Ultrafiltration in Heart Failure: A Review

Ultrafiltration is an effective method to get rid of fluid retention and congestion in patients with acute decompensated heart failure (HF) without affecting the circulating volume. Although its efficacy in comparison to diuretics is debatable, the evaluation of our analysis is based on various studies that comprise published clinical trials on ultrafiltration and studies comparing the efficacy of diuretics and ultrafiltration. Apart from this, we also look at literature that provides shortcomings of the said procedure and its scope for future advancements. Heart failure ultimately leads to volume overload, which is a highly concerning complication. Diuretics have been used as a first-line treatment for fluid overload but are becoming inefficacious due to the development of resistance and renal dysfunction. Ultrafiltration, on the other hand, is an attractive alternative to counter volume overload and congestion, which are unresponsive to medical therapy. There is also evidence that it significantly decreases the probability of future episodes of decompensation. There are, however, disagreements about whether ultrafiltration is an effective method to improve mortality in these patients. There is a lack of conclusive studies demonstrating the superiority of one fluid removal method over another. Hence, it is imperative to continue searching for the most effective method to treat congestion. Priority should be given to more mechanistic studies regarding ultrafiltration.

Frailty Syndrome as a Transition from Compensation to Decompensation: Application to the Biomechanical Regulation of Gait

Most gait parameters decrease with age and are even more importantly reduced with frailty. However, other gait parameters exhibit different or even opposite trends for aging and frailty, and the underlying reason is unclear. Literature focuses either on aging, or on frailty, and a comprehensive understanding of how biomechanical gait regulation evolves with aging and with frailty seems to be lacking. We monitored gait dynamics in young adults (19-29 years, n = 27, 59% women), middle-aged adults (30-59 years, n = 16, 62% women), and non-frail (>60 years, n = 15, 33% women) and frail older adults (>60 years, n = 31, 71% women) during a 160 m walking test using the triaxial accelerometer of the Zephyr Bioharness 3.0 device (Zephyr Technology, Annapolis, MD, USA). Frailty was evaluated using the Frail Scale (FS) and the Clinical Frailty Scale (CFS). We found that in non-frail older adults, certain gait parameters, such as cadence, were increased, whereas other parameters, such as step length, were decreased, and gait speed is maintained. Conversely, in frail older adults, all gait parameters, including gait speed, were decreased. Our interpretation is that non-frail older adults compensate for a decreased step length with an increased cadence to maintain a functional gait speed, whereas frail older adults decompensate and consequently walk with a characteristic decreased gait speed. We quantified compensation and decompensation on a continuous scale using ratios of the compensated parameter with respect to the corresponding compensating parameter. Compensation and decompensation are general medical concepts that can be applied and quantified for many, if not all, biomechanical and physiological regulatory mechanisms of the human body. This may allow for a new research strategy to quantify both aging and frailty in a systemic and dynamic way.

Sudden Decompensation of Patients Admitted to Non-ICU Settings Within 24 h of Emergency Department Admission

BACKGROUND

Patients admitted to the hospital floor (non-intensive care (ICU) settings) from the emergency department (ED) are generally stable. Unfortunately, some will unexpectedly decompensate rapidly. This study explores these patients and their characteristics.

METHODS

This retrospective, observational study examined patients admitted to non-ICU settings at a community hospital. Patients were identified by rapid response team (RRT) activation, triggered by acute decompensation. ED chief complaint, reason for activation, and vital signs were compared between patients transferred to a higher level of care versus those who were not.

RESULTS

Throughout 2019, 424 episodes of acute decompensation were identified, 118 occurring within 24 h of admission. A higher rate of ICU transfers was seen in patients with initial ED chief complaints of general malaise (87.5% vs 12.5%, p  =  0.023) and dyspnea (70.6% vs 29.4%, p  =  0.050). Patients with sudden decompensation were more likely to need ICU transfer if the RRT reason was respiratory issues (47% vs 24%, p  =  0.010) or hypertension (9.1% vs 0%, p  =  0.019). Patients with syncope as a reason for decompensation were less likely to need transfer (0% vs 10.3%, p  =  0.014). Patients requiring ICU transfer were significantly older (74.4 vs 71.8 years, p  =  0.016). No differences in admission vital signs, APACHE score, or qSOFA score were found.

CONCLUSIONS

Patients admitted to the floor with chief complaint of general malaise or dyspnea should be considered at higher risk of having a sudden decompensation requiring transfer to a higher level of care. Therefore, greater attention should be taken with disposition of these patients at the time of admission.

[Functional morphology of the bladder and its vascular system in relation to age changes and evolution of BPH]

INTRODUCTION

The increase in the proportion of people with various urinary disorders, which are based on anatomical and functional bladder remodeling due to aging, is currently un-deniable. This problem becomes more relevant due to the elevation in life expectancy. At the same time, the features of bladder remodeling, in particular, the structural changes of its vascular bed, are still practically not described in the literature. In men, the lower urinary tract undergoes additional transformation associated with age due to bladder outlet obstruction caused by benign prostatic hyperplasia (BPH). Despite the long history of studying BPH, the morphological basics of its evolution have not yet been fully elucidated, including the development of lower urinary tract decompensation and, in particular, the role of vascular changes. In addition, structural re-modeling of the bladder muscles in BPH is formed in those with pre-existing age-related changes in both the detrusor and its vascular system, which cannot but influence the dynamics of disease progression.

AIM

To study the structural changes of detrusor and its vascular bed associated with age, and to establish the role of their patterns in patients with BPH.

MATERIALS AND METHODS

The material was a specimen of the bladder wall obtained dur-ing: a) autopsies of 35 men aged 60-80 years who died from diseases not related to urological or cardiovascular pathology; b) autopsies of 35 men aged 60-80 years who had BPH without blad-der decompensation; c) intraoperative biopsies of 25 men of the same age who undergone surgi-cal treatment for chronic urinary retention (postvoid residual volume of more than 300 ml), bilat-eral hydronephrosis, as complications of BPH. As a control, we used the specimens obtained from 20 males aged 20-30 years who died as a result of violence. Histological sections of the bladder wall were stained with hematoxylin-eosin, according to Mason and Hart. Standard microscopy and stereometry of detrusor structural components and morphometry of the urinary bladder vessels were performed using a special ocular insert with 100 equidistant points. During morphometric examination of the vascular bed the thickness of the middle layer of arteries wall (tunica media) was measured, as well as a thickness of the entire wall of the veins in microns. In addition, a Schiff test and Immunohistochemistry (IHC) of these histological sections were performed. The IHC was evaluated using a semi-quantitative method, taking into account the degree of staining in 10 fields of vision (200). The digital material was processed with the STATISTICA program using the Student's t-test. The distribution of the obtained data corresponded to normal. The data were considered re-liable if the probability of making error did not exceed 5% (p<0.05).

RESULTS AND DISCUSSION

In the course of natural aging, a structural remodeling of bladder vascular bed was observed, from the development of atherosclerosis of extra-organ arteries to restructuring of intra-organ arteries due to arterial hypertension. The progression of angiopathy leads to the development of chronic detrusor ischemia, which initiates the formation of focal at-rophy of the smooth muscles, destructive changes in the elastic fibers, neurodegeneration and stroma sclerosis. A long-term BPH leads to compensatory detrusor remodeling with hypertrophy of previously unchanged areas. At the same time, age-related atrophic and sclerotic changes in smooth muscles are accompanied with hypertrophy of individual areas of the bladder detrusor. To maintain adequate blood supply to hypertrophied detrusor areas in the arterial and venous bladder vessels, a complex of myogenic structures is formed that can regulate blood circulation, making it dependent on the energy consumption of specific areas. However, progressive age-related changes in the arteries and veins eventually lead to an increase in chronic hypoxia, im-paired nervous regulation and vascular dystonia, increased blood vessels sclerosis and hyalinosis, and sclerosis of intravascular myogenic structures with loss of their function of blood flow regu-lation, as well as the development of vein thrombosis. As a result, increasing vascular decom-pensation in patients with bladder outlet obstruction results in bladder ischemia and accelerates the decompensation of the lower urinary tract.

Prediction and Analysis of Heart Failure Decompensation Events Based on Telemonitored Data and Artificial Intelligence Methods

Cardiovascular diseases are the leading cause of death globally, taking an estimated 17.9 million lives each year. Heart failure (HF) occurs when the heart is not able to pump enough blood to satisfy metabolic needs. People diagnosed with chronic HF may suffer from cardiac decompensation events (CDEs), which cause patients' worsening. Being able to intervene before decompensation occurs is the major challenge addressed in this study. The aim of this study is to exploit available patient data to develop an artificial intelligence (AI) model capable of predicting the risk of CDEs timely and accurately. Materials and Methods: The vital variables of patients (n = 488) diagnosed with chronic heart failure were monitored between 2014 and 2022. Several supervised classification models were trained with these monitoring data to predict CDEs, using clinicians' annotations as the gold standard. Feature extraction methods were applied to identify significant variables. Results: The XGBoost classifier achieved an AUC of 0.72 in the cross-validation process and 0.69 in the testing set. The most predictive physiological variables for CAE decompensations are weight gain, oxygen saturation in the final days, and heart rate. Additionally, the answers to questionnaires on wellbeing, orthopnoea, and ankles are strongly significant predictors.

Impact of pre-operative transjugular intrahepatic portosystemic shunt on post-operative outcomes following non-transplant surgeries in patients with decompensated cirrhosis

Background

Patients with cirrhosis have a high risk for morbidity and mortality in relation to abdominal surgery. Despite improvements in surgical techniques and intensive care, major abdominal surgery still remains a challenge. Major factors determining short- and long-term survival and perioperative complications in this patient population include severity of liver dysfunction, degree of portal hypertension (PHTN), and the presence of related complications such as ascites. Elective transjugular intrahepatic portosystemic shunt (TIPS) placement prior to surgery has been reported to improve perioperative outcomes, but available data is limited to case reports and small case series. We aimed to determine the impact of elective TIPS placement on perioperative outcomes after abdominal-pelvic surgeries in patients with cirrhosis.

Methods

We performed a retrospective chart review of patients who underwent elective TIPS and compared these patients with a cohort of cirrhotic patients who underwent any abdominal surgeries without TIPS placement. The primary outcomes were mortality at 30 days and 1 year following surgery. Other post-operative outcomes compared between the two groups, included: blood loss, worsening ascites, wound leak, infections, encephalopathy, liver decompensation, and length of hospitalization.

Results

Among 38 patients with cirrhosis who underwent abdominal surgery, 20 patients underwent pre-operative elective TIPS placement. Demographic characteristics of the two groups were comparable including age, gender, and body mass index (BMI). The median age was 62 years with a male predominance (62.5%). Both groups had similar etiologies of cirrhosis with hepatitis C virus (HCV) (34.2%) being most common. The most frequent indications for surgery were strangulated hernia (50%) in the TIPS group and acute cholecystitis (55.6%) in the non-TIPS group. Mean pre-TIPS hepato-venous portal gradient (HVPG) was 16.5 mmHg and mean post-TIPS HVPG was 7.0 mmHg. Mortality at 1 month was not statistically different between the groups (20% vs. 5.6%, respectively, P=0.19). The 1-year mortality was also not statistically different between the two groups (20% vs. 11.1%, P=0.36).

Conclusions

We found no statistically significant difference in mortality or rate of post-operative complications between patients who received pre-operative TIPS and those who did not in our age-matched cohort.

Incidence and Predictors of Liver-Related Events in Patients With Nonalcoholic Fatty Liver Disease

Background

Nonalcoholic fatty liver disease (NAFLD) is the commonest type of liver disease worldwide. We aimed to assess the incidence and predictors of liver-related events (LREs) and mortality in NAFLD patients.

Methods

NAFLD patients (n = 957) evaluated between January 2000 and November 2021 were included. Patients were categorised as noncirrhosis (NC), compensated cirrhosis (CC) and decompensated cirrhosis (DC), and the incidence of LRE and mortality were estimated and compared.

Results

The proportions of NC, CC and DC were 87.8% (n = 840), 8.8% (n = 84) and 3.4% (n = 33), respectively. The median follow-up duration was 3.9 (3.0-5.7) years, and the total cumulative duration was 4633 person-years. The incidence of LRE per 100 person-years was 0.14, 2.72 and 10.24 in patients with NC, CC and DC, respectively. The incidence of mortality was 0.12, 1.05 and 4.24 per 100 person-years, respectively, in the 3 groups. The causes of mortality in the 3 groups were liver related in 1/5 (20%), 3/4 (75%) and 6/9 (66.7%), respectively. Overall, the mortality rate was higher in those with diabetes than those without diabetes (log-rank P value = 0.005). On further analysis, diabetes was associated with poor outcomes only in NC group (log-rank P value = 0.036), and not in CC (log-rank P value = 0.353) or DC groups (log-rank P value = 0.771). On multivariate Cox proportional hazard analysis, age (hazard ratio [HR] 1.070), hypertension (HR 4.361) and DC (HR 15.036) were independent predictors of poor outcomes. Liver stiffness measurement, bilirubin, CC and DC were independent predictors of LRE.

Conclusion

In our study of NAFLD from India, the incidence of LRE was found to be similar to that seen in Western studies. In NC NAFLD, diabetes was associated with poor outcomes.

Association of Time to Rapid Response Team Activation With Patient Outcomes Using a Range of Physiologic Deterioration Thresholds

Clinical deterioration of hospitalized patients is common and can lead to critical illness and death. Rapid response teams (RRTs) assess and treat high-risk patients with signs of clinical deterioration to prevent further worsening and subsequent adverse outcomes. Whether activation of the RRT early in the course of clinical deterioration impacts outcomes, however, remains unclear. We sought to characterize the relationship between increasing time to RRT activation after physiologic deterioration and short-term patient outcomes.

DESIGN

Retrospective multicenter cohort study.

SETTING

Three academic hospitals in Pennsylvania.

PATIENTS

We included the RRT activation of a hospitalization for non-ICU inpatients greater than or equal to 18 years old.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary exposure was time to RRT activation after physiologic deterioration. We selected four Cardiac Arrest Risk Triage (CART) score thresholds a priori from which to measure time to RRT activation (CART score ≥ 12, ≥ 16, ≥ 20, and ≥ 24). The primary outcome was 7-day mortality-death or discharge to hospice care within 7 days of RRT activation. For each CART threshold, we modeled the association of time to RRT activation duration with 7-day mortality using multivariable fractional polynomial regression. Increased time from clinical decompensation to RRT activation was associated with higher risk of 7-day mortality. This relationship was nonlinear, with odds of mortality increasing rapidly as time to RRT activation increased from 0 to 4 hours and then plateauing. This pattern was observed across several thresholds of physiologic derangement.

CONCLUSIONS

Increasing time to RRT activation was associated in a nonlinear fashion with increased 7-day mortality. This relationship appeared most marked when using a CART score greater than 20 threshold from which to measure time to RRT activation. We suggest that these empirical findings could be used to inform RRT delay definitions in further studies to determine the clinical impact of interventions focused on timely RRT activation.

Real-world clinical features, health-care utilization, and economic burden in decompensated cirrhosis patients: A national database

BACKGROUND

Patients with decompensated cirrhosis are well known to experience morbidity and mortality.

AIM

We assessed clinical characteristics, health-care utilization, and economic burden according to the type, number, and combination of decompensation-related complications.

METHODS

We used recent nationally representative sample data from 2016 to 2018, covering approximately 13% of hospitalized patients in South Korea annually. Decompensation-related complications included ascites, hepatic encephalopathy (HE), gastroesophageal variceal (GEV) bleeding, and hepatorenal syndrome (HRS).

RESULTS

Among 14 601 patients with decompensated cirrhosis, 11 201 (76.7%) experienced ≥ 1 decompensation-related complications, and approximately three-quarters underwent hospitalization. The most prevalent decompensation-related complications were ascites (54.8%), GEV bleeding (33.2%), HE (27.4%), and HRS (3.6%). Patients with GEV bleeding exhibited the highest hospitalization rate (95.7%), and patients with HE or HRS underwent hospitalization for 4 weeks/year due to decompensated cirrhosis. Hospitalization costs were 1.9 times higher in patients with HRS than in those with ascites alone ($9022 vs $4673; P < 0.01). Once patients developed decompensation-related complications, 41.3% had ≥ 2 types of decompensation-related complications. As the number of decompensation-related complications increased from 0 to ≥ 3, health-care utilization and economic burden significantly increased in a stepwise manner; patients with ascites, GEV bleeding, and HE visited medical institutions 2.2 times more (11 vs 5/year; P < 0.01) and incurred 6.4 times greater medical expenditure ($11 060 vs $1728/year; P < 0.01) than those with ascites only.

CONCLUSION

A substantial proportion of patients had multiple decompensation-related complications and socioeconomic burdens for decompensated cirrhosis considering admission rate, hospital stay, and costs increased markedly, depending on the number of decompensation-related complications.

Increased platelet aggregation in patients with decompensated cirrhosis indicates higher risk of further decompensation and death

BACKGROUND & AIMS

Studies on platelet aggregation in cirrhosis are controversial because interpretation of platelet function is challenged by thrombocytopenia. We conducted a prospective study to investigate whole blood platelet aggregation in cirrhosis and its association with liver-related outcomes.

METHODS

Platelet aggregation was assessed by whole blood aggregometry (Multiplate®). To overcome the influence of platelet count and compare cirrhosis with thrombocytopenia vs. controls with normal platelet count, we calculated a ratio between platelet aggregation and platelet count (PLT ratio). Then, we prospectively followed patients with cirrhosis and ascertained predictors of decompensation, transplantation, and death.

RESULTS

Two-hundred and three patients with cirrhosis were prospectively recruited (77% decompensated). PLT ratio was significantly higher in cirrhosis than in those with chronic hepatitis and healthy individuals (0.44 vs. 0.25 and 0.26, respectively; p <0.0001). In cirrhosis, the ratio increased with disease severity (Child-Pugh class C>B>A) and was particularly elevated in decompensated patients with severe thrombocytopenia. Among decompensated patients, 65 had further decompensation, underwent transplantation, or died during a 6-month follow-up. On multivariate analysis, PLT ratio (odds ratio 1.87; 95% CI 1.23-2.84; p = 0.003) and MELD score (odds ratio 1.05; 95% CI 1.01-1.08; p = 0.01) were independently associated with outcome. The relative risk of events was 7.5-fold higher in patients with PLT ratio >0.75 vs. patients with PLT ratio <0.25 (95% CI 2.5-21.9; p = 0.003). The increased PLT ratio, its discriminative ability for composite outcome, and the prognostic value of PLT ratio >0.75 were confirmed in an independent cohort of hospitalized patients with decompensated cirrhosis (n = 41).

CONCLUSIONS

Patients with cirrhosis, particularly when decompensated, exhibit significantly increased whole blood platelet aggregation. Decompensated patients with a PLT ratio >0.75 have a >80% probability of further decompensation, transplantation, or liver-related death within 6 months.

LAY SUMMARY

In patients with cirrhosis, previous studies have suggested that platelets (i.e. circulating blood cells that help form clots to stop bleeding) are dysfunctional. In particular, these studies suggested that platelet aggregation (the process by which platelets adhere to each other to form clots) is reduced. Since platelet aggregation is important for clot formation, it has been hypothesized that alterations of platelet aggregation may be responsible for the increased risk of bleeding observed in patients with cirrhosis. Our study demonstrates: i) that platelet aggregation in patients with cirrhosis is higher than in healthy individuals; ii) that platelet aggregation in patients with decompensated cirrhosis (i.e. those who have already experienced some complications of cirrhosis) is particularly elevated and associated with risk of further complications and death.

Association between sustained virological response and clinical outcomes in patients with hepatitis C infection and hepatocellular carcinoma

Background

Sustained viral response (SVR) improves survival for patients with hepatitis C (HCV) and hepatocellular carcinoma (HCC) after curative treatment; however, the benefit of SVR in those with active HCC with a significant competing risk of mortality is unknown. This study aimed to evaluate the association between SVR and outcomes in patients with active HCC.

Methods

The authors performed a multicenter, retrospective cohort study including consecutive adults with HCV cirrhosis and treatment‐naive HCC diagnosed between 2014 and 2018. Patients were stratified into two groups: active viremia (n = 431) and SVR before HCC diagnosis (n = 135). All patients underwent nonsurgical therapy as their initial treatment and were followed until liver transplantation, last follow‐up, or death. The primary outcome was incident or worsening hepatic decompensation within 6 months and the secondary outcome was overall survival. All analyses used inverse probability of treatment weights (IPTW) to account for differences between the nonrandomized cohorts.

Results

Post‐SVR patients had significantly lower odds of hepatic decompensation compared to viremic patients (odds ratio [OR], 0.18; 95% confidence interval [CI], 0.06–0.59). Results were consistent among subgroups of patients with Child Pugh A cirrhosis (OR, 0.22; 95% CI, 0.04–0.77), Barcelona Clinic Liver Cancer stage B/C HCC (OR, 0.20; 95% CI, 0.04–0.65), and those receiving nonablative HCC therapies (OR, 0.21; 95% CI, 0.07–0.67). However, in IPTW multivariable Cox regression, SVR was not associated with improved survival (hazard ratio, 0.79; 95% CI, 0.56–1.12).

Conclusions

Patients with HCV‐related HCC and SVR are less likely to experience hepatic decompensation than viremic patients, suggesting patients with HCC who are undergoing nonsurgical therapies may benefit from DAA treatment.

Hepatitis C virus‐related hepatocellular carcinoma remains prevalent in clinical practice, however, whether treatment of hepatitis C improves outcomes is unknown. The authors have shown an association between hepatitis C sustained virological response and decreased risk of hepatic decompensation in patients with hepatocellular carcinoma, across stages of disease and types of therapy received. See also pages 000–000.

Efficacy of Nondiuretic Pharmacotherapy for Improving the Treatment of Congestion in Patients with Acute Heart Failure: A Systematic Review of Randomised Controlled Trials

Diuretic therapy is the mainstay during episodes of acute heart failure (AHF). Diuretic resistance is often encountered and poses a substantial challenge for clinicians. There is a lack of evidence on the optimal strategies to tackle this problem. This review aimed to compare the outcomes associated with congestion management based on a strategy of pharmacological nondiuretic-based regimens. The PubMed, Cochrane Library, Scopus, and ScienceDirect databases were systematically searched for all randomised controlled trials (RCTs) of adjuvant pharmacological treatments used during hospitalisation episodes of AHF patients. Congestion relief constitutes the main target in AHF; hence, only studies with efficacy indicators related to decongestion enhancement were included. The Cochrane risk-of-bias tool was used to evaluate the methodological quality of the included RCTs. Twenty-three studies were included; dyspnea relief constituted the critical efficacy endpoint in most included studies. However, substantial variations in dyspnea measurement were found. Tolvaptan and serelaxin were found to be promising options that might improve decongestion in AHF patients. However, further high-quality RCTs using a standardised approach to diuretic management, including dosing and monitoring strategies, are crucial to provide new insights and recommendations for managing heart failure in acute settings.

Decongestive treatment adjustments in heart failure patients remotely monitored with a multiparametric implantable defibrillators algorithm

AIMS

HeartLogic algorithm combines data from multiple implantable defibrillators (ICD)-based sensors to predict impending heart failure (HF) decompensation. A treatment protocol to manage algorithm alerts is not yet known, although decongestive treatment adjustments are the most frequent alert-triggered actions reported in clinical practice. We describe the implementation of HeartLogic for remote monitoring of HF patients, and we evaluate the approach to diuretic dosing and timing of the intervention in patients with device alerts.

METHODS

The algorithm was activated in 229 ICD patients at eight centers. The median follow-up was 17 months (25th-75th percentile: 11-24). Remote data reviews and patient phone contacts were undertaken at the time of HeartLogic alerts, to assess the patient's status and to prevent HF worsening. We analyzed alert-triggered augmented HF treatments, consisting of isolated increases in diuretics dosage.

RESULTS

We reported 242 alerts (0.8 alerts/patient-year) in 123 patients, 137 (56%) alerts triggered clinical actions to treat HF. The HeartLogic index decreased after the 56 actions consisting of diuretics increase. Specifically, alerts resolved more quickly when the increases in dosing of diuretics were early rather than late: 28 days versus 62 days, p < .001. The need of hospitalization for further treatments to resolve the alert condition was associated with higher HeartLogic index values on the day of the diuretics increase (odds ratio: 1.11, 95% CI: 1.02-1.20, p = .013) and with late interventions (odds ratio: 5.11, 95% CI: 1.09-24.48, p = .041). No complications were reported after drug adjustments.

CONCLUSIONS

Decongestive treatment adjustments triggered by alerts seem safe and effective. The early use of decongestive treatment and the use of high doses of diuretics seem to be associated with more favorable outcomes.

Factor VIII/protein C ratio independently predicts liver-related events but does not indicate a hypercoagulable state in ACLD

BACKGROUND & AIMS

It has been suggested that the ratio of procoagulant factor VIII to anticoagulant protein C (FVIII/PC) reflects the hemostatic equilibrium. Moreover, FVIII/PC predicted decompensation/death in a small study not accounting for portal hypertension severity. We investigated (i) the prognostic value of FVIII/PC (outcome-cohort) and (ii) whether FVIII/PC reflects the hypercoagulable state (assessed by thrombomodulin-modified thrombin generation assay [TM-TGA]) or the risk of bleeding/thrombotic events in patients undergoing hepatic venous pressure gradient (HVPG) measurement during follow-up.

METHODS

(i) The outcome-cohort comprised 576 patients with evidence of advanced chronic liver disease (liver stiffness measurement ≥10 kPa and/or HVPG ≥6 mmHg). (ii) TM-TGA-cohort patients (n = 142) were recruited from the prospective VIenna CIrrhosis Study (VICIS: NCT03267615).

RESULTS

(i) FVIII/PC significantly increased across clinical stages (p <0.001) as well as HVPG (p <0.001) and MELD score (p <0.001) strata and remained independently associated with decompensation/liver-related death (adjusted hazard ratio 1.06; 95% CI 1.01-1.11; p = 0.013), even after multivariable adjustment. It was also associated with acute-on-chronic liver failure (ACLF) development (adjusted hazard ratio 1.10; 95% CI 1.02-1.19; p = 0.015) in patients with decompensated cirrhosis. (ii) FVIII/PC showed a weak positive correlation with endogenous thrombin potential (Spearman's ρ = 0.255; p = 0.002), but this association disappeared after adjusting for the severity of liver disease. FVIII/PC was not associated with the development of bleeding (p = 0.272) or thrombotic events (p = 0.269). However, FVIII/PC correlated with biomarkers of different pathophysiological mechanisms that promote liver disease progression.

CONCLUSION

FVIII/PC provides prognostic information regarding hepatic decompensation/death and ACLF, independently of established prognostic indicators. However, this is not evidence that hypercoagulability drives disease progression, as the correlation between FVIII/PC and thrombin generation is confounded by liver disease severity and FVIII/PC was not associated with thrombosis. Therefore, FVIII/PC does not reflect coagulation and results from previous studies on FVIII/PC require re-interpretation.

CLINICAL TRIAL NUMBER

NCT03267615 (in part).

LAY SUMMARY

A balanced coagulation system is essential for preventing bleeding episodes and blood clot formation (thrombosis). Blood of patients with advanced liver disease may have increased coagulation potential, possibly promoting the worsening of liver disease via thrombosis in the blood vessels of the liver. The ratio between the results of 2 blood tests (procoagulant factor VIII to anticoagulant protein C) has been suggested to reflect these increases in coagulation potential. Our study demonstrates, on the one hand, that this ratio is a versatile predictor of the development of complications of cirrhosis, yet on the other hand, that it is unrelated to coagulation.

Risk Difference of Liver-Related and Cardiovascular Events by Liver Fibrosis Status in Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) has affected more than one-fourth of the global population, thus emerging as a worldwide health and economic burden.1 The common causes of death in patients with NAFLD include cardiovascular disease (CVD), decompensation, and hepatocellular carcinoma (HCC). However, identifying the risk of these complications in patients with NAFLD remains an unmet need in clinical practice.

Multiple cArdiac seNsors for mAnaGEment of Heart Failure (MANAGE-HF) - Phase I Evaluation of the Integration and Safety of the HeartLogic Multisensor Algorithm in Patients With Heart Failure

BACKGROUND

Patients with heart failure and reduced ejection fraction (HFrEF) suffer from a relapsing and remitting disease, where early treatment changes may improve outcomes. We assessed the clinical integration and safety of the HeartLogic multi-sensor index and alerts in heart failure care.

METHODS

The Multiple cArdiac seNsors for mAnaGEment of Heart Failure (MANAGE-HF) study enrolled 200 patients with HFrEF (< 35%), NYHA class II-III symptoms, implanted with a CRT-D or ICD, who had either a hospitalization for HF within 12 months or unscheduled visit for HF exacerbation within 90 days or an elevated natriuretic peptide concentration (BNP≥150 pg/mL or NT-proBNP≥600 pg/mL). This phase included development of an alert management guide and evaluated changes in medical treatment, natriuretic peptide levels, and safety.

RESULTS

Mean age of participants was 67 years, 68% were men, 81% were white, and 61% had a HF hospitalization in prior 12 months. During follow-up there were 585 alert cases with an average of 1.76 alert cases/pt-yr. HF medications were augmented during 74% of the alert cases. HF treatment augmentation within 2 weeks from an initial alert was associated with more rapid recovery of the HeartLogic Index. Five SAEs (0.015 per pt-year) occurred in relation to alert-prompted medication change. NTproBNP levels decreased from median of 1316 pg/mL at baseline to 743 pg/mL at 12 months (p<0.001).

CONCLUSIONS

HeartLogic alert management was safely implemented in HF care and may optimize HF management. This phase supports further evaluation in larger studies.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03237858).

Baveno VII - Renewing consensus in portal hypertension

To expand on the work of previous meetings, a virtual Baveno VII workshop was organised for October 2021. Among patients with compensated cirrhosis or compensated advanced chronic liver disease (cACLD - defined at the Baveno VI conference), the presence or absence of clinically significant portal hypertension (CSPH) is associated with differing outcomes, including risk of death, and different diagnostic and therapeutic needs. Accordingly, the Baveno VII workshop was entitled "Personalized Care for Portal Hypertension". The main fields of discussion were the relevance and indications for measuring the hepatic venous pressure gradient as a gold standard, the use of non-invasive tools for the diagnosis of cACLD and CSPH, the impact of aetiological and non-aetiological therapies on the course of cirrhosis, the prevention of the first episode of decompensation, the management of an acute bleeding episode, the prevention of further decompensation, as well as the diagnosis and management of splanchnic vein thrombosis and other vascular disorders of the liver. For each of these 9 topics, a thorough review of the medical literature was performed, and a series of consensus statements/recommendations were discussed and agreed upon. A summary of the most important conclusions/recommendations derived from the workshop is reported here. The statements are classified as unchanged, changed, and new in relation to Baveno VI.

Rates of decompensation, hepatocellular carcinoma and mortality in AMA-negative primary biliary cholangitis cirrhosis

BACKGROUND

The natural history of patients with anti-mitochondrial antibody (AMA)-negative Primary Biliary Cholangitis (PBC) cirrhosis has not been well defined, with prior studies showing discordant results. Furthermore, most studies of AMA-negative PBC have limited numbers of patients with cirrhosis and liver-related outcomes.

METHODS

We investigated the association of AMA-negative PBC and the development of death, liver-related death, decompensation and hepatocellular carcinoma (HCC), in a large cohort of predominantly male patients with PBC cirrhosis assembled from the Veterans Health Administration.

RESULTS

In a cohort of 521 patients with PBC cirrhosis (65 AMA-negative) with a total follow-up of 2504.3 person-years (PY) from cirrhosis diagnosis, patients with AMA-negative PBC were younger and more likely to be black but had similar rates of UDCA response. AMA-negative PBC cirrhosis was associated with similar unadjusted rates of liver-related death (4.6 vs 5.9 per 100 PY, P = .44), overall death (7.7 vs 9.6 per 100 PY, P = .31), decompensation (7.3 vs 5.1 per 100 PY, P = .12) and HCC (0.6 vs 1.0 per 100 PY, P = .63) to AMA-positive PBC. After adjusting for confounders, AMA-negative PBC cirrhosis was associated with similar rates of liver-related death (sub-Hazard Ratio [sHR] 1.27, 95% CI 0.71-2.28, P = .42, death [sHR] 1.24, 95% CI 0.81-1.90, P = .32), decompensation (sHR 1.05, 95% CI 0.56-1.98, P = .87) and HCC (sHR 0.48, 95% CI 0.11-2.10, P = .33) to AMA-positive patients.

CONCLUSION

In a cohort of predominantly male patients, AMA-negative PBC cirrhosis was associated with similar rates of overall or liver-related death, HCC or decompensation compared with AMA-positive disease.

Temporal Association of Atrial Fibrillation With Cardiac Implanted Electronic Device Detected Heart Failure Status

OBJECTIVES

This study sought to investigate the temporal association between changes in physiologic heart failure (HF) sensors, atrial fibrillation (AF) progression, and clinical HF in patients with cardiac resynchronization therapy implantable defibrillators (CRT-D) designed to monitor AF and HF daily.

BACKGROUND

AF is a common comorbidity in HF; however, it is unclear if HF triggers AF, or vice-versa. Current implantable cardiac devices have sensors capable of quantifying HF status, which permits a greater understanding of the impact of AF on HF status and may help guide treatment.

METHODS

The MultiSENSE (Multisensor Chronic Evaluation in Ambulatory Heart Failure Patients) study collected multiple sensor data indicative of HF status in patients with CRT-D followed for up to 12 months. Patients were grouped according to their longest daily AF burden: 1) at least 24 hours of AF (HIGH AF); 2) between 6 minutes and 24 hours (MID AF); and 3) <6 minutes (NO AF). Sensor data were aligned to the first qualifying AF event or a randomly selected day for patients in the NO AF group.

RESULTS

Among 869 patients with daily AF data available, 98 patients had HIGH AF, 141 patients MID AF, and 630 patients NO AF. At baseline, history of AF, N-terminal pro hormone B-type natriuretic peptide and device-measured S3 were associated with development of AF. HeartLogic index increased before AF onset (Δ HeartLogic = 9.83 ± 2.49; P < 0.001). Multivariable time-dependent Cox regression showed an increased risk for HF events following a 24-hour AF episode compared with no 24-hour AF (hazard ratio: 1.96; 95% confidence interval: 1.03-3.74).

CONCLUSIONS

Device-measured HF indicators worsened before AF onset, whereas clinical HF deterioration only became apparent after AF occurred. Thus, the sensitivity of methods to ascertain AF and HF status appear to influence the direction of perceived causality. (Multisensor Chronic Evaluation in Ambulatory Heart Failure Patients [MultiSENSE]; NCT01128166).

Gut Barrier and Microbiota in Cirrhosis

Gut microbiota and their homeostatic functions are central to the maintenance of the intestinal mucosal barrier. The gut barrier functions as a structural, biological, and immunological barrier, preventing local and systemic invasion and inflammation of pathogenic taxa, resulting in the propagation or causation of organ-specific (liver disease) or systemic diseases (sepsis) in the host. In health, commensal bacteria are involved in regulating pathogenic bacteria, sinister bacterial products, and antigens; and help control and kill pathogenic organisms by secreting antimicrobial metabolites. Gut microbiota also participates in the extraction, synthesis, and absorption of nutrient metabolites, maintains intestinal epithelial integrity and regulates the development, homeostasis, and function of innate and adaptive immune cells. Cirrhosis is associated with local and systemic immune, vascular, and inflammatory changes directly or indirectly linked to perturbations in quality and quantity of intestinal microbiota and intestinal mucosal integrity. Dysbiosis and gut barrier dysfunction are directly involved in the pathogenesis of compensated cirrhosis and the type and severity of complications in decompensated cirrhosis, such as bacterial infections, encephalopathy, extrahepatic organ failure, and progression to acute on chronic liver failure. This paper reviews the normal gut barrier, gut barrier dysfunction, and dysbiosis-associated clinical events in patients with cirrhosis. The role of dietary interventions, antibiotics, prebiotics, probiotics, synbiotics, and healthy donor fecal microbiota transplantation (FMT) to modulate the gut microbiota for improving patient outcomes is further discussed.

Carbohydrate Antigen 125: A Biomarker at the Crossroads of Congestion and Inflammation in Heart Failure

Because heart failure (HF) is more lethal than some of the common malignancies in the general population, such as prostate cancer in men and breast cancer in women, there is a need for a cost-effective prognostic biomarker in HF beyond natriuretic peptides, especially concerning congestion, the most common reason for the hospitalisation of patients with worsening of HF. Furthermore, despite diuretics being the mainstay of treatment for volume overload in HF patients, no randomised trials have shown the mortality benefits of diuretics in HF patients, and appropriate diuretic titration strategies in this population are unclear. Recently, carbohydrate antigen (CA) 125, a well-established marker of ovarian cancer, emerged as both a prognostic indicator and a guide in tailoring decongestion therapy for patients with HF. Hence, in this review the authors present the molecular background regarding the role of CA125 in HF and address valuable clinical aspects regarding the relationship of CA125 with both prognosis and therapeutic management in HF.

Altered Heart Rate Variability Early in ICU Admission Differentiates Critically Ill Coronavirus Disease 2019 and All-Cause Sepsis Patients

IMPORTANCE

Altered heart rate variability has been associated with autonomic dysfunction in a number of disease profiles, in this work we elucidate differences in the biomarker among patients with all-cause sepsis and coronavirus disease 2019.

OBJECTIVES

To measure heart rate variability metrics in critically ill coronavirus disease 2019 patients with comparison to all-cause critically ill sepsis patients.

DESIGN SETTING AND PARTICIPANTS

Retrospective analysis of coronavirus disease 2019 patients admitted to an ICU for at least 24 hours at any of Emory Healthcare ICUs between March 2020 and April 2020 up to 5 days of ICU stay. The comparison group was a cohort of all-cause sepsis patients prior to coronavirus disease 2019 pandemic.

MAIN OUTCOMES AND MEASURES

Continuous waveforms were captured from the patient monitor. The electrocardiogram was then analyzed for each patient over a 300 seconds observational window that was shifted by 30 seconds in each iteration from admission till discharge. A total of 23 heart rate variability metrics were extracted in each iteration. We use the Kruskal-Wallis and Steel-Dwass tests (p < 0.05) for statistical analysis and interpretations of heart rate variability multiple measures.

RESULTS

A total of 141 critically ill coronavirus disease 2019 patients met inclusion criteria, who were compared with 208 patients with all-cause sepsis. Three nonlinear markers, including the ratio of standard deviation derived from the Poincaré plot, sample entropy, and approximate entropy and four linear features, including mode of beat-to-beat interval, acceleration capacity, deceleration capacity, and the proportion of consecutive RR intervals that differ by more than 50 ms, were all statistically significant (p < 0.05) between the coronavirus disease 2019 and all-cause sepsis cohorts. The three nonlinear features and acceleration capacity, deceleration capacity, and beat-to-beat interval (mode) were statistically significant (p < 0.05) when comparing pairwise analysis among the combinations of survivors and nonsurvivors between the coronavirus disease 2019 and sepsis cohorts. Temporal analysis of the main markers showed low variability across the 5 days of analysis compared with sepsis patients.

CONCLUSIONS AND RELEVANCE

In this descriptive statistical study, heart rate variability measures were found to be statistically different across critically ill patients infected with severe acute respiratory syndrome coronavirus 2 and distinct from bacterial sepsis.

Creatinine and NT-ProBNP levels could predict the length of hospital stay of patients with decompensated heart failure

BACKGROUND

Heart failure (HF) is a clinical syndrome that causes high morbidity and mortality with a high number of admissions and sometimes prolonged admissions. This study aimed at assessing whether parameters detected during the first 24 h of admission may predict a prolonged hospital stay in patients admitted to hospital for decompensated HF.

METHODS

From January 2016 to December 2019, 2359 admissions of decompensated HF were recorded. In-hospital transfers, de novo HF, deaths and scheduled admissions were discarded to homogenise the sample. Finally, 1196 patients were included. The sample was divided into two groups: (a) non-prolonged admission (n = 643, admission ≤7 days) or (b) prolonged admission (n = 553, admission >7 days). Clinical, analytical, electrocardiographic and echocardiographic variables obtained during the first 24 h of admission were analysed.

RESULTS

Univariate differences were found at admission in NT-ProBNP, creatinine, history of cardiac surgery, smoking and alcoholism, left and right ventricular ejection fraction, systolic blood pressure and heart rate. The ROC analysis showed significant areas under the curve for the NT-ProBNP (AUC: 0.63, 95% CI: 0.60-0.67; p < 0.001) and creatinine (AUC: 0.69, 95% CI: 0.66-0.72; p < 0.0001). The variables associated with prolonged hospital admission were NT-ProBNP (OR: 1, 95% CI: 1-1; p < 0.001), creatinine (OR: 2.2, 95% CI: 1.8-2.7; p < 0.0001) and previous smoking (OR: 1.5, 95% CI: 0.4-1; p < 0.02).

CONCLUSIONS

Variables such as creatinine and NT-ProBNP at hospital admission may define a subgroup of patients who will probably have a long hospital stay. Therefore, the planning of hospital care and transition to discharge may be enhanced.