Evaluation and monitoring of patients with acute heart failure syndromes

Diagnostic and Prognostic Value of Lung Ultrasound B-Lines in Acute Heart Failure With Concomitant Pneumonia

Purpose: To evaluate the potential confounding effect of concomitant pneumonia (PNM) on lung ultrasound (LUS) B-lines in acute heart failure (AHF).

Methods: We enrolled 86 AHF patients with (31 pts, AHF/PNM) and without (55 pts, AHF) concomitant PNM. LUS B-lines were evaluated using a combined antero-lateral (AL) and posterior (POST) approach at admission (T0), after 24 h from T0 (T1), after 48 h from T0 (T2) and before discharge (T3). B-lines score was calculated at each time point on AL and POST chest, dividing the number of B-lines by the number of explorable scanning sites. The decongestion rate (DR) was calculated as the difference between the absolute B-lines number at discharge and admission, divided by the number of days of hospitalization. Patients were followed-up and hospital readmission for AHF was considered as adverse outcome.

Results: At admission, AHF/PNM patients showed no difference in AL B-lines score compared with AHF patients [AHF/PNM: 2.00 (IQR: 1.44–2.94) vs. AHF: 1.65 (IQR: 0.50–2.66), p = 0.072], whereas POST B-lines score was higher [AHF/PNM: 3.76 (IQR: 2.70–4.77) vs. AHF = 2.44 (IQR: 1.20–3.60), p < 0.0001]. At discharge, AL B-lines score [HR: 1.907 (1.097–3.313), p = 0.022] and not POST B-lines score was found to predict adverse events (AHF rehospitalization) after a median follow-up of 96 days (IQR: 30–265) in the overall population.

Conclusions: Assessing AL B-lines alone is adequate for diagnosis, pulmonary congestion (PC) monitoring and prognostic stratification in AHF patients, despite concomitant PNM.

Acute Hemodynamic Index Predicts In-Hospital Mortality in Acute Decompensated Heart Failure

Fundamento

O exame físico permite a avaliação prognóstica de pacientes com insuficiência cardíaca (IC) descompensada, porém não é suficientemente confiável e depende da experiência clínica do profissional. Considerando as respostas hemodinâmicas a situações do tipo “luta ou fuga” tais como a admissão no serviço de emergência, foi proposto o índice hemodinâmico agudo (IHA), calculado a partir da frequência cardíaca e pressão de pulso.

Objetivo

avaliar a capacidade prognóstica intra-hospitalar do IHA na IC descompensada.

Métodos

estudo prospectivo, multicêntrico e observacional baseado no registro BREATHE, incluindo dados de hospitais públicos e privados no Brasil. Foram utilizadas análises ROC ( Receiver Operating Characteristic ), de estatística c e de regressão multivariada, assim como o critério de informação de Akaike, para testar a capacidade prognóstica do IHA. O valor-p < 0,05 foi considerado estatisticamente significativo.

Resultados

Foram analisados dados de 463 pacientes com IC com fração de ejeção reduzida a partir do registro BREATHE. A mortalidade intra-hospitalar foi de 9%. A mediana do IHA foi considerada o valor de corte (4 mmHg⋅bpm). Um baixo IHA (≤ 4 mmHg⋅bpm) foi encontrado em 80% dos pacientes falecidos. O risco de mortalidade intra-hospitalar em pacientes com baixo IHA foi 2,5 vezes maior que aquele para pacientes com IHA > 4 mmHg⋅bpm. O IHA foi capaz de predizer independentemente a mortalidade intra-hospitalar na IC aguda descompensada [sensibilidade: 0,786; especificidade: 0,429; AUC (área sob a curva): 0,607 (0,540-0,674), p = 0,010] mesmo depois dos ajustes para comorbidades e uso de medicamentos [razão de chances (RC): 0,061 (0,007-0,114), p = 0,025].

Conclusões

O IHA é capaz de predizer independentemente a mortalidade intra-hospitalar na IC aguda descompensada. Esse índice simples e realizado à beira do leito pode se mostrar útil em serviços de emergência. (Arq Bras Cardiol. 2021; 116(1):77-86)

Venom natriuretic peptides guide the design of heart failure therapeutics

Heart failure (HF) affects over 26 million people world-wide. It is a syndrome triggered by loss of normal cardiac function due to many acute (eg myocardial infarction) and/or chronic (eg hypertension) causes and characterized by mixed beneficial and deleterious activation of a complex of multifaceted neurohormonal systems the net effect of which frequently is further adverse disruption of pressure-volume homeostasis. Unlike the situation in chronic heart failure, current strategies for treatment of acute heart failure are empirical and lack a strong evidence base. Management includes any of a combination of vasodilators, diuretics and ionotropic agents depending on the hemodynamic profile of the patient. Despite the improvement in the options available to improve outcomes in patients with chronic HF, for several decades little gain has been made in the treatment of the acute decompensated state. Morbidity and mortality rates remain high necessitating new therapeutic agents. The cardiac natriuretic peptides (NPs) are key hormones in pressure-volume homoeostasis. There are three isoforms of mammalian NPs, namely ANP, BNP and CNP. These peptides bind to membrane-bound NP receptors (NPRs) on the heart, vasculature and kidney to lower blood pressure and circulating volume. Intravenous infusion of NPs in HF patients improves hemodynamic status but is associated with occasional severe hypotension. Apart from mammalian NPs, snake venom NPs are an excellent source of pharmacologically distinct ligands that offer the possibility of engineering NPs for therapeutic purposes. Venom NPs have long half-lives, differential NPR activation profiles and varied NPR specificity. The scaffolds of venom NPs encode the molecular information for designing NPs with longer half-lives and improved and differential vascular and renal functions. This review focuses on the structure-function paradigm of mammalian and venom NPs and the different peptide engineering strategies that have been utilized in the design of clinically relevant new NP-analogues.

UBE3A alleviates isoproterenol-induced cardiac hypertrophy through the inhibition of the TLR4/MMP-9 signaling pathway

Cardiac hypertrophy is considered to be a leading factor in heart function-related deaths. In this study, we explored the potential mechanism underlying cardiac hypertrophy induced by isoproterenol. Our results showed that isoproterenol induced cardiac hypertrophy in AC16 cells, as reflected by the increased cell surface area and increased hypertrophic markers, which was accompanied by increased ubiquitin-protein ligase E3a (UBE3A) expression. Moreover, UBE3A knockdown by siRNAs accelerated cardiac hypertrophy, suggesting that increased UBE3A expression induced by isoproterenol might be a protective response and UBE3A might be a protective factor against cardiac hypertrophy. Our study also revealed that UBE3A knockdown increased the protein expression of the TLR4/MMP-9 pathway that has been shown to be associated with cardiac hypertrophy, which suggested that UBE3A-mediated protection is likely to be associated with the blockade of the TLR4/MMP-9 signaling pathway. UBE3A might be thus a potential target gene for the treatment of cardiac hypertrophy.

Thermodilution vs Estimated Fick Cardiac Output Measurement in Clinical Practice: An Analysis of Mortality From the Veterans Affairs Clinical Assessment, Reporting, and Tracking (VA CART) Program and Vanderbilt University

Importance

Thermodilution (Td) and estimated oxygen uptake Fick (eFick) methods are widely used to measure cardiac output (CO). They are often used interchangeably to make critical clinical decisions, yet few studies have compared these approaches as applied in medical practice.

Objectives

To assess agreement between Td and eFick CO and to compare how well these methods predict mortality.

Design, Setting, and Participants

This investigation was a retrospective cohort study with up to 1 year of follow-up. The study used data from the Veterans Affairs Clinical Assessment, Reporting, and Tracking (VA CART) program. The findings were corroborated in a cohort of patients cared for at Vanderbilt University, an academic referral center. Participants were more than 15 000 adults who underwent right heart catheterization, including 12 232 in the Veterans Affairs cohort between October 1, 2007, and September 30, 2013, and 3391 in the Vanderbilt cohort between January 1, 1998, and December 31, 2014.

Exposures

A single cardiac catheterization was performed on each patient with CO estimated by both Td and eFick methods. Cardiac output was indexed to body surface area (cardiac index [CI]) for all analyses.

Main Outcomes and Measures

All-cause mortality over 90 days and 1 year after catheterization.

Results

Among 12 232 VA patients (mean [SD] age, 66.4 [9.9] years; 3.3% female) who underwent right heart catheterization in this cohort study, Td and eFick CI estimates correlated modestly (r = 0.65). There was minimal mean difference (eFick minus Td = -0.02 L/min/m2, or -0.4%) but wide 95% limits of agreement between methods (-1.3 to 1.3 L/min/m2, or -50.1% to 49.4%). Estimates differed by greater than 20% for 38.1% of patients. Low Td CI (<2.2 L/min/m2 compared with normal CI of 2.2-4.0 L/min/m2) more strongly predicted mortality than low eFick CI at 90 days (Td hazard ratio [HR], 1.71; 95% CI, 1.47-1.99; χ2 = 49.5 vs eFick HR, 1.42; 95% CI, 1.22-1.64; χ2 = 20.7) and 1 year (Td HR, 1.53; 95% CI, 1.39-1.69; χ2 = 71.5 vs eFick HR, 1.35; 1.22-1.49; χ2 = 35.2). Patients with a normal CI by both methods had 12.3% 1-year mortality. There was no significant additional risk for patients with a normal Td CI but a low eFick CI (12.9%, P = .51), whereas a low Td CI but normal eFick CI was associated with higher mortality (15.4%, P = .001). The results from the Vanderbilt cohort were similar in the context of a more balanced sex distribution (46.6% female).

Conclusions and Relevance

There is only modest agreement between Td and eFick CI estimates. Thermodilution CI better predicts mortality and should be favored over eFick in clinical practice.

Mechanical circulatory support devices: methods to optimize hemodynamics during use

INTRODUCTION

Mechanical circulatory support (MCS) is an increasingly utilized mode of therapy in the management of advanced heart failure, both as bridge to heart transplantation and destination therapy. As MCS becomes more prevalent, it is ever more important to understand the complex hemodynamics of these devices, as well as the strategies for hemodynamic optimization. Areas covered: This review provides an overview of hemodynamics in the normal human heart and the failing heart. We discuss the various short-term mechanical circulatory support devices and their hemodynamic consequences. We will then discuss the differences between left ventricular assist devices, and the impact of these differences on hemodynamics. We will describe the strategies for hemodynamic optimization using echocardiographic and invasive ramp studies. Finally, we will discuss the impact of speed changes with exercise and discuss future directions for advancements in MCS therapies. Expert commentary: We advocate for a deeper understanding of the hemodynamics underpinning MCS devices. We also recommend the more widespread use of ramp studies for speed optimization, which have been well validated across a number of different left ventricular assist device types.

Marked regional endothelial dysfunction in mottled skin area in patients with severe infections

Background

Mottling around the knee, reflecting a reduced skin blood flow, is predictive of mortality in patients with septic shock. However, the causative pathophysiology of mottling remains unknown. We hypothesized that the cutaneous hypoperfusion observed in the mottled area is related to regional endothelial dysfunction.

Methods

This was a prospective, observational study in a medical ICU in a tertiary teaching hospital. Consecutive adult patients with sepsis admitted to ICU were included. After resuscitation, endothelium-dependent vasodilation in the skin circulation was measured before and after iontophoresis of acetylcholine (Ach) in the forearm and the knee area. We analyzed the patterns of induced vasodilatation according to the presence or absence of mottling and vital status at 14 days.

Results

We evaluated 37 septic patients, including 11 without and 26 with septic shock. Overall 14-day mortality was 22%. Ten patients had mottling around the knee (10/37, 27%). In the knee area, the increased skin blood flow following iontophoresis of Ach was lower in patients with mottled skin as compared to patients without mottled skin (area under curve (AUC) 3280 (2643–6440) vs. 7980 (4233–19,707), both P < 0.05). In the forearm area, the increased skin blood flow following iontophoresis of Ach was similar in patients with and without mottled skin. Among patients with septic shock, the increased skin blood flow following iontophoresis of Ach in the knee area was significantly lower in non-survivors as compared to survivors at 14 days (AUC 3256 (2600–4426) vs. 7704 (4539–15,011), P < 0.01). In patients with septic shock, the increased skin blood flow in the forearm area following iontophoresis of Ach was similar in survivors and non-survivors at 14 days.

Conclusion

Mottling is associated with regional endothelial dysfunction in patients with septic shock. Endothelial dysfunction in the knee skin area was more pronounced in non-survivors than in survivors.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1742-x) contains supplementary material, which is available to authorized users.

Variation in Hospital Use and Outcomes Associated With Pulmonary Artery Catheterization in Heart Failure in the United States

BACKGROUND

There has been an increase in the use of pulmonary artery (PA) catheters in heart failure (HF) in the United States in recent years. However, patterns of hospital use and trends in patient outcomes are not known.

METHODS AND RESULTS

In the National Inpatient Sample 2001 to 2012, using International Classification of Diseases-Ninth Revision codes, we identified 11 888 525 adult (≥18 years) HF hospitalizations nationally, of which an estimated 75 209 (SE 0.6%) received a PA catheter. In 2001, the number of hospitals with ≥1 PA catheterization was 1753, decreasing to 1183 in 2011. The mean PA catheter use per hospital trended from 4.9 per year in 2001 (limits 1-133) to 3.8 per year in 2007 (limits 1-46), but increased to 5.5 per year in 2011 (limits 1-70). During 2001 to 2006, PA catheterization declined across hospitals; however, in 2007 to 2012, there was a disproportionate increase at hospitals with large bedsize, teaching programs, and advanced HF capabilities. The overall in-hospital mortality with PA catheter use was higher than without PA catheter use (13.1% versus 3.4%; P<0.0001); however, in propensity-matched analysis, differences in mortality between these groups have attenuated over time-risk-adjusted odds ratio for mortality for PA catheterization, 1.66 (95% confidence interval, 1.60-1.74) in 2001 to 2003 down to 1.04 (95% confidence interval, 0.97-1.12) in 2010 to 2012.

CONCLUSIONS

There is substantial hospital-level variability in PA catheterization in HF along with increasing volume at fewer hospitals over-represented by large, academic hospitals with advanced HF capabilities. This is accompanied by a decline in excess mortality associated with PA catheterization.

Acute Decompensated Heart Failure

Heart failure (HF) is a societal burden due to its high prevalence, frequent admissions for acute decompensated heart failure (ADHF), and the economic impact of direct and indirect costs associated with HF and ADHF. Common etiologies of ADHF include medication and diet noncompliance, arrhythmias, deterioration in renal function, poorly controlled hypertension, myocardial infarction, and infections. Appropriate medical management of ADHF in patients is guided by the identification of signs and symptoms of fluid overload or low cardiac output and utilization of evidence-based practices. In patients with fluid overload, various strategies for diuresis or ultrafiltration may be considered. Depending on hemodynamics and patient characteristics, vasodilator, inotropic, or vasopressor therapies may be of benefit. Upon ADHF resolution, patients should be medically optimized, have lifestyle modifications discussed and implemented, and medication concierge service considered. After discharge, a multidisciplinary HF team should follow up with the patient to ensure a safe transition of care. This review article evaluates the management options and considerations when treating a patient with ADHF.

Diagnosis and management of acute heart failure

Acute heart failure (AHF) is a life threatening clinical syndrome with a progressively increasing incidence in general population. Turkey is a country with a high cardiovascular mortality and recent national statistics show that the population structure has turned to an 'aged' population.As a consequence, AHF has become one of the main reasons of admission to cardiology clinics. This consensus report summarizes clinical and prognostic classification of AHF, its worldwide and national epidemiology, diagnostic work-up, principles of approach in emergency department,intensive care unit and ward, treatment in different clinical scenarios and approach in special conditions and how to plan hospital discharge.

Current Management of Heart Failure: When to Refer to Heart Failure Specialist and When Hospice is the Best Option

Heart failure is a common syndrome caused by different abnormalities of the cardiovascular system that result in impairment of the ventricles in filling or ejecting blood. It is one of the most common causes of hospitalization in the United States, with a very high cost to the health care system. This article focuses on the causes of left ventricle dysfunction and the presentation and management of heart failure, both acute and chronic.

Comprehensive Guideline for Care of Patients With Heart Failure

Heart failure (HF) is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood. More than 5.1 million people are living with HF in the United States today. This number will continue to rise with the increase in the aging population. With so many people living with HF, nurses need to be well versed on how best to care for them. The 2013 American College of Cardiology Foundation/American Heart Association guideline for the management of HF is a comprehensive guide for all clinicians caring for patients with HF. The updated guideline was developed to assist providers in decision making in the diagnosis and treatment of HF. The goals of the writing committee were to improve quality of care for patients with HF, optimize their outcomes, and improve the efficient use of various resources in the treatment of patients with HF.

Heart failure outcomes based on race and gender of patients in a medically undeserved area

The purpose of this descriptive study was to investigate changes in quality of life (QoL), disease severity and exercise tolerance of heart failure (HF) patients in a medically underserved clinic based on race and gender. Despite advances in the treatment of HF over the past decade, incidence, morbidity and mortality for patients continue to rise while QoL declines. HF is common in African-Americans and women; however, there is limited research focusing on race and gender variables. Health related QoL, disease severity measured by B-type natriuretic peptide blood test (BNP) and ejection fraction (EF), and exercise tolerance measured by six minute walk test (6MWT) were assessed at admission and at 6 months in a convenience sample of 53 patients. Variables were compared by race and gender. The sample was 67.9% African American and 62.3% male. Men had greater improvements than women in QoL, BNP, and EF, while women had greater improvements in the 6MWT. African Americans had greater improvements than Whites in all four variables. Even in the presence of disease severity in patients with New York Heart Association (NYHA) Class III and IV HF, there were significant improvements in QoL, BNP, HF outcomes demonstrating the importance of developing culturally sensitive and gender-specific treatment plans.

Early emergency management of acute decompensated heart failure

PURPOSE OF REVIEW

Acute decompensated heart failure (ADHF) is characterized by a complex spectrum of pathophysiology that emerges as a common clinical disease state, which manifests as a failure of the circulation to provide for the needs of the body systems. Whereas ADHF is often characterized by the findings of pulmonary congestion and dyspnea, a variety of clinical presentations are possible, with each requiring differing management strategies. This review examines the approach of the four-quadrant clinical profile for differentiation of the ADHF patient during the emergent resuscitative phase of the decompensation.

RECENT FINDINGS

Clinical and diagnostic information can be used to determine the relative degree of pulmonary congestion and peripheral tissue perfusion in patients suspected of ADHF. This information can be used in a four-quadrant approach to differentiate patients into pathophysiologic categories. These profiles can then be translated into management strategies from a physiology based perspective in which the specific mechanisms of the failure are targeted.

SUMMARY

ADHF can present in a variety of clinical forms in the emergent setting. Categorization of the ADHF patient according to their individual hemodynamic profile can assist in management decisions during the emergent resuscitative phase of the decompensation based upon an approach that targets causative pathophysiologic mechanisms.

Association of furosemide dose with clinical status, left ventricular dysfunction, natriuretic peptides, and outcome in clinically stable patients with chronic systolic heart failure

In chronic heart failure (HF), high daily doses of furosemide have been associated with increased mortality. The authors sought to evaluate the relationships between orally administered furosemide doses, clinical status, left ventricular (LV) dysfunction, N-terminal proBNP (NT-proBNP), and outcome in 400 outpatients with chronic HF and LV ejection fraction (EF) ≤ 45%. Clinical status, NT-proBNP levels, and estimated glomerular filtration rate (eGFR) were evaluated. Median follow-up duration was 32 months. The median values of daily-dose furosemide and of furosemide dose normalized to body surface area were 25 mg (12.5-62.5 mg) and 15 mg/m(2) (13-34 mg/m(2)), respectively. A total of 32% of patients had decompensated HF according to Framingham score and criteria for congestion. In clinically stable patients, a multivariable Cox model, which included clinical and echocardiographic parameters plus NT-proBNP, hemoglobin, and eGFR, showed that normalized furosemide dose (P=.017), anemia (P=.060), age (P=.080), and New York Heart Association class (P=.080) were predictors of all cause-mortality. In patients with decompensated HF, LV end-systolic volume index (P=.018), NT-proBNP (P=.060), and reduced eGFR (P=.070) were independently related to the outcome. Normalized furosemide dose was a major determinant of prognosis in patients with chronic HF but without ongoing signs and symptoms, and this suggests a possible negative interaction of this drug in clinically stable patients.

[Palliative medicine and advanced incurable illness]

Advanced incurable and life-threatening diseases of internal organs such as chronic obstructive pulmonary disease (COPD), heart failure, and terminal kidney failure are associated with considerable burden for the patients caused by pronounced symptoms (e.g., dyspnea, anxiety, depression) and unmet psychosocial needs. Nevertheless, in Germany addressing palliative medicine in the context of these disorders and co-treatment of these patients by cross-sector partnership with specialized palliative care physicians are not very developed. Against the background of an international perspective and current guidelines, general aspects of palliative care needs (symptom control, communication, advance care planning, etc.) are discussed together with the resultant implications for potential cooperation between internal medicine and palliative care as well as special aspects of the individual diseases (e.g., prognosis or implications of certain treatment options such as "automatic implantable cardioverter-defibrillator", AICD). Timely involvement of the specific expertise of palliative care medicine can ensure that the workload of the primary providers (and their teams) is reduced and better cross-sector management (hospital and home) of the severely ill patients and their families is achieved.

The interpretation of brain natriuretic peptide in critical care patients; will it ever be useful?

The measurement of B-type natriuretic peptide (BNP) is recommended for the diagnosis of decompensated heart failure, the prognosis of chronic heart failure is worse if BNP is increased and studies suggest that BNP is useful to guide therapy. A study by Di Somma and colleagues adds to the body of evidence showing that patients with a marked decrease in BNP concentrations during their hospital admission are less likely to be readmitted with a further adverse cardiac event than patients in whom BNP fails to decrease. However, the wider interpretation of BNP concentrations in critically ill patients with other conditions remains uncertain.

Clevidipine for severe hypertension in acute heart failure: a VELOCITY trial analysis

Acute severe hypertension occurs in approximately 50% of patients with acute heart failure (AHF). Clevidipine, the latest-generation dihydropyridine calcium channel blocker, may be useful in the treatment of this patient population. The Evaluation of the Effect of Ultra-Short-Acting Clevidipine in the Treatment of Patients With Severe Hypertension (VELOCITY) trial enrolled 126 patients with systolic blood pressure (SBP) >180 mm Hg for treatment with clevidipine to a patient-specific prespecified initial target range (ITR) of SBP to be achieved within 30 minutes. Of the enrolled patients, 19 had AHF on presentation. Primary end points were the percentage in whom ITR was achieved within 30 minutes and the number whose SBP was below the ITR after 3 minutes of clevidipine infusion. Among the 19 AHF patients in VELOCITY, median time to ITR was 11.3 minutes (95% confidence interval, 7-19). ITR was reached in most patients (94%) within 30 minutes. No patient had hypotension below the ITR, and heart rate remained stable. At 18 hours, 16 of 19 patients had received continuous clevidipine infusion, and their SBP was reduced by mean of 50 mm Hg (25%) from baseline. There were no treatment-related adverse events or adverse events that led to clevidipine discontinuation. Clevidipine safely decreases SBP in AHF and does not cause unexpected hypotension. The results of this post hoc subgroup analysis suggest that clevidipine is safe, well tolerated, and efficacious in AHF patients with hypertension.

Acute decompensated heart failure syndromes (ATTEND) registry. A prospective observational multicenter cohort study: rationale, design, and preliminary data

Acute heart failure syndromes (AHFS) are likely to increase in the future, and the high readmission rate of patients with AHFS is an important issue in Western countries. However, there are very few published epidemiological studies on AHFS in the Asia Pacific region. Because AHFS are heterogeneous, the characteristics, clinical profile, and management of AHFS should be clarified in an epidemiological study. The acute decompensated heart failure syndromes (ATTEND) registry is a prospective, observational, multicenter cohort study being performed in Japan and is the first epidemiological study of AHFS in the Asia Pacific region. This study is designed to investigate several aspects of AHFS as follows: (1) the registry allows patient-based data collection for precise evaluation of patient characteristics and short-term outcomes, including the readmission rate; (2) confirmation of clinical assessments can be performed, and new clinical assessments can be created; and (3) feedback allows the modification of guidelines for clinical management. The present report describes the clinical characteristics of patients with AHFS in Japan based on the preliminary data collected in this study, and the similarities and differences in characteristics of these patients compared with those in Western countries. Although most of the patient characteristics did not differ from those reported in Western studies, there are some unique findings in this study, including a high rate of treatment with carperitide (69.4%) and angiotensin II receptor blockers (53.9%) at discharge and a longer hospital stay (median 21 days). The ATTEND registry is designed to provide valuable information to clarify the characteristics of patients with AHFS to improve their management.

Continuous monitoring of intrathoracic impedance and right ventricular pressures in patients with heart failure

BACKGROUND

Hemodynamic monitoring using implantable devices may provide early warning of volume overload in patients with heart failure (HF). This study was designed to prospectively compare information from intrathoracic impedance monitoring and continuous right ventricular pressure measurements in patients with HF.

METHODS AND RESULTS

Sixteen patients with HF (age, 63.5+/-13.8 years; left ventricular ejection fraction, 23.2+/-11.3%; New York Heart Association, II and III) and a previous HF decompensation received both a cardiac resynchronization therapy defibrillator providing a daily average of intrathoracic impedance and an implantable hemodynamic monitor providing an estimate of the pulmonary artery diastolic pressure. At the end of a 6-month investigator-blinded period, baseline reference hemodynamic values were determined over 4 weeks during which the patient was clinically stable. A major HF event was defined as HF decompensation requiring hospitalization, IV diuretic treatment, or leading to death. Sixteen major HF events occurred in 10 patients. Within 30 days and 14 days before a major HF event, impedance decreased by 0.12+/-0.21 Omega/d and 0.20+/-0.20 Omega/d, respectively, whereas estimated pulmonary arterial diastolic pressure increased by 0.10+/-0.20 mm Hg/d and 0.16+/-0.15 mm Hg/d, respectively. During these periods, impedance decreased by 3.8+/-5.4 Omega (P<0.02) and 4.9+/-6.1 Omega (P<0.007), respectively, whereas estimated pulmonary arterial diastolic pressure increased by 5.8+/-5.7 mm Hg (P<0.002) and 6.8+/-6.1 mm Hg (P<0.001), respectively, compared with baseline. In all patients, impedance and estimated pulmonary arterial diastolic pressure were inversely correlated (r = -0.48+/-0.25). Within 30 days preceding a major HF event, this correlation improved to r =-0.58+/-0.24.

CONCLUSIONS

Decompensated HF develops based on hemodynamic derangements and is preceded by significant changes in intrathoracic impedance and right ventricular pressures during the month prior to a major clinical event. Impedance and pressure changes are moderately correlated. Future research may establish the complementary contribution of both parameters to guide diagnosis and management of patients with HF by implantable devices.

A single supratherapeutic dose of rolofylline does not prolong the QTcF interval in healthy volunteers

Rolofylline is a potent, selective adenosine A1 receptor antagonist that was under development for the treatment of patients with acute decompensated heart failure and renal function impairment. The 30-mg dose of rolofylline administered by intravenous infusion over 4 hours for 3 days represented the anticipated recommended clinical regimen of rolofylline. This was a randomized, double-blind, double-dummy, placebo-controlled, three-period crossover study performed with a single 2-hour intravenous infusion of 60 mg rolofylline, placebo, or oral moxifloxacin in healthy subjects. Plasma samples were collected for determination of rolofylline, M1-trans, and M1-cis pharmacokinetic parameters. The upper limit of the two-sided 90% confidence interval for the placebo-adjusted least squares mean change from baseline in QTcF interval for rolofylline was less than 5 msec at every time point. Moxifloxacin demonstrated an increase in QTcF of greater than 10 msec at 2, 2.5, and 3 hours postdose, thus establishing the sensitivity of the assay to detect modest increases in QTcF interval. Mean Cmax values of 1947.4, 739.2, and 54.8 nM were attained for rolofylline and its metabolites M1-trans and M1-cis, respectively, which were 2.2- to 3.1-fold higher than historic Cmax values seen at the anticipated clinical dose and regimen. Adenosine A1 receptor antagonism from a single supratherapeutic intravenous dose of 60 mg rolofylline over 2 hours was generally well tolerated and did not prolong the QTcF interval relative to placebo.

Rolofylline: a selective adenosine 1 receptor antagonist for the treatment of heart failure

BACKGROUND

Co-existent cardiac and renal dysfunction is increasingly recognized as both a predictor and mediator of poor outcomes in patients with advanced heart failure. Novel therapies, including adenosine receptor antagonists, are currently under development for the treatment of 'cardiorenal syndrome'.

OBJECTIVES

To review the pathophysiologic rationale for using rolofylline, a selective adenosine 1 receptor antagonist, in patients with cardiorenal syndrome; and to provide a critical overview of safety and efficacy data from clinical studies.

METHODS

We reviewed published data on the pharmacology of rolofylline, and used this to inform a comprehensive summary of preclinical and clinical trials. Cardiac and renal effects, and safety data with a particular reference to seizures, are highlighted.

RESULTS/CONCLUSION

Rolofylline facilitates diuresis and preserves renal function in patients with acute decompensated heart failure and renal dysfunction. Pilot data also suggest beneficial effects on symptoms and short-term outcomes. The risk of seizures may be minimized by excluding high-risk patients.

Comparison of pulmonary artery and aortic transpulmonary thermodilution for monitoring of cardiac output in patients with severe heart failure: validation of a novel method

OBJECTIVE

Hemodynamic monitoring with the pulmonary artery catheter is frequently used in the management of severe heart failure. For measurement of cardiac output (CO), transpulmonary thermodilution (TPTD) has recently been adopted into clinical practice as an alternative to pulmonary artery thermodilution. However, no data have been published on the comparability of the two methods for patients with severely reduced left ventricular function. Our objective was to evaluate the correlation between these two methods of CO determination in patients with severe left ventricular dysfunction.

DESIGN

Prospective observational clinical study.

SETTING

Cardiological intermediate care unit and medical intensive care unit of a university hospital.

PATIENTS

Twenty-nine patients with left ventricular ejection fraction <35% and symptoms of heart failure (New York Heart Association class III-IV).

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

The two methods of intermittent CO measurement were compared by simultaneously recording the results of pulmonary artery thermodilution and TPTD after injection of a cold saline bolus. Measurements were performed when clinically necessary. A total of 325 data pairs were analyzed. Mean CO of both methods was 4.4 L/min with a bias of 0.45 L/min (2 SD 1.20 L/min), resulting in a percentage error of 27.3%.

CONCLUSION

In patients with severely impaired left ventricular function, measurement of CO by TPTD provides valid results.

Can monitoring of intrathoracic impedance reduce morbidity and mortality in patients with chronic heart failure? Rationale and design of the Diagnostic Outcome Trial in Heart Failure (DOT-HF)

BACKGROUND

Chronic heart failure is associated with frequent hospitalisations which are often due to volume-overload decompensation. Monitoring of intrathoracic impedance, measured from an implanted device, can detect increases in pulmonary fluid retention early and facilitate timely treatment interventions.

OBJECTIVE

The DOT-HF trial is designed to investigate if ambulatory monitoring of intrathoracic impedance together with other device-based diagnostic information can reduce morbidity and mortality in patients with chronic heart failure who are treated with cardiac resynchronization therapy (CRT) and/or an implantable defibrillator (ICD).

METHODS

Approximately 2400 patients will be randomised in a 1:1 fashion to a management strategy with access to the diagnostic information from the implantable device ("access arm"), or a "control arm", where this information is not made available. Study subjects fulfil standard indications for CRT and/or ICD as outlined in current guidelines. In the access arm, a fluid alert algorithm is used to give early warning of decreasing intrathoracic impedance indicating a high risk of an impending volume-overload decompensation. The primary endpoint of DOT-HF is the composite of all-cause mortality or heart failure hospitalisation. Secondary and exploratory endpoints include all-cause mortality, the impact on total health care utilization, quality of life and cost effectiveness. The study is expected to close recruitment during 2010 and to report in 2012.

Nesiritide: the clinical experience

Nesiritide is an effective therapy in decreasing symptoms and left ventricular filling pressure in patients with acute decompensated heart failure. Health Canada has recently approved this agent for the management of this patient population. The clinical trials to date using nesiritide for the management of decompensated heart failure have been summarized. The clinical experience including indications for use, contraindications, dosage and monitoring has been reviewed. The following should serve as a general guide for the clinical use of nesiritide.

N-terminal pro-brain natriuretic peptide testing in the emergency department: beneficial effects on hospitalization, costs, and outcome

BACKGROUND

N-terminal pro-brain natriuretic peptide (NT-proBNP) is an established biomarker for heart failure. Assessment of this biomarker in patients with acute dyspnea presenting to the emergency department (ED) may aid diagnostic decision-making, resulting in improved patient care and reduced costs.

METHODS

In a prospective clinical trial, patients presenting with acute dyspnea to the ED of the Erasmus Medical College, Rotterdam, the Netherlands, were randomized for either rapid measurement or no measurement of NT-proBNP. For ruling out heart failure, cutoff values of 93 pg/mL in male and 144 pg/mL in female patients were used, and for ruling in heart failure, a cutoff value of 1,017 pg/mL was used. Time to discharge from the hospital and costs related to hospital admission were primary end points. Bootstrap analysis was used for comparison of costs and 30-day mortality between the NT-proBNP and control group.

RESULTS

A total of 477 patients (54% male) was enrolled. The mean age was 59 years, with 44% of patients having a history of cardiac disease. Median time to discharge from the hospital was 1.9 days (interquartile range [IQR], 0.12-8.4 days) in the NT-proBNP group (n = 241) compared with 3.9 days (IQR, 0.16-11.0 days) in the control group (n = 236) (P = .04). Introduction of NT-proBNP testing resulted in a trend toward reduction in costs related to hospital admission and diagnostic investigations of $1,364 per patient (95% CI $-246 to $3,215), whereas 30-day mortality was similar (15 patients in the NT-proBNP and 18 patients in the control group).

CONCLUSIONS

Introduction of NT-proBNP testing for heart failure in the ED setting reduces the time to discharge and is associated with a trend toward cost reduction.

New therapies in acute decompensated heart failure

PURPOSE OF REVIEW

Hospitalization and mortality rates associated with heart failure are persistently high. This is due partly to aging of the population but mostly to delayed progress in the pharmacological treatment of decompensated heart failure. We will review the current recommendations and most recent advancement in the pharmacological treatment of acute decompensated heart failure while providing a systematic approach to the management of this prevalent condition.

RECENT FINDINGS

Loop diuretics, nitrates and inotropes such as dobutamine and milrinone are the current mainstay of acute heart failure management although their associated morbidity and possible mortality have raised serious concerns. Recent vasoactive agents such as Nesiritide, Tolvaptan and more recently the inotropic agent Levosimedan could offer improved hemodynamics and congestive relief to patients in acute pulmonary edema.

SUMMARY

Despite the promising results of these agents, further clinical trials are required prior to their international approval as first-line therapy. Although we can be optimistic that these vasoactive drugs might have favorable clinical outcomes and improve the intricate management of decompensated heart failure, their associated mortality benefit remains unclear and controversial.

Advances in congestive heart failure management in the intensive care unit: B-type natriuretic peptides in evaluation of acute heart failure

BACKGROUND

Circulating concentrations of B-type natriuretic peptide (BNP) and the aminoterminal fragment (NT-proBNP) of its prohormone (proBNP) are increased in congestive heart failure in proportion to the severity of symptoms, the degree of left ventricular dysfunction, and cardiac filling pressures. Following the introduction of rapid, automated assays for determination of BNP and NT-proBNP, these peptides are increasingly used for diagnostic and prognostic purposes.

OBJECTIVE

To review studies evaluating the diagnostic and prognostic value of BNP and NT-proBNP, with special emphasis on their performance as indicators of acute heart failure in the intensive care unit.

RESULTS

In patients presenting with acute dyspnea, both BNP and NT-proBNP are accurate indicators of acute heart failure and provide prognostic information above and beyond conventional risk markers. Increased plasma levels of BNP and NT-proBNP are not specific for heart failure and may be influenced by a variety of cardiac and noncardiac conditions commonly seen in the intensive care unit, including myocardial ischemia, cardiac arrhythmias, sepsis, shock, anemia, renal failure, hypoxia, acute pulmonary embolism, pulmonary hypertension, and acute respiratory distress syndrome.

CONCLUSIONS

The diagnostic performance of BNP and NT-proBNP as indicators of acute heart failure depends on the clinical setting. In the intensive care unit, particular caution should be used in the interpretation of elevated BNP and NT-proBNP levels.

Proactive monitoring: implications of implantable devices for future heart failure management

Heart failure (HF) decompensation continues to account for approximately 1 million hospitalizations per year in the United States. Pulmonary congestion is the hallmark sign of worsening HF. Better strategies aimed at identifying subclinical congestion would be of great value in the management of HF. Implantable hemodynamic and/or thoracic impedance monitoring systems, both currently available and under investigation, can detect pulmonary congestion before traditional signs and symptoms occur. These implantable monitors can provide valuable information of ongoing fluid status. Data retrieval can be useful for monitoring effectiveness of treatment and patient teaching, thereby resulting in an individualized treatment regimen based on real-time data. Proactive monitoring of HF patients may prevent future HF decompensation.

Management of acute decompensated heart failure

Acute decompensated heart failure is the most common cause for hospitalization among patients over 65 years of age. It may result from new onset of ventricular dysfunction or, more typically, exacerbation of chronic heart failure symptoms. In-hospital mortality remains high for both systolic and diastolic forms of the disease. Therapy is largely empirical as few randomized, controlled trials have focused on this population and consensus practice guidelines are just beginning to be formulated. Treatment should be focused upon correction of volume overload, identifying potential precipitating causes, and optimizing vasodilator and beta-adrenergic blocker therapy. The majority of patients (>90%) will improve without the use of positive inotropic agents, which should be reserved for patients with refractory hypotension, cardiogenic shock, end-organ dysfunction, or failure to respond to conventional oral and/or intravenous diuretics and vasodilators. The role of aldosterone antagonists, biventricular pacing, and novel pharmacological agents including vasopressin antagonists, endothelin blockers, and calcium-sensitizing agents is also reviewed.

Phosphodiesterase 5A Inhibition Induces Na + /H + Exchanger Blockade and Protection Against Myocardial Infarction

Acute phosphodiesterase 5A inhibition by sildenafil or EMD360527/5 promoted profound inhibition of the cardiac Na(+)/H(+) exchanger (NHE-1), detected by the almost null intracellular pH recovery from an acute acid load (ammonium prepulse) in isolated papillary muscles from Wistar rats. Inhibition of phosphoglycerate kinase-1 (KT5823) restored normal NHE-1 activity, suggesting a causal link between phosphoglycerate kinase-1 increase and NHE-1 inhibition. We then tested whether the beneficial effects of NHE-1 inhibitors against the deleterious postmyocardial infarction (MI) remodeling can be detected after sildenafil-mediated NHE-1 inhibition. MI was induced by left anterior descending coronary artery ligation in Wistar rats, which were randomized to placebo or sildenafil (100 mg kg(-1) day(-1)) for 6 weeks. Sildenafil significantly increased left ventricular phosphoglycerate kinase-1 activity in the post-MI group without affecting its expression. MI increased heart weight/body weight ratio, left ventricular myocyte cross-sectional area, interstitial fibrosis, and brain natriuretic peptide and NHE-1 expression. Sildenafil blunted these effects. Neither a significant change in infarct size nor a change in arterial or left ventricular systolic pressure was detected after sildenafil. MI decreased fractional shortening and the ratio of the maximum rate of rise of LVP divided by the pressure at the moment such maximum occurs, effects that were prevented by sildenafil. Intracellular pH recovery after an acid load was faster in papillary muscles from post-MI hearts (versus sham), whereas sildenafil significantly inhibited NHE-1 activity in both post-MI and sildenafil-treated sham groups. We conclude that increased phosphoglycerate kinase-1 activity after acute phosphodiesterase 5A inhibition blunts NHE-1 activity and protects the heart against post-MI remodeling and dysfunction.

Management of acute decompensated heart failure

Acute decompensated heart failure represents a heterogeneous group of disorders that typically present as dyspnea, edema and fatigue. Despite the high prevalence of this condition and its associated major morbidity and mortality, diagnosis can be difficult, and optimal treatment remains poorly defined. Identification of the acute triggers for the decompensation as well as noninvasive characterization of cardiac filling pressures and output is central to management. Diuretics, vasodilators, continuous positive airway pressure and inotropes can be used to alleviate symptoms. However, few agents currently available for the treatment of acute decompensated heart failure have been definitively shown in large prospective randomized clinical trials to provide meaningful improvements in intermediate-term clinical outcomes. Multiple novel therapies are being developed, but previous treatment failures indicate that progress in the management of acute decompensated heart failure is likely to be slow.

Early postoperative tako-tsubo-like left ventricular dysfunction: transient left ventricular apical ballooning syndrome

We diagnosed transient left ventricular apical wall motion abnormalities after surgery in a patient presenting with a clinical and electrocardiographic picture of acute myocardial infarction in the absence of significant coronary disease. These angiographic, clinical, and electrocardiographic features satisfied the criteria of the recently described tako-tsubo-like left ventricular dysfunction.

Impedance cardiography for cardiac output estimation: reliability of wrist-to-ankle electrode configuration

BACKGROUND

Non-invasive measurement of cardiac output (CO) may become an important modality for the treatment of heart failure. Among the several methods proposed, impedance cardiography (ICG) has gained particular attention. There are 2 basic technologies of ICG: thoracic and whole-body ICG whereby the electrodes are applied either to the chest or to the limbs. The present study is aimed to test the effectiveness of the Non-Invasive Cardiac System (NICaS), a new ICG device working with a wrist-to-ankle configuration.

METHODS AND RESULTS

To evaluate the reliability of NICaS derived CO (NI-CO), 50 CO measurements were taken simultaneously with thermodilution (TD-CO) and modified Fick (Fick-CO) in 35 cardiac patients, with the TD-CO serving as the gold-standard for the evaluation. Overall, 2-tailed Pearson's correlation and Bland-Altman limits of agreement between NI-CO and TD-CO were r=0.91 and -1.06 and 0.68 L/min and between Fick-CO and TD-CO, r=0.80 and -1.52 and 0.88 L/min, respectively. Good correlation was observed in patients with loading conditions altered by nitroglycerin and also in patients with moderate valvular diseases.

CONCLUSION

Agreement between NI-CO and TD-CO is within the boundaries of the FDA guidelines of bio-equivalence. NI-CO is applicable for non-invasive assessment of cardiac function.