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Marti CN, Fonarow GC, Anker S, Yancy C, Vaduganathan M, Greene SJ, Ahmed A, Januzzi JL, Gheorghiade M, Filippatos G, Butler J. Medication dosing for heart failure with reduced ejection fraction - opportunities and challenges. Eur J Heart Fail 2019; 21:286-296. [PMID: 30537163 PMCID: PMC6528811 DOI: 10.1002/ejhf.1351] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/18/2018] [Accepted: 08/23/2018] [Indexed: 12/11/2022] Open
Abstract
Multiple drug classes have shown incremental benefits in heart failure with reduced ejection fraction. Most of these trials were designed to achieve specific doses of the investigational agent. Clinical practice guidelines recommend using the same target dosing of therapies, as tolerated. However, with the increasing number of available therapies, clinicians face the challenge of simultaneously using several drugs, achieving target doses, and managing side effects that are often overlapping. Blood pressure, renal function, hyperkalaemia, and other factors may impede achieving target doses of all medications, leaving clinicians with dilemmas as to how to sequence and dose these various classes of drugs. The guideline-directed eligibility for certain drugs and devices requires stability on maximally tolerated doses of background therapies. However, significant variability exists in dosing achieved in clinical practice. We discuss the existing background data regarding the doses of heart failure medications in clinical trials and in practice, and provide recommendations on how to navigate this complex therapeutic decision-making.
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Affiliation(s)
- Catherine N. Marti
- Piedmont Heart Institute, Atlanta, GA and University of Georgia, Athens, GA
| | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, CA
| | - Stefan Anker
- Division of Cardiology and Metabolism - Heart Failure, Cachexia & Sarcopenia; Department of Cardiology (CVK); and Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Charité University Medicine, Berlin, Germany
| | - Clyde Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (* Posthumous)
| | - Muthiah Vaduganathan
- Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Stephen J. Greene
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Ali Ahmed
- Veterans Affairs Medical Center and George Washington University, Washington DC
| | - James L. Januzzi
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, and the Baim Institute for Clinical Research, Boston, MA
| | - Mihai Gheorghiade
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (* Posthumous)
| | | | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS
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302
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Turgeon RD, Kolber MR, Loewen P, Ellis U, McCormack JP. Higher versus lower doses of ACE inhibitors, angiotensin-2 receptor blockers and beta-blockers in heart failure with reduced ejection fraction: Systematic review and meta-analysis. PLoS One 2019; 14:e0212907. [PMID: 30817783 PMCID: PMC6394936 DOI: 10.1371/journal.pone.0212907] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 02/12/2019] [Indexed: 11/18/2022] Open
Abstract
Background Current heart failure (HF) guidelines recommend titrating angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) and beta-blockers (BBs) to target doses used in pivotal placebo-controlled randomized controlled trials (RCTs). Despite a number of RCTs comparing different doses (i.e. higher versus lower doses) of ACEIs, ARBs and BBs, the effects of higher versus lower doses on efficacy and safety remains unclear. For this reason, we performed a systematic review and meta-analysis to evaluate the efficacy and safety of higher versus lower doses of ACEIs, ARBs and BBs in patients with HFrEF. Methods We searched MEDLINE, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) via Ovid from inception to April 25th, 2018 and opentrials.net and clinicaltrials.gov for relevant trials that compared different doses of medications in heart failure. We analyzed trials by drug class (ACEIs, ARBs, and BBs) for efficacy outcomes (all-cause mortality, cardiovascular mortality, all-cause hospitalizations, HF hospitalizations, HF worsening). For safety outcomes, we pooled trials within and across drug classes. Results Our meta-analysis consisted of 14 RCTs. Using GRADE criteria, the quality of evidence for ACEIs and ARBs was assessed as generally moderate for efficacy and high for adverse effects, whereas overall quality for BBs was very low to low. Over ~2–4 years higher versus lower doses of ACEIs, ARBs or BBs did not significantly reduce all-cause mortality [ACEIs relative risk (RR) 0.94 (95% confidence interval 0.87–1.02)], ARBs RR 0.96 (0.87–1.04), BBs RR 0.25 (0.06–1.01)] or all cause hospitalizations [ACEIs relative risk (RR) 0.94 (95% confidence interval 0.86–1.02)], ARBs RR 0.98 (0.93–1.04), BBs RR 0.93 (0.39–2.24)]. However, all point estimates favoured higher doses. Higher doses of ARBs significantly reduced hospitalization for HF [RR 0.89 (0.80–0.99)– 2.8% ARR], and higher doses of ACEIs and ARBs significantly reduced HF worsening [RR 0.85 (0.79–0.92)– 5.1% ARR and 0.91 (0.84–0.99)– 3.2% ARR, respectively] compared to lower doses. None of the differences between higher versus lower doses of BBs were significant; however, precision was low. Higher doses of these medications compared to lower doses increased the risk of discontinuation due to adverse events, hypotension, dizziness, and for ACEIs and ARBs, increased hyperkalemia and elevations in serum creatinine. Absolute increase in harms for adverse effects ranged from ~ 3 to 14%. Conclusions Higher doses of ACEIs and ARBs reduce the risk of HF worsening compared to lower doses, and higher doses of ARBs also reduce the risk of HF hospitalization but the evidence is sparse and imprecise. Higher doses increase the chance of adverse effects compared to lower doses. Evidence for BBs is inconclusive. These results support initially always starting at low doses of ACEIs/ARBs and only titrating the dose up if the patient tolerates dose increases.
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Affiliation(s)
- Ricky D. Turgeon
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Michael R. Kolber
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Peter Loewen
- Faculty of Pharmaceutical Sciences, Collaboration for Outcomes Research & Evaluation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ursula Ellis
- Woodward Library, University of British Columbia, Vancouver, British Columbia, Canada
| | - James P. McCormack
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
- * E-mail:
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303
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Girerd N, Platz E. Beyond clinical examination and natriuretic peptides: comprehensive quantification of congestion with ultrasound in ambulatory heart failure patients. Eur J Heart Fail 2019; 21:917-920. [PMID: 30773751 DOI: 10.1002/ejhf.1422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 12/21/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Nicolas Girerd
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques 1433, CHRU de Nancy, Institut Lorrain du Cœur et des Vaisseaux, Nancy, France, and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
| | - Elke Platz
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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304
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Cleland JGF, van Veldhuisen DJ, Ponikowski P. The year in cardiology 2018: heart failure. Eur Heart J 2019; 40:651-661. [DOI: 10.1093/eurheartj/ehz010] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/02/2019] [Accepted: 01/08/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
- John G F Cleland
- Robertson Centre for Biostatistics & Clinical Trials, University of Glasgow, Glasgow, UK
- National Heart & Lung Institute, Royal Brompton & Harefield Hospitals, Imperial College, London, UK
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Centre for Heart Diseases, Military Hospital, ul.Weigla 5, 50-981 Wroclaw, Poland
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305
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Abstract
Normal brain natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) levels are helpful in excluding chronic heart failure in the ambulatory setting, although they have been studied less well and possibly less accurately than in acute care. They may also be of help in screening patients at risk to intervene and reduce the development of heart failure. Natriuretic peptides are also excellent prognostic markers of chronic heart failure, but the clinical value of such prognostic information is less clear. One possible application for this information is guiding medical therapy in chronic heart failure. Many studies have investigated this approach, but results are mixed and do not clearly show improvement in outcome. Still, it may be that in patients with reduced ejection fraction and few comorbidities, measuring NT-proBNP to uptitrate medication improves prognosis.
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306
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Soucier RJ, Miller PE, Ingrassia JJ, Riello R, Desai NR, Ahmad T. Essential Elements of Early Post Discharge Care of Patients with Heart Failure. Curr Heart Fail Rep 2019; 15:181-190. [PMID: 29700697 DOI: 10.1007/s11897-018-0393-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Heart failure is associated with an enormous burden on both patients and health care systems in the USA. Several national policy initiatives have focused on improving the quality of heart failure care, including reducing readmissions following hospitalization, which are common, costly, and, at least in part, preventable. The transition from inpatient to ambulatory care setting and the immediate post-hospitalization period present an opportunity to further optimize guideline concordant medical therapy, identify reversible issues related to worsening heart failure, and evaluate prognosis. It can also provide opportunities for medication reconciliation and optimization, consideration of device-based therapies, appropriate management of comorbidities, identification of individual barriers to care, and a discussion of goals of care based on prognosis. RECENT FINDINGS Recent studies suggest that attention to detail regarding patient comorbidities, barriers to care, optimization of both diuretic and neurohormonal therapies, and assessment of prognosis improve patient outcomes. Despite the fact that the transition period appears to be an optimal time to address these issues in a comprehensive manner, most patients are not referred to programs specializing in this approach post hospital discharge. The objective of this review is to provide an outline for early post discharge care that allows clinicians and other health care providers to care for these heart failure patients in a manner that is both firmly rooted in the guidelines and patient-centered. Data regarding which intervention is most likely to confer benefit to which subset of patients with this disease is lacking and warrants further study.
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Affiliation(s)
- Richard J Soucier
- Sections of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT, 06520, USA
| | - P Elliott Miller
- Sections of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT, 06520, USA
| | - Joseph J Ingrassia
- Division of Cardiology, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT, 06032, USA
| | - Ralph Riello
- Division of Pharmacy, Yale University School of Medicine, New Haven, CT, USA
| | - Nihar R Desai
- Sections of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT, 06520, USA.,Center for Outcomes Research and Evaluation, Yale New Haven Health System, Yale New Haven Hospital, New Haven, CT, USA
| | - Tariq Ahmad
- Sections of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT, 06520, USA.
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307
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Pellicori P, Shah P, Cuthbert J, Urbinati A, Zhang J, Kallvikbacka-Bennett A, Clark AL, Cleland JGF. Prevalence, pattern and clinical relevance of ultrasound indices of congestion in outpatients with heart failure. Eur J Heart Fail 2019; 21:904-916. [PMID: 30666769 DOI: 10.1002/ejhf.1383] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/13/2018] [Accepted: 11/11/2018] [Indexed: 12/28/2022] Open
Abstract
AIMS Even if treatment controls symptoms, patients with heart failure may still be congested. We aimed at assessing the prevalence and clinical relevance of congestion in outpatients with chronic heart failure. METHODS AND RESULTS We recorded clinical and ultrasound [lung B-lines; inferior vena cava (IVC) diameter; internal jugular vein diameter before and after a Valsalva manoeuvre (JVD ratio)] features of congestion in heart failure patients during a routine check-up. Of 342 patients who attended, predominantly in New York Heart Association class I or II (n = 257; 75%), 242 (71%) had at least one feature of congestion, either clinical (n = 139; 41%) or by ultrasound (n = 199; 58%). Amongst patients (n = 203, 59%) clinically free of congestion, 31 (15%) had ≥ 14 B-lines, 57 (29%) had a dilated IVC (> 2.0 cm), 38 (20%) had an abnormal JVD ratio (< 4), 87 (43%) had at least one of these, and 27 (13%) had two or more. During a median follow-up of 234 (interquartile range 136-351) days, 60 patients (18%) died or were hospitalized for heart failure. In univariable analysis, each clinical and ultrasound measure of congestion was associated with increased risk but, in multivariable models, only higher N-terminal pro-B-type natriuretic peptide and IVC, and lower JVD ratio, were associated with the composite outcome. CONCLUSIONS Many patients with chronic heart failure with few symptoms have objective evidence of congestion and this is associated with an adverse prognosis. Whether using these measures of congestion to guide management improves outcomes requires investigation.
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Affiliation(s)
- Pierpaolo Pellicori
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK.,Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - Parin Shah
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK
| | - Joe Cuthbert
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK
| | - Alessia Urbinati
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK
| | - Jufen Zhang
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK.,Faculty of Medical Science, Anglia Ruskin University, Chelmsford, UK
| | - Anna Kallvikbacka-Bennett
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK
| | - Andrew L Clark
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK
| | - John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, UK.,National Heart & Lung Institute and National Institute of Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield Hospitals, Imperial College London, London, UK
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308
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Baumann P, Wiegert S, Greco F, Wellmann S, L'Abate P, Cannizzaro V. Mechanical ventilation strategies alter cardiovascular biomarkers in an infant rat model. Physiol Rep 2019; 6. [PMID: 29380954 PMCID: PMC5789718 DOI: 10.14814/phy2.13553] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 11/23/2017] [Accepted: 11/29/2017] [Indexed: 11/24/2022] Open
Abstract
Mechanical ventilation (MV) is routinely used in pediatric general anesthesia and critical care, but may adversely affect the cardiocirculatory system. Biomarkers are increasingly measured to assess cardiovascular status and improve clinical treatment decision-making. As the impact of mechanical ventilation strategies on cardiovascular biomarkers in ventilated infants is largely unknown, we conducted this retrospective study in a healthy in vivo infant rat ventilation model using 14-days old Wistar rats. We hypothesized that 2 h of mechanical ventilation with high and low positive end-expiratory pressure (PEEP), hyperoxemia, hypoxemia, hypercapnia, and hypocapnia would significantly impact B-type natriuretic peptide (BNP), vascular endothelial growth factor (VEGF), and endothelin-1 (ET-1). We found BNP to be driven by both high (9 cmH2 O) and low (1 cmH2 O) PEEP compared to ventilated control animals (P < 0.05). VEGF concentrations were associated with high PEEP, hyperoxemia, hypoxemia, and hypocapnia (P < 0.05), whereas ET-1 levels were changed only in response to hypoxemia (P < 0.05). In conclusion, the mode of mechanical ventilation alters plasma biomarker concentrations. Moreover, BNP and VEGF might serve as surrogate parameters for ventilation induced cardiovascular compromise and lung tissue damage. Furthermore, our data support the hypothesis, that sudden onset of hyperoxemia may trigger a quick VEGF release as a possible cellular survival reflex.
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Affiliation(s)
- Philipp Baumann
- Department of Intensive Care Medicine and Neonatology, University Children's Hospital of Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital of Zurich, Zurich, Switzerland
| | - Susanne Wiegert
- Department of Intensive Care Medicine and Neonatology, University Children's Hospital of Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital of Zurich, Zurich, Switzerland.,Zurich Centre for Integrative Human Physiology, Zurich, Switzerland
| | - Francesco Greco
- Department of Intensive Care Medicine and Neonatology, University Children's Hospital of Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital of Zurich, Zurich, Switzerland.,Zurich Centre for Integrative Human Physiology, Zurich, Switzerland
| | - Sven Wellmann
- Department of Neonatology, University Children's Hospital of Basel, Basel, Switzerland
| | - Pietro L'Abate
- Department of Intensive Care Medicine and Neonatology, University Children's Hospital of Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital of Zurich, Zurich, Switzerland
| | - Vincenzo Cannizzaro
- Department of Intensive Care Medicine and Neonatology, University Children's Hospital of Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital of Zurich, Zurich, Switzerland.,Zurich Centre for Integrative Human Physiology, Zurich, Switzerland
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309
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NT-proBNP Goal Achievement Is Associated With Significant Reverse Remodeling and Improved Clinical Outcomes in HFrEF. JACC-HEART FAILURE 2019; 7:158-168. [PMID: 30611722 DOI: 10.1016/j.jchf.2018.10.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 10/05/2018] [Accepted: 10/12/2018] [Indexed: 01/16/2023]
Abstract
OBJECTIVES This study aims to assess the association between biomarker-guided therapy and left ventricular (LV) remodeling. BACKGROUND In patients with heart failure with reduced ejection fraction (HFrEF), it is unclear if lowering natriuretic peptides reflects structural and functional changes in the heart. This study aims to assess the association between biomarker-guided therapy and left ventricular (LV) remodeling. METHODS The GUIDE-IT (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure) Echo Substudy was a multicenter study that randomized 268 patients with HFrEF (EF ≤40%) to either pro-B-type natriuretic peptide (NT-proBNP)-guided treatment or usual care. Echocardiograms were performed at baseline and 12 months in 124 patients. Remodeling indices and clinical outcomes were compared between treatment arms and by achievement of the NT-proBNP goal of <1,000 pg/ml at 12 months. RESULTS At 12 months, the changes in EF and LV volumes were similar between the biomarker-guided and usual care arms with no difference in clinical outcomes; however, lowering NT-proBNP to <1,000 pg/ml, regardless of treatment strategy, was associated with a significantly greater increase in EF compared with those not reaching goal (9.9 ± 8.8% vs. 2.9 ± 7.9%; p < 0.001) and lower LV volumes. The extent of reverse remodeling correlated with the change in NT-proBNP: a decrease of 1,000 pg/ml was associated with an increase in EF of 6.7% and a reduction in systolic and diastolic volumes of 17.3 ml/m2 and 15.7 ml/m2, respectively. Adverse events were significantly lower among patients achieving the NT-proBNP goal (p < 0.001). CONCLUSIONS Among patients with HFrEF, lowering NT-proBNP to <1,000 pg/ml by 12 months was associated with significant reverse remodeling and improved outcomes. A greater reduction in NT-proBNP was associated with more extensive reverse remodeling. (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment [GUIDE-IT]; NCT01685840).
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310
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311
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Chronic Heart Failure: Impact of the Current Guidelines. J Nurse Pract 2019. [DOI: 10.1016/j.nurpra.2018.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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312
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The Urgency of Doing. JACC-HEART FAILURE 2019; 7:22-24. [DOI: 10.1016/j.jchf.2018.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 01/07/2023]
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313
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Choi HM, Park MS, Youn JC. Update on heart failure management and future directions. Korean J Intern Med 2019; 34:11-43. [PMID: 30612416 PMCID: PMC6325445 DOI: 10.3904/kjim.2018.428] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 12/09/2018] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) is an important cardiovascular disease because of its increasing prevalence, significant morbidity, high mortality, and rapidly expanding health care cost. The number of HF patients is increasing worldwide, and Korea is no exception. There have been marked advances in definition, diagnostic modalities, and treatment of HF over the past four decades. There is continuing effort to improve risk stratification of HF using biomarkers, imaging and genetic testing. Newly developed medications and devices for HF have been widely adopted in clinical practice. Furthermore, definitive treatment for end-stage heart failure including left ventricular assist device and heart transplantation are rapidly evolving as well. This review summarizes the current state-of-the-art management for HF and the emerging diagnostic and therapeutic modalities to improve the outcome of HF patients.
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Affiliation(s)
- Hong-Mi Choi
- Division of Cardiology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Myung-Soo Park
- Division of Cardiology, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
| | - Jong-Chan Youn
- Division of Cardiology, Hallym University Dongtan Sacred Heart Hospital, Hwaseong, Korea
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314
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Michel L, Rassaf T, Totzeck M. Biomarkers for the detection of apparent and subclinical cancer therapy-related cardiotoxicity. J Thorac Dis 2018; 10:S4282-S4295. [PMID: 30701097 DOI: 10.21037/jtd.2018.08.15] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Progress in cancer therapy over the past decades improved long-term survival but increased cancer therapy-related cardiotoxicity. Many novel treatment options have been implemented with yet incompletely characterized cardiovascular side effects including heart failure, coronary artery disease, arrhythmias, valvular disease, venous thromboembolism and myocarditis. Diagnosis of potential cardiotoxic side effects is essential for an optimal treatment but remains challenging. Cardiac biomarkers troponin and brain natriuretic peptide/N-terminal proBNP (BNP/NT-proBNP) have been extensively studied in heart failure and acute coronary syndromes. Emerging evidence implicates a significant role in the detection of cardiotoxicity and guidance of therapy in cancer patients. Elevated troponin or BNP/NT-proBNP levels were associated with increased all-cause mortality in cancer patients and have been shown to predict manifest heart failure. BNP/NT-proBNP may be useful for the prediction of cancer therapy-related heart failure and response to heart failure therapy in adult and pediatric cancer patients while troponin can indicate acute myocardial infarction in patients with cancer therapy-related risk for coronary artery disease. Furthermore, troponin may be used for the identification of immune checkpoint inhibitor-related myocarditis with very high sensitivity. Finally, even D-dimer levels have been shown to improve risk stratification and diagnosis in cancer-associated venous thromboembolism. This review aims to summarize the current knowledge about biomarkers in cancer therapy-related cardiotoxicity. We also outline possible clinical recommendations for the detection and treatment of subclinical and clinically apparent cardiotoxic effects using biomarkers.
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Affiliation(s)
- Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
| | - Matthias Totzeck
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, Medical Faculty, University Hospital Essen, Essen, Germany
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315
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Dinatolo E, Sciatti E, Anker MS, Lombardi C, Dasseni N, Metra M. Updates in heart failure: what last year brought to us. ESC Heart Fail 2018; 5:989-1007. [PMID: 30570225 PMCID: PMC6300825 DOI: 10.1002/ehf2.12385] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Indexed: 12/21/2022] Open
Affiliation(s)
- Elisabetta Dinatolo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Edoardo Sciatti
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Markus S. Anker
- Division of Cardiology and Metabolism, Department of Cardiology, Berlin‐Brandenburg Center for Regenerative Therapies (BCRT), DZHK (German Centre for Cardiovascular Research), partner site BerlinCharité—Universitätsmedizin BerlinBerlinGermany
| | - Carlo Lombardi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Nicolò Dasseni
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
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316
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Brunner-La Rocca HP, Sanders-van Wijk S. Guiding Heart Failure Therapy After GUIDE-IT: Back to the Drawing Board. J Am Coll Cardiol 2018; 72:2563-2566. [PMID: 30466513 DOI: 10.1016/j.jacc.2018.08.2185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 08/24/2018] [Indexed: 10/27/2022]
Affiliation(s)
| | - Sandra Sanders-van Wijk
- Department of Cardiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
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317
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Lyngbakken MN, Myhre PL, Røsjø H, Omland T. Novel biomarkers of cardiovascular disease: Applications in clinical practice. Crit Rev Clin Lab Sci 2018; 56:33-60. [DOI: 10.1080/10408363.2018.1525335] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Magnus Nakrem Lyngbakken
- Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Peder Langeland Myhre
- Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Helge Røsjø
- Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Torbjørn Omland
- Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Center for Heart Failure Research, University of Oslo, Oslo, Norway
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318
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Moayedi Y, Etchells E, Kobulnik J, Ross H. Brain natriuretic peptide and shortness of breath in the emergency department. CMAJ 2018; 190:E1361-E1363. [PMID: 30455271 DOI: 10.1503/cmaj.170770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Yasbanoo Moayedi
- Division of Cardiology (Moayedi, Kobulnik, Ross), Department of Medicine, University Health Network, Toronto, Ont.; Division of Cardiovascular Medicine (Moayedi), Section of Heart Failure, Stanford University, Stanford, Calif.; Division of General Internal Medicine (Etchells), Department of Medicine, Sunnybrook Health Sciences Centre; Division of Cardiology (Kobulnik), Department of Medicine, Mount Sinai Hospital, University of Toronto; Ted Rogers and Family Centre of Excellence in Heart Function (Moayedi, Kobulnik, Ross), Toronto, Ont
| | - Edward Etchells
- Division of Cardiology (Moayedi, Kobulnik, Ross), Department of Medicine, University Health Network, Toronto, Ont.; Division of Cardiovascular Medicine (Moayedi), Section of Heart Failure, Stanford University, Stanford, Calif.; Division of General Internal Medicine (Etchells), Department of Medicine, Sunnybrook Health Sciences Centre; Division of Cardiology (Kobulnik), Department of Medicine, Mount Sinai Hospital, University of Toronto; Ted Rogers and Family Centre of Excellence in Heart Function (Moayedi, Kobulnik, Ross), Toronto, Ont
| | - Jeremy Kobulnik
- Division of Cardiology (Moayedi, Kobulnik, Ross), Department of Medicine, University Health Network, Toronto, Ont.; Division of Cardiovascular Medicine (Moayedi), Section of Heart Failure, Stanford University, Stanford, Calif.; Division of General Internal Medicine (Etchells), Department of Medicine, Sunnybrook Health Sciences Centre; Division of Cardiology (Kobulnik), Department of Medicine, Mount Sinai Hospital, University of Toronto; Ted Rogers and Family Centre of Excellence in Heart Function (Moayedi, Kobulnik, Ross), Toronto, Ont
| | - Heather Ross
- Division of Cardiology (Moayedi, Kobulnik, Ross), Department of Medicine, University Health Network, Toronto, Ont.; Division of Cardiovascular Medicine (Moayedi), Section of Heart Failure, Stanford University, Stanford, Calif.; Division of General Internal Medicine (Etchells), Department of Medicine, Sunnybrook Health Sciences Centre; Division of Cardiology (Kobulnik), Department of Medicine, Mount Sinai Hospital, University of Toronto; Ted Rogers and Family Centre of Excellence in Heart Function (Moayedi, Kobulnik, Ross), Toronto, Ont.
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319
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Oke J, Clements A, McLellan J, Bankhead C, Taylor CJ, Spence G, Banerjee A, Perera R. Essential components in natriuretic peptide-guided management of heart failure: an intervention synthesis. Open Heart 2018; 5:e000826. [PMID: 30364517 PMCID: PMC6196949 DOI: 10.1136/openhrt-2018-000826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/29/2018] [Accepted: 07/24/2018] [Indexed: 12/02/2022] Open
Abstract
Aim To identify the key components of natriuretic peptide (NP)-guided treatment interventions which reduced hospitalisation in patients with heart failure (HF). Methods and results We extracted detailed information on the components of interventions from studies of NP-guided treatment of HF identified in a previous systematic review. We used meta-regression techniques to assess univariate associations between components and the strength of the reduction in HF hospitalisations and all-cause mortality. A Bayesian meta-analysis approach was used to re-estimate study-level effects in order to identify the study with the most effective NP-guided monitoring intervention. Finally, we examined the intervention options common to the studies in which the 95% credible interval excluded no effect. We identified eight components of NP-guided treatment from ten studies. Univariate comparisons produced mainly equivocal results, but single trial choice and common components analysis led to similar conclusions. Using a predefined treatment protocol, setting a stringent NP target (N-terminal pro-B-type natriuretic peptide of 1000 pg/mL or B-type natriuretic peptide 100 pg/mL) and including a relative targetwere potential key components to reducing HF hospitalisations using NP-guided therapy. Conclusion This analysis provides a description of the key components of NP-guided treatment which could help policy makers develop specific recommendations for HF management. Our research suggests that NP-guided interventions could be simplified, but more research in relevant health settings, such as primary care, is required.
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Affiliation(s)
- Jason Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Alison Clements
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Julie McLellan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare J Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Graeme Spence
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amitava Banerjee
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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320
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Sadanaga T. Are serial measurements of plasma concentrations of natriuretic peptide useful in real-world practice in patients with heart failure? Int J Cardiol 2018; 269:220-221. [DOI: 10.1016/j.ijcard.2018.07.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 07/17/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
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321
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Balderston JR, Shah KB, Paciulli SC, Gertz ZM. Usefulness of Estimated Plasma Volume at Postdischarge Follow-Up to Predict Recurrent Events in Patients With Heart Failure. Am J Cardiol 2018; 122:1191-1194. [PMID: 30241666 DOI: 10.1016/j.amjcard.2018.06.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 06/11/2018] [Accepted: 06/11/2018] [Indexed: 01/12/2023]
Abstract
Hospital readmission for patients admitted with heart failure is a persistent problem. Better identification of patients at high risk of readmission for volume overload could have clinical implications. We evaluated estimated plasma volume (ePV), a marker of congestion, to predict readmission for patients seen early after discharge for heart failure. We identified patients hospitalized with a primary heart failure diagnosis and were then seen in a postdischarge clinic. We assessed clinical factors, ePV (derived from hemoglobin and hematocrit), and B-type natriuretic peptide (BNP). The primary outcome was death or readmission for heart failure within 90 days of discharge. We identified 218 patients, of whom 23% experienced the primary outcome. No clinical variables at time of admission were different between those who did and did not experience the primary outcome, nor were BNP (1,581 vs 1,267 pg/ml, p = 0.33) or ePV (6.00 vs 5.80, p = 0.36). At clinic follow-up, both BNP (1,164 vs 636, p = 0.002) and ePV (6.18 vs 5.58, p = 0.02) were higher in those with subsequent events. Kaplan-Meier survival analysis showed that the lowest tertile of ePV had significantly lower incidence of the primary outcome than the other 2 tertiles (12% vs 29% and 27%, p = 0.02). Estimated plasma volume remained independently predictive of outcomes after controlling for BNP (p <0.05). In conclusion, EPV may be predictive of death or hospital readmission in heart failure patients seen soon after discharge, independent of BNP. Its potential warrants future prospective research evaluating its utility in larger heart failure cohorts.
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Affiliation(s)
- Jessica R Balderston
- Department of Emergency Medicine, Virginia Commonwealth University, Richmond, VA
| | - Keyur B Shah
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA
| | - Sarah C Paciulli
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA
| | - Zachary M Gertz
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA.
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322
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National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart Lung Circ 2018; 27:1123-1208. [DOI: 10.1016/j.hlc.2018.06.1042] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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323
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Abstract
Primary care physicians play a significant role in managing heart failure (HF), with the goals of reducing mortality, avoiding hospitalization, and improving patients’ quality of life. Most HF-related hospitalizations and deaths occur in patients with New York Heart Association functional class II or III, many of whom are perceived to have stable disease, which often progresses without clinical symptoms due to underlying deleterious effects of neurohormonal imbalance and endothelial dysfunction. Management includes lifestyle changes and stepped pharmacological therapy directed at the four stages of HF, with aggressive uptitration of therapies, including beta-blockers and inhibitors of the renin-angiotensin-aldosterone system. Recently, two new HF treatments have become available in clinical practice. Ivabradine was approved to reduce the risk of hospitalization for HF in patients with stable, symptomatic HF. Additionally, the angiotensin receptor–neprilysin inhibitor (ARNI), sacubitril/valsartan, was found to be significantly superior to enalapril in reducing risks of cardiovascular death and HF-related hospitalization. The respective 2016 and 2017 American College of Cardiology/American Heart Association/Heart Failure Society of America clinical practice guideline updates recommend that patients taking angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy be switched to ARNI therapy to further reduce morbidity and mortality. For HF management to be maximally effective, physicians must be knowledgeable about the risks and benefits of treatments and stay engaged with patients to identify signs of disease progression. This article provides an overview of the progressive nature of HF in apparently stable patients and describes areas for treatment improvement that may help to optimize patient care.
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Affiliation(s)
- Inder Anand
- Cardiovascular Division, University of Minnesota Medical School, Minneapolis, MN, 55455, USA.
- VA Medical Center, One Veterans Dr., Minneapolis, MN, 55417, USA.
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324
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Li J, Gu C, Li D, Chen L, Lu Z, Zhu L, Huang H. Effects of serum N-terminal pro B-type natriuretic peptide and D-dimer levels on patients with acute ischemic stroke. Pak J Med Sci 2018; 34:994-998. [PMID: 30190768 PMCID: PMC6115578 DOI: 10.12669/pjms.344.15432] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objective: To detect the serum levels of D-dimer and N-terminal pro B-type natriuretic peptide (NT-pro BNP) in patients with Acute Ischemic Stroke (AIS), and to explore the risk factors of AIS. Methods: A total of 246 AIS patients treated in our hospital from January 2015 to January 2017 were selected. Meanwhile, 240 healthy subjects were selected as a control group. The D-dimer and NT-pro BNP levels of the two groups were compared. Correlations of such levels with age, gender, blood lipid, Intima-Media Thickness (IMT), fibrinogen and degree of neurological deficits were analyzed. Results: The AIS group had significantly higher levels of Triglyceride (TG), Low-Density Lipoprotein (LDL), D-dimer, NT-pro BNP and fibrinogen as well as IMT than those of the control group, but the High-Density Lipoprotein (HDL) level of the AIS group was significantly lower (P<0.05). The patients with different genders and ages had significantly different D-dimer and NT-pro BNP levels (P<0.05). The D-dimer and NT-pro BNP levels were correlated with gender and age. Such levels of females were significantly higher than those of males (P<0.05). The D-dimer and NT-pro BNP levels of the ≥60 years old group significantly exceeded those of the <60 years old group (P<0.05). The levels of D-dimer and NT-pro BNP were negatively correlated with that of HDL (P<0.05), but positively correlated with TG, LDL and fibrinogen levels, IMT, and National Institutes of Health Stroke Scale score (P<0.05). Multivariate Logistic regression analysis showed that the OR values of D-dimer and NT-pro BNP were 3.65 and 6.96 respectively. Conclusion: Serum D-dimer and NT-pro BNP levels usually increased in AIS patients, and the levels were significantly correlated with AIS onset.
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Affiliation(s)
- Jia Li
- Jia Li, Department of Neurology, Second Affiliated Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Chengzhi Gu
- Chengzhi Gu, Department of Neurology, Second Affiliated Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Dan Li
- Dan Li, Department of Neurology, Second Affiliated Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Lan Chen
- Lan Chen, Department of Neurology, Second Affiliated Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Zhenhui Lu
- Zhenhui Lu, Department of Neurology, Second Affiliated Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Lianhai Zhu
- Lianhai Zhu, Department of Neurology, Second Affiliated Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
| | - Huaiyu Huang
- Huaiyu Huang, Department of Neurology, Second Affiliated Hospital of Nantong University, Nantong 226001, Jiangsu Province, China
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325
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Assessment of Congestion in Acute Heart Failure: When Simplicity Does Not Go Along With Accuracy. J Card Fail 2018; 24:550-552. [DOI: 10.1016/j.cardfail.2018.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 08/07/2018] [Indexed: 12/28/2022]
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326
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Krichevskiy LA, Kozlov IA. Natriuretic Peptides in Cardiac Anesthesia and Intensive Care. J Cardiothorac Vasc Anesth 2018; 33:1407-1419. [PMID: 30228053 DOI: 10.1053/j.jvca.2018.08.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Indexed: 01/16/2023]
Abstract
Natriuretic peptides, predominantly B-type, are widely used in cardiology as prognostic and diagnostic biomarkers or, much less often, as a substantive treatment tool. They are hormones that are produced mainly in the myocardium in response to overload and ischemia, and their level quite accurately reflects the degree of myocardial dysfunction. Although their use in cardiac anesthesia and intensive care setting seems to be very beneficial for assessing the risk of acute disturbance of myocardial function or its laboratory monitoring, the actual significance of natriuretic peptides in this area is not yet recognized. This is due to the lack of clear diagnostic and prognostic values for these biomarkers supported by high-quality researches. On the basis of the available data, main advantages, existing difficulties, and most effective ways of using natriuretic peptides for determining the risk of heart surgery and assessing the severity of sepsis, pneumonia, and other critical conditions have been discussed in this review. In addition, the expediency of using natriuretic peptides as target parameters for goal-oriented therapy and as a substantive tool for treatment is considered.
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Affiliation(s)
- Lev A Krichevskiy
- Department of Anesthesiology and Intensive Care, City Clinical Hospital n.a. S.S.Yudin, Department of Health of Moscow, Moscow, Russia.
| | - Igor A Kozlov
- Department of Anaesthesiology, Moscow Regional Research Clinical Institute n.a. M.F. Vladimirskiy, Moscow, Russia
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327
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Kleiner Shochat M, Fudim M, Shotan A, Blondheim DS, Kazatsker M, Dahan I, Asif A, Rozenman Y, Kleiner I, Weinstein JM, Panjrath G, Sobotka PA, Meisel SR. Prediction of readmissions and mortality in patients with heart failure: lessons from the IMPEDANCE-HF extended trial. ESC Heart Fail 2018; 5:788-799. [PMID: 30094959 PMCID: PMC6165944 DOI: 10.1002/ehf2.12330] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 05/09/2018] [Accepted: 06/13/2018] [Indexed: 12/17/2022] Open
Abstract
Aims Readmissions for heart failure (HF) are a major burden. We aimed to assess whether the extent of improvement in pulmonary fluid content (ΔPC) during HF hospitalization evaluated by lung impedance (LI), or indirectly by other clinical and laboratory parameters, predicts readmissions. Methods and results The present study is based on pre‐defined secondary analysis of the IMPEDANCE‐HF extended trial comprising 266 HF patients at New York Heart Association Class II–IV and left ventricular ejection fraction ≤ 35% randomized to LI‐guided or conventional therapy during long‐term follow‐up. Lung impedance‐guided patients were followed for 58 ± 36 months and the control patients for 46 ± 34 months (P < 0.01) accounting for 253 and 478 HF hospitalizations, respectively (P < 0.01). Lung impedance, N‐terminal pro‐brain natriuretic peptide, weight, radiological score, New York Heart Association class, lung rales, leg oedema, or jugular venous pressure were measured at admission and discharge on each hospitalization in both groups with the difference defined as ΔPC. Average LI‐assessed ΔPC was 12.1% vs. 9.2%, and time to HF readmission was 659 vs. 306 days in the LI‐guided and control groups, respectively (P < 0.01). Lung impedance‐based ΔPC predicted 30 and 90 day HF readmission better than ΔPC assessed by the other variables (P < 0.01). The readmission rate for HF was lower if ΔPC > median compared with ΔPC ≤ median for all parameters evaluated in both study groups with the most pronounced difference predicted by LI (P < 0.01). Net reclassification improvement analysis showed that adding LI to the traditional clinical and laboratory parameters improved the predictive power significantly. Conclusions The extent of ΔPC improvement, primarily the LI based, during HF‐hospitalization, and study group allocation strongly predicted readmission and event‐free survival time.
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Affiliation(s)
- Michael Kleiner Shochat
- Heart InstituteHillel Yaffe Medical CenterPO Box 169Hadera38100Israel, Rappaport School of Medicine, Technion, Haifa, Israel
| | - Marat Fudim
- Department of CardiologyDuke University Medical CenterDurhamNCUSA
| | - Avraham Shotan
- Heart InstituteHillel Yaffe Medical CenterPO Box 169Hadera38100Israel, Rappaport School of Medicine, Technion, Haifa, Israel
| | - David S. Blondheim
- Heart InstituteHillel Yaffe Medical CenterPO Box 169Hadera38100Israel, Rappaport School of Medicine, Technion, Haifa, Israel
| | - Mark Kazatsker
- Heart InstituteHillel Yaffe Medical CenterPO Box 169Hadera38100Israel, Rappaport School of Medicine, Technion, Haifa, Israel
| | - Iris Dahan
- Heart InstituteHillel Yaffe Medical CenterPO Box 169Hadera38100Israel, Rappaport School of Medicine, Technion, Haifa, Israel
| | - Aya Asif
- Heart InstituteHillel Yaffe Medical CenterPO Box 169Hadera38100Israel, Rappaport School of Medicine, Technion, Haifa, Israel
| | - Yoseph Rozenman
- Cardiovascular Institute, Sackler Faculty of MedicineWolfson Medical Center, Holon, Tel‐Aviv UniversityTel‐AvivIsrael
| | - Ilia Kleiner
- Cardiology DepartmentUniversity Medical CenterBeer‐ShevaIsrael
| | | | - Gurusher Panjrath
- Department of Medicine (Cardiology)George Washington University School of Medicine and Health SciencesWashingtonDCUSA
| | - Paul A. Sobotka
- Department of CardiologyThe Ohio State UniversityColumbusOHUSA
| | - Simcha R. Meisel
- Heart InstituteHillel Yaffe Medical CenterPO Box 169Hadera38100Israel, Rappaport School of Medicine, Technion, Haifa, Israel
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328
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Hollinger A, Cerlinskaite K, Bastian K, Mebazaa A. Biomarkers of increased intraventricular pressure: are we ready? Eur Heart J Suppl 2018. [DOI: 10.1093/eurheartj/suy025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Alexa Hollinger
- Department of Anaesthesiology, Burn and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, 2 rue A. Paré, Paris, France
- Inserm 942 Paris, Biomarqueurs et maladies cardiaques, Hôpital Lariboisière - Bâtiment Viggo Petersen, 41, boulevard de la Chapelle, Paris Cedex 10, France
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Kamile Cerlinskaite
- Department of Anaesthesiology, Burn and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, 2 rue A. Paré, Paris, France
- Inserm 942 Paris, Biomarqueurs et maladies cardiaques, Hôpital Lariboisière - Bâtiment Viggo Petersen, 41, boulevard de la Chapelle, Paris Cedex 10, France
- Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Santariškių g. 2, Vilnius, Lithuania
| | - Kathleen Bastian
- Department of Anaesthesiology, Burn and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, 2 rue A. Paré, Paris, France
- Inserm 942 Paris, Biomarqueurs et maladies cardiaques, Hôpital Lariboisière - Bâtiment Viggo Petersen, 41, boulevard de la Chapelle, Paris Cedex 10, France
- Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Alexandre Mebazaa
- Department of Anaesthesiology, Burn and Critical Care Medicine, AP-HP, Saint Louis and Lariboisière University Hospitals, 2 rue A. Paré, Paris, France
- Inserm 942 Paris, Biomarqueurs et maladies cardiaques, Hôpital Lariboisière - Bâtiment Viggo Petersen, 41, boulevard de la Chapelle, Paris Cedex 10, France
- University Paris Diderot, 5 rue Thomas Mann, Paris, France
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329
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Pufulete M, Maishman R, Dabner L, Higgins JPT, Rogers CA, Dayer M, MacLeod J, Purdy S, Hollingworth W, Schou M, Anguita-Sanchez M, Karlström P, Shochat MK, McDonagh T, Nightingale AK, Reeves BC. B-type natriuretic peptide-guided therapy for heart failure (HF): a systematic review and meta-analysis of individual participant data (IPD) and aggregate data. Syst Rev 2018; 7:112. [PMID: 30064502 PMCID: PMC6069819 DOI: 10.1186/s13643-018-0776-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 07/16/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND We estimated the effectiveness of serial B-type natriuretic peptide (BNP) blood testing to guide up-titration of medication compared with symptom-guided up-titration of medication in patients with heart failure (HF). METHODS Systematic review and meta-analysis of randomised controlled trials (RCTs). We searched: MEDLINE (Ovid) 1950 to 9/06/2016; Embase (Ovid), 1980 to 2016 week 23; the Cochrane Library; ISI Web of Science (Citations Index and Conference Proceedings). The primary outcome was all-cause mortality; secondary outcomes were death related to HF, cardiovascular death, all-cause hospital admission, hospital admission for HF, adverse events, and quality of life. IPD were sought from all RCTs identified. Random-effects meta-analyses (two-stage) were used to estimate hazard ratios (HR) and confidence intervals (CIs) across RCTs, including HR estimates from published reports of studies that did not provide IPD. We estimated treatment-by-covariate interactions for age, gender, New York Heart Association (NYHA) class, HF type; diabetes status and baseline BNP subgroups. Dichotomous outcomes were analysed using random-effects odds ratio (OR) with 95% CI. RESULTS We identified 14 eligible RCTs, five providing IPD. BNP-guided therapy reduced the hazard of hospital admission for HF by 19% (13 RCTs, HR 0.81, 95% CI 0.68 to 0.98) but not all-cause mortality (13 RCTs; HR 0.87, 95% CI 0.75 to 1.01) or cardiovascular mortality (5 RCTs; OR 0.88, 95% CI 0.67 to 1.16). For all-cause mortality, there was a significant interaction between treatment strategy and age (p = 0.034, 11 RCTs; HR 0.70, 95% CI 0.53-0.92, patients < 75 years old and HR 1.07, 95% CI 0.84-1.37, patients ≥ 75 years old); ejection fraction (p = 0.026, 11 RCTs; HR 0.84, 95% CI 0.71-0.99, patients with heart failure with reduced ejection fraction (HFrEF); and HR 1.33, 95% CI 0.83-2.11, patients with heart failure with preserved ejection fraction (HFpEF)). Adverse events were significantly more frequent with BNP-guided therapy vs. symptom-guided therapy (5 RCTs; OR 1.29, 95% CI 1.04 to 1.60). CONCLUSION BNP-guided therapy did not reduce mortality but reduced HF hospitalisation. The overall quality of the evidence varied from low to very low. The relevance of these findings to unselected patients, particularly those managed by community generalists, are unclear. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42013005335.
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Affiliation(s)
- Maria Pufulete
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Level 7, Bristol Royal Infirmary, Queen's Building, Bristol, BS2 8HW, UK.
| | - Rachel Maishman
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Level 7, Bristol Royal Infirmary, Queen's Building, Bristol, BS2 8HW, UK
| | - Lucy Dabner
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Level 7, Bristol Royal Infirmary, Queen's Building, Bristol, BS2 8HW, UK
| | - Julian P T Higgins
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Level 7, Bristol Royal Infirmary, Queen's Building, Bristol, BS2 8HW, UK
| | - Mark Dayer
- Department of Cardiology, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - John MacLeod
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Sarah Purdy
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Morten Schou
- Herlev and Gentofte University Hospital, Herlev, DK-2730, Copenhagen, Denmark
| | | | - Patric Karlström
- Division of Cardiology, Department of Medicine, County Hospital Ryhov, Jönköping, Sweden
| | | | - Theresa McDonagh
- Cardiovascular Division, King's College Hospital, King's College London, Denmark Hill, London, SE5 9RS, UK
| | - Angus K Nightingale
- Department of Cardiology, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, BS2 8HW, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Level 7, Bristol Royal Infirmary, Queen's Building, Bristol, BS2 8HW, UK
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330
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Circulating macrophage migration inhibitory factor (MIF) in patients with heart failure. Cytokine 2018; 110:104-109. [PMID: 29723777 DOI: 10.1016/j.cyto.2018.04.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/25/2018] [Accepted: 04/26/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Heart failure (HF) is characterized by impaired systolic ejection capacity and/or diastolic filling of the heart, leading to a multisystem disorder. Remote organ failure, systemic inflammation or pulmonary hypertension (PH) are hallmarks of the pathophysiological changes in HF. The Macrophage migration inhibitory factor (MIF) is a pro-inflammatory cytokine that is involved in a variety of cardiovascular and inflammatory diseases. Circulating MIF levels and their potential role as a disease marker in the different subgroups of HF have not been investigated yet. We here aimed to unravel a potential role of MIF in HF. METHODS AND RESULTS MIF plasma levels were assessed in 249 consecutive patients with HF. MIF was detectable in all investigated subjects and showed no difference with regard to the nature of HF (preserved or reduced ejection fraction). Spearman correlation revealed an association with inflammatory biomarkers (white blood cell count r = 0.18, p = 0.005; c-reactive protein r = 0.20, p = 0.003). MIF was associated with higher pulmonary artery systolic pressure (PASP) as assessed by echocardiography (r = 0.23, p < 0.001). Log-transformed PASP was also independently associated with MIF in a multivariable linear regression model (p = 0.02). Follow-up (FU) data after 180 days revealed that patients with increased MIF values (in ng/ml) were more likely to reach the endpoint all-cause mortality (HR 1.01, 95% CI 1.004-1.02, p = 0.005, per unit change). CONCLUSION MIF is detectable in the circulation of patients with HF and might be associated with clinical endpoints in HF, markers of inflammation and PH. These promising results should stimulate further research to elucidate the role of MIF in the multisystem disorder of HF.
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331
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Primo EN, Kogan MJ, Verdejo HE, Bollo S, Rubianes MD, Rivas GA. Label-Free Graphene Oxide-Based Surface Plasmon Resonance Immunosensor for the Quantification of Galectin-3, a Novel Cardiac Biomarker. ACS APPLIED MATERIALS & INTERFACES 2018; 10:23501-23508. [PMID: 29985579 DOI: 10.1021/acsami.8b03039] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
We report the first optical biosensor for the novel and important cardiac biomarker, galectin-3 (Gal3), using the anti-Gal3 antibody as a biorecognition element and surface plasmon resonance (SPR) for transducing the bioaffinity event. The immunosensing platform was built at a thiolated Au surface modified by self-assembling four bilayers of poly(diallyldimethylammonium chloride) and graphene oxide (GO), followed by the covalent attachment of 3-aminephenylboronic acid (3ABA). The importance of GO, both as the anchoring point of the antibody and as a field enhancer for improving the biosensor sensitivity, was critically discussed. The advantages of using 3ABA to orientate the anti-Gal3 antibody through the selective link to the Fc region were also demonstrated. The new platform represents an interesting alternative for the label-free biosensing of Gal3 in the whole range of clinically relevant concentrations (linear range between 10.0 and 50.0 ng mL-1, detection limit of 2.0 ng mL-1) with successful application for Gal3 biosensing in enriched human serum samples.
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Affiliation(s)
- Emiliano N Primo
- INFIQC (CONICET), Haya de la Torre s/n, Ciudad Universitaria , X5000HUA Córdoba , Argentina
- Departamento de Fisicoquímica, Facultad de Ciencias Químicas , Universidad Nacional de Córdoba, Ciudad Universitaria , X5000HUA Córdoba , Argentina
| | - Marcelo J Kogan
- Advanced Center for Chronic Diseases (ACCDiS), Facultad de Ciencias Químicas y Farmacéuticas, Departamento de Química Farmacológica y Toxicológica , Universidad de Chile , 8380492 Santiago , Chile
| | - Hugo E Verdejo
- Advanced Center for Chronic Diseases (ACCDiS), División de Enfermedades Cardiovasculares, Facultad de Medicina , Pontificia Universidad Católica de Chile , 7500011 Santiago , Chile
| | - Soledad Bollo
- Advanced Center for Chronic Diseases (ACCDiS), Facultad de Ciencias Químicas y Farmacéuticas, Departamento de Química Farmacológica y Toxicológica , Universidad de Chile , 8380492 Santiago , Chile
| | - María D Rubianes
- INFIQC (CONICET), Haya de la Torre s/n, Ciudad Universitaria , X5000HUA Córdoba , Argentina
- Departamento de Fisicoquímica, Facultad de Ciencias Químicas , Universidad Nacional de Córdoba, Ciudad Universitaria , X5000HUA Córdoba , Argentina
| | - Gustavo A Rivas
- INFIQC (CONICET), Haya de la Torre s/n, Ciudad Universitaria , X5000HUA Córdoba , Argentina
- Departamento de Fisicoquímica, Facultad de Ciencias Químicas , Universidad Nacional de Córdoba, Ciudad Universitaria , X5000HUA Córdoba , Argentina
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332
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Farnsworth CW, Bailey AL, Jaffe AS, Scott MG. Diagnostic concordance between NT-proBNP and BNP for suspected heart failure. Clin Biochem 2018; 59:50-55. [PMID: 30111510 DOI: 10.1016/j.clinbiochem.2018.07.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 06/26/2018] [Accepted: 07/05/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES BNP and NT-proBNP are viewed as comparable in their ability to diagnose and monitor HF in clinical guidelines. However, no recent large-scale study has directly established diagnostic concordance between BNP and NT-proBNP. This study sought to assess diagnostic concordance of BNP and NT-proBNP for ruling in and ruling out heart failure (HF). METHODS Simultaneous BNP and NT-proBNP testing was performed on 2729 patient samples with routinely ordered BNP testing. Hospital location, age, sex, creatinine, BNP and NT-proBNP were also recorded. Recommended cutoffs for BNP and NT-proBNP for ruling in and out HF were used for assessing diagnostic concordance and correlation. RESULTS In the ED setting, concordance between BNP and NT-proBNP was 0.695 (95% CI, 0.668-0.723) by weighted kappa using the recommended cutoffs for the acute setting. In non-ED patients, the concordance was 0.642 (95% CI, 0.580-0.705) using non-acute setting cutoffs. In the ED setting, patients with eGFR <60 mL/min/1.73m2 had lower overall concordance (0.626; 95% CI 0.580-0.672) compared to those with eGFR >60 mL/min/1.73m2 (0.707, 95% CI 0.669-0.744). Patients with an eGFR <15 mL/min/1.73m2 had a much higher ratio of NT-proBNP to BNP than patients with eGFR >60 mL/min/1.73m2 (17.0 vs. 4.7, P < .001). Linear regression revealed an r2 of 0.52 in the ED setting and 0.49 in the non-ED setting between BNP and NT-proBNP. For 368 patients with multiple measurements of natriuretic peptides, 19.7% of paired temporal measurements had an increase in one peptide and a decrease in the other. CONCLUSION The current cutoffs for diagnosing HF for NT-proBNP and BNP have relatively low diagnostic concordance and correlation, particularly among patients with chronic kidney disease.
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Affiliation(s)
- Christopher W Farnsworth
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University, St. Louis, MO, United States
| | - Adam L Bailey
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University, St. Louis, MO, United States
| | - Alan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Mitchell G Scott
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University, St. Louis, MO, United States.
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333
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The Effect of Left Ventricular Assist Device Therapy on Cardiac Biomarkers: Implications for the Identification of Myocardial Recovery. Curr Heart Fail Rep 2018; 15:250-259. [DOI: 10.1007/s11897-018-0399-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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334
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Medical Therapy for Heart Failure With Reduced Ejection Fraction. J Am Coll Cardiol 2018; 72:351-366. [DOI: 10.1016/j.jacc.2018.04.070] [Citation(s) in RCA: 494] [Impact Index Per Article: 82.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/21/2018] [Accepted: 04/23/2018] [Indexed: 12/11/2022]
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335
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Abstract
Heart failure is one of the leading diseases in internal medicine worldwide. Because of the increase in population aging, the incidence and prevalence of heart insufficiency is rising annually and is now the most frequent individual diagnosis among hospitalized patients in Germany. The mortality rate has recently been reduced, since new pharmacological options, especially the inhibition of neprilysin, have been developed; however, heart failure is still associated with a high mortality and morbidity rate. Thus, guideline-conform treatment is of crucial importance. This review highlights and summarizes the current scientific knowledge on heart failure from 2017 and 2018 based on the guidelines of the European Society of Cardiology. New aspects about heart failure with middle grade limitations of ejection fraction are firstly presented. Subsequently, innovative diagnostic and therapeutic strategies, new pharmacological developments and handling of frequent comorbidities in patients with heart failure are discussed.
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Affiliation(s)
- J Wintrich
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrbergerstraße, 66421, Homburg/Saar, Deutschland.
| | - I Kindermann
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrbergerstraße, 66421, Homburg/Saar, Deutschland
| | - M Böhm
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrbergerstraße, 66421, Homburg/Saar, Deutschland
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336
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Thibodeau JT, Drazner MH. The Role of the Clinical Examination in Patients With Heart Failure. JACC-HEART FAILURE 2018; 6:543-551. [PMID: 29885957 DOI: 10.1016/j.jchf.2018.04.005] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 03/26/2018] [Accepted: 04/03/2018] [Indexed: 10/14/2022]
Abstract
Despite advances in biomarkers and technology, the clinical examination (i.e., a history and physical examination) remains central in the management of patients with heart failure. Specifically, the clinical examination allows noninvasive assessment of the patient's underlying hemodynamic state, based on whether the patient has elevated ventricular filling pressures and/or an inadequate cardiac index. Such assessments provide important prognostic information and help guide therapeutic decision-making. Herein, the authors critically assess the utility of the clinical examination for these purposes and provide practical tips we have gleaned from our practice in the field of advanced heart failure. The authors note that the ability to assess for congestion is superior to that for inadequate perfusion. Furthermore, in current practice, elevated left ventricular filling pressures are inferred by findings related to an elevated right atrial pressure. They discuss an emerging classification system from the clinical examination that categorizes patients based on whether elevation of ventricular filling pressures occurs on the right side, left side, or both sides.
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Affiliation(s)
- Jennifer T Thibodeau
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mark H Drazner
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
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337
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Abstract
Heart failure affects more than 6 million people in the United States and incurs a heavy toll in morbidity, mortality, and health care costs. It frequently coexists with other important disorders, including hypertension, coronary artery disease, diabetes, and obesity. Decades of clinical trials have shown that several medications and interventions are effective for improving outcomes; however, mortality and hospitalization rates remain high. More recently, additional medications and devices have shown promise in reducing the health burden of heart failure.
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Affiliation(s)
- Audrey Wu
- From the University of Michigan, Ann Arbor, Michigan. (A.W.)
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338
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Magnussen C, Blankenberg S. Biomarkers for heart failure: small molecules with high clinical relevance. J Intern Med 2018; 283:530-543. [PMID: 29682806 DOI: 10.1111/joim.12756] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Heart failure (HF) is a rising epidemic due to the ageing population and progress in all areas of medicine. Thus, research efforts are made to ensure a timely diagnosis, to improve prognosis and treatment of the disease and to facilitate risk prediction at the population level. Because of their noninvasive determination with mostly high sensitivity and accuracy, circulating blood biomarkers are becoming increasingly important for daily clinical practice. Natriuretic peptides, especially B-type natriuretic peptide (BNP), N-terminal pro-B-type natriuretic peptide (Nt-proBNP) and midregional pro-atrial natriuretic peptide (MR-proANP) and cardiac troponins are established blood biomarkers in HF diagnosis and prognosis of HF-related outcomes. Inflammatory molecules as C-reactive protein (CRP) may have added value in anti-inflammatory therapy guidance. Next-generation biomarkers including soluble source of tumorigenicity 2 (sST2), growth differentiation factor-15 (GDF-15), galectin-3 (Gal-3) and diverse microribonucleic acids (miRNAs) may have additional benefit in assessment of cardiac remodeling or differentiation of HF subtypes. Multimarker approaches containing different combinations of established and novel biomarkers might improve HF risk prediction at the population level once they are used on top of clinical variables.
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Affiliation(s)
- C Magnussen
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Hamburg, Germany
| | - S Blankenberg
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Hamburg, Germany
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339
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Utility of Left Atrial Expansion Index and Stroke Volume in Management of Chronic Systolic Heart Failure. J Am Soc Echocardiogr 2018; 31:650-659.e1. [DOI: 10.1016/j.echo.2018.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Indexed: 11/19/2022]
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340
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Xu L, Chen Y, Ji Y, Yang S. Influencing factors of NT-proBNP level inheart failure patients with different cardiacfunctions and correlation with prognosis. Exp Ther Med 2018; 15:5275-5280. [PMID: 29904410 PMCID: PMC5996675 DOI: 10.3892/etm.2018.6114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 04/20/2018] [Indexed: 11/30/2022] Open
Abstract
Factors influencing N-terminal pro-brain natriuretic peptide (NT-proBNP) level in heart failure patients with different cardiac functions were identified to explore the correlations with prognosis. Eighty heart failure patients with different cardiac functions treated in Yixing People's Hospital from January 2016 to June 2017 were selected, and divided into two groups (group with cardiac function in class II and below and group with cardiac function in class III and above), according to the cardiac function classification established by New York Heart Association (NYHA). Blood biochemical test and outcome analysis were conducted to measure serum NT-proBNP and matrix metalloproteinase-9 (MMP-9) levels in patients with different cardiac functions, and correlations between levels of NT-proBNP and MMP-9 and left ventricular ejection fraction (LVEF) level were analyzed in patients with different cardiac functions at the same time. In addition, risk factors for heart failure in patients with different cardiac functions were analyzed. Compared with the group with cardiac function in class III and above, the group with cardiac function in class II and below had significantly lower serum NT-proBNP and MMP-9 levels (p<0.05). For echocardiogram indexes, left ventricular end-diastolic diameter (LVEDD) and left ventricular end-systolic diameter (LVESD) in the group with cardiac function in class II and below were obviously lower than those in the group with cardiac function in class III and above (p<0.05), while LVEF was higher in group with cardiac function in class II and below than that in group with cardiac function in class III and above (p<0.05). NT-proBNP and MMP-9 levels were negatively correlated with LVEF level [r=−0.8517 and −0.8517, respectively, p<0.001 (<0.05)]. Cardiac function in class III and above, increased NT-proBNP, increased MMP-9 and decreased LVEF were relevant risk factors and independent risk factors for heart failure in patients with different cardiac functions. NT-proBNP and MMP-9 levels are negatively correlated with LVEF in patients regardless of the cardiac function class. Therefore, attention should be paid to patients who have cardiac function in class III and above, increased NT-proBNP and MMP-9 levels and decreased LVEF in clinical practices, so as to actively prevent and treat heart failure.
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Affiliation(s)
- Liang Xu
- Department of Cardiovascular Disease, Yixing People's Hospital, Yixing, Jiangsu 214200, P.R. China
| | - Yanchun Chen
- Department of Cardiovascular Disease, Yixing People's Hospital, Yixing, Jiangsu 214200, P.R. China
| | - Yanni Ji
- Department of Cardiovascular Disease, Yixing People's Hospital, Yixing, Jiangsu 214200, P.R. China
| | - Song Yang
- Department of Cardiovascular Disease, Yixing People's Hospital, Yixing, Jiangsu 214200, P.R. China
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341
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Abstract
The common ultimate pathological feature for all cardiovascular diseases, congestive heart failure (CHF), is now considered as one of the main public health burdens that is associated with grave implications. Neurohormonal systems play a critical role in cardiovascular homeostasis, pathophysiology, and cardiovascular diseases. Hormone treatments such as the newly invented dual-acting drug valsartan/sacubitril are promising candidates for CHF, in addition to the conventional medications encompassing beta receptor blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and mineralocorticoid receptor antagonists. Clinical trials also indicate that in CHF patients with low insulin-like growth factor-1 or low thyroid hormone levels, supplemental treatment with growth hormone or thyroid hormone seems to be cardioprotective; and in CHF patients with volume overload the vasopressin antagonists can relieve the symptoms superior to loop diuretics. Furthermore, a combination of selective glucocorticoid receptor agonist and mineralocorticoid receptor antagonist may be used in patients with diuretic resistance. Finally, the potential cardiovascular efficacy and safety of incretin-based therapies, testosterone or estrogen supplementation needs to be prudently evaluated in large-scale clinical studies. In this review, we briefly discuss the therapeutic effects of several key hormones in CHF.
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Affiliation(s)
- Lei Lei
- Department of Endocrinology, Aerospace Center Hospital, Peking University Affiliate, Beijing, China
| | - Yuanjie Mao
- Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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342
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Miles M, Alvis BD, Hocking K, Baudenbacher F, Guth C, Lindenfeld J, Brophy C, Eagle S. Peripheral Intravenous Volume Analysis (PIVA) for Quantitating Volume Overload in Patients Hospitalized With Acute Decompensated Heart Failure-A Pilot Study. J Card Fail 2018; 24:525-532. [PMID: 29777760 DOI: 10.1016/j.cardfail.2018.05.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 04/23/2018] [Accepted: 05/11/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND To determine the feasibility of peripheral intravenous volume analysis (PIVA) of venous waveforms for assessing volume overload in patients admitted to the hospital with acute decompensated heart failure (ADHF). METHODS Venous waveforms were captured from a peripheral intravenous catheter in subjects admitted for ADHF and healthy age-matched controls. Admission PIVA signal, brain natriuretic peptide, and chest radiographic measurements were related to the net volume removed during diuresis. RESULTS ADHF patients had a significantly greater PIVA signal on admission compared with the control group (P = .0013, n = 18). At discharge, ADHF patients had a PIVA signal similar to the control group. PIVA signal, not brain natriuretic peptide or chest radiographic measures, accurately predicted the amount of volume removed during diuresis (R2 = 0.781, n = 14). PIVA signal at time of discharge greater than 0.20, demonstrated 83.3% 120-day readmission rate. CONCLUSIONS This study demonstrates the feasibility of PIVA for assessment of volume overload in patients admitted to the hospital with ADHF.
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Affiliation(s)
- Merrick Miles
- Vanderbilt University Medical Center, Department of Anesthesiology, Division of Critical Care, Nashville, Tennessee
| | - Bret D Alvis
- Vanderbilt University Medical Center, Department of Anesthesiology, Division of Critical Care, Nashville, Tennessee.
| | - Kyle Hocking
- Vanderbilt University Medical Center, Department of Surgery, Nashville, Tennessee
| | - Franz Baudenbacher
- Vanderbilt University, Institute for Integrative Biosystems Research and Education (VIIBRE) Department of Engineering, Nashville, Tennessee
| | - Christy Guth
- Vanderbilt University Medical Center, Department of Surgery, Nashville, Tennessee
| | - Joann Lindenfeld
- Vanderbilt University Medical Center, Department of Medicine, Division of Cardiology, Nashville, Tennessee
| | - Colleen Brophy
- Vanderbilt University Medical Center, Department of Surgery, Nashville, Tennessee
| | - Susan Eagle
- Vanderbilt University Medical Center, Department of Anesthesiology, Division of Cardiac & Thoracic Anesthesia, Nashville, Tennessee
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343
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344
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Cheng RK, Levy WC. Echocardiographic Insights into the Hemodynamics of Systolic Heart Failure: Can This Guide Titration of Medical Therapy? J Am Soc Echocardiogr 2018; 31:660-663. [PMID: 29730184 DOI: 10.1016/j.echo.2018.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Richard K Cheng
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, Washington; Department of Radiology, University of Washington Medical Center, Seattle, Washington.
| | - Wayne C Levy
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, Washington
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345
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Similar BNP and Mortality Association in Patients With and Without Heart Failure. J Am Coll Cardiol 2018; 71:2089-2091. [DOI: 10.1016/j.jacc.2018.03.454] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/21/2018] [Indexed: 11/19/2022]
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346
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Abel AA. Highlights from the British Society for Heart Failure 20th Annual Autumn Meeting: three decades of heart failure. Future Cardiol 2018; 14:203-206. [PMID: 29767536 DOI: 10.2217/fca-2018-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The 20th Annual Autumn Meeting of the British Society for Heart Failure took place on the 23-24 November 2017 at the Queen Elizabeth II Conference Centre, London, UK. Over 800 delegates were in attendance: a multidisciplinary league of professionals who treat patients with heart failure, including specialist nurses, trainees, cardiologists, geriatricians, pharmacists and general practitioners. The theme of the conference was 'three decades of heart failure' and celebrated the success of modern heart failure management. This report highlights the 'three decades' session, the clinical trials update, and the main discussion points from heart failure question time.
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347
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Harjola VP, Parissis J, Brunner-La Rocca HP, Čelutkienė J, Chioncel O, Collins SP, De Backer D, Filippatos GS, Gayat E, Hill L, Lainscak M, Lassus J, Masip J, Mebazaa A, Miró Ò, Mortara A, Mueller C, Mullens W, Nieminen MS, Rudiger A, Ruschitzka F, Seferovic PM, Sionis A, Vieillard-Baron A, Weinstein JM, de Boer RA, Crespo-Leiro MG, Piepoli M, Riley JP. Comprehensive in-hospital monitoring in acute heart failure: applications for clinical practice and future directions for research. A statement from the Acute Heart Failure Committee of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC). Eur J Heart Fail 2018; 20:1081-1099. [PMID: 29710416 DOI: 10.1002/ejhf.1204] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/20/2018] [Accepted: 03/26/2018] [Indexed: 12/17/2022] Open
Abstract
This paper provides a practical clinical application of guideline recommendations relating to the inpatient monitoring of patients with acute heart failure, through the evaluation of various clinical, biomarker, imaging, invasive and non-invasive approaches. Comprehensive inpatient monitoring is crucial to the optimal management of acute heart failure patients. The European Society of Cardiology heart failure guidelines provide recommendations for the inpatient monitoring of acute heart failure, but the level of evidence underpinning most recommendations is limited. Many tools are available for the in-hospital monitoring of patients with acute heart failure, and each plays a role at various points throughout the patient's treatment course, including the emergency department, intensive care or coronary care unit, and the general ward. Clinical judgment is the preeminent factor guiding application of inpatient monitoring tools, as the various techniques have different patient population targets. When applied appropriately, these techniques enable decision making. However, there is limited evidence demonstrating that implementation of these tools improves patient outcome. Research priorities are identified to address these gaps in evidence. Future research initiatives should aim to identify the optimal in-hospital monitoring strategies that decrease morbidity and prolong survival in patients with acute heart failure.
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Affiliation(s)
- Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | | | | | - Jelena Čelutkienė
- Vilnius University, Faculty of Medicine, Institute of Clinical Medicine, Clinic of Cardiac and Vascular Diseases, Vilnius, Lithuania
| | - Ovidiu Chioncel
- University of Medicine Carol Davila/Institute of Emergency for Cardiovascular Disease, Bucharest, Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniel De Backer
- Department of Intensive Care Medicine, CHIREC Hospitals, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Etienne Gayat
- Département d'Anesthésie- Réanimation-SMUR, Hôpitaux Universitaires Saint Louis-Lariboisière, INSERM-UMR 942, AP-, HP, Université Paris Diderot, Paris, France
| | | | - Mitja Lainscak
- Department of Internal Medicine and Department of Research and Education, General Hospital Murska Sobota, Murska Sobota, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Johan Lassus
- Cardiology, Heart and Lung Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Josep Masip
- Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain.,Hospital Sanitas CIMA, Barcelona, Spain
| | - Alexandre Mebazaa
- U942 INSERM, AP-HP, Paris, France.,Investigation Network Initiative Cardiovascular and Renal Clinical Trialists (INI-CRCT), Nancy, France.,University Paris Diderot, Sorbonne Paris Cité, Paris, France.,AP-HP, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisière, Paris, France
| | - Òscar Miró
- Emergency Department, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Andrea Mortara
- Department of Cardiology, Policlinico di Monza, Monza, Italy
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Basel, Switzerland
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost Limburg, Genk - Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | | | - Alain Rudiger
- Cardio-surgical Intensive Care Unit, University and University Hospital Zurich, Zurich, Switzerland
| | - Frank Ruschitzka
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Petar M Seferovic
- Department of Internal Medicine, Belgrade University School of Medicine and Heart Failure Center, Belgrade University Medical Center, Belgrade, Serbia
| | - Alessandro Sionis
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antoine Vieillard-Baron
- INSERM U-1018, CESP, Team 5 (EpReC, Renal and Cardiovascular Epidemiology), UVSQ, 94807 Villejuif, France, University Hospital Ambroise Paré, AP-, HP, Boulogne-Billancourt, France
| | | | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maria G Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC, La Coruña, Spain
| | - Massimo Piepoli
- Heart Failure Unit, Cardiology, G. da Saliceto Hospital, Piacenza, Italy
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348
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Möckel M, von Haehling S, Vollert JO, Wiemer JC, Anker SD, Maisel A. Early identification of acute heart failure at the time of presentation: do natriuretic peptides make the difference? ESC Heart Fail 2018; 5:309-315. [PMID: 29667356 PMCID: PMC5933954 DOI: 10.1002/ehf2.12290] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 03/21/2018] [Accepted: 03/23/2018] [Indexed: 11/21/2022] Open
Abstract
Background The early identification of patients with acute heart failure (AHF) is challenging as many other diseases lead to a clinical presentation with dyspnea. Aim The aim of the study was to evaluate the impact of natriuretic peptides at common HF study cut‐offs on the diagnosis of patients with dyspnea at admission. Methods and results For this post hoc analysis, we analysed n = 726 European Union (EU) patients from the prospective BACH (Biomarkers in Acute Heart Failure) study. Cut‐offs were 350 ng/L (BNP), 300 pmol/L [pro‐atrial natriuretic peptide (proANP)], and 1800 ng/L (NT‐proBNP). These cut‐offs had equivalent 90 days' mortality in the EU cohort of BACH. We analysed the effect of selection using these cut‐offs on the prevalence of the gold standard diagnoses made in the BACH study and the respective mortality. The prevalence of AHF is increased from 47.5 to 75.6% (NT‐proBNP criteria) up to 79.7% (BNP criteria). With the use of the proANP criteria, 90 days' mortality of patients with AHF rose from 14 to 17% (P = 0.029). In the group with no‐AHF diagnoses, mortality rose from 10 to 25% (P < 0.001). Conclusions The prevalence of patients with the gold standard diagnoses of AHF among those presenting with dyspnea to the emergency department is significantly increased by the use of natriuretic peptides with common cut‐offs used in prospective HF studies. Nevertheless, in the selected groups, patients with no AHF diagnosis have the highest mortality, and therefore, the addition of a natriuretic peptide alone is insufficient to start specific therapies.
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Affiliation(s)
- Martin Möckel
- Division of Emergency and Acute Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Jan C Wiemer
- BRAHMS, Thermo Fisher Scientific, Hennigsdorf, Germany
| | - Stefan D Anker
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany.,Division of Cardiology and Metabolism, Department of Cardiology (Campus Virchow-Klinikum), Berlin-Brandenburg Center for Regenerative Therapies (BCRT) and German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Alan Maisel
- University of California, San Diego and Veterans Affairs Medical Center, San Diego, CA, USA
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349
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Abstract
PURPOSE OF REVIEW The goal of this paper is to provide a summary of the new recommendations in the most recent 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. The intent is to provide the background and the supporting evidence for the recommendations and to provide practical guidance for management strategies in treatment of heart failure patients. RECENT FINDINGS In the 2017 ACC/AHA/HFSA Focused Update of HF guidelines, important additions include new information on biomarkers, specifically on the topics of the diagnostic, prognostic role of natriuretic peptides in heart failure, and the role of natriuretic peptides in screening in patients high risk for HF and prevention of HF. There are important recommendations for treatment of patients with HF with reduced EF (HFrEF), including the beneficial role of angiotensin receptor blocker and neprilysin inhibition (ARNI) treatment in reducing outcomes including mortality, ivabradine in reducing heart failure hospitalizations in stable HFrEF patients with sinus rhythm and heart rate ≥ 70 bpm despite β-blockers. In patients with HF with preserved EF (HFpEF), though there are no studies demonstrating survival benefit, potential benefit with aldosterone antagonism in reducing HF hospitalizations is noted. In treatment of comorbidities, optimization of blood pressure control to less than 130 mmHg is recommended in hypertensive patients to prevent HF or in patients with hypertension and HFrEF or HFpEF. In addition to recognition on the potential role of treatment of iron deficiency anemia to improve symptoms and functional capacity, caution against use of adaptive servo-ventilation in patients with HFrEF and central sleep apnea and against use of erythropoietin stimulating agents in patients with HFrEF is provided. There are new treatment strategies that are associated with significant improvements in mortality and other outcomes in patients with HF. Successful management of HF requires recognition of indications, contraindications, benefits, safety, and risk of these new therapies. In addition to incorporation of these new treatment strategies, it is critical to focus also on patient education, care coordination, identification of goals of care, monitoring, management of comorbidities, and individualization of therapies. New treatment modalities increase the choices for treatment and provide the opportunity to implement individualized treatment strategies for our patients.
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350
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Khan MS, Siddiqi TJ, Usman MS, Sreenivasan J, Fugar S, Riaz H, Murad MH, Mookadam F, Figueredo VM. Does natriuretic peptide monitoring improve outcomes in heart failure patients? A systematic review and meta-analysis. Int J Cardiol 2018; 263:80-87. [PMID: 29685696 DOI: 10.1016/j.ijcard.2018.04.049] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/02/2018] [Accepted: 04/10/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Current guidelines do not support the use of serial natriuretic peptide (NP) monitoring for heart failure with preserved (HFpEF) or reduced ejection fraction (HFrEF) treatment, despite some studies showing benefit. We conducted an updated meta-analysis to address whether medical therapy in HFpEF or HFrEF should be titrated according to NP levels. METHODS MEDLINE, Scopus and Cochrane CENTRAL databases were searched for randomized controlled trials (RCTs) comparing NP versus guideline directed titration in HF patients through December 2017. The key outcomes of interest were mortality, HF hospitalizations and all-cause hospitalizations. Risk ratios and 95% confidence intervals were pooled using random effects model. Sub-group analyses were performed for type of NP used, average age and acute or chronic HF. RESULTS Eighteen trials including 5116 patients were included. Meta-analysis showed no significant difference between the NP-guided arm versus guideline directed titration in all-cause mortality (RR = 0.91 [0.81, 1.03]; p = 0.13), HF hospitalizations (RR = 0.81 [0.65, 1.01]; p = 0.06), and all cause hospitalizations (RR = 0.93 [0.86, 1.01]; p = 0.09). The results were consistent upon subgroup analysis by biomarker type (NT-proBNP or BNP) and type of heart failure (acute or chronic and HFrEF or HFpEF). Sub-group analysis suggested that NP-guided treatment was associated with decreased all-cause hospitalizations in patients younger than 72 years of age. CONCLUSION The available evidence suggests that NP-guided therapy provides no additional benefit over guideline directed therapy in terms of all-cause mortality and HF-related hospitalizations in acute or chronic HF patients, regardless of their ejection fraction.
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Affiliation(s)
- Muhammad Shahzeb Khan
- Department of Internal Medicine, John H Stroger Jr. Hospital of Cook County, Chicago, IL, USA.
| | - Tariq Jamal Siddiqi
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Shariq Usman
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Jayakumar Sreenivasan
- Department of Internal Medicine, John H Stroger Jr. Hospital of Cook County, Chicago, IL, USA
| | - Setri Fugar
- Department of Internal Medicine, John H Stroger Jr. Hospital of Cook County, Chicago, IL, USA
| | - Haris Riaz
- Division of Cardiology, Cleveland Clinic, Cleveland, OH, USA
| | - M H Murad
- Evidence-based Practice Center, Mayo Clinic, Rochester, MN, USA
| | - Farouk Mookadam
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Vincent M Figueredo
- Cardiology, Institute for Heart & Vascular Health, Einstein Medical Center Philadelphia, PA, USA; Medicine, Sidney Kimmel College of Medicine at Thomas Jefferson University, Philadelphia, PA, USA
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