The Importance of Optimal Hydration in Patients with Heart Failure-Not Always Too Much Fluid

Oedema index trajectories at heart failure nurse clinics over 6 months after acute heart failure predict patient outcomes: a retrospective cohort study

AIMS

Fluid accumulation is associated with poor outcomes in patients with heart failure (HF). After acute HF, HF nurses provide home care suggestions based on oedema status assessed at outpatient clinics. However, the pattern of serial oedema changes and their associations with patient outcomes are unknown. We investigated the trajectories of bioimpedance analysis (BIA)-derived oedema index (EI) changes following acute HF and their prognostic value.

METHODS AND RESULTS

This was a retrospective cohort study. We recruited 761 patients hospitalized for HF. Multisegmented and multifrequency BIA-derived EIs were measured at HF nurse outpatient clinics after discharge for 6 months. We explored the trajectories of EIs and their associations with all-cause rehospitalization and death within 2 years. Four EI trajectories were identified: trajectory 1 [T1, no oedema, n = 181 (23.8%)], T2 [transient, n = 341 (44.8%)], T3 [fluctuation, n = 195 (25.6%)], and T4 [worsening, n = 44 (5.8%)]. Compared with the T1 group, the T3 and T4 groups included more females; were older; had higher natriuretic peptide and glycohaemoglobin levels; and had higher incidences of comorbidities but lower albumin and cholesterol and worse kidney function (all P < 0.05). The Kaplan-Meier survival curves showed that T2, T3, and T4 patients had lower event-free survival rates than did T1 patients (all P < 0.01). Multivariable analysis demonstrated that T3 and T4 were independently associated with an increased risk for events (P < 0.001).

CONCLUSION

During the 6-month outpatient period after hospitalization, the EI trajectory of fluctuation or worsening was associated with poor outcomes. In the post-acute phase, monitoring the EI trajectory helps identify high-risk patients for optimizing HF management.

Exploring Neurohormonal Modulation by Acetazolamide in Heart Failure

Background Heart failure (HF) is commonly managed by addressing water and sodium (Na) balance, with arterial circulation playing a major role in influencing renal Na and water excretion. Recently, chloride (Cl) has been recognized as an important factor in HF, associated with volume regulation and its modulation of renin-angiotensin-aldosterone system (RAAS) activity through macula densa signaling, which impacts Na retention and neurohormonal activation. Acetazolamide, a carbonic anhydrase inhibitor, can enhance decongestion in HF by increasing urinary Na and Cl excretion when added to loop diuretics, a mechanism supported by prior studies demonstrating improved urine output and decongestion. Objective This study investigates the neurohormonal effects of acetazolamide in acute HF, focusing on its ability to enhance decongestion, reduce neurohormonal activation (e.g., renin and aldosterone), and modulate RAAS markers. Methods In this prospective, single-center observational study, 80 patients with acute HF were enrolled and divided into two groups: a case group (n=40) receiving acetazolamide with standard therapy and a control group (n=40) on standard therapy alone. Patients were matched based on clinical characteristics to reduce selection bias. Baseline characteristics, neurohormonal profiles, including plasma renin activity (PRA) and aldosterone, electrolyte levels, and clinical outcomes were compared. Results The acetazolamide group exhibited higher urinary Cl excretion (108.9±25.3 mEq/L vs. 79.2±22.7 mEq/L; p<0.001) and reduced PRA and aldosterone levels (1.3±0.4 ng/mL/h and 88±21 pg/mL) compared to controls (1.7±0.6 ng/mL/h and 128±29 pg/mL; p=0.002 and p=0.006, respectively). These reductions in PRA and aldosterone are significant as they correlate with improved volume status and reduced neurohormonal stress, which are critical components in HF management. Improved clinical outcomes included a greater percentage of patients becoming symptom-free within 72 hours (77.5% vs. 52.5%; p=0.018) and shorter hospitalization (5.6±1.4 days vs. 7.1±1.7 days; p=0.028). Conclusion Acetazolamide in addition to standard therapy enhances decongestion and reduces neurohormonal activation in acute HF, suggesting its dual benefit in fluid management and neurohormonal modulation. Further research is needed to confirm these benefits, assess long-term effects, and overcome limitations, including the study's single-center observational design.

Nutritional and Nutraceutical Support to the Failing Myocardium: A Possible Way of Potentiating the Current Treatment of Heart Failure

Heart failure (HF) is a complex condition that affects 1-2% of the global population. The presence of comorbidities like diabetes, hypertension, hyperlipidemia, or obesity has been shown in various studies to elevate mortality and hospitalization rates in HF patients. Insufficient outcomes persist in HF, necessitating additional research to address unmet needs in disease management. Lifestyle modifications, including smoking cessation, decreased alcohol consumption, regular exercise, cardiac rehabilitation, and a balanced diet, can prevent and treat a wide range of HF cases. In this review, we aimed to examine how lifestyle changes, nutrition, and nutraceutical supplements can play a role in preventing heart failure and supporting its treatment. A detailed and comprehensive analysis of the most recent data present in the literature could help identify potential candidates for future clinical trials in HF management. There is a growing body of evidence supporting the importance of closely monitoring nutritional balance, including micronutrients and nutraceuticals, in HF patients for better symptom management and outcomes. Despite promising results from initial approaches, the lack of conclusive evidence from recent studies and meta-analyses questions the widespread use of nutraceutical supplementation in HF patients. Further studies are necessary to determine the most effective way to use nutraceutical supplementation in the treatment of myocardial dysfunction in HF patients.

Heart failure related fatigue: An exploratory analysis of serum osmolality from the national health and nutrition examination survey

BACKGROUND

Fatigue is a prominent symptom of heart failure (HF). However, underlying mechanisms remain poorly understood. Fluid volume status has been suggested as a physiologic mechanism of HF-related fatigue. Serum osmolality may fluctuate with changes in volume status associated with neurohormonal dysregulation. The relationship of fatigue to serum osmolality has not been assessed in adults with HF.

OBJECTIVES

Describe the relationship between serum osmolality and fatigue in adults with HF.

METHODS

We analyzed two waves of cross-sectional data from the National Health and Nutrition Examination Survey (2015-2016 and 2017-2018). Adults who self-reported having HF without select co-morbid conditions known to contribute to fatigue were included. Data were weighted to provide US national estimates, and complex sample design used for analyses. Sequential logistic regression was used to isolate the effect of serum osmolality on the odds of having fatigue.

RESULTS

Data from the sample represented 1.4 million Americans with HF (58.5 % male; median age 68 years), of whom 1,001,589 (67.9 %) reported fatigue. Participants with fatigue had lower serum osmolality compared to those without fatigue (t = -3.04, p = .009). Higher serum osmolality was associated with 8.8 % lower odds of experiencing fatigue when controlling for sex and body mass index (OR = 0.912, p = .007, CI 0.857 - 0.972).

CONCLUSIONS

HF-related fatigue is associated with lower serum osmolality. Low serum osmolality may indicate excess volume and the presence of a heightened neurohormonal response, both of which may influence fatigue. Alternatively, serum osmolality may directly affect other physiologic changes that may contribute to fatigue.

Association of hydration status and in-hospital mortality in critically ill patients with ischemic stroke: Data from the MIMIC-IV database

BACKGROUND

Hydration plays a critical role in the pathophysiological progression of ischemic stroke. However, the impact of extreme hydration on the mortality of critically ill patients with ischemic stroke remains unclear. Therefore, our objective was to evaluate the association between hydration, as indicated by the blood urea nitrogen to creatinine ratio (UCR), and in-hospital mortality in critically ill patients with ischemic stroke.

METHODS

Data from the Medical Information Mart for Intensive Care (MIMIC-IV) database were utilized. Patients with ischemic stroke admitted to the Intensive Care Unit (ICU) for the first time were identified. The exposure variable was the hydration state represented by the UCR. The study outcome measure was in-hospital mortality. The primary analytical approach involved multivariate Cox regression analysis. Kaplan-Meier curves were constructed, and subgroup analyses with interaction were performed.

RESULTS

A total of 1539 patients, with a mean age of 69.9 years, were included in the study. Kaplan-Meier curves illustrated that patients in higher UCR tertiles exhibited increased in-hospital mortality. Accordingly, the risk of in-hospital mortality significantly rose by 29 % with every 10 units increase in UCR. Subgroup analysis indicated a robust association between UCR and in-hospital mortality in each subgroup, with no statistically significant interactions observed.

CONCLUSION

Hydration status is significantly associated with in-hospital all-cause mortality in critically ill patients with ischemic stroke. This finding underscores the importance of closely monitoring critically ill patients for adequate hydration and implementing appropriate rehydration strategies.

Fluid Restriction for Patients with Heart Failure: Current Evidence and Future Perspectives

Fluid restriction has long been believed to benefit patients with heart failure by counteracting the activated renin-angiotensin aldosterone system and sympathetic nervous activity. However, its effectiveness remains controversial. In this paper, we summarized the current recommendations and reviewed the scientific evidence on fluid restriction in the setting of both acute decompensated heart failure and compensated heart failure. While a recent meta-analysis demonstrated the beneficial effects of fluid restriction on both all-cause mortality and hospitalization compared to usual care, several weaknesses were identified in the assessment of the methodological quality of the meta-analysis using AMSTAR 2. Further randomized controlled trials with larger sample sizes are needed to elucidate the benefits of fluid restriction for both clinical outcomes and patient-reported outcomes in patients with heart failure.

Impact of homeostatic body hydration status, evaluated by hemodynamic measures, on different pain sensitization paths to a chronic pain syndrome

Contrasting findings on the mechanisms of chronic pain and hypertension development render the current conventional evidence of a negative relationship between blood pressure (BP) and pain severity insufficient for developing personalized treatments. In this interdisciplinary study, patients with fibromyalgia (FM) exhibiting clinically normal or elevated BP, alongside healthy participants were assessed. Different pain sensitization responses were evaluated using a dynamic 'slowly repeated evoked pain' (SREP) measure, as well as static pain pressure threshold and tolerance measures. Cardiovascular responses to clino-orthostatic (lying-standing) challenges were also examined as acute re- and de-hydration events, challenging cardiovascular and cerebrovascular homeostasis. These challenges involve compensating effects from various cardiac preload or afterload mechanisms associated with different homeostatic body hydration statuses. Additionally, hair cortisol concentration was considered as a factor with an impact on chronic hydration statuses. Pain windup (SREP) and lower pain threshold in FM patients were found to be related to BP rise during clinostatic (lying) rehydration or orthostatic (standing) dehydration events, respectively. These events were determined by acute systemic vasoconstriction (i.e., cardiac afterload response) overcompensating for clinostatic or orthostatic cardiac preload under-responses (low cardiac output or stroke volume). Lower pain tolerance was associated with tonic blood pressure reduction, determined by permanent hypovolemia (low stroke volume) decompensated by permanent systemic vasodilation. In conclusion, the body hydration status profiles assessed by (re)activity of systemic vascular resistance and effective blood volume-related measures can help predict the risk and intensity of different pain sensitization components in chronic pain syndrome, facilitating a more personalized management approach.