Integrative Assessment of Congestion in Heart Failure Throughout the Patient Journey

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.

Perspectives of Healthcare Professionals on Clinician-Patient Communication of Cardiovascular Disease Risk

When the consultation is predominantly verbal, existing research in clinician-patient communication indicates that many patients struggle to understand and recall medical consultations or may not understand the extent of their illness or the purpose of their treatment plan. When the clinician-patient discussion centers around the risk of a repeated cardiovascular disease (CVD) related event, qualitatively assessing what factors affect the communication of this risk may guide the creation of effective communication solutions. Semi-structured interviews were conducted with 17 clinicians treating patients at stages along the cardiac rehabilitation patients' journey. Thematic analysis identified factors that prevent patients from understanding the risk they face of experiencing a repeated cardiac event. Results indicate a clearer understanding of the cardiac rehabilitation patient journey by means of a patient journey map; an overview of how CVD risk is currently communicated; and the factors that affect communication of these risks in the form of themes and sub-themes. Findings shape the proposal of an evidence informed model of opportunities for enhanced digital media supported communication in cardiac rehabilitation.

Hemodynamic Changes in Intrarenal Blood Flow are Associated With Poor Prognosis in Patients With Acute Decompensated Heart Failure

AIM

To evaluate a potential role of different patterns of intrarenal blood flow using Doppler ultrasound as a part of determining the severity of venous congestion, predicting impairment of renal function and an unfavorable prognosis in patients with acute decompensated chronic heart failure (ADCHF).

MATERIAL AND METHODS

This prospective observational single-site study included 75 patients admitted in the intensive care unit for ADCHF. Upon admission all patients underwent bedside renal venous Doppler ultrasound to determine the blood flow pattern (continuous, biphasic, monophasic). In one hour after the initiation of intravenous diuretic therapy, sodium concentration was measured in a urine sample. The primary endpoint was the development of acute kidney injury (AKI). The secondary endpoints were the development of diuretic resistance (a need to increase the furosemide daily dose by more than 2 times compared with the baseline), decreased natriuretic response (defined as urine sodium concentration less than 50-70 mmol/l), and in-hospital death.

RESULTS

According to the data of Doppler ultrasound, normal renal blood flow was observed in 40 (53%) patients, biphasic in 21 (28%) patients, and monophasic in 14 (19%) patients. The monophasic pattern of intrarenal blood flow was associated with the highest incidence of AKI: among 14 patients in this group, AKI developed in 100% of cases (OR 3.8, 95% CI: 2.5-5.8, p<0.01), while among patients with normal and moderate impairment of renal blood flow, there was no significant increase in the risk of developing AKI. The odds of in-hospital death were increased 25.77 times in patients with monophasic renal blood flow (95% CI: 5.35-123.99, p<0.001). Patients with a monophasic intrarenal blood flow pattern were also more likely to develop diuretic resistance compared to patients with other blood flow patterns (p<0.001) and had a decreased sodium concentration to less than 50 mmol/l (p<0.001) in a spot urine test obtained one hour after the initiation of furosemide administration.

CONCLUSION

Patients with monophasic intrarenal blood flow are at a higher risk of developing AKI, diuretic resistance with decreased natriuretic response, and in-hospital death.

The Congestion "Pandemic" in Acute Heart Failure Patients

Congestion not only represents a cardinal sign of heart failure (HF) but is also now recognized as the primary cause of hospital admissions, rehospitalization, and mortality among patients with acute heart failure (AHF). Congestion can manifest through various HF phenotypes in acute settings: volume overload, volume redistribution, or both. Recognizing the congestion phenotype is paramount, as it implies different therapeutic strategies for decongestion. Among patients with AHF, achieving complete decongestion is challenging, as more than half still experience residual congestion at discharge. Residual congestion is one of the strongest predictors of future cardiovascular events and poor outcomes. Through this review, we try to provide a better understanding of the congestion phenomenon among patients with AHF by highlighting insights into the pathophysiological mechanisms behind congestion and new diagnostic and management tools to achieve and maintain efficient decongestion.

Lung ultrasound and diuretic therapy in chronic heart failure: a randomised trial

BACKGROUND

Lung congestion is frequent in heart failure (HF) and is associated with symptoms and poor prognosis. Lung ultrasound (LUS) identification of B-lines may help refining congestion assessment on top of usual care. Three small trials comparing LUS-guided therapy to usual care in HF suggested that LUS-guided therapy could reduce urgent HF visits. However, to our knowledge, the usefulness of LUS in influencing loop diuretic dose adjustment in ambulatory chronic HF has not been studied.

AIMS

To study whether to show or not LUS results to the HF assistant physician would change loop diuretic adjustments in "stable" chronic ambulatory HF patients.

METHODS

Prospective randomised single-blinded trial comparing two strategies: (1) open 8-zone LUS with B-line results available to clinicians, or (2) blind LUS. The primary outcome was change in loop diuretic dose (up- or down-titration).

RESULTS

A total of 139 patients entered the trial, 70 were randomised to blind LUS and 69 to open LUS. The median (percentile25-75) age was 72 (63-82) years, 82 (62%) were men, and the median LVEF was 39 (31-51) %. Randomisation groups were well balanced. Furosemide dose changes (up- and down-titration) were more frequent among patients in whom LUS results were open to the assistant physician: 13 (18.6%) in blind LUS vs. 22 (31.9%) in open LUS, OR 2.55, 95%CI 1.07-6.06. Furosemide dose changes (up- and down-titration) were more frequent and correlated significantly with the number of B-lines when LUS results were open (Rho = 0.30, P = 0.014), but not when LUS results were blinded (Rho = 0.19, P = 0.13). Compared to blind LUS, when LUS results were open, clinicians were more likely to up-titrate furosemide dose if the result "presence of pulmonary congestion" was identified and more likely to decrease furosemide dose in the case of an "absence of pulmonary congestion" result. The risk of HF events or cardiovascular death did not differ by randomisation group: 8 (11.4%) in blind LUS vs. 8 (11.6%) in open LUS.

CONCLUSIONS

Showing the results of LUS B-lines to assistant physicians allowed more frequent loop diuretic changes (both up- and down-titration), which suggests that LUS may be used to tailor diuretic therapy to each patient congestion status.

Conduction System Pacing: Have We Finally Found the Holy Grail of Physiological Pacing?

The late fifties are considered a high point in the history of cardiac pacing, since this era is marked by the first pacemaker implantation, which has since evolved into life-saving therapy. Right ventricular apical and biventricular pacing are the classic techniques that are recommended as first-l ine approaches for most indications in current guidelines. However, conduction system pacing has emerged as being able to deliver a more physiological form of pacing and is becoming mainstream practice in a growing number of centres. In this review, we aim to compare traditional pacing methods with conduction system pacing.

A Personalized Approach to the Management of Congestion in Acute Heart Failure

Heart failure (HF) is the common final pathway of several conditions and is characterized by hyperactivation of numerous neurohumoral pathways. Cardiorenal interaction plays an essential role in the progression of the disease, and the use of diuretics is a cornerstone in the treatment of hypervolemic patients, especially in acute decompensated HF (ADHF). The management of congestion is complex and, to avoid misinterpretations and errors, one must understand the interface between the heart and the kidneys in ADHF. Congestion itself may impair renal function and must be treated aggressively. Transitory elevations in serum creatinine during decongestion is not associated with worse outcomes and diuretics should be maintained in patients with clear hypervolemia. Monitoring urinary sodium after diuretic administration seems to improve the response to diuretics as it allows for adjustments in doses and a personalized approach. Adequate assessment of volemia and the introduction and titration of guideline-directed medical therapy are mandatory before discharge. An early visit after discharge is highly recommended, to assess for residual congestion and thus avoid readmissions.

Acute heart failure: current pharmacological treatment and perspectives

Acute heart failure (AHF) represents the most frequent cause of unplanned hospital admission in patients older than 65 years. Symptoms and clinical signs of AHF (e.g. dyspnoea, orthopnoea, oedema, jugular vein distension, and variation of body weight) are mostly related to systemic venous congestion secondary to various mechanisms including extracellular fluids, increased ventricular filling pressures, and/or auto-transfusion of blood from the splanchnic into the pulmonary circulation. Thus, the initial management of AHF patients should be mostly based on decongestive therapies on admission followed, before discharge, by rapid implementation of guideline-directed oral medical therapies for heart failure. The therapeutic management of AHF requires the identification and rapid diagnosis of the disease, the diagnosis of the cause (or triggering factor), the evaluation of severity, the presence of comorbidities, and, finally, the initiation of a rapid treatment. The most recent guidelines from ESC and ACC/AHA/HFSA have provided updated recommendations on AHF management. Recommended pharmacological treatment for AHF includes diuretic therapy aiming to relieve congestion and achieve optimal fluid status, early and rapid initiation of oral therapies before discharge combined with a close follow-up. Non-pharmacological AHF management requires risk stratification in the emergency department and non-invasive ventilation in case of respiratory failure. Vasodilators should be considered as initial therapy in AHF precipitated by hypertension. On the background of recent large randomized clinical trials and international guidelines, this state-of-the-art review describes current pharmacological treatments and potential directions for future research in AHF.

Beta-blocker management in patients admitted for acute heart failure and reduced ejection fraction: a review and expert consensus opinion

The role of the beta-adrenergic signaling pathway in heart failure (HF) is pivotal. Early blockade of this pathway with beta-blocker (BB) therapy is recommended as the first-line medication for patients with HF and reduced ejection fraction (HFrEF). Conversely, in patients with severe acute HF (AHF), including those with resolved cardiogenic shock (CS), BB initiation can be hazardous. There are very few data on the management of BB in these situations. The present expert consensus aims to review all published data on the use of BB in patients with severe decompensated AHF, with or without hemodynamic compromise, and proposes an expert-recommended practical algorithm for the prescription and monitoring of BB therapy in critical settings.

Estimated plasma volume status adds prognostic value to hemodynamic parameters in advanced heart failure

BACKGROUND

Estimated plasma volume status (ePVS) is a marker of intravascular congestion and has prognostic value in patients with heart failure (HF). The elevation of intracardiac filling pressures is defined as hemodynamic congestion and is also associated with poor prognosis. However, the relationship between intravascular congestion and hemodynamic congestion remains unclear. This study sought to explore the correlation between ePVS and hemodynamic parameters and determine the association between ePVS and clinical outcomes in patients with advanced HF.

METHODS

Patients with advanced HF underwent right heart catheterization (RHC) for hemodynamic profiles. The sum of right atrial pressure (RAP) and pulmonary arterial wedge pressure (PAWP) > 30 mmHg was considered to present with hemodynamic congestion. Blood tests were conducted within 24 h of RHC. We calculated ePVS using the Strauss-derived Duarte formula. The primary outcome was all-cause mortality.

RESULTS

A total of 195 patients were divided into two groups based on the cut-off value of ePVS (4.08 dL/g) calculated from receiver operating characteristic analysis. Patients with ePVS > 4.08 dL/g were more likely to present with wet rales (21.2% vs. 9.9%, P = 0.032) and had a higher risk of death (HR 4.748, 95% CI 2.385-9.453), regardless of whether RAP + PAWP was normal or elevated (all P < 0.05). Hemodynamic parameters and ePVS were not correlated (all P > 0.05). High ePVS significantly improved the predictive value beyond the clinical plus hemodynamic prognostic model (area under the curve of 0.844, Delong test, P = 0.024).

CONCLUSION

ePVS could additionally add prognostic value to hemodynamic parameters in advanced heart failure, although not correlated with hemodynamic parameters.

Carbohydrate antigen 125 in congestive heart failure: ready for clinical application?

Congestion is the permanent mechanism driving disease progression in patients with acute heart failure (AHF) and also is an important treatment target. However, distinguishing between the two different phenotypes (intravascular congestion and tissue congestion) for personalized treatment remains challenging. Historically, carbohydrate antigen 125 (CA125) has been a frequently used biomarker for the screening, diagnosis, and prognosis of ovarian cancer. Interestingly, CA125 is highly sensitive to tissue congestion and shows potential for clinical monitoring and optimal treatment of congestive heart failure (HF). Furthermore, in terms of right heart function parameters, CA125 levels are more advantageous than other biomarkers of HF. CA125 is expected to become a new biological alternative marker for congestive HF and thereby is expected be widely used in clinical practice.

Correlation of left atrial function and pulmonary edema in patients with left heart failure on cardiopulmonary ultrasonography

Objective

Patients with heart failure with pulmonary edema may have declining left atrial (LA) function. Left atrial strain (LAS) imaging enables quantitative assessment of LA function. The aim of this prospective study was to assess the LA function and pulmonary edema in patients with heart failure evaluated by cardiopulmonary ultrasonography.

Methods

Two-dimensional speckle-tracking echocardiography for LAS was performed in 115 consecutive patients with congestive heart failure. A semiquantitative B-lines score of pleural effusions was derived by pulmonary ultrasound almost at the same time by combined cardiopulmonary ultrasound.

Results

Compared with those who did not have pulmonary edema, patients with pulmonary edema had lower LAS (LASreservoir, 21.5 ± 4.9% vs. 9.2 ± 3.7% [P < 0.001]; LASconduit, 10.7 ± 3.5% vs. 5.1 ± 2.1% [P < 0.001]; LASpump, 11.3 ± 5.4% vs. 4.0 ± 2.7% [P < 0.001]), lower LVEF, TAPSE; and higher SPAP, E/e', larger LA, LV, RV; more severe MR. However, there were no significant between-group differences with respect to sex and body surface area. In patients with pulmonary edema, B-lines score was independently associated with LASreservoir (R = -0.71, P < 0.001); LASpump (R = -0.66, P < 0.001) and LASconduit (R = -0.56, P < 0.001). On multiple linear regression, decreased LASreservoir (beta = -0.61, B = -0.71, P < 0.001) and elevated SPAP (beta = 0.31, B = 0.13, P = 0.01) were significantly associated with B-lines score in heart failure.

Conclusion

Declining LA function, especially the reservoir function, assessed by speckle-tracking echocardiography is related to the degree and occurrence of pulmonary edema in patients with left heart failure.

Optimisation of treatments for heart failure with reduced ejection fraction in routine practice: a position statement from a panel of experts

Major international practice guidelines recommend the use of a combination of 4 medication classes in the treatment of patients with heart failure with reduced ejection fraction (HFrEF) but do not specify how these treatments should be introduced and up-titrated. Consequently, many patients with HFrEF do not receive an optimized treatment regimen. This review proposes a pragmatic algorithm for treatment optimization designed to be easily applied in routine practice. The first goal is to ensure that all 4 recommended medication classes are initiated as early as possible to establish effective therapy, even at a low dose. This is considered preferable to starting fewer medications at a maximum dose. The second goal is to ensure that the intervals between the introduction of different medications and between different titration steps are as short as possible to ensure patient safety. Specific proposals are made for older patients (> 75 years) who are frail, and for those with cardiac rhythm disorders. Application of this algorithm should allow an optimal treatment protocol to be achieved within 2-months in most patients, which should the treatment goal in HFrEF.

Diuretic dose is a strong prognostic factor in ambulatory patients awaiting heart transplantation

AIMS

The prognostic value of 'high dose' loop diuretics in advanced heart failure outpatients is unclear. We aimed to assess the prognosis associated with loop diuretic dose in ambulatory patients awaiting heart transplantation (HT).

METHODS AND RESULTS

All ambulatory patients (n = 700, median age 55 years and 70% men) registered on the French national HT waiting list between 1 January 2013 and 31 December 2019 were included. Patients were divided into 'low dose', 'intermediate dose', and 'high dose' loop diuretics corresponding to furosemide equivalent doses of ≤40, 40-250, and >250 mg, respectively. The primary outcome was a combined criterion of waitlist death and urgent HT. N-terminal pro-B-type natriuretic peptide, creatinine levels, pulmonary capillary wedge pressure, and pulmonary pressures gradually increased with higher diuretic dose. At 12 months, the risk of waitlist death/urgent HT was 7.4%, 19.2%, and 25.6% (P = 0.001) for 'low dose', 'intermediate dose', and 'high dose' patients, respectively. When adjusting for confounders, including natriuretic peptides, hepatic, and renal function, the 'high dose' group was associated with increased waitlist mortality or urgent HT [adjusted hazard ratio (HR) 2.23, 1.33 to 3.73; P = 0.002] and a six-fold higher risk of waitlist death (adjusted HR 6.18, 2.16 to 17.72; P < 0.001) when compared with the 'low dose' group. 'Intermediate doses' were not significantly associated with these two outcomes in adjusted models (P > 0.05).

CONCLUSIONS

A 'high dose' of loop diuretics is strongly associated with residual congestion and is a predictor of outcome in patients awaiting HT despite adjustment for classical cardiorenal risk factors. This routine variable may be helpful for risk stratification of pre-HT patients.

Early improvement of strain imaging parameters predicts long-term response to sacubitril/valsartan in patients with heart failure with reduced ejection fraction: An observational prospective study

BACKGROUND

Management of patients affected by heart failure with reduced ejection fraction (HFrEF) has deeply changed thanks to novel pharmacological therapies, such as Sacubitril/Valsartan, which assured morbidity and mortality advantages in this population. These effects may be mediated by both left atrial (LA) and ventricular reverse remodeling, although left ventricular ejection fraction (LVEF) recovery still represents the main parameter of treatment response.

METHODS

In this prospective, observational study, 66 patients with HFrEF and naïve from Sacubitril/Valsartan were enrolled. All patients were evaluated at baseline, at 3 months and 12 months from therapy initiation. Echocardiographic parameters, including speckle tracking analysis, LA functional and structural metrics, were collected at three timepoints. The endpoints of our study were: (1) to evaluate the effects of Sacubitril/Valsartan on echo measurements; (2) to assess the predictive role of early modifications of these parameters (expressed as ∆ 3-0 months) on long-term LVEF significant recovery, defined as >15% improvement from baseline.

RESULTS

The majority of echocardiographic parameters evaluated progressively improved during the observation period, including LVEF, ventricular volumes and LA metrics. ∆(3-0 months) of LV Global Longitudinal Strain (LVGLS) and LA Reservoir Strain (LARS) were associated with significant LVEF improvement at 12 months (p < 0.001 and p = 0.019 respectively). A cut-off of ∆(3-0 months) LVGLS of 3% and of ∆(3-0 months) LARS of 2% could predict LVEF recovery with satisfactory sensitivity and specificity.

CONCLUSIONS

LV and LA strain analysis may identify patients who adequately respond to HFrEF medical treatment and should be routinely used in the evaluation of these patients.

Sodium-glucose cotransporter-2 inhibitors in heart failure: Potential decongestive mechanisms and current clinical studies

Congestion is a key pathophysiological feature of heart failure (HF) syndrome that drives most of the clinical manifestations of acute HF and is related with poor quality of life and outcomes. Therefore, safe and effective decongestion is an important therapeutic target in the management of acute HF and despite the use of guideline-recommended loop diuretics, adequate decongestion is not always achieved in patients with acute HF. Recently, sodium-glucose cotransporter-2 (SGLT-2) inhibitors have been shown to provide clinical benefits across a broad spectrum of patients with HF, including consistent reduction in the risk of acute HF episodes. While the exact mechanisms underlying these benefits remain a matter of debate, a growing body of evidence suggests that effective decongestion may be partly responsible, especially in the setting of acute HF. In this review, we discuss the potential decongestive mechanisms of SGLT-2 inhibitors, such as osmotic diuresis, natriuresis, preservation of glomerular filtration and facilitation of interstitial drainage, which can collectively translate into effective and safe decongestion. Furthermore, we provide a comprehensive review of up-to-date clinical data of SGLT-2 inhibitor use in the acute HF population.

Changes in Doppler-Derived Kidney Venous Flow and Adverse Cardiorenal Outcomes in Patients With Heart Failure

Background The impact of changes in Doppler-derived kidney venous flow in heart failure (HF) is not well studied. We aimed to investigate the association of Doppler-derived kidney venous stasis index (KVSI) and intrakidney venous-flow (IKVF) patterns with adverse cardiorenal outcomes in patients with HF. Methods and Results In this observational cohort study, consecutive inpatients with HF referred to a nephrologist because of a history of diuretic resistance and abnormal kidney function (n=216) underwent spectral kidney assessments after admission (Doppler 1) and 25 to 35 days later (Doppler 2) to identify IKVF patterns (continuous/pulsatile/biphasic/monophasic) and KVSI levels. Cox proportional hazard regression models were used to evaluate the associations between KVSI/IKVF patterns at Doppler 1 as well as changes from Doppler 1 to Doppler 2 and risk of cardiorenal events up to 18 months after admission. Worsening HF or death occurred in 126 patients. Both baseline KVSI (hazard ratio [HR], 1.49 [95% CI, 1.37-1.61] per 0.1-unit increase) and baseline IKVF pattern (HR, 2.47 [95% CI, 2.01-3.04] per 1 pattern severity increase) were significantly associated with worsening HF/death. Increases in both KVSI and IKVF pattern severity from Doppler 1 to 2 were also associated with an increased risk of worsening HF/death (HR, 3.00 [95% CI, 2.08-4.32] per 0.1-unit increase change; and HR, 6.73 [95% CI, 3.27-13.86] per 1 pattern increase in severity change, respectively). Similar results were observed for kidney outcomes. Conclusions Baseline kidney venous flow predicted adverse cardiorenal events, and inclusion of serial kidney venous flow in cardiorenal risk stratification could facilitate clinical decision-making for patients with HF. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03039959.

Pre-discharge and early post-discharge management of patients hospitalized for acute heart failure: A scientific statement by the Heart Failure Association of the ESC

Acute heart failure is a major cause of urgent hospitalizations. These are followed by marked increases in death and rehospitalization rates, which then decline exponentially though they remain higher than in patients without a recent hospitalization. Therefore, optimal management of patients with acute heart failure before discharge and in the early post-discharge phase is critical. First, it may prevent rehospitalizations through the early detection and effective treatment of residual or recurrent congestion, the main manifestation of decompensation. Second, initiation at pre-discharge and titration to target doses in the early post-discharge period, of guideline-directed medical therapy may improve both short- and long-term outcomes. Third, in chronic heart failure, medical treatment is often left unchanged, so the acute heart failure hospitalization presents an opportunity for implementation of therapy. The aim of this scientific statement by the Heart Failure Association of the European Society of Cardiology is to summarize recent findings that have implications for clinical management both in the pre-discharge and the early post-discharge phase after a hospitalization for acute heart failure.

The Potential Role of Torsemide in Optimizing Loop Diuretic Therapy for Heart Failure Patients

Heart failure is associated with an increased frequency of hospitalization, reduced life span, and greater risk to public health, thus posing a challenge. In India, torsemide is one of the commonly used loop diuretics for decongestion in heart failure. However, this use of torsemide, including its dosing, and up/down titration, is based on practical experience. Loop diuretic therapy for heart failure patients poses several dilemmas due to the lack of robust evidence based on which treatment decisions can be made. To guide physicians on the optimal use of torsemide in heart failure patients with or without renal impairment, a panel of expert cardiologists and nephrologists from India convened to develop this expert opinion document for the use of torsemide. This expert opinion on torsemide will pave the way for optimal management with loop diuretic therapy in real-world heart failure patients.

The incremental value of multi-organ assessment of congestion using ultrasound in outpatients with heart failure

AIMS

We investigated the prevalence and clinical value of assessing multi-organ congestion by ultrasound in heart failure (HF) outpatients.

METHODS AND RESULTS

Ultrasound congestion was defined as inferior vena cava of ≥21 mm, highest tertile of lung B-lines, or discontinuous renal venous flow. Associations with clinical characteristics and prognosis were explored. We enrolled 310 HF patients [median age: 77 years, median NT-proBNP: 1037 ng/L, 51% with a left ventricular ejection fraction (LVEF) <50%], and 101 patients without HF. There were no clinical signs of congestion in 224 (72%) patients with HF, of whom 95 (42%) had at least one sign of congestion by ultrasound (P < 0.0001). HF patients with ≥2 ultrasound signs were older, and had greater neurohormonal activation, lower urinary sodium concentration, and larger left atria despite similar LVEF. During a median follow-up of 13 (interquartile range: 6-15) months, 77 patients (19%) died or were hospitalized for HF. HF patients without ultrasound evidence of congestion had a similar outcome to patients without HF [reference; hazard ratio (HR) 1.02, 95% confidence interval (CI) 0.86-1.35], while those with ≥2 ultrasound signs had the worst outcome (HR 26.7, 95% CI 12.4-63.6), even after adjusting for multiple clinical variables and NT-proBNP. Adding multi-organ assessment of congestion by ultrasound to a clinical model, including NT-proBNP, provided a net reclassification improvement of 28% (P = 0.03).

CONCLUSION

Simultaneous assessment of pulmonary, venous, and kidney congestion by ultrasound is feasible, fast, and identifies a high prevalence of sub-clinical congestion associated with poor outcomes.

Hepatic Venous Stasis Index Reflects Hepatic Congestion and Predicts Adverse Outcomes in Patients With Heart Failure

Background It has been reported that the hepatic vein waveforms determined by abdominal ultrasonography can assess hepatic congestion in patients with heart failure (HF). However, the parameter that quantifies hepatic vein waveforms has not been established. We suggest the hepatic venous stasis index (HVSI) as the novel indicator to evaluate hepatic congestion quantitatively. To examine the clinical significance of HVSI in patients with HF, we aimed to clarify the associations of HVSI with the parameters of cardiac function and right heart catheterization, as well as that with prognosis, in patients with HF. Methods and Results We performed abdominal ultrasonography, echocardiography, and right heart catheterization in patients with HF (n=513). The patients were divided into 3 groups based on HVSI as follows: HVSI 0 (HVSI=0, n=253), low HVSI (HVSI 0.01-0.20, n=132), and high HVSI (HVSI>0.20, n=128). We examined the associations of HVSI with parameters of cardiac function and right heart catheterization and followed up for cardiac events defined as cardiac death or worsening HF. There was a significant increase in level of B-type natriuretic peptide, inferior vena cava diameter, and mean right atrial pressure with increasing HVSI. During the follow-up period, cardiac events occurred in 87 patients. In the Kaplan-Meier analysis, cardiac event rate increased across increasing HVSI (log-rank, P=0.002). Conclusions HVSI assessed by abdominal ultrasonography reflects hepatic congestion and right-sided HF and is associated with adverse prognosis in patients with HF.

The Role of Congestion Biomarkers in Heart Failure with Reduced Ejection Fraction

In heart failure with reduced ejection fraction, edema and congestion are related to reduced cardiac function. Edema and congestion are further aggravated by chronic kidney failure and pulmonary abnormalities. Furthermore, together with edema/congestion, sodium/water retention is an important sign of the progression of heart failure. Edema/congestion often anticipates clinical symptoms, such as dyspnea and hospitalization; it is associated with a reduced quality of life and a major risk of mortality. It is very important for clinicians to predict the signs of congestion with biomarkers and, mainly, to understand the pathophysiological findings that underlie edema. Not all congestions are secondary to heart failure, as in nephrotic syndrome. This review summarizes the principal evidence on the possible roles of the old and new congestion biomarkers in HFrEF patients (diagnostic, prognostic, and therapeutic roles). Furthermore, we provide a description of conditions other than congestion with increased congestion biomarkers, in order to aid in reaching a differential diagnosis. To conclude, the review focuses on how congestion biomarkers may be affected by new HF drugs (gliflozins, vericiguat, etc.) approved for HFrEF.

Lung water estimation on cardiac magnetic resonance imaging for predicting adverse cardiovascular outcomes in patients with heart failure

OBJECTIVES

Pulmonary congestion is a central feature of heart failure (HF) seen in acute decompensated state as well as in chronic stable disease. The present study sought to determine whether simplified cardiac magnetic resonance imaging (CMR)-derived lung water density (LWD) measurement has prognostic relevance in predicting adverse cardiovascular outcomes in patients with HF and left ventricular ejection fraction (LVEF)<50%.

METHODS

Eighty consecutive patients referred for CMR with HF and LVEF<50% along with 22 healthy age- and sex-matched controls were prospectively recruited. LWD was the lung-to-liver signal intensity ratio multiplied by 70% (estimated hepatic water density). The primary endpoint was composite of all-cause mortality or HF-related hospitalization within 6 months from CMR.

RESULTS

The mean LWD was significantly higher in HF patients compared to healthy controls (19.78 ± 6.1 vs 13.6 ± 2.3; p < 0.001). The mean LWD was significantly different among patients with NYHA class I/II and NYHA class III/IV (17.88 ± 4.8 vs 21.77 ± 1.08; p = 0.004). At 6 months, the primary endpoint was reached in 12 (15%) patients. Patients with "wet lungs" (LWD > 18.1%) had higher incidence of adverse cardiovascular outcomes compared to patients with "dry lungs". LWD was an independent predictor of adverse cardiovascular outcomes in multivariable analysis. At the optimal cut-off of LWD > 23.38%, the sensitivity and specificity were 91.67 and 91.18%, respectively, to predict adverse cardiovascular outcomes.

CONCLUSION

LWD on CMR is independently associated with increased risk of mortality and HF-related hospitalization in HF patients with LVEF<50%.

ADVANCES IN KNOWLEDGE

Non-invasive quantitative estimation of LWD on CMR can improve risk stratification and guide management in HF patients.

Remote dielectric sensing and lung ultrasound to assess pulmonary congestion

We investigated the agreement between remote dielectric sensing (ReDS) system, which is a recently introduced non-invasive technology to quantify the degree of pulmonary congestion, and lung ultrasound (LUS), which is a gold standard to assess the existence of severe pulmonary congestion. Consecutive patients who were hospitalized to examine the cause of heart failure and treat their heart failure in our institute were prospectively included. They received LUS and simultaneous ReDS measurements. Three or more B-lines at each LUS zone was assigned to B-profile positive, indicating the existence of significant pulmonary congestion. ReDS values ≥ 35% were defined as significant pulmonary congestion. A total of 19 heart failure patients were included (77 years, 13 men). Plasma B-type natriuretic peptide level was 131 (36, 416) pg/ml. Three patients had B-profile, indicating significant pulmonary congestion, and two of them had ≥ 35% of ReDS (sensitivity 66.7%, specificity 87.5%, and negative predictive value 93.3%). Most of the patients (79%) had lower B-lines below 3 and did not satisfy the criteria of B-profile, irrespective of wide ranges of ReDS values. ReDS system had as acceptable predictability as LUS in assessing the existence of significant pulmonary congestion. ReDS would be recommended to rule out significant pulmonary congestion or quantify the degree of less significant pulmonary congestion.

Assessment Of Fluid Retention In Patients With Paroxysmal And Long-Standing Persistent Types Of Atrial Fibrillation

Determining fluid retention in circulatory system currently remains a challenge. The objective of our study was to determine the sensitivity of individual symptoms and signs of chronic heart failure (CHF) and echocardiographic criteria for detecting fluid retention in patients with atrial fibrillation and invasively measured elevated atrial pressure. Methods — We conducted a prospective study of adult patients with a history of cardiovascular disease (coronary artery disease or/and arterial hypertension in combination with atrial fibrillation [AF]) hospitalized for radiofrequency catheter ablation. All patients underwent expert ultrasound examination of the heart using Philips HD 15 and Philips iE33 devices, as well as invasive measurement of pressure in the left and right atria at rest (n=20). Results — The sensitivity of dyspnea in patients with paroxysmal AF and long-standing persistent AF was 44.4% and 90.9%, respectively. The sensitivity of the mean E/e' ratio in patients with paroxysmal AF and long-standing persistent AF was 22.2% and 18.1%, correspondingly. According to the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging (ASE/EACVI) algorithm, only one patient (11.1%) in the group with paroxysmal AF and 54.5% of subjects in the group with a long-standing persistent AF type had two positive criteria. The sensitivity of lower limb edema was 0% in patients with paroxysmal AF and 57.1% in those with long-standing persistent AF. The sensitivity of IVC diameter >22 mm was 80% in patients with paroxysmal AF and 57.1% in the group with long-standing persistent AF. At the same time, the sensitivity of the IVC inspiratory collapse ≤50% was significantly lower in both groups: 60% in patients with paroxysmal AF and 42.9% in subjects with long-standing persistent AF. Conclusion — Clinical symptoms and signs of chronic heart failure (CHF), as well as echocardiographic parameters reflecting an increase in the filling pressure of the heart chambers, are characterized by extremely low sensitivity in a cohort of patients with paroxysmal AF. The use of more stringent criteria for diagnosing congestion in this group of patients leads to a significant underdiagnosis of elevated filling pressure in the left chambers of the heart, which, in turn, increases the likelihood of insufficient prescription of diuretic therapy when it is objectively necessary.

Validation of the MEDIA echo score for the prognosis of heart failure with preserved ejection fraction

There is currently no widely used prognostic score in heart failure (HF) with preserved ejection fraction (HFpEF). The MEDIA echo score, including four variables (pulmonary arterial systolic pressure > 40 mmHg, inferior vena cava collapsibility index < 50%, average E/e' > 9, and lateral mitral annular s' < 7 cm/s), has been proposed as a useful risk stratification tool. This study aimed at further validating the MEDIA echo score in both hospitalised and ambulatory HFpEF patients. The MEDIA echo score ranges from 0 to 4 (each criterion scores 1 point). The associations between MEDIA echo score and cardiovascular outcomes were assessed in two independent HFpEF cohorts, namely patients hospitalised for worsening HFpEF (N = 242, mean age 78 ± 11), and stable ambulatory HFpEF patients (N = 76, mean age 65 ± 8). Using multivariable Cox models, in the worsening HFpEF cohort, patients with a MEDIA echo score of 3-4 displayed a significant increased risk of death (HR 2.10, 95%CI 1.02-4.33, P = 0.043, score 0-1 as reference). In the ambulatory HFpEF cohort, patients with a MEDIA echo score of 2 had a significantly higher risk of death or HF hospitalisation (HR 3.44, 95%CI 1.27-9.30, P = 0.015, score 0 as reference), driven by HF hospitalisation; in that cohort, adding the MEDIA echo score to the clinical model significantly improved reclassification for the combined endpoint (integrated discrimination improvement 6.2%, P = 0.006). The MEDIA echo score significantly predicted the outcome of HFpEF patients in both hospital and ambulatory settings; its use may help refine routine risk stratification on top of well-established prognosticators in stable HFpEF patients.

Prognostic implications of post-discharge hemodynamic congestion assessed by peripheral venous pressure among patients discharged from acute heart failure

BACKGROUND

Congestion is a major cause of hospitalization for heart failure (HF). Peripheral venous pressure (PVP) strongly correlates with right atrial pressure. We recently reported that high PVP at discharge portends a poor prognosis in patients hospitalized for HF. In the same population, we aimed to analyze changes in PVP after discharge and to evaluate prognostic implications of post-discharge PVP.

METHODS

PVP was measured at the forearm vein of 163 patients in the 1-month post-discharge follow-up visit. The primary outcome was a composite of cardiovascular death or re-hospitalization for HF after the 1-month follow-up visit up to 1 year after discharge.

RESULTS

Post-discharge PVP correlated with jugular venous pressure, the inferior vena cava diameter, and brain-type natriuretic peptide levels. The cumulative incidence of the primary outcome event was significantly higher in patients with PVP above the median (6 mmHg) than in those with median PVP or lower (39.8% versus 16.9%, Log-rank P = 0.04). Age- and sex-adjusted risk of PVP per 1 mmHg for the primary outcome measure was significant (hazard ratio: 1.12 [95% confidence interval 1.03-1.21]). 35% of patients who had PVP ≤6 mmHg at discharge had PVP >6 mmHg at the 1-month follow-up. PVP significantly decreased from discharge to 1-month follow-up in patients without the primary outcome event (from 6 [4-10] to 6 [4-8] mmHg, P=0.01), but remained high in those with the primary outcome event (from 8 [5-11] to 7 [5-10.5] mmHg, P = 0.9).

CONCLUSIONS

PVP measurements during the early post-discharge period may be useful to identify high risk patients.

TRIAL REGISTRATION NUMBER

UMIN000034279.

Effect of eplerenone on clinical stability of Japanese patients with acute heart failure

BACKGROUND

In the EARLIER (Efficacy and Safety of Early Initiation of Eplerenone Treatment in Patients with Acute Heart Failure) trial, eplerenone did not reduce heart failure (HF) hospitalizations or all-cause mortality in 300 patients admitted for acute HF (AHF). However, the trial might have been underpowered for these endpoints, and a comprehensive overview of the effect of eplerenone on diuretic doses and patients' clinical stability is warranted.

METHODS

The EARLIER trial included Japanese patients hospitalized for AHF randomly assigned to eplerenone or placebo over 6 months. Cox proportional hazards and mixed-effects models were used for analyses.

RESULTS

Three hundred patients were included (mean age, 67 ± 13 years; 73% males). The median furosemide equivalent dose was 40 (20-62) mg at randomization. Patients with higher furosemide-equivalent doses had more severe signs and symptoms of congestion and a higher risk of all-cause mortality or HF hospitalization during 6-month follow-up (adjusted-hazard ratio per 10 mg/day increase = 1.25, 95% confidence interval: 1.05-1.49). Eplerenone significantly decreased furosemide-equivalent diuretic doses and b-type natriuretic levels throughout the follow-up (overall-joint-p < 0.05 for both) and reduced E/e' and inferior vena cava diameter at 4 weeks (both p < 0.05). Additionally, eplerenone significantly reduced left ventricular (LV) end-diastolic diameter at 24 weeks (p < 0.05).

CONCLUSIONS

Eplerenone treatment improved the clinical stability particularly during short period following hospitalization for AHF, translated by lower diuretic doses, natriuretic peptide levels, indirect markers of filling pressure and venous congestion, and a smaller LV volume.

Relationship between atrial fibrillation and a liver fibrogenesis marker in patients with acute heart failure

BACKGROUND

Hemodynamic disturbance in heart failure (HF) induces extra-cardiac organ injury. Atrial fibrillation (AF) is common in patients with HF. The relationship between AF and organ injury in HF remains unclear. We investigated the relationship between AF and the liver fibrosis marker, type IV collagen 7S (P4NP 7S) in patients with HF.

METHODS AND RESULTS

From a pooled dataset of 3 observational cohorts of hospitalized HF, 720 patients in whom P4NP 7S was measured before discharge were included. Median P4NP 7S were 5.1, 5.3, and 6.2 ng/mL in the sinus rhythm (SR) (n = 368), paroxysmal AF (n = 67), and persistent AF (n = 285) groups, respectively (P < 0.001). In the multiple linear regression analysis, the significant association with P4NP 7S was found for persistent AF (P < 0.001). The cumulative 1-year incidence of the primary composite endpoint of cardiac death and HF hospitalization were 27.6, 24.1, and 34.5% in the SR, paroxysmal AF, and persistent AF groups, respectively (Log-rank P = 0.07) and 25.3 and 34.5% in the low (below median) and high P4NP 7S groups, respectively (Log-rank P = 0.005). The adjusted risks of persistent AF versus SR and high P4NP 7S versus low P4NP 7S for the primary endpoint were 1.38 (95% confidence interval 1.02-1.89) and 1.52 (1.14-2.03), respectively. When patients were divided based on a combination of AF and P4NP 7S, concomitant persistent AF and high P4NP 7S portended a dismal prognosis.

CONCLUSION

AF is associated with an increase in the liver fibrosis marker. Co-presence of persistent AF and P4NP 7S may portend adverse clinical outcomes.

Pulmonary Artery Systolic Pressure and Cava Vein Status in Acute Heart Failure with Preserved Ejection Fraction: Clinical and Prognostic Implications

BACKGROUND

Peak tricuspid regurgitation (TR) velocity and inferior cava vein (ICV) distention are two recognized features of increased pulmonary artery pressure (PASP) and right atrial pressure, respectively. Both parameters are related to pulmonary and systemic congestion and adverse outcomes. However, few data exist about the assessment of PASP and ICV in acute patients affected by heart failure with preserved ejection fraction (HFpEF). Thus, we investigated the relationship existing among clinical and echocardiographic features of congestion, and we analyzed the prognostic impact of PASP and ICV in acute HFpEF patients.

METHODS AND RESULTS

We analyzed clinical congestion PASP and ICV value in consecutive patients admitted in our ward by echocardiographic examination using peak Doppler velocity tricuspid regurgitation and ICV diameter and collapse for the assessment of PASP and ICV dimension, respectively. A total of 173 HFpEF patients were included in the analysis. The median age was 81 and median left ventricular ejection fraction (LVEF) was 55% [50-57]. Mean values of PASP was 45 mmHg [35-55] and mean ICV was 22 [20-24] mm. Patients with adverse events during follow-up showed significantly higher values of PASP (50 [35-55] vs. 40 [35-48] mmHg, (p = 0.005) and increased values of ICV (24 [22-25] vs. 22 [20-23] mm, p < 0.001). Multivariable analysis showed prognostic power of ICV dilatation (HR 3.22 [1.58-6.55], p = 0.001) and clinical congestion score ≥ 2 (HR 2.35 [1.12-4.93], p = 0.023), but PASP increase did not reach statistical significance (p = 0.874). The combination of PASP > 40 mmHg and ICV > 21 mm was capable of identifying patients with increased events (45% vs. 20%).

CONCLUSIONS

ICV dilatation provides additional prognostic information with respect to PASP in patients with acute HFpEF. A combined model adding PASP and ICV assessment to clinical evaluation is a useful tool for predicting HF related events.

Lung ultrasound in congestion assessment of patients with advanced heart failure referred for heart transplant: Correlations with right heart catheterization findings

Background

In advanced heart failure (HF), diagnostic performance of physical exam may be poor. Physical examination associated with lung ultrasound (LUS) may be an important tool to facilitate congestion screening.

Objective

To evaluate performance of LUS for congestion screening in advanced HF referred for transplant, as compared to findings of right heart catheterization (RHC).

Methods

Prospective study of 23 subjects with advanced HF referred for RHC. LUS was performed in association with clinical congestion score (CCS), analogue-visual dyspnea scale (AVDS) and presence of trepopnea/bendopnea prior to catheterization. Congestion was assessed by the number of B-lines in the LUS, and by findings of physical examination as well as by NT-proBNP serum values.

Results

Congestion was present in 43.4 % of patients by LUS (B-lines ≥ 15), as compared to 21.7 % by CCS (score greater than or equal to 5), 56.5 % by NT-proBNP (>1000 pg/ml), and 60.8 % by pulmonary capillary wedge pressure (PCWP) (>15 mm Hg). The number of B-lines was correlated to cardiac index (CI) (rho = -0.619; p 0.002), but not with PCWP (rho 0.190; p 0.386), RAP (rho -0.244; p 0.262), CCS (rho 0.198; p 0.36) and neither with NT-proBNP (rho 0.282; p 0.193). Otherwise, NT-proBNP was correlated with PCWP (rho = 0.636; p = 0.001) and with CI (rho -0.667 p 0.001).

Conclusions

In advanced HF patients referred for transplant, number of B-lines in LUS was not correlated with PCWP or RAP. Advanced HF patients seem to have increased filling pressures, but no interstitial pulmonary congestion that LUS could detect.

Prognostic Role of Sonographic Decongestion in Patients with Acute Heart Failure with Reduced and Preserved Ejection Fraction: A Multicentre Study

BACKGROUND

We investigated the role of the dynamic changes of pulmonary congestion, as assessed by sonographic B-lines, as a tool to stratify prognosis in patients admitted for acute heart failure with reduced and preserved ejection fraction (HFrEF, HFpEF).

METHODS

In this multicenter, prospective study, lung ultrasound was performed at admission and before discharge by trained investigators, blinded to clinical findings.

RESULTS

We enrolled 208 consecutive patients (mean age 76 [95% confidence interval, 70-84] years), 125 with HFrEF, 83 with HFpEF (mean ejection fraction 32% and 57%, respectively). The primary composite endpoint of cardiovascular death or HF re-hospitalization occurred in 18% of patients within 6 months. In the overall population, independent predictors of the occurrence of the primary endpoint were the number of B-lines at discharge, NT-proBNP levels, moderate-to-severe mitral regurgitation, and inferior vena cava diameter on admission. B-lines at discharge were the only independent predictor in both HFrEF and HFpEF subgroups. A cut-off of B-lines > 15 at discharge displayed the highest accuracy in predicting the primary endpoint (AUC = 0.80, p < 0.0001). Halving B-lines during hospitalization further improved event classification (continuous net reclassification improvement = 22.8%, p = 0.04).

CONCLUSIONS

The presence of residual subclinical sonographic pulmonary congestion at discharge predicts 6-month clinical outcomes across the whole spectrum of acute HF patients, independent of conventional biohumoral and echocardiographic parameters. Achieving effective pulmonary decongestion during hospitalization is associated with better outcomes.

Meta-Analysis on the Safety and Efficacy of Sodium Glucose Cotransporters 2 Inhibitors in Patients With Heart Failure With and Without Diabetes

Heart failure (HF) is the most common cardiovascular cause of hospitalization in patients over 60 years, affecting about 64.3 million patients worldwide. Few studies have investigated the role of sodium glucose cotransporter inhibitors (SGLT2Is) in patients with HF without and without diabetes. Thus, we conducted our meta-analysis to further investigate the role of SGLT2I role in patients with HF without and without diabetes. PubMed, Scopus, Web of Science, and Embase were searched. All clinical trials that compared the effect of SGLT2Is versus placebo on patients with HF were included. Dichotomous data were extracted, pooled as risk ratio (RR) with 95% confidence interval (CI), and analyzed using RevMan version 5.3 for windows using the Mantel-Haenszel method. A total of 13 randomized clinical trials were included for analysis, with a total number of 75,287 patients. SGLT2Is significantly lowered the risk of hospitalization for HF in patients with (RR = 0.68, 95% CI 0.63 to 0.74) and without diabetes (RR = 0.75, 95% CI 0.62 to 0.89). Furthermore, they lowered the mortality risk in both patients with diabetes with statistical significance (RR = 0.87, 95% CI 0.77 to 0.99), yet without statistical significance in patients without diabetes (RR = 0.93, 95% CI 0.70 to 1.23). Further analyses for serious adverse events were conducted, and SGLT2I showed a significant lower risk in patients with diabetes (RR = 0.94, 95% CI 0.90 to 0.98) and without diabetes (RR = 0.72, 95% CI 0.38 to 1.39). in patients with diabetes, SGLT2Is significantly reduced cardiovascular mortality, HHF, and serious adverse events. However, in patients without, despite showing a significant reduction in HHF, SGLT2I reduced cardiovascular mortality or serious adverse events but without statistical significance.

Lack of correlation between different congestion markers in acute decompensated heart failure

BACKGROUND

Hospitalizations for acute decompensated heart failure (ADHF) are commonly associated with congestion-related signs and symptoms. Objective and quantitative markers of congestion have been identified, but there is limited knowledge regarding the correlation between these markers.

METHODS

Patients hospitalized for ADHF irrespective of left ventricular ejection fraction were included in a prospective registry. Assessment of congestion markers (e.g., NT-proBNP, maximum inferior vena cava diameter, dyspnea using visual analogue scale, and a clinical congestion score) was performed systematically on admission and at discharge. Telephone interviews were performed to assess clinical events, i.e., all-cause death or readmission for cardiovascular cause, after discharge. Missing values were handled by multiple imputation.

RESULTS

In total, 130 patients were prospectively enrolled. Median length of hospitalization was 9 days (interquartile range 6 to 16). All congestion markers declined from admission to discharge (p < 0.001). No correlation between the congestion markers could be identified, neither on admission nor at discharge. The composite endpoint of all-cause death or readmission for cardiovascular cause occurred in 46.2% of patients. Only NT-proBNP at discharge was predictive for this outcome (hazard ratio 1.48, 95% confidence interval 1.15 to 1.90, p = 0.002).

CONCLUSION

No correlation between quantitative congestion markers was observed. Only NT-proBNP at discharge was significantly associated with the composite endpoint of all-cause death or readmission for cardiovascular cause. Findings indicate that the studied congestion markers reflect different aspects of congestion.

Bedside Ultrasound for Hemodynamic Monitoring in Cardiac Intensive Care Unit

Thanks to the advances in medical therapy and assist devices, the management of patients hospitalized in cardiac intensive care unit (CICU) is becoming increasingly challenging. In fact, Patients in the cardiac intensive care unit are frequently characterized by dynamic and variable diseases, which may evolve into several clinical phenotypes based on underlying etiology and its complexity. Therefore, the use of noninvasive tools in order to provide a personalized approach to these patients, according to their phenotype, may help to optimize the therapeutic strategies towards the underlying etiology. Echocardiography is the most reliable and feasible bedside method to assess cardiac function repeatedly, assisting clinicians not only in characterizing hemodynamic disorders, but also in helping to guide interventions and monitor response to therapies. Beyond basic echocardiographic parameters, its application has been expanded with the introduction of new tools such as lung ultrasound (LUS), the Venous Excess UltraSound (VexUS) grading system, and the assessment of pulmonary hypertension, which is fundamental to guide oxygen therapy. The aim of this review is to provide an overview on the current knowledge about the pathophysiology and echocardiographic evaluation of perfusion and congestion in patients in CICU, and to provide practical indications for the use of echocardiography across clinical phenotypes and new applications in CICU.

Traditional and new biomarkers of congestion in heart failure

The presence of pulmonary and systemic congestion is the main cause of the poor outcome of the patients with heart failure. Despite of the availability of several tools of the modern medicine, the degree of congestion is usualy difficult to evaulate. The clinical, imaging and laboratory methods are the tools, which can estimated the degree of congestion.

Prediction of rehospitalization in patients with acute heart failure using point-of-care lung ultrasound

Background

More than 50% of patients admitted for acute heart failure are discharged with residual pulmonary congestion. Residual pulmonary congestion at discharge is associated with rehospitalization and death within 6 months after discharge. B-lines detected by lung ultrasound are the sonographic manifestation of pulmonary congestion, a major predictor of morbidity and mortality in patients with heart failure. The present study was performed to evaluate the prognostic value of B-lines at discharge for prediction of rehospitalization and death at 6 months in patients with acute heart failure.

Methods

This study involved a prospective cohort of 126 patients admitted to Ramathibodi Hospital for acute heart failure (mean age, 69 ± 15 years). B-lines and the size of the inferior vena cava were assessed within 24 h before discharge. The patients were followed up for 6 months after discharge.

Results

The mean number of B-lines at discharge was 9 ± 9, and the rate of rehospitalization within 6 months was significantly higher in patients with a significant number of B-lines (≥ 12) than in patients with a non-significant number of B-lines (< 12) (log rank χ² = 7.74, P = 0.004). In the univariable analysis, the presence of ≥ 12 B-lines before discharge (hazard ratio = 2.15, 95% confidence interval = 1.27–3.63) was an independent predictor of events at 6 months.

Conclusions

Residual pulmonary congestion before discharge as detected by point-of-care lung ultrasound predicts rehospitalization for heart failure at 6 months. The presence of non-significant B-lines identifies a subgroup at low risk of rehospitalization for heart failure.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02781-9.

Congestion in heart failure: a circulating biomarker-based perspective. A review from the Biomarkers Working Group of the Heart Failure Association, European Society of Cardiology

Congestion is a cardinal sign of heart failure (HF). In the past, it was seen as a homogeneous epiphenomenon that identified patients with advanced HF. However, current evidence shows that congestion in HF varies in quantity and distribution. This updated view advocates for a congestive-driven classification of HF according to onset (acute vs. chronic), regional distribution (systemic vs. pulmonary), compartment of distribution (intravascular vs. extravascular), and clinical vs. subclinical. Thus, this review will focus on the utility of circulating biomarkers for assessing and managing the different fluid overload phenotypes. This discussion focused on the clinical utility of the natriuretic peptides, carbohydrate antigen 125 (also called mucin 16), bio-adrenomedullin and mid-regional pro-adrenomedullin, ST2 (also known as interleukin-1 receptor-like 1), cluster of differentiation 146, troponin, C-terminal pro-endothelin-1, and parameters of haemoconcentration. The utility of circulation biomarkers on top of clinical evaluation, haemodynamics, and imaging needs to be better determined by dedicated studies. Some multiparametric frameworks in which these tools contribute to management are proposed.

Non-invasive assessment of acute heart failure by Stevenson classification: Does echocardiographic examination recognize different phenotypes?

Background

Acute heart failure (AHF) presentation is universally classified in relation to the presence or absence of congestion and the peripheral perfusion condition according to the Stevenson diagram. We sought to evaluate a relationship existing between clinical assessment and echocardiographic evaluation in patients with AHF.

Materials and methods

This is a retrospective blinded multicenter analysis assessing both clinical and echocardiographic analyses during the early hospital admission for AHF. Patients were categorized into four groups according to the Stevenson presentation: group A (warm and dry), group B (cold and dry), group C (warm and wet), and group D (cold and wet). Echocardiographic evaluation was executed within 12 h from the first clinical evaluation. The following parameters were measured: left ventricular (LV) volumes, LV ejection fraction (LVEF); pattern Doppler by E/e1 ratio, pulmonary artery systolic pressure (PASP), tricuspid annular plane systolic excursion (TAPSE), and inferior cave vein diameter (ICV).

Results

We studied 208 patients, 10 in group A, 16 in group B, 153 in group C, and 29 in group D. Median age of our sample was 81 [69–86] years and the patients enrolled were mainly men (66.8%). Patients in groups C and A showed significant higher levels of systolic arterial pressures with respect to groups B and D (respectively, 130 [115–145] mmHg vs. 122 [119–130] mmHg vs. 92 [90–100] mmHg vs. 95 [90–100] mmHg, p < 0.001). Patients in groups A and C (warm) demonstrated significant higher values of LVEF with respect to patients in groups B and D (43 [34–49] vs. 42 [30–49] vs. 27 [15–31] vs. 30 [22–42]%, p < 0.001). Whereas group B experienced significant lower TAPSE values compared with other group (14 [12–17] mm vs. A: 17 [16–21] mm vs. C: 18 [14–20] mm vs. D: 16 [12–17] mm; p = 0.02). Finally, echocardiographic congestion score including PASP ≥ 40 mmHg, ICV ≥ 21, mm and E/e’ > 14 did not differ among groups. Follow-up analysis showed an increased mortality rate in D group (HR 8.2 p < 0.04).

Conclusion

The early Stevenson classification remains a simple and universally recognized approach for the detection of congestion and perfusion status. The combined clinical and echocardiographic assessment may be useful to better define the patients’ profile.

Fluid Volume Homeostasis in Heart Failure: A Tale of 2 Circulations

Fluid volume homeostasis in health and heart failure (HF) requires a complex interaction of 2 systems, the intravascular and interstitial-lymphatic circulations. With the development of HF both the intravascular and interstitial compartments undergo variable degrees of volume remodeling which can include significant expansion. This reflects the impact of multiple pathophysiologic mechanisms on both fluid compartments which initially play a compensatory role to stabilize intravascular circulatory integrity but with progression in HF can evolve to produce the various manifestations of volume overload and clinical HF congestion. The intent of this review is to help enhance recognition of the pathophysiologic and clinical importance of the interlinked roles of these 2 circulatory systems in volume regulation and chronic HF. It would also be hoped that a better understanding of the interacting functions of the intravascular and interstitial-lymphatic fluid compartments can potentially aid development of novel management strategies particularly addressing the generally undertargeted interstitial-lymphatic system and help bring such approaches forward through a more integrated view of these 2 circulatory systems.

Bedside ultrasound to assess acute central venous pressure change during treatment of decompensated heart failure

•

Volume status assessment by physical exam in heart failure patients is often inaccurate.

•

Right heart catheterization (RHC) carries safety, pragmatic and financial burdens.

•

A non-invasive, safe, and reliable alternative for accurate assessment of volume status is needed for optimal management of heart failure.

•

Serial portable ultrasonic assessment of internal jugular vein compliance can act as a surrogate for RHC to determine volume status.

Background

Accurate volume status assessment is crucial for the treatment of acute decompensated heart failure (ADHF). Volume status assessment by physical exam is often inaccurate, necessitating invasive measurement with right heart catheterization (RHC), which carries safety, pragmatic (scheduling, holding anticoagulants, etc.), and financial burdens. Therefore, a reliable, non-invasive, cost-effective alternative is desired. Previously, we developed an ultrasound (US) based technique to measure internal jugular vein (IJV) compliance during RHC which was used for single time point central venous pressure (CVP) predictions. We now aim to apply this technique to track acute changes in CVP during diuresis for ADHF in patients with an in-dwelling pulmonary artery catheter (PAC).

Methods

We used an observational, prospective study design and recruited 15 patients from the cardiac critical unit (CCU) being treated for ADHF (systolic or diastolic) with intravenous (IV) diuretics with/without inotropic agents who underwent Swan- Ganz catheter/PAC insertion for continuous CVP monitoring. 13 of 15 patients received milrinone infusions. US images of the IJV were obtained at end-expiration and during the strain phase of Valsalva at multiple 2–3 hours intervals. Change in IJV cross-sectional area (CSA) (ImageJ) was used as a measure of IJV compliance. Patients unable to perform the Valsalva maneuver were excluded.

Results

Calculated percentage change (%Δ) in CSA of IJV was plotted against CVP. An inverse relationship was observed between CVP and %Δ in CSA of IJV. The data was fit with a polynomial regression curve (R² = 0.36, root mean square error = 3.19). Fivefold cross-validation showed a stable model for predicting CVP based on CSA (R² = 0.31, root mean square error = 3.18)

Conclusion

Serial portable US assessment of IJV compliance can act as a surrogate measure of CVP and, therefore, can provide reliable information on acute hemodynamic changes in ADHF.

Multimodal Strategies for the Diagnosis and Management of Refractory Congestion. An Integrated Cardiorenal Approach

Refractory congestion is common in acute and chronic heart failure, and it significantly impacts functional class, renal function, hospital admissions, and survival. In this paper, the pathophysiological mechanisms involved in cardiorenal syndrome and the interplay between heart failure and chronic kidney disease are reviewed. Although the physical exam remains key in identifying congestion, new tools such as biomarkers or lung, vascular, and renal ultrasound are currently being used to detect subclinical forms and can potentially impact its management. Thus, an integrated multimodal diagnostic algorithm is proposed. There are several strategies for treating congestion, although data on their efficacy are scarce and have not been validated. Herein, we review the optimal use and monitorization of different diuretic types, administration route, dose titration using urinary volume and natriuresis, and a sequential diuretic scheme to achieve a multitargeted nephron blockade, common adverse events, and how to manage them. In addition, we discuss alternative strategies such as subcutaneous furosemide, hypertonic saline, and albumin infusions and the available evidence of their role in congestion management. We also discuss the use of extracorporeal therapies, such as ultrafiltration, peritoneal dialysis, or conventional hemodialysis, in patients with normal or impaired renal function. This review results from a multidisciplinary view involving both nephrologists and cardiologists.

Venous Leg Compression for Tissue Decongestion in Patients With Worsening Congestive Heart Failure

Aims

Venous leg compression (VLC) with elastic bandages has been proposed as a potentially useful strategy for decreasing tissue congestion. We aimed to evaluate the effect of VLC on short-term changes on intravascular refill, assessed by inferior vena cava (IVC) diameter in patients with worsening heart failure (WHF) requiring parenteral furosemide. Additionally, we sought to evaluate whether early changes in IVC were related to short-term decongestion.

Methods

This is a prospective study in which we included 20 consecutive ambulatory patients with WHF treated with subcutaneous furosemide and VLC for at least 72 h. The endpoints were (a) short-term changes in IVC, (b) the association between decongestion and 3-h IVC changes following VLC. Changes in continuous endpoints and their longitudinal trajectories were estimated with linear mixed regression models. All analyses were adjusted for multiple comparisons.

Results

Following administration of subcutaneous furosemide and VLC, we found a significant increase in 3-h IVC diameter (ΔIVC = 1.6 mm, CI 95%: 0.7–2.5; p &lt; 0.001), with a greater increase in those with baseline IVC≤21 mm (2.4 vs. 0.8 mm; p &lt; 0.001). 3-h intravascular refill (increase in IVC≥2 mm) was associated with greater decongestion (natriuresis, weight, peripheral edemas, and dyspnea) in those with baseline IVC≤21 mm but not when IVC&gt;21 mm (p &lt; 0.05 for all comparisons).

Conclusions

In this cohort of patients with congestive WHF treated with subcutaneous furosemide and VLC, we found a greater increase in short-term IVC in those with IVC ≤21 mm at baseline. In this subset of patients, a 3-h increase in IVC≥2 mm was associated with greater short-term decongestion.

Prognosis of Advanced Heart Failure Patients according to Their Hemodynamic Profile Based on the Modified Forrester Classification

Introduction: Heart transplantation (HT) remains the gold-standard treatment but is conditioned by organ shortage. This study aimed to evaluate the value of Forrester classification and determine which congestion criteria had the best prognostic value to predict cardiorenal events on heart transplant waiting list. Methods and results: One hundred consecutive patients (54 years old, 72% men) with available right heart catheterization (RHC) listed in our center for HT between 2014 and 2019 were included. Cardiac catheterization measurements were obtained at the time of HT listing evaluation. Patients were classified according to perfusion and congestion status in four groups: “warm and dry”, “warm and wet”, “cold and dry”, and “cold and wet”. pWet was used to classify patients with pulmonary congestion and sWet for systemic congestion. The primary endpoint was the rate of a composite criteria of cardiogenic shock, acute kidney injury, and acute heart failure. Secondary endpoint was the incidence of waitlist death, emergency HT, or left ventricular assist device (LVAD) implantation at 12 months evaluated by Kaplan–Meier curves and log-rank test. Only Forrester classification according to systemic congestion was associated with the primary composite endpoint (p = 0.011), while patients’ profile according to pulmonary congestion was not (p = 0.331). Similarly, only the Forrester classification according to systemic congestion predicted waitlist death, emergency HT, or LVAD implantation at 12 months, with p = 0.010 and p = 0.189 for systemic and pulmonary congestion, respectively. Moreover, systemic congestion was the main driver of cardiorenal events on waitlist. Conclusions: Forrester classification according to systemic congestion is associated with cardiorenal outcomes in patients listed for heart transplant and the risk of waitlist death, emergency HT, or LVAD implantation at 12 months.

Prognostic values of B-lines combined with clinical congestion assessment at discharge in heart failure patients

AIMS

We aim to investigate the additive effect of B-lines on lung ultrasound (LUS) for predicting outcome in patients with heart failure (HF) when combined with conventional assessment of clinical congestion.

METHODS AND RESULTS

This study prospectively enrolled 117 hospitalized HF patients (61 ± 16 years, 70.1% males) who underwent congestion assessment by the 'wet/dry' status, clinical congestion score (CCS), and B-lines on LUS. The primary endpoint was all-cause mortality or hospitalization for HF during the 180-day follow-up after discharge. The 'Wet', CCS ≥ 3, and B-lines >5, indicators of congestion positive (+), were observed in 83.8%, 76.1%, and 70.1% of the patients on admission, respectively; and the numbers significantly decreased to 41.9%, 41.9%, and 35.9% at discharge, respectively. The agreement between the 'wet/dry' status and B-lines (58.1%) or between CCS and B-lines (56.4%) was moderate at discharge, in terms of both positive and both negative. By incorporating the B-lines with assessment of clinical congestion, the patients at discharge were divided into three phenotypes as clinical congestion (+), clinical congestion (-) with B-lines (+), and clinical congestion (-) with B-lines (-). The Kaplan-Meier analysis showed a better survival in the both (-) group ('wet/dry' with B-lines: Chi-square 10.591, P = 0.005; CCS with B-lines: χ² 6.239, P = 0.031). When the 'wet' patients (n = 49) being taken as the reference, the 'dry' patients with B-lines (+) (n = 21) had an identical risk of the composite endpoint (hazard ratio [HR] adjusted for clinical covariates 1.021, 95% confidence interval [CI] 0.480-2.134, P = 0.974), while the 'dry' patients with B-lines (-) (n = 47) had a lower risk (HR 0.264, 95% CI 0.113-0.617, P = 0.002). When the CCS (+) patients (n = 49) being regarded as the reference, similar results were obtained in the patients with CCS (-) but B-lines (+) (n = 22) (HR 1.348, 95% CI 0.627-2.896, P = 0.444) as well as in those with both CCS (-) and B-lines (-) (n = 46) (HR 0.447, 95% CI 0.202-0.992, P = 0.048).

CONCLUSIONS

The combination of B-lines on LUS and conventional assessment helped to identify new phenotypes of congestion that aid in the risk stratification of discharged HF patients. Further investigation is warranted to determine whether this strategy could be adopted as a guide for decongestion therapy.

Association of peripheral venous pressure with adverse post-discharge outcomes in patients with acute heart failure: a prospective cohort study

AIMS

Congestion is the major cause of hospitalization for heart failure (HF). Traditional bedside assessment of congestion is limited by insufficient accuracy. Peripheral venous pressure (PVP) has recently been shown to accurately predict central venous congestion. We examined the association between PVP before discharge and post-discharge outcomes in hospitalized patients with acute HF.

METHODS AND RESULTS

Bedside PVP measurement at the forearm vein and traditional clinical examination were performed in 239 patients. The association with the primary composite endpoint of cardiovascular death or HF hospitalization and the incremental prognostic value beyond the established HF risk score was examined. The PVP correlated with peripheral oedema, jugular venous pressure, and inferior vena cava diameter, but not with brain-type natriuretic peptide. The 1-year incidence of the primary outcome measure in the first, second, and third tertiles of PVP was 21.4, 29.9, and 40.7%, respectively (log-rank P = 0.017). The adjusted hazard ratio of PVP per 1 mmHg increase for the 1-year outcome was 1.08 [95% confidence interval (1.03-1.14), P = 0.004]. When added onto the Meta-Analysis Global Group in Chronic HF risk score, PVP significantly increased the area under the receiver-operating characteristic curve for predicting the outcome [from 0.63 (0.56-0.71) to 0.70 (0.62-0.77), P = 0.02), while traditional assessments did not. The addition of PVP also yielded significant net reclassification improvement [0.46 (0.19-0.74), P < 0.001].

CONCLUSION

The PVP at discharge correlated with prognosis. The results warrant further investigation to evaluate the clinical application of PVP measurement in the care of HF.

TRIAL REGISTRATION NUMBER

UMIN000034279.

The use of multidisciplinary teams, electronic health records tools, and technology to optimize heart failure population health

PURPOSE OF REVIEW

Given the limited population level, adoption of optimal therapy that has been shown in recent clinical trials and heart failure registries, efforts to rapidly and safely improve adoption of guideline-directed medical therapy for heart failure should be prioritized. Opportunities to leverage remote monitoring technology, the electronic health record (EHR), and multidisciplinary teams to improve heart failure care merit review.

RECENT FINDINGS

Dedicated multidisciplinary teams employing algorithmic medication titration schema have shown better efficacy than clinician alerts or quality initiatives that focus on education and audit-feedback processes alone. Technology that enables invasive pressure monitoring and wearable devices that transmit physiologic data have the potential to predict decompensation and allow for early intervention by alerting clinicians to signs of congestion/clinical worsening but further real-world data is needed to prove efficacy and develop effective treatment protocols.

SUMMARY

The combination of technology, multidisciplinary teams, and identification of populations for intervention using the EHR will be central to impactful innovation in heart failure population health and prevention of avoidable morbidity. Novel approaches to study implementation efforts including cluster randomized trials are needed.

Understanding the Pathobiology of Pulmonary Hypertension Due to Left Heart Disease

The development of pulmonary hypertension (PH) is common and has adverse prognostic implications in patients with heart failure due to left heart disease (LHD), and thus far, there are no known treatments specifically for PH-LHD, also known as group 2 PH. Diagnostic thresholds for PH-LHD, and clinical classification of PH-LHD phenotypes, continue to evolve and, therefore, present a challenge for basic and translational scientists actively investigating PH-LHD in the preclinical setting. Furthermore, the pathobiology of PH-LHD is not well understood, although pulmonary vascular remodeling is thought to result from (1) increased wall stress due to increased left atrial pressures; (2) hemodynamic congestion-induced decreased shear stress in the pulmonary vascular bed; (3) comorbidity-induced endothelial dysfunction with direct injury to the pulmonary microvasculature; and (4) superimposed pulmonary arterial hypertension risk factors. To ultimately be able to modify disease, either by prevention or treatment, a better understanding of the various drivers of PH-LHD, including endothelial dysfunction, abnormalities in vascular tone, platelet aggregation, inflammation, adipocytokines, and systemic complications (including splanchnic congestion and lymphatic dysfunction) must be further investigated. Here, we review the diagnostic criteria and various hemodynamic phenotypes of PH-LHD, the potential biological mechanisms underlying this disorder, and pressing questions yet to be answered about the pathobiology of PH-LHD.