Pharmacological and Non-pharmacological Treatment for Decompensated Heart Failure: What Is New?

A Pilot Study on Standardized In-hospital Education About Heart Failure Conducted During the First Days After Decompensation

INTRODUCTION

Education addressed to heart failure (HF) patients constitutes an important element of modern comprehensive treatment programs. The present article demonstrates a novel method of standardized in-hospital education addressed to patients admitted due to decompensation in HF.

METHODS

This pilot study was conducted among 20 patients [19 men, age 63 ± 16 years, NYHA (Classification according to New York Heart Association) on admission (II/III/IV): 5/25/70%]. Five-day education was based on individual sessions conducted using colorful boards demonstrating selected, highly practical elements of the knowledge about HF management, prepared by experts in HF management (medical doctors, a psychologist, and a dietician). The level of knowledge about HF was measured before and after education, based on a questionnaire prepared by the authors of the boards.

RESULTS

All patients experienced an improvement of their clinical status (confirmed by reduced New York Heart Association class and body mass, both P < 0.05). Mini Mental State Exam (MMSE) confirmed that no one demonstrated cognitive impairment. The score reflecting the level of knowledge about HF improved significantly after 5 days of in-hospital treatment accompanied by education (P = 0.0001).

CONCLUSIONS

We showed that the proposed model of education addressed to patients with decompensated HF, conducted using colorful boards demonstrating selected, highly practical elements of the knowledge about HF management, prepared by experts in HF management lead to significant increase of HF-related knowledge.

Efficacy and Safety of Ultrafiltration in Patients with Heart Failure: A Single-Center Experience

INTRODUCTION

There is a paucity of literature on the efficacy and safety of ultrafiltration in Chinese patients with heart failure (HF). Therefore, we aimed to compare the efficacy and safety of ultrafiltration with diuretics and provide information and evidence as to the best approach for patients with HF.

METHODS

In this single-center, non-randomized interventional study patients with HF either received diuretics or ultrafiltration. The efficacy outcomes included changes in the weight, dyspnea score, and 6-min walk distance from baseline to 48 h after treatment. Safety outcomes were evaluated in both the groups with respect to changes in systolic blood pressure, heart rate, serum creatinine, blood urea nitrogen, blood potassium ion concentration, and blood sodium ion concentration.

RESULTS

A total of 149 patients with HF (diuretics, 73; ultrafiltration, 76) were included. At 48 h, patients in the ultrafiltration group showed significantly greater weight loss and better improvement in dyspnea score and 6-min walk distance compared to patients in the control group (P < 0.05). However, the two groups showed no statistically significant difference in terms of safety outcomes such as systolic blood pressure, heart rate, serum creatinine, blood urea nitrogen, blood potassium ion concentration, and blood sodium ion concentration, suggesting similar safety profiles of both the groups.

CONCLUSION

Ultrafiltration was associated with greater weight loss and better dyspnea score and 6-min walk distance with similar safety profiles as compared with diuretics. Ultrafiltration can be considered as an optimal option for Chinese patients with HF.

MicroRNA-200c/429 mediated regulation of Zeb1 augments N-Cadherin in mouse cardiac mesenchymal cells

Cardiac mesenchymal cells (CMCs) are a promising cell type that showed therapeutic potential in heart failure models. The analysis of the underlying mechanisms by which the CMCs improve cardiac function is on track. This study aimed to investigate the expression of N-Cadherin, a transmembrane protein that enhances cell adhesion, and recently gained attention for differentiation and augmentation of stem cell function. The mouse CMCs were isolated and analyzed for the mesenchymal markers using flow cytometry. Quantitative real-time polymerase chain reaction (qRT-PCR) and western blot analysis were used to assess the expression of N-Cadherin along with its counteracting molecule E-Cadherin and their regulator Zeb1 in CMCs and dermal fibroblast. The expression level of miR-200c and miR-429 was analyzed using miRNA assays. Transient transfection of miR-200c followed by qRT-PCR, western blot analysis, and immunostaining was done in CMCs to analyze the expression of Zeb1, N-Cadherin, and E-Cadherin. Flow cytometry analysis showed that CMCs possess mesenchymal markers and absence for hematopoietic and immune cell markers. Increased expression of N-Cadherin and Zeb1 in CMCs was observed in CMCs at both RNA and protein levels compared to fibroblast. We found significant downregulation of miR-200c and miR-429 in CMCs. The ectopic expression of miR-200c in CMCs significantly downregulated Zeb1 and N-Cadherin expression. Our findings suggest that the significant downregulation of miR-200c/429 in CMCs maintains the expression of N-Cadherin, which may be important for its functional integrity.

Efficiency of Hypertonic Saline in the Management of Decompensated Heart Failure: A Systematic Review and Meta-Analysis of Clinical Studies

INTRODUCTION

Acute decompensated heart failure (ADHF), with an incidence of 1-2%, is a clinical syndrome with significant morbidity and mortality despite therapeutic advancements and ongoing clinical trials. A recent therapeutic approach to patients with ADHF includes combination therapy with hypertonic saline solution (HSS) and furosemide, based on the hypothesis that resistance to loop diuretics occurs because of achievement of plateau in water and sodium excretion in patients receiving long-term loop diuretic therapy.

OBJECTIVE

Our aim was to conduct a meta-analysis to evaluate the efficiency of combination HSS plus furosemide therapy in patients with ADHF in terms of mortality, readmissions, length of hospital stay, kidney function, urine output, body weight, and B-type natriuretic peptide (BNP).

METHODS

A total of 14 studies-four observational and ten randomized studies (total 3398 patients)-were included in the meta-analysis.

RESULTS

Our results demonstrate the superiority of combination HSS plus furosemide therapy over furosemide alone in terms of kidney function preservation (mean creatinine difference - 0.33 mg/dL; P < 0.00001), improved diuresis (mean difference [MD] 581.94 mL/24 h; P < 0.00001) and natriuresis (MD 57.19; P < 0.00001), weight loss (MD 0.99 kg; P < 0.00001), duration of hospital stay (MD - 2.72 days; P < 0.00001), readmissions (relative risk 0.63; P = 0.01), and mortality (relative risk 0.55; P < 0.00001). However, no difference in BNP levels was detected (MD 19.88 pg/mL; P = 0.50).

CONCLUSION

Despite the heterogeneity and possible risk of bias among the studies, results appear promising on multiple aspects. A clear need exists for future randomized controlled trials investigating the role of combination HSS plus furosemide therapy to clarify these effects and their possible mechanisms.

Elucidation of the mechanism of action of pinitol against pressure overload-induced cardiac hypertrophy and fibrosis in an animal model of aortic stenosis

The long-term imposition of pressure overload on the cardiac tissue causes left ventricular hypertrophy (LVH) and cardiac fibrosis. Pinitol has been reported to possess antioxidant potential. The aim was to evaluate the efficacy of pinitol against pressure overload-induced cardiac hypertrophy and fibrosis in the aortic stenosis (AS) rat model. Cardiac hypertrophy was produced in Sprague-Dawley rats by abdominal aortic constriction and treated with lisinopril (15 mg/kg) or pinitol (5, 10, and 20 mg/kg). Pressure overload-induced alterations in hemodynamic and left ventricular function tests, cardiac SOD, GSH, MDA, NO, Na-K-ATPase, and mitochondrial complex enzyme levels were significantly attenuated by pinitol. The upregulated mRNA expressions of cardiac ANP, BNP, cTn-I, TNF-α, IL-1β, IL-6, Bax, Caspase-3, collagen-I, and cardiac apoptosis were markedly downregulated by pinitol. In conclusion, pinitol ameliorated pressure overload-induced LVH and fibrosis via its anti-inflammatory, antioxidant, antifibrotic, and antiapoptotic potential in experimental AS.

Cardiogenic pulmonary edema: mechanisms and treatment - an intensivist's view

PURPOSE OF REVIEW

This review summarizes current understanding of the pathophysiology of cardiogenic pulmonary edema, its causes and treatment.

RECENT FINDINGS

The pathobiology and classification of pulmonary edema is more complex than the hydrostatic vs. permeability dichotomy of the past. Mechanisms of alveolar fluid clearance and factors that affect the clearance rate are under intensive study to find therapeutic strategies. Patients need early stabilization of oxygenation and ventilation, preferably with high-flow nasal cannula oxygen or noninvasive ventilation whereas the diagnostic cause is quickly sought with echocardiography and other testing.

SUMMARY

Treatments must be initiated early, whereas evaluation still is occurring and requires multimodality intervention. The general treatment of cardiogenic pulmonary edema includes diuretics, possibly morphine and often nitrates. The appropriate use of newer approaches - such as, nesiritide, high-dose vasodilators, milrinone, and vasopressin receptor antagonists - needs larger clinical trials.

Real-world analysis of acute decompensated heart failure outcomes in Portugal

Aims

In Portugal, in the last 5 years, no study has published recent data regarding outcomes of patients with acute decompensated heart failure (ADHF). We aimed to determine the characteristics and outcomes of a large contemporaneous Portuguese cohort of ADHF patients admitted to our emergency department (ED).

Methods and results

We conducted a retrospective, study of all 1024 patients admitted to our ED with a discharge diagnosis of ADHF from November 2016 to December 2017. Baseline clinical data and outcomes {in‐hospital, 30 day, and follow‐up all‐cause mortality, and readmissions; median follow‐up, 5 months; interquartile range [(IQR), 3–11 months]} were determined. Mean age was 78 ± 10 years, and 53% were male; of the 1024 patients, 554 (54%) were hospitalized. The median hospitalization length was 9 (IQR, 5–15) days, and in‐hospital mortality was 12.7%. Hospitalized patients were predominantly men (56% vs. 47%; P < 0.001), younger (77 ± 9 vs. 79 ± 11 years; P = 0.002) and had higher creatinine values and B‐type natriuretic peptide values (P < 0.001) than discharged patients. Patients with prior hospitalization had lower 30 day readmission rate (8% vs. 14%; P = 0.01), same overall readmission rate (30% vs. 32%), and higher 30 day (13% vs. 5%; P < 0.001) and overall mortality rates (28% vs. 15%; P < 0.001).

Conclusions

Approximately half of the patients admitted to the ED were hospitalized. Of these, only 8% were readmitted in the ED within 30 days. The clinical and analytical status in the ED are important predictors of hospitalization.