Clinical significance of heart rate during acute decompensated heart failure to predict left ventricular reverse remodeling and prognosis in response to therapies in nonischemic dilated cardiomyopathy

Peri-Procedural Blood Pressure Changes and Their Relationship with MACE in Patients Undergoing Percutaneous Coronary Intervention: A Cross-Sectional Study

Background

Peri-procedural blood-pressure (BP) changes were investigated and correlated to Major adverse cardiovascular events (MACE) as predictor of outcome for patients undergoing percutaneous coronary intervention (PCI); whether acute coronary syndrome (Unstable angina, or MI; STEMI or NSTEMI) or scheduled for elective PCI.

Methods

Resting BP in the 204 recruited patients undergoing PCI throughout 2018 was measured thrice – in the ward before transferring to the cardiac catheterization lab (cath lab), in the cath lab, and after transfer to the recovery room. Patients were categorized based on their systolic and diastolic BP peri-procedural difference as systolic (SBP): with a large difference (>20 mmHg, n=47), with a small difference (≤20 mmHg, n=157) (shock patients excluded); diastolic (DBP): with a large difference (>10 mmHg, n=65), and with a small difference (≤10 mmHg, n=139). The primary end-points were MACE including all-cause mortality, non-fatal myocardial infarction, and stroke during the hospital stay. The Mann–Whitney U and Chi-square tests were used to analyze the data accordingly (p<0.005).

Results

Within the category of MACE, cardiac mortality was the only adverse cardiac event encountered in the study sample. Cardiac mortality was significantly higher in both the large SBP-difference group versus the other group (10.6% vs 0.6%, p=0.003) and the large DBP-difference group versus the small-difference group (7.7% vs 0.7%, p=0.013).

Conclusion

Peri-procedural systolic and diastolic BP differences, greater than 20 mmHg and 10 mmHg, respectively, correlated with MACE in all patients undergoing PCI.

Heart rate at discharge in patients with acute decompensated heart failure is a predictor of mortality

Aims

Heart failure is a syndrome with increasing prevalence in concordance with the aging population and better survival rates from myocardial infarction. Morbidity and mortality are high in chronic heart failure patients, particularly in those with hospital admission for acute decompensation. Several risk stratification tools and score systems have been established to predict mortality in chronic heart failure patients. However, identification of patients at risk with easy obtainable clinical factors that can predict mortality in acute decompensated heart failure (ADHF) are needed to optimize the care-path.

Methods and results

We retrospectively analyzed electronic medical records of 78 patients with HFrEF and HFmrEF who were hospitalized with ADHF in the Heart Center of the University Hospital Cologne in the year 2011 and discharged from the ward after successful treatment. 37.6 ± 16.4 months after index hospitalization 30 (38.5%) patients had died. This mortality rate correlated well with the calculated predicted survival with the Seattle Heart Failure Model (SHFM) for each individual patient. In our cohort, we identified elevated heart rate at discharge as an independent predictor for mortality (p = 0.016). The mean heart rate at discharge was lower in survived patients compared to patients who died (72.5 ± 11.9 vs. 79.1 ± 11.2 bpm. Heart rate of 77 bpm or higher was associated with an almost doubled mortality risk (p = 0.015). Heart rate elevation of 5 bpm was associated with an increase of mortality of 25% (p = 0.022).

Conclusions

Patients hospitalized for ADHF seem to have a better prognosis, when heart rate at discharge is < 77 bpm. Heart rate at discharge is an easily obtainable biomarker for risk prediction of mortality in HFrEF and HFmrEF patients treated for acute cardiac decompensation. Taking into account this parameter could be useful for guiding treatment strategies in these high-risk patients. Prospective data for validation of this biomarker and specific intervention are needed.

Evaluation of ivabradine in left ventricular dyssynchrony and reverse remodeling in patients with chronic heart failure

OBJECTIVES

Ivabradine is a pharmacological agent used in patients with heart failure and sinus rhythm. Its only known pharmacological effect is to slow the heart rate. In this study, we investigated the impact of ivabradine on dyssynchrony parameters in heart failure patients.

METHODS

In this study, we assigned 55 patients taking medication for heart failure to receive ivabradine in addition (Group I). Twenty healthy volunteers comprised Group II. Echocardiographic measurements (dyssynchrony, left ventricular volumes and left ventricular ejection fraction) were taken at baseline, 1 month, and 3 months.

RESULTS

A total of 32 heart failure patients in Group I completed the study. There was significant improvement in dyssynchrony parameters after ivabradine treatment in Group I. Interventricular dyssynchrony (IVD) decreased from 42.0 ± 24.4 milliseconds at baseline to 33.6 ± 20.7 milliseconds at 1 month (P = .001) and to 30.7 ± 19.4 milliseconds at 3 months (P < .001). Septal to posterior wall motion delay decreased from 90.3 ± 21.4 milliseconds to 83.9 ± 26.9 milliseconds (P = .011) at 1 month and to 81.5 ± 27.3 milliseconds at 3 months (P = .001). Septal to lateral Ts delay (Ts-SL) decreased from 42.7 ± 24.5 milliseconds to 35.8 ± 22.6 milliseconds at 1 month (P < .001) and to 34.8 ± 22.4 milliseconds at 3 months (P = .002). Left ventricular end-systolic volume (LVESV) decreased from 139.4 ± 42.2 mL to 135.3 ± 39.6 mL at 1 month (P = .006) and to 123.3 ± 39.5 mL at 3 months (P < .001).

CONCLUSION

The addition of ivabradine to heart failure treatment improves cardiac dyssynchrony parameters in chronic systolic heart failure patients with sinus rhythm.

Prognostic significance of brain-derived neurotrophic factor levels in patients with heart failure and reduced left ventricular ejection fraction

Objective:

Brain-derived neurotrophic factor (BDNF) is a member of the neurotrophin family. The aim of the present study was to investigate the relationship between BDNF levels and prognostic markers in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF), considering death or rehospitalization due to HF.

Methods:

Patients with severe left ventricular systolic dysfunction (LVEF ≤35%) and individuals with no history of cardiac disease (control group) were included in the study conducted between 2013 and 2017. Of the included patients, 52 were classified as mildly symptomatic [New York Heart Association (NYHA) I–II], and 108 were classified as severely symptomatic (NYHA III). The control group comprised 50 individuals. The primary endpoints of the study consisted of cardiovascular death during long-term follow-up and hospitalization for worsening of HF.

Results:

The mean age of the patient group was 67.60±11.45 years and 58% were male, whereas that of the control group was 66.28±11.30 years and 48% were male. The N-terminal pro-brain-type natriuretic peptide (NT-pro-BNP) serum levels in patients with HF were higher, whereas the BDNF values were lower than those in the control group (NT-pro-BNP: 5010±851 pg/mL vs. 33±11 pg/mL, p<0.001; BDNF: 8.64±1.12 ng/mL vs. 17.58±4.51 ng/mL, p<0.001). Multivariable analysis suggested that there was a significant association between BDNF levels and clinical status, generating the primary endpoints of death [BDNF levels: Odds ratio (OR)=0.17, 95% confidence interval (CI): 0.05–0.53, p=0.002], and rehospitalization (BDNF levels: OR=0.702, 95%CI: 0.54–0.92, p=0.010).

Conclusion:

Decreased serum BDNF levels were associated with death and rehospitalization in patients with HF, suggesting that these levels can be useful prognostic biomarkers.

Heart rate at first postdischarge visit and outcomes in patients with heart failure

Objective

Heart rate control is important to prevent adverse outcomes in patients with heart failure (HF). However, postdischarge activity may worsen heart rate control, resulting in readmission. This study aimed to explore the implications of the heart rate differences between discharge and the first outpatient visit (D-O diff).

Methods

We retrospectively identified 458 patients (male: 46%; mean age: 72 years) discharged after HF. The heart rates at admission, discharge and first outpatient visit were analysed. The primary outcome was a composite of cardiovascular (CV) death and readmission of non-fatal myocardial infarction (MI), non-fatal stroke or non-fatal HF over a mean follow-up of 16 months.

Results

During follow-up, the clinical outcomes were noted in 223 patients (49%): HF, 199; stroke, 9; MI, 6; CV death, 9. The heart rate at the first outpatient visit (r=−0.311, P<0.001) and D-O diff (r=0.416, P<0.001) showed a better correlation with the time-to-clinical event than the heart rate at admission or discharge. The events group displayed a pronounced heart rate increase (13 beats/min) from discharge to the first outpatient visit compared with the event-free group (a decrease of 2 beats/min). A decrease less than −15 in the D-O diff showed a 4.5-fold risk of clinical outcomes during follow-up (P<0.001).

Conclusions

A decreased D-O diff was related to the adverse outcomes of HF. The failure of heart rate control within more than 15 beats/min at the first outpatient visit was an independent factor for CV events.

Hemodynamic, management, and outcomes of patients admitted to emergency department with heart failure

Background

Heart failure is one of the leading reasons for hospitalization in developed countries. Our goal was to describe the hemodynamic vital signs (heart rate and systolic blood pressure) of patients presenting to the emergency department (ED) with heart failure and to describe the frequency of adverse events for patients presenting with various heart rate and systolic blood pressure values.

Method

We conducted two prospective cohort studies of heart failure conducted at six Canadian teaching hospital sites and this study was a secondary analysis of these data. The primary outcome was serious adverse events defined as death from any cause within 30 days of the ED visit or any complication following within 14 days of the index ED visit.

Results

We included a convenience sample of adults > 50 years of age who presented with acute shortness of breath or new-onset heart failure. In total, 1,638 patients were included in this analysis. Patients with heart rates < 50 % MHR (maximal heart rate) and systolic blood pressure (SBP) > 140 mmHg had the lowest rate of serious adverse events (6 %). patients with heart rates > 75 % MHR had the highest rate of serious adverse events, regardless of the SBP. Among patients with heart rates > 75 % MHR, the proportion of serious adverse events decreased as SBP increased (30 % when SBP < 120 mmHg, 24 % when SBP between 120 and 140 mmHg, and 21 % when SBP > 140 mm Hg). Patients with heart rates < 50 % MHR and with SBP > 140 mm Hg had the lowest rate of admissions to hospital (38 %).

Conclusions

We found a relatively high frequency of serious adverse events among patients who present to the ED with heart failure, particularly among the patients having low systolic blood pressure and high heart rate.

Prognostic value of diastolic wall strain in patients with chronic heart failure with reduced ejection fraction

Left ventricular (LV) diastolic dysfunction plays a crucial role in heart failure with reduced ejection fraction (HFrEF). LV stiffness is a main component of diastolic function, but its role and prognostic value in HFrEF patients remains unclear. This study aimed to determine whether diastolic wall strain (DWS) as a noninvasive and simple marker of LV stiffness can predict the prognosis of HFrEF patients who were administrated chronic beta blockade enough. We enrolled 75 HFrEF patients who were administrated chronic beta blockade. We evaluated the echocardiographic parameters and plasma brain natriuretic peptide (BNP) before the induction of beta blockade and also obtained pulmonary artery wedge pressure (PAWP) from the right heart catheterization. DWS was obtained from standard M-mode echocardiography as follows: DWS = [(LV posterior wall thickness (LVPWT) at end-systole - LVPWT at end-diastole)/LVPWT] at end-systole. DWS did not correlate with other echocardiographic parameters and PAWP. We defined primary outcome as HF hospitalization or cardiovascular death and followed for 7 years. The incidence rate was higher in low DWS than high DWS patients (p = 0.04). Other echocardiographic parameters could not be significant predictors of HFrEF outcome under the condition of enough beta blocker therapy. In multivariate analysis, DWS was the independent contributor to the event-free time. Impaired LV stiffness evaluated with DWS was associated with worse outcome and DWS might be an independent prognostic factor in HFrEF patients with chronic beta blockade.

Ivabradine treatment prevents dobutamine-induced increase in heart rate in patients with acute decompensated heart failure

BACKGROUND

Ivabradine is a heart rate (HR)-lowering agent acting by inhibiting the If-channel. Dobutamine does increase the HR and has some deleterious effects on myocardium. So, we aimed to evaluate whether ivabradine treatment blunts a dobutamine-induced increase in HR.

METHODS

The main study population consisted of 58 acute decompensated heart failure patients requiring inotropic support with left-ventricular ejection fraction below 35%, who were randomized to ivabradine (n = 29) or control (n = 29). All patients underwent Holter recording for 6 h and then dobutamine was administered at incremental doses of 5, 10 and 15 μg/kg/min, with 6-h steps. Holter recording was continued during dobutamine infusion. Ivabradine 7.5 mg was given at the initiation of dobutamine and readministered at 12 h of infusion. Also, a nonrandomized beta-blocker group with 15 patients receiving beta-blocker was included in the analysis. Control and beta-blocker groups did not receive ivabradine.

RESULTS

In the control group, mean HR gradually and significantly increased at each step of dobutamine infusion (81 ± 11, 90 ± 16, 97 ± 14 and 101 ± 16 b.p.m., respectively; P = 0.001), whereas no significant increase in HR was observed in the ivabradine group (82 ± 17, 82 ± 15, 85 ± 14 and 83 ± 12 b.p.m., respectively; P = 0.439). Mean HR was also found to significantly increase during dobutamine infusion in the beta-blocker group (75 ± 13, 82 ± 13, 86 ± 14 and 88 ± 13 b.p.m., respectively; P = 0.001). The median increase in HR from baseline was significantly higher in the control group compared to those in the ivabradine group (5 vs. 2 b.p.m.; P = 0.007 at first step, 13 vs. 5 b.p.m.; P = 0.001 at second step and 18 vs. 6 b.p.m.; P = 0.0001 at third step of dobutamine, respectively).

CONCLUSIONS

Ivabradine treatment prevents dobutamine-induced increase in HR and may be useful in reducing HR-related adverse effects of dobutamine.

Is there a heart rate paradox in acute heart failure?

BACKGROUND

Higher heart rate predicts higher mortality in chronic heart failure (HF). We studied the prognostic impact of admission heart rate in acute HF and analysed the importance of its change during hospitalization.

METHODS

Acute HF patients were studied. Endpoint was all-cause death. Patients were followed-up for 12 months from hospital admission. Cox-regression analysis was used to study the association of heart rate (both as a continuous and as a categorical variable) with mortality. Analysis was stratified according to admission rhythm and to systolic dysfunction. Multivariate models were built. Patients surviving hospitalization were additionally cross-classified attending to admission and discharge heart rates – cut-offs: 100 and 80 beats per minute (bpm), respectively.

RESULTS

We analysed 564 patients. Median age was 78 years and median admission heart rate 87 bpm. In a 12-month period 205 patients died, 23 in-hospital. Mortality increased steadily with heart rate decrease. Patients with heart rate ≥ 100 bpm had a multivariate-adjusted HR of 12-month death of 0.57 (95%CI: 0.39-0.81), and the HR was 0.92 (0.85-0.98) per 10 bpm increase in heart rate. Association of heart rate with mortality was stronger in patients in sinus rhythm (SR) and in those with systolic dysfunction. Eighty-seven patients had admission heart rate ≥ 100 and discharge heart rate < 80 bpm. In them, death rate was 14.9%; in the remaining patients it was 37.7%.

CONCLUSIONS

Higher admission heart rate predicted survival advantage in acute HF. Patients presenting with tachycardia and discharged with a controlled heart rate had better outcome than those admitted non-tachycardic or discharged with a non-controlled heart rate.

Effect of Ginkgo biloba extract on experimental cardiac remodeling

Background

To investigate the ameliorated effects of an extract of Ginkgo biloba extract (GBE) on experimental cardiac remodeling in rats induced by acute cardiac infarction, and further explore the mechanism concentrated on myocardial type I collagen, transforming growth factor beta 1 (TGF-β1), matrix metalloproteinase 2 (MMP-2) and matrix metalloproteinase 9 (MMP-9), and provide the experimentaldata for clinical application of GBE.

Methods

Rats were divided into five groups (n = 20) as following: sham operation group (group A), acute myocardial infarction model group (group B), acute myocardial infarction model + aspirin (10 mg/kg) treatment group (group C), acute myocardial infarction model + captopril (20 mg/kg) treatment group (group D) and acute myocardial infarction model + Ginkgo biloba extract (100 mg/kg) treatment group (group E). The rat acute myocardial infarction model was reproduced by ligaturing the left anterior descending artery excluding the sham operation group which did not ligation only completed the operational process. Each group was further subdivided into treatment regimens lasting 4 weeks and 8 weeks. Immunohistochemistry and real-time polymerase chain reaction (PCR) methods were used to detect the protein expression and mRNA transcriptional levels of rat myocardial TGF-β1, type I collagen, MMP-2 and MMP-9.

Results

Compared with group B, regardless of the length of treatment (4 or 8 weeks), the TGF-β1, MMP-2 and MMP-9 mRNA transcriptional levels, and the protein expression levels of type I collagen, MMP-2 and MMP-9 in groups D, C and E were significantly decreased (P < 0.01). Furthermore, the mRNA expression levels of TGF-β1 in groups D, C and E were significantly lower after 8 weeks compared to after 4 weeks (P < 0.01), as were the expression levels of type I collagen in groups D, C and E (P < 0.05). There was no statistically significant difference in the protein expression levels of MMP-2 and MMP-9 between groups E and C.

Conclusions

GBE could inhibit experimental rat myocardial remodeling after acute myocardial infarction via reduced transcription of TGF-β1, MMP-2 and MMP-9 genes and by the decreased expression of type I collagen, MMP-2 and MMP-9 proteins in myocardial cells.

Electronic supplementary material

The online version of this article (doi:10.1186/s12906-015-0719-z) contains supplementary material, which is available to authorized users.

Changes in collagen metabolism account for ventricular functional recovery following beta-blocker therapy in patients with chronic heart failure

While beta blockade improves left ventricular (LV) function in patients with chronic heart failure (CHF), the mechanisms are not well known. This study aimed to examine whether changes in myocardial collagen metabolism account for LV functional recovery following beta-blocker therapy in 62 CHF patients with reduced ejection fraction (EF). LV function was echocardiographically measured at baseline and 1, 6, and 12 months after bisoprolol therapy along with serum markers of collagen metabolism including C-terminal telopeptide of collagen type I (CITP) and matrix metalloproteinase (MMP)-2. Deceleration time of mitral early velocity (DcT) increased even in the early phase, but LVEF gradually improved throughout the study period. Heart rate (HR) was reduced from the early stage, and CITP gradually decreased. LVEF and DcT increased more so in patients with the larger decreases in CITP (r = -0.33, p < 0.05; r = -0.28, p < 0.05, respectively), and HR (r = -0.31, p < 0.05; r = -0.38, p < 0.05, respectively). In addition, there were greater decreases in CITP, MMP-2 and HR from baseline to 1, 6, or 12 months in patients with above-average improvement in LVEF than in those with below-average improvement in LVEF. Similar results were obtained in terms of DcT. There was no significant correlation between the changes in HR and CITP. In conclusion, improvement in LV systolic/diastolic function was greatest in patients with the larger inhibition of collagen degradation. Changes in myocardial collagen metabolism are closely related to LV functional recovery somewhat independently from HR reduction.

Differences in ward-to-cath lab systolic blood pressure predicts long-term adverse outcomes after drug-eluting stent implantation

We sought to investigate the effect of ward-to-cath lab blood pressure (BP) differences on long-term clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stent (DES). There are limited data available on the association between PCI with DES and BP differences on long-term clinical outcomes. This study enrolled 994 patients who underwent PCI with DES from March 2003 to August 2007. Resting BP was measured in a ward environment before transfer to the cardiac catheterization lab (cath lab), and again when the patient was laid down on the cath lab table. Patients were divided into two groups according to the difference in ward-to-cath lab systolic BP. Large difference group (n = 383) was defined as the absolute systolic difference of >20 mmHg and small difference group (n = 424) as the absolute systolic difference of ≤20 mmHg. The primary endpoints were all-cause mortality, cardiac death, nonfatal myocardial infarction and stroke. A total of 807 patients (mean age 60 ± 10 years, 522 males) received follow-up for 5.1 ± 2.4 years. The rate of all-cause mortality was significantly higher in the large difference group compared to the small difference group (6.6 vs. 2.8 %; adjusted hazard ratio (HR) 2.43; 95 % confidence interval (CI) 1.22-4.83; p = 0.012). There were higher cardiac deaths seen in the large difference group compared to the small difference group (3.9 vs. 1.4 %; adjusted HR 2.84; 95 % CI 1.1-7.31; p = 0.031). Stroke (2.4 vs. 1.2 %, p = 0.125) and TVR (3.7 vs. 1.7 %, p = 0.051) had higher trends in the large difference group compared to the small difference group. The composite of primary endpoints (all-cause mortality, cardiac death, nonfatal MI and stroke) occurred more frequently in the large difference group compared to the small difference group (10.0 vs. 6.4 %; adjusted HR 1.71; 95 % CI 1.04-2.81; p = 0.033). A difference in ward-to-cath lab systolic BP of >20 mmHg may contribute to increased adverse outcomes in the form of all-cause mortality and cardiac deaths in patients undergoing PCI with DES.

New scoring system (APACHE-HF) for predicting adverse outcomes in patients with acute heart failure: evaluation of the APACHE II and Modified APACHE II scoring systems

BACKGROUND

No scoring system for assessing acute heart failure (AHF) has been reported.

METHODS AND RESULTS

Data for 824 AHF patients were analyzed. The subjects were divided into an alive (n=750) and a dead group (n=74). We constructed a predictive scoring system based on eight significant APACHE II factors in the alive group [mean arterial pressure (MAP), pulse, sodium, potassium, hematocrit, creatinine, age, and Glasgow Coma Scale (GCS); giving each one point], defined as the APACHE-HF score. The patients were assigned to five groups by the APACHE-HF score [Group 1: point 0 (n=70), Group 2: points 1 and 2 (n=343), Group 3: points 3 and 4 (n=294), Group 4: points 5 and 6 (n=106), and Group 5: points 7 and 8 (n=11)]. A higher optimal balance was observed in the APACHE-HF between sensitivity and specificity [87.8%, 63.9%; area under the curve (AUC)=0.779] at 2.5 points than in the APACHE II (47.3%, 67.3%; AUC=0.558) at 17.5 points. The multivariate Cox regression model identified belonging to Group 5 [hazard ratio (HR): 7.764, 95% confidence interval (CI) 1.586-38.009], Group 4 (HR: 6.903, 95%CI 1.940-24.568) or Group 3 (HR: 5.335, 95%CI 1.582-17.994) to be an independent predictor of 3-year mortality. The Kaplan-Meier curves revealed a poorer prognosis, including all-cause death and HF events (death, readmission-HF), in Group 5 and Group 4 than in the other groups, in Group 3 than in Group 2 or Group 1, and in Group 2 than in Group 1.

CONCLUSIONS

The new scoring system including MAP, pulse, sodium, potassium, hematocrit, creatinine, age, and GCS (APACHE-HF) can be used to predict adverse outcomes of AHF.

Baseline cardiac magnetic resonance imaging versus baseline endomyocardial biopsy for the prediction of left ventricular reverse remodeling and prognosis in response to therapy in patients with idiopathic dilated cardiomyopathy

Endomyocardial biopsy (EMB) and late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) imaging performed at baseline are both used to evaluate the extent of myocardial fibrosis. However, no study has directly compared the effectiveness of these diagnostic tools in the prediction of left ventricular reverse remodeling (LVRR) and prognosis in response to therapy in patients with idiopathic dilated cardiomyopathy (IDCM). Seventy-five patients with newly diagnosed IDCM who were undergoing optimal therapy were assessed at baseline using LGE-CMR imaging and EMB; the former measured LGE area and the latter measured collagen volume fraction (CVF) as possible predictive indices of LVRR and cardiac event-free survival. Among all the baseline primary candidate factors with P < 0.2 as per univariate analysis, multivariate analysis indicated that only LGE area was an independent predictor of subsequent LVRR (β = 0.44; 95 % confidence interval (CI) 0.87–2.53; P < 0.001), as indicated by decreasing left ventricular end-systolic volume index over the 1-year follow-up. Kaplan–Meier curves indicated significantly lower cardiac event-free survival rates in patients with LGE at baseline than in patients without (P < 0.01). By contrast, there was no significant difference in prognosis between patients with CVF values above (severe fibrosis) and below (mild fibrosis) the median of 4.9 %. Cox proportional hazard analysis showed that LGE area was an independent predictor of subsequent cardiac events (hazard ratio 1.06; 95 % CI 1.02–1.10; P ≤ 0.01). The degree of myocardial fibrosis estimated by baseline LGE-CMR imaging, but not that estimated by baseline EMB, can predict LVRR and cardiac event-free survival in response to therapy in patients with newly diagnosed IDCM.