What Is New in Heart Failure Management in 2017? Update on ACC/AHA Heart Failure Guidelines

The treatment of chronic anemia in heart failure: a global approach

Chronic anemia is an independent risk factor for mortality in patients with heart failure (HF). Restoring physiological hemoglobin (Hb) levels is essential to increase oxygen transport capacity to tissues and improve cell metabolism as well as physical and cardiac performance. Nutritional deficits and iron deficiency are the major causes of chronic anemia, but other etiologies include chronic kidney disease, inflammatory processes, and unexplained anemia. Hormonal therapy, including erythropoietin (EPO) and anabolic treatment in chronic anemia HF patients, may contribute to improving Hb levels and clinical outcomes. Although preliminary studies showed a beneficial effect of EPO therapy on cardiac efficiency and in HF, more recent studies have not confirmed this positive impact of EPO, alluding to its side effect profile. Physical exercise significantly increases Hb levels and the response of anemia to treatment. In malnourished patients and chronic inflammatory processes, low levels of anabolic hormones, such as testosterone and insulin-like growth factor-1, contribute to the development of chronic anemia. This paper aims to review the effect of nutrition, EPO, anabolic hormones, standard HF treatments, and exercise as regulatory mechanisms of chronic anemia and their cardiovascular consequences in patients with HF.

Heart Failure With Preserved Ejection Fraction: Will Cardiac Magnetic Imaging Impact on Diagnosis, Treatment, and Outcomes?: Explaining the Need for Advanced Imaging to Clinical Stakeholders

Clinicians frequently equate symptoms of volume overload to heart failure (HF) but such generalization may preclude diagnostic or etiologic precision essential to optimizing outcomes. HF itself must be specified as the disparate types of cardiac pathology have been traditionally surmised by examination of left ventricular (LV) ejection fraction (EF) as either HF with preserved LVEF (HFpEF-LVEF >50%) or reduced LVEF of (HFrEF-LVEF <40%). More recent data support a third, potentially transitional HF subtype, but therapy, assessment, and prognosis have been historically dictated within the corresponding LV metrics determined by echocardiography. The present effort asks whether this historically dominant role of echocardiography is now shifting slightly, becoming instead a shared if not complimentary test. Will there be a gradual increasing profile for cardiac magnetic resonance as the attempt to further refine our understanding, diagnostic accuracy, and outcomes for HFpEF is attempted?

Feasibility, Acceptability, and Intervention Description of a Mobile Health Intervention in Patients With Heart Failure

Mobile health (mHealth) is used to encourage and support self-management skills in patients with heart failure. The purpose of the study was to describe the feasibility, fidelity, usability, and acceptability of mHealth interventions. This pilot study used a randomized 3-group (enhanced usual care, mHealth, and mHealth plus, which included a nurse practitioner and community health worker) repeated-measure design to determine the feasibility of using a self-management behavior app and a Bluetooth-enabled scale for daily self-monitoring of weights and medications. In the 2 mHealth groups, of the 48 patients, 38 (79%) engaged partially in recording daily weights and medications, and of the 74 patients in the sample, we obtained partial to complete data on 63 (85%) of the patients during follow-up outcome phone calls. Most patients found the intervention to be feasible, usable, and acceptable, and (93%) patients in the mHealth group and 100% of patients in the mHealth plus group agreed or strongly agreed that they learned how to self-manage their heart failure using the app. The intervention was reasonable to implement and provided insight for future intervention improvements.

ECG Signal-Enabled Automatic Diagnosis Technology of Heart Failure

Usually, heart failure occurs when heart-related diseases are developed and continue to deteriorate veins and arteries. Heart failure is the final stage of heart disease, and it has become an important medical problem, particularly among the aging population. In medical diagnosis and treatment, the examination of heart failure contains various indicators such as electrocardiogram. It is one of the relatively common ways to collect heart failure or attack related information and is also used as a reference indicator for doctors. Electrocardiogram indicates the potential activity of patient's heart and directly reflects the changes in it. In this paper, a deep learning-based diagnosis system is presented for the early detection of heart failure particularly in elderly patients. For this purpose, we have used two datasets, Physio-Bank and MIMIC-III, which are publicly available, to extract ECG signals and thoroughly examine heart failure. Initially, a heart failure diagnosis model which is based on attention convolutional neural network (CBAM-CNN) is proposed to automatically extract features. Additionally, attention module adaptively learns the characteristics of local features and efficiently extracts the complex features of the ECG signal to perform classification diagnosis. To verify the exceptional performance of the proposed network model, various experiments were carried out in the realistic environment of hospitals. Influence of signal preprocessing on the performance of model is also discussed. These results show that the proposed CBAM-CNN model performance is better for both classifications of ECG signals. Likewise, the CBAM-CNN model is sensitive to noise, and its accuracy is effectively improved as soon as signal is refined.

Astragaloside IV alleviates heart failure by regulating SUMO-specific protease 1

The present study investigated whether the protective effect and mechanism of astragaloside IV (AS-IV) on heart failure (HF) involves small ubiquitin-like modifier (SUMO)-specific protease 1 (Senp1). Mouse HF was established by aortic constriction, inducing pressure overload. The model was confirmed by echocardiography 6 weeks after surgery. Mice were randomly divided into control, HF, HF+AS-IV, and AS-IV groups. Ventricular function was examined by echocardiography. Morphological changes of myocardial tissues were examined by H&E staining. The protein levels of the apoptosis-related proteins, cleaved caspase-3, caspase-3, Bcl2, Bax, and SUMO-Senp1 were determined by Western blotting. H₂O₂ in isolated mitochondria and cells was determined by Amplex Red. A reactive oxygen species (ROS) detection kit determined ROS levels in isolated mitochondria and HL-1 cells. JC-1 reagent measured mitochondrial membrane potential (ΔΨm). Apoptosis of HL-1 cells was examined by terminal deoxynucleotidyl transferase dUTP nick end labeling. Compared with the control group, the heart weight and heart mass/body weight ratio increased in the HF group (P<0.05). Furthermore, the ejection fraction and left ventricular shortening fraction decreased (P<0.05), while the left ventricular end-diastolic diameter (LVID;d) and end-systolic diameter (LVID;s) increased (P<0.05). Finally, mitochondrial ROS and H₂O₂ increased (P<0.05), while the ΔΨm decreased (P<0.05). However, AS-IV improved the cardiac function of HF mice, decreased the level of ROS and H₂O₂ in the myocardium, suppressed the decrease in ΔΨm, and decreased the apoptosis of myocardial cells (P<0.05). AS-IV also decreased the Senp1-overexpression. Furthermore, in HL-1 cells, Senp1-overexpression significantly inhibited the protective effects of AS-IV. AS-IV decreased oxidative stress in cardiomyocytes, decreased mitochondrial damage, inhibited ventricular remodeling, and ultimately improved cardiac function by inhibiting HF-induced Senp1-overexpression. This mechanism provides a novel theoretical basis and clinical treatment for HF.

Coenzyme Q10 and Cardiovascular Diseases

Coenzyme Q₁₀ (CoQ₁₀), which plays a key role in the electron transport chain by providing an adequate, efficient supply of energy, has another relevant function as an antioxidant, acting in mitochondria, other cell compartments, and plasma lipoproteins. CoQ₁₀ deficiency is present in chronic and age-related diseases. In particular, in cardiovascular diseases (CVDs), there is a reduced bioavailability of CoQ₁₀ since statins, one of the most common lipid-lowering drugs, inhibit the common pathway shared by CoQ₁₀ endogenous biosynthesis and cholesterol biosynthesis. Different clinical trials have analyzed the effect of CoQ₁₀ supplementation as a treatment to ameliorate these deficiencies in the context of CVDs. In this review, we focus on recent advances in CoQ₁₀ supplementation and the clinical implications in the reduction of cardiovascular risk factors (such as lipid and lipoprotein levels, blood pressure, or endothelial function) as well as in a therapeutic approach for the reduction of the clinical complications of CVD.

Pharmacokinetics and tissue distribution study of 18 bioactive components in healthy and chronic heart failure rats after oral administration of Qi-Shen-Ke-Li formula using ultra-high-performance liquid chromatography/triple quadrupole mass spectrometry

RATIONALE

Qi-Shen-Ke-Li (QSKL) is a traditional Chinese formula used in clinical practice to treat chronic heart failure (CHF) in humans. To rationalize the use of this formula in clinical practice, the pharmacokinetics and tissue distribution in rats after oral administration of QSKL were investigated using ultra-high-performance liquid chromatography/triple quadrupole mass spectrometry (UHPLC/TQ-MS).

METHODS

The CHF model was induced by intraperitoneal injection of isoprenaline (ISO; also known as isoproterenol) and evaluated by HE staining and brain natriuretic peptide (BNP) measurement. The UHPLC/TQ-MS method was then applied to determine the concentrations of 18 bioactive components in rat plasma and tissues of heathy and CHF rats after oral administration of QSKL. This was followed by investigating the pharmacokinetics and tissue distribution profiles of these bioactive compounds in the heathy and CHF rats.

RESULTS

The pharmacokinetics results showed that the duration time of two compounds was prolonged, the absorption rate of four compounds was accelerated, and the bioavailability of four compounds was increased in the CHF rats compared with the healthy rats. Meanwhile, the tissue distribution results showed that the QSKL formula could be distributed rapidly and widely in different rat tissues. The bioavailability of eight compounds in the liver was enhanced in CHF rats. This suggested that the drug/toxic effects should be considered in clinical practice, as drug-drug interactions might occur in liver metabolism during the drug combination.

CONCLUSIONS

The pharmacokinetic profiles and tissue distribution of 18 bioactive compounds in QSKL are altered by the CHF status. This study provides insight for better clinical applications of this formula in the future and lays the foundation for the development of a new drug for chronic heart failure based on the QSKL formula.

Machine Learning-Driven Models to Predict Prognostic Outcomes in Patients Hospitalized With Heart Failure Using Electronic Health Records: Retrospective Study

Background

With the prevalence of cardiovascular diseases increasing worldwide, early prediction and accurate assessment of heart failure (HF) risk are crucial to meet the clinical demand.

Objective

Our study objective was to develop machine learning (ML) models based on real-world electronic health records to predict 1-year in-hospital mortality, use of positive inotropic agents, and 1-year all-cause readmission rate.

Methods

For this single-center study, we recruited patients with newly diagnosed HF hospitalized between December 2010 and August 2018 at the First Affiliated Hospital of Dalian Medical University (Liaoning Province, China). The models were constructed for a population set (90:10 split of data set into training and test sets) using 79 variables during the first hospitalization. Logistic regression, support vector machine, artificial neural network, random forest, and extreme gradient boosting models were investigated for outcome predictions.

Results

Of the 13,602 patients with HF enrolled in the study, 537 (3.95%) died within 1 year and 2779 patients (20.43%) had a history of use of positive inotropic agents. ML algorithms improved the performance of predictive models for 1-year in-hospital mortality (areas under the curve [AUCs] 0.92-1.00), use of positive inotropic medication (AUCs 0.85-0.96), and 1-year readmission rates (AUCs 0.63-0.96). A decision tree of mortality risk was created and stratified by single variables at levels of high-sensitivity cardiac troponin I (<0.068 μg/L), followed by percentage of lymphocytes (<14.688%) and neutrophil count (4.870×10⁹/L).

Conclusions

ML techniques based on a large scale of clinical variables can improve outcome predictions for patients with HF. The mortality decision tree may contribute to guiding better clinical risk assessment and decision making.

Ivabradine in Cardiovascular Disease Management Revisited: a Review

Ivabradine is a unique agent that is distinct from beta-blockers and calcium channel blockers as it reduces heart rate without affecting myocardial contractility or vascular tone. Ivabradine is a use-dependent inhibitor targeting the sinoatrial node. It is approved for use in the United States as an adjunct therapy for heart rate reduction in patients with heart failure with reduced ejection fraction. In this scenario, ivabradine has demonstrated improved clinical outcomes due to reduction in heart failure readmissions. However, there has been conflicting evidence from prospective studies and randomized controlled trials for its use in stable ischemic heart disease regarding efficacy in symptom reduction and mortality benefit. Ivabradine may also play a role in the treatment of patients with inappropriate sinus tachycardia, who often cannot tolerate beta-blockers and/or calcium channel blockers. In this review, we highlight the evidence for the nuances of using ivabradine in heart failure, stable ischemic heart disease, and inappropriate sinus tachycardia to raise awareness for its vital role in the treatment of select populations.

The role of β-adrenergic system remodeling in human heart failure: A mechanistic investigation

β-adrenergic receptor antagonists (β-blockers) are extensively used to improve cardiac performance in heart failure (HF), but the electrical improvements with these clinical treatments are not fully understood. The aim of this study was to analyze the electrophysiological effects of β-adrenergic system remodeling in heart failure with reduced ejection fraction and the underlying mechanisms. We used a combined mathematical model that integrated β-adrenergic signaling with electrophysiology and calcium cycling in human ventricular myocytes. HF remodeling, both in the electrophysiological and signaling systems, was introduced to quantitatively analyze changes in electrophysiological properties due to the stimulation of β-adrenergic receptors in failing myocytes. We found that the inotropic effect of β-adrenergic stimulation was reduced in HF due to the altered Ca²⁺ dynamics resulting from the combination of structural, electrophysiological and signaling remodeling. Isolated cells showed proarrhythmic risk after sympathetic stimulation because early afterdepolarizations appeared, and the vulnerability was greater in failing myocytes. When analyzing coupled cells, β-adrenergic stimulation reduced transmural repolarization gradients between endocardium and epicardium in normal tissue, but was less effective at reducing these gradients after HF remodeling. The comparison of the selective activation of β-adrenergic isoforms revealed that the response to β₂-adrenergic receptors stimulation was blunted in HF while β₁-adrenergic receptors downstream effectors regulated most of the changes observed after sympathetic stimulation. In conclusion, this study was able to reproduce an altered β-adrenergic activity on failing myocytes and to explain the mechanisms involved. The derived predictions could help in the treatment of HF and guide in the design of future experiments.

Cross-cultural applicability of the Self-Care Self-Efficacy Scale in a multi-national study

AIM

The Self-Care Self-Efficacy Scale (SCSES) was newly developed as a self-report measure for self-care self-efficacy for chronic illness. This study investigated its measurement equivalence (ME) in different cultural groups, including United States, China (Hong Kong), Italy, and Brazil.

DESIGN

A multi-national study for cross-cultural validation of the Scale.

METHODS

From January 2015 - December 2018, investigators recruited 957 patients (United State: 200; Hong Kong: 300; Italy: 285; and Brazil: 142) with chronic illness from inpatient and outpatient settings. The SCSES was administered and clinical and demographic data were collected from participants. Based on the Meredith framework, multi-group confirmatory factor analysis evaluated the configural, metric, scalar, and strict invariance of the scale across the four populations through a series of nested models, with evaluation of reliability and coherence of the factor solution.

RESULTS

The mean ages of the groups ranged from 65-77 years, 56.4% was male. The Cronbach's alpha coefficients of the single-factor SCSES were 0.93, 0.89, 0.92, and 0.90 for the United States, China (Hong Kong), Italy, and Brazil, respectively. Three of the four levels of ME were partially or totally supported. The highest level achieved was partial scalar invariance level (χ² [52] = 313.4, p < 0.001; RMSEA = 0.067; 95% CI = 0.056-0.077; CFI = 0.966; TLI = 0.960, SRMR = 0.080).

CONCLUSION

Patients from the four countries shared the same philosophical orientation towards scale items, although some of the items contributed differently to represent the concept and participants shared the same schemata for score interpretation.

IMPACT

Self-efficacy is important in producing effective and sustainable self-care behavioural changes. Cultural ideation shapes the ways individuals interpret and report their self-care self-efficacy. The study findings support cross-cultural and cross-national utility of the SCSES for research on self-care across United States, China (Hong Kong), Italy, and Brazil.

Clinically Silent Brain Injury and Perioperative Neurological Events in Patients With Left Ventricular Assist Device: A Brain Autopsy Study

Current studies underestimate the prevalence of brain injury in patients with left ventricular assist devices (LVADs), as CT scans are not sensitive in detecting cerebral ischemia. Using postmortem neuropathological evaluation, we sought to characterize the types and risk factors of brain injury in LVAD patients. We reviewed 24 LVAD patients who underwent brain autopsy with gross and microscopic examinations from 1993 through 2019 at a single tertiary center. Patients who expired less than 7 days after implantation or who underwent explantation more than 7 days before death were excluded. Our study demonstrated that all LVAD nonsurvivors developed brain injury. The most common brain injury was hemorrhage (71%), followed by infarct (42%) and hypoxic ischemic brain injury (HIBI) (33%), and 10 patients (42%) presented with more than 1 brain injury. Cerebral microbleeds (CMBs) and intracranial hemorrhage were present in 33% and 42%, respectively. In those with intracranial hemorrhage, subarachnoid hemorrhage (25%) and intracerebral hemorrhage (25%) were more common than subdural hematoma (4%). Intracranial hemorrhage was associated with driveline infection (P = 0.047), and HIBI was associated with prior history of chronic obstructive pulmonary disease (P = 0.037). Fourteen (60%) had clinically silent brain injury with 65% of hemorrhages and 70% of infarcts being silent. However, the impact of silent brain injury on neurologic outcome and mortality remains unclear. Standardized neurologic monitoring and surveillance are recommended to better detect these clinically silent brain injury.

Readmission Risk Factors and Heart Failure With Preserved Ejection Fraction

Context

Cases of heart failure with preserved ejection fraction (HFpEF) exacerbations continue to affect patients' quality of life and cause significant financial burden on our healthcare system.

Objective

To identify risk factors for readmission in patients discharged with a diagnosis of HFpEF.

Methods

Electronic health records of patients over 18 years of age with a primary diagnosis of HFpEF treated between August 1, 2017 and March 1, 2018 in a community hospital were retrospectively reviewed. The study population included patients with HFpEF greater than 40% who were screened but did not qualify for the ongoing CONNECT- HF trial being conducted by Duke Clinical Research. To be included, subjects had to fall into 1 of 2 classifications (NYHA Class II-IV or ACC/AHA Stage B-D) and have a life expectancy greater than 6 months. Patients were excluded if they had terminal illness other than HF, a prior heart transplant or were on a transplant list, a current or planned placement of a left ventricular assist device, chronic kidney disease requiring hemodialysis, inability to use mobile applications, or inability to participate in longitudinal follow up. Readmission rate was analyzed at 30 and 90 days along with patients' demographics and associated comorbidities, including peripheral vascular disease, anemia, pulmonary hypertension, arrythmia, and valvular heart disease. Patients were risk stratified using the LACE index readmission score and the Charlson comorbidity index.

Results

Of the 492 cases of HFpEF identified during the 7-month study period, 212 patients were included. The majority of patients were women (126; 59.4%), had a median body mass index above 30 kg/m2 (123; 58%), and had pulmonary hypertension (94; 44.3%), anemia (146; 68.8%), and arrhythmia (101, 47.6%). Forty-five (21.2%) patients were readmitted for HFpEF within 90 days of initial discharge; 32 of those (71.1%) were readmitted within 30 days of initial discharge. Patients with higher LACE and Charlson comorbidity index scores were more likely to be readmitted within 90 days. Peripheral vascular disease (P=.002), tricuspid regurgitation (P=.001), pulmonary hypertension (P=.049), and anemia (P=.029) were risk factors associated with readmissions. Use of ACEi/ARBs (P=.017) was associated with fewer readmissions.

Conclusion

Anemia, peripheral vascular disease, pulmonary hypertension, and valvular heart disease are not only postulated mechanisms of HFpEF, but also important risk factors for readmission. These study findings affirm the need for continued research of the pathophysiology and associated comorbidities of the HFpEF population to improve quality of life and lower healthcare costs.

Coenzyme Q10 Supplementation for the Reduction of Oxidative Stress: Clinical Implications in the Treatment of Chronic Diseases

Apart from its main function in the mitochondria as a key element in electron transport, Coenzyme Q₁₀ (CoQ₁₀) has been described as having multiple functions, such as oxidant action in the generation of signals and the control of membrane structure and phospholipid and cellular redox status. Among these, the most relevant and most frequently studied function is the potent antioxidant capability of its coexistent redox forms. Different clinical trials have investigated the effect of CoQ₁₀ supplementation and its ability to reduce oxidative stress. In this review, we focused on recent advances in CoQ₁₀ supplementation, its role as an antioxidant, and the clinical implications that this entails in the treatment of chronic diseases, in particular cardiovascular diseases, kidney disease, chronic obstructive pulmonary disease, non-alcoholic fatty liver disease, and neurodegenerative diseases. As an antioxidant, CoQ₁₀ has proved to be of potential use as a treatment in diseases in which oxidative stress is a hallmark, and beneficial effects of CoQ₁₀ have been reported in the treatment of chronic diseases. However, it is crucial to reach a consensus on the optimal dose and the use of different formulations, which vary from ubiquinol or ubiquinone Ubisol-Q₁₀ or Qter^®, to new analogues such as MitoQ, before we can draw a clear conclusion about its clinical use. In addition, a major effort must be made to demonstrate its beneficial effects in clinical trials, with a view to making the implementation of CoQ₁₀ possible in clinical practice.

Cardiac cachexia: the mandate to increase clinician awareness

PURPOSE OF REVIEW

Heart failure is a frequent problem in an ageing population, associated with high rates of morbidity and mortality. Today, it is important to not only treat heart failure itself but also the related comorbidities. Among them, cardiac cachexia is one of the major challenges. It is a complex multifactorial disease with a negative impact on quality of life and prognosis. Therefore, prevention, early recognition and treatment of cardiac cachexia is essential.

RECENT FINDINGS

Cardiac cachexia frequently presents with skeletal as well as heart muscle depletion. Imaging-based diagnostic techniques can help to identify patients with cardiac cachexia and muscle wasting. Several blood biomarkers are available to detect metabolic changes in cardiac cachexia.

SUMMARY

Several studies are currently ongoing to better comprehend the underlying pathophysiological mechanisms of cardiac cachexia and to find new treatments. It is essential to diagnose it as early as possible to initiate therapy.

Adverse Cardiac Remodelling after Acute Myocardial Infarction: Old and New Biomarkers

The prevalence of heart failure (HF) due to cardiac remodelling after acute myocardial infarction (AMI) does not decrease regardless of implementation of new technologies supporting opening culprit coronary artery and solving of ischemia-relating stenosis with primary percutaneous coronary intervention (PCI). Numerous studies have examined the diagnostic and prognostic potencies of circulating cardiac biomarkers in acute coronary syndrome/AMI and heart failure after AMI, and even fewer have depicted the utility of biomarkers in AMI patients undergoing primary PCI. Although complete revascularization at early period of acute coronary syndrome/AMI is an established factor for improved short-term and long-term prognosis and lowered risk of cardiovascular (CV) complications, late adverse cardiac remodelling may be a major risk factor for one-year mortality and postponded heart failure manifestation after PCI with subsequent blood flow resolving in culprit coronary artery. The aim of the review was to focus an attention on circulating biomarker as a promising tool to stratify AMI patients at high risk of poor cardiac recovery and developing HF after successful PCI. The main consideration affects biomarkers of inflammation, biomechanical myocardial stress, cardiac injury and necrosis, fibrosis, endothelial dysfunction, and vascular reparation. Clinical utilities and predictive modalities of natriuretic peptides, cardiac troponins, galectin 3, soluble suppressor tumorogenicity-2, high-sensitive C-reactive protein, growth differential factor-15, midregional proadrenomedullin, noncoding RNAs, and other biomarkers for adverse cardiac remodelling are discussed in the review.

Coenzyme Q10: Clinical Applications in Cardiovascular Diseases

Coenzyme Q₁₀ (CoQ₁₀) is a ubiquitous factor present in cell membranes and mitochondria, both in its reduced (ubiquinol) and oxidized (ubiquinone) forms. Its levels are high in organs with high metabolism such as the heart, kidneys, and liver because it acts as an energy transfer molecule but could be reduced by aging, genetic factors, drugs (e.g., statins), cardiovascular (CV) diseases, degenerative muscle disorders, and neurodegenerative diseases. As CoQ₁₀ is endowed with significant antioxidant and anti-inflammatory features, useful to prevent free radical-induced damage and inflammatory signaling pathway activation, its depletion results in exacerbation of inflammatory processes. Therefore, exogenous CoQ₁₀ supplementation might be useful as an adjuvant in the treatment of cardiovascular diseases such as heart failure, atrial fibrillation, and myocardial infarction and in associated risk factors such as hypertension, insulin resistance, dyslipidemias, and obesity. This review aims to summarize the current evidences on the use of CoQ₁₀ supplementation as a therapeutic approach in cardiovascular diseases through the analysis of its clinical impact on patients' health and quality of life. A substantial reduction of inflammatory and oxidative stress markers has been observed in several randomized clinical trials (RCTs) focused on several of the abovementioned diseases, even if more RCTs, involving a larger number of patients, will be necessary to strengthen these interesting findings.

Update in recent clinical trials in heart failure

PURPOSE OF REVIEW

Heart failure represents a major growing health problem in developed world. This article aims to review recent heart failure trials that have significantly impacted the management of heart failure.

RECENT FINDINGS

Despite advances in heart failure, mortality and morbidity remains elevated amongst patients. Recent clinical trials demonstrate promising treatment strategies that likely impact clinical practice; including heart failure prevention with the use of SGLT2-inhibitors in patients with diabetes and cardiovascular risk, new treatments that may abrogate disease progression in cardiac amyloidosis, intravenous iron therapy in iron deficiency anemia in chronic systolic heart failure, predischarge treatment with angiotensin receptor blocker with neprilysin inhibition (ARNi) in patients hospitalized for acute decompensated heart failure, and newer continuous flow left ventricular assist device with increased durability and efficacy in patients with Stage D heart failure.

SUMMARY

Recent clinical trials with SGLT2 inhibitors, therapies targeting transthyretin cardiac amyloidosis, iron, angiotensin receptor blocker with neprilysin inhibition and newer mechanical circulatory support devices are very promising as practice changing new treatment strategies in prevention and treatment of heart failure. This article presents a summary of important trials and should be of practical value to both clinicians and researchers.

Inflammaging as a common ground for the development and maintenance of sarcopenia, obesity, cardiomyopathy and dysbiosis

Sarcopenia, obesity and their coexistence, obese sarcopenia (OBSP) as well as atherosclerosis-related cardio-vascular diseases (ACVDs), including chronic heart failure (CHF), are among the greatest public health concerns in the ageing population. A clear age-dependent increased prevalence of sarcopenia and OBSP has been registered in CHF patients, suggesting mechanistic relationships. Development of OBSP could be mediated by a crosstalk between the visceral and subcutaneous adipose tissue (AT) and the skeletal muscle under conditions of low-grade local and systemic inflammation, inflammaging. The present review summarizes the emerging data supporting the idea that inflammaging may serve as a mutual mechanism governing the development of sarcopenia, OBSP and ACVDs. In support of this hypothesis, various immune cells release pro-inflammatory mediators in the skeletal muscle and myocardium. Subsequently, the endothelial structure is disrupted, and cellular processes, such as mitochondrial activity, mitophagy, and autophagy are impaired. Inflamed myocytes lose their contractile properties, which is characteristic of sarcopenia and CHF. Inflammation may increase the risk of ACVD events in a hyperlipidemia-independent manner. Significant reduction of ACVD event rates, without the lowering of plasma lipids, following a specific targeting of key pro-inflammatory cytokines confirms a key role of inflammation in ACVD pathogenesis. Gut dysbiosis, an imbalanced gut microbial community, is known to be deeply involved in the pathogenesis of age-associated sarcopenia and ACVDs by inducing and supporting inflammaging. Dysbiosis induces the production of trimethylamine-N-oxide (TMAO), which is implicated in atherosclerosis, thrombosis, metabolic syndrome, hypertension and poor CHF prognosis. In OBSP, AT dysfunction and inflammation induce, in concert with dysbiosis, lipotoxicity and other pathophysiological processes, thus exacerbating sarcopenia and CHF. Administration of specialized, inflammation pro-resolving mediators has been shown to ameliorate the inflammatory manifestations. Considering all these findings, we hypothesize that sarcopenia, OBSP, CHF and dysbiosis are inflammaging-oriented disorders, whereby inflammaging is common and most probably the causative mechanism driving their pathogenesis.

Pain Management in Patients with Heart Failure: A Survey of Nurses' Perception

BACKGROUND

Over 50% of patients with heart failure (HF) report suffering from pain and pain-related burdens; however, pain in HF patients has not been recognized or well treated. Few studies have comprehensively examined pain management in patients with HF from nurses' perception.

AIMS

To investigate nurses' perception of pain management in HF patients.

METHODS

Members of American Association of Heart Failure Nurses (AAHFN) were invited to participate in a cross-sectional online survey.

RESULTS

A total of 147 nurses responded and completed the survey. The majority agreed that pain in HF patients was related to anxiety, depression, fatigue, and unplanned hospitalization, and that pain should be individually assessed and managed. More than 80% thought pain management practice in HF patients should be improved, and 78.1% were interested in getting more information and believed an online education module was the most preferable approach. Lack of pain assessment tools, drug addiction, side effect, overuse, underuse, and contraindication with other medications were the main concerns regarding opioid use in pain management in HF. The gaps in pain management in HF patients included lack of knowledge of opioid use, lack of consideration and awareness of pain, no clinical guidelines for pain assessment and treatment, and complicated pain management with multiple chronic conditions.

CONCLUSIONS

The impact of pain and need for individual assessment and management of pain in HF patients were perceived by nurses; improvement in pain management practice in HF patients is needed. Concerns regarding opioid use and gaps in pain management of HF patients should be addressed.