Impact of haemoconcentration during acute heart failure therapy on mortality and its relationship with worsening renal function

Fractional excretion of urea nitrogen can identify true worsening renal function in patients with heart failure

AIMS

Fractional excretion of urea nitrogen (FEUN), used to differentiate the cause of acute kidney injury, has emerged as a useful fluid index in patients with heart failure (HF). We hypothesized that FEUN could be useful in identifying worsening renal function (WRF) associated with poor outcomes in patients with acute HF (AHF).

METHODS AND RESULTS

Overall, 1103 patients with AHF (median age, 78 years; male proportion, 60%) were categorized into six groups according to the presence of WRF and FEUN values (low, ≤32.1%; medium, >32.1% and ≤38.0%; and high, >38.0%) at discharge. WRF was defined as an increase of ≥0.3 mg/dL in the serum creatinine level from admission to discharge. FEUN was calculated by the following formula: (urinary urea × serum creatinine) × 100/(serum urea × urinary creatinine). The cut-off values for low, medium, and high FEUN were based on a previous study. The primary outcome of this study was HF readmission after hospital discharge. During the 1 year follow-up, 170 HF readmissions occurred. Kaplan-Meier analysis revealed significantly higher HF readmission rates in patients with WRF than in those without WRF (log-rank test, P < 0.001). Additionally, among patients with WRF, HF readmission rates were lowest in those with medium FEUN values, followed by those with low FEUN values and those with high FEUN values. On multivariable analysis, the presence of WRF with low or high FEUN values was independently associated with increased HF readmission, as compared with the absence of WRF with medium FEUN values. Notably, no association was noted between WRF with medium FEUN values and HF readmission.

CONCLUSIONS

The prognostic impact of WRF was significantly mediated by the FEUN values and was associated with worse outcomes only when the FEUN values were either low or high. Our study suggests that FEUN can identify prognostically relevant WRF in patients with AHF.

Kidney function changes in acute heart failure: a practical approach to interpretation and management

Worsening kidney function (WKF) is common in patients with acute heart failure (AHF) syndromes. Although WKF has traditionally been associated with worse outcomes on a population level, serum creatinine concentrations vary greatly during episodes of worsening heart failure, with substantial individual heterogeneity in terms of their clinical meaning. Consequently, interpreting such changes within the appropriate clinical context is essential to unravel the pathophysiology of kidney function changes and appropriately interpret their clinical meaning. This article aims to provide a critical overview of WKF in AHF, aiming to provide physicians with some tips and tricks to appropriately interpret kidney function changes in the context of AHF.

Critical Analysis of the Effects of SGLT2 Inhibitors on Renal Tubular Sodium, Water and Chloride Homeostasis and Their Role in Influencing Heart Failure Outcomes

SGLT2 (sodium-glucose cotransporter 2) inhibitors interfere with the reabsorption of glucose and sodium in the early proximal renal tubule, but the magnitude and duration of any ensuing natriuretic or diuretic effect are the result of an interplay between the degree of upregulation of SGLT2 and sodium-hydrogen exchanger 3, the extent to which downstream compensatory tubular mechanisms are activated, and (potentially) the volume set point in individual patients. A comprehensive review and synthesis of available studies reveals several renal response patterns with substantial variation across studies and clinical settings. However, the common observation is an absence of a large acute or chronic diuresis or natriuresis with these agents, either when given alone or combined with other diuretics. This limited response results from the fact that renal compensation to these drugs is rapid and nearly complete within a few days or weeks, preventing progressive volume losses. Nevertheless, the finding that fractional excretion of glucose and lithium (the latter being a marker of proximal sodium reabsorption) persists during long-term treatment with SGLT2 inhibitors indicates that pharmacological tolerance to the effects of these drugs at the level of the proximal tubule does not meaningfully occur. This persistent proximal tubular effect of SGLT2 inhibitors can be hypothesized to produce a durable improvement in the internal set point for volume homeostasis, which may become clinically important during times of fluid expansion. However, it is difficult to know whether a treatment-related change in the volume set point actually occurs or contributes to the effect of these drugs to reduce the risk of major heart failure events. SGLT2 inhibitors exert cardioprotective effects by a direct effect on cardiomyocytes that is independent of the presence of or binding to SGLT2 or the actions of these drugs on the proximal renal tubule. Nevertheless, changes in the volume set point mediated by SGLT2 inhibitors might potentially act cooperatively with the direct favorable molecular and cellular effects of these drugs on cardiomyocytes to mediate their benefits on the development and clinical course of heart failure.

Pre-discharge and early post-discharge management of patients hospitalized for acute heart failure: A scientific statement by the Heart Failure Association of the ESC

Acute heart failure is a major cause of urgent hospitalizations. These are followed by marked increases in death and rehospitalization rates, which then decline exponentially though they remain higher than in patients without a recent hospitalization. Therefore, optimal management of patients with acute heart failure before discharge and in the early post-discharge phase is critical. First, it may prevent rehospitalizations through the early detection and effective treatment of residual or recurrent congestion, the main manifestation of decompensation. Second, initiation at pre-discharge and titration to target doses in the early post-discharge period, of guideline-directed medical therapy may improve both short- and long-term outcomes. Third, in chronic heart failure, medical treatment is often left unchanged, so the acute heart failure hospitalization presents an opportunity for implementation of therapy. The aim of this scientific statement by the Heart Failure Association of the European Society of Cardiology is to summarize recent findings that have implications for clinical management both in the pre-discharge and the early post-discharge phase after a hospitalization for acute heart failure.

Impact of the degree of worsening renal function and B-type natriuretic peptide on the prognosis of patients with acute heart failure

Background

The impact of the degree of worsening renal function (WRF) and B-type natriuretic peptide (BNP) on the prognosis of patients with acute heart failure (AHF) is still debatable. The present study investigated the influence of different degrees of WRF and BNP levels at discharge on 1-year all-cause mortality in AHF.

Methods

Hospitalized AHF patients diagnosed with acute new-onset/worsening of chronic heart failure (HF) between January 2015 and December 2019 were included in this study. Patients were assigned into high and low BNP groups based on the median BNP level at discharge (464 pg/ml). According to serum creatinine (Scr) levels, WRF was divided into non-severe WRF (nsWRF) (Scr increased ≥0.3 mg/dl and &lt;0.5 mg/dl) and severe WRF (sWRF) (Scr increased ≥0.5 mg/dl); non-WRF (nWRF) was defined as Scr increased of &lt;0.3 mg/dl). Multivariable cox regression was used to evaluate the association of low BNP value and different degrees of WRF with a all-cause death, as well as testing for an interaction between the two.

Results

Among 440 patients in the high BNP group, there was a significant difference in WRF on mortality (nWRF vs. nsWRF vs. sWRF: 22% vs. 23.8% vs. 58.8%, P &lt; 0.001). Yet, mortality did not significantly differ across the WRF subgroups in the low BNP group (nWRF vs. nsWRF vs. sWRF: 9.1% vs. 6.1% vs. 15.2%, P = 0.489). In multivariate Cox regression analysis, low BNP group at discharge (HR, 0.265; 95%CI, 0.162–0.434; P &lt; 0.001) and sWRF (HR, 2.838; 95%CI, 1.756–4.589; P &lt; 0.001) were independent predictors of 1-year mortality in AHF.There was a significant interaction between low BNP group and sWRF(HR, 0.225; 95%CI, 0.055–0.918; P &lt; 0.05).

Conclusions

nsWRF does not increase the 1-year mortality in AHF patients, whereas sWRF does. A low BNP value at discharge is associated with better long-term outcomes and mitigates the adverse effects of sWRF on prognosis.

Association between changes in loop diuretic dose and outcomes in acute heart failure

AIMS

Little is known about the association between the starting of or dose changes in loop diuretics during acute heart failure (AHF) hospitalization and post-discharge outcomes. We investigated the clinical impact of starting loop diuretics and changing the loop diuretics dose during hospitalization on post-discharge outcomes.

METHODS AND RESULTS

From the Kyoto Congestive Heart Failure registry, 3665 consecutive patients hospitalized for HF and discharged alive were included in this study. We analysed 1906 patients without loop diuretics on admission and were discharged alive and 1759 patients who received loop diuretics on admission and were discharged alive. The primary outcome measure was all-cause death. Of the 1906 patients without loop diuretics on admission, 1366 (71.7%) patients started loop diuretics during the index AHF hospitalization. Starting loop diuretics was not associated with lower post-discharge mortality [adjusted hazard ratio (HR) 0.92, 95% confidence interval (CI) 0.68-1.25]. Of the 1759 patients who received loop diuretics on admission, loop diuretic dose was decreased in 23.8%, unchanged in 44.6%, and increased in 31.6% of the patients. Changes in the dose at discharge compared with no change in dose were not associated with lower risk of post-discharge mortality (decrease relative to no change: adjusted HR 0.98, 95% CI 0.76-1.28; increase relative to no change: adjusted HR 1.00, 95% CI 0.78-1.27). Compared with no loop diuretics at discharge, a loop diuretics dose of ≥80 mg at discharge was associated with higher post-discharge mortality risk.

CONCLUSIONS

In patients with AHF, we found no association between the starting of loop diuretics and post-discharge outcomes and between dose changes and post-discharge outcomes.

Utility of fractional excretion of urea nitrogen in heart failure patients with chronic kidney disease

AIMS

Maintenance of euvolaemia with diuretics is critical in heart failure (HF) patients with chronic kidney disease (CKD); however, it is challenging because no reliable marker of volume status exists. Fractional excretion of urea nitrogen (FEUN) is a useful index of volume status in patients with renal failure. We aimed to examine whether FEUN is a surrogate marker of volume status for risk stratification in HF patients with CKD.

METHODS AND RESULTS

We examined 516 HF patients with CKD (defined as discharge estimated glomerular filtration rate < 60 mL/min/1.73 m² ) whose FEUN was measured at discharge (median age, 80 years; 58% male). The patients were divided into four groups according to quartile FEUN value at discharge: low-FEUN, FEUN ≤ 32.1; medium-FEUN, 32.1 < FEUN ≤ 38.0; high-FEUN, 38.0 < FEUN ≤ 43.7; and extremely-high-FEUN, FEUN > 43.7. FEUN was calculated by the following formula: (urinary urea × serum creatinine) × 100/(serum urea × urinary creatinine). During the 3 year follow-up, 131 HF readmissions occurred. Kaplan-Meier analysis showed that the HF readmission rate was significantly lower in the medium-FEUN group than in the other three groups (log-rank test, P = 0.029). Multivariate Cox regression analysis identified the low-FEUN, high-FEUN, and extremely-high-FEUN values as independent factors associated with post-discharge HF readmission. In the analysis of 130 patients who underwent right heart catheterization during hospitalization, a significant correlation between FEUN value and right atrial pressure was observed (R = 0.243, P = 0.005). Multivariate linear regression analysis revealed that FEUN value at discharge decreased in a dose-dependent manner with loop diuretics.

CONCLUSIONS

In HF patients with CKD, FEUN is a potential marker of volume status for risk stratification of post-discharge HF readmission. Low FEUN value (FEUN ≤ 32.1) may represent intravascular dehydration, whereas high FEUN value (FEUN > 38.0) may represent residual congestion; both of them were independent risk factors for HF readmission. FEUN may be useful to determine euvolaemia and guide fluid management in HF patients with CKD.

Renal Assessment in Acute Cardiorenal Syndrome

Cardiorenal syndrome (CRS) is a complex, heterogeneous spectrum of symptoms that has kept cardiologists awake for decades. The heart failure (HF) population being burdened with multimorbidity poses diagnostic and therapeutic challenges even for experienced clinicians. Adding deteriorated renal function to the equation, which is one of the strongest predictors of adverse outcome, we measure ourselves against possibly the biggest problem in modern cardiology. With the rapid development of new renal assessment methods, we can treat CRS more effectively than ever. The presented review focuses on explaining the pathophysiology, recent advances and current practices of monitoring renal function in patients with acute CRS. Understanding the dynamic interaction between the heart and the kidney may improve patient care and support the selection of an effective and nephroprotective treatment strategy.

How to interpret serum creatinine increases during decongestion

During decongestion in acute decompensated heart failure (ADHF), it is common to observe elevations in serum creatinine (sCr) values due to vascular congestion, a mechanism that involves increased central venous pressure that has a negative impact on the nephron, promoting greater absorption of water and sodium, increased interstitial pressure in an encapsulated organ developing "renal tamponade" which is one of main physiopathological mechanism associated with impaired kidney function. For the treatment of this syndrome, it is recommended to use diuretics that generate a high urinary output and natriuresis to decongest the venous system, during this process the sCr values can rise, a phenomenon that may bother some cardiologist and nephrologist, since raise the suspicion of kidney damage that could worsen the prognosis of these patients. It is recommended that increases of up to 0.5 mg/dL from baseline are acceptable, but some patients have higher increases, and we believe that an arbitrary number would be impractical for everyone. These increases in sCr may be related to changes in glomerular hemodynamics and true hypovolemia associated with decongestion, but it is unlikely that they are due to structural injury or truly hypoperfusion and may even have a positive connotation if accompanied by an effective decongestion and be associated with a better prognosis in the medium to long term with fewer major cardiovascular and renal events. In this review, we give a comprehensive point of view on the interpretation of creatinine elevation during decongestion in patients with ADHF.

The combined impact of hyponatremia and hematocrit on the risk for 90-day readmission and death in patients with heart failure: dilutional hyponatremia versus depletional hyponatremia

BACKGROUND

Hyponatremia is common in hospitalized patients with heart failure (HF) and predicts a poor prognosis after discharge. In general, hyponatremia can be divided into two types: dilutional or depletional.

OBJECTIVE

Assess the impact of hyponatremia type on short-term outcomes.

DESIGN

Retrospective cohort SETTINGS: Single center in China PATIENTS AND METHODS: We sorted patients by hyponatremia into two types: dilutional hyponatremia (DiH, with hematocrit <35%) and depletional hyponatremia (DeH, with hematocrit ≥35%). The Kaplan-Meier method and Cox regression analysis were used to identify the impact of hyponatremia types on the risk for 90-day readmission and death.

MAIN OUTCOME MEASURES

90-day readmission and death combined.

SAMPLE SIZE

1770 patients.

RESULTS

Hyponatremia was present in 324/1770 patients with 182 cases classified as DiH versus 142 as DeH. Kaplan-Meier analyses showed a higher incidence of poor short-term outcomes in hyponatremia compared with normonatremia (log-rank P<.001), and the risk was higher in DiH than DeH although the difference was not statistically significant (log-rank P=.656). Multivariate Cox regression analyses showed that only DiH was independently associated with short-term outcomes (HR=1.34, 95%CI: 1.02-1.77, P=.038), but not DeH (HR=1.32, 95%CI: 0.97-1.80, P=.081). Analysis of the secondary endpoints showed that DiH increased the risk of readmission but not death (HR=1.36, P=.035 for readmission; HR=1.13, P=.831 for all-cause death).

CONCLUSIONS

Low hematocrit, rather than high hematocrit, with hyponatremia was associated with a risk of 90-day readmission in patients with HF.

LIMITATIONS

Single center, nonrandomized.

CONFLICT OF INTEREST

None.

Worsening of Renal Function Among Hospitalized Patients With Acute Heart Failure: Phenotyping, Outcomes, and Predictors

OBJECTIVE

To define clinical phenotyping and its associated outcome of worsening of renal function (WRF) in hospitalized acute heart failure (AHF) patients.

PATIENTS AND METHODS

Latent class analysis was performed in 113 AHF patients who developed WRF within 72 hours in the DOSE (Diuretic Optimization Strategies Evaluation) trial (from March 2008 to November 2009) and ROSE-AHF (Renal Optimization Strategies Evaluation in Acute Heart Failure) trial (from September 2010 to March 2013) to identify potential WRF phenotypes. Clinical characteristics and outcome (in-hospital and post-discharge) were compared between different phenotypes.

RESULTS

Two WRF phenotypes were identified by latent class analysis, which we named WRF minimally responsive to diuretics (WRF-MRD) and WRF responsive to diuretics (WRF-RD). Among the population, 58 (9.5%) developed WRF-MRD and 55 (9.0%) developed WRF-RD. Patients with WRF-MRD had more comorbidities than WRF-RD. In WRF-MRD, there were an early increase in serum creatinine, a smaller amount of net fluid loss and weight loss, and a higher rate of worsening or persistent heart failure over 72 hours. In contrast, for those with WRF-RD, they had faster in-hospital net fluid loss and weight loss and a better 60-day survival after discharge even compared with patients without WRF (P=.004). Furthermore, baseline chronic obstructive pulmonary disease, diabetes, and cystatin C were independent predictors of WRF-MRD, whereas serum hemoglobin and sodium predicted WRF-RD.

CONCLUSIONS

Among hospitalized AHF patients, we identified two phenotypes of WRF with distinct response to heart failure treatment, predictors, and short-term prognosis after discharge. The results could help early differentiation of WRF phenotypes in clinical practice.

Mechanistic insights into chloride-related heart failure progression according to the plasma volume status

Aims

Two types of heart failure (HF) progression were recently proposed on the basis of an increased vs. non‐increased serum chloride concentration. The applicability of this concept to real‐world HF pathophysiology requires further investigation. The present study evaluated the mechanisms of HF progression to a different type according to changes in the estimated plasma volume status (ePVS).

Methods and results

Data from 47 patients (32% men; 78.2 ± 9.7 years of age) with stable to worsening HF (37.5 ± 16 days) were analysed. Physical examination, standard blood tests, and b‐type natriuretic peptide (BNP) measurements were conducted. The ePVS was calculated as follows: ePVS (dL/g) = [100 − haematocrit (%)]/[haemoglobin (g/dL)]. For the study subjects as a whole (n = 47), changes in the ePVS correlated positively with changes in the serum chloride concentration from stable to worsening HF (r = 0.398, P = 0.0056). When divided into two groups of worsening HF with an increased (n = 31) vs. non‐increased serum chloride concentration (n = 16), no significant baseline differences in body weight, serum logBNP, or ePVS were detected between groups. Under worsening HF, the increase in body weight (2.34 ± 1.12 vs. 2.59 ± 1.56 kg, P = 0.57) and logBNP (0.39 ± 0.30 vs. 0.54 ± 0.31 pg/mL, P = 0.13) did not differ between groups, but the increase in the ePVS was smaller in the group with a non‐increased serum chloride concentration compared with that with an increased serum chloride concentration (0.292 ± 0.49 vs. 0.653 ± 0.60 dL/g, P = 0.044). An increase in the %change in ePVS ≥ 10% was less common in patients with a non‐increased chloride concentration (37% vs. 71%, P = 0.03). Patients with a non‐increased serum chloride concentration had more HF signs (3.31 ± 0.79 vs. 2.65 ± 0.71, P = 0.005) and a higher incidence of pulmonary rales (63% vs. 16%, P = 0.0024) than those with an increased serum chloride concentration.

Conclusions

According to the changes in the ePVS, HF progression may result from a difference between two HF types (i.e. increased vs. non‐increased serum chloride concentration) in the cardiac reserve in response to a given cardiac burden by modulating plasma volume status via the possible tonicity potential of chloride.

Dose of furosemide before admission predicts diuretic efficiency and long-term prognosis in acute heart failure

AIMS

The outpatient diuretic dose is a marker of diuretic resistance and prognosis in chronic heart failure (HF). Still, the impact of the preadmission dose on diuretic efficiency (DE) and prognosis in acute HF is not fully known.

METHODS AND RESULTS

We conducted an observational and prospective study. All patients admitted for acute HF treated with intravenous diuretic and at least one criterion of congestion on admission were evaluated. Decongestion [physical examination, hemoconcentration, N-terminal pro-brain natriuretic peptide (NT-proBNP) change, and lung ultrasound], DE (weight loss and urine output per unit of 40 mg furosemide), and urinary sodium were monitored on the fifth day of admission. DE was dichotomized into high-low based on the median value. A multivariate Cox regression analysis was conducted to find predictors of HF readmission or mortality. A total of 105 patients were included between July 2017 and July 2019. Mean age was 74.5 ± 12.0 years, 64.8% were male, 33.3% had de novo HF, and mean left ventricular ejection fraction was 46 ± 17%. Median follow-up was 26 [15-35] months. Low DE based on weight loss was associated with a higher previous dose of furosemide (odds ratio [OR] 1.01 [1.00-1.02]), thiazide treatment before admission (OR 9.37 [2.19-40.14]), and lower diastolic blood pressure (OR 0.95 [0.91-0.98]) in the multivariate regression model. Only previous dose of furosemide (OR 1.01 [1.00-1.02]) and haemoglobin at admission (OR 0.76 [0.58-0.99]) were associated with low DE based on urine output in the multivariate analysis. The correlation between the previous dose of furosemide and DE based on weight loss was poor (r = -0.12; P = 0.209) and with DE based on urine output was weak to moderate (r = -0.33; P < 0.001). Low DE based on weight loss and urine output was associated with lesser decongestion measured by NT-proBNP (P = 0.011; P = 0.007), hemoconcentration (P = 0.006; P = 0.044), and lung ultrasound (P = 0.034; P = 0.029), but not by physical examination (P = 0.506; P = 0.560). Survival and event-free survival in acute decompensated HF (ADHF) were lower than in de novo HF; a preadmission dose of furosemide > 80 mg in ADHF identified patients with particularly poor prognosis (log-rank < 0.001). In ADHF, the preadmission dose of furosemide (hazard ratio [HR] 1.34 [1.08-1.67] per 40 mg) and NT-proBNP at admission (HR 1.03 [1.01-1.06] per 1000 pg/mL) were independently associated with mortality or HF readmission in the multivariate Cox regression analysis.

CONCLUSIONS

The outpatient dose of furosemide before acute HF admission predicts DE and must be taken into account when deciding on the initial diuretic dose. In ADHF, the outpatient dose of furosemide can predict long-term prognosis better than DE during hospitalization.

Integration of imaging and circulating biomarkers in heart failure: a consensus document by the Biomarkers and Imaging Study Groups of the Heart Failure Association of the European Society of Cardiology

Circulating biomarkers and imaging techniques provide independent and complementary information to guide management of heart failure (HF). This consensus document by the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) presents current evidence-based indications relevant to integration of imaging techniques and biomarkers in HF. The document first focuses on application of circulating biomarkers together with imaging findings, in the broad domains of screening, diagnosis, risk stratification, guidance of treatment and monitoring, and then discusses specific challenging settings. In each section we crystallize clinically relevant recommendations and identify directions for future research. The target readership of this document includes cardiologists, internal medicine specialists and other clinicians dealing with HF patients.

Chloride in Heart Failure Syndrome: Its Pathophysiologic Role and Therapeutic Implication

Until recently, most studies of heart failure (HF) focused on body fluid dynamics through control of the sodium and water balance in the body. Chloride has remained largely ignored in the medical literature, and in clinical practice, chloride is generally considered as an afterthought to the better-known electrolytes of sodium and potassium. In recent years, however, the important role of chloride in the distribution of body fluid has emerged in the field of HF pathophysiology. Investigation of HF pathophysiology according to the dynamics of serum chloride is rational considering that chloride is an established key electrolyte for tubulo-glomerular feedback in the kidney and a possible regulatory electrolyte for body fluid distribution. The present review provides a historical overview of HF pathophysiology, followed by descriptions of the recent attention to the electrolyte chloride in the cardiovascular field, the known role of chloride in the human body, and recent new findings regarding the role of chloride leading to the proposed ‘chloride theory’ hypothesis in HF pathophysiology. Next, vascular and organ congestion in HF is discussed, and finally, a new classification and potential therapeutic strategy are proposed according to the ‘chloride theory’.

Tricuspid regurgitation pressure gradient identifies prognostically relevant worsening renal function in acute heart failure

AIMS

Not all worsening renal function (WRF) during heart failure treatment is associated with a poor prognosis. However, a metric capable providing a prognosis of relevant WRF has not been developed. Our aim was to evaluate if a change in tricuspid regurgitation pressure gradient (TRPG) could discriminate prognostically relevant and not relevant WRF in patients with acute heart failure (AHF).

METHODS AND RESULTS

We examined 809 consecutive hospitalized patients with heart failure (78 ± 12 years, 54% male). WRF was defined as an increase in creatinine >0.3 mg and ≥25% from admission to discharge. TRPG was measured at admission and before discharge using echocardiography. The primary outcome was all-cause death within 1-year after discharge. Patients were classified as follows for analysis: no WRF and no TRPG increase (n = 523); no WRF and TRPG increase (no WRF with iTRPG, n = 170); WRF and no TRPG increase (WRF without iTRPG, n = 90); and WRF and TRPG increase (WRF with iTRPG, n = 26). A change in TRPG weakly but significantly correlated to a change in haemoglobin and haematocrit, a percent decrease in brain natriuretic peptide, and body weight reduction during the index period of hospitalization. All-cause mortality within 1 year was higher in patients with WRF and iTRPG, compared to the other three groups (P = 0.026). On Cox regression analysis, only WRF with iTRPG was associated with higher mortality (hazard ratio 4.24, P = 0.001), even after adjustment for other confounders.

CONCLUSION

An increase in TRPG may provide a marker to identify prognostically relevant WRF in patients with AHF.

Activity of the adrenomedullin system to personalise post-discharge diuretic treatment in acute heart failure

Background

Quantifying the activity of the adrenomedullin system might help to monitor and guide treatment in acute heart failure (AHF) patients. The aims were to (1) identify AHF patients with marked benefit or harm from specific treatments at hospital discharge and (2) predict mortality by quantifying the adrenomedullin system activity.

Methods

This was a prospective multicentre study. AHF diagnosis and phenotype were centrally adjudicated by two independent cardiologists among patients presenting to the emergency department with acute dyspnoea. Adrenomedullin system activity was quantified using the biologically active component, bioactive adrenomedullin (bio-ADM), and a prohormone fragment, midregional proadrenomedullin (MR-proADM). Bio-ADM and MR-proADM concentrations were measured in a blinded fashion at presentation and at discharge. Interaction with specific treatments at discharge and the utility of these biomarkers on predicting outcomes during 365-day follow-up were assessed.

Results

Among 1886 patients with adjudicated AHF, 514 patients (27.3%) died during 365-day follow-up. After adjusting for age, creatinine, and treatment at discharge, patients with bio-ADM plasma concentrations above the median (> 44.6 pg/mL) derived disproportional benefit if treated with diuretics (interaction p values < 0.001). These findings were confirmed when quantifying adrenomedullin system activity using MR-proADM (n = 764) (interaction p values < 0.001). Patients with bio-ADM plasma concentrations above the median were at increased risk of death (hazard ratio 1.87, 95% CI 1.57–2.24; p < 0.001). For predicting 365-day all-cause mortality, both biomarkers performed well, with MR-proADM presenting an even higher predictive accuracy compared to bio-ADM (p < 0.001).

Conclusions

Quantifying the adrenomedullin’s system activity may help to personalise post-discharge diuretic treatment and enable accurate risk-prediction in AHF.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00392-021-01909-9.

Arginine Vasopressin as an Important Mediator of Fluctuations in the Serum Creatinine Concentration Under Decongestion Treatment in Heart Failure Patients

Background: The mechanism underlying serum creatinine (SCr) fluctuations in heart failure (HF) patients remains unclear. This study examined mediators of SCr fluctuations under diuretic treatment in HF patients.

Methods and Results: Data from 26 HF patients were analyzed. Clinical tests included measurement of peripheral blood, blood urea nitrogen, SCr, serum and urinary electrolytes, B-type natriuretic peptide (BNP), and plasma neurohormones. Among the 26 patients recovering from worsening HF, changes in SCr were negatively correlated with changes in serum Cl, and positively correlated with changes in plasma arginine vasopressin (AVP). According to the median change in SCr, patients were divided into high (range 0.16–0.79 mg/dL; n=13) and low (range −0.35 to 0.14 mg/dL; n=13) change groups. Plasma AVP concentrations after treatment decreased in the low SCr change group and increased in the high SCr change group (−1.28±2.8 vs. 2.14±4.4 pg/mL, respectively; P=0.027). In both groups, there was no change in plasma volume, plasma BNP and norepinephrine concentrations decreased, and plasma renin activity increased after treatment. Multivariate logistic regression analysis showed a tendency towards an independent association between an increase in SCr and an increase or no change in the plasma AVP after decongestion (odds ratio 4.44; 95% confidence interval 0.81–24.3; P=0.086).

Conclusions: Plasma AVP appears to be a physiologically important mediator of SCr fluctuations under decongestion treatment in HF patients.

The renal patient seen by non-renal physicians: the kidney embedded in the 'milieu intérieur'

Chronic kidney disease is defined as a decrease in renal function or evidence of kidney injury for >3 months. This represents an oversimplification that may confuse physicians. Thus kidney function is equated to glomerular filtration rate, which represents one of multiple kidney functions. Some potentially more important renal functions are lost earlier, such as the production for the anti-ageing factor Klotho. Overall, these changes modify the emergent properties of the body, altering the relationships between different organs and systems, in a manner that is difficult to predict the response to interventions based on normal physiology concepts, as there is a novel steady state of interorgan relations. In this regard we now discuss the impact of CKD on heart failure; osteomuscular and joint pain and bone fragility and fractures; and osteosarcopaenia as seen by a cardiologist, a rheumatologist and a geriatrician.

Worsening Renal Function during Index Hospitalization Does Not Predict Prognosis in Heart Failure with Preserved Ejection Fraction Patients

INTRODUCTION

Worsening renal function (WRF) predicts poor prognosis in patients with left ventricular systolic dysfunction. The effect of WRF in heart failure with preserved ejection fraction (HFpEF) is unclear.

OBJECTIVE

The objective of this study was to determine whether WRF during index hospitalization for HFpEF is associated with increased death or readmission for heart failure.

METHODS

National Veterans Affairs electronic medical data recorded between January 1, 2002, and December 31, 2014, were screened to identify index hospitalizations for HFpEF using an iterative algorithm. Patients were divided into 3 groups based on changes in serum Cr (sCr) during this admission. WRF was defined as a rise in sCr ≥0.3 mg/dL. Group 1 had no evidence of WRF, group 2 had transient WRF, and group 3 had persistent WRF at the time of discharge.

RESULTS

A total of 10,902 patients with index hospitalizations for HFpEF were identified (mean age 72, 97% male). Twenty-nine percent had WRF during this hospital admission, with 48% showing recovery of sCr and 52% with no recovery at discharge. The mortality rate over a mean follow-up duration of 3.26 years was 72%. Compared to group 1, groups 2 and 3 showed no significant difference in risk of death from any cause (hazard ratio [HR] = 0.95 [95% confidence interval [CI]: 0.87, 1.03] and 1.02 [95% CI: 0.93, 1.11], respectively), days hospitalized for any cause (incidence density ratio [IDR] = 1.01 [95% CI: 0.92, 1.11] and 1.01 [95% CI: 0.93, 1.11], respectively), or days hospitalized for heart failure (IDR = 0.94 [95% CI: 0.80, 1.10] and 0.94 [95% CI: 0.81, 1.09], respectively) in analyses adjusted for covariates affecting renal function and outcomes.

CONCLUSIONS

While there is a high incidence of WRF during index hospitalizations for HFpEF, WRF is not associated with an increased risk of death or hospitalization. This suggests that WRF alone should not influence decisions regarding heart failure management.

Renal dysfunction in cardiovascular diseases and its consequences

It is well known that the heart and kidney and their synergy is essential for hemodynamic homeostasis. Since the early XIX century it has been recognized that cardiovascular and renal diseases frequently coexist. In the nephrological field, while it is well accepted that renal diseases favor the occurrence of cardiovascular diseases, it is not always realized that cardiovascular diseases induce or aggravate renal dysfunctions, in this way further deteriorating cardiac function and creating a vicious circle. In the same clinical field, the role of venous congestion in the pathogenesis of renal dysfunction is at times overlooked. This review carefully quantifies the prevalence of chronic and acute kidney abnormalities in cardiovascular diseases, mainly heart failure, regardless of ejection fraction, and the consequences of renal abnormalities on both organs, making cardiovascular diseases a major risk factor for kidney diseases. In addition, with regard to pathophysiological aspects, we attempt to substantiate the major role of fluid overload and venous congestion, including renal venous hypertension, in the pathogenesis of acute and chronic renal dysfunction occurring in heart failure. Furthermore, we describe therapeutic principles to counteract the major pathophysiological abnormalities in heart failure complicated by renal dysfunction. Finally, we underline that the mild transient worsening of renal function after decongestive therapy is not usually associated with adverse prognosis. Accordingly, the coexistence of cardiovascular and renal diseases inevitably means mediating between preserving renal function and improving cardiac activity to reach a better outcome.

[The use of diuretics in chronic heart failure. Position paper of the Russian Heart Failure Society]

The document focuses on key issues of diuretic therapy in CHF from the standpoint of current views on the pathogenesis of edema syndrome, its diagnosis, and characteristics of using diuretics in various clinical situations.

Proposal for New Classification and Practical Use of Diuretics According to Their Effects on the Serum Chloride Concentration: Rationale Based on the "Chloride Theory"

Currently, diuretic therapy for heart failure (HF) pathophysiology is primarily focused on the sodium and water balance. Over the last several years, however, chloride (Cl) has been recognized to have an important role in HF pathophysiology, as both a prognostic marker and a possible central factor regulating the body fluid status. I recently proposed a unifying hypothesis for HF pathophysiology, called the "chloride theory", during HF worsening and recovery, as follows. Chloride is the key electrolyte for regulating both reabsorption of tubular electrolytes and water in the kidney through the renin-angiotensin-aldosterone system and distributing body fluid in each compartment of the body. As changes between the serum Cl concentration and plasma volume are intimately associated with worsening HF and its recovery after decongestive therapy, modulation of the serum Cl concentration by careful selection and combination of various diuretics and their doses could become an attractive therapeutic option for HF. In this review, I will propose a new classification and practical use of diuretics according to their effects on the serum Cl concentration. Diuretic use according to this classification is expected to be a useful strategy for the treatment of patients with HF.

Congestion occurrence and evaluation in acute heart failure scenario: time to reconsider different pathways of volume overload

Although congestion is considered to be the main reason for hospital admission in patients with acute heart failure, a simplistic view considering idro saline retention and total body volume accumulation did not provide convincing data. Clinical congestion occurrence is often the tip of the iceberg of several different mechanisms ranging from increased filling pressure to extravascular fluid accumulation and blood flow redistribution. Therefore, the clinical evaluation is often restricted to a simple physical examination including few and inaccurate signs and symptoms. This superficial approach has led to contradictory data and patients have not been evaluated according to a more realistic clinical scenario. The integration with new diagnostic ultrasonographic and laboratory tools would substantially improve these weaknesses. Indeed, congestion could be assessed by following the most recognized HF subtypes including primitive cardiac defect, presence of right ventricular dysfunction, and organ perfusion. Moreover, there is a tremendous gap regarding the interchangeable concept of fluid retention and redistribution used with a univocal meaning. Overall, congestion assessment should be revised, considering it as either central, peripheral, or both. In this review, we aim to provide different evidence regarding the concept of congestion starting from the most recognized pathophysiological mechanisms of AHF decompensation. We highlight the fact that a better knowledge of congestion is a challenge for future investigation and it could lead to significant advances in HF treatment.

Correlation of laboratory haemoconcentration measures with filling pressures obtained via pulmonary arterial pressure sensors in ambulatory heart failure patients

AIMS

Laboratory measures of haemoconcentration correlate with invasive haemodynamics and clinical outcomes in hospitalized heart failure (HF) patients. We aimed to determine the association between haemoconcentration and haemodynamic measures in ambulatory HF patients with implantable pulmonary arterial pressure (PAP) sensors.

METHODS AND RESULTS

We reviewed ambulatory HF patients (n = 23) managed at the Brigham and Women's Hospital with implantable PAP sensors (CardioMEMS™, Abbott, Atlanta, GA, USA) who had sufficient data for serial haemodynamic-haemoconcentration correlation. The primary measures of interest were the absolute changes in haemoglobin and diastolic PAP at follow-up compared to baseline values (obtained at implantation). In 23 patients (median age 64 years, 57% with HF with preserved ejection fraction), 518 paired laboratory-haemodynamic measurements were evaluated. At a median follow-up of 27 (interquartile range 13-42) months, 17 (74%) patients had at least one hospitalization (59 total hospitalizations including 30 HF hospitalizations). For the population as a whole, diastolic PAP was negatively correlated with haemoglobin level (r = -0.09, P = 0.053). This negative correlation was more apparent when changes in haemoglobin and diastolic PAP were evaluated at the time of HF hospitalization compared to baseline values (r = -0.40, P = 0.029). The mean rise in diastolic PAP of 3.6 mmHg at HF hospitalization corresponded to a numerical decline of 0.6 g/dL in haemoglobin (P = 0.20).

CONCLUSION

Change in haemoglobin was correlated with change in diastolic PAP in ambulatory HF patients, especially at the time of HF hospitalization. These findings support the potential for investigation into the role of ambulatory monitoring of haemoglobin as an inexpensive, non-invasive tool to guide de-congestion strategies and potentially prevent HF hospitalizations.

Systematic Review of the Association Between Worsening Renal Function and Mortality in Patients With Acute Decompensated Heart Failure

Introduction

Outcomes in acute decompensated heart failure (ADHF) have remained poor. Worsening renal function (WRF) is common among patients with ADHF. However, the impact of WRF on the prognosis is controversial. We hypothesized that in patients with ADHF, the achievement of concomitant decongestion would diminish the signal for harm associated with WRF.

Methods

We performed a systematic search of PubMed, EMBASE, and the Cochrane Library up to December 2019 for studies that assessed signs of decongestion in patients with WRF during ADHF admission. The primary outcome was all-cause mortality and heart transplantation.

Results

Thirteen studies were selected with a pooled population of 8138 patients. During the follow-up period of 60–450 days, 19.2% of patients died. Unstratified, patients with WRF versus no WRF had a higher risk for mortality (odds ratio [OR], 1.71 [95% confidence interval {CI}, 1.45–2.01]; P < 0.0001). However, patients who achieved decongestion had a similar prognosis (OR, 1.15 [95% CI, 0.89–1.49]; P = 0.30). Moreover, patients with WRF who achieved decongestion had a better prognosis compared with those without WRF or decongestion (OR, 0.63 [95% CI, 0.46–0.86]; P = 0.004). This tendency persisted for the sensitivity analyses.

Conclusions

Decongestion is a powerful effect modifier that attenuates harmful associations of WRF with mortality. Future studies should not assess WRF as an endpoint without concomitant assessment of achieved volume status.

Poor prognosis of heart failure patients with in-hospital worsening renal function and elevated BNP at discharge

Aims

Our purpose was to investigate the association between the B‐type natriuretic peptide (BNP) level at discharge, the occurrence of worsening renal function (WRF), and long‐term outcomes in patients with heart failure (HF).

Methods and results

We enrolled hospitalized acute HF patients. We divided patients into four groups on the basis of BNP <250 pg/mL (BNP−) or BNP ≥250 pg/mL (BNP+) at discharge and the occurrence of WRF during admission: BNP−/WRF−, BNP−/WRF+, BNP+/WRF−, and BNP+/WRF+. We evaluated the association between BNP at discharge, WRF, and cardiovascular/all‐cause mortality/hospitalization due to HF. Clinical follow‐up was completed in 301 patients. At discharge, percentages of the patients with clinical signs of HF were low and similar among four groups. The median follow‐up period was 1206 days (interquartile range, 733–1825 days). The composite endpoint of cardiovascular mortality and HF hospitalization was significantly different between the four groups [12.9% (BNP−/WRF−), 22.7% (BNP−/WRF+), 35.8% (BNP+/WRF−), and 55.4% (BNP+/WRF+), P < 0.0001]. All‐cause mortality was also different etween the four groups (15.1%, 38.6%, 28.7%, and 39.3%, respectively, P = 0.003). In the multivariate Cox proportional hazards model, the combination of BNP ≥250 pg/mL and WRF showed the highest hazard ratio (HR) for composite endpoint (HR, 5.201; 95% confidence interval, 2.582–11.11; P < 0.0001), and BNP−/WRF+ was associated with increased all‐cause mortality (HR, 2.286; 95% confidence interval, 1.089–4.875; P = 0.03). Patients in BNP+/WRF+ had a higher cardiovascular mortality (28.6%), and those in BNP−/WRF+ had a high non‐cardiovascular mortality (29.5%).

Conclusions

Heart failure patients with BNP ≥250 pg/mL at discharge and in‐hospital occurrence of WRF had the highest risk for the composite endpoint (cardiovascular mortality and HF hospitalization) among groups.

Impact of brain natriuretic peptide reduction on the worsening renal function in patients with acute heart failure

Aims

The prognostic impact of worsening renal function (WRF) in patients with acute heart failure (AHF) remains under debate. Successful decongestion might offset the negative impact of WRF, but little is known about indicators of successful decongestion in the very acute phase of AHF. We hypothesized that decongestion as evaluated by the percent reduction in brain natriuretic peptide (BNP) could identify relevant prognostic implications of WRF in the very acute phase of AHF.

Methods and results

Data on 907 consecutive hospitalized patients with AHF in the REALITY-AHF study (age: 78±12 years; 55.1% male) were analyzed. Creatinine and BNP were measured at baseline and 48 hours from admission. WRF was defined as an increase in creatinine >0.3 mg at 48 hours from admission. The primary endpoint was 1-year all-cause mortality. Patients were divided into four groups according to the presence/absence of WRF and a BNP reduction higher/lower than the median: no-WRF/higher-BNP-reduction (n = 390), no-WRF/lower-BNP-reduction (n = 397), WRF/higher-BNP-reduction (n = 63), and WRF/lower-BNP-reduction groups (n = 57). Kaplan-Meier curve analysis showed that the WRF/lower-BNP-reduction group had a worse prognosis than the other groups. In a Cox regression analysis, only the WRF/lower-BNP-reduction group had higher mortality compared to the no-WRF/higher-BNP-reduction group (hazard ratio: 3.34, p<0.001).

Conclusion

In the very acute phase of AHF, BNP reduction may aid in identifying relevant prognostic significance of WRF.

Mortality and pathophysiology of acute kidney injury according to time of occurrence in acute heart failure

Aims

Acute kidney injury (AKI) during acute heart failure (AHF) is common and associated with increased morbidity and mortality. The underlying pathophysiological mechanism appears to have prognostic relevance; however, the differentiation of true, structural AKI from hemodynamic pseudo‐AKI remains a clinical challenge.

Methods and results

The Basics in Acute Shortness of Breath Evaluation Study (NCT01831115) prospectively enrolled adult patients presenting with AHF to the emergency department. Mortality of patients was prospectively assessed. Haemoconcentration, transglomerular pressure gradient (n = 231) and tubular injury patterns (n = 253) were evaluated to investigate pathophysiological mechanisms underlying AKI timing (existing at presentation vs. developing during in‐hospital period). Of 1643 AHF patients, 755 patients (46%) experienced an episode of AKI; 310 patients (19%; 41% of AKI patients) presented with community‐acquired AKI (CA‐AKI), 445 patients (27%; 59% of AKI patients) developed in‐hospital AKI. CA‐AKI but not in‐hospital AKI was associated with higher mortality compared with no‐AKI (adjusted hazard ratio 1.32 [95%‐CI 1.01–1.74]; P = 0.04). Independent of AKI timing, haemoconcentration was associated with a lower two‐year mortality. Transglomerular pressure gradient at presentation was significantly lower in CA‐AKI compared to in‐hospital AKI and no‐AKI (P < 0.01). Urinary NGAL ratio concentrations were significantly higher in CA‐AKI compared to in‐hospital AKI (P < 0.01) or no‐AKI (P < 0.01).

Conclusions

CA‐AKI but not in‐hospital AKI is associated with increased long‐term mortality and marked by decreased transglomerular pressure gradient and tubular injury, probably reflecting prolonged tubular ischemia due to reno‐venous congestion. Adequate decongestion, as assessed by haemoconcentration, is associated with lower long‐term mortality independent of AKI timing.

Acute heart failure: More questions than answers

Acute heart failure (AHF) is a life-threatening condition with a dramatic burden in terms of symptoms, morbidity and mortality. It is a specific syndrome requiring urgent, life-saving treatment. Multiple specific pathophysiologic mechanisms may be involved, including congestion, inflammation, and neurohormonal activation. This process eventually leads to symptoms, end-organ damage, and adverse outcomes. Clinical presentation varies, but it almost universally includes worsening of congestion associated with different degrees of hypoperfusion. Due to substantial early symptoms burden and high morbidity and mortality, patients with AHF require intensive monitoring and intravenous treatment. However, beyond variable improvement in congestion, none of the available intravenous therapies for AHF was shown to improve longer term outcomes. Although oral treatment with guideline-directed therapies for stable patients with HF and reduced ejection fraction (HFrEF) before discharge may fully prevent subsequent episodes, proof that this strategy may benefit patients is lacking. First, most patients with AHF have preserved EF (HFpEF) where no therapies have been shown to be effective. Second, all therapies developed for patients with HFrEF were tested for efficacy on outcomes in patients who were stable without recent AHF. Hence, the implementation of these chronic therapies during an AHF episode is untested. Third, the problem to better treat AHF patients in their early phase remains crucial with treatment strategies largely untested, yet. Further studies targeting AHF specific mechanisms, such as inflammation and end-organ damage, and finding effective intravenous drugs remain therefore warranted.

Renal function, electrolytes, and congestion monitoring in heart failure

Congestion, renal function, and electrolyte imbalance (particularly potassium) are common problems in the management of the complex multi-morbid patient with heart failure (HF). Poor control of these fundamental clinical features is associated with adverse outcomes. Close monitoring of serum potassium and renal function is recommended by most current guidelines during the management of an episode of acute decompensated HF, yet the recommendations remain poorly implemented. Physicians are advised to treat a state of euvolaemia after an admission with decompensated HF and residual congestion is a marker of worse outcome, yet control of congestion is poorly assessed and managed in real-world practice. This document reflects the key points discussed by a panel of experts during a Heart Failure Association meeting on physiological monitoring of the complex multi-morbid HF patient, and here, we present to aspects related to renal function, electrolyte, and congestion monitoring.

Effect of a Strategy of Comprehensive Vasodilation vs Usual Care on Mortality and Heart Failure Rehospitalization Among Patients With Acute Heart Failure: The GALACTIC Randomized Clinical Trial

IMPORTANCE

Short-term infusions of single vasodilators, usually given in a fixed dose, have not improved outcomes in patients with acute heart failure (AHF).

OBJECTIVE

To evaluate the effect of a strategy that emphasized early intensive and sustained vasodilation using individualized up-titrated doses of established vasodilators in patients with AHF.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, open-label blinded-end-point trial enrolling 788 patients hospitalized for AHF with dyspnea, increased plasma concentrations of natriuretic peptides, systolic blood pressure of at least 100 mm Hg, and plan for treatment in a general ward in 10 tertiary and secondary hospitals in Switzerland, Bulgaria, Germany, Brazil, and Spain. Enrollment began in December 2007 and follow-up was completed in February 2019.

INTERVENTIONS

Patients were randomized 1:1 to a strategy of early intensive and sustained vasodilation throughout the hospitalization (n = 386) or usual care (n = 402). Early intensive and sustained vasodilation was a comprehensive pragmatic approach of maximal and sustained vasodilation combining individualized doses of sublingual and transdermal nitrates, low-dose oral hydralazine for 48 hours, and rapid up-titration of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or sacubitril-valsartan.

MAIN OUTCOMES AND MEASURES

The primary end point was a composite of all-cause mortality or rehospitalization for AHF at 180 days.

RESULTS

Among 788 patients randomized, 781 (99.1%; median age, 78 years; 36.9% women) completed the trial and were eligible for primary end point analysis. Follow-up at 180 days was completed for 779 patients (99.7%). The primary end point, a composite of all-cause mortality or rehospitalization for AHF at 180 days, occurred in 117 patients (30.6%) in the intervention group (including 55 deaths [14.4%]) and in 111 patients (27.8%) in the usual care group (including 61 deaths [15.3%]) (absolute difference for the primary end point, 2.8% [95% CI, -3.7% to 9.3%]; adjusted hazard ratio, 1.07 [95% CI, 0.83-1.39]; P = .59). The most common clinically significant adverse events with early intensive and sustained vasodilation vs usual care were hypokalemia (23% vs 25%), worsening renal function (21% vs 20%), headache (26% vs 10%), dizziness (15% vs 10%), and hypotension (8% vs 2%).

CONCLUSIONS AND RELEVANCE

Among patients with AHF, a strategy of early intensive and sustained vasodilation, compared with usual care, did not significantly improve a composite outcome of all-cause mortality and AHF rehospitalization at 180 days.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00512759.

Highlights in heart failure

Heart failure (HF) remains a major cause of mortality, morbidity, and poor quality of life. It is an area of active research. This article is aimed to give an update on recent advances in all aspects of this syndrome. Major changes occurred in drug treatment of HF with reduced ejection fraction (HFrEF). Sacubitril/valsartan is indicated as a substitute to ACEi/ARBs after PARADIGM-HF (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.73 to 0.87 for sacubitril/valsartan vs. enalapril for the primary endpoint and Wei, Lin and Weissfeld HR 0.79, 95% CI 0.71-0.89 for recurrent events). Its initiation was then shown as safe and potentially useful in recent studies in patients hospitalized for acute HF. More recently, dapagliflozin and prevention of adverse-outcomes in DAPA-HF trial showed the beneficial effects of the sodium-glucose transporter type 2 inhibitor dapaglifozin vs. placebo, added to optimal standard therapy [HR, 0.74; 95% CI, 0.65 to 0.85;0.74; 95% CI, 0.65 to 0.85 for the primary endpoint]. Trials with other SGLT 2 inhibitors and in other patients, such as those with HF with preserved ejection fraction (HFpEF) or with recent decompensation, are ongoing. Multiple studies showed the unfavourable prognostic significance of abnormalities in serum potassium levels. Potassium lowering agents may allow initiation and titration of mineralocorticoid antagonists in a larger proportion of patients. Meta-analyses suggest better outcomes with ferric carboxymaltose in patients with iron deficiency. Drugs effective in HFrEF may be useful also in HF with mid-range ejection fraction. Better diagnosis and phenotype characterization seem warranted in HF with preserved ejection fraction. These and other burning aspects of HF research are summarized and reviewed in this article.

Prognostic Significance of Creatinine Increases During an Acute Heart Failure Admission in Patients With and Without Residual Congestion: A Post Hoc Analysis of the PROTECT Data

BACKGROUND

The importance of a serum creatinine increase, traditionally considered worsening renal function (WRF), during admission for acute heart failure has been recently debated, with data suggesting an interaction between congestion and creatinine changes.

METHODS AND RESULTS

In post hoc analyses, we analyzed the association of WRF with length of hospital stay, 30-day death or cardiovascular/renal readmission and 90-day mortality in the PROTECT study (Placebo-Controlled Randomized Study of the Selective A1 Adenosine Receptor Antagonist Rolofylline for Patients Hospitalized With Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function). Daily creatinine changes from baseline were categorized as WRF (an increase of 0.3 mg/dL or more) or not. Daily congestion scores were computed by summing scores for orthopnea, edema, and jugular venous pressure. Of the 2033 total patients randomized, 1537 patients had both available at study day 14. Length of hospital stay was longer and 30-day cardiovascular/renal readmission or death more common in patients with WRF. However, these were driven by significant associations in patients with concomitant congestion at the time of assessment of renal function. The mean difference in length of hospital stay because of WRF was 3.51 (95% confidence interval, 1.29-5.73) more days (P=0.0019), and the hazard ratio for WRF on 30-day death or heart failure hospitalization was 1.49 (95% confidence interval, 1.06-2.09) times higher (P=0.0205), in significantly congested than nonsignificantly congested patients. A similar trend was observed with 90-day mortality although not statistically significant.

CONCLUSIONS

In patients admitted for acute heart failure, WRF defined as a creatinine increase of ≥0.3 mg/dL was associated with longer length of hospital stay, and worse 30- and 90-day outcomes. However, effects were largely driven by patients who had residual congestion at the time of renal function assessment.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifiers: NCT00328692 and NCT00354458.

New treatments for hyperkalaemia: clinical use in cardiology

Hyperkalaemia causes significant burden, and even mild hyperkalaemia has been independently associated with increased morbidity and mortality. Patients with chronic disease states, such as heart failure, hypertension, chronic kidney disease and diabetes mellitus, are increasingly susceptible to the development of hyperkalaemia. Options for management of hyperkalaemia had mainly been limited to short-term, temporizing methods with focus on rapid achievement of normokalaemia. Until recently, there was a lack of safe, efficacious and well-tolerated therapies for long-term management. Two novel potassium binders, patiromer and sodium zirconium cyclosilicate, have recently been approved by the US Food and Drug Administration for the management of hyperkalaemia. This review discusses these potassium binders with focus largely on the clinical implications of these agents in patients with chronic cardiovascular conditions.

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.

The use of diuretics in heart failure with congestion - a position statement from the Heart Failure Association of the European Society of Cardiology

The vast majority of acute heart failure episodes are characterized by increasing symptoms and signs of congestion with volume overload. The goal of therapy in those patients is the relief of congestion through achieving a state of euvolaemia, mainly through the use of diuretic therapy. The appropriate use of diuretics however remains challenging, especially when worsening renal function, diuretic resistance and electrolyte disturbances occur. This position paper focuses on the use of diuretics in heart failure with congestion. The manuscript addresses frequently encountered challenges, such as (i) evaluation of congestion and clinical euvolaemia, (ii) assessment of diuretic response/resistance in the treatment of acute heart failure, (iii) an approach towards stepped pharmacologic diuretic strategies, based upon diuretic response, and (iv) management of common electrolyte disturbances. Recommendations are made in line with available guidelines, evidence and expert opinion.

Worsening renal function during decongestion among patients hospitalized for heart failure: Findings from the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial

INTRODUCTION

Worsening renal function (WRF) can occur throughout a hospitalization for acute heart failure (HF). However, decongestion can be measured in different ways and the prognostic implications of WRF in the setting of different measures of decongestion are unclear.

METHODS

Patients (N = 433) from the ESCAPE were classified by measures of decongestion during hospitalization: hemodynamic (right atrial pressure ≤8 mmHg and/or wedge pressure ≤15 mmHg at discharge), clinical (≤1 sign of congestion at discharge), hemoconcentration (any increase in hemoglobin) and estimated plasma volume using the Hakim formula (5% reduction in plasma volume). WRF was defined as creatinine increase ≥0.3 mg/dl during hospitalization. The association between WRF and 180-day all-cause death was assessed.

RESULTS

Successful decongestion was observed in 124 (60%) patients by hemodynamics, 204 (49%) by clinical exam, 173 (47%) by hemoconcentration, and 165 (45%) by plasma volume. There was no agreement between the hemodynamic assessment and other decongestion measures in up to 43% of cases. Persistent congestion with concomitant WRF at discharge was associated with worse outcomes compared to patients without congestion and WRF. Among patients decongested at discharge, in-hospital WRF was not significantly associated with 180-day all-cause death, when using hemodynamic, clinical or estimated plasma volume as measures of decongestion (P > .05 for all markers).

CONCLUSIONS

In patients hospitalized for HF, although there was disagreement across common measures of decongestion, in-hospital WRF was not associated with increased hazard of all-cause mortality among patients successfully decongested at discharge.

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.

Hyponatremia in Acute Heart Failure in Relation to Hematocrit Levels: Clinical Relevance and Prognostic Implication

BACKGROUND

Hyponatremia is the most common electrolyte abnormality found in hospitalized patients with acute heart failure (AHF) and is related to poor prognosis. This study sought to evaluate: (1) the different prognostic impact of dilutional versus depletional hyponatremia, evaluating short- and long-term outcome; (2) the relationship between both types of hyponatremia and intravenous furosemide dose, renal function changes, and persistent congestion at discharge.

METHODS

This retrospective single-center study included 233 consecutive patients with a primary diagnosis of AHF. Hyponatremia was defined as serum sodium < 135 mEq/L, which could be either dilutional (hematocrit < 35%) or depletional (hematocrit ≥35%). Persistent congestion was defined as a congestion score ≥2 at discharge. Patients were followed 180 days for occurrence of death or rehospitalization for AHF.

RESULTS

Hyponatremia was present in 68/233 patients with 27 cases classified as dilutional hyponatremia versus 41 as depletional. The proportion of patients with persistent congestion was higher in the dilutional hyponatremia group, but similar in the depletional hyponatremia group (52 vs. 81 vs. 58%; p = 0.02). After adjustment for important baseline characteristics, dilutional hyponatremia was significantly associated with the risk of death or rehospitalization for AHF at 60 days (HR 2.17 [1.08-4.37]; p = 0.03) and 180 days (HR 1.88 [1.10-3.21]; p = 0.02). In contrast, depletional hyponatremia was only significantly associated with the same endpoint at 180 days (HR 1.64 [1.05-2.57]; p = 0.03).

CONCLUSIONS

Low hematocrit levels in AHF patients with hyponatremia characterize a population that is more difficult to decongest and has poor clinical outcome. In contrast, patients with hyponatremia but normal hematocrit are better decongested and have better short-term outcome.

Increased Urinary Liver-Type Fatty Acid-Binding Protein Level Predicts Worsening Renal Function in Patients With Acute Heart Failure

BACKGROUND

Urinary liver-type fatty acid-binding protein (L-FABP) is a potential biomarker for acute kidney injury, and it in turn increases cardiovascular mortality. We tested whether the urinary L-FABP level predicted short- and mid-term outcomes in patients with acute heart failure.

METHODS AND RESULTS

We enrolled consecutive patients with acute heart failure, and measured their urinary L-FABP levels before acute treatment. Worsening renal function (WRF), defined as both an absolute increase in the serum creatinine level of ≥0.3mg/dL and a ≥25% relative increase in its level from baseline, occurred in 37 (26.8%) of 138 patients. Patients with a urinary L-FABP level above the upper normal limit (8.4 µg/g creatinine) (n = 49; 35.5%) were more likely than those with a urinary L-FABP level within normal limits (n = 89; 64.5%) to develop WRF (n = 26 [53.1%] vs n = 11 [12.4%]; P < .001). A urinary L-FABP level above the upper limit was independently associated with WRF (hazard ratio 1.8; P = .01). During 1 year of follow-up, 12 patients (8.7%) died, and urinary L-FABP level had no association with all-cause mortality. There was, however, a tendency toward a higher readmission rate in patients with a urinary L-FABP level above the upper normal limit who survived the index hospitalization (n = 46) than in those without an abnormal L-FABP level (n = 88; n = 13 [28.3%] vs n = 13 [14.8%]; log-rank P = .06).

CONCLUSIONS

Increased urinary L-FABP level before treatment may predict WRF in patients with acute heart failure. Further investigation is warranted for its predictive ability of adverse outcomes.