Hyponatremia in congestive heart failure

Association between serum osmolality and 28-day all-cause mortality in patients with heart failure and reduced ejection fraction: a retrospective cohort study from the MIMIC-IV database

Background

Previous studies have not thoroughly explored the impact of serum osmolality levels on early mortality in heart failure and reduced ejection fraction (HFrEF) patients. The purpose of this study was to investigate the relationship between serum osmolality levels and early all-cause mortality in patients with HFrEF.

Methods

The open access MIMIC-IV database was the source of data for our study. We collected demographic data, vital signs, laboratory parameters, and comorbidities of the included patients and divided them into 3 groups based on their initial serum osmolality on admission, with the primary outcome being all-cause mortality within 28 days of admission. Smoothing Spline Fitting Curve, the Kaplan-Meier survival curve, and Threshold effect analysis were used to assess the relationship between serum osmolality and early mortality in HFrEF patients.

Results

A total of 6228 patients (55.31% male) were included. All-cause mortality within 28 days on admission was 18.88% in all patients. After adjusting for confounders, higher serum osmolality levels were independently associated with an increased risk of 28-days all-cause mortality compared with the reference group (Reference group Q2: 290-309 mmol/L, Q4: HR, 1.82 [95% CI 1.19-2.78] P<0.05, Q5: HR, 1.99 [95% CI 1.02-3.91] P<0.05). Smooth spline fitting revealed a U-shaped association between serum osmolality and 28-days all-cause mortality. Further threshold effect analysis results suggested that each unit increase in serum osmolality level was associated with a 2% increase in 28-days all-cause mortality when serum osmolality levels were ≥ 298.8 mmol/L (HR, 1.019 [95% CI 1.012-1.025] P<0.05).

Conclusion

A U-shaped correlation between initial serum osmolality and 28-days all-cause mortality in HFrEF patients was identified, revealing higher osmolality levels significantly increase mortality risk. These results underscore serum osmolality's critical role in early mortality among HFrEF patients, highlighting the need for further, larger-scale studies for validation.

Evaluation and Management of Hyponatremia in Heart Failure

PURPOSE OF REVIEW

To provide a contemporary overview of the pathophysiology, evaluation, and treatment of hyponatremia in heart failure (HF).

RECENT FINDINGS

Potassium and magnesium losses due to poor nutritional intake and treatment with diuretics cause an intracellular sodium shift in HF that may contribute to hyponatremia. Impaired renal blood flow leading to a lower glomerular filtration rate and increased proximal tubular reabsorption lead to an impaired tubular flux through diluting distal segments of the nephron, compromising electrolyte-free water excretion. Hyponatremia in HF is typically a condition of impaired water excretion by the kidneys on a background of potassium and magnesium depletion. While those cations can and should be easily repleted, further treatment should mainly focus on improving the underlying HF and hemodynamics, while addressing congestion. For decongestive treatment, proximally acting diuretics such as sodium-glucose co-transporter-2 inhibitors, acetazolamide, and loop diuretics are the preferred options.

Grouped mixtures of air pollutants and seasonal temperature anomalies and cardiovascular hospitalizations among U.S. Residents

BACKGROUND

Air pollution is a recognized risk factor for cardiovascular disease (CVD). Temperature is also linked to CVD, with a primary focus on acute effects. Despite the close relationship between air pollution and temperature, their health effects are often examined separately, potentially overlooking their synergistic effects. Moreover, fewer studies have performed mixture analysis for multiple co-exposures, essential for adjusting confounding effects among them and assessing both cumulative and individual effects.

METHODS

We obtained hospitalization records for residents of 14 U.S. states, spanning 2000-2016, from the Health Cost and Utilization Project State Inpatient Databases. We used a grouped weighted quantile sum regression, a novel approach for mixture analysis, to simultaneously evaluate cumulative and individual associations of annual exposures to four grouped mixtures: air pollutants (elemental carbon, ammonium, nitrate, organic carbon, sulfate, nitrogen dioxide, ozone), differences between summer and winter temperature means and their long-term averages during the entire study period (i.e., summer and winter temperature mean anomalies), differences between summer and winter temperature standard deviations (SD) and their long-term averages during the entire study period (i.e., summer and winter temperature SD anomalies), and interaction terms between air pollutants and summer and winter temperature mean anomalies. The outcomes are hospitalization rates for four prevalent CVD subtypes: ischemic heart disease, cerebrovascular disease, heart failure, and arrhythmia.

RESULTS

Chronic exposure to air pollutant mixtures was associated with increased hospitalization rates for all CVD subtypes, with heart failure being the most susceptible subtype. Sulfate, nitrate, nitrogen dioxide, and organic carbon posed the highest risks. Mixtures of the interaction terms between air pollutants and temperature mean anomalies were associated with increased hospitalization rates for all CVD subtypes.

CONCLUSIONS

Our findings identified critical pollutants for targeted emission controls and suggested that abnormal temperature changes chronically affected cardiovascular health by interacting with air pollution, not directly.

Prognostic impact of abnormal sodium burden in heart failure patients with preserved ejection fraction

BACKGROUND

Sodium abnormality is common in patients with heart failure (HF) and is associated with adverse clinical outcomes. The aim of this study is to determine the impact of abnormal sodium burden on long-term mortality and hospitalization in HF with preserved ejection fraction (HFpEF).

METHODS

We analysed participants from the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial with available baseline and follow-up data (n = 1717). Abnormal sodium burden was defined as the proportion of days with abnormal sodium plasma levels (either <135 mmol/L or > 145 mmol/L). To determine the independent prognostic impact of abnormal sodium burden on the long-term clinical adverse outcomes (The primary outcome was any cause death, the secondary outcomes include cardiovascular disease death, HF hospitalization, any cause hospitalization and the primary endpoint of the original study), a multivariable Cox proportional hazard model and time-updated Cox regression model were performed.

RESULTS

Abnormal sodium burden occurred in 717 patients (41.76%). A high abnormal sodium burden was associated with 1.47 (95% CI, 1.15-1.89) higher risk with any cause mortality, 1.51 (95% CI, 1.08-2.09) higher risk with CVD death and 1.31 (95% CI, 1.02-1.69) higher risk with HF hospitalization when compared with no burden group. When sodium level changes over time were accounted for in time-updated models, abnormal sodium level was still associated with poor clinical outcomes. Diuretic and spironolactone usage did not show a statistical interaction effect on the prognostic significance.

CONCLUSIONS

In HFpEF patients, abnormal sodium burden was an independent predictor long-term any-cause mortality and HF hospitalization.

Medical Treatment in Heart Failure with Reduced Ejection Fraction: A Proposed Algorithm Based on the Patient's Electrolytes and Congestion Status

In heart failure (HF) with reduced ejection fraction (HFrEF), four classes of drugs (β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor neprilysin inhibitors, mineralocorticoid receptor antagonists, and the most recent Sodium-Glucose Co-Transporters 2 Inhibitors) have demonstrated positive results in randomized controlled trials (RCTs). Nevertheless, the latest RCTs are not proper for comparison since they were carried out at various times with dissimilar background therapies and the patients enrolled did not have the same characteristics. The difficulty of extrapolating from these trials and proposing a common framework appropriate for all cases is thus obvious. Despite the fact that these four agents are now the fundamental pillars of HFrEF treatment, the built-up algorithm of initiation and titration is a matter of debate. Electrolyte disturbances are common in HFrEF patients and can be attributed to several factors, such as the use of diuretics, renal impairment, and neurohormonal activation. We have identified several HFrEF phenotypes according to their sodium (Na+) and potassium (K+) status in a "real world" setting and suggest an algorithm on how to introduce the most appropriate drug and set up therapy based on the patients' electrolytes and the existence of congestion.

Hyponatremia Is an Overlooked Sign of Trouble Following Total Joint Arthroplasty

BACKGROUND

Hyponatremia is a common electrolyte abnormality in arthroplasty patients. This issue, underrecognized by surgeons, can impact the postoperative course of patients. There are, however, little data on the implications of sodium disturbances following total joint arthroplasty (TJA). The primary aims of this study were to (1) report the rate of hyponatremia following TJA, and (2) examine the impact of hyponatremia on the perioperative course of TJA patients.

METHODS

This was a retrospective analysis of 3,071 primary and revision TJAs performed between 2015 and 2017. Based on preoperative and postoperative sodium values (pre-post), patients were classified into 4 groups: normonatremic-normonatremic (Group 1), normonatremic-hyponatremic (Group 2), hyponatremic-normonatremic (Group 3), and hyponatremic-hyponatremic (Group 4). Primary end points were length of stay (LOS), postoperative discharge, in-hospital complications, and 90-day readmissions.

RESULTS

The distribution of cases was 84.6% Group 1, 9.4% Group 2, 2.1% Group 3, and 3.8% Group 4. Overall, 13.2% of patients had hyponatremia after TJA. Older age, hip arthroplasty, general anesthesia, higher Charlson Comorbidity Index, congestive heart failure, revision surgery, and history of stroke, liver disease, and chronic kidney disease were risk factors for postoperative hyponatremia. Patients with postoperative hyponatremia (Groups 2 and 4) had greater likelihoods of having a 90-day complication and non-home discharge and greater LOS.

CONCLUSIONS

Postoperative hyponatremia was a relatively common occurrence in patients undergoing TJA, and was associated with greater LOS, complications, and non-home discharge. Surgeons should identify patients at risk for developing sodium abnormalities in order to optimize these patients and avoid increased resource utilization.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Detection of Hyponatremia Development in Hemodialysis Patients by Routine Automated Conductivity-Based Monitoring

Predialytic hyponatremia is associated with poor outcome in hemodialysis patients. Hypotonic hyponatremia is the most frequently encountered disorder reflecting mixed disorders combining extracellular fluid overload and free water excess, resulting from the interplay of intermittency of dialysis and diet observance, and likely precipitated by an acute or subacute illness. In this context, hyponatremia requires to be detected and worked up to identify and cure the cause. In this clinical case report, we describe preliminary results of using an online biosensor on a dialysis machine that provides automated predialysis plasma sodium concentration derived from dialysate conductivity measurements. Based on this biosensor, within a 5 year time frame, 11 patients out of more than 130 maintenance hemodialysis patients and over 40,000 dialysis sessions were identified with episodes of predialysis hyponatremia (≤135 mmol/l). In all patients, hyponatremic episodes were indicative of a severe underlying illness associated with fluid overload leading to plasma hypotonicity. Automated online predialysis plasma sodium concentration measurement offers an innovative, reliable, and cost-free tool that permits to detect hyponatremia as marker of an underlying illness development in dialysis patients. The value of this tool in supporting clinical decision-making deserves further studies in a large dialysis population.

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.

Association of preoperative hyponatremia with surgical outcomes: a systematic review and meta-analysis of 32 observational studies

BACKGROUND

Preoperative hyponatremia is prevalent in patients undergoing surgical procedures, but it is uncertain if hyponatremia will lead to increased risk of surgical mortality and morbidity.

METHODS

A systematic search of Medline (PubMed), Embase and Cochrane Library from inception till 2 July 2021 was performed. Full length articles that reported on the association between surgical outcomes among adults ≥18 years with documented preoperative hyponatremia were included.

FINDINGS

We identified 32 observational studies comprising 1,301,346 participants. All studies had low risk of bias. When adjusted for covariates, patients with hyponatremia had significantly higher odds of developing major complications (defined as a composite measure of 9 major complications) compared to patients with normal sodium concentrations (aOR =  1.37, 95%CI = 1.23-1.53, I2 = 78%. N = 10). Additionally, patients with preoperative hyponatremia also significantly higher hazards of early mortality (<90 days) compared to patients with normonatremia (aHR = 1.27, 95%CI = 1.13-1.43, I2 = 97%. N = 10) after adjustment for covariates. Preoperative hyponatremia also had significant associations with respiratory, renal and septic complications. In terms of prognostic performance, preoperative hyponatremia performed adequately in predicting major complications in surgical patients (AUC = 0.70, LR- 0.90) with a specificity of 88% and a sensitivity of 25%.

INTERPRETATION

Our meta-analysis suggests that preoperative hyponatremia is associated with poorer early mortality and major morbidity outcomes in surgical patients. Hyponatremia is also a specific prognosticator for major complications in surgical patients, reiterating its potential use as a clinical indicator of poor outcomes.

Optimizing exercise testing‐based risk stratification to predict poor prognosis after acute heart failure

AIMS

The timely selection of severe heart failure (HF) patients for cardiac transplantation and advanced HF therapy is challenging. Peak oxygen consumption (VO₂ ) values obtained by the cardiopulmonary exercise testing are used to determine the transplant recipient list. This study reassessed the prognostic predictability of peak VO₂ and compared it with the Heart Failure Survival Score (HFSS) in the modern optimized guideline-directed medical therapy (GDMT) era.

METHODS AND RESULTS

We retrospectively selected 377 acute HF patients discharged from the hospital. The primary outcome was a composite of all-cause mortality, or urgent cardiac transplantation. We divided these patients into the more GDMT (two or more types of GDMT) and less GDMT groups (fewer than two types of GDMT) and compared the performance of their peak VO₂ and HFSS in predicting primary outcomes. The median follow-up period was 3.3 years. The primary outcome occurred in 57 participants. Peak VO₂ outperformed HFSS when predicting 1 year (0.81 vs. 0.61; P = 0.017) and 2 year (0.78 vs. 0.58; P < 0.001) major outcomes. The cutoff peak VO₂ for predicting a 20% risk of a major outcome within 2 years was 10.2 (11.8-7.0) for the total cohort. Multivariate Cox regression analyses showed that peak VO₂ , sodium, previous implantable cardioverter defibrillator (ICD) implantation, and estimated glomerular filtration rate were significant predictors of major outcomes.

CONCLUSIONS

Optimizing the cutoff value of peak VO₂ is required in the current GDMT era for advanced HF therapy. Other clinical factors such as ICD use, hyponatraemia, and chronic kidney disease could also be used to predict poor prognosis. The improvement of resource allocation and patient outcomes could be achieved by careful selection of appropriate patients for advanced HF therapies, such as cardiac transplantation.

Serum chloride and serum sodium derangements in children on prolonged furosemide therapy and their effect on diuretic response

Background

Electrolyte disturbances are not uncommon in patients on chronic furosemide therapy. We hypothesized that serum chloride (Cl) and serum sodium (Na) abnormalities may occur in children on prolonged furosemide therapy affecting the diuretic response in these children.

Methods

The study included 45 children, with congenital left to right shunts causing chronic congestive state which necessitated chronic furosemide therapy. Patients in need to an increase of their furosemide dose were recruited in the study. We assessed serum Cl and serum Na as well as parameters of diuretic responsiveness; net fluid output and change in body weight/40 mg furosemide, and change in urinary Na/K ratio. These parameters were assessed initially and at day 3 after increasing furosemide dose.

Results

According to serum levels of Cl and Na, patients were divided into four groups: isolated hyponatremia (15 patients, 33.3%), isolated hypochloremia (9 patients, 20%), combined hypochloremia and hyponatremia (12 patients, 26.7%), and normal serum electrolytes (9 patients, 20%). Patients with combined hyponatremia and hypochloremia and those with isolated hypochloremia showed minimal clinical and radiological signs of decongestion as well as lowest changes in urinary Na/K ratio, fluid output and weight change/40 mg furosemide on augmenting the diuretic dose, unlike the hyponatremic patients who had near normal parameters with no evidence of diuretic resistance.

Conclusion

Both hypochloremia and hyponatremia are common in patients on prolonged furosemide therapy. Hypochloremia is associated with a poor diuretic response, unlike isolated hyponatremia which does not seem to affect the diuretic response. Concomitant occurrence of hyponatremia and hypochloremia is associated with poor diuretic response as well which can be worse than that seen in isolated hypochloremia.

Efficacy of tolvaptan on advanced chronic kidney disease with heart failure: a randomized controlled trial

Background

Tolvaptan (TLV) is reported to improve diuretic effects in patients with chronic kidney disease (CKD) when furosemide (FUR) is not sufficiently effective. However, it is not clear whether TLV addition is effective for advanced CKD patients with heart failure.

Methods

An open-label, parallel-group randomized trial was performed. The subjects were 33 patients with CKD stage G3–G5 who had fluid overload despite taking 20–100 mg/day FUR. They were divided into two groups: a group administered 15 mg/day TLV plus their original FUR dose for 7 days (TLV group), and a group administered 120–200 mg/day FUR (i.e., 100 mg/day over their previous dose) for 7 days (FUR group).

Results

The mean change in urine volume was significantly higher in the TLV group compared to the FUR group (637 ml vs 119 ml; p < 0.05). The difference was greater when the urine osmolality before treatment was high. Serum creatinine was increased only in the FUR group. The incidence of worsening renal function (WRF) was significantly lower in the TLV group (18.8% vs 58.8%; p < 0.05). Serum sodium decreased significantly in the FUR group, but did not change in the TLV group.

Conclusions

In patients with advanced CKD with fluid overload, the addition of TLV achieved a significantly higher urine volume with less adverse effects on renal function compared with increasing the dose of FUR. The efficacy and safety of TLV were higher in patients who had higher urine osmolality and lower serum sodium before treatment.

Clinical trial registration

UMIN000014763.

A Wearable Microneedle-Based Extended Gate Transistor for Real-Time Detection of Sodium in Interstitial Fluids

Sodium is a prominent prognostic biomarker for assessing health status, such as dysnatremia. As of now, detection and monitoring of sodium levels in the human body is carried out by means of laborious and bulky laboratory equipmentand/or by offline analysis of various body fluids. Herein, an innovative stretchable, skin-conformal and fast-response microneedle extended-gate FET biosensor is reported for real-time detection of sodium in interstitial fluids for minimally invasive health monitoring along with high sensitivity, low limit of detection, excellent biocompatibility, and on-body mechanical stability. The integration of the reported device with a wireless-data transmitter and the Internet-of-Things cloud for real-time monitoring and long-term analysis is reported and discussed. This platform would eventually help bringing unlimited possibilities for effecient medical care and accurate clinical decision-making.

Prevalence and Prognostic Significance of Hyponatremia in Patients With Lung Cancer: Systematic Review and Meta-Analysis

Background: The prevalence of hyponatremia is highly variable among patients with lung cancer. However, its prevalence and prognostic significance in subgroups of patients with lung cancer have not yet been evaluated in a meta-analysis. Methods: We have registered our meta-analysis and review protocol to the PROSPERO International Prospective Register of Systematic Reviews, with the following registration number: CRD42020167013. A systematic search was done in the following sources: MEDLINE, Embase, CENTRAL, Web of Science, ClinicalTrials.gov, a WHO Global Health Library. Results: We identified a total of 8,962 potentially eligible studies, and we included 31 articles in our evaluation. The prevalence of hyponatremia in patients with lung cancer varied between 3 and 94.8% with an average of 25% without any significant differences between the following subgroups: histotype, gender, age, Eastern Cooperative Oncology Group (ECOG) state, and the extent of disease. The overall survival (OS) was significantly lower in hyponatremic compared to normonatremic patients at 10 months [RR.59 (95% CI.47-0.74), p < 0.001] and at 20 months [RR.44 (95% CI.33-0.59), p < 0.001], with worse survival rates in non-small cell lung cancer (NSCLC) [RR.27 (95% CI.12-0.44), p < 0.001] than in small cell lung cancer (SCLC) [RR.42 (95% CI.27-0.57), p < 0.001]. If hyponatremia was corrected, OS at 10 months was significantly higher than in the uncorrected hyponatremia group [RR 1.83 (95% CI 1.37-2.44), p < 0.001], but, at 20 months, no statistically significant difference could be found between these subgroups [RR 2.65 (95% CI.94-7.50), p = 0.067]. Conclusions: Patients with lung cancer diagnosed with hyponatremia, especially patients with NSCLC, seem to have significantly lower survival rates than normonatremic patients. If hyponatremia remains uncorrected, the mortality rates might be even higher.

The Clinical Importance of Hyponatremia in Patients with Left Ventricular Assist Devices

Hyponatremia is associated with increased morbidity and mortality in heart failure (HF) patients. The implication of hyponatremia during left ventricular assist device (LVAD) therapy remains unknown. In this retrospective study, consecutive LVAD patients implanted between April 2014 and March 2018 were stratified by the presence of hyponatremia (serum sodium <135 mEq/L) at 30 days post-LVAD. Incidence of HF readmissions and survival during 1-year follow-up were compared between the groups. Of 204 patients identified, 170 were included. Serum sodium levels improved significantly from pre-LVAD to 1-year post-LVAD (136 [133, 139] mEq/L to 137 [135, 140] mEq/L, p < 0.001). At 30 days, 35 patients (21%) were in the hyponatremia group. No difference was observed for 1-year survival between groups (77% vs. 81%, p = 0.66). However, the incidence of HF readmissions was significantly higher in the hyponatremia group (44% vs. 15%, p = 0.001). Among the patients with pre-LVAD hyponatremia (N = 60), those with normalized serum sodium levels (N = 42) had a lower incidence of HF readmissions compared with those with persistent hyponatremia (12% vs. 44%, p = 0.008). Hyponatremia in LVAD patients is associated with a higher incidence of HF readmissions. Further studies are needed to elucidate whether therapies directed at hyponatremia (e.g., vasopressin antagonists) would improve outcomes in LVAD patients.

First report of rheumatoid arthritis and secondary Sjögren's syndrome complicated with heart failure

A 70-year-old woman with rheumatoid arthritis for 45 years developed secondary Sjögren's syndrome. She had a long-term low-salt and low-fat diet and did not adhere to long-term hormone and rheumatic immunotherapy, which led to heart failure.

Current and emerging drug targets in heart failure treatment

After initial strategies targeting inotropism and congestion, the neurohormonal interpretative model of heart failure (HF) pathophysiology has set the basis for current pharmacological management of HF, as most of guideline recommended drug classes, including beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and mineralocorticoid receptor antagonists, blunt the activation of detrimental neurohormonal axes, namely sympathetic and renin–angiotensin–aldosterone (RAAS) systems. More recently, sacubitril/valsartan, a first-in-class angiotensin receptor neprilysin inhibitor, combining inhibition of RAAS and potentiation of the counter-regulatory natriuretic peptide system, has been consistently demonstrated to reduce mortality and HF-related hospitalization. A number of novel pharmacological approaches have been tested during the latest years, leading to mixed results. Among them, drugs acting directly at a second messenger level, such as the soluble guanylate cyclase stimulator vericiguat, or other addressing myocardial energetics and mitochondrial function, such as elamipretide or omecamtiv-mecarbil, will likely change the therapeutic management of patients with HF. Sodium glucose cotransporter 2 inhibitors, initially designed for the management of type 2 diabetes mellitus, have been recently demonstrated to improve outcome in HF, although mechanisms of their action on cardiovascular system are yet to be elucidated. Most of these emerging approaches have shifted the therapeutic target from neurohormonal systems to the heart, by improving cardiac contractility, metabolism, fibrosis, inflammation, and remodeling. In the present paper, we review from a pathophysiological perspective current and novel therapeutic strategies in chronic HF.

Prognostic relevance of elevated plasma osmolality on admission in acute decompensated heart failure with preserved ejection fraction: insights from PURSUIT-HFpEF registry

Background

Complicated pathophysiology makes it difficult to identify the prognosis of heart failure with preserved ejection fraction (HFpEF). While plasma osmolality has been reported to have prognostic importance, mainly in heart failure with reduced ejection fraction (HFrEF), its prognostic meaning for HFpEF has not been elucidated.

Methods

We prospectively studied 960 patients in PURSUIT-HFpEF, a multicenter observational study of acute decompensated HFpEF inpatients. We divided patients into three groups according to the quantile values of plasma osmolality on admission. During a follow-up averaging 366 days, we examined the primary composite endpoint of cardiac mortality or heart failure re-admission using Kaplan–Meier curve analysis and Cox proportional hazard testing.

Results

216 (22.5%) patients reached the primary endpoint. Kaplan–Meier curve analysis revealed that the highest quantile of plasma osmolality on admission (higher than 300.3 mOsm/kg) was significantly associated with adverse outcomes (Log-rank P = 0.0095). Univariable analysis in the Cox proportional hazard model also revealed significantly higher rates of adverse outcomes in the higher plasma osmolality on admission (hazard ratio [HR] 7.29; 95% confidence interval [CI] 2.25–23.92, P = 0.0009). Multivariable analysis in the Cox proportional hazard model also showed that higher plasma osmolality on admission was significantly associated with adverse outcomes (HR 5.47; 95% CI 1.46–21.56, P = 0.0113) independently from other confounding factors such as age, gender, comorbid of atrial fibrillation, hypertension history, diabetes, anemia, malnutrition, E/e′, and N-terminal pro-B-type natriuretic peptide elevation.

Conclusions

Higher plasma osmolality on admission was prognostically important for acute decompensated HFpEF inpatients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02098-z.

Resistant hyponatraemia in a patient with follicular lymphoma and heart failure with reduced ejection fraction: a case report

Background

Hyponatraemia is a common problem in patients with heart failure. It can be difficult to treat, especially in the presence of the patient’s needs for diuresis and manipulation of the renin–angiotensin–aldosterone system (RAAS).

Case summary

This concerns a 74-year-old woman with follicular lymphoma and severe global left ventricular systolic dysfunction secondary to treatment with R-CHOP chemotherapy. She presented a difficult challenge in the management of her decompensated heart failure alongside hyponatraemia as low as 113 mmol/L. This was resistant to standard treatment. The resistance to usual measures necessitated treatment with Tolvaptan, a selective arginine vasopressin V2 inhibitor used to treat hyponatraemia in syndrome of inappropriate anti-diuretic hormone. This, along with a strict fluid restriction of 500 mL/day, resolved the patient’s hyponatraemia and enabled her discharge home on tolerated heart failure treatment. She has now remained stable for almost 12 months.

Discussion

The potential causes of hyponatraemia are discussed along with the role of Tolvaptan in its management.

Assessing congestion in acute heart failure using cardiac and lung ultrasound - a review

Introduction: Acute heart failure (AHF) is one of the leading causes of hospital admissions and is characterized by systemic and pulmonary congestion, which often precedes the overt clinical signs and symptoms. Echocardiography in the management of chronic HF is well described; however, there are less evidence regarding echocardiography and lung ultrasound (LUS) in the acute setting.Areas covered: We have summarized current evidence regarding the use of echocardiography and LUS for assessing congestion in patients with AHF. We discuss the value and reliability of handheld/pocketsize ultrasound devices in AHF.Expert opinion: Echocardiography is an essential tool for the diagnostic work up in patients with AHF. No individual parameter reliably detects congestion, thus the physician must integrate several measurements from the right and left heart. Novel methods and advances in cardiac imaging and clinical chemistry make it possible to detect congestion at an early stage. LUS is particularly helpful in assessing congestion, and it has demonstrated diagnostic, therapeutic, and prognostic value in AHF. LUS is relatively easy to learn and allows for quick assessment of the presence of pulmonary congestion and pleural effusion. We recommend integration of LUS for routine management of patients with AHF.

Sodium Abnormalities in Cardiac Surgery With Cardiopulmonary Bypass in Adults: A Narrative Review

Perioperative sodium abnormalities or dysnatremia is not uncommon in patients presenting for cardiac surgery and is associated with increased morbidity and mortality. Both the disease process of heart failure and its treatment may contribute to abnormalities in serum sodium concentration. Serum sodium is the main determinant of serum osmolality, which in turn affects cell volume. Brain cells are particularly vulnerable to changes in serum osmolality because of the nondistensible cranium. The potentially catastrophic neurologic sequelae of rapidly correcting chronic dysnatremia and the time-sensitive nature of cardiac surgery can make the management of these patients challenging. The use of cardiopulmonary bypass to facilitate surgery adds another layer of complexity in the intraoperative management of sodium and water balance. This narrative review examines the definition and classification of dysnatremia. It also covers the etiology and pathophysiology of dysnatremia, implications during cardiac surgery requiring cardiopulmonary bypass, and the perioperative management of dysnatremia.

Furosemide and spironolactone doses and hyponatremia in patients with heart failure

Background

Hyponatremia, a marker of disease severity and prognosis, has been associated with various clinical factors and drug use, especially diuretics.

Methods

This observational prospective cohort study enrolled patients hospitalized at the University Hospital Center Split because of heart failure (HF). We investigated the association of clinical variables and cardiovascular drugs, including furosemide, hydrochlorothiazide, spironolactone, and their doses, with the presence of hyponatremia at admission.

Results

Of the 565 included patients, 32.4% were hyponatremic, 62.6% were males, and the mean age was 73.1 ± 10.6 years. In the univariate analysis, hyponatremic patients were more often current smokers (p = 0.01), alcohol consumers (p = 0.01), receiving spironolactone (p = 0.004) or combination of furosemide and spironolactone (p = 0.003). Patients who received 50 and 100 mg of spironolactone, compared to those receiving 25 mg (p < 0.0001), as well as patients who received 250 to 500 mg of furosemide compared to ≤240 mg (p = 0.001), were significantly more often hyponatremic. In the multivariate analysis, when diuretic doses were accounted for, furosemide doses of 250 to 500 mg (p = 0.009), spironolactone doses of 50 to 100 mg (p = 0.0003), increasing age (p = 0.03), diabetes mellitus (p = 0.02) and alcohol consumption (p = 0.04) were independently associated with hyponatremia.

Conclusion

High doses of furosemide and spironolactone, or concomitant use of these diuretics, seem to be an important cause of hyponatremia in HF patients, particularly in combination with advanced age, diabetes and alcohol consumption. Diuretic dose reduction may help avoid hyponatremia and improve clinical status and prognosis in such patients.

Prognostic Impact of Early Changes in Serum Chloride Concentrations Among Hospitalized Acute Heart Failure Patients - A Retrospective Cohort Study

Background: Serum electrolyte concentrations on admission and after the administration of loop diuretics may be associated with prognosis in patients hospitalized due to acute heart failure (AHF). This study investigated the prognostic impact of early changes in chloride (Cl) concentrations after diuretic administration, according to stratified Cl concentrations on admission, in AHF. Methods and Results: In all, 355 consecutive patients hospitalized due to AHF were included in this single-center retrospective cohort study. Patients were divided into 2 groups based on whether Cl decreased (n=196) or not (n=159) during the first 5 days in hospital. These 2 groups were further stratified according to Cl on admission into 4 groups: Group 1, decrease in Cl and no hypochloremia (n=127); Group 2, decrease in Cl and hypochloremia (n=69); Group 3, no decrease in Cl and no hypochloremia (n=50); and Group 4, no decrease in Cl and hypochloremia (n=109). The risk of death was significantly higher in the group without than with a decrease in Cl (all-cause death hazard ratio [HR] 1.79; 95% confidence interval [CI] 1.15-2.78; P=0.009). Group 4 had the worst prognosis and a significantly higher risk of death (all-cause death [vs. Group 1 as a reference], HR 2.51; 95% CI 1.45-4.32; P=0.001). Conclusions: The absence of an early decline in Cl was associated with poor prognosis in AHF, especially in patients with hypochloremia on admission.

Hyponatremia in Heart Failure: Pathogenesis and Management

Hyponatremia is a very common electrolyte abnormality, associated with poor short- and long-term outcomes in patients with heart failure (HF). Two opposite processes can result in hyponatremia in this setting: Volume overload with dilutional hypervolemic hyponatremia from congestion, and hypovolemic hyponatremia from excessive use of natriuretics. These two conditions require different therapeutic approaches. While sodium in the form of normal saline can be lifesaving in the second case, the same treatment would exacerbate hyponatremia in the first case. Hypervolemic hyponatremia in HF patients is multifactorial and occurs mainly due to the persistent release of arginine vasopressin (AVP) in the setting of ineffective renal perfusion secondary to low cardiac output. Fluid restriction and loop diuretics remain mainstay treatments for hypervolemic/dilutional hyponatremia in patients with HF. In recent years, a few strategies, such as AVP antagonists (Tolvaptan, Conivaptan, and Lixivaptan), and hypertonic saline in addition to loop diuretics, have been proposed as potentially promising treatment options for this condition. This review aimed to summarize the current literature on pathogenesis and management of hyponatremia in patients with HF.

Predicting the 1-Year All-Cause Mortality After Hospitalisation for an Acute Heart Failure Event: A Real-World Derivation Cohort for the Development of the S2PLiT-UG Score

BACKGROUND

Acute heart failure (AHF) is a complex syndrome associated with high morbidity and mortality. This study aimed to derive a simple risk score with which to identify AHF patients at high risk for an all-cause death event during the first year after hospital discharge.

METHODS

Three hundred AHF patients from the Heart Failure registry were included in the analysis. Cox regression with a forward-conditional algorithm and bootstrapping procedure was used to build the prognostic score, while c-statistic was used to assess the prognostic performance of the score.

RESULTS

Seven variables were independently associated with an all-cause mortality event during the 1-year follow-up (FU): estimated glomerular filtration rate of 40-60; estimated glomerular filtration rate <40 mL/min/1.73 m²; uric acid >450 μmol/L; left-ventricular ejection fraction <45%; sodium <136 mmol/L; systolic blood pressure <115 mmHg; and a positive history of previous heart failure-related decompensation event(s). The score derived from significant variables enabled classification of patients into three risk categories: low (0-2 points), intermediate (3 points), and high (4-6 points). Observed all-cause mortality rates during the 1-year FU were 6.1%, 30.5%, and 80.9% across the three risk categories, respectively. The score demonstrated a high level of discrimination for an all-cause death event in the derivation cohort with the c-statistic value of 0.907 (95% CI, 0.867-0.939; p < 0.0001) and adequate calibration.

CONCLUSIONS

The S₂PLiT-UG score is a simple tool with potential for facilitating risk stratification and therapeutic decision-making during the first year after hospitalisation for an AHF event. Future external validation studies are required to confirm its prognostic performance.

A normal sodium diet preserves serum sodium levels during treatment of acute decompensated heart failure: A prospective, blind and randomized trial

BACKGROUND

We tested the hypothesis that a normal sodium diet could be associated with preservation of serum sodium during treatment of acute decompensated heart failure (ADHF).

METHODS AND RESULTS

Forty-four patients hospitalized for ADHF were blindly randomized by using block method to a low sodium diet (LS: 3 g/day of dietary sodium chloride; n = 22, 59.5 ± 11.9 y.o., 50% males. LVEF = 30.0 ± 13.6%); and a normal sodium diet (NS: 7 g/day; n = 22, 56.4 ± 10.3 y.o., 68% males; LVEF = 27.8 ± 11.7%), and both groups were submitted to fluid restriction of 1.000 mL/day. At the 7th day of intervention 16 patients of LS group and 15 patients of NS group were assessed for difference in serum sodium. Both groups had equivalent decongestion, reflected by similar percent reduction of body weight (LS: -5.0 ± 4.7% vs NS: -4.5 ± 5.2%. p = 0.41). Reduction of the N terminal fragment of type B natriuretic peptide (NT-proBNP) was significant only in the NS (-1497.0 [-18843.0 - 1191.0]. p = 0.04). The LS group showed lower levels of serum sodium (135.4 ± 3.5 mmol/L) compared to the NS group (137.5 ± 1.9 mmol/L; p = 0.04). Four cases of hyponatremia were observed only in the LS group (22%). The NS group exhibited higher mean blood pressure values (79.4 ± 2.4 mmHg vs 75.5 ± 3.0 mmHg. p = 0.03), and lower heart rate (73.2 ± 1.6 bpm vs 75.5 ± 2.1 bpm. p = 0.02).

CONCLUSIONS

These results suggest that a normal sodium diet, when compared to a low sodium diet, is associated with similar degrees of decongestion, but with higher levels of natremia, blood pressure and lower neurohormonal activation during ADHF treatment.

TRIAL REGISTRATION

clinicaltrials.gov Identifier no. NCT03722069.

Serial sodium values and adverse outcomes in heart failure with preserved ejection fraction

OBJECTIVE

The purpose of our study is to examine whether serial measurements of serum sodium values after diagnosis identify a higher-risk subset of patients with heart failure with preserved ejection fraction.

METHODS

We identified 50,932 subjects with HFpEF with 759,577 recorded sNa measurements (mean age 72 ± 11 years) using a validated algorithm in the VA national database from 2002 to 2012. We examined the association of repeated measures of sNa with mortality using a multivariable Cox proportional hazards model.

RESULTS

After a median follow-up of 2.9 years (IQR: 1.2-5.4), 19,011 deaths occurred. After adjusting for age, sex, race, BMI, glomerular filtration rate, potassium, coronary artery disease, hypertension, hyperlipidemia, atrial fibrillation, pulmonary disease, diabetes, anemia, and medications, we found J-shaped associations of serum sodium with mortality. HRs for all-cause mortality were 2.48 (95% CI: 2.38-2.60) for the sNA 115.00-133.99 category; and 1.40 (95% CI: 1.35-1.46) for the sNA 143.00-175.00 category compared to the 137.01-140.99 category (ref). We used generalized estimating equation-based negative binomial regression to compute the incidence density ratios (IDR) to examine days hospitalized for heart failure and for all causes. There were a total of 1,275,614 days of all-cause hospitalization and 104,006 days of heart-failure hospitalization. The IDRs for the lowest sNA group were 2.03 (95% CI: 1.90-2.18) for all-cause hospitalization and 1.73 (95% CI: 1.39-2.16) for heart-failure hospitalization.

CONCLUSIONS

Our findings suggest that monitoring of serum sodium values during longitudinal follow-up can identify HFpEF patients at risk of adverse outcomes.

Higher Diuretic Requirements in Acute Heart Failure With Admission Hyponatraemia Versus Normonatraemia

BACKGROUND

Diuretic requirements in patients with acute decompensated heart failure (ADHF) and hyponatraemia versus normonatraemia on admission has not been previously explored.

METHODS

The Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial dataset was utilised to examine the characteristics and diuretic requirements of patients with ADHF with hyponatraemia or normonatraemia on admission.

RESULTS

Patients with ADHF and admission hyponatraemia (n = 103, average Na 130.2 meq/L) had a higher degree of congestion evident in higher frequency of jugular venous distension (JVD) >12 cmH₂O (p = 0.007), 2+ lower extremity oedema (p = 0.001), and higher right atrial pressure (p = 0.007), compared with normonatraemic patients (n = 327, average Na 138.6 meq/L). Despite a similar baseline furosemide dose in both groups (median 200 mg), the hyponatraemia group received higher in-hospital furosemide (280 vs. 200 mg, in both groups, respectively, p < 0.001) which represented a higher percentage of furosemide utilisation relative to baseline, compared with the normonatraemia group (33% vs 0%, in both groups respectively, p = 0.007). With in-hospital diuresis, the Na level of hyponatraemic subjects started significantly increasing at discharge and up to 6 months after randomisation-all relative to baseline. Hyponatraemic patients had significantly lower systolic blood pressure (SBP) longitudinally at multiple time points compared with normonataremic patients, but it did not further decrease despite the higher furosemide dose in the former group.

CONCLUSION

Patients with ADHF and hyponatraemia on admission had a higher degree of congestion and required higher doses of furosemide, compared with normonatraemic subjects. The lower Na and SBP in this instance should not lead to withholding or minimising diuretic dosage which should rather be dictated by volume status.

THE EFFECTS OF HYPONATREMIA ON BONE DENSITY AND FRACTURES: A SYSTEMATIC REVIEW AND META-ANALYSIS

Objective: Hyponatremia decreases bone mineral density and is a major risk factor for fragility fractures. Objectives of our systematic review and meta-analysis were to analyze the overall effects of hyponatremia on bone fractures, osteoporosis, and mortality. Methods: We extracted data from Medline, Cochrane Central, and EMBASE 1960-2017 and conference abstracts from 2007-2017. We included studies with data on serum sodium, fractures, bone density, or diagnoses of osteoporosis. Studies were independently reviewed by two authors and assessed for bias using the Newcastle-Ottawa scale. Random effect models meta-analysis was used when at least three studies reported the same outcome measures. We reported summary odds ratios (ORs) and 95% confidence intervals (CIs). Results: We included 26 studies for qualitative analysis. Fifteen studies were included in the meta-analysis to evaluate the effects of hyponatremia on fractures, four studies for bone mineral density changes, and six for mortality. Hyponatremia increased the odds of fractures at all sites (summary OR, 2.34 [95% CI, 1.86, 2.96]. There was an increase in the odds of osteoporosis (summary OR, 2.67 [95% CI, 2.07, 3.43]). Mortality risk among the included studies remained high (summary OR, 1.31 [95% CI, 1.16, 1.47]). Conclusion: Our meta-analysis confirms a statistically significant association of hyponatremia with bone fractures and osteoporosis along with higher mortality. Long-term prospective studies evaluating the impact of correcting hyponatremia on bone health, fractures, and mortality are required. Abbreviations: AVP = arginine vasopressin; CI = confidence interval; CKD = chronic kidney disease; OR = odds ratio; SIADH = syndrome of inappropriate antidiuretic hormone.

The prognosis of heart failure patients: Does sodium level play a significant role?

Introduction

Heart failure (HF), a major cardiovascular disorder, remains a grievous clinical condition regardless of advances in medical care. Hyponatremia is classified as a serum sodium concentration of <135 mEq/L, and the prevalence, clinical impact and prognostic factor of hyponatremia in heart failure patients varies widely. The current study was conducted with the aim of assessing the prevalence of hyponatremia in patients hospitalized with a diagnosis of HF and comparing baseline clinical characteristic of HF patients based on their sodium status. Survival difference between patients with hyponatremia and normonatremia was also assessed and the clinical prognostic indicators of overall mortality in HF patients were evaluated.

Method

A retrospective cohort study was conducted to assess medical records of heart failure patients who were admitted to Gondar University Referral Hospital. Patients were categorized based on their sodium level status at their first admission to the internal medicine department. Each patient was assigned to either of the following groups: hyponatremia if sodium < 135 mmol/L, or normonatremia if sodium ≥ 135 mmol/L.

Result

Among 388 participants, the prevalence of hyponatremia in the study cohorts was 51.03%. Kaplan-Meier survival curves showed that there was a significant difference in survival status of HF patients among the two cohorts (Log—Rank test, P <0.0001). Hence, patients with normal sodium levels had a higher chance of survival over hyponatremic patients. Multivariate Cox regression has revealed a statistically significant association of mortality with the following variables: advanced age (AHR = 1.035 (1.012–1.058), P = 0.003), hyponatremia (AHR = 4.003 (1.778–9.009), P = 0.001), higher creatinine level (AHR = 1.929 (1.523–2.443), P = <0.0001) and, prescription of angiotensin-converting enzyme inhibitors (AHR = 0.410 (0.199–0.842), P = 0.015) and spironolactone (AHR = 0.511 (0.275–0.949), P = 0.033.

Conclusion

In conclusion, hyponatremia is one of the crucial factors in the clinical prognosis of heart failure patients. However, as other prognostic factors (i.e. medication, creatine level, and age) also played vital roles in overall survival, well-controlled clinical trials (complete with medication dosing, laboratory outputs and long-term prospective follow up) are required to further study the impact of hyponatremia in HF patient’s prognosis in low income nations.

Hyponatremia associates with poor outcome in metastatic renal cell carcinoma patients treated with everolimus: prognostic impact

BACKGROUND

The prognostication of metastatic renal cell carcinoma (mRCC) is based on Memorial Sloan Kettering Cancer Center (MSKCC) and International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) risk classifications. Research has shown that hyponatremia is associated with worse prognosis in cancer. We analyzed the association of hyponatremia and outcome in everolimus-treated mRCC patients.

PATIENTS AND METHODS

Baseline and on-treatment (≤12 weeks) sodium in 233 mRCC patients was analyzed using Kaplan-Meier, Cox regression and logistic regression. Baseline sodium was correlated with baseline thrombocyte and neutrophil values.

RESULTS

65 (28%) and 41 (18%) patients had sodium < lower limit of normal (LLN) at baseline and on-treatment, respectively. Baseline sodium < LLN was associated with shorter overall survival (OS) (6.1 vs. 10.3 months; p < .001) and progression-free survival (PFS) (2.8 vs. 3.5 months; p = .04). On-treatment sodium < LLN was associated with shorter OS (5.4 vs. 9.9 months; p < .001) and PFS (2.8 vs. 4.0 months; p < .001). In multivariate analyses adjusted for IMDC factors, baseline and on-treatment sodium < LLN were significantly associated with shorter OS (adjusted HR 1.46 (95% CI 1.04-2.05); p = .02; adjusted HR 1.80 (95% CI 1.23-2.61); p = .002; respectively). On-treatment sodium < LLN was significantly associated with progressive disease (OR 0.23 (95% CI 0.10-0.56); p = .001). A landmark analysis demonstrated that on-treatment hyponatremia was significantly associated with shorter OS and PFS (p = .01 and p = .03, respectively). On-treatment normalization of hyponatremia was associated with improved OS (unadjusted HR 0.61 (95% CI 0.35-0.98); p = .04), as compared to patients with sustained hyponatremia throughout follow-up.

CONCLUSIONS

Hyponatremia associates with poor outcome in mRCC patients treated with everolimus. On-treatment normalization of hyponatremia to normal sodium values associates with favorable outcome.

High salt loading increases brain derived neurotrophic factor in supraoptic vasopressin neurones

High salt loading (SL) is associated with inappropriate arginine vasopressin (AVP) release and increased mean arterial pressure. Previous work has shown that chronic high salt intake impairs baroreceptor inhibition of rat AVP neurones through brain-derived neurotrophic factor (BDNF) dependent activation of tyrosine receptor kinase B (TrkB) and down-regulation of K+/Cl- co-transporter KCC2. This mechanism diminishes the GABA_A inhibition of AVP neurones in the supraoptic nucleus (SON) by increasing intracellular chloride. However, the source of BDNF leading to this ionic plasticity is unknown. In the present study, we used adeno-associated viral vectors with short hairpin RNA against BDNF to test whether SON is the source of BDNF contributing to increased AVP release and elevated mean arterial pressure in high salt loaded rats. Virally mediated BDNF knockdown (shBDNF) in the SON of salt loaded rats significantly blocked the increases in BDNF mRNA and AVP heterogeneous RNA expression. The observed increase in the activation of TrkB receptor during salt loading is consistent with previous studies. Western blot analysis of SON punches revealed that tyrosine phosphorylation of TrkB (pTrkBY515) was significantly decreased in salt shBDNF rats compared to the salt scrambled (SCR) rats. Injections of shBDNF in the SON also significantly prevented the increase in plasma AVP concentration associated with salt loading. However, the salt loading induced increase in mean arterial pressure was not decreased with BDNF knockdown in the SON. Average daily fluid intake and urine output were significantly elevated in both salt SCR and salt shBDNF rats compared to the euhydrated controls. Daily average urine sodium concentration was significantly higher in shBDNF injected salt rats than the other groups. These findings indicate that BDNF produced in the SON contributes to the increased AVP secretion during high salt loading but not with respect to the subsequent increase in mean arterial pressure.

Changes in Daily Measures of Blood Pressure and Heart Rate Improve Weight-Based Detection of Heart Failure Deterioration in Patients on Telemonitoring

Blood pressure (BP) and heart rate (HR) are often captured in conjunction with weight in telemonitoring systems, but the additional prognostic potential of daily measurements of BP and HR in providing information on upcoming hospitalizations for worsening heart failure (HFH) have not been explored thoroughly. We retrospectively analyzed 267 daily home-telemonitored heart failure (HF) subjects. We extracted those episodes of HFHs that had sufficient data entries in the days leading up to hospitalization and tested the prognostic potential of 48 trend features based on weight, systolic BP, diastolic BP, pulse pressure (PP), and HR with a Naïve Bayesian model. The single best-performing trend feature-with a cross-validated estimate of 0.64 for the area under the curve (AUC) with a standard deviation (SD) of 0.01-is based on a 2-day weight trend. The best multivariate feature set (cross-validated [Formula: see text], [Formula: see text]) comprises of 2-day trend features based on weight, systolic BP, and HR. There were large variations in the weight trends preceding hospitalizations and weight change alone had a modest predictive ability. Readily interpretable features capturing trends in BP and HR provided additional prognostic information and can be used for improving classification.

Managing hyponatremia in lung cancer: latest evidence and clinical implications

Hyponatremia is the most common electrolyte disorder in lung cancer patients. This condition may be related to many causes including incidental medications, concurrent diseases and side effects of antineoplastic treatments or the disease itself. Although not frequently life-threatening, it is usually associated with prolonged hospitalization, delays in scheduled chemotherapy, worsening of patient performance status and quality of life and may also negatively affect treatment response and survival. Most of the available data focus on thoracic tumors, especially small-cell lung cancer (SCLC), where hyponatremia is frequently related to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Few studies specifically focus on non-small cell lung cancer (NSCLC) patients. Hyponatremia treatment needs to be personalized based on severity and duration of sodium serum reduction, extracellular fluid volume and etiology. However, literature data highlight the importance of early correction of the serum concentration levels. To achieve this the main options are fluid restriction, hypertonic saline, loop diuretics, isotonic saline, tolvaptan and urea. The aim of this review is to analyze the role of hyponatremia in lung cancer patients, evaluating causes, diagnosis, management and clinical implications.

The prognostic significance of serum sodium in a population undergoing cardiac resynchronisation therapy

PURPOSE

To determine the prognostic implications of changes towards hyponatremia at varying time-points in the treatment of patients undergoing cardiac resynchronisation therapy (CRT).

METHODS

A retrospective series of 249 patients was studied from 2002 to 2013. The population was categorized on the basis of serum sodium profile at baseline, at 1 month and at 6 month follow up visits following successful CRT implantation. The composite endpoint was all-cause mortality and heart failure hospitalisation (defined by the need for intravenous diuretic therapy) following CRT implantation.

RESULTS

A total of 249 patients (67.8±12.5 years; NYHA class III/IV 75; LVEF 27.2±8.8%) were followed up for a median of 5.5 years. Hyponatremia at baseline, 1 month or 6 months follow up did not predict the composite endpoint. 26% of patients showed hyponatremia at baseline prior to CRT implantation, while it was present in 19.9% of patients 1 month (p=0.003) and in 16% (p<0.001) 6 months after CRT implantation. There was a significantly worse outcome for those patients who developed hyponatremia 6 months after CRT implantation. In multivariate analysis, the intake of loop diuretics (HR 1.76 [1.04-2.95], p=0.03) and renal impairment (urea>7.0mmol/l) (HR 1.61 [1.05-2.46], p=0.03) at baseline were associated with an increased risk of unplanned heart failure hospitalisation and all-cause mortality after CRT implantation.

CONCLUSIONS

A change towards hyponatremia when observed 6 months after CRT implantation may predict a worse clinical outcome. Additionally, renal impairment and higher diuretic doses are associated with an increased risk of mortality in the population analysed.

Prognostic importance of sodium level trajectory in acute heart failure

Low sodium levels are strongly associated with poor prognosis in acute heart failure (AHF); however, the prognostic impact of the sodium level trajectory overtime has not been determined. A secondary analysis of the AQUAMARINE study in which patients with AHF and renal impairment were randomized to receive either tolvaptan or conventional treatment was performed. Sodium levels were evaluated at the baseline and at 6, 12, 24, and 48 h. We defined 'sodium dipping' as sodium level falling below the baseline level at any time point. The primary endpoint was the combined event of all-cause death and heart failure rehospitalization during follow-up. The analysis included 184 patients with a median follow-up of 21.1 months. Sodium levels more steeply increased during the 48 h in patients without events as compared to sodium levels in patients with events (P = 0.018 in linear-mixed effect model). The sodium dipping group (n = 100; 54.3%) demonstrated significantly less urine output, less body weight reduction, and poorer diuretic response within 48 h compared to the non-dipping group. The sodium dipping group was also significantly associated with a low combined-event-free survival after adjustment for other prognostic factors (HR 1.97; 95% CI 1.06-3.38; P = 0.033). The trajectory of sodium levels during the acute phase is associated with the prognosis of patients with AHF independently of the baseline sodium level.

Hyponatraemia - presentations and management

Hyponatraemia is the most common electrolyte disturbance encountered in clinical practice. It is associated with -significant morbidity and mortality, thus appropriate investigation and treatment is essential. Hyponatraemia presents with a spectrum of clinical presentations ranging from no symptoms to life-threatening neurological sequelae. Hyponatraemia has multiple aetiologies and distinguishing the underlying aetiology facilitates appropriate treatment. This review provides an overview of the presentations and approaches to management of this common clinical condition.

A Review of Prognostic Tools in Heart Failure

A minority of patients with end-stage disease are referred to palliative medicine for consultation in advanced heart failure. Educating stakeholders, including primary care, cardiology, and critical care of the benefits of hospice and palliative medicine for patients with poor prognosis, may increase appropriately timed referrals and improve quality of life for these patients. This article reviews multiple tools useful in prognostication in the setting of advanced heart failure.

Hyponatraemia and congestive heart failure refractory to diuretic treatment. Utility of tolvaptan

Heart failure (HF) is currently one of the most significant healthcare problems in Spain and has a continuously increasing prevalence. Advances in our understanding of the various biological responses that promote cardiac remodelling and pulmonary venous congestion constitute the basis of current treatment. This article, prepared by members of the HF groups of the Spanish Society of Cardiology and the Spanish Society of Internal Medicine, discusses the current therapeutic strategies for patients with congestion refractory to diuretic treatment. The article includes our clinical experience with the use of tolvaptan as an additional treatment for congestion associated with hyponatraemia. To this end, we propose an algorithm for the use of tolvaptan in patients with congestive HF, natraemia <130mEq/l and poor response to conventional diuretic treatment.

Benefit of tolvaptan in the management of hyponatraemia in patients with diuretic-refractory congestive heart failure: the SEMI-SEC project

Aims

Hyponatraemia is an electrolyte disorder that occurs in advanced congestive heart failure (HF) and worsens prognosis. We explored the usefulness of tolvaptan, which has shown promising results in the treatment of this condition.

Methods and results

This study is based on a retrospective national registry (2011–15) of patients hospitalized with refractory HF and hyponatraemia who agreed to receive tolvaptan when standard treatment was ineffective. The benefit of tolvaptan was analysed according to the following criteria: normalization ([Na⁺] ≥ 135 mmol/L) or increased sodium levels [Na⁺] ≥ 4 mEq/L on completion of treatment, and increase in urine output by 300 or 500 mL at 48 h. Factors associated with tolvaptan benefit were explored. A total of 241 patients were included, 53.9% of whom had ejection fraction <40%. All patients received concomitant loop diuretics. Initial tolvaptan dose was 17.2 ± 6.1 mg, and end dose was 26.4 ± 23.2 mg (duration 7.8 ± 8.6 days). Serum sodium concentrations increased significantly at 24–48 h, from 126.5 ± 6.2 mEq/L at baseline to 134.1 ± 6.1 mEq/L at the end of treatment (P < 0.0001). Weight fell by ~5 kg before discharge (P < 0.0001) and urine output increased 1.3‐fold (P < 0.0001). Normal sodium levels and/or increases of 500 mL in urine output were achieved by 90.8% of patients (35.7% achieved both) and 94.8% increased to [Na⁺] ≥ 4 mEq/L and/or +300 mL in urine output (54.4% both).

Conclusions

An increase in sodium levels and/or improvement in urine output was observed in patients admitted for HF and refractory hyponatraemia under tolvaptan treatment. Tolvaptan may be useful in this setting, in which no effective proven alternatives are available.

Use of Tolvaptan in a Patient With Palliated Congenital Heart Disease

Heart failure is a common problem in the ever growing population of patients with palliated congenital heart disease. It is frequently complicated by hyponatremia that has been associated with increased morbidity and mortality. Tolvaptan is a vasopressin receptor antagonist that has been effective in improving hyponatremia and congestive symptoms in adults with chronic heart failure. We describe the short-term use of tolvaptan to treat hyponatremic hypervolemia in an adolescent patient with chronic heart failure in the setting of palliated congenital heart disease prior to definitive surgical intervention. In this case, the patient had improvement in hyponatremia and a decrease in body weight, without any adverse effects.

Hyponatremia in patients hospitalized with heart failure: a condition often overlooked in low-income settings

Background

Hyponatremia is a common electrolyte abnormality in patients with heart failure (HF). It is independently associated with increased short-term and long-term morbidity and mortality. The main objective of this study was to assess patterns of hyponatremia and its association with discharge outcomes in patients with HF admitted to a teaching hospital in Ethiopia.

Patients and methods

This is a descriptive, prospective, hospital-based cohort study of patients with HF admitted to Jimma University Hospital, Ethiopia, between November 1, 2013 and July 31, 2014. A structured questionnaire was used to collect information on sociodemographic characteristics, clinical profile at admission, and outcomes at discharge. Plasma sodium concentration was analyzed at admission for all patients. The relationship between hyponatremia at admission and in-hospital mortality, as well as length of hospital stay, was assessed using both bivariate analysis and multivariable logistic regressions. The level of statistical significance was set at P<0.05.

Results

Of 152 participants admitted with HF, 44 (28.9%) had hyponatremia, which is defined as serum sodium level <135 mmol/L. Patients on salt restriction, on chronic diuretic treatment (furosemide and spironolactone), and with impaired renal function at admission were found to be highly affected. Hyponatremia was found to be associated with increased in-hospital mortality (P=0.008) and longer hospital stay (16.6 vs 12 days, P<0.001). Patients with hyponatremia also had lower blood pressure and poor functional status at discharge.

Conclusion

This study demonstrates that hyponatremia is highly prevalent in patients hospitalized with HF and is associated with increased in-hospital mortality and longer hospital stay. Thus, great emphasis should be given to identify high-risk patients, and prevention and early detection of hyponatremia to prevent its deleterious effects. Large-scale national studies are also needed to complement our findings.

Incidence and Risk Factors for Prolonged Hospitalization and Readmission after Transsphenoidal Pituitary Surgery

Objective

To evaluate the incidence and factors associated with 30-day readmission and to analyze risk factors for prolonged hospital length of stay following transsphenoidal pituitary surgery.

Study Design

Retrospective longitudinal claims analysis.

Setting

American College of Surgeons National Surgical Quality Improvement Program.

Subjects and Methods

The database of the American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent transsphenoidal pituitary surgery ( Current Procedural Terminology code 61548 or 62165) between 2005 and 2014. Patient demographic information, indications for surgery, and incidence of hospital readmission and length of stay were reviewed. Risk factors for readmission and prolonged length of stay, defined as >75th percentile for the cohort, were identified through logistic regression modeling.

Results

A total of 1006 patients were included for analysis. Mean hospital length of stay after surgery was 4.1 ± 0.2 days. Predictors of prolonged length of stay were operative time ( P < .001, odds ratio [OR] = 1.7, 95% confidence interval [95% CI] = 1.5-2.0), bleeding disorder ( P = .049, OR = 3.1, 95% CI = 1.0-9.5), insulin-dependent diabetes ( P = .007, OR = 2.4, 95% CI = 1.3-4.4), and reoperation ( P < .001, OR = 10.3, 95% CI = 4.7-23.9). In a subset analysis of 529 patients who had surgery between 2012 and 2014, 7.2% (n = 38) required hospital readmission. History of congestive heart failure (CHF) was a predictor of hospital readmission ( P = 0.03, OR = 12.7, 95% CI = 1.1-144.0).

Conclusion

This review of a large validated surgical database demonstrates that CHF is an independent predictor of hospital readmission after transsphenoidal surgery. Although CHF is a known risk factor for postoperative complications, it poses unique challenges to patients with potential postoperative pituitary dysfunction.

High serum osmolarity at admission determines a worse outcome in patients with heart failure: Is a new target emerging?

AIMS

The osmolarity of human serum is restricted to a tightly regulated range, and any deviation has clinical implications. Our aim in this study was to establish whether differences in serum osmolarity in heart failure (HF) patients are related with a worse outcome.

METHODS

We evaluated the prognostic value of serum osmolarity in patients with HF from the Spanish National Registry on Heart Failure (RICA), a multicenter, prospective registry that enrolls patients admitted for decompensated HF and follows them for 1year. Patients were divided into quartiles according to osmolarity levels. Primary endpoint was the combination of all-cause mortality and hospital readmissions for HF.

RESULTS

A total of 2568 patients (47.46% men) were included. Patients with higher osmolarity were older, presented more comorbidities (especially diabetes mellitus and chronic kidney disease), and consequently had higher levels of glucose, urea, creatinine and potassium. During the 1-year follow-up, mortality among the quartiles was 18% (Q1), 18% (Q2), 23% (Q3) and 28% (Q4), p<0.001. After adjusting for baseline characteristics, high serum osmolarity was significantly associated with all-cause mortality (RR 1.02, 95% CI 1.01-1.03, p<0.001). We also found a significant increase in the combined endpoint of mortality and readmission among quartiles with higher osmolarity (p<0.001). Diabetes, eGFR, Barthel index, systolic blood pressure, body mass index, hemoglobin, NYHA class and beta-blocking agents were also independently associated with the primary endpoint.

CONCLUSIONS

In patients admitted for decompensated HF, high serum osmolarity predicts a worse outcome, and is associated with a higher comorbidity burden, supporting its use as a candidate prognostic target in HF.

Posttransplant Hyponatremia Predicts Graft Failure and Mortality in Kidney Transplantation Recipients: A Multicenter Cohort Study in Korea

Although hyponatremia is related to poorer outcomes in several clinical settings, its significance remains unresolved in kidney transplantation. Data on 1,786 patients who received kidney transplantations between January 2000 and December 2011 were analyzed. The patients were divided into two groups according to the corrected sodium values for serum glucose 3 months after their transplantations (<135 mmol/L vs. ≥135 mmol/L). Subsequently, the hazard ratios (HRs) for biopsy-proven acute rejection, graft failure, and all-cause mortality were calculated after adjustments for several immunological and non-immunological covariates. 4.0% of patients had hyponatremia. Patients with hyponatremia had higher risks for graft failure and all-cause mortality than did the counterpart normonatremia group; the adjusted HRs for graft failure and mortality were 3.21 (1.47-6.99) and 3.03 (1.21-7.54), respectively. These relationships remained consistent irrespective of heart function. However, hyponatremia was not associated with the risk of acute rejection. The present study addressed the association between hyponatremia and graft and patient outcomes in kidney transplant recipients. Based on the study results, our recommendation is to monitor serum sodium levels after kidney transplantations.

Acid-base and electrolyte abnormalities in heart failure: pathophysiology and implications

Electrolyte and acid–base abnormalities are a frequent and potentially dangerous complication in subjects with congestive heart failure. This may be due either to the pathophysiological alterations present in the heart failure state leading to neurohumoral activation (stimulation of the renin–angiotensin–aldosterone system, sympathoadrenergic stimulation), or to the adverse events of therapy with diuretics, cardiac glycosides, and ACE inhibitors. Subjects with heart failure may show hyponatremia, magnesium, and potassium deficiencies; the latter two play a pivotal role in the development of cardiac arrhythmias. The early identification of these alterations and the knowledge of the pathophysiological mechanisms are very useful for the management of these patients.

Hyponatremia and Worsening Sodium Levels Are Associated With Long-Term Outcome in Patients Hospitalized for Acute Heart Failure

Background

Hyponatremia predicts poor prognosis in patients with acute heart failure (AHF). However, the association of the severity of hyponatremia and changes of serum sodium levels with long‐term outcome has not been delineated.

Methods and Results

The study population was drawn from the HARVEST registry (Heart Failure Registry of Taipei Veterans General Hospital), so that patients hospitalized for acute heart failure (AHF) composed this study. The National Death Registry was linked to identify the clinical outcomes of all‐cause mortality and cardiovascular death, with a follow‐up duration of up to 4 years. Among a total of 2556 patients (76.4 years of age, 67% men), 360 had on‐admission hyponatremia, defined as a serum sodium level of <135 mEq/L on the first day of hospitalization. On‐admission hyponatremia was a predictor for all‐cause mortality (hazard ratio and 95% CI: 1.43, 1.11–1.83) and cardiovascular mortality (1.50, 1.04–2.17), independent of age, sex, hematocrit, estimated glomerular filtration rate, left ventricular ejection fraction, and prescribed medications. Subjects with severe hyponatremia (<125 mEq/L) would even have worse clinical outcomes. During hospitalization, a drop of sodium levels of >3 mEq/L was associated with a marked increase of mortality than those with minimal or no drop of sodium levels. In addition, subjects with on‐admission hyponatremia and drops of serum sodium levels during hospitalization had an incremental risk of death (2.26, 1.36–3.74), relative to those with normonatremia at admission and no treatment‐related drop of serum sodium level in the fully adjusted model.

Conclusions

On‐admission hyponatremia is an independent predictor for long‐term outcomes in patients hospitalized for AHF. Combined the on‐admission hyponatremia with drops of serum sodium levels during hospitalization may make a better risk assessment in AHF patients.