Freedom from congestion predicts good survival despite previous class IV symptoms of heart failure

Determinants of survival following hospitalization for acute heart failure

Heart failure constitutes a major public health concern in the United States and is one of the leading causes of hospitalization, readmission, and death. Due to an aging U.S. population, it is estimated that the prevalence of heart failure will increase by 25% over the coming decades, affecting approximately 3.5% of the population by the year 2030. The ability to discriminate patients admitted with acute heart failure syndromes who are at increased risk for poor post-hospitalization outcomes is thus critical to guide therapeutic decision making for healthcare providers. This review paper will discuss clinical, hemodynamic, as well as biochemical markers that have been demonstrated to predict post-discharge outcomes among patients hospitalized with acute heart failure.

Cardiorenal syndrome type 2: from diagnosis to optimal management

The deterioration of renal function, which is linked to chronic heart failure by a chronological and causal relationship (ie, the so-called cardiorenal syndrome [CRS] type 2), has recently become a matter of growing debate. This debate has concerned the efficacy, safety, and cost effectiveness of the therapies that have been implemented thus far for this syndrome (for example, the intravenous [IV] loop diuretics, such as repeated IV boluses or slow IV infusions, as well as mechanical fluid removal, particularly by means of isolated ultrafiltration [IUF]). Further controversies have also emerged concerning the optimal dosage and timing of some evidence-based drugs, such as angiotensin-converting-enzyme inhibitors. The present review summarizes the currently used diagnostic tools for detecting renal damage in CRS type 2. Subsequently, the meaning of worsening renal function is outlined, as well as the sometimes inconsistent therapeutic schemes that have been implemented in order to prevent or counteract worsening renal function. The need to elaborate upon more detailed and comprehensive scientific recommendations for targeted prevention and/or therapy of CRS type 2 is also underlined. The measures usually adopted (such as the more accurate modulation of loop diuretic dose, combined with the exploitation of other diuretics that are able to achieve a sequential blockade of the nephron, as well as the use of IV administration for loop diuretics) are briefly presented. The concept of diuretic resistance is illustrated, along with the paramount operational principles of IUF in diuretic-resistant patients. Some controversies regarding the comparison of IUF with stepped diuretic therapy in patients with CRS type 2 are also addressed.

Prognostic effect of carbohydrate antigen 125-guided therapy in patients recently discharged for acute heart failure (CHANCE-HF). Study design

INTRODUCTION AND OBJECTIVES

Morbidity and mortality after admission for acute heart failure remain prohibitively high. In that setting, plasma levels of antigen carbohydrate 125 have shown to correlate with the severity of fluid overload and the risk of mortality and readmission. Preliminary data suggests a potential role of antigen carbohydrate 125 to guide therapy. The objective of this study is to evaluate the prognostic effect of an antigen carbohydrate 125-guided management strategy vs standard therapy in patients recently discharged for acute heart failure.

METHODS

This is a multicenter, randomized, single-blind, efficacy trial study of patients recently discharged from acute heart failure (< 180 days), New York Heart Association functional class II-IV and antigen carbohydrate 125 > 35 U/ml. A randomization scheme was used to allocate participants (in a 1:1 ratio) to receive therapy guided by antigen carbohydrate 125 (aiming to keep normal values) or standard treatment. Mainly, antigen carbohydrate 125-guided therapy is focused on the frequency of monitoring and titration of decongestive therapies and statins. As of December 10, 2013, there were 383 patients enrolled. The primary outcome was the composite of 1-year all-cause mortality or rehospitalization for acute heart failure. Analysis was planned to be intention-to-treat.

CONCLUSIONS

Discovering novel therapeutic strategies or finding better ways of optimizing established treatments have become a health care priority in heart failure. This study will add important knowledge about the potential of antigen carbohydrate 125 as a management tool for monitoring and titration of therapies where optimal utilization has not been well defined, such as diuretics and statins.

TRIAL REGISTRATION

ClinicalTrials.gov number: NCT02008110.

Extracorporeal ultrafiltration for heart failure: focus on organ cross talk and clinical trials

Despite major advances in pharmacological therapy and cardiac devices, heart failure patients continue to be frequently (re-)hospitalized with signs and symptoms of fluid overload. Diuretics improve the symptoms of fluid overload, but their effectiveness is reduced by a number of factors including excess salt intake, underlying chronic kidney disease, renal adaptation to their actions and neurohormonal activation. Ultrafiltration (UF) is a mechanical method of fluid removal with several potential advantages over diuretic-based conventional therapies: several recent studies have demonstrated favorable clinical response to UF therapy. Such studies have shown that removal of large amounts of isotonic fluid, in addition to relieving symptoms of congestion, can improve exercise capacity, reduce cardiac filling pressures, restore diuretic responsiveness, and portend a favorable effect on cardio-pulmonary, cardiorenal interactions, and neurohormonal hyperactivation. However, despite these proposed benefits, so far, no clinical study has yet been carried out to explore the impact of UF therapy on hard clinical endpoints such as long-term mortality. In this article, we review a number of mechanistic aspects of UF therapy, with particular emphasis on cardio-pulmonary and cardiorenal interactions, and revisit the results of more recent clinical trials in order to highlight the characteristics that can help identify patients who are more likely to benefit from this therapeutic modality.

Pathophysiology and potential treatments of pulmonary hypertension due to systolic left heart failure

Pulmonary hypertension (PH) due to left heart failure is becoming increasingly prevalent and is associated with poor outcome. The precise pathophysiological mechanisms behind PH due to left heart failure are, however, still unclear. In its early course, PH is caused by increased left ventricular filling pressures, without pulmonary vessel abnormalities. Conventional treatment for heart failure may partly reverse such passive PH by optimizing left ventricular function. However, if increased pulmonary pressures persist, endothelial damage, excessive vasoconstriction and structural changes in the pulmonary vasculature may occur. There is, at present, no recommended medical treatment for this active component of PH due to left heart failure. However, as the vascular changes in PH due to left heart failure may be similar to those in pulmonary arterial hypertension (PAH), a selected group of these patients may benefit from PAH treatment targeting the endothelin, nitric oxide or prostacyclin pathways. Such potent pulmonary vasodilators could, however, be detrimental in patients with left heart failure without pulmonary vascular pathology, as selective pulmonary vasodilatation may lead to further congestion in the pulmonary circuit, resulting in pulmonary oedema. The use of PAH therapies is therefore currently not recommended and would require the selection of suitable patients based on the underlying causes of the disease and careful monitoring of their progress. The present review focuses on the following: (i) the pathophysiology behind PH resulting from systolic left heart failure, and (ii) the current evidence for medical treatment of this condition, especially the role of PAH-targeted therapies in systolic left heart failure.

Swine model of chronic postcapillary pulmonary hypertension with right ventricular remodeling: long-term characterization by cardiac catheterization, magnetic resonance, and pathology

Pulmonary hypertension (PH) is prevalent and carries high morbidity and mortality, mostly due to right ventricular (RV) dysfunction. Postcapillary PH is the most frequent form but there are no large-animal models available. We developed and characterized a porcine model of postcapillary PH by non-restrictive banding of the confluent of both inferior pulmonary veins (n = 10; sham controls n = 3). Right heart catheterization and magnetic resonance were performed before the procedure and monthly during 4 months. All banded animals developed PH. Compared to controls, banded animals presented higher mean pulmonary artery pressure [median (first to third quartile) 30 mmHg (25-37) vs. 20 mmHg (18-23); p = 0.018] and higher pulmonary vascular resistance [5.2 WU (3.8-7.1) vs. 2.3 WU (2.1-3.5); p = 0.028] after 2 months. Differences in indexed RV end-systolic volume [42 mL/m(2) (36-53) vs. 24 mL/m(2) (24-33); p = 0.028] and RV ejection fraction [59 % (54-63) vs. 66 % (64-68); p = 0.028] were also significant after 2 months. Differences remained significant throughout the study. Histopathology revealed increased lung weight and fibrosis but no increase in average water content. Also, remodeling on pulmonary arteries including increased medial and intimal thickness and fibrosis and RV myocardial disarray and fibrosis was demonstrated. Lung remodeling findings were similar in all pulmonary lobes.

Decongestion in acute heart failure

Congestion is a major reason for hospitalization in acute heart failure (HF). Therapeutic strategies to manage congestion include diuretics, vasodilators, ultrafiltration, vasopressin antagonists, mineralocorticoid receptor antagonists, and potentially also novel therapies such as gut sequesterants and serelaxin. Uncertainty exists with respect to the appropriate decongestion strategy for an individual patient. In this review, we summarize the benefit and risk profiles for these decongestion strategies and provide guidance on selecting an appropriate approach for different patients. An evidence-based initial approach to congestion management involves high-dose i.v. diuretics with addition of vasodilators for dyspnoea relief if blood pressure allows. To enhance diuresis or overcome diuretic resistance, options include dual nephron blockade with thiazide diuretics or natriuretic doses of mineralocorticoid receptor antagonists. Vasopressin antagonists may improve aquaresis and relieve dyspnoea. If diuretic strategies are unsuccessful, then ultrafiltration may be considered. Ultrafiltration should be used with caution in the setting of worsening renal function. This review is based on discussions among scientists, clinical trialists, and regulatory representatives at the 9th Global Cardio Vascular Clinical Trialists Forum in Paris, France, from 30 November to 1 December 2012.

Ultrafiltration for acute decompensated heart failure

For the 13th consecutive year, acute decompensated heart failure is the most common reason for admission to American hospitals. Most patients admitted for decompensated heart failure are by definition, diuretic resistant. The therapeutic objective in these patients is volume and sodium removal, and the restoration of diuretic sensitivity. In a significant proportion of patients, this objective is not met, subjecting patients to readmission for recurrent (or continued) heart failure decompensation. Ultrafiltration therapy offers the potential of greater volume and sodium removal as compared with conventional therapies in a more expeditious manner. Ultrafiltration can be accomplished safely, quickly and on a regular telemetry ward in extremely ill patients, but relies on earlier discharge with reduced readmission rates to be economically feasible.