2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure: A Report of the American College of Cardiology Solution Set Oversight Committee

Natriuretic response prediction equation for use with oral diuretics in heart failure

BACKGROUND AND AIMS

Limited data are available to assess oral diuretic response in outpatients with heart failure (HF). The natriuretic response prediction equation (NRPE) predicts natriuresis following a loop diuretic dose using a urine sample 2 h after the dose and was validated to accurately predict intravenous diuretic response. The primary aim was to validate the NRPE's assessment of oral diuretic response in patients with HF.

METHODS

The NRPE was evaluated in two HF patient cohorts receiving oral loop diuretics: Mechanisms of Diuretic Resistance (MDR) and TRANSFORM-Mechanism. Participants received their home oral loop diuretic followed by a supervised timed urine collection including spot urine samples at 1 and 2 h. Patients quantified their self-assessed diuretic response (urine volume) via a standardized survey. A poor diuretic response was defined as cumulative natriuresis < 50 mmol over the study visit.

RESULTS

The MDR cohort included 318 oral diuretic administrations from 237 patients. The NRPE predicted a poor natriuretic response with an area under the curve (AUC) of .87 [95% confidence interval (CI) .83-.91] and similar accuracy to the previously validated intravenous NRPE performance (P = .16). Patient's ability to self-estimate their diuretic response was poor with an AUC of .57 (95% CI .44-.70) and significantly worse than the oral NRPE (P < .001). In TRANSFORM-Mechanism (110 oral diuretic administrations), the NRPE had similar operating characteristics (AUC .89, 95% CI .80-1.0) for poor diuretic response.

CONCLUSIONS

Natriuretic response to an oral diuretic can be rapidly and accurately assessed with a urine sample collected 2 h after an oral diuretic dose and the NRPE.

PINK1-mediated mitophagy attenuates pathological cardiac hypertrophy by suppressing the mtDNA release-activated cGAS-STING pathway

AIMS

Sterile inflammation is implicated in the development of heart failure (HF). Mitochondria play important roles in triggering and maintaining inflammation. Mitophagy is important for regulation of mitochondrial quality and maintenance of cardiac function under pressure overload. The association of mitophagy with inflammation in HF is largely unclear. As PINK1 is a central mediator of mitophagy, our objective was to investigate its involvement in cardiac hypertrophy, and the effect of PINK1-mediated mitophagy on cGAS-STING activation during cardiac hypertrophy.

METHODS AND RESULTS

PINK1 knockout and cardiac-specific PINK1-overexpressing transgenic mice were created and subsequently subjected to transverse aortic constriction (TAC) surgery. In order to explore whether PINK1 regulates STING-mediated inflammation during HF, PINK1/STING (stimulator of interferon genes) double-knockout (DKO) mice were created. Pressure overload was induced by TAC. Our findings indicate a significantly decline in PINK1 expression in TAC-induced hypertrophy. Cardiac hypertrophic stimuli caused the release of mitochondrial DNA (mtDNA) into the cytosol, activating the cGAS-STING signalling, which in turn initiated cardiac inflammation and promoted the progression of cardiac hypertrophy. PINK1 deficiency inhibited mitophagy activity, promoted mtDNA release, and then drove the overactivation of cGAS-STING signalling, exacerbating cardiac hypertrophy. Conversely, cardiac-specific PINK1 overexpression protected against hypertrophy thorough inhibition of the cGAS-STING signalling. DKO mice revealed that the effects of PINK1 on hypertrophy were dependent on STING.

CONCLUSION

Our findings suggest that PINK1-mediated mitophagy plays a protective role in pressure overload-induced cardiac hypertrophy via inhibiting the mtDNA-cGAS-STING pathway.

Meteorin-like protein plasma levels are associated with worse outcomes in de novo heart failure

BACKGROUND AND AIMS

Meteorin-like protein (Metrnl) has been recently suggested as a new adipokine with protective cardiovascular effects. Its circulating levels in patients seem to be associated with heart failure (HF), although with contradictory results. Our aim was to ascertain whether this adipokine could estimate the prognosis of HF in de novo HF (DNHF) patients.

METHODS

Metrnl plasma levels of 400 patients hospitalized with DNHF (55% of patients with HF with reduced ejection fraction, 17.3% HF with mid-range ejection fraction, 27.8% HF with preserved ejection fraction) were measured by enzyme-linked immunosorbent assay. We performed both sex-pooled and sex-specific analyses. A 12-month follow-up was conducted, during which clinical outcomes such as all-cause mortality, cardiovascular death and re-hospitalization due to HF were collected.

RESULTS

After a 12-month follow up, higher plasma Metrnl levels were associated with an increased risk for all-cause death and cardiovascular death after adjusting by sex, age, LVEF, hypertension, diabetes, ischemic aetiology, chronic renal failure, NT-proBNP and troponin (hazard ratio [HR] = 1.003, 95% confidence interval [CI] = 1.000-1.005; p-value<.05 and HR = 1.004, 95% CI = 1.001-1.007, p-value<.05, respectively). In line with this, DNHF patients with increased levels of circulating Metrnl had a higher number of occurrences of cardiovascular events. Regarding Metrnl associations with parameters implicated in the development and progression of HF, we found that Metrnl circulating levels were positively correlated with age (r = .322, p-value<.0001), NT-proBNP (r = .281, p-value<.0001) and with the renal dysfunction markers urea (r = .322, p-value<.0001) and creatinine (r = .353, p-value<.0001) and higher in women than men (473.7 [385.9-594.0] pg/mL vs. 428.7 [349.1-561.3] pg/mL, p-value<.006). Finally, concerning the subtype of HF, Metrnl plasma levels were higher in HF with preserved ejection fraction.

CONCLUSION

Patients with higher Metrnl levels have a worse prognosis in DNHF. Our results reinforce the association of Metrnl plasma levels with HF progression and outcomes.

In-Hospital or Out-of-Hospital Initiation of Sacubitril/Valsartan Versus Valsartan in Patients With Mildly Reduced or Preserved Ejection Fraction After A Worsening Heart Failure Event: The PARAGLIDE-HF Trial

BACKGROUND

Efficacy and tolerability of sacubitril/valsartan (Sac/Val) is not well characterized in heart failure (HF) with ejection fraction >40% initiated in-hospital. Thus, this prespecified PARAGLIDE-HF (Prospective Comparison of ARNI With ARB Given Following Stabilization In Decompensated HFpEF) analysis assessed the effects of Sac/Val versus valsartan (Val) by location of initiation in HF with ejection fraction >40% and recent worsening HF.

METHODS AND RESULTS

This analysis of the double-blind, randomized controlled trial assessed patients by in-hospital and out-of-hospital (≤30 days of worsening HF) initiation. The primary end point was time-averaged proportional change in NT-proBNP (N-terminal pro-B-type natriuretic peptide) from baseline through weeks 4 and 8. A secondary hierarchical outcome consisted of cardiovascular death, HF hospitalizations, urgent HF visits, and NT-proBNP change. Safety end points were symptomatic hypotension, hyperkalemia, and worsening renal function. Overall, 324 (70%, 162 Sac/Val, 162 Val) were initiated in-hospital and 142 (71 Sac/Val, 71 Val) out-of-hospital. There was no evidence of a statistically significant differential treatment benefit of Sac/Val versus Val on NT-proBNP change by location of initiation (in-hospital, 0.86 [95% CI, 0.70-1.05] and out-of-hospital, 0.87 [95% CI, 0.70-1.09]; Pinteraction=0.99). The win ratio for the hierarchical outcome was 1.09 (95% CI, 0.82-1.45; P=0.57) for in-hospital and 1.43 (95% CI, 0.91-2.26; P=0.12) for out-of-hospital. For the safety end points of symptomatic hypotension, hyperkalemia, and worsening renal function, no statistically significant differences in tolerability were seen between in-hospital and out-hospital initiation (Pinteraction>0.1).

CONCLUSIONS

Sac/Val provided consistent benefit compared with Val, whether initiated in-hospital or out-of-hospital in HF with ejection fraction >40% with a recent worsening HF event, demonstrating an opportunity to improve postdischarge outcomes by initiating Sac/Val during hospitalization.

Diuretic strategies in acute decompensated heart failure

Hospitalization for ADHF is linked to poor outcomes, with residual congestion at discharge significantly increasing the risk of HF readmissions and mortality. Diuretic resistance is a major contributor to inadequate decongestion during ADHF treatment. In this review, we discuss various decongestive strategies, emphasizing the management of diuretic resistance. Additionally, we examine the limitations of current decongestion trials and highlight key priorities for future research.

Hospital Variability in the Use of Vasoactive Agents in Patients Hospitalized for Acute Decompensated Heart Failure for Clinical Phenotypes

BACKGROUND

The absence of practice standards in vasoactive agent usage for acute decompensated heart failure has resulted in significant treatment variability across hospitals, potentially affecting patient outcomes. This study aimed to assess temporal trends and institutional differences in vasodilator and inotrope/vasopressor utilization among patients with acute decompensated heart failure, considering their clinical phenotypes.

METHODS

Data were extracted from a government-funded multicenter registry covering the Tokyo metropolitan area, comprising consecutive patients hospitalized in intensive/cardiovascular care units with a primary diagnosis of acute decompensated heart failure between January 2013 and December 2021. Clinical phenotypes, that is, pulmonary congestion or tissue hypoperfusion, were defined through a comprehensive assessment of clinical signs and symptoms, vital signs, and laboratory findings. We assessed the frequency and temporal trends in phenotype-based drug utilization of vasoactive agents and investigated institutional characteristics associated with adopting the phenotype-based approach using generalized linear mixed-effects models, with random intercepts to account for hospital-level variability.

RESULTS

Among 37 293 patients (median age, 80 years; 43.7% female), 88.6% and 21.2% had pulmonary congestion and tissue hypoperfusion status, respectively. Throughout the study period, both overall and phenotype-based vasodilator utilizations showed significant declines, with overall usage dropping from 61.4% in 2013 to 48.6% in 2021 (Ptrend<0.001). Conversely, no temporal changes were observed in overall inotrope/vasopressor utilization from 24.6% in 2013 to 25.8% in 2021 or the proportion of phenotype-based utilization. Notably, there was considerable variability in phenotype-based drug utilization among hospitals, with a median ranging from 48.3% to 77.8%. In multivariable-adjusted models, a higher number of board-certified cardiologists were significantly associated with lower rates of phenotype-based vasodilator utilization and reduced inappropriate inotrope/vasopressor utilization, while tertiary care hospitals were linked to more appropriate inotrope/vasopressor utilization.

CONCLUSIONS

Substantial variability existed among hospitals in phenotype-based drug utilization of vasoactive agents for patients with acute decompensated heart failure, highlighting the need for standardized treatment protocols.

REGISTRATION

URL: https://www.umin.ac.jp/ctr/index.htm; Unique identifier: UMIN000013128.

Cardio-Oncology and Heart Failure: a Scientific Statement From the Heart Failure Society of America

Heart failure and cancer remain 2 of the leading causes of morbidity and mortality, and the 2 disease entities are linked in a complex manner. Patients with cancer are at increased risk of cardiovascular complications related to the cancer therapies. The presence of cardiomyopathy or heart failure in a patient with new cancer diagnosis portends a high risk for adverse oncology and cardiovascular outcomes. With the rapid growth of cancer therapies, many of which interfere with cardiovascular homeostasis, heart failure practitioners need to be familiar with prevention, risk stratification, diagnosis, and management strategies in cardio-oncology. This Heart Failure Society of America statement addresses the complexities of heart failure care among patients with active cancer diagnoses and cancer survivors. Risk stratification, monitoring and management of cardiotoxicity are presented across stages A through D heart failure, with focused discussion on heart failure with preserved ejection fraction and special populations, such as survivors of childhood and young-adulthood cancers. We provide an overview of the shared risk factors between cancer and heart failure, highlighting heart failure as a form of cardiotoxicity associated with many different cancer therapeutics. Finally, we discuss disparities in the care of patients with cancer and cardiac disease and present a framework for a multidisciplinary-team approach and critical collaboration among heart failure, oncology, palliative care, pharmacy, and nursing teams in the management of these complex patients.

Enhancing Sweat Rate for In-Hospital and Home-Based Decongestive Therapy

BACKGROUND

The interstitial fluid compartment is disproportionally expanded in heart failure (HF). Enhancing sweat rate removes fluids and sodium directly from the interstitial compartment.

OBJECTIVES

To study the feasibility and efficacy of direct interstitial decongestion in hospitalized HF patients.

METHODS

We used a device designed to enhance fluid and salt expulsion via the eccrine sweat glands. Patients were treated for 1 to 6 days in the hospital. Following discharge, home therapy continued for 30 to 60 days (1-4 treatments/week). The primary efficacy endpoint for the in-hospital phase was a fluid loss of ≥500 mL per ≥4 hours per treatment. Secondary performance endpoints included changes in congestion score and N-terminal pro b-type natriuretic peptide (NT-proBNP) levels, evaluated for each phase separately.

RESULTS

We studied 15 patients, 12 completing both the hospital and home phases. During the in-hospital phase, median weight change due to device therapy was 2.4 kg (interquartile range [IQR] 2.20-3.77), and the primary endpoint was met in 86% of treatment sessions. During the home treatment, median weight loss was 3.1 kg (IQR 0.6 to 7.4 Kg). Congestion score declined from 6 (IQR 6-7) to 1 (IQR 1-1.5) at the end of home therapy (P = 0.002). Median NT-proBNP levels decreased from 7732 (IQR 4694-9746) to 4984 pg/mL (IQR 3559-8950, P = 0.01) during the hospital phase and to 3596 ng/mL (IQR 1640-5742, P = 0.02) at the end of home therapy.

CONCLUSION

Fluid removal via the skin is an effective strategy for enhancing decongestion in hospitalized patients with acute decompensated heart failure. Following hospital discharge, device therapy was associated with additional improvement in decongestion.

Association of non-cardiac comorbidities and sex with long-term Re-hospitalization for heart failure

Heart failure (HF) often coexists with non-cardiac comorbidities (NCC), but their association with long-term HF re-hospitalizations is not defined. Using the Lombardy Regional Health Database, that includes >10 million residents, we assessed the risk of re-hospitalization for HF after first HF discharge as a function of NCC, employing age- and sex-adjusted Cox proportional-hazard models. Kaplan Meier curves for HF re-hospitalizations were stratified for number of NCC. End of follow-up was June 30th 2021. Between January 1st 2015 to December 31st 2019, 88,528 consecutive patients were discharged from hospital with a primary diagnosis of HF; over 42.8 ± 18.3 months follow-up, 79,533 HF re-hospitalizations occurred (32.94/100 patient/year). Number of NCC, age, and male sex were significantly associated with re-hospitalization risk. Compared to those without NCC, females and males with >4 NCC had a 3.08 (CI 2.73-3.47) and a 2.62 (CI 2.39-2.87) fold higher risk, respectively. Risk of all-cause death increased with number of NCC (hazard ratio (HR): 1.42 (1.38-1.46) for HF patients with 1-2 NCC, HR: 1.90 (1.82-1.98) for patients with 3-4 NCC, HR: 2.20 (2.01-2.40) for those with HF and >4 NCC), as it did the number of days spent in hospital because of HF (from 19.91±19.25 for patients without NCC to 45.35±33.00 days for those with >4 NCC, p < 0.0001). In conclusion, this study shows that in patients hospitalized with HF, HF re-hospitalizations, all-cause mortality, and time spent in hospital increased with number of NCC. NCC associates with a worse clinical trajectory in patients with HF.

Treatment strategies for diuretic resistance in patients with heart failure

Improving congestion with diuretic therapy is crucial in the treatment of heart failure (HF). However, despite the use of loop diuretics, diuresis may be inadequate and congestion persists, which is known as diuretic resistance. Diuretic resistance and residual congestion are associated with a higher risk of rehospitalization and mortality. Causes of diuretic resistance in HF include diuretic pharmacokinetic changes, renal hemodynamic perturbations, neurohumoral activations, renal tubular remodeling, and use of nephrotoxic drugs as well as patient comorbidities. Combination diuretic therapy (CDT) has been advocated for the treatment of diuretic resistance. Thiazides, acetazolamides, tolvaptan, mineralocorticoid receptor antagonist, and sodium-glucose co-transporter-2 inhibitors are among the candidates, but none of these treatments has yet demonstrated significant diuretic efficacy or improved prognosis. At present, it is essential to identify and treat the causes of diuretic resistance in individual patients and to use CDT based on a better understanding of the characteristics of each drug to achieve adequate diuresis. Further research is needed to effectively assess and manage diuretic resistance and ultimately improve patient outcomes.

Development of a Novel Intraperitoneal Icodextrin/Dextrose Solution for Enhanced Sodium Removal

Rationale & Objective

Peritoneal dialysis (PD) solutions provide both clearance of uremic toxins and sodium and water. An intraperitoneal (IP) solution of icodextrin and glucose designed without the requirement for uremic toxin clearance could provide substantially greater sodium and water removal than PD solutions.

Study Design

We examined varying concentrations of icodextrin and dextrose IP solutions in rats. We evaluated a 30% icodextrin and 10% dextrose IP solution in animals and humans.

Participants

Small and large animal models, and humans (N = 10) with kidney failure.

Exposure

30% icodextrin and 10% dextrose IP solution.

Outcomes

We evaluated ultrafiltration (UF), sodium removal, and peritoneal health in animals. We evaluated safety, tolerability, and efficacy in humans.

Results

In rats, increasing concentrations of icodextrin and dextrose IP solutions, up to 30% icodextrin and 10% dextrose, produced progressively greater UF (P < 0.001). In sheep treated with 30% icodextrin and 10% dextrose, the mean UF was ∼3.5-fold greater (1.77 ± 0.22 L vs 0.47 ± 0.34 L; P = 0.005) and the mean sodium removal was ∼4-fold greater (7.07 ± 0.72 g vs 1.78 ± 1.27 g; P = 0.003) compared with commercially available 7.5% icodextrin PD solution. Long-term exposure of mice (30 days) and sheep (30-45 days) to a 30% icodextrin and 10% dextrose IP solution resulted in no significant structural tissue changes compared with the control 4.25% commercially available PD solution. In humans, a 24-hour dwell of a 30% icodextrin and 10% dextrose IP solution resulted in median net UF of 2,498 mL (IQR, 2,249-2,768), and median sodium removal of 387 mmol (IQR, 372-434 mmol). No serious adverse events occurred.

Limitations

The long-term safety with chronic therapy and the efficacy in patients without kidney failure were not established and require future studies.

Conclusions

A 30% icodextrin and 10% dextrose IP solution provides more efficient UF and sodium removal than traditional PD solutions. The promising inhuman safety and efficacy results warrant future investigation as a sodium removal therapy in patients with edematous disorders such as heart failure.

Clinical Trial Registration

NCT05780086.

Summary

We aimed to design a novel intraperitoneal solution designed for optimal sodium and water removal. A sodium-free 30% icodextrin and 10% dextrose intraperitoneal solution was evaluated in animal models and humans to determine the safety and efficacy. A 30% icodextrin and 10% dextrose solution provides more efficient sodium and water removal than traditional peritoneal dialysis solutions. The promising inhuman safety and efficacy results warrant future investigation as a sodium removal therapy in patients with edematous disorders such as heart failure.

Changes in Medication Complexity and Post-Hospitalization Outcomes in Older Adults Hospitalized for Heart Failure

INTRODUCTION

Medication regimen complexity may be an important risk factor for adverse outcomes in older adults with heart failure. However, increasing complexity is often necessary when prescribing guideline-directed medical therapy at the time of a heart failure hospitalization. We sought to determine whether increased medication regimen complexity following a heart failure hospitalization was associated with worse post-hospitalization outcomes.

METHODS

This retrospective cohort study included Reasons for Geographic and Racial Differences in Stroke (REGARDS) participants aged at least 65 years hospitalized for heart failure between 2003 and 2014. We calculated changes between hospital admission and discharge in medication count (Δcount) and in the validated Medication Regimen Complexity Index (ΔMRCI), which incorporates each medication's dosage formulation, frequency, timing, and special instructions. The primary outcome was a composite of 90-day all-cause readmission and all-cause mortality post-discharge. We calculated ΔMRCI and Δcount, identified their predictors, and examined their association with the primary outcome.

RESULTS

Among 725 patients hospitalized for heart failure, the mean (SD) age was 77 (7.2) years, 46% were female, and 35% were Black. At discharge, nearly 75% had an increase in their medication regimen complexity and 60% had an increase in their medication count. Patients with the highest ΔMRCI and Δcount were more likely to be female and Black. Predictors of the highest ΔMRCI included Charlson comorbidity index and not being discharged home; predictors of the highest Δcount included intensive care unit stay. Approximately 48% of patients experienced a 90-day readmission or death. Neither ΔMRCI (highest versus lowest tertile; HR 1.14, 95% CI 0.86, 1.50) nor Δcount (HR 0.97, 95% CI 0.73, 1.27) were associated with 90-day outcomes.

CONCLUSION

Following a heart failure hospitalization, increased medication regimen complexity was common but was not associated with 90-day post-hospitalization outcomes. These are reassuring data, suggesting that it is reasonable for clinicians to focus on optimizing medication regimens for patients with heart failure even if it increases regimen complexity.

Association between oral loop diuretics duration before discharge and hospital readmission in acute decompensated heart failure: A multicenter retrospective cohort study

There are uncertainties when to start patients on oral loop diuretics after managing acute decompensated heart failure (ADHF) before discharge. This study aims to investigate the impact of prolonging observation duration on hospital readmissions following the switch to oral loop diuretics before discharge in patients with ADHF. A multicenter retrospective study that included adult patients (>18 years) diagnosed with ADHF and discharged on oral loop diuretics in Saudi Arabia. Patients who received oral loop diuretics were divided into 2 groups based on the observation duration before discharge. The primary outcome was a 30-day readmission rate for all causes; the secondary outcomes were 60- and 90-day readmission rates for all causes; and 30-, 60-, and 90-day readmission rates for heart failure. A total of 400 ADHF patients were included in the final analysis. Patients in group 1 (n = 142; < 24 hours) and group 2 (n = 258; ≥ 24 hours) had similar baseline characteristics (P > .05), except for the length of hospital stay (P = .03) and total observation time (P  = <.01). ADHF patients with <24 hours observation durations were significantly associated with higher all-cause 30-day readmissions compared to those with ≥24 hours observations (odds ratio = 1.83, 95% confidence interval = 1.11-3.02, P = .017). Our study showed a significant decrease in all-cause 30-day readmissions for ADHF patients who received oral loop diuretics at discharge with a longer duration of observation. This study emphasizes the significance of standardizing the observational period when initiating oral loop diuretics before discharge following admission to ADHF.

Time to intravenous diuretic administration in patients hospitalized with heart failure: An observational study

AIMS

To help establish optimized treatment strategies for congestion in patients with acute heart failure, this study aimed to provide a detailed summary of real-world diuretic use in hospitalized patients with heart failure requiring urgent therapy in Japan.

METHODS AND RESULTS

This observational study used a Japanese medical records database to extract data of patients admitted to hospital with a heart failure diagnosis and an intravenous diuretic prescription from the day before admission to 2 days after. Time from hospital visit to first dose, second dose, and maximum dose of intravenous diuretics were determined. Patients were grouped according to whether they received diuretic modification, defined as an intravenous diuretic dose increase or concomitant use of other diuretics.

RESULTS

Overall, 1577 patients were included in the study (without diuretic modification, n = 1140 [72.3%]; with diuretic modification, n = 437 [27.7%]). The study population was 49.5% female (n = 780) and the mean age ± standard deviation was 80.1 ± 12.7 years. Intravenous diuretic treatment was received within 1 h of their hospital visit in 43.5% of patients (686/1577) and ≤2 h in 16.4% of patients (258/1577). Among 437 patients with an inadequate response following their first dose, 42.1% received an intravenous dose titration, 56.5% received combination diuretics, and 1.4% received both. Over half of the patients (59.0% [258/437]) with diuretic modification received it after the first 24 h of the hospital visit. The median time from hospital visit to first dose titration was similar to time to first combination diuretic use (18.6 h and 17.0 h, respectively). The mean ± standard deviation duration of intravenous diuretic use was significantly longer for patients with versus without diuretic modification (6.3 ± 5.2 vs. 3.7 ± 3.2 days), and a significantly greater proportion of patients (44.6% [195/437] vs. 35.0% [399/1140]) received repeated intravenous diuretic administration. Other characteristics/outcomes of intravenous diuretic use were similar with versus without diuretic modification, including in-hospital death (15.6% [68/437] vs. 13.9% [159/1140]) and mean ± standard deviation length of hospitalization (21.9 ± 14.7 days vs. 22.1 ± 21.2 days).

CONCLUSIONS

In Japan, real-world patterns of intravenous diuretic administration for patients with heart failure remains far from the time-sensitive approach recommended in Japanese, European, and United States guidelines.

Post-Discharge Self-Care Confidence and Performance Levels in Patients Hospitalized due to Heart Failure

BACKGROUND

Multidisciplinary self-care education plays a critical role in ensuring the high-quality transitional care of patients hospitalized due to heart failure (HF). However, whether confidence concerning self-care during their index hospitalizations would influence their post-discharge self-care performances and long-term outcomes remains uncertain.

METHODS

We conducted an assessment of 100 consecutive patients with HF who completed self-care questionnaires both during their hospitalizations and 1 year after discharge. Among these patients hospitalized due to HF, self-care confidence was assessed immediately after they completed their pre-discharge education program. One year after the index hospitalization, we evaluated self-care performance by using the European Heart Failure Self-care Behavior Scale. Logistic regression analysis was employed to identify determinants of poor self-care behavior 1 year after the hospitalization. Additionally, the Cox proportional hazards model with adjustment for the Seattle Heart Failure Model was applied to assess their association with 2-year mortality and readmission risk.

RESULTS

The enrolled patients predominantly had HF with reduced ejection fraction (43.0%), and approximately half of the patients had experienced a previous hospitalization due to HF (47.0%). The 3 worst-performing aspects of post-discharge self-care behavior (among the 12 items) were appropriate consultation for fatigue (40.0%), weight gain (52.0%) and application of regular exercise (57.0%). After adjustment, low self-care confidence during the index hospitalization was associated with poor post-discharge self-care performance (OR: 1.11, CI: 1.00-1.21). Poor post-discharge self-care behavior was not associated with worse prognoses over a 2-year follow-up (hazard ratio [HR]: 1.82, CI: 0.85-3.86); however, the association was significant in patients with reduced ejection fraction (HR: 4.04, CI: 1.17-13.89) and previous HF hospitalization (HR: 3.66, CI: 1.46-9.13).

CONCLUSIONS

Post-discharge self-care performance was associated with self-care confidence during the index HF hospitalization. Effective measures that improve pre-discharge confidence levels in self-care should be considered to enhance the quality of transitional care.

Effect of basic activities of daily living independence on home discharge and long-term outcomes in patients hospitalized with heart failure

Patients hospitalized for heart failure (HF) experience impairments in functional status, primarily affecting basic activities of daily living (ADL). We investigated the independent effect of functional status for ADL on patient-centered outcomes (i.e., home discharge) and conventional clinical outcomes in HF. We analyzed 2936 consecutive hospitalized patients with HF from a prospective multicenter registry. The functional status of ADL was assessed before discharge by using the Barthel index (BI). Patients were categorized into the lower BI group (≤85; the lowest tertile) and higher BI group (>85). We evaluated the risk-adjusted association between BI and non-home discharge, as well as the two-year all-cause mortality. Exploratory subgroups included patients categorized by age, sex, HF hospitalization, left ventricular ejection fraction, body mass index, and estimated glomerular filtration rate (eGFR). Of the participants (age: 79 [69-85] years; 41.1% women), 86.3% were discharged home. A lower BI was independently associated with non-home discharge (OR: 5.12, 95% CI 3.86-6.80) and higher all-cause mortality rates (HR: 1.96, 95% CI 1.58-2.45). Two-year cardiac and non-cardiac mortality rates were higher in the lower BI group; however, the proportion of cardiac causes in two-year deaths did not differ between the lower and higher BI groups (48.8% vs. 49.5%, P = 0.891). Subgroup analyses consistently demonstrated an association between two-year mortality and lower BI; however, this association was stronger among patients with a higher eGFR (P-value for interaction = 0.004). A lower BI was independently associated with non-home discharge and higher mortality rates because of cardiac- and non-cardiac-related causes in hospitalized patients with HF.

Effects of Implementing a Heart Failure Order Set to Optimize Guideline-Directed Medical Therapy and Diuresis in Patients with Acute Heart Failure

Background: Utilization of guideline-directed medical therapy in patients hospitalized for acute heart failure is suboptimal during the hospitalization and after discharge. An inpatient heart failure order set may be a convenient and useful intervention to improve heart failure therapy in the inpatient setting. Methods: This is a retrospective study that assessed the use of an inpatient heart failure order set on pharmacologic therapy in patients hospitalized for acute heart failure from May to August 2022. Patients with heart failure with an ejection fraction less than 50% were included in the analysis. The co-primary endpoints were maintenance or optimization of guideline-directed medical therapy during the hospitalization. Results: Maintenance of guideline-directed medical therapy was significantly greater when providers used the heart failure order set (OR 2.35, 95% CI 1.03-5.33, P = .041). Optimization of guideline-directed medical therapy was also statistically greater with use of the order set (OR 11.31, 95% CI 4.37-29.31, P < .001). Conclusions: An inpatient heart failure order set may be an effective strategy to improve heart failure pharmacotherapy in patients hospitalized with acute heart failure.

Inferior vena CAVA and lung ultraSound-guided therapy in acute heart failure: A randomized pilot study (CAVAL US-AHF study)

BACKGROUND

The optimal assessment of systemic and lung decongestion during acute heart failure is not clearly defined. We evaluated whether inferior vena cava (IVC) and pulmonary ultrasound (CAVAL US) guided therapy is superior to standard care in reducing subclinical congestion at discharge in patients with AHF.

METHODS

CAVAL US-AHF was an investigator-initiated, single-center, single-blind, randomized controlled trial. A daily quantitative ultrasound protocol using the 8-zone method was used and treatment was adjusted according to an algorithm. The primary endpoint was the presence of more than 5 B-lines and/or an increase in IVC diameter and collapsibility at discharge. And secondary endpoint exploratory outcome was the composite of readmission for HF, unplanned visit for worsening HF or death at 90 days RESULTS: Sixty patients were randomized to CAVAL US (n = 30) or control (n = 30). The primary endpoint was achieved in 4 patients (13.3%) in the CAVAL US group and 20 patients (66.6%) in the control group (P < .001). A significant reduction in HF readmission, unplanned visit for worsening HF or death at 90 days was seen in the CAVAL US group (13.3% vs 36.7%; log rank P = .038). Other endpoints such as NT-proBNP reduction at discharge showed a nonstatistically significant reduction in the CAVAL US group (48% IQR 27-67 vs 37% -3-59; P = .09). Safety outcomes were similar in both groups.

CONCLUSION

IVC and lung ultrasound-guided therapy in AHF patients significantly reduced subclinical congestion at discharge. CAVAL US-AHF provides preliminary evidence for the potential use of a simple technique to guide decongestive therapy during hospitalization for AHF, which may reduce the composite outcome at 90 days.

The utility of urine sodium-guided diuresis during acute decompensated heart failure

Diuresis to achieve decongestion is a central aim of therapy in patients hospitalized for acute decompensated heart failure (ADHF). While multiple approaches have been tried to achieve adequate decongestion rapidly while minimizing adverse effects, no single diuretic strategy has shown superiority, and there is a paucity of data and guidelines to utilize in making these decisions. Observational cohort studies have shown associations between urine sodium excretion and outcomes after hospitalization for ADHF. Urine chemistries (urine sodium ± urine creatinine) may guide diuretic titration during ADHF, and multiple randomized clinical trials have been designed to compare a strategy of urine chemistry-guided diuresis to usual care. This review will summarize current literature for diuretic monitoring and titration strategies, outline evidence gaps, and describe the recently completed and ongoing clinical trials to address these gaps in patients with ADHF with a particular focus on the utility of urine sodium-guided strategies.

Metolazone Versus Chlorothiazide in Acute Heart Failure Patients With Diuretic Resistance and Renal Dysfunction: A Retrospective Cohort Study

ABSTRACT

Guidelines recommend intravenous loop diuretics as first-line therapy for patients hospitalized with acute heart failure (AHF) and volume overload. Additional agents can be used for augmentation, but there is limited guidance on agent selection. The study objective was to determine if chlorothiazide or metolazone is associated with differences in diuretic efficacy or safety in loop diuretic-resistant patients with AHF and renal dysfunction (eGFR <45 mL/min/1.73 m²). We conducted a multicenter, retrospective cohort study of patients hospitalized with AHF and renal dysfunction who received metolazone or chlorothiazide in addition to intravenous loop diuretics. The primary end point was a comparison of 24-hour urine output (UOP) between the 24 hours before and after thiazide administration. Secondary and safety end points included weight change, requirement for vasopressors or inotropes, electrolyte abnormalities, and changes in renal function. A total of 221 patients were included. The mean daily diuretic doses were chlorothiazide 632 mg and metolazone 7 mg. The mean 24-hour UOP increased more among chlorothiazide-treated (from 1668 mL to 3826 mL) versus metolazone-treated patients (from 1672 mL to 2834 mL) ( P < 0.001) after the addition of the second diuretic. Statistically significant reductions in serum creatinine were observed in the chlorothiazide group following 72 hours of treatment ( P = 0.016). More hypomagnesemia was observed in the chlorothiazide group; no differences in other electrolytes or changes in weight were observed. Overall, chlorothiazide was associated with a greater increase in 24-hour UOP than metolazone without an excess of potassium or serum creatinine derangements. However, weight changes did not differ significantly between groups. Future prospective studies are needed to confirm potential differences in diuretic response and safety.

Feasibility of self-measurement telemonitoring using a handheld heart sound recorder in patients with heart failure - SELPH multicenter pilot study

BACKGROUND

Multi-parametric assessment, including heart sounds in addition to conventional parameters, may enhance the efficacy of noninvasive telemonitoring for heart failure (HF). We sought to assess the feasibility of self-telemonitoring with multiple devices including a handheld heart sound recorder and its association with clinical events in patients with HF.

METHODS

Ambulatory HF patients recorded their own heart sounds, mono‑lead electrocardiograms, oxygen saturation, body weight, and vital signs using multiple devices every morning for six months.

RESULTS

In the 77 patients enrolled (63 ± 13 years old, 84 % male), daily measurements were feasible with a self-measurement rate of >70 % of days in 75 % of patients. Younger age and higher Minnesota Living with Heart Failure Questionnaire scores were independently associated with lower adherence (p = 0.002 and 0.027, respectively). A usability questionnaire showed that 87 % of patients felt self-telemonitoring was helpful, and 96 % could use the devices without routine cohabitant support. Six patients experienced ten HF events of re-hospitalization and/or unplanned hospital visits due to HF. In patients who experienced HF events, a significant increase in heart rate and diastolic blood pressure and a decrease in the time interval from Q wave onset to the second heart sound were observed 7 days before the events compared with those without HF events.

CONCLUSIONS

Self-telemonitoring with multiple devices including a handheld heart sound recorder was feasible even in elderly patients with HF. This intervention may confer a sense of relief to patients and enable monitoring of physiological parameters that could be valuable in detecting the deterioration of HF.

Thoracic Fluid Content as an Indicator of High Intravenous Diuretic Requirements in Hospitalized Patients with Decompensated Heart Failure

Background: The main cause of hospitalization in patients with heart failure is hypervolemia. Therefore, the primary treatment strategy involves diuretic therapy using intravenous loop diuretics to achieve decongestion and euvolemia. Some patients with acutely decompensated heart failure (ADHF) do not respond well to diuretic treatment, which may be due to diuretic resistance (DR). Such cases require high doses of diuretic medications and combination therapy with diuretics of different mechanisms of action. Although certain predisposing factors for diuretic resistance have been identified (such as hypotension, type 2 diabetes, impaired renal function, and hyponatremia), further research is needed to identify other pathophysiological markers of DR. Objective: This study aims to identify admission markers that can predict a high requirement for intravenous diuretics in hospitalized patients with decompensated heart failure. Methods: This study included 102 adult patients hospitalized for ADHF. At admission, patients underwent clinical assessment, laboratory parameter evaluation (including the N-terminal prohormone of brain natriuretic peptide [NT-proBNP] levels), and hemodynamic assessment using impedance cardiography (ICG). Hemodynamic profiles were based on the use of parameters such as heart rate (HR), blood pressure (BP), and thoracic fluid content (TFC) as markers of volume status. The analysis included 97 patients with documented doses of intravenous diuretic use. Patients were stratified into two groups based on median diuretic consumption (equivalent to 540 mg of intravenous furosemide): the high-loop diuretic utilization (LDU) group (n = 49) and the low-LDU group (n = 48). Results: Compared to low-LDU patients, high-LDU patients had greater thoracic fluid content at admission, both quantitatively (37.4 ± 8.1 vs. 34.1 ± 6.9 kOhm-1; p = 0.024) and qualitatively (TFC ≥ 35 kOhm-1: 59.2% vs. 33.3%; p = 0.011). Anemia was more common in the high-LDU group (67.4% vs. 43.8%; p = 0.019), as was elevated NT-proBNP (≥median of 3952 pg/mL: 60.4% vs. 37.5%; p = 0.024). High LDU was associated with a significantly longer hospitalization duration (12.9 ± 6.4 vs. 7.0 ± 2.6 days; p < 0.001). Logistic regression analysis identified anemia, elevated NT-proBNP, and high TFC as predictors of high LDU (HR: 2.65, 2.54, and 2.90, respectively). In a multifactorial model, only high TFC remained an independent predictor (HR: 2.60, 95% CI 1.04-6.49; p = 0.038). Conclusions: TFC was the sole independent admission marker of a high requirement for intravenous diuretics in patients hospitalized for decompensated heart failure. An objective assessment of volume status by impedance cardiography may support intensive personalized decongestion therapy.

Effects of Sotagliflozin on Health Status in Patients With Worsening Heart Failure: Results From SOLOIST-WHF

BACKGROUND

Sodium-glucose cotransporter 2 (SGLT2) inhibitors improve health status in heart failure (HF) across the left ejection fraction ejection spectrum. However, the effects of SGLT1 and SGLT2 inhibition on health status are unknown.

OBJECTIVES

These prespecified analyses of the SOLOIST-WHF (Effect of Sotagliflozin on Cardiovascular Events in Patients with Type 2 Diabetes Post Worsening Heart Failure) trial examined the effects of sotagliflozin vs placebo on HF-related health status.

METHODS

SOLOIST-WHF randomized patients hospitalized or recently discharged after a worsening HF episode to receive sotagliflozin or placebo. The primary endpoint was total number of HF hospitalizations, urgent HF visits, and cardiovascular death. Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) score was a prespecified secondary endpoint. This analysis evaluated change in the KCCQ-12 score from baseline to month 4.

RESULTS

Of 1,222 patients randomized, 1,113 (91%) had complete KCCQ-12 data at baseline and 4 months. The baseline KCCQ-12 score was low overall (median: 41.7; Q1-Q3: 27.1-58.3) and improved by 4 months in both groups. Sotagliflozin vs placebo reduced the risk of the primary endpoint consistently across KCCQ-12 tertiles (Ptrend = 0.54). Sotagliflozin-treated patients vs those receiving placebo experienced modest improvement in KCCQ-12 at 4 months (adjusted mean change: 4.1 points; 95% CI: 1.3-7.0 points; P = 0.005). KCCQ-12 improvements were consistent across prespecified subgroups, including left ventricular ejection fraction <50% or ≥50%. More patients receiving sotagliflozin vs those receiving placebo had at least small (≥5 points) improvements in KCCQ-12 at 4 months (OR: 1.38; 95% CI: 1.06-1.80; P = 0.017).

CONCLUSIONS

Sotagliflozin improved symptoms, physical limitations, and quality of life within 4 months after worsening HF, with consistent benefits across baseline demographic and clinical characteristics. (Effect of Sotagliflozin on Cardiovascular Events in Participants With Type 2 Diabetes Post Worsening Heart Failure [SOLOIST-WHF]; NCT03521934).

Propelling Nurse-Led Structured Intervention to Enhance Self-Care among Patients with Chronic Heart Failure (PROACT-HF): A Cluster Randomized Controlled Trial Study Protocol

BACKGROUND

Heart Failure (HF) is a common chronic disease that has a high readmission rate and is associated with worsening symptoms and major financial impacts. Disease management implemented during or after an HF hospitalization has been shown to reduce hospitalization and mortality rates. Particularly for outpatients, it is necessary to provide self-care interventions. Structured nurse-led support such as timely follow-ups, including phone calls, is beneficial for improving self-care assessments. Evidence for nurse-led support has been investigated but is less than conclusive. The aim of this study is to compare the effectiveness of a nurse-led structured intervention for outpatients with chronic HF against the usual medical care in terms of self-care behaviors and occurrence of symptom exacerbation or rehospitalization.

METHODS AND ANALYSIS

This is a cluster-randomized controlled trial. A total of 40 facilities with certified HF nurses will be allocated to two-arm clusters at a 1:1 ratio, randomly to the intervention or usual care arms. A total of 210 participants will be assigned from the hospital. Participants will be adults aged 18 years or older diagnosed with chronic HF who are classified as Stage C according to the ACCF/AHA Heart Failure staging system. In the intervention group, patients will receive structured nursing support. This begins with weekly support, including phone calls, for the first month, then transitions to monthly support thereafter. The aim is to ensure the stability of their living conditions, promote medication adherence, and encourage self-management. In the control group, patients will receive the usual care. Primary outcomes will assess the improvement or continuation of self-care behavior as measured by changes in EHFScBS (European Heart Failure Self-Care Behavior Scale) scores. Secondary outcomes include occurrence of readmission within 30 days, 3 months, 6 months, and 1 year after discharge, duration of home care until readmission, and blood levels of BNP and NT-proBNP.

Comparison of Colchicine Monotherapy Versus Nonsteroidal Anti-Inflammatory Drugs Monotherapy or Combination Therapy for the Prevention of Recurrent Pericarditis in Patients With Heart Failure With Reduced Ejection Fraction and/or Coronary Artery Disease

Objective: Guidelines recommend nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin for 2-4 weeks with colchicine for 3 months for the treatment of acute pericarditis. In patients with HFrEF and/or CAD, the adverse effect profile of NSAIDs pose concern. While previous studies evaluated colchicine as adjunctive therapy, colchicine monotherapy has never been assessed. This study aims to compare the efficacy of colchicine monotherapy to NSAID monotherapy or combination therapy for the prevention of recurrent pericarditis in patients with HFrEF and/or CAD. Methods: This was a single health-system, retrospective, observational cohort study. Patients were 18 years or older, had a diagnosis of acute pericarditis and HFrEF and/or CAD, and were discharged on colchicine and/or NSAID therapy. Patients were excluded if they had an episode of pericarditis within the previous 12 months. The primary outcome was the incidence of pericarditis recurrence or documentation of incessant symptoms within 12 months of the index hospitalization. Results: Of the 77 patients included, 43 (55.8%) were treated with colchicine monotherapy, 7 (9.1%) were treated with NSAID monotherapy, and 27 (35.1%) were treated with combination therapy. Pericarditis recurrence or documentation of incessant symptoms occurred in 16.3% of patients treated with colchicine monotherapy, 28.6% of those treated with NSAID monotherapy, and 18.5% of those treated with combination therapy (P = .740). Conclusion: In this study, no difference in the primary outcome was observed between groups. However, a prospective, randomized trial is needed to further elucidate the efficacy of colchicine monotherapy for the treatment of acute pericarditis in patients with HFrEF and/or CAD.

Representativeness of the PIONEER-HF and PARAGLIDE-HF in patients hospitalized with acute heart failure

AIMS

The PIONEER-HF and PARAGLIDE-HF trials aimed to determine the efficacy and safety of the in-hospital initiation of sacubitril/valsartan in patients hospitalized for AHF. However, whether the inclusion and exclusion criteria of the trials apply to patients encountered in real-world routine care is unclear. This study aimed to investigate the applicability of the PIONEER-HF and PARAGLIDE-HF trials to real-world AHF patients.

METHODS AND RESULTS

We identified 28 293 AHF hospitalized patients between August 2008 to August 2017 from the Chang Gung Research Database and classified them into four groups based on left ventricular ejection fraction (LVEF) and trial criteria. Cox proportional hazards models were used to compare the risk of HF hospitalization and cardiovascular (CV) death. We defined PIONEER-HF eligible (n = 3683) and non-eligible (n = 3502) patients with an LVEF ≤40%, and PARAGLIDE-HF eligible (n = 5191) and non-eligible (n = 5832) patients with an LVEF >40%. Over a mean follow-up of 3.5 years, the PIONEER-HF non-eligible and eligible groups exhibited similar rates of HF hospitalization and CV death (41.1% vs. 41.8%, adjusted hazard ratio [aHR]: 0.95; 95% CI: 0.88-1.04). No significant difference was found in the composite outcome between PARAGLIDE-HF non-eligible and eligible groups (36.7% vs. 38.6%; aHR: 0.97; 95% CI: 0.90-1.04).

CONCLUSIONS

Using trial criteria, only 31.3% of AHF patients were eligible for sacubitril-valsartan. Yet, non-eligible patients demonstrated similar outcomes to eligible patients, indicating a need for further evaluation of sacubitril-valsartan benefits in non-eligible AHF patients.

Applications of 3D Printing Technology in Diagnosis and Management of Heart Failure

Purpose of Review

3D printing (3DP) technology has emerged as a valuable tool for surgeons and cardiovascular interventionalists in developing and tailoring patient-specific treatment strategies, especially in complex and rare cases. This short review covers advances, primarily in the last three years, in the use of 3DP in the diagnosis and management of heart failure and related cardiovascular conditions.

Recent Findings

Latest studies include utilization of 3DP in ventricular assist device placement, congenital heart disease identification and treatment, pre-operative planning and management in hypertrophic cardiomyopathy, clinician as well as patient education, and benchtop mock circulatory loops.

Summary

Studies reported benefits for patients including significantly reduced operation time, potential for lower radiation exposure, shorter mechanical ventilation times, lower intraoperative blood loss, and less total hospitalization time, as a result of the use of 3DP. As 3DP technology continues to evolve, clinicians, basic science researchers, engineers, and regulatory authorities must collaborate closely to optimize the utilization of 3D printing technology in the diagnosis and management of heart failure.

Optimising Transitional Care Following a Heart Failure Hospitalisation in Australia

Hospitalisations for heart failure (HF) are associated with high rates of readmission and death, the most vulnerable period being within the first few weeks post-hospital discharge. Effective transition of care from hospital to community settings for patients with HF can help reduce readmission and mortality over the vulnerable period, and improve long-term outcomes for patients, their family or carers, and the healthcare system. Planning and communication underpin a seamless transition of care, by ensuring that the changes to patients' management initiated in hospital continue to be implemented following discharge and in the long term. This evidence-based guide, developed by a multidisciplinary group of Australian experts in HF, discusses best practice for achieving appropriate and effective transition of patients hospitalised with HF to community care in the Australian setting. It provides guidance on key factors to address before and after hospital discharge, as well as practical tools that can be used to facilitate a smooth transition of care.

Prognostic impact of residual pulmonary congestion assessed by remote dielectric sensing system in patients admitted for heart failure

AIMS

Remote dielectric sensing (ReDS) represents a contemporary non-invasive technique reliant on electromagnetic energy to quantify pulmonary congestion. Its prognostic significance within the context of heart failure (HF) patients remains elusive. This study aimed to assess the prognostic implications of residual pulmonary congestion, as gauged by the ReDS system, among patients admitted due to congestive HF.

METHODS AND RESULTS

We enrolled hospitalized HF patients who underwent ReDS assessments upon admission and discharge in a blinded manner, independent of attending physicians. We evaluated the prognostic impact of the ReDS ratio between admission and discharge on the primary outcome, which encompassed all-cause mortality and HF-related re-hospitalizations. A cohort of 133 patients (median age 78 [72, 84] years, 78 male [59%]) was included. Over a median observation period of 363 days post-index discharge, an escalated ReDS group (ReDS ratio > 100%), determined through statistical calculation, emerged as an independent predictor of the primary outcome, exhibiting an adjusted hazard ratio of 4.37 (95% confidence interval 1.13-16.81, P = 0.032). The cumulative incidence of the primary outcome was notably higher in the increased ReDS group compared with the decreased ReDS group (50.1% vs. 8.5%, P = 0.034).

CONCLUSIONS

Elevated ReDS ratios detected during the index hospitalization could serve as a promising prognostic indicator in HF patients admitted for treatment. The clinical ramifications of ReDS-guided HF management warrant validation in subsequent studies.

Diagnostic and predictive abilities of myokines in patients with heart failure

Myokines are defined as a heterogenic group of numerous cytokines, peptides and metabolic derivates, which are expressed, synthesized, produced, and released by skeletal myocytes and myocardial cells and exert either auto- and paracrine, or endocrine effects. Previous studies revealed that myokines play a pivotal role in mutual communications between skeletal muscles, myocardium and remote organs, such as brain, vasculature, bone, liver, pancreas, white adipose tissue, gut, and skin. Despite several myokines exert complete divorced biological effects mainly in regulation of skeletal muscle hypertrophy, residential cells differentiation, neovascularization/angiogenesis, vascular integrity, endothelial function, inflammation and apoptosis/necrosis, attenuating ischemia/hypoxia and tissue protection, tumor growth and malignance, for other occasions, their predominant effects affect energy homeostasis, glucose and lipid metabolism, adiposity, muscle training adaptation and food behavior. Last decade had been identified 250 more myokines, which have been investigating for many years further as either biomarkers or targets for heart failure management. However, only few myokines have been allocated to a promising tool for monitoring adverse cardiac remodeling, ischemia/hypoxia-related target-organ dysfunction, microvascular inflammation, sarcopenia/myopathy and prediction for poor clinical outcomes among patients with HF. This we concentrate on some most plausible myokines, such as myostatin, myonectin, brain-derived neurotrophic factor, muslin, fibroblast growth factor 21, irisin, leukemia inhibitory factor, developmental endothelial locus-1, interleukin-6, nerve growth factor and insulin-like growth factor-1, which are suggested to be useful biomarkers for HF development and progression.

Transcriptomic and spatial dissection of human ex vivo right atrial tissue reveals proinflammatory microvascular changes in ischemic heart disease

Cardiovascular disease plays a central role in the electrical and structural remodeling of the right atrium, predisposing to arrhythmias, heart failure, and sudden death. Here, we dissect with single-nuclei RNA sequencing (snRNA-seq) and spatial transcriptomics the gene expression changes in the human ex vivo right atrial tissue and pericardial fluid in ischemic heart disease, myocardial infarction, and ischemic and non-ischemic heart failure using asymptomatic patients with valvular disease who undergo preventive surgery as the control group. We reveal substantial differences in disease-associated gene expression in all cell types, collectively suggesting inflammatory microvascular dysfunction and changes in the right atrial tissue composition as the valvular and vascular diseases progress into heart failure. The data collectively suggest that investigation of human cardiovascular disease should expand to all functionally important parts of the heart, which may help us to identify mechanisms promoting more severe types of the disease.

Establishment of in-hospital nutrition support program for middle-aged and elderly patients with acute decompendated heart failure

OBJECTIVE

To construct a nutrition support program for middle-aged and elderly patients with acute decompensated heart failure (ADHF) during hospitalization.

METHODS

Based on the JBI Evidence-Based Health Care Model as the theoretical framework, the best evidence was extracted through literature analysis and a preliminary nutrition support plan for middle-aged and elderly ADHF patients during hospitalization was formed. Two rounds of expert opinion consultation were conducted using the Delphi method. The indicators were modified, supplemented and reduced according to the expert's scoring and feedback, and the expert scoring was calculated.

RESULTS

The response rates of the experts in the two rounds of consultation were 86.7% and 100%, respectively, and the coefficient of variation (CV) for each round was between 0.00% and 29.67% (all < 0.25). In the first round of expert consultation, 4 items were modified, 3 items were deleted, and 3 items were added. In the second round of the expert consultation, one item was deleted and one item was modified. Through two rounds of expert consultation, expert consensus was reached and a nutrition support plan for ADHF patients was finally formed, including 4 first-level indicators, 7 s-level indicators, and 24 third-level indicators.

CONCLUSION

The nutrition support program constructed in this study for middle-aged and elderly ADHF patients during hospitalization is authoritative, scientific and practical, and provides a theoretical basis for clinical development of nutrition support program for middle-aged and elderly ADHF patients during hospitalization.

Acute Heart Failure: From The Emergency Department to the Intensive Care Unit

Acute heart failure (AHF) is a frequent cause of hospitalization around the world and is associated with high in-hospital and post-discharge morbidity and mortality. This review summarizes data on diagnosis and management of AHF from the emergency department to the intensive care unit. While more evidence is needed to guide risk stratification and care of patients with AHF, hospitalization is a key opportunity to optimize evidence-based medical therapy for heart failure. Close linkage to outpatient care is essential to improve post-hospitalization outcomes.

Carbohydrate Antigen 125 (CA 125): A Novel Biomarker in Acute Heart Failure

BACKGROUND

Heart failure is a global major healthcare problem with millions of hospitalizations annually and with a very high mortality. There is an increased interest in finding new and reliable biomarkers for the diagnostic, prognostic and therapeutic guidance of patients hospitalized for acute heart failure; Our review aims to summarize in an easy-to-follow flow recent relevant research evaluating the possible use and the clinical value of measuring CA 125 serum levels in acute HF.

METHODS

A thorough search in the main international databases identified a relevant pool of 170 articles, providing recently published data for this narrative review that used PRISMA guidelines.

RESULTS

There are data to sustain the role of carbohydrate antigen 125 (CA 125), a worldwide used marker of ovarian cancer, in patients with heart failure. Several studies have shown links between CA 125 levels and congestion seen in acute heart failure, high mortality and readmission rates at 6 months follow-up after discharge from acute heart failure and also a role of CA 125 in the guidance of heart failure therapy. There are also clinical trials that showed that several particularities of CA 125 make it even better than N-terminal pro b-type natriuretic peptide (NT-pro BNP)-a classical and more utilized marker of heart failure) in several scenarios of acute heart failure.

CONCLUSIONS

Although the mechanism behind the upregulation of serum CA 125 in patients with congestive HF has not been confirmed nor fully understood.

Efficacy and Safety of Dapagliflozin in Patients With Acute Heart Failure

BACKGROUND

The primary goals during acute heart failure (AHF) hospitalization are decongestion and guideline-directed medical therapy (GDMT) optimization. Unlike diuretics or other GDMT, early dapagliflozin initiation could achieve both AHF goals.

OBJECTIVES

The authors aimed to assess the diuretic efficacy and safety of early dapagliflozin initiation in AHF.

METHODS

In a multicenter, open-label study, 240 patients were randomized within 24 hours of hospital presentation for hypervolemic AHF to dapagliflozin 10 mg once daily or structured usual care with protocolized diuretic titration until day 5 or hospital discharge. The primary outcome, diuretic efficiency expressed as cumulative weight change per cumulative loop diuretic dose, was compared across treatment assignment using a proportional odds model adjusted for baseline weight. Secondary and safety outcomes were adjudicated by a blinded committee.

RESULTS

For diuretic efficiency, there was no difference between dapagliflozin and usual care (OR: 0.65; 95% CI: 0.41-1.02; P = 0.06). Dapagliflozin was associated with reduced loop diuretic doses (560 mg [Q1-Q3: 260-1,150 mg] vs 800 mg [Q1-Q3: 380-1,715 mg]; P = 0.006) and fewer intravenous diuretic up-titrations (P ≤ 0.05) to achieve equivalent weight loss as usual care. Early dapagliflozin initiation did not increase diabetic, renal, or cardiovascular safety events. Dapagliflozin was associated with improved median 24-hour natriuresis (P = 0.03) and urine output (P = 0.005), expediting hospital discharge over the study period.

CONCLUSIONS

Early dapagliflozin during AHF hospitalization is safe and fulfills a component of GDMT optimization. Dapagliflozin was not associated with a statistically significant reduction in weight-based diuretic efficiency but was associated with evidence for enhanced diuresis among patients with AHF. (Efficacy and Safety of Dapagliflozin in Acute Heart Failure [DICTATE-AHF]; NCT04298229).

Heart failure with preserved ejection fraction: everything the clinician needs to know

Heart failure with preserved ejection fraction (HFpEF) is increasingly recognised and diagnosed in clinical practice, a trend driven by an ageing population and a rise in contributing comorbidities, such as obesity and diabetes. Representing at least half of all heart failure cases, HFpEF is recognised as a complex clinical syndrome. Its diagnosis and management are challenging due to its diverse pathophysiology, varied epidemiological patterns, and evolving diagnostic and treatment approaches. This Seminar synthesises the latest insights on HFpEF, integrating findings from recent clinical trials, epidemiological research, and the latest guideline recommendations. We delve into the definition, pathogenesis, epidemiology, diagnostic criteria, and management strategies (non-pharmacological and pharmacological) for HFpEF. We highlight ongoing clinical trials and future developments in the field. Specifically, this Seminar offers practical guidance tailored for primary care practitioners, generalists, and cardiologists who do not specialise in heart failure, simplifying the complexities in the diagnosis and management of HFpEF. We provide practical, evidence-based recommendations, emphasising the importance of addressing comorbidities and integrating the latest pharmacological treatments, such as SGLT2 inhibitors.

Assessment and management of heart failure in patients with chronic kidney disease

Heart failure (HF) and chronic kidney disease (CKD) are two pathological conditions with a high prevalence in the general population. When they coexist in the same patient, a strict interplay between them is observed, such that patients affected require a clinical multidisciplinary and personalized management. The diagnosis of HF and CKD relies on signs and symptoms of the patient but several additional tools, such as blood-based biomarkers and imaging techniques, are needed to clarify and discriminate the main characteristics of these diseases. Improved survival due to new recommended drugs in HF has increasingly challenged physicians to manage patients with multiple diseases, especially in case of CKD. However, the safe administration of these drugs in patients with HF and CKD is often challenging. Knowing up to which values ​​of creatinine or renal clearance each drug can be administered is fundamental. With this review we sought to give an insight on this sizable and complex topic, in order to get clearer ideas and a more precise reference about the diagnostic assessment and therapeutic management of HF and CKD.

Impact of Advanced Therapy Centers on Characteristics and Outcomes of Heart Failure Admissions

BACKGROUND

Although much attention has been paid to admission and transfer patterns for cardiogenic shock, contemporary data are lacking on decompensated heart failure (HF) admissions and transfers and the impact of advanced therapy centers (ATCs) on outcomes.

METHODS

HF hospitalizations were obtained from the Nationwide Readmissions Database 2016 to 2019. Centers performing at least 1 heart transplant or left ventricular assist device were classified as ATCs. Patient characteristics, outcomes, and procedural volume were compared among 3 cohorts: admissions to non-ATCs, admissions to ATCs, and transfers to ATCs. A secondary analysis evaluated outcomes for severe HF hospitalizations (cardiogenic shock, cardiac arrest, and mechanical ventilation). Multivariable logistic regression was performed to adjust for the presence of HF decompensations and significant clinical variables during univariate analysis.

RESULTS

A total of 2 331 690 hospitalizations (81.2%) were admissions to non-ATCs (94.5% of centers), 525 037 (18.3%) were admissions to ATCs (5.5% of centers), and 15 541 (0.5%) were transferred to ATCs. Patients treated at ATCs (especially those transferred) had higher rates of HF decompensations, procedural frequency, lengths of stay, and costs. Unadjusted mortality was 2.6% at non-ATCs and was higher at ATCs, both for directly admitted (2.9%, P<0.001) and transferred (11.2%, P<0.001) patients. However, multivariable-adjusted mortality was significantly lower at ATCs, both for directly admitted (odds ratio, 0.82 [95% CI, 0.78-0.87]; P<0.001) and transferred (odds ratio, 0.66 [95% CI, 0.57-0.78]; P<0.001) patients. For severe HF admissions, unadjusted mortality was 37.2% at non-ATCs and was lower at ATCs, both for directly admitted (25.3%, P<0.001) and transferred (25.2%, P<0.001) patients, with similarly lower multivariable-adjusted mortality.

CONCLUSIONS

Patients with HF treated at ATCs were sicker but associated with higher procedural volume and lower adjusted mortality.

Prognostic impact of acute decompensated heart failure in patients with heart failure with mildly reduced ejection fraction

AIMS

This study sought to determine the prognostic impact of acute decompensated heart failure (ADHF) in patients with heart failure with mildly reduced ejection fraction (HFmrEF). ADHF is a major complication in patients with heart failure (HF). However, the prognostic impact of ADHF in patients with HFmrEF has not yet been clarified.

METHODS AND RESULTS

Consecutive patients hospitalized with HFmrEF (i.e. left ventricular ejection fraction 41-49% and signs and/or symptoms of HF) were retrospectively included at one institution from 2016 to 2022. The prognosis of patients with ADHF was compared with those without (i.e. non-ADHF). The primary endpoint was long-term all-cause mortality. Secondary endpoints included in-hospital all-cause mortality and long-term HF-related re-hospitalization. Kaplan-Meier, multivariable Cox proportional regression, and propensity score matched analyses were performed for statistics. Long-term follow-up was set at 30 months. A total of 2184 patients with HFmrEF were included, ADHF was present in 22%. The primary endpoint was higher in ADHF compared to non-ADHF patients with HFmrEF [50% vs. 26%; hazard ratio (HR) = 2.269; 95% confidence interval (CI) 1.939-2.656; P = 0.001]. Accordingly, the secondary endpoint of long-term HF-related re-hospitalization was significantly higher (27% vs. 10%; HR = 3.250; 95% CI 2.565-4.118; P = 0.001). A history of previous ADHF before the index hospitalization was associated with higher rates of long-term HF-related re-hospitalization (42% vs. 23%; HR = 2.073; 95% CI 1.420-3.027; P = 0.001), but not with long-term all-cause mortality (P = 0.264).

CONCLUSION

ADHF is a common finding in patients with HFmrEF associated with an adverse impact on long-term prognosis.

Vulnerable period in heart failure: a window of opportunity for the optimization of treatment - a statement by Mexican experts

Acute heart failure (HF) is associated with poor prognosis. After the acute event, there is a vulnerable period during which the patient has a marked risk of readmission or death. Therefore, early optimization of treatment is mandatory during the vulnerable period. The objective of this article is to provide recommendations to address the management of patients with HF during the vulnerable period from a practical point of view. A group of Mexican experts met to prepare a consensus document. The vulnerable period, with a duration of up to 6 months after the acute event - either hospitalization, visit to the emergency department or the outpatient clinic/day hospital - represents a real window of opportunity to improve outcomes for these patients. To best individualize the recommendations, the management strategies were divided into three periods (early, intermediate and late vulnerable period), including not only therapeutic options but also evaluation and education. Importantly, the recommendations are addressed to the entire cardiology team, including physicians and nurses, but also other specialists implicated in the management of these patients. In conclusion, this document represents an opportunity to improve the management of this population at high risk, with the aim of reducing the burden of HF.

Revisiting nitrates use in pre-shock state of contemporary cardiogenic shock classification

Patients at each shock stage may behave and present differently with a spectrum of shock severity and adverse outcomes. Shock severity, shock aetiology, and several factors should be integrated in management decision-making. Although the contemporary shock stages classification provided a standardized shock severity assessment, individual agents or management strategy has not yet been studied in the context of each shock stage. The pre-shock state may comprise a wide range of presentations. Nitrate therapy has potential benefit in myocardial infarction and acute heart failure. Herein, this review aims to discuss the potential use of nitrate therapy in the context of the pre-shock state or stage B of the contemporary shock classification given its various presentations.