Outcomes for patients with implanted cardioverter-defibrillators admitted to the Emergency Department due to electrical shock during the pre-pandemic and COVID-19 era

BACKGROUND

Implantable cardioverter-defibrillators (ICD)/cardiac resynchronization therapy with defibrillation (CRT-D) recipients may be susceptible to the arrhythmic effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

AIMS

We aimed to evaluate characteristics and outcomes of patients hospitalized for ICD/CRT-D shocks during the pandemic compared to the pre-pandemic period.

METHODS

This retrospective study analyzed medical records of patients hospitalized for ICD/CRT-D shock in the pre-pandemic (January 1, 2018-December 31, 2019) and pandemic periods (March 4, 2020-March 3, 2022). Survival data were obtained on October 24, 2022.

RESULTS

In total, 198 patients (average age 65.6 years) had 138 pre-pandemic and 124 pandemic visits. Of these patients, 115 were hospitalized during pre-pandemic, 108 during the pandemic, and 25 in both periods. No significant differences were noted in age, sex, number of shocks, or appropriateness of therapy between these periods. During the pandemic, during 14 hospital stays of patients with SARS-CoV-2, 8 (57.1%) received electrical shocks, compared to 12 (10.9%) with negative SARS-CoV-2 tests (P <0.001). The in-hospital mortality rate was 2 of 115 patients hospitalized during the pre-pandemic and 7 of 108 during pandemic periods (4 patients with and 3 without SARS-CoV-2 [P = 0.10]). During the follow-up, there were 66 deaths. Cox regression analysis showed that survival decreased with age and heart failure decompensation in medical history but increased with higher ejection fraction. The pandemic alone was not a survival predictor. However, SARS-CoV-2 infection, older age, and heart failure decompensation in medical history predicted worse outcomes during the pandemic period.

CONCLUSIONS

The pandemic did not increase the number of hospital visits due to ICD/CRT-D discharges. SARS-CoV-2 infection predicts increased mortality in patients with ICD/CRT-D shocks.

Redox imbalance in patients with heart failure and ICD/CRT-D intervention. Can it be an underappreciated and overlooked arrhythmogenic factor? A first preliminary clinical study

Introduction: Redox imbalance and oxidative stress are involved in the pathogenesis of arrhythmias. They also play a significant role in pathogenesis of heart failure (HF). In patients with HFand implanted cardioverter-defibrillator (ICD) or cardiac resynchronization therapy defibrillator (CRT-D), the direct current shocks may be responsible for additional redox disturbances and additionally increase arrhythmia risk. However, the precise role of oxidative stress in potentially fatal arrhythmias and shock induction remains unclear. Methods: 36 patients with diagnosed HF and implanted ICD/CRT-D were included in this study. Patients were qualified to the study group in case of registered ventricular arrhythmia and adequate ICD/CRT-D intervention. The control group consisted of patients without arrhythmia with elective replacement indicator (ERI) status. Activity of superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), glutathione (GSH) in erythrocyte (RBC), SOD, GPx activity and reactive oxygen/nitrogen species (ROS/RNS) concentration in plasma were determined. The values were correlated with glucose, TSH, uric acid, Mg and ion concentrations. Results: In the perishock period, we found a significant decrease in RBC and extracellular (EC) SOD and RBC CAT activity (p = 0.0110, p = 0.0055 and p = 0.0002, respectively). EC GPx activity was also lower (p = 0.0313). In all patients, a decrease in the concentration of all forms of glutathione was observed compared to the ERI group. Important association between ROS/RNS and GSH, Mg, TSH and uric acid was shown. A relationship between the activity of GSH and antioxidant enzymes was found. Furthermore, an association between oxidative stress and ionic imbalance has also been demonstrated. The patients had an unchanged de Haan antioxidant ratio and glutathione redox potential. Conclusion: Here we show significant redox disturbances in patients with HF and ICD/CRT-D interventions. Oxidative stress may be an additional risk factor for the development of arrhythmia in patients with HF. The detailed role of oxidative stress in ventricular arrhythmias requires further research already undertaken by our team.

Intravenous iron supplementation improves energy metabolism of exercising skeletal muscles without effect on either oxidative stress or inflammation in male patients with heart failure with reduced ejection fraction

BACKGROUND

Skeletal muscle dysfunction is a feature of heart failure (HF). Iron deficiency (ID) is prevalent in patients with HF associated with exercise intolerance and poor quality of life. Intravenous iron in iron deficient patients with HF has attenuated HF symptoms, however the pathomechanisms remain unclear. The aim of study was to assess whether intravenous iron supplementation as compared to placebo improves energy metabolism of skeletal muscles in patients with HF.

METHODS

Men with heart failure with reduced ejection fraction (HFrEF) and ID were randomised in 1:1 ratio to either intravenous ferric carboxymaltose (IV FCM) or placebo. In vivo reduction of lactates by exercising skeletal muscles of forearm was analyzed. A change in lactate production between week 0 and 24 was considered as a primary endpoint of the study.

RESULTS

There were two study arms: the placebo and the IV FCM (12 and 11 male patients with HFrEF). At baseline, there were no differences between these two study arms. IV FCM therapy as compared to placebo reduced the exertional production of lactates in exercising skeletal muscles. These effects were accompanied by a significant increase in both serum ferritin and transferrin saturation in the IV FCM arm which was not demonstrated in the placebo arm.

CONCLUSIONS

Intravenous iron supplementation in iron deficient men with HFrEF improves the functioning of skeletal muscles via an improvement in energy metabolism in exercising skeletal muscles, limiting the contribution of anaerobic reactions generating ATP as reflected by a lower in vivo lactate production in exercising muscles in patients with repleted iron stores.

Atrioventricular synchronous leadless pacing: Micra AV

Since the arrival of leadless pacemakers (LPs), they have become a cornerstone in remedial treatment of bradycardia and atrioventricular (AV) conduction disorders, as an alternative to transvenous pacemakers. Even though clinical trials and case reports show indisputable benefits of LP therapy, they also bring some doubts. Together with the positive results of the MARVEL trials, AV synchronization has become widely available in LPs, presenting a significant development in leadless technology. This review presents the Micra AV (MAV), describes major clinical trials, and introduces the basics of AV synchronicity obtained with the MAV and its unique programming options.

Impact of assisted exercises on skeletal muscle oxygenation levels in men with acutely decompensated heart failure

BACKGROUND

The complex clinical status of modern day patients hospitalized due to acute heart failure (AHF) results from their advanced age, comorbidities, frailty, heart failure symptoms (including massive swelling of the lower limb), and dramatic reduction of exercise tolerance. Hence, there is a need to implement physiotherapeutic procedures as early as possible, aiming to both accelerate the restoration of clinical stabilization and prevent post-hospital disability.

OBJECTIVES

We investigated whether assisted lower limb exercises have an impact on perfusion and oxygenation in skeletal muscle and if they are feasible in patients with AHF.

MATERIAL AND METHODS

We examined 34 men (age: 66 ±11 years; left ventricular ejection fraction (LVEF): 34 ±11%; clinical presentation: 31 wet-warm and 3 wet-cold). The intervention (carried out on the 2nd day of hospitalization) included: 1) a 3-minute rest period; 2) an exercise phase (45 repetitions of assisted flexion and extension of the lower limb; and 3) a 10-minute relaxation period. We analyzed blood pressure (BP), heart rate (HR), respiratory rate (RR), tissue oxygenation (reflected by oxygen saturation measured with a pulse oximeter), and changes in peripheral tissue perfusion (reflected by the tissue oxygenation index (TOI) measured with near-infrared spectroscopy (NIRS)).

RESULTS

The hemodynamic parameters (both ΔHR and Δsystolic BP) and oxygen saturation did not change (all p > 0.05), whereas the RR declined (p < 0.001). The exercises improved venous outflow (reflected by decreased oxygenated, deoxygenated and total hemoglobin, all p < 0.05) and increased peripheral tissue perfusion, as reflected by the TOI (p < 0.05). The patients reported relief and lack of dyspnea during and after the assisted exercises.

CONCLUSIONS

The physiotherapeutic intervention improved both venous outflow and muscle oxygenation in men with AHF. The presented protocol was safe, feasible and well-tolerated, and resulted in relief for the patients. We believe that such procedures might be recommended for the initial period of rehabilitation in this challenging subgroup of patients.

Induction of Day-Time Periodic Breathing is Associated With Augmented Reflex Response From Peripheral Chemoreceptors in Male Patients With Systolic Heart Failure

Spontaneous day-time periodic breathing (sPB) constitutes a common phenomenon in systolic heart failure (HF). However, it is unclear whether PB during wakefulness could be easily induced and what are the physiological and clinical correlates of patients with HF in whom PB induction is possible. Fifty male HF patients (age 60.8 ± 9.8 years, left ventricle ejection fraction 28.0 ± 7.4%) were prospectively screened and 46 enrolled. After exclusion of patients with sPB the remaining underwent trial of PB induction using mild hypoxia (stepwise addition of nitrogen gas to breathing mixture) which resulted in identification of inducible (iPB) in 51%. All patients underwent assessment of hypoxic ventilatory response (HVR) using transient hypoxia and of hypercapnic ventilatory response (HCVR) employing Read’s rebreathing method. The induction trial did not result in any adverse events and minimal SpO₂ during nitrogen administration was ∼85%. The iPB group (vs. non-inducible PB group, nPB) was characterized by greater HVR (0.90 ± 0.47 vs. 0.50 ± 0.26 L/min/%; p <0.05) but comparable HCVR (0.88 ± 0.54 vs. 0.67 ± 0.68 L/min/mmHg; p = NS) and by worse clinical and neurohormonal profile. Mean SpO₂ which induced first cycle of PB was 88.9 ± 3.7%, while in sPB mean SpO₂ preceding first spontaneous cycle of PB was 96.0 ± 2.5%. There was a reverse relationship between HVR and the relative variation of SpO₂ during induced PB (r = −0.49, p = 0.04). In summary, PB induction is feasible and safe in HF population using simple and standardized protocol employing incremental, mild hypoxia. Pathophysiology of iPB differs from sPB, as it relies mostly on overactive peripheral chemoreceptors. At the same time enhanced HVR might play a protective role against profound hypoxia during iPB.

Implantation of a Leadless Pacemaker after Incomplete Transvenous Lead Extraction in a 90-Year-Old Pacemaker-Dependent Patient

Transluminal lead extraction (TLE) is a well-established procedure for the removal of damaged or infected pacing systems. Despite its high efficacy, the procedure is associated with significant risks, some of which may contribute to severe life-threatening complications. Herein, we present the case of a 90-year-old female who was 100% pacemaker-dependent (PM-dependent) and had ventricular lead fragmentation after the TLE procedure. In this elderly patient, after taking into account the whole clinical context-age, frailty syndrome, infection, and high peri- and postprocedural risks-we decided on MICRA VR implantation as well as leaving the remains of the ventricular lead in the right heart chambers. A Leadless pacemaker (LP) is an excellent alternative to PM-dependent individuals, in whom implantation of permanent transvenous PM is precluded due to multiple infectious and non-infectious issues.

Acute hyperoxia reveals tonic influence of peripheral chemoreceptors on systemic vascular resistance in heart failure patients

Peripheral chemoreceptors’ (PCh) hyperactivity increases sympathetic tone. An augmented acute ventilatory response to hypoxia, being a marker of PCh oversensitivity, was also identified as a marker of poor prognosis in HF. However, not much is known about the tonic (chronic) influence of PCh on cardio-respiratory parameters. In our study 30 HF patients and 30 healthy individuals were exposed to 100% oxygen for 1 min during which minute ventilation and hemodynamic parameters were non-invasively recorded. Systemic vascular resistance (SVR) and mean arterial pressure (MAP) responses to acute hyperoxia differed substantially between HF and control. In HF hyperoxia caused a significant drop in SVR in early stages with subsequent normalization, while increase in SVR was observed in controls. MAP increased in controls, but remained unchanged in HF. Bilateral carotid bodies excision performed in two HF subjects changed the response to hyperoxia towards the course seen in healthy individuals. These differences may be explained by the domination of early vascular reaction to hyperoxia in HF by vasodilation due to the inhibition of augmented tonic activity of PCh. Otherwise, in healthy subjects the vasoconstrictive action of oxygen remains unopposed. The magnitude of SVR change during acute hyperoxia may be used as a novel method for tonic PCh activity assessment.

Effects of an outpatient intervention comprising nurse-led non-invasive assessments, telemedicine support and remote cardiologists' decisions in patients with heart failure (AMULET study): a randomised controlled trial

Aim

Prevention of heart failure (HF) hospitalisations and deaths constitutes a major therapeutic aim in patients with HF. The role of telemedicine in this context remains equivocal. We investigated whether an outpatient telecare based on nurse‐led non‐invasive assessments supporting remote therapeutic decisions (AMULET telecare) could improve clinical outcomes in patients after an episode of acute HF during 12‐month follow‐up.

Methods and results

In this prospective randomised controlled trial, patients with HF and left ventricular ejection fraction (LVEF) ≤49%, after an episode of acute HF within the last 6 months, were randomly assigned to receive either an outpatient telecare based on nurse‐led non‐invasive assessments (n = 300) (AMULET model) or standard care (n = 305). The primary composite outcome of unplanned HF hospitalisation or cardiovascular death occurred in 51 (17.1%) patients in the telecare group and 73 (23.9%) patients in the standard care group up to 12 months after randomization [hazard ratio (HR) 0.69, 95% confidence interval (CI) 0.48–0.99; P = 0.044]. The implementation of AMULET telecare, as compared to standard care, reduced the risk of first unplanned HF hospitalisation (HR 0.62, 95% CI 0.42–0.91; P = 0.015) as well as the risk of total unplanned HF hospitalisations (HR 0.64, 95% CI 0.41–0.99; P = 0.044).There was no difference in cardiovascular mortality between the study groups (HR 1.03, 95% CI 0.54–1.67; P = 0.930).

Conclusions

AMULET telecare as compared to standard care significantly reduced the risk of HF hospitalisation or cardiovascular death during 12‐month follow‐up among patients with HF and LVEF ≤49% after an episode of acute HF.

Simple demographic characteristics and laboratory findings on admission may predict in-hospital mortality in patients with SARS-CoV-2 infection: development and validation of the covid-19 score

Background

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) constitutes a major health burden worldwide due to high mortality rates and hospital bed shortages. SARS-CoV-2 infection is associated with several laboratory abnormalities. We aimed to develop and validate a risk score based on simple demographic and laboratory data that could be used on admission in patients with SARS-CoV-2 infection to predict in-hospital mortality.

Methods

Three cohorts of patients from different hospitals were studied consecutively (developing, validation, and prospective cohorts). The following demographic and laboratory data were obtained from medical records: sex, age, hemoglobin, mean corpuscular volume (MCV), platelets, leukocytes, sodium, potassium, creatinine, and C-reactive protein (CRP). For each variable, classification and regression tree analysis were used to establish the cut-off point(s) associated with in-hospital mortality outcome based on data from developing cohort and before they were used for analysis in the validation and prospective cohort. The covid-19 score was calculated as a sum of cut-off points associated with mortality outcome.

Results

The developing, validation, and prospective cohorts included 129, 239, and 497 patients, respectively (median age, 71, 67, and 70 years, respectively). The following cut of points associated with in-hospital mortality: age > 56 years, male sex, hemoglobin < 10.55 g/dL, MCV > 92.9 fL, leukocyte count > 9.635 or < 2.64 10³/µL, platelet count, < 81.49 or > 315.5 10³/µL, CRP > 51.14 mg/dL, creatinine > 1.115 mg/dL, sodium < 134.7 or > 145.4 mEq/L, and potassium < 3.65 or > 6.255 mEq/L. The AUC of the covid-19 score for predicting in-hospital mortality was 0.89 (0.84–0.95), 0.850 (0.75–0.88), and 0.773 (0.731–0.816) in the developing, validation, and prospective cohorts, respectively (P < 0.001The mortality of the prospective cohort stratified on the basis of the covid-19 score was as follows: 0–2 points,4.2%; 3 points, 15%; 4 points, 29%; 5 points, 38.2%; 6 and more points, 60%.

Conclusion

The covid-19 score based on simple demographic and laboratory parameters may become an easy-to-use, widely accessible, and objective tool for predicting mortality in hospitalized patients with SARS-CoV-2 infection.

Iron deficiency contributes to resistance to endogenous erythropoietin in anaemic heart failure patients

AIMS

Abnormal endogenous erythropoietin (EPO) constitutes an important cause of anaemia in chronic diseases. We analysed the relationships between iron deficiency (ID) and the adequacy of endogenous EPO in anaemic heart failure (HF) patients, and the impact of abnormal EPO on 12-month mortality.

METHODS AND RESULTS

We investigated 435 anaemic HF patients (age: 74 ± 10 years; males: 60%; New York Heart Association class I or II: 39%; left ventricular ejection fraction: 43 ± 17%). Patients with EPO higher than expected for a given haemoglobin were considered EPO-resistant whereas those with EPO lower than expected - EPO-deficient. ID was defined as serum ferritin <100 µg/L or 100-299 µg/L with transferrin saturation <20%. EPO-resistant patients (22%) had more advanced HF whereas those with EPO deficiency (57%) were more frequently females and had worse renal function. Lower serum ferritin (indicating depleted body iron stores) was related to higher EPO observed/predicted ratio when adjusted for significant clinical confounders, including C-reactive protein. One year all-cause mortality was 28% in patients with EPO resistance compared to 17% in patients with EPO deficiency and 10% in patients with adequate EPO (log-rank test for the comparison EPO resistance vs. adequate EPO: P = 0.02). When adjusted for other prognosticators, there was still a trend towards increased 12-month mortality in patients with higher EPO level.

CONCLUSION

Anaemic HF patients with endogenous EPO deficiency vs. resistance have different clinical and laboratory characteristics. In such patients, ID contributes to EPO resistance independently of inflammation.

Rationale and design of the AMULET study: A new Model of telemedical care in patients with heart failure

Aims

Heart failure (HF) is characterized by high mortality and hospital readmission rates. Limited access to cardiologists restricts the application of guideline‐directed, patient‐tailored medical therapy. Some telemedicine solutions and novel non‐invasive diagnostic tools may facilitate real‐time detection of early HF decompensation symptoms, prompt initiation of appropriate treatment, and optimal management of medical resources. We describe the rationale and design of the AMULET trial, which investigates the effect of comprehensive outpatient intervention, based on individualized haemodynamic assessment and teleconsultations, on cardiovascular mortality and unplanned hospitalizations in HF patients.

Methods and results

The AMULET trial is a multicentre, prospective, randomized, open‐label, and controlled parallel group trial (ClinicalTrials.gov Identifier: NCT03476590). Six hundred and five eligible patients with HF (left ventricular ejection fraction ≤49%, at least one hospitalization due to acute HF decompensation within 6 months prior to enrolment) were randomly assigned in a 1:1 ratio to either an intervention group or a standard care group. The planned follow‐up is 12 months. The AMULET interventions are performed in ambulatory care points operated by nurses, with the remote support of cardiologists. The comprehensive clinical evaluation comprises measurements of heart rate, blood pressure, body mass, thoracic fluid content, and total body water. A recommendation support module based on these objective parameters is implemented in remote therapeutic decision‐making. The primary complex endpoints are cardiovascular mortality and unplanned HF hospitalization.

Conclusions

The AMULET trial will provide a prospective assessment of the effect of comprehensive ambulatory intervention, based on telemedicine and haemodynamically guided therapy, on mortality and readmissions in HF patients.

Nurse-led ambulatory care supported by non-invasive haemodynamic assessment after acute heart failure decompensation

Heart failure (HF) is characterized by frequent decompensation and an unpredictable trajectory. To prevent early hospital readmission, coordinated discharge planning and individual therapeutic approach are recommended.

Aims

We aimed to assess the effect of 1 month of ambulatory care, led by nurses and supported by non‐invasive haemodynamic assessment, on the functional status, well‐being, and haemodynamic status of patients post‐acute HF decompensation.

Methods and results

This study had a multicentre, prospective, and observational design and included patients with at least one hospitalization due to acute HF decompensation within 6 months prior to enrolment. The 1 month ambulatory care included three visits led by a nurse when the haemodynamic state of each patient was assessed non‐invasively by impedance cardiography, including thoracic fluid content assessment. The pharmacotherapy was modified basing on haemodynamic assessment. Sixty eight of 73 recruited patients (median age = 67 years; median left ventricular ejection fraction = 30%) finished 1 month follow‐up. A significant improvement was observed in both the patients' functional status as defined by New York Heart Association class (P = 0.013) and sense of well‐being as evaluated by a visual analogue score (P = 0.002). The detailed patients' assessment on subsequent visits resulted in changes of pharmacotherapy in a significant percentage of patients (Visit 2 = 39% and Visit 3 = 44%).

Conclusions

The proposed model of nurse‐led ambulatory care for patients after acute HF decompensation, with consequent assessment of the haemodynamic profile, resulted in: (i) improvement in the functional status, (ii) improvement in the well‐being, and (iii) high rate of pharmacotherapy modifications.

High soluble transferrin receptor in patients with heart failure: a measure of iron deficiency and a strong predictor of mortality

AIMS

Iron deficiency (ID) is frequent in heart failure (HF), linked with exercise intolerance and poor prognosis. Intravenous iron repletion improves clinical status in HF patients with left ventricular ejection fraction (LVEF) ≤45%. However, uncertainty exists about the accuracy of serum biomarkers in diagnosing ID. The aims of this study were (i) to identify the iron biomarker with the greatest accuracy for the diagnosis of ID in bone marrow in patients with ischaemic HF, and (ii) to establish the prevalence of ID using this biomarker and its prognostic value in HF patients.

METHODS AND RESULTS

Bone marrow was stained for iron in 30 patients with ischaemic HF with LVEF ≤45% and 10 healthy controls, and ID was diagnosed for 0-1 grades (Gale scale). A total of 791 patients with HF with LVEF ≤45% were prospectively followed up for 3 years. Serum ferritin, transferrin saturation, soluble transferrin receptor (sTfR) were assessed as iron biomarkers. Most patients with HF (n = 25, 83%) had ID in bone marrow, but none of the controls (P < 0.001). Serum sTfR had the best accuracy in predicting ID in bone marrow (area under the curve 0.920, 95% confidence interval 0.761-0.987, for cut-off 1.25 mg/L sensitivity 84%, specificity 100%). Serum sTfR was ≥1.25 mg/L in 47% of HF patients, in 56% and 46% of anaemics and non-anaemics, respectively (P < 0.05). The reclassification methods revealed that serum sTfR significantly added the prognostic value to the baseline prognostic model, and to the greater extent than plasma N-terminal pro B-type natriuretic peptide. Based on internal derivation and validation procedures, serum sTfR ≥1.41 mg/L was the optimal threshold for predicting 3-year mortality, independent of other established variables.

CONCLUSIONS

High serum sTfR accurately reflects depleted iron stores in bone marrow in patients with HF, and identifies those with a high 3-year mortality.

Renal profiling based on estimated glomerular filtration rate and spot urine sodium identifies high-risk acute heart failure patients

AIMS

In acute heart failure (AHF), assessment of renal function comprises estimation of glomerular filtration rate (eGFR), which does not provide any information about renal sodium/water handling. We describe the interactions between urinary sodium concentration and eGFR to better characterize AHF patients.

METHODS AND RESULTS

In 219 patients with AHF, spot urine sodium (UNa⁺ ) and eGFR were assessed on admission, day 1 and day 2 of hospitalization. We found no correlation between UNa⁺ and eGFR (calculated on each consecutive day, as an average of all three values, and as changes from baseline; all P > 0.05). The population was subsequently divided into four profiles based on eGFR (preserved vs. impaired; cutoff of 60 mL/min/1.73 m² ) and UNa⁺ (sodium excreter vs. non-excreter; cutoff of 60 mmol/L). At day 1, there were 70 (31.9%) patients classified as preserved eGFR/sodium excreter, 37 (16.8%) as impaired eGFR/sodium non-excreter, 72 (32.9%) as impaired eGFR/sodium excreter, and 40 (18%) as preserved eGFR/sodium non-excreter. Both sodium non-excreter profiles were associated with an increased risk of in-hospital heart failure worsening [odds ratio (OR) 2.8, 95% confidence interval (CI) 1.3-6.4], inotrope use (OR 2.6, 95% CI 1.1-6.7) and rehospitalization due to AHF (OR 3.2, 95% CI 1.6-6.2; all P < 0.05). The preserved eGFR/sodium non-excreter profile was associated with highest 1-year mortality (52.5%) and remained an independent prognosticator after adjustment for other prognosticators (hazard ratio 2.9, 95% CI 1.7-5.2; P < 0.0005).

CONCLUSIONS

In AHF, values of spot UNa⁺ and eGFR are not interrelated. Concomitant assessment of eGFR and spot UNa⁺ may be useful for better clinical and therapeutic profiling of patients.

Iron status, catabolic/anabolic balance, and skeletal muscle performance in men with heart failure with reduced ejection fraction

BACKGROUND

Metabolic derangements related to tissue energetics constitute an important pathophysiological feature of heart failure. We investigated whether iron deficiency and catabolic/anabolic imbalance contribute to decreased skeletal muscle performance in men with heart failure with reduced ejection fraction (HFrEF), and whether these pathologies are related to each other.

METHODS

We comprehensively examined 23 men with stable HFrEF (median age [interquartile range]: 63 [59-66] years; left ventricular ejection fraction: 28 [25-35]%; New York Heart Association class I/II/III: 17/43/39%). We analyzed clinical characteristics, iron status, hormones, strength and fatigability of forearm flexors and quadriceps (surface electromyography), and exercise capacity (6-minute walking test).

RESULTS

None of the patients had anemia whereas 8 were iron-deficient. Flexor carpi radialis fatigability correlated with lower reticulocyte hemoglobin content (CHR, p < 0.05), and there was a trend towards greater fatigability in patients with higher body mass index and lower serum ferritin (both p < 0.1). Flexor carpi ulnaris fatigability correlated with lower serum iron and CHR (both p < 0.05). Vastus medialis fatigability was related to lower free and bioavailable testosterone (FT and BT, respectively, both p < 0.05), and 6-minute walking test distance was shorter in patients with higher cortisol/FT and cortisol/BT ratio (both p < 0.05). Lower ferritin and transferrin saturation correlated with lower percentage of FT and BT. Men with HFrEF and iron deficiency had higher total testosterone, but lower percentage of FT and BT.

CONCLUSIONS

Iron deficiency correlates with lower bioactive testosterone in men with HFrEF. These two pathologies can both contribute to decreased skeletal muscle performance in such patients.

Intravenous iron therapy and circulating biomarkers of inflammation in men with heart failure with reduced ejection fraction

Background

Large randomized clinical trials have demonstrated that intravenous (IV) iron therapy in iron-deficient patients with heart failure with reduced ejection fraction (HFrEF) brings clinical benefits related to symptoms of the disease and exercise capacity. Mechanisms underlying beneficial effects of such repletion are still the subject of interest as this is not solely related to improved haematopoiesis (IV iron works also in non-anaemic subjects). In patients with chronic heart failure iron deficiency (ID) is linked with inflammatory processess but data regarding the impact of IV iron on inflammation is scarce.

Purposes

We evaluated whether IV iron therapy affects circulating biomarkers of pro-inflammatory state in men with HFrEF and concomitant ID.

Methods

This is the sub-analysis of the study to investigate the effects of IV ferric carboxymaltose (FCM) on the functioning of skeletal muscles in men with HFrEF. For the purposes of current research we analyzed data of 20 men with HFrEF (median age 68 (62, 75 – in brackets interquartile ranges, respectively) years, LVEF: 30 (25, 35) %, ischaemic HF aetiology: 85%, NYHA class I/II/III: 30%/50%/20%) and ID (definition according to ESC guidelines - ferritin &lt;100 ng/mL, or ferritin 100–299 ng/mL with transferrin saturation [TSAT] &lt;20%) who were randomized in a 1:1 ratio to receive either the 24-week therapy with IV FCM (dosing scheme as in the CONFIRM-HF trial) or saline (controls). The study was double-blinded. We used ELISA to evaluate different circulating pro-inflammatory biomarkers (high-sensitivity C-reactive protein [hs-CRP], tumor necrosis factor alpha [TNF-α], interleukin 6 [IL-6], interleukin 1 beta [IL-1β], interleukin 22 [IL-22]) at baseline and week 24.

Results

IV FCM therapy repleted iron stores in men with HFrEF as reflected by an increase in serum ferritin and TSAT, which was not seen in a control group. IV FCM therapy (as well as the saline administration) affected neither haemoglobin concentration nor parameters reflecting iron stores in red cells.

Baseline serum ferritin was not related to hs-CRP, TNF-α, IL-6, IL-1β, and IL-22 (all p&gt;0.23). Baseline TSAT was related to hs-CRP (r=−0.47, p=0.02) but not other inflammatory biomarkers.

Levels of hs-CRP, TNF-α, IL-6, IL-1β, and IL-22 at week 0 were similar in subjects who received IV iron and controls (all p&gt;0.22).

Change from week 0 to week 24 adjusted for baseline value (delta W24-W0 as the percentage of W0) regarding IL-22 was lower in an active treatment arm as compared with saline (p=0.049) and there was a trend towards lower delta TNF-α in FCM group compared to saline (p=0.067). These findings were not valid for other measured pro-inflammatory biomarkers.

Conclusions

In men with HFrEF and concomitant ID intravenous iron therapy with FCM affects biomarkers of pro-inflammatory state. Clinical relevance of this finding requires further translational research.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This research was funded by the National Science Centre (Poland) grant allocated on the basis of the decision number DEC-2012/05/E/NZ5/00590

On the search for the right definition of heart failure with preserved ejection fraction

The definition of heart failure with preserved ejection fraction (HFpEF) has evolved from a clinically based "diagnosis of exclusion" to definitions focused on objective evidence of diastolic dysfunction and/or elevated left ventricular filling pressures. Despite advances in our understanding of HFpEF pathophysiology and the development of more sophisticated imaging modalities, the diagnosis of HFpEF remains challenging, especially in the chronic setting, given that symptoms are provoked by exertion and diagnostic evaluation is largely conducted at rest. Invasive hemodynamic study, and in particular - invasive exercise testing, is considered the reference method for HFpEF diagnosis. However, its use is limited as opposed to the high number of patients with suspected HFpEF. Thus, diagnostic criteria for HFpEF should be principally based on non-invasive measurements. As no single non-invasive variable can adequately corroborate or refute the diagnosis, different combinations of clinical, echocardiographic, and/or biochemical parameters have been introduced. Recent years have brought an abundance of HFpEF definitions. Here, we present and compare four of them: 1) the 2016 European Society of Cardiology criteria for HFpEF; 2) the 2016 echocardiographic algorithm for diagnosing diastolic dysfunction; 3) the 2018 evidence-based H2FPEF score; and 4) the most recent, 2019 Heart Failure Association HFA-PEFF algorithm. These definitions vary in their approach to diagnosis, as well as sensitivity and specificity. Further studies to validate and compare the diagnostic accuracy of HFpEF definitions are warranted. Nevertheless, it seems that the best HFpEF definition would originate from a randomized clinical trial showing a favorable effect of an intervention on prognosis in HFpEF.

Distinct clinical phenotypes of congestion in acute heart failure: characteristics, treatment response, and outcomes

Aims

Patients with acute heart failure (AHF) are included into clinical trials regardless of differences in baseline clinical characteristics. The aim of this study was to assess patients with AHF according to the presence of central and/or peripheral congestion at hospital admission and evaluate treatment response and outcomes in studied phenotypes.

Methods and results

We investigated retrospectively 352 patients (mean age: 68 ± 13 years, 77% men) hospitalized due to AHF with the signs of congestion on admission. Patients were divided according to the type of signs of congestion into three groups: A, isolated pulmonary congestion (n = 52, 15%); B, isolated peripheral congestion (n = 31, 9%); and C, signs of mixed (peripheral and central) congestion (n = 269, 76%). Patients from Group A had lower concentration of urea, bilirubin, and gamma‐glutamyl transferase whereas higher level of haematocrit, albumin, and leukocytes on admission. The highest baseline N‐terminal pro‐B‐type natriuretic peptide level (median: 4113 vs. 3634 vs. 6093 pg/mL) and percentage of patients with chronic heart failure (56 vs. 58 vs. 74%; A vs. B. vs. C, respectively, all P < 0.01) were observed in Group C. There were no differences in terms of demographics, co‐morbidities, left ventricular ejection fraction, and applied treatment between studied groups. Patients from Group A had the highest systolic blood pressure on admission (145 ± 37 vs. 122 ± 20 vs. 130 ± 29 mmHg) and the biggest decrease in systolic blood pressure [−22 (−45 to −4) vs. −2 (−13 to 2) vs. −10 (−25 to 0) mmHg] and heart rate [−16 (−35 to −1.5) vs. −1 (−10 to 5) vs. −7 (−20 to 0) b.p.m.] with the lowest weight change [−1.0 (−1.0 to 0) vs. −2.9 (−3.8 to −0.9) vs. −2.0 (−3.0 to −1.0) kg; all P < 0.01] after 48 h of hospitalization. There were differences in short‐term and long‐term outcomes with favourable results in Group A. Group A experienced less frequent in‐hospital heart failure worsening during the first 48 h (4 vs. 23 vs. 7%), had shorter length of hospital stay [6 (5–8) vs. 7 (5–11) vs. 7 (6–11) days], and had lower 1 year all‐cause mortality (12 vs. 28 vs. 29%; all P < 0.05). Presence of peripheral congestion on admission was independent predictor for all‐cause mortality within 1 year [hazard ratio (95% confidence interval): 2.68 (1.06–6.79); P = 0.04].

Conclusions

Patterns of congestion in AHF are associated with differences in clinical characteristics, treatment response, and outcomes. It needs to be considered once planning clinical trials in AHF.

Expression of sex steroid receptors and aromatase in adipose tissue in different body regions in men with coronary artery disease with and without ischemic systolic heart failure

Background: The hormonal metabolism of adipose tissue differs across regions of fat. This issue has never been verified in male patients with coronary artery disease (CAD) with and without systolic heart failure (SHF).Methods: We examined 90 male patients with CAD with and without SHF and 42 healthy controls.Results: In patients with CAD with and without SHF, androgen receptor (AR) expression in adipose tissue of the lower leg was higher than AR expression of the thoracic wall and epicardial adipose tissue (EAT) (both p < .0001 for SHF patients and both p < .001 for patients without SHF). Expression of aromatase in adipose tissue of the lower leg among patients with CAD and SHF was higher than aromatase expression of the thoracic wall and EAT (p < .001 and p < .05, respectively), and in patients without SHF, it was higher only than aromatase expression of the thoracic wall (p < .05). There were no differences in expression of estrogen receptor (ER) between three regions of adipose tissue both in men with CAD with and without SHF.Conclusions: In male patients with CAD, site-related differences of adipose tissue in expression of AR and aromatase are present regardless of coexisting SHF with the highest hormonal activity within peripheral subcutaneous adipose tissue.

Frailty and cognitive impairment are predictive of takotsubo syndrome following pacemaker implantation

BACKGROUND

Pacemaker (PM) implantation may cause acute emotional distress leading to takotsubo syndrome (TTS). Frailty and cognitive impairment are known to influence outcomes after surgical procedures. It is unclear whether they may also predispose to TTS following PM implantation.

METHODS

We identified nine cases (81 ± 6 years) of TTS following PM implantation that took place between 2013 and 2017 in one high volume implantation center. TTS was diagnosed based on typical echocardiographic appearance with resolution over time and (in cases where deemed necessary) normal coronary angiography. The TTS cases were compared with 30 consecutive cases of PM implantation (75 ± 9 years), which were not complicated by TTS (control group). Frailty was assessed using retrospective Risk Analysis Index (RAI-A). Pacing parameters were analyzed during PM implantation and after 1 month.

RESULTS

Cognitive impairment was more prevalent (67% vs 10%, P = .0005), and RAI-A index was significantly higher in the TTS group compared to the control group (26 ± 13.7 vs 13.1 ± 9.8, P = .008). Perioperative right ventricular threshold was significantly higher in patients with TTS comparing to controls (0.99 ± 0.43 V vs 0.74 ± 0.20 V, P = .04). The magnitude of decrease in right ventricular threshold between implantation and 1 month follow-up was greater in TTS patients compared to controls (-0.41 ± 0.29 V vs -0.15 ± 0.38 V, P = .049).

CONCLUSIONS

TTS is a rare complication of PM implantation. Patients with cognitive impairment and frailty are at risk of TTS. Right ventricular pacing threshold is acutely affected by TTS and improves over time.

Management of bleeding in patients hospitalized in the intensive cardiac care unit: expert opinion of the Association of Intensive Cardiac Care and Section of Cardiovascular Pharmacotherapy of the Polish Cardiac Society in cooperation with specialists in other fields of medicine

Nowadays, the intensive cardiac care unit (ICCU) provides care for patients with acute coronary syndrome, acute and exacerbated chronic heart failure, cardiogenic shock, sudden cardiac arrest, electrical storm, as well as with indications for urgent cardiac surgical treatment. Most of these patients require the use of 1, 2, or frequently even 3 drugs that act on the blood coagulation pathway. While antithrombotic drugs prevent thromboembolic events, they are associated with a higher risk of bleeding. In this population of patients, bleeding may often have a worse impact on prognosis than the primary disease. In this expert opinion of the Association of Intensive Cardiac Care, we presented practical guidelines on the management of bleeding in patients hospitalized at the ICCU, including bleeding risk reduction and treatment recommendations. Because of multiple comorbidities and diverse organs that may be the source of bleeding, we provided also recommendations from specialists in other fields of medicine. We hope that this document will facilitate the management of one of the most challenging populations at the ICCU.

P754Iron status indices (transferrin saturation, serum ferritin) in the course of acute myocarditis: relations with neurohormonal activation, cardiac dysfunction and clinical recovery

Introduction

Acute myocarditis (MCD) can progress to post-myocarditis cardiomyopathy. Immune response is the major pathophysiological trigger leading to MCD. Optimal iron status is essential for the functioning of immune cells, cardiomyocytes and cardiofibroblasts. Therefore, there are premises to consider iron metabolism as a significant modulator of complex pathophysiology of MCD.

Purpose

We aimed to assess iron status in the course of MCD and relate it with clinical and laboratory measures.

Methods

We prospectively enrolled consecutive patients hospitalized for acute MCD in 2 tertiary referral cardiology centers during 2015–2018 and followed them up for 30 weeks. MCD was diagnosed based on the following criteria: 1) new onset symptoms suggestive of myocarditis (effort intolerance, dyspnea, palpitations or chest pain), 2) elevated high sensitivity cardiac troponin I (hs-cTnI), 3) exclusion of obstructive coronary artery disease.

Results

Study group comprised 41 patients with confirmed MCD [age: 31 (26–34) years, men: 95%] and 15 healthy age- and gender-matched subjects [age: 30 (28–33) years, men: 87%]. All patients survived hospitalization and follow-up, no subject needed ventricular assist device.

Patients with MCD had lower LVEF (56±10% vs. 69±14%) and higher CRP [32 (14–8754) vs. 3 (3–3) mg/l], NT-proBNP [452 (240–877) vs. 33 (18–46) pg/ml], hs-cTnI [7.3 (3.3–12.8) vs. 0,01 (0.01–0.01) μg/l] than the control group (all p<0.001). Regarding iron status, MCD group presented higher serum ferritin [213 (121–386) vs. 135 (84–210) μg/l] and lower transferrin saturation (TSAT) [21±10 vs. 28±15%] (all p<0.05). In patients with MCD ferritin correlated with CRP (r=0.46, p<0.01), TSAT correlated neither with CRP nor with ferritin (all p>0.02).

Patients with MCD and NT-proBNP >1000 pg/ml had lower TSAT (16±8 vs. 23±9%; p<0.05) and LVEF (47±13 vs. 59±7%; p<0.001) than the remaining subjects. No difference in ferritin was observed (p>0.2). 46% of patients during acute phase of MCD had LVEF≤55% – these patients presented lower TSAT (17±8% vs. 24±10%) and higher NT-proBNP – [577 (436–1657) vs. 358 (167–499) pg/ml] (all p<0.05). After 30 weeks only in 13% patients LVEF≤55% persisted and related to lower baseline TSAT (9±1% vs. 21±9%) and higher CRP (147±113 vs. 52±40 mg/l) (all p<0.05). LVEF≤55% was not related to ferritin (both p>0.2).

After 6 weeks of follow-up patients with MCD already presented higher LVEF (61±8%; p<0.05) and haemoglobin [14.7 (14.0–15.7) g/dl], lower CRP [3 (3–3) mg/l], NT-proBNP [34 (25–67) pg/ml], hs-cTnI [0.01 (0.01–0.01)], ferritin [124 (78–168) μg/l] and higher TSAT (26±7%) (all p<0.01). There was no further change in these parameters within the next 24 weeks (all p>0.2).

Conclusions

Iron status is deranged in acute MCD. Serum ferritin is an indicator of inflammatory response, whereas TSAT relates to neurohormonal activation and cardiac dysfunction. Iron status normalizes within 6 weeks after acute phase of MCD.

Acknowledgement/Funding

This research was financially supported by the National Science Centre (Poland) grant number 2014/13/B/NZ5/03146.

P6353Iron depletion in human cardiomyocytes cultured with sera from myocarditis patients

Background

Cardiac myocytes, which are particularly sensitive to disordered iron homeostasis, are the main cells affected in the course of myocarditis. Iron is essential for the proper maintenance of energy metabolism but also plays key role in inflammation and ROS production. We hypothesize that iron homeostasis might be involved in the pathophysiology of myocarditis.

Purpose

The aim of the study was to assess differences in the expression of key genes and proteins involved in iron homeostasis, cardiac malfunctioning, and protection against ROS in human cardiomyocytes (HCMs) cultured in the indirect model of myocarditis.

Methods

HCMs were cultured for 48 hours with 10% of sera from patients with acute myocarditis (n=11) and after 6 weeks of recovery, and also with sera from healthy controls (n=7). We analyzed expression of light and heavy ferritin chains [FTL, FTH], transferrin receptor 1 [TfR1], galectin 3 [LGALs3], TGFβ signaling [TGFβ1, TGFβ2, TGFβ3], glutathione peroxidase [GPX] and superoxide dismutase [SOD1] at the mRNA level using RTqPCR and at the protein level using Western bloting. We compared obtained data with the clinical characteristics of patients.

Results

In HCMs exposed to sera from myocarditis patients, in comparison to those treated with sera from healthy controls, we found a significant increase in an expression of TfR1 both at mRNA and protein level (p<0,01). We also observed that elevated expression of TfR1 in cells correlated with serum levels of total iron (R=-0,52; p<0,05), CRP (R=0,67; p<0,05), and NT-proBNP (R=0,55; p<0,05), suggesting increased iron demand in HCMs and its possible relation to inflammation and hemodynamic dysfunction in patients.

Moreover, we observed elevated expression of FTH and FTL at the mRNA level (both p<0,01) and its strong correlation with expression of TfR1 as well as with increased levels of CRP in sera. It could be explained by the double role of ferritin in iron storage and in inflammation.

Interestingly, we noticed detrimental effects of myocarditis sera on HCMs reflected by augmented expression of galectin 3 (p<0,01) and disturbances in TGFβ genes, in comparison to those treated with sera from healthy controls. Augmented expression of galectin 3 was strongly related to disturbed iron homeostasis, manifesting itself by correlations with TfR1 (R=0,77; p<0,05), FTH (R=0,92; p<0,05) and FTL (R=0,76; p<0,05).

In addition, HCMs treated with sera from myocarditis patients showed an increase in expression of ROS protective genes such as SOD1 and GPX (both p<0,01), indicating higher oxidative stress in these cells.

We noticed that gene expression profile was similar in HCMs treated with sera collected after 6 weeks of clinical recovery, suggesting that the negative impact of sera was preserved.

Conclusions

Malfunctioning of cardiomyocytes in course of myocarditis might be related to disturbances in the iron homeostasis.

Acknowledgement/Funding

The present study was financially supported by the National Science Centre (Krakow, Poland; grant no. 2014/13/B/NZ5/03146)

Controlled decongestion by Reprieve therapy in acute heart failure: results of the TARGET-1 and TARGET-2 studies

AIMS

Safe and effective decongestion is the main goal of therapy in acute heart failure (AHF). In the non-randomized, prospective TARGET-1 and TARGET-2 studies (NCT03897842), we investigated whether adding the Reprieve System® (which continuously monitors urine output and delivers a matched volume of hydration fluid sufficient to maintain the set fluid balance rate) to standard diuretic-based regimen improves decongestion in AHF.

METHODS AND RESULTS

The population consisted of 19 patients hospitalized with AHF (mean age 67 ± 10 years, 18 male, ejection fraction 34 ± 15%, median N-terminal pro-B-type natriuretic peptide 4492 pg/mL). Patients served as their own controls: each patient underwent 24 h of standard diuretic therapy followed by 24 h of diuretics with Reprieve therapy (with normal saline used for matched volume replacement). The primary efficacy endpoint of actual fluid loss not exceeding the target fluid loss at the end of therapy was met in all 19 (100%) patients. The mean diuresis during Reprieve therapy was 6284 ± 2679 mL (vs. 1966 ± 1057 mL 24 h before therapy) and 2053 ± 888 mL (24 h after therapy) (both P < 0.0001). At the end of therapy, patient global assessment improved from 7.7 ± 1.1 to 3.0 ± 1.3 points (P < 0.001), central venous pressure decreased from 15.5 ± 5.3 mmHg to 12.8 ± 4.8 mmHg (P < 0.05) and the median urine sodium loss was 9.7 [3-13] mmol/h. The Reprieve therapy was safe, systolic blood pressure remained stable, mean creatinine dropped from 1.45 ± 0.4 mg/dL to 1.26 ± 0.4 mg/dL (P < 0.001) and biomarkers of renal injury did not change during treatment.

CONCLUSIONS

The Reprieve System in conjunction with diuretic therapy supports safe and controlled decongestion in AHF.

Prognostic importance of serum troponin concentration in patients with an implanted cardioverter‑defibrillator admitted to the emergency department due to electric shock

BACKGROUND

High-energy implantable cardioverter-defibrillator (ICD) therapy may increase serum troponin (cTnI) concentration.   Aims: We aimed to assess an impact of cTnI concentration after ICD high-energy therapy on mortality.

METHODS

A total of 150 patients aged 64.2 +/- 12.8 years admitted to the Emergency Departments (EDs) due to at least one electrical shock during the last 24 hours with measured serum cTnI concentration at admission were included. Age, gender, comorbidities, shocks' numbers, therapy appropriateness, serum creatinine concentration, and left ventricular ejection fraction were noted for the retrospective analysis. Survival was obtained using the personal identification numbers (PESEL), on November 2018 until death or a period of three years had elapsed (1057 days).

RESULTS

cTnI concentration was increased in 92 (61.3%) patients. The mortality rate was related to age - HR: 1.04, 95% CI: 1.01-1.08, p = 0.026; increased cTnI concentration - HR: 2.88, 95% CI: 1.30-6.37, p = 0.009; diabetes - HR: 2.19, 95% CI: 1.09-4.39, p = 0.027; ischemic heart disease - HR: 2.96, 95% CI: 1.11-7.87, p = 0.030, serum creatinine concentration - HR: 2.17, 95% CI: 1.18-4.00, p = 0.013; LVEF (HR 0.95, 95% CI: 0.91-0.99, p = 0.009), and previous or current CABG or PCI (HR: 0.38, 95% CI: 0.15-0.96, p = 0.040 and HR: 0.29, 95% CI: 0.13-0.65, p = 0.003, respectively).

CONCLUSIONS

Increased mortality rate in patients with ICD shocks is multifactorial. Increased cTnI concentration at ED admission, but not the number of ICD shocks, is an independent marker of higher long-term mortality.

Phrenic nerve stimulation in patients with central sleep apnea: a single‑center experience from pilot and pivotal trials evaluating the remedē System

BACKGROUND

Patients with central sleep apnea (CSA) have recently been shown to have improved sleep metrics and quality of life (QoL) with phrenic nerve stimulation (PNS).

AIMS

The aim of this study was to report the results of a partnership between cardiology, sleep medicine, and electrophysiology in a single clinical center as well as the enrollment, implantation, and follow‑up experience demonstrating both the safety and efficacy of PNS.

METHODS

This analysis included data from the pilot and pivotal trials investigating the effect of PNS using an implantable transvenous system in patients with CSA. We present our experience and data on the enrollment processes, implantation feasibility and safety, sleep indices, and QoL at 6 and 12 months of follow‑up.

RESULTS

Between June 2010 and May 2015, cardiology patients were prescreened and 588 of them were sent for in‑home sleep test. Ninety‑six patients were referred for polysomnographic studies, and 33 were enrolled and had an implant attempt, with 31 successfully receiving an implant. The apnea-hypopnea index was reduced in the pilot trial (mean [SD] of 48.7 [15.5] events/h to 22.5 [13.2] events/h; P <0.001) and in the pivotal trial (mean [SD] of 48.3 [18.8] events/h to 26.0 [21.9] events/h; P <0.001). Improvement in QoL was also observed.

CONCLUSIONS

We showed that PNS improved sleep metrics and QoL in patients with CSA, which is a result of multiple factors, including a comprehensive coordination between cardiology, sleep medicine, and electrophysiology. This ensures appropriate patient identification leading to safe implantation and full patient compliance during follow‑up visits.

Serial assessment of spot urine sodium predicts effectiveness of decongestion and outcome in patients with acute heart failure

AIMS

The clinical significance of the measurement of urine sodium concentration (UNa⁺ ) in response to loop diuretic administration in patients with acute heart failure (AHF) is still unsettled. We studied the association of serial measurements of spot UNa⁺ during the first 48 h of AHF treatment with the indices of decongestion, renal function, and prognosis.

METHODS AND RESULTS

We enrolled 111 AHF patients, all of whom received intravenous furosemide on admission. The mean spot UNa⁺ significantly increased in the 6 h sample (P < 0.05 vs. baseline) and returned to baseline values in the 24 and 48 h samples. Based on the increase or decrease/no change of UNa⁺ in the 6 and 48 h samples vs. baseline, patients were divided into two groups at each time point, respectively. Patients did not differ in baseline clinical and laboratory characteristics. Patients with a decrease/no change of UNa⁺ in the 6 and 48 h samples had a lower weight loss during hospitalization. Patients with a decrease/no change of UNa⁺ in the 48 h sample had a poorer diuretic response and a significant increase in the urinary levels of the tubular biomarkers: kidney injury molecule-1 and neutrophil gelatinase-associated lipocalin. Low UNa⁺ and decrease/no change in UNa⁺ in the 6 and 48 h samples were independent predictors of higher risk of all-cause mortality during 1-year follow-up (all P < 0.05).

CONCLUSION

In AHF, low spot UNa+ and lack to increase UNa⁺ in response to intravenous diuretics are associated with poor diuretic response, markers of tubular injury and high risk of 1-year mortality.

Persistent hyperlactataemia is related to high rates of in-hospital adverse events and poor outcome in acute heart failure

BACKGROUND

Although lactate is a well-established marker in intensive care, our understanding of its utility in acute heart failure (AHF) is modest and based on studies with a single measurement of this marker.

AIM

We aimed to investigate whether persistent elevation of lactate during hospitalisation is related to a higher risk of ad- verse events.

METHODS

We conducted a prospective study to assess AHF patients hospitalised in one cardiac centre. The diagnosis of persistent hyperlactataemia was based on two measurements of the marker (on admission and at 24 h of hospitalisation) and it was defined as lactate elevation (≥ 2 mmol/L) at both time points.

RESULTS

The population consisted of 222 patients at a mean age of 70 ± 13 years. Mean ejection fraction and creatinine level on admission were 37% ± 16% and 1.36 ± 0.51 mg/dL, respectively. The percentage of patients with elevated lactates on admission, at 24 h of hospitalisation, and persistent hyperlactataemia were 47%, 35%, and 24%, respectively. The group with persistent hyperlactataemia did not differ in most clinical and laboratory variables from the rest of the population. Patients with persistent hyperlactataemia had higher rate of adverse events during hospitalisation: worsening of heart failure (22.6% vs. 6.5%, p < 0.05), inotrope use (22.6% vs. 5.3%, p < 0.05), and increase of N-terminal pro-B-type natriuretic peptide at 48 h of hospitalisation (30% vs. 18%, p < 0.05). Persistent hyperlactataemia was an independent predictor of one-year mortality (hazard ratio 2.5, 95% confidence interval 1.5-4.3, p < 0.001).

CONCLUSIONS

Persistent hyperlactataemia within the first 24 h of hospitalisation is a predictor of a worse outcome in AHF and is related to higher rates of in-hospital adverse events and one-year mortality.

Recommendations on the use of innovative medical technologies in cardiology and cardiac surgery and solutions leading to increased availability for Polish patients

There is a great need for innovative technologies that will improve the health and quality of life (QoL) of Polish patients with cardiac problems. It is important that the safety and effectiveness of the technology are confirmed by scientific evidence on which guidelines and clinical recommendations are based. Scientific evidence for medical devices is also increasingly important for decision-making in finance approval from public funds. New technologies in cardiology and cardiac surgery contribute to improved patient QoL, increased treatment effectiveness and facilitated diagnosis. Hence, it is necessary to increase accessibility to such technologies, primarily through the development of clinical recommendations, and education of medical personnel in conjunction with public funding. The aim of this publication is to present the recommendations of leading experts in the field of cardiology and cardiosurgery, supported by clinical research results, regarding the use of the cited innovative medical technologies and solutions leading to their increased availability for Polish patients.

Seat belts-related behaviors in car drivers with cardiac implantable electronic devices

BACKGROUND

Seat belt use is the single most effective means of reducing fatal injuries in road traffic accidents. The presence of a cardiac implantable electronic device (CIED) might influence seat belt-related behaviors due to the physical proximity of the seat belt and left subclavian area in which the device is usually implanted. Understanding the underlying mechanisms of improper seat belt use may improve safety of these patients.

METHODS

We performed a prospective study using a structured questionnaire with 120 CIED recipients (age, 63.9 ± 10.9 years) attending a pacing outpatient clinic. All study participants were active drivers and predominantly male. The majority of patients (79%) had undergone high-energy device implantation.

RESULTS

We found that 18% of study participants do not fasten seat belts on a regular basis or use the seat belt in an atypical fashion (such as under the armpit). Moderate or high level of discomfort from the interaction between seat belt and CIED was present in 27%, while more than half (51%) were afraid of seat belt-induced CIED damage. In multifactorial analysis, we found the following independent predictors of improper seat belt use: (1) at least moderate level of discomfort at the CIED site (P = 0.02); (2) fear of CIED damage (P = 0.009); and (3) irregular seat belt use prior to CIED implantation (P = 0.037).

CONCLUSIONS

Improper seat belt-related behaviors are common in CIED recipients. They arise from previous habits and from CIED-related physical and psychological factors. Patients' education regarding the importance and safety of proper seat belt use is a priority.

Predictors of inappropriate shocks from implantable cardioverter-defibrillators

OBJECTIVE

Introduction: Inappropriate shocks in patients with an implantable cardioverter-defibrillator (ICD) are associated with significant psychological and physical consequences and increased long-term mortality. The aim: To assess predictors associated with inappropriate high-energy discharges of implantable cardioverter-defibrillators.

PATIENTS AND METHODS

Material and Methods: Retrospective data analysis of 150 patients aged 64.2±12.8 years (84.7% male) admitted to the Hospital Emergency Department due to at least one cardioverter-defibrillator discharge was performed. All of the discharges were inappropriate in the group of 33 patients, and in the group of 117 patients at least one discharge was appropriate. The following data: age, gender, concomitant diseases, type of ICD implantation (primary vs. secondary prevention), type of discharge, number of discharges, serum potassium, and sodium concentration were collected.

RESULTS

Results: Patients with only inappropriate discharges were younger, significantly more often had chronic atrial fibrillation, a significantly higher number of discharges, and ischaemic cardiomyopathy. Logistic regression analysis revealed that the occurrence of only inappropriate discharges was related to the number of discharges over three, the age of patients below 60 years, the serum sodium concentration between 135 mEq/L and 142 mEq/L, and the primary type of prevention of sudden cardiac death.

CONCLUSION

Conclusions: 1. Predictors of inappropriate discharges include: age, serum sodium concentration, and primary type of indications for cardioverter-defibrillator implantation. 2. Further research is necessary to determine the influence of disturbances in the sodium economy on the occurrence of appropriate and inappropriate interventions of implantable cardioverter-defibrillators.

Clinical, respiratory, haemodynamic, and metabolic determinants of lactate in heart failure

BACKGROUND

Lactate is an end-product of anaerobic cell metabolism. Although it is believed to have prognostic significance in heart failure (HF), data on the pathomechanisms that lead to lactate accumulation are scarce.

AIM

We aimed to determine the clinical, respiratory, biochemical, and haemodynamic correlates of lactate in HF.

METHODS

Patients diagnosed with HF hospitalised in a single cardiac centre, who underwent haemodynamic monitoring, were included in this retrospective analysis.

RESULTS

The population consisted of 93 patients (44 acute HF [AHF] and 49 chronic HF [CHF] cases). The mean age, left ventricular ejection fraction, and lactate level were 60 ± 13 years, 33% ± 17%, 1.4 ± 0.9 mmol/L, respectively. The mean cardiac index (CI), right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP) were 2.2 ± 0.5 L/min/m², 8.7 ± 6 mmHg, and 18 ± 6 mmHg, respectively. AHF patients had significantly higher RAP, heart rate (HR), and levels of N-terminal pro-B-type natriuretic peptide and creatinine, compared to the CHF group. Both HR and natriuretic peptide level were correlated with lactate. Among haemodynamic indices, lactate correlated with CI (r = -0.25, p = 0.01). We found no correlation between lactate and RAP (p > 0.05) or PCWP (p > 0.05). There was no relationship between lactate and peripheral blood gases. Lactate was strongly correlated with mixed venous oxygen saturation (svO2) (r = -0.61, p < 0.05). HR, svO2, and systemic vascular resistance (SVR) were found to be independent determinants of lactate.

CONCLUSIONS

Lactate accumulation in HF is not a result of respiratory disturbances or hypoxaemia. Among haemodynamic indices, CI is correlated with lactate. The strongest determinants of lactate included svO2, SVR, and HR.

Multi-organ dysfunction/injury on admission identifies acute heart failure patients at high risk of poor outcome

BACKGROUND

Clinical consequences of an interplay between dysfunction/injury of different end-organs in acute heart failure (AHF) remain unknown.

METHODS AND RESULTS

In 284 consecutive AHF patients, end-organ dysfunction/injury was defined as cardiac [troponin I level above the upper reference limit (URL, > 0.056 ng/mL)], kidney (estimated glomerular filtration rate < 60 mL/min/1.73 m² ), and liver [at least one of the following: aspartate transaminase (AST)/alanine transaminase (ALT) > 3 times the URL (> 114 IU/L and > 105 IU/L for AST and ALT, respectively), bilirubin above the URL (> 1.3 mg/mL), albumin below the lower reference limit (< 3.5 mg/dL)]. The primary endpoints were early (within first 48 h) in-hospital worsening of heart failure and 1-year all-cause mortality. On admission, cardiac, kidney, liver dysfunction/injury were present in 38%, 50%, and 54% of patients, respectively. Patients were classified as having 0, 1, 2, or 3 organ injury/dysfunction (17%, 36%, 35%, and 12% of patients, respectively). Baseline clinical characteristics and co-morbidity profile were similar across groups. Patients with three organ dysfunction/injury had the worst 1-year survival rate [46%; hazard ratio (HR) with 95% confidence interval (CI) vs. patients without organ dysfunction: 6.75 (2.52-18.13), those with two (67%; HR 3.54, 95% CI 1.38-9.08), one (84%; HR 1.58, 95% CI 0.58-4.30), or no organ dysfunction/injury (90%); P < 0.01]. Worsening of heart failure was more frequent in patients with three and two vs. those with one or no organ dysfunction/injury (37% vs. 38% vs. 23% vs. 21%, P < 0.05).

CONCLUSIONS

In patients with AHF, dysfunction/injury of > 1 end-organ dysfunction/injury identifies patients at the highest risk of poor outcomes.

Cardiovascular stress biomarker assessment of middle-aged non-athlete marathon runners

Background

Cardiovascular safety of marathon running in recreational runners remains unclear. We set up this study to comprehensively evaluate the effects of a marathon run on the profile of cardiovascular stress biomarkers in connection with transthoracic echocardiography.

Design and methods

Thirty-three healthy male amateur runners, aged ≥50 years (mean age 57 ± 7) were enrolled. Venous blood samples were obtained before the marathon, just after the race, 2–4 and seven days after the marathon. Using novel single molecule counting technology we measured: plasma concentrations of high-sensitivity cardiac troponin I (hs-cTnI) and endothelin-1. N-terminal pro B-type natriuretic peptide was measured using electrochemiluminescence. Each participant had transthoracic echocardiography before and immediately after the race.

Results

We observed a sharp rise in the levels of all biomarkers after the race (all p < 0.01), which subsequently normalized after 2–4 days and stayed within normal range after seven days. Runners with intensive training programmes (>169 km/month, a median for the studied group) had lower hs-cTnI leak after the race (median 15.11 ng/ml and 31.2 ng/ml, respectively; p < 0.05). Neither transthoracic echocardiography measures of ventricles nor strain rates changed after the run. We observed a decrease in the left atrial volume index and increase in the maximal right atrial volumes (all p < 0.05). Changes in Doppler indices of diastolic function suggestive of alteration in left ventricular relaxation were observed.

Conclusions

Marathon run is associated with sharp and significant rises in the biomarkers of cardiovascular stress. The profile of these changes, however, along with echocardiographic parameters, does not suggest irreversible myocardial damage.

Patterns of dyspnoea onset in patients with acute heart failure: clinical and prognostic implications

Aims

Despite attempts to improve the management of patients with acute heart failure (HF), virtually all therapeutic agents investigated in large clinical trials failed to show any consistent reduction in mortality and morbidity. Complexity of the clinical syndrome of acute HF seems to be likely an underlying explanation. Traditionally, clinical trials studied mixed patient populations with acute HF, and only recently, better clinical characterization of patients has been proposed. Dyspnoea is the most common presenting symptom related to hospital admission for acute HF. Whether in patients with acute HF, the pattern of symptoms onset preceding hospital admission is associated with clinical characteristics, and the outcomes have not yet been established.

Methods and results

We investigated 137 patients (mean age: 65 ± 13 years; 80% men) hospitalized due to acute HF with dyspnoea as major reported symptom, who were divided according to the time of its onset into those with acute (n = 98) vs. subacute (n = 39) onset (i.e. within 7 days vs. >7 days preceding hospital admission, respectively). On admission, the former group presented higher blood pressure (138 ± 33 vs. 121 ± 32 mmHg), more often moderate–severe pulmonary congestion (33 vs. 8%), and lower bilirubin level [1.07 (0.72–1.60) vs. 1.27 (0.87–2.06); P < 0.05 in all comparisons]. There were no other differences in baseline clinical characteristics and laboratory indices. Higher percentage of patients with an acute dyspnoea onset reported marked/moderate dyspnoea relief after 6 (18% vs. 7%), 24 (59% vs. 24%), and 48 h (80% vs. 46% assessed as an improvement of at least 5 points in self‐reported 10‐point Likert scale; P < 0.05 in all time points). In patients with an acute onset of dyspnoea after 48 h, a decrease of N‐terminal pro BNP was more frequently observed (83% vs. 65%), and the levels of endothelin‐1 were more reduced [−1.1 (−2.9–0.03) vs 0.4 (−2.2–1.4); all P < 0.05]. Patients with acute onset experienced less in‐hospital HF worsening (13% vs. 40%, P = 0.001), and 1 year cardiovascular mortality was significantly lower (20% vs. 41%, P = 0.01). On the multivariable analysis, subacute pattern of dyspnoea was independent predictor of 12 month cardiovascular mortality in patients with acute HF after adjusting for other prognostic factors: systolic blood pressure, urea, and HF de novo [hazard ratio (95% confidence interval): 2.32 (1.13–4.75), P = 0.02].

Conclusions

In patients with acute HF, the pattern of symptoms onset is associated with baseline differences in clinical characteristics, biomarker profile, response to standard treatment, and the long‐term outcomes. This is relevant information for planning future clinical trials.