The Prognostic Value of Right Ventricular Function in Patients with Chronic Heart Failure-A Prospective Study

Background: In patients with stable chronic heart failure with a reduced ejection fraction (HFrEF), left ventricular ejection fraction (LVEF) provides limited prognostic value, especially in patients with moderately to severely reduced LVEF. Echocardiographic parameters of right ventricular function may be associated with adverse clinical events in these patients. Therefore, we analyzed 164 patients with HFrEF in a prospective single-center cohort study to evaluate whether the parameters of right ventricular function are associated with worsening heart failure (WHF) hospitalizations, cardiovascular and all-cause deaths and combined endpoints. Methods: Echocardiographic cine loops were analyzed using vendor-independent post-processing software. Multivariate Cox regression analyses were performed, which were then adjusted for clinical characteristics and left ventricular functional parameters. Results: In these models, higher tricuspid annular plane systolic excursion (TAPSE) was significantly associated with lower rates of WHF hospitalizations (HR 0.880, 95%CI 0.800-0.968, p = 0.008), a composite endpoint of WHF hospitalizations and cardiovascular death (HR 0.878, 95%CI 0.800-0.964, p = 0.006), and a composite endpoint of WHF hospitalization and all-cause death (HR 0.918, 95%CI 0.853-0.988, p = 0.023). These associations were more pronounced in patients with LVEF ≤ 35%. Conclusions: In conclusion, in patients with HFrEF, TAPSE is an independent prognosticator for adverse clinical outcomes, warranting further studies to elucidate whether incorporating TAPSE into established risk scores improves their diagnostic accuracy.

Prevalence and prognostic impact of bone disease in chronic heart failure with reduced ejection fraction

AIMS

Chronic heart failure is associated with a bone-catabolic state and increases the risk of osteoporosis and fractures. Prospective studies investigating the clinical relevance of bone disease in heart failure are lacking. We aimed to assess the prevalence and prognostic impact of osteoporosis and vertebral fractures (VFs) in chronic heart failure with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

Symptomatic outpatients with chronic heart failure and a previous diagnosis of overtly reduced left ventricular ejection fraction < 40% on stable, optimal HFrEF therapy and left ventricular ejection fraction < 50% at enrolment were included into a prospective single-centre study. Osteoporosis was determined with dual-energy X-ray absorptiometry and defined as a T-score ≤ 2.5 at any site. VFs were assessed using X-ray of both thoracic and lumbar spine applying the semiquantitative Genant score. We enrolled 205 patients (22% women), with a median age of 66 (IQR 58-74) years. Median left ventricular ejection fraction was 37 (IQR 30-43) % and median N-terminal pro B-type natriuretic peptide was 964 (IQR 363-2173) pg/mL. Osteoporosis, as defined by bone mineral density, and at least one VF were prevalent in 31 (15%) and 29 patients (14%). Osteoporosis or VF were present in 55 patients (27%) and 5 patients (2%) had both osteoporosis and a VF. During a median follow-up of 4.7 (IQR 4.0-5.3) years, 18 patients (9%) died due to cardiovascular (CV) cause, and 46 patients (22%) had a worsening heart failure (WHF) hospitalization. In multivariate Cox regression analyses, presence of VF independently predicted CV death (HR 2.82, 95% CI 1.04-7.65, P = 0.042), WHF hospitalizations (HR 2.39, 95% CI 1.18-4.82, P = 0.015), and a composite endpoint of CV death and WHF hospitalizations (HR 2.44, 95% CI 1.23-4.82, P = 0.011). Osteoporosis was not significantly associated with CV events.

CONCLUSIONS

In a prospective study, bone disease affected every fourth patient with HFrEF, and patients with VF at baseline had a two-fold risk of subsequent CV death or WHF hospitalization. Prevalent bone disease, particularly VF, should be considered as a clinically relevant comorbidity in HFrEF.

[Pathophysiological significance of steatorrhea as well as of hydroxystearic acids in the feces of calves with diarrhea]

The objective of this study was to determine the digestibility of milk lipids in calves with diarrhoea, the pathophysiological effects of fat intake on the course of the disease and the conversion of malabsorbed longchain fatty acids to secretory effective hydroxy fatty acids by the intestinal flora.

ANIMALS

32 male calves of the breed "Deutsches Fleckvieh" with spontaneous occurring diarrhoea, age 3-14 days. Reference group: 6 clinically healthy calves of the same age group. Feed: whole milk, daily ration corresponding to 10% of the BM, divided into 3 meals; supplementary oral rehydration solution as required.

METHODS

Quantitative collection of the faeces excreted over a period of at least 72 hours, determination of fatty acids and glycerides, identification and quantification of hydroxystearic acids in the faeces by gas chromatography; calculation of the apparent digestibility of the milk lipids.

RESULTS

The apparent digestibility of the milk lipids was in part considerably reduced in direct relation (r = 0.8) to the severity of the diarrhoea. In the case of daily fecal outputs of over 50 g/kg BM (watery diarrhoea), the apparent fat digestibility was reduced below 50%. Even so, the apparent digestibility correlated positively with the milk intake (r = 0.5). The fat excretion in the patients showed an average of 1.4 g/kg BM/24 h and was thus nearly nine times higher in comparison to the reference group (0.16 g/kg BM/24 h). In the case of severe diarrhoea, fat excretion rates of over 2 (up to max. 5.8) g/kg BM in 24 hours were recorded. However, in the main (approx. 70%) it was not glycerides but nonesterified fatty acids. A part of the longchain fatty acids were converted to hydroxy fatty acids by the intestinal flora. It was possible to quantify alpha-, 10(9)- and 12-hydroxystearic acids individually in the faeces of both healthy calves and those with diarrhoea. However, the total concentration of hydroxystearic acids in the faces of 26 out of 32 patients was considerably under the secretory effective concentration of 2 mmol/kg (mean = 1.5 mmol/kg), the other six lay between 2.9 and 11.6 mmol/kg. Only a weakly positive correlation (r = 0.23 or 0.24) existed between the amount of milk intake and the fecal concentration resp. excretion of hydroxystearic acids.

CONCLUSIONS

There was no evidence that the consumption of milk lipids influenced the diarrhoea negatively. In individual cases, it could not be completely excluded that fluid and electrolyte absorption was affected by hydroxystearic acids produced in the intestine, but the quantitative effects of this process are of minor significance in comparison to other diarrhoea inducing factors.

[Bile acid concentrations in serum, bile and feces of healthy calves and calves with diarrhea]

On 32 calves (age 3 to 14 days) with spontaneously occurring diarrhoea, the following investigations were carried out: Regular examination of serum bile acid concentrations, collection of the entire faeces with determination of bile acid concentrations, as well as microbiological examinations. Six clinically healthy calves served as control group. In addition, bile acids in bile were determined in 16 other calves of the same age group and in 6 beef bulls. There was no significant influence of daytime or feed intake on serum bile acid concentration in diarrhoeic or healthy calves. Possibly due to the low concentrations of bile acids in the bile of young calves (4.8 +/- 3.7 mmol/l, compared to 57 +/- 13 mmol/l in the bulls), the concentrations in faeces were also rather low (control group 623 +/- 92, calves with diarrhoea 318 +/- 277, after diarrhoea. 794 +/- 935 mumol/kg). Most of it was cholic acid, whereas only traces of desoxycholic acid were found. In spite of the comparatively low concentrations of fecal bile acids, the diarrhoeic calves excreted larger amounts of bile acids than the healthy calves (12.7 +/- 13.5 vs. 1.4 +/- 0.8 mumol/kg), but this was independent of the type of enteropathogen or pathogen combinations which were detected. There were no indications for a direct influence of the diarrhoea by bile acids. However, through enteral bile acid losses, profuse diarrhoea lasting several days can cause a reduction in the total bile acid pool.

[Comparison between dialysis methods and centrifugation/filtration for collecting fecal fluid from calves]

Faecal samples of different consistency from 15 calves were subjected to two methods to separate faecal fluid. Osmolality as well as the concentrations of electrolytes and short chain fatty acids were determined for each of the fluid samples obtained and the results compared. For dialysis the following procedure was used: small dialysis bags filled with dextran 10% were placed in the cooled (4 degrees C) faecal sample to which gentamycin was added to inhibit fermentation. Equilibrium between dialysate and surrounding fluid was reached after 24 hours. However, depending on the consistency of the faeces, after 6 hours 90 to 95% of the final osmolality at 24 hours was reached. In regard to osmolality, sodium, potassium and chloride concentrations as well as to concentrations of short chain fatty acids no significant differences could be observed between the faecal fluid obtained by dialysis or by centrifugation (3500 g, 20 min, 4 degrees C) and subsequent filtration. Distinctly higher concentrations of calcium and inorganic phosphate were measured in the filtrates; the probable explanation is that these ions in faeces are largely present as poorly diffusible compounds (in particular with faeces of a more solid consistency) or bound to the cell membranes.