH₄ did not show any prognostic value.

Prognostic Nutritional Index and the Risk of Mortality in Patients With Acute Heart Failure

Background

Nutritional status has been related to clinical outcomes in patients with heart failure. We assessed the association between nutritional status, indexed by prognostic nutritional index (PNI), and survival in patients hospitalized for acute heart failure.

Methods and Results

A total of 1673 patients (age 76±13 years, 68% men) hospitalized for acute heart failure in a tertiary medical center were analyzed. PNI was calculated as 10×serum albumin (g/dL)+0.005×total lymphocyte count (per mm³). National Death Registry was linked to identify the clinical outcomes of all‐cause and cardiovascular death. With increasing tertiles of PNI, age and N‐terminal probrain natriuretic peptide decreased, and body mass index, estimated glomerular filtration rate, and hemoglobin increased. During a mean follow‐up duration of 31.5 months, a higher PNI tertile was related to better survival free from all‐cause and cardiovascular mortality in the total study population and in participants with either reduced or preserved left ventricular ejection fraction. After accounting for age, sex, estimated glomerular filtration rate, left ventricular ejection fraction, serum sodium level, and on‐admission systolic blood pressure, PNI was independently associated with cardiovascular death and total mortality (hazard ratio per 1 SD of the natural logarithm of the PNI: 0.76 [95% CI, 0.66–0.87] and 0.79 [95% CI, 0.73–0.87], respectively). In subgroup analyses stratified by age, sex, left ventricular ejection fraction, body mass index, or estimated glomerular filtration rate, PNI was consistently related to mortality.

Conclusions

PNI is independently associated with long‐term survival in patients hospitalized for acute heart failure with either reduced or preserved left ventricular ejection fraction.