Worsening renal function definition is insufficient for evaluating acute renal failure in acute heart failure

Diuretic Treatment in Heart Failure: A Practical Guide for Clinicians

Congestion and fluid retention are the hallmarks of decompensated heart failure and the major reason for the hospitalization of patients with heart failure. Diuretics have been used in heart failure for decades, and they remain the backbone of the contemporary management of heart failure. Loop diuretics is the preferred diuretic, and it has been given a class I recommendation by clinical guidelines for the relief of congestion symptoms. Although loop diuretics have been used virtually among all patients with acute decompensated heart failure, there is still very limited clinical evidence to guide the optimized diuretics use. This is a sharp contrast to the rapidly growing evidence of the rest of the guideline-directed medical therapy of heart failure and calls for further studies. The loop diuretics possess a unique pharmacology and pharmacokinetics that lay the ground for different strategies to increase diuretic efficiency. However, many of these approaches have not been evaluated in randomized clinical trials. In recent years, a stepped and protocolized diuretics dosing has been suggested to have superior benefits over an individual clinician-based strategy. Diuretic resistance has been a major challenge to decongestion therapy for patients with heart failure and is associated with a poor clinical prognosis. Recently, therapy options have emerged to help overcome diuretic resistance to loop diuretics and have been evaluated in randomized clinical trials. In this review, we aim to provide a comprehensive review of the pharmacology and clinical use of loop diuretics in the context of heart failure, with attention to its side effects, and adjuncts, as well as the challenges and future direction.

Long-term outcomes of acute kidney injury in acute decompensated heart failure: identifying true cardiorenal syndrome and unveiling prognostic significance

BACKGROUND

Cardiorenal syndrome (CRS) type 1 defined as acute kidney injury (AKI) in acute decompensated heart failure (ADHF), is complicated due to diverse definitions. Recently, a more precise CRS type 1 definition was proposed, mandating concurrent AKI and signs of unimproved heart failure (HF). Our study explores the incidence, predictors, and long-term outcomes of AKI in ADHF under this new definition.

METHODS

A prospective observation study of ADHF patients categorized into the CRS type 1, pseudo-CRS, and non-AKI groups, followed for 12 months. CRS type 1 involved AKI with clinical congestion, while pseudo-CRS included AKI with clinical decongestion (clinical congestion score <2). The primary outcome was a 1-year composite of mortality or HF rehospitalization.

RESULTS

Among 250 consecutive ADHF patients, 46.0% developed CRS type 1; chronic kidney disease (CKD) and blood urea nitrogen were significant risk factors (odds ratios, 1.37; p = 0.002 and OR, 1.05; p < 0.001, respectively). The CRS type 1 group exhibited shorter times to AKI development and peak serum creatinine than the pseudo-CRS group (1 day vs. 4 days and 2 days vs. 4 days, respectively). At 12 months, composite outcomes of mortality or HF rehospitalization and CKD progression were significantly higher in the CRS type 1 group than in the pseudo-CRS and non-AKI groups (63.5% vs. 31.7% vs. 36.1%, p < 0.001; 28.1% vs. 16.2% vs. 11.4%, p = 0.024, respectively).

CONCLUSION

Distinguishing between CRS type 1 and pseudo-CRS is vital, highlighting significant disparities in short-term and longterm outcomes. Notably, pseudo-CRS exhibits comparable long-term cardiovascular and renal outcomes to those without AKI.

The role of tolvaptan add-on therapy in patients with acute heart failure: a systematic review and network meta-analysis

Background

Several conflicting reviews have concluded that the use of loop diuretics is associated with poorer clinical and safety outcomes. Therefore, this study aimed to investigate the efficacy and safety of tolvaptan as an adjunct to conventional diuretic therapy in patients with acute heart failure (AHF).

Methods

A comprehensive search was conducted on PubMed, Embase, ProQuest, EBSCO, and Cochrane Library until 24 May 2023 to identify randomized controlled trials that compared the effects of tolvaptan with conventional therapy and placebo in patients with AHF. The quality assessment of the included trials was conducted using the Cochrane risk of bias. A network meta-analysis (NMA) was conducted to examine the dosage effect of tolvaptan.

Result

A total of 17 studies with 18 reports, involving 10,039 patients, were selected. The tolvaptan add-on therapy significantly alleviated dyspnea [24 h: RR 1.16 (1.04, 1.29), 48 h: RR 1.18 (1.04, 1.33)], reduced body weight within 48 h [Asian group, MD -0.93 (-1.48, -0.38); non-Asian group, MD -2.76 (-2.88, -2.65)], reduced edema [RR 1.08 (1.02, 1.15)], increased serum sodium [non-Asian group, MD 3.40 (3.02, 3.78)], and resulted in a change in serum creatinine [MD -0.10 (-0.18, -0.01)]. No significant differences were observed in mortality and rehospitalization. The NMA suggested that an intermediate dosage (15 mg/day) might offer the best efficacy in reducing dyspnea within 24 h, reducing edema, increasing serum sodium, and lowering the incidence of worsening renal function (WRF).

Conclusion

In conclusion, the meta-analysis showed that tolvaptan contributed to the short-term alleviation of congestive symptoms, elevated sodium levels, and a lower incidence of WRF. However, no significant benefits were observed in long-term symptoms, rehospitalization rates, and mortality. An intermediate dosage of tolvaptan might be considered the optimal choice for various clinical outcomes.

Systematic Review Registration

https://www.crd.york.ac.uk/, PROSPERO (CRD42023420288).

Late Kidney Injury After Admission to Intensive Care Unit for Acute Heart Failure

Late kidney injury (LKI) in patients with acute heart failure (AHF) requiring intensive care is poorly understood.We analyzed 821 patients with AHF who required intensive care. We defined LKI based on the ratio of the creatinine level 1 year after admission for AHF to the baseline creatinine level. The patients were categorized into 4 groups based on this ratio: no-LKI (< 1.5, n = 509), Class R (risk; ≥ 1.5, n = 214), Class I (injury; ≥ 2.0, n = 78), and Class F (failure; ≥ 3.0, n = 20). Median follow-up after admission for AHF was 385 (346-426) days. Multivariate logistic regression analysis revealed that acute kidney injury (AKI) during hospitalization (Class R, odds ratio [OR]: 1.710, 95% confidence interval [CI]: 1.138-2.571, P = 0.010; Class I, OR: 6.744, 95% CI: 3.739-12.163, P < 0.001; and Class F, OR: 9.259, 95% CI: 4.078-18.400, P < 0.001) was independently associated with LKI. Multivariate Cox regression analysis showed that LKI was an independent predictor of 3-year all-cause death after final follow-up (hazard ratio: 1.545, 95% CI: 1.099-2.172, P = 0.012). The rate of all-cause death was significantly lower in the no-AKI/no-LKI group than in the no-AKI/LKI group (P = 0.048) and in the AKI/no-LKI group than in the AKI/LKI group (P = 0.017).The incidence of LKI was influenced by the presence of AKI during hospitalization, and was associated with poor outcomes within 3 years of final follow-up. In the absence of LKI, AKI during hospitalization for AHF was not associated with a poor outcome.

Incidence, mortality, and predictors of acute kidney injury in patients with heart failure: a systematic review

Acute kidney injury (AKI) is common in patients with heart failure (HF), but studies have been inconsistent about the incidence of AKI in patients with HF. We conducted a meta-analysis to examine the incidence of AKI and its impact on mortality in patients with HF. We also looked at inpatient variables that could predict the development of AKI to identify potential risk factors, so that these can be used as a starting point for intervention and prevention in this group. The Embase, Medline, PubMed, Cochrane libraries, and Web of Science databases were used for searching articles from the inception of the database to October 2022. The EndNote software was used for screening. Meta-analysis was performed using Stata 16.0 software to combine effect sizes. A total of 37 studies were included. Of all the 3 533 583 patients with HF, 774 887 had AKI, with a pooled incidence of 33% [95% confidence interval (CI): 32-35%]. The incidence rate of AKI in acute HF and chronic HF was 36% (95% CI: 31-40%) and 30% (95% CI: 24-35%), respectively. Eleven studies found that AKI patients had higher in-hospital mortality than non-AKI patients [risk ratio (RR): 3.65; 95% CI: 3.04-4.39, P < 0.001]. Mortality was assessed in five studies, and it was found that mortality remained high at 1-year follow-up after onset of AKI (RR: 1.85, 95% CI: 1.54-2.22, P < 0.001). Fifteen admission variables were included and analysed in 13 studies. The combined results showed that diabetes, hypertension, history of chronic kidney disease, chronic HF systolic, age, N-terminal pro-B-type natriuretic peptide, creatinine > 1.0 mg/dL, index estimated glomerular filtration rate < 60 mL/min/1.73 m2 , blood urea nitrogen > 24 mg/dL, intravenous dobutamine, and serum albumin were predictor factors for HF patients with AKI (P < 0.05). In this meta-analysis, AKI occurred in approximately 33% of HF patients during hospitalization and the risk of dying in the hospital was tripled. Even during 1-year long-term follow-up, the risk of death remained high, and multiple inpatient variables showed that HF patients tended to have AKI. Early intervention and treatment are important to reduce the incidence of AKI and improve the prognosis.

Patient Selection and End Point Definitions for Decongestion Studies in Acute Decompensated Heart Failure: Part 1

Despite recent advances in the treatment of patients with chronic heart failure, acute decompensated heart failure remains associated with significant mortality and morbidity because many novel therapies have failed to demonstrate meaningful benefit. Persistent congestion in the setting of escalating diuretic therapy has been repeatedly shown to be a marker of poor prognosis and is currently being targeted by various emerging device-based therapies. Because these therapies inherently carry procedural risk, patient selection is key in the future trial design. However, it remains unclear which patients are at a higher risk of residual congestion or adverse outcomes despite maximally tolerated decongestive therapy. In the first part of this 2-part review, we aimed to outline patient risk factors and summarize current evidence for early recognition of high-risk profile for residual congestion and adverse outcomes. These factors are classified as relating to the following: (1) previous clinical course, (2) severity of congestion, (3) diuretic response, and (4) degree of renal impairment. We also aimed to provide an overview of key inclusion criteria in recent acute decompensated heart failure trials and investigational device studies and propose potential criteria for selection of high-risk patients in future trials.

Angio-based coronary functional assessment predicts 30-day new-onset heart failure after acute myocardial infarction

AIMS

Suboptimal perfusion leading to heart failure (HF) often occurs after ST-segment elevation myocardial infarction (STEMI), despite restoration of epicardial coronary flow in primary percutaneous coronary intervention (PPCI) era. We determined the clinical implications of angio-based coronary functional assessment in evaluation of suboptimal perfusion and further outcomes among STEMI patients after successful PPCI.

METHODS AND RESULTS

In this study, STEMI patients in the Chinese STEMI PPCI registry trial (NCT04996901) who achieved post-PPCI thrombolysis in myocardial infarction grade 3 flow were retrospectively screened. Post-procedural quantitative flow ratio (QFR), angio-based microvascular resistance (AMR), and coronary flow velocity (CFV) of the infarct-related artery were calculated. QFR and AMR measure epicardial stenosis severity and microvascular resistance, respectively. QFR+ was defined as QFR < 0.90 while QFR- was QFR ≥ 0.90. AMR+ was defined as AMR ≥ 250 mmHg*s/m while AMR- was AMR < 250 mmHg*s/m. The primary outcome was 30-day new-onset HF. The Kaplan-Meier curves were used to establish the associations between QFR, AMR, CFV, and HF incidences. The relationship between CFV and combined QFR and AMR indices was further assessed. Independent predictors were determined using Cox regression analysis. The receiver-operating characteristic curve was used to assess discriminant ability to predict HF. A total of 942 patients (mean age was 57.8 ± 11.7 years and 84.6% were men) were enrolled. Among them, 129 patients had new-onset HF episodes. Patients in the QFR-/AMR- group had a low risk of HF compared with those in the QFR+/AMR+ group (10.5% vs. 27.3%, P = 0.027). A higher CFV ≥ 17.4 cm/s was associated with low HF incidences as compared with CFV < 17.4 cm/s (10.3% vs. 16.8%, P = 0.005), whereas isolated QFR or AMR did not reveal any marked differences in HF incidences (P = 0.150 and 0.079, respectively). The highest and lowest medians of CFV were observed in the QFR-/AMR- and QFR+/AMR+ groups, respectively. CFV correlated well with the QFR/AMR ratio (adjusted R2  = 1, P < 0.001) and post-PPCI CFV was found to be an independent predictor of post-STEMI HF (adjusted hazard ratio: 0.61, 95% confidence interval: 0.41-0.90, P = 0.012). The area under curve estimate of the multivariable regression model was 0.749.

CONCLUSIONS

CFV is an integrated coronary physiological assessment approach that incorporates epicardial and microcirculatory contributions. Patients with post-PPCI CFV < 17.4 cm/s were strongly associated with a high risk for post-STEMI HF, even achieving thrombolysis in myocardial infarction grade 3 flow. The immediate angio-based coronary functional assessment is a feasible tool for evaluating suboptimal perfusion and risk stratification.

Timing and Degree of Acute Kidney Injury in Patients Requiring Non-Surgical Intensive Care

BACKGROUND

The degree and timing of acute kidney injury (AKI) on admission and during hospitalization in patients requiring non-surgical intensive care remain unclear.

METHODS AND RESULTS

In this study, 3,758 patients requiring intensive care were analyzed retrospectively. AKI was defined based on the ratio of serum creatinine concentrations recorded at each time point (i.e., on admission and during the first 5 days in the intensive care unit and during hospitalization) to those measured at baseline. Patients were grouped by combining AKI severity (RIFLE class) and timing (i.e., from admission to 5 days [A-5D]; from 5 days to hospital discharge [5D-HD]) as follows: No-AKI; New-AKI (no AKI to Class R [risk; ≥1.5-fold increase in serum creatinine], I [injury; ≥2.0-fold increase in serum creatinine], and F [failure; ≥3.0-fold increase in serum creatinine or receiving dialysis during hospitalization]); Stable-AKI (Class R to R; Class I to I); and Worsening-AKI (Class R to I or F; Class I to F). Multivariate logistic regression analysis indicated that 730-day mortality was independently associated with Class R, I, and F on admission; Class I and F during the 5D-H period; and New-AKI and Worsening-AKI during A-5D and 5D-HD.

CONCLUSIONS

AKI on admission, even Class R, was associated with a poor prognosis. An increase in RIFLE class during hospitalization was identified as an important factor for poor prognosis in patients requiring intensive care.

Novel Treatments of Hypertrophic Cardiomyopathy in GDMT for Heart Failure: A State-of-art Review

This state-of-the-art review discuss the available evidence on the use of novel treatments of hypertrophic cardiomyopathy such as omecamtiv mecarbil, EMD-57033, levosimendan, pimobendan, and mavacamten for the treatment of heart failure (HF) in the context of guideline-directed medical therapy (GDMT). The paper provides a detailed overview of these agents' mechanisms of action, potential benefits and limitations, and their effects on clinical outcomes. The review also evaluates the efficacy of the novel treatments in comparison to traditional medications such as digoxin. Finally, we seek to provide insight and guidance to clinicians and researchers in the management of HF patients.

Early glomerular filtration rates changes and risk of mortality in acute heart failure. The modifying role of admission renal function and decongestion

BACKGROUND

The pathophysiology of changes in estimated glomerular filtration rate (eGFR) in acute heart failure (AHF) is complex and multifactorial. We evaluated the associated mortality risk of early changes in eGFR across baseline renal function on admission and early changes in natriuretic peptides in patients admitted with AHF.

METHODS

We retrospectively evaluated 2,070 patients admitted with AHF. Renal dysfunction on admission was defined as eGFR<60 ml/min/1.73m2 and successful decongestion as NT-proBNP decreased >30% from baseline. We assessed the mortality risk associated with eGFR changes from baseline at 48-72 h after admission (ΔeGFR%) according to baseline renal function, and NT-proBNP changes at 48-72 h through Cox regression analyses.

RESULTS

The mean age was 74.4 ± 11.2 years, and 930 (44.9%) were women. The proportion of admission eGFR<60 ml/min/1.73m2 and 48-72 h changes in NT-proBNP>30% were 50.5% and 32.8%, respectively. At a median follow-up of 1.75 years, 928 deaths were registered. In the whole sample, changes in renal function were not associated with mortality (p = 0.208). The adjusted analysis revealed that the risk of mortality related to ΔeGFR% was heterogeneous across baseline renal function and changes in NT-proBNP (p-value for interaction=0.003). ΔeGFR% was not associated with mortality in patients with baseline eGFR≥60 ml/min/1.73m2. In those with eGFR<60 ml/min/1.73m2, a decrease in eGFR was associated with higher mortality, particularly in those with a reduction in NT-proBNP<30%.

CONCLUSION

In patients with AHF, early ΔeGFR% was associated with the risk of long-term mortality only in patients with renal dysfunction on admission and no early decline in NT-proBNP.

Telmisartan versus EnalapRil In heart failure with redUced ejection fraction patients with Moderately impaired kidney Functions; randomized controlled trial: "TRIUMF trial"

BACKGROUND

When heart failure with reduced ejection fraction (HFrEF) and chronic kidney disease (CKD) co-exist, Renin angiotensin-aldosterone system inhibitors (RAASi) are often underutilized for the fear of worsening renal function (WRF). Telmisartan is a RAASi characteristic for a favorable renal profile, although data on its utility in HFrEF is limited. This study aimed to compare efficacy and tolerability of Telmisartan versus Enalapril in patients with HFrEF and CKD.

RESULTS

This study randomized 107 patients with HFrEF and CKD to either Telmisartan (10-80 mg) or Enalapril (5-40 mg) daily. The achieved RAASi dose, dose reductions (DR) or dis-continuation (DC), death/Heart failure rehospitalization (HFH), NYHA class and 6MWT were compared at 3- and 6-months. At 3- and 6-months, 93.5% versus 68.6% and 95.2% versus 72.9% were maintaining ≥ 50% of the target dose in the Telmisartan- versus Enalapril-group, respectively. Despite the higher achieved dose by 3- and 6-months, Telmisartan versus Enalapril was associated with less WRF (6.4% vs. 22.9%, p = 0.022 and 7.3% vs. 13.6%, p = 0.28) and fewer episodes of DR-DC (31.9% vs. 55.1%, p = 0.018 and 35.7% vs. 56.5%, p = 0.041), respectively. By the end of the study, there were 5 deaths in each group, yet, HFH occurred in 34.1% versus 55.3%, p = 0.035, and NYHA class changed by - 1 [- 2, 0] versus 0 [- 1, 1], p = 0.017 in Telmisartan- versus Enalapril patients, respectively. Within-group results showed improvement in 6MWT in Telmisartan-, and increase in diuretic requirements in Enalapril-group.

CONCLUSIONS

In patients with HFrEF and CKD, Telmisartan was better tolerated to uptitrate, caused less WRF, less HFH and showed better functional improvement compared to Enalapril. Clinical trial registration This study was prospectively registered on clinicaltrials.gov, with registration number (NCT04736329).

Incidence, Predictors, and Outcomes Associated With Worsening Renal Function in Patients With Heart Failure and Secondary Mitral Regurgitation: The COAPT Trial

Background The incidence and implications of worsening renal function (WRF) after mitral valve transcatheter edge-to-edge repair (TEER) in patients with heart failure (HF) are unknown. Therefore, the aim of this study was to determine the proportion of patients with HF and secondary mitral regurgitation who develop persistent WRF within 30 days following TEER, and whether this development portends a worse prognosis. Methods and Results In the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial, 614 patients with HF and severe secondary mitral regurgitation were randomized to TEER with the MitraClip plus guideline-directed medical therapy (GDMT) versus GDMT alone. WRF was defined as serum creatinine increase ≥1.5× or ≥0.3 mg/dL from baseline persisting to day 30 or requiring renal replacement therapy. All-cause death and HF hospitalization rates between 30 days and 2 years were compared in patients with and without WRF. WRF at 30 days was present in 11.3% of patients (9.7% in the TEER plus GDMT group and 13.1% in the GDMT alone group; P=0.23). WRF was associated with all-cause death (hazard ratio [HR], 1.98 [95% CI, 1.3-3.03]; P=0.001) but not HF hospitalization (HR, 1.47 [ 95% CI, 0.97-2.24]; P=0.07) between 30 days and 2 years. Compared with GDMT alone, TEER reduced both death and HF hospitalization consistently in patients with and without WRF (P_interaction=0.53 and 0.57, respectively). Conclusions Among patients with HF and severe secondary mitral regurgitation, the incidence of WRF at 30 days was not increased after TEER compared with GDMT alone. WRF was associated with greater 2-year mortality but did not attenuate the treatment benefits of TEER in reducing death and HF hospitalization compared with GDMT alone. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01626079.

Organ dysfunction, injury, and failure in cardiogenic shock

BACKGROUND

Cardiogenic shock (CS) is caused by primary cardiac dysfunction and induced by various and heterogeneous diseases (e.g., acute impairment of cardiac performance, or acute or chronic impairment of cardiac performance).

MAIN BODY

Although a low cardiac index is a common finding in patients with CS, the ventricular preload, pulmonary capillary wedge pressure, central venous pressure, and systemic vascular resistance might vary between patients. Organ dysfunction has traditionally been attributed to the hypoperfusion of the organ due to either progressive impairment of the cardiac output or intravascular volume depletion secondary to CS. However, research attention has recently shifted from this cardiac output ("forward failure") to venous congestion ("backward failure") as the most important hemodynamic determinant. Both hypoperfusion and/or venous congestion by CS could lead to injury, impairment, and failure of target organs (i.e., heart, lungs, kidney, liver, intestines, brain); these effects are associated with an increased mortality rate. Treatment strategies for the prevention, reduction, and reversal of organ injury are warranted to improve morbidity in these patients. The present review summarizes recent data regarding organ dysfunction, injury, and failure.

CONCLUSIONS

Early identification and treatment of organ dysfunction, along with hemodynamic stabilization, are key components of the management of patients with CS.

Acute kidney injury in patients with acute decompensated heart failure-cardiogenic shock: Prevalence, risk factors and outcome

BACKGROUND

Acute Kidney Injury (AKI) represents a major complication of acute heart failure and cardiogenic shock (CS). There is a paucity of data on AKI complicating acutely decompensated heart failure patients presenting with CS (ADHF-CS). We aimed to investigate AKI prevalence, risk factors and outcomes in this subgroup of patients.

METHODS

Retrospective observational study on patients admitted for ADHF-CS to our 12-bed Intensive Care Unit (ICU), between January 2010 and December 2019. Demographic, clinical, and biochemical variables were collected at baseline and during hospital stay.

RESULTS

Eighty-eight patients were consecutively recruited. The predominant etiologies were idiopathic dilated cardiomyopathy (47%), followed by post-ischemic (24%). AKI was diagnosed in 70 (79.5%) of patients. Forty-three out of 70 patients met the criteria for AKI at ICU admission. On multivariate analysis, a central venous pressure (CVP) higher than 10 mmHg (OR 3.9; 95%CI 1.2-12.6; p = 0.025) and serum lactate higher than 3 mmol/L (OR 4.1; 95%CI 1.01-16.3; p = 0.048) were identified to be independently associated with AKI. Age and AKI stage were independent predictors of 90-day mortality.

CONCLUSION

AKI is a common and early complication of ADHF-CS. Venous congestion and severe hypoperfusion are risk factors for AKI development. Early detection and prevention of AKI could lead to better outcome in this clinical subgroup.

Impact of worsening renal function detected at emergency department arrival on acute heart failure short-term outcomes

BACKGROUND AND IMPORTANCE

Deterioration of renal function with respect to baseline during an acute heart failure (AHF) episode is frequent, but impact on outcomes is still a matter of debate.

OBJECTIVE

To investigate the association of creatinine deterioration detected at emergency department (ED) arrival and short-term outcomes in patients with AHF.

DESIGN

Secondary analysis of a large multipurpose registry.

SETTINGS AND PARTICIPANTS

Patients with AHF were diagnosed in 10 Spanish ED for whom a previous baseline creatinine was available.

EXPOSURE

Difference between creatinine at ED arrival and at baseline was calculated (∂-creatinine).

OUTCOME MEASURES AND ANALYSIS

Primary outcome was 30-day all-cause death, and secondary outcomes were inhospital all-cause death, prolonged hospitalization (>7 days) and 7-day postdischarge adverse events. Associations between ∂-creatinine and outcomes were explored using logistic regression by restricted cubic spline (RCS) curves and expressed as odds ratio (OR) with 95% confidence interval (CI), taking ∂-creatinine = 0 mg/dl as reference. Curves were adjusted by age, sex, comorbidities, patient baseline status, chronic treatments, and vitals and laboratory results at ED arrival. Interactions for the primary outcome also were investigated.

MAIN RESULTS

We analyzed 3036 patients (median age = 82 years; IQR = 75-87; women = 55%), with ∂-creatinine ranged from -0.3 to 3 mg/dl. The 30-day mortality was 11.6%. Increments of ∂-creatinine were associated with progressive increase in risk of 30-day death, although adjustment attenuated this association: ∂-creatinine of 0.3/1/2/3 mg/dl were, respectively, associated with adjusted OR of 1.41 (1.02-1.95), 1.69 (1.02-2.80), 1.46 (0.56-3.80) and 1.27 (0.27-5.83). Distinctively significant higher risk was found for patients over 80 years old, female, nondiabetic, functionally disabled and on digoxin therapy. With respect to secondary outcomes, inhospital mortality was 8.1%, prolonged hospitalization was 33.6% and 7-day postdischarge adverse event was 9.7%. Inhospital death steadily increased with increments in ∂-creatinine [from 1.50 (1.04-2.17) with ∂-creatinine = 0.3 to 3.78 (0.78-18.3) with ∂-creatinine = 3], as well as prolonged hospitalization did [from 1.41 (1.11-1.77) to 2.24 (1.51-3.33), respectively]. Postdischarge adverse events were not associated with ∂-creatinine.

CONCLUSION

WRF detected at ED arrival has prognostic value in AHF, being associated with increased risk of death and prolonged hospitalization. These associations showed different patterns of risk but, remarkably, risk started with increments as low as 0.3 mg/dl.

Acute kidney injury patterns in acute heart failure: The prognostic value of worsening renal function and its timing

INTRODUCTION

Acute decompensated heart failure (ADHF) admissions are frequently complicated by different patterns of serum creatinine (SCr) elevation. We aimed to assess the prognostic impact of worsening renal function (WRF) based on the timing of its occurrence.

METHODS

This was a retrospective cohort of patients admitted for ADHF. Standard WRF was defined as an increase in SCr of ≥0.3 mg/dl during hospitalization. WRF timing was classified as early (within 48 hours of admission) or late (>48 hours). Acute kidney injury (AKI) at admission was defined as a rise in SCr of ≥0.3 mg/dl from outpatient baseline measurement to first measurement at admission. The primary endpoint was a composite of all-cause mortality or hospitalization for cardiovascular events at one-year follow-up.

RESULTS

Overall, 249 patients were included (mean age 77±11 years, 62% with preserved left ventricular ejection fraction). Early WRF occurred in 49 patients (19.7%) and was associated with a higher risk of the primary outcome (HR 2.49; 95% CI 1.66-3.73), whereas late WRF was not (p=0.411). After stratification for the presence of early WRF and/or AKI at admission, only patients with early WRF but no AKI at admission and patients with both AKI at admission and early WRF showed a higher risk of the primary outcome after multivariate Cox regression.

CONCLUSION

Early WRF was associated with a higher risk of the primary outcome. The timing of WRF seems to be an important factor to take into account when considering the prognostic impact of creatinine variations during hospitalization for ADHF.

Implications of worsening renal function before hospitalization for acute heart failure

AIMS

Kidney function changes dynamically during AHF treatment, but risk factors for and consequences of worsening renal function (WRF) at hospital admission are uncertain. We aimed to determine the significance of WRF at admission for acute heart failure (AHF).

METHODS AND RESULTS

We evaluated a subgroup of 406 patients from The Acute Kidney Injury Neutrophil gelatinase-associated lipocalin Evaluation of Symptomatic heart failure Study (AKINESIS) who had serum creatinine measurements available within 3 months before and at the time of admission. Admission WRF was primarily defined as a 0.3 mg/dL or 50% creatinine increase from preadmission. Alternative definitions evaluated were a ≥0.5 mg/dL creatinine increase, ≥25% glomerular filtration rate decrease, and an overall change in creatinine. Predictors of admission WRF were evaluated. Outcomes evaluated were length of hospitalization, a composite of adverse in-hospital events, and the composite of death or HF readmission at 30, 90, and 365 days. Biomarkers' prognostic ability for these outcomes were evaluated in patients with admission WRF. One-hundred six patients (26%) had admission WRF. These patients had features of more severe AHF with lower blood pressure, higher BUN, and lower serum sodium concentrations at admission. Higher BNP (odds ratio [OR] per doubling 1.16-1.28, 95% confidence interval [CI] 1.00-1.55) and lower diastolic blood pressure (OR 0.97-0.98, 95% CI 0.96-0.99) were associated with a higher odds for the three definitions of admission WRF. The primary WRF definition was not associated with a longer hospitalization, but alternative WRF definitions were (1.3 to 1.6 days longer, 95% CI 1.0-2.2). WRF across definitions was not associated with a higher odds of adverse in-hospital events or a higher risk of death or HF readmission. In the subset of patients with WRF, biomarkers were not prognostic for any outcome.

CONCLUSIONS

Admission WRF is common in AHF patients and is associated with an increased length of hospitalization, but not adverse in-hospital events, death, or HF readmission. Among those with admission WRF, biomarkers did not risk stratify for adverse events.

Determining the factors for interhospital transfer in advanced heart failure cases

Background

There are some patients with advanced heart failure (HF), for whom implantable left ventricular assist device (LVAD) or heart transplantation (HTx) should be considered. Some of them need to be transferred between hospitals. There are few reports on the interhospital transfer of patients with advanced HF and their subsequent clinical course.

In this study, we investigated the characteristics and clinical course of patients transferred to a LVAD/HTx center, focusing on the distance between hospitals.

Methods

We retrospectively examined 141 patients who were transferred to our hospital, considering the indications of LVAD implantation or HTx. We divided the patients into two groups: those referred <33 km (short-distance) and those referred more than 33 km (long-distance). The primary outcome was the composite outcome of increased catecholamine dose, mechanical support, or renal dysfunction within 1 week of transfer.

Results

Continuous catecholamine infusion was significantly more common in patients in the long-distance group, whereas extracorporeal membrane oxygenation (ECMO) placement was significantly more common in short-distance group.

Patients transferred via long distance had significantly higher rates of increased catecholamine doses, mechanical support including intra-aortic balloon pumping (IABP) and ECMO, and renal dysfunction within 1 week of transfer than patients transferred via short distance. Multivariate analysis showed that low body mass index (BMI) and long distance were independent predictive factors for the primary outcome.

Conclusions

When patients with advanced HF are transferred from far distant hospitals or with low BMI, it may be necessary to devise various measures for interhospital transport.

Type III procollagen peptide level can indicate liver dysfunction associated with volume overload in acute heart failure

Aim

The role of serum type III procollagen peptide (P3P) level in the acute phase of acute heart failure (AHF) requires clarification. We hypothesized that serum P3P level is temporarily higher during the acute phase, reflecting liver dysfunction due to congestion.

Methods and results

A total of 800 AHF patients were screened, and data from 643 patients were analysed. Heart failure was diagnosed by the treating physician according to the European Society of Cardiology (ESC) guidelines, and included patients being treated with high‐concentration oxygen inhalation (including mechanical support) for orthopnea, inotrope administration, or mechanical support for low blood pressure, and various types of diuretics for peripheral or pulmonary oedema. In all cases, diuretics or vasodilators were administered to treat AHF. The patients were divided into three groups according to their quartile (Q) serum P3P level: low‐P3P (Q1, P3P ≤ 0.6 U/mL), mid‐P3P (Q2/Q3, 0.6 < P3P <1.2 U/mL), and high‐P3P (Q4, P3P ≥ 1.2 U/mL). The plasma volume status (PVS) was calculated using the following formula: ([actual PV − ideal PV]/ideal PV) × 100 (%). The primary endpoint was 365 day mortality. A Kaplan–Meier curve analysis showed that prognoses, including all‐cause mortality and heart failure events within 365 days, were significantly (P < 0.001) worse in the high‐P3P group when compared with the mid‐P3P and low‐P3P groups. A multivariate logistic regression analysis showed that high PVS (Q4, odds ratio [OR]: 4.702, 95% CI: 2.012–20.989, P < 0.001), high fibrosis‐4 index (Q4, OR: 2.627, 95% CI: 1.311–5.261, P = 0.006), and low estimated glomerular filtration rate per 10 mL/min/1.73 m² decrease (OR: 1.996, 95% CI: 1.718–2.326, P < 0.001) were associated with high P3P values. The Kaplan–Meier curve analysis demonstrated a significantly lower survival rate, as well as a higher rate of heart failure events, in the high‐P3P and high‐PVS groups when compared with the other groups. A multivariate Cox regression model identified high P3P level and high PVS as an independent predictor of 365 day all‐cause mortality (hazard ratio [HR]: 2.249; 95% CI: 1.081–3.356; P = 0.026) and heart failure events (HR: 1.586, 95% CI: 1.005–2.503, P = 0.048).

Conclusion

A high P3P level during the acute phase of AHF served as a comprehensive biomarker of liver dysfunction with volume overload (i.e. liver congestion) and renal dysfunction. A high P3P level at admission may be able to predict adverse outcomes in AHF patients.

Different Renal Function Patterns in Patients With Acute Heart Failure: Relationship With Outcome and Congestion

Background

The role of worsening renal function during acute heart failure (AHF) hospitalization is still debated. Very few studies have extensively evaluated the renal function (RF) trend during hospitalization by repetitive measurements.

Objectives

To investigate the prognostic relevance of different RF trajectories together with the congestion status in hospitalized patients.

Methods

This is a post hoc analysis of a multi-center study including 467 patients admitted with AHF who were screened for the Diur-AHF Trial. We recognized five main RF trajectories based on serum creatinine and estimated glomerular filtration rate (eGFR) behavior. According to the RF trajectories our sample was divided into 1-stable (S), 2-transient improvement (TI), 3-permanent improvement (PI), 4-transient worsening (TW), and 5-persistent worsening (PW). The primary outcome was the combined endpoint of 180 days including all causes of mortality and re-hospitalization.

Results

We recruited 467 subjects with a mean congestion score of 3.5±1.08 and a median creatinine value of 1.28 (1.00-1.70) mg/dl, eGFR 50 (37-65) ml/min/m2 and NTpro B-type natriuretic peptide (BNP) 7,000 (4,200-11,700) pg/ml. A univariate analysis of the RF pattern demonstrated that TI and PW patterns were significantly related to poor prognosis [HR: 2.71 (1.81-4.05); p < 0.001; HR: 1.68 (1.15-2.45); p = 0.007, respectively]. Conversely, the TW pattern showed a significantly protective effect on outcome [HR:0.34 (0.19-0.60); p < 0.001]. Persistence of congestion and BNP reduction ≥ 30% were significantly related to clinical outcome at univariate analysis [HR: 2.41 (1.81-3.21); p < 0.001 and HR:0.47 (0.35-0.67); p < 0.001]. A multivariable analysis confirmed the independently prognostic role of TI, PW patterns, persistence of congestion, and reduced BNP decrease at discharge.

Conclusions

Various RF patterns during AHF hospitalization are associated with different risk(s). PW and TI appear to be the two trajectories related to worse outcome. Current findings confirm the importance of RF evaluation during and after hospitalization.

Insights of Worsening Renal Function in Type 1 Cardiorenal Syndrome: From the Pathogenesis, Biomarkers to Treatment

Type-1 cardiorenal syndrome refers to acute kidney injury induced by acute worsening cardiac function. Worsening renal function is a strong and independent predictive factor for poor prognosis. Currently, several problems of the type-1 cardiorenal syndrome have not been fully elucidated. The pathogenesis mechanism of renal dysfunction is unclear. Besides, the diagnostic efficiency, sensitivity, and specificity of the existing biomarkers are doubtful. Furthermore, the renal safety of the therapeutic strategies for acute heart failure (AHF) is still ambiguous. Based on these issues, we systematically summarized and depicted the research actualities and predicaments of the pathogenesis, diagnostic markers, and therapeutic strategies of worsening renal function in type-1 cardiorenal syndrome.

Clinical Outcomes in Patients with Ischemic versus Non-Ischemic Cardiomyopathy after Angiotensin-Neprilysin Inhibition Therapy

Background: The angiotensin receptor-neprilysin inhibitor (ARNI) decreases cardiovascular mortality in patients with chronic heart failure with a reduced ejection fraction (HFrEF). Data regarding the impact of ARNI on the outcome in HFrEF patients according to heart failure etiology are limited. Methods and results: One hundred twenty-one consecutive patients with HFrEF from the years 2016 to 2017 were included at the Medical Centre Mannheim Heidelberg University and treated with ARNI according to the current guidelines. Left ventricular ejection fraction (LVEF) was numerically improved during the treatment with ARNI in both patient groups, that with ischemic cardiomyopathy (n = 61) (ICMP), and that with non-ischemic cardiomyopathy (n = 60) (NICMP); p = 0.25. Consistent with this data, the NT-proBNP decreased in both groups, more commonly in the NICMP patient group. In addition, the glomerular filtration rate (GFR) and creatinine changed before and after the treatment with ARNI in both groups. In a one-year follow-up, the rate of ventricular tachyarrhythmias (ventricular tachycardia and ventricular fibrillation) tended to be higher in the ICMP group compared with the NICMP group (ICMP 38.71% vs. NICMP 17.24%; p = 0.07). The rate of one-year all-cause mortality was similar in both groups (ICMP 6.5% vs. NICMP 6.6%; log-rank = 0.9947). Conclusions: This study shows that, although the treatment with ARNI improves the LVEF in ICMP and NICMP patients, the risk of ventricular tachyarrhythmias remains higher in ICMP patients in comparison with NICMP patients. Renal function is improved in the NICMP group after the treatment. Long-term mortality is similar over a one-year follow-up.

Clinical Significance of Low-Triiodothyronine Syndrome in Patients Requiring Non-Surgical Intensive Care - Triiodothyronine Is a Comprehensive Prognostic Marker for Critical Patients With Cardiovascular Disease

Background: Low-triiodothyronine (T₃) syndrome is a known complication in intensive care unit (ICU) patients, but the underlying mechanisms and prognostic impact are unclear.

Methods and Results: This study retrospectively enrolled 2,976 patients who required care in the ICU. Of these patients, 2,425 were euthyroid and were divided into normal (n=1,666; free T₃ [FT₃] ≥1.88 µIU/L) and low-FT₃ (n=759; FT₃ <1.88 µIU/L) groups. Multivariate logistic regression analysis revealed that prognostic nutritional index >46.03 (odds ratio [OR] 2.392; 95% confidence interval [CI] 1.904–3.005), age (per 1-year increase; OR 1.022; 95% CI 1.013–1.031), creatinine (per 0.1-mg/dL increase; OR 1.019; 95% CI 1.014–1.024), and C-reactive protein (per 1-mg/dL increase; OR 1.123; 95% CI 1.095–1.151) were independently associated with low FT₃. Survival rates (within 365 days) were significantly lower in the low-FT₃ group. A multivariate Cox regression model showed that low FT₃ was an independent predictor of 365-day mortality (hazard ratio 1.785; 95% CI 1.387–2.297). Low-T₃ syndrome was significantly more frequent in patients with non-cardiovascular than cardiovascular diseases (73.5% vs. 25.8%). Prognosis was significantly poorer in the low-FT₃ than normal group for patients with cardiovascular disease, particularly those with acute coronary syndrome and acute heart failure.

Conclusions: Low-T₃ syndrome was associated with aging, inflammatory reaction, malnutrition, and renal insufficiency and could lead to adverse outcomes in patients admitted to a non-surgical ICU.

Any heart failure treatments associated with worsening renal function in patients admitted due to acute heart failure?

Background

Worsening renal function (WRF) occurs in approximately 25% of acute heart failure patients, and both baseline characteristics and heart failure treatment may increase the risk of WRF. This study aimed to evaluate additional risk factors for WRF in acute heart failure, particularly those related to heart failure treatment.

Methods

This was a retrospective, observational, analytical study. The inclusion criteria were age 18 years or over, hospital admission due to acute heart failure, and having undergone at least two serum creatinine tests during admission. The eligible patients were classified into two groups: WRF and non-WRF. Predictors for WRF (including treatment parameters) were determined using logistic regression analysis.

Results

During the study period, there were 301 eligible patients who met the study criteria. Of those, 82 (27.24%) had WRF. There were two independent factors associated with WRF occurrence: baseline diastolic blood pressure and beta blocker treatment, with adjusted odds ratios (95% confidence interval) of 1.060 (1.008, 1.114) and 0.064 (0.006, 0.634), respectively. The Hosmer-Lemeshow Chi square for the final model was 6.11 (p = .634).  

Conclusions

After examining several heart failure treatments and baseline factors, we found that beta blocker treatment results improvement in kidney function.

LncRNA promoted inflammatory response in ischemic heart failure through regulation of miR-455-3p/TRAF6 axis

OBJECTIVES

Ischemic heart failure (IHF) is the most common cause of death globally. Growing evidence shows abnormal expression of long non-coding RNAs in heart failure patients. This study aims to investigate the effect of sex-determining region Y-box 2 (SOX2) overlapping transcript (SOX2-OT) on the regulation of the inflammatory response in ischemic heart failure.

METHODS

IHF rat and oxygen and glucose deprivation (OGD) cell models were established. qRT-PCR was employed to investigate the expression of SOX2-OT. ELISA, western blot and cell viability/apoptosis assays were performed to assess the effects of SOX2-OT. Online software program was used to identify miRNAs that target SOX2-OT, followed by validation using RNA pull-down. Potential targets of miRNAs were searched, and examined by immunoblotting, qRT-PCR and luciferase reporter assay.

RESULTS

SOX2-OT was up-regulated in IHF and OGD. Knockdown of SOX2-OT promoted cell proliferation, decreased apoptosis rate and cell oxidative damage, and ameliorated inflammatory response. SOX2-OT contains binding sites for miR-455-3p, miR-5586-3p and miR-1252-5p. RNA pull-down confirmed the binding ability between SOX2-OT and miR-455-3p. TRAF6 is a direct target of miR-455-3p. Moreover, the regulatory activity of SOX2-OT on inflammatory response was partially through its negative regulation of miR-455-3p, which directly regulates TRAF6. Down-regulation of SOX2-OT improved myocardial dysfunction in IHF rat.

CONCLUSIONS

Our results reveal that SOX2-OT may be a driver of IHF through repression of miR-455-3p, and miR-455-3p alleviates IHF by targeting TRAF6. Therefore, SOX2-OT/miR-455-3p/TRAF6 may be a potential target for advanced therapeutic strategy for IHF.

The difference in referencing in Web of Science, Scopus, and Google Scholar

AIMS

How often a medical article is cited is important for many people because it is used to calculate different variables such as the h-index and the journal impact factor. The aim of this analysis was to assess how the citation count varies between Web of Science (WoS), Scopus, and Google Scholar in the current literature.

METHODS

We included the top 50 cited articles of four journals ESC Heart Failure; Journal of cachexia, sarcopenia and muscle; European Journal of Preventive Cardiology; and European Journal of Heart Failure in our analysis that were published between 1 January 2016 and 10 October 2019. We recorded the number of citations of these articles according to WoS, Scopus, and Google Scholar on 10 October 2019.

RESULTS

The top 50 articles in ESC Heart Failure were on average cited 12 (WoS), 13 (Scopus), and 17 times (Google Scholar); in Journal of cachexia, sarcopenia and muscle 37 (WoS), 43 (Scopus), and 60 times (Google Scholar); in European Journal of Preventive Cardiology 41 (WoS), 56 (Scopus), and 67 times (Google Scholar); and in European Journal of Heart Failure 76 (WoS), 108 (Scopus), and 230 times (Google Scholar). On average, the top 50 articles in all four journals were cited 41 (WoS), 52 (Scopus, 26% higher citations count than WoS, range 8-42% in the different journals), and 93 times (Google Scholar, 116% higher citation count than WoS, range 42-203%).

CONCLUSION

Scopus and Google Scholar on average have a higher citation count than WoS, whereas the difference is much larger between Google Scholar and WoS.

Urgent Control of Rapid Atrial Fibrillation by Landiolol in Patients With Acute Decompensated Heart Failure With Severely Reduced Ejection Fraction

Background: We investigated the clinical usefulness of landiolol for rapid atrial fibrillation (AF) in patients with acute decompensated heart failure (ADHF) and identify the patients eligible for landiolol.

Methods and Results: A total of 101 ADHF patients with reduced ejection fraction (HFrEF) with rapid AF were enrolled. Immediately after admission, an initial dose of landiolol was given (1 μg/kg⁻¹/min⁻¹), and then the dose was increased to decrease heart rate (HR) to <110 beats/min and change HR (∆HR) >20% in ≤24 h. Thirty-seven were monitored using right heart catheterization at 3 points (baseline, 1 μg/kg⁻¹/min⁻¹, and maximum dose). We checked the major adverse events (MAE) during initial hospitalization, which included cardiac death, HF prolongation (required i.v. treatment at 30 days), and worsening renal function. The average maximum dose of landiolol was 3.8±2.3 μg/kg⁻¹/min⁻¹. HR (P<0.0001) and pulmonary capillary wedge pressure (P=0.0008) decreased safely. MAE occurred in 39 patients. The patients with left ventricular (LV) end-diastolic volume index <84.0 mL/m² and mean blood pressure (mean BP) >97 mmHg had less frequent MAE (P<0.0001).

Conclusions: Landiolol was effective for safely controlling rapid AF in patients with HFrEF with ADHF, leading to hemodynamic improvement and avoidance of short-term MAE, especially in patients with relatively smaller LV and higher BP.

Early diagnosis of acute renal injury in patients with acute decompensation of chronic heart failure

AIM

To study the possibilities of previously diagnosing acute renal damage in patients with acute decompensation of chronic heart failure with reduced systolic function using biomarkers of acute renal injury.

MATERIALS AND METHODS

The study included 60 patients (62.0±11.1 years) with HADS (BNP &gt;500 pg/ml) and a reduced left ventricular ejection fraction (LV 27.05% [23.25; 32.75], c FC III-IV NYHA). The level of creatinine, urea, uric acid, albumin in serum was determined in all patients, as well as a number of biomarkers: lipocalin associated with neutrophil gelatinase (NGAL) and cystatin C (CysC) in serum; kidney damage molecule-1 (KIM-1) and angiotensinogen (AGT) in the urine.

RESULTS

AKI is determined based on changes in serum creatinine concentration or diuresis value. The results obtained indicate a high specificity and sensitivity of the use of biomarkers for the diagnosis of AKI in patients with ADHF. NGAL AUC - 0.833 (p&lt;0.001), Se - 82.8%, Sp - 4.2%. CysC AUC - 0.823 (p&lt;0.001), Se - 79.3%, Sp - 74.2%. KIM-1 AUC - 0.782 (p&lt;0.001), Se - 75.9%, Sp - 74.2%. AGT AUC - 0.829 (p&lt;0.001), Se - 82.8%, Sp - 77.4%. In a multifactorial regression analysis, it was found that with NGAL greater than 157.35 ng/ml, the risk of AKI increases 13.1 times (95% CI 1.365-126.431), with an increase in KIM-1, the risk of the development of AKI increases 20.6 times (95% CI 1.802-235.524), and with an increase in AGT more than 14.31 leng/ml, the risk of AKI increases 32.8 times (95% CI 2.752-390.110).

CONCLUSION

Acute kidney injury develops in 48.3% of patients hospitalized with acute decompensation of chronic heart failure. Patients with acute decompensation of chronic heart failure and AKI have significantly higher serum NGAL and CysC, KIM-1 and AGT values in the urine compared with patients without impairing renal function. These biomarkers can serve both for the early diagnosis of acute kidney damage and the prediction of AKI in patients with acute decompensation of chronic heart failure.

Worsening renal failure in patients with acute heart failure: the importance of cardiac biomarkers

Aims

The importance of true worsening renal failure (WRF), which is associated with a poor prognosis, had been suggested in patients with acute heart failure (AHF). The aim of the present study was to establish the biomarker strategy for the prediction of true WRF in AHF.

Methods and results

Two hundred eighty‐one patients with AHF were analysed. Their biomarkers were measured within 30 min of admission. Patients were assigned to the non‐WRF (n = 168), pseudo‐WRF (n = 56), or true‐WRF (n = 57) groups using the criteria of both acute kidney injury on admission and increasing serum creatinine value during the first 7 days. A Kaplan–Meier curve showed that the survival and heart failure event rate of the true‐WRF group within 1000 days was significantly lower than that of the non‐WRF and pseudo‐WRF groups (P ≤ 0.001). The multivariate Cox regression model also indicated that true WRF was an independent predictor of 1000 day mortality and heart failure events [hazard ratio: 4.315, 95% confidence interval (CI): 2.466–7.550, P ≤ 0.001, and hazard ratio: 2.834, 95% CI: 1.893–4.243, P ≤ 0.001, respectively]. The serum heart‐type fatty acid‐binding protein (s‐HFABP) levels were significantly higher in the true‐WRF group than in the non‐WRF and pseudo‐WRF groups (P ≤ 0.001). The multivariate logistic regression model indicated that the predictive biomarker for the true‐WRF group was the s‐HFABP level (odds ratio: 5.472, 95% CI: 2.729–10.972, P ≤ 0.001). The sensitivity and specificity for indicating the presence of true WRF were 73.7% and 76.8% (area under the curve = 0.831) for s‐HFABP in whole patients, respectively, and 94.7% and 72.7% (area under the curve = 0.904) in non‐chronic kidney disease (CKD) patients, respectively.

Conclusions

Cardiac biomarkers, especially the s‐HFABP, might predict the development of true WRF in AHF patients. Furthermore, the predictive value was higher in AHF patients without CKD than in those with CKD.

Impact of renal dysfunction on the management and outcome of acute heart failure: results from the French prospective, multicentre, DeFSSICA survey

OBJECTIVES

Cardiorenal syndrome (CRS) is the combination of acute heart failure syndrome (AHF) and renal dysfunction (creatinine clearance (CrCl) ≤60 mL/min). Real-life data were used to compare the management and outcome of AHF with and without renal dysfunction.

DESIGN

Prospective, multicentre.

SETTING

Twenty-six academic, community and regional hospitals in France.

PARTICIPANTS

507 patients with AHF were assessed in two groups according to renal function: group 1 (patients with CRS (CrCl ≤60 mL/min): n=335) and group 2 (patients with AHF with normal renal function (CrCl >60 mL/min): n=172).

RESULTS

Differences were observed (group 1 vs group 2) at admission for the incidence of chronic heart failure (56.42% vs 47.67%), use of furosemide (60.9% vs 52.91%), insulin (15.52% vs 9.3%) and amiodarone (14.33% vs 4.65%); additionally, more patients in group 1 carried a defibrillator (4.78% vs 0%), had ≥2 hospitalisations in the last year (15.52% vs 5.81%) and were under the care of a cardiologist (72.24% vs 61.63%). Clinical signs were broadly similar in each group. Brain-type natriuretic peptide (BNP) and BNP prohormone were higher in group 1 than group 2 (1157.5 vs 534 ng/L and 5120 vs 2513 ng/mL), and more patients in group 1 were positive for troponin (58.2% vs 44.19%), had cardiomegaly (51.04% vs 37.21%) and interstitial opacities (60.3% vs 47.67%). The only difference in emergency treatment was the use of nitrates, (higher in group 1 (21.9% vs 12.21%)). In-hospital mortality and the percentage of patients still hospitalised after 30 days were similar between groups, but the median stay was longer in group 1 (8 days vs 6 days).

CONCLUSIONS

Renal impairment in AHF should not limit the use of loop diuretics and/or vasodilators, but early assessment of pulmonary congestion and close monitoring of the efficacy of conventional therapies is encouraged to allow rapid and appropriate implementation of alternative therapies if necessary.

Plasma xanthine oxidoreductase activity in patients with decompensated acute heart failure requiring intensive care

Aims

Plasma xanthine oxidoreductase (XOR) activity during the acute phase of acute heart failure (AHF) requires further elucidation.

Methods and results

One hundred eighteen AHF patients and 231 control patients who attended a cardiovascular outpatient clinic were prospectively analysed. Blood samples were collected within 15 min of admission from AHF patients (AHF group) and control patients who visited a daily cardiovascular outpatient clinic (control group). Plasma XOR activity was compared between the two groups, and factors independently associated with extremely elevated XOR activity were identified using a multivariate logistic regression model. Plasma XOR activity in the AHF group (median, 104.0 pmol/h/mL; range, 25.9–423.5 pmol/h/mL) was significantly higher than that in the control group (median, 45.2 pmol/h/mL; range, 19.3–98.8 pmol/h/mL). The multivariate logistic regression model showed that serum uric acid (per 1.0 mg/dL increase, odds ratio: 1.280; 95% confidence interval: 1.066–1.536; P = 0.008) and lactate levels (per 1.0 mmol/L increase, odds ratio: 1.239; 95% confidence interval: 1.040–1.475; P = 0.016) were independently associated with high plasma XOR activity (>300 pg/h/mL) during the acute phase of AHF.

Conclusions

Plasma XOR activity was extremely high in patients with severely decompensated AHF. This would be associated with a high lactate value and would eventually lead to hyperuricaemia in patients with AHF.

Epidemiology of Cardiorenal Syndrome

Cardiorenal syndrome is a spectrum of disorders that emphasizes the bidirectional nature of cardiac and kidney injury. Observational and retrospective studies have helped us to understand the prevalence and burden of each of the 5 types of cardiorenal syndromes. Cardiorenal syndrome type 1 is the most common. The nature of epidemiologic data limits clear delineation between cardiorenal syndrome types 2 and 4. Overall, the presence of cardiac or renal dysfunction strongly predicts a poor outcome of the contrary organ.

Heart-Kidney Interactions in Cardiorenal Syndrome Type 1

The exact significance of kidney function deterioration during acute decompensated heart failure (ADHF) episodes is still under debate. Several studies reported a wide percentage of worsening renal function (WRF) in ADHF patients ranging from 20% to 40%. This is probably because of different populations enrolled with different baseline kidney and cardiac function, varying definition of acute kidney injury (AKI), etiology of kidney dysfunction (KD), and occurrence of transient or permanent KD over the observational period. Current cardiorenal syndrome classification does not distinguish among the mechanisms leading to cardiac and renal deterioration. Cardiorenal syndrome type 1 (CRS-1) is the result of a combination of neurohormonal activation, fluid imbalance, arterial underfilling, increased renal and abdominal pressure, and aggressive decongestive treatment. A more complete mechanistic approach to CRS-1 should include evaluation of baseline kidney function, timing, course and magnitude of KD, and introduction of specific biomarkers able to identify early kidney damage. Therefore, clinical and laboratory parameters may yield a different combination among predisposing, precipitating, and amplifying factors that may influence cardiorenal syndrome development. Thus, CRS-1 is a heterogeneous syndrome that needs to be better defined and categorized taking into account clinical status, renal condition, and treatment. The application of universal definitions for WRF/AKI definition would be the first step to achieve a clear classification.

Worsening renal function definition is insufficient for evaluating acute renal failure in acute heart failure

Aims

Whether or not the definition of a worsening renal function (WRF) is adequate for the evaluation of acute renal failure in patients with acute heart failure is unclear.

Methods and results

One thousand and eighty‐three patients with acute heart failure were analysed. A WRF, indicated by a change in serum creatinine ≥0.3 mg/mL during the first 5 days, occurred in 360 patients while no‐WRF, indicated by a change <0.3 mg/dL, in 723 patients. Acute kidney injury (AKI) upon admission was defined based on the ratio of the serum creatinine value recorded on admission to the baseline creatinine value and placed into groups based on the degree of AKI: no‐AKI (n = 751), Class R (risk; n = 193), Class I (injury; n = 41), or Class F (failure; n = 98). The patients were assigned to another set of four groups: no‐WRF/no‐AKI (n = 512), no‐WRF/AKI (n = 211), WRF/no‐AKI (n = 239), and WRF/AKI (n = 121). A multivariate logistic regression model found that no‐WRF/AKI and WRF/AKI were independently associated with 365 day mortality (hazard ratio: 1.916; 95% confidence interval: 1.234–2.974 and hazard ratio: 3.622; 95% confidence interval: 2.332–5.624). Kaplan–Meier survival curves showed that the rate of any‐cause death during 1 year was significantly poorer in the no‐WRF/AKI and WRF/AKI groups than in the WRF/no‐AKI and no‐WRF/no‐AKI groups and in Class I and Class F than in Class R and the no‐AKI group.

Conclusions

The presence of AKI on admission, especially Class I and Class F status, is associated with a poor prognosis despite the lack of a WRF within the first 5 days. The prognostic ability of AKI on admission may be superior to WRF within the first 5 days.