Acute decompensated heart failure: pathophysiology and treatment

Temporal trends in acute decompensated heart failure outcomes: A single-center 11-year retrospective analysis

Background

Acute Decompensated Heart Failure (ADHF) is associated with frequent hospitalizations, posing a significant health and economic burden globally. Despite advancements in heart failure management, studies delineating temporal trends in ADHF outcomes are sparse.Methods: in this retrospective analysis, ADHF patients admitted to Shamir Medical Center from 2007 to 2017 were categorized into two cohorts: early (2007-2011) and recent (2012-2017). Clinical characteristics, in-hospital interventions, and outcomes were compared. Survival analysis was performed using Kaplan-Meier methods with log-rank tests.

Results

8332 admitted patients were analyzed, 4366 (52.4 %) in the early period, and 3966 (47.6 %) in the recent period. In the recent cohort, ischemic heart disease decreased significantly (from 45.2 % to 34.7 %), while hypertension and smoking rates increased. Additionally, a significant increase in coronary artery bypass grafting (from 0.8 % to 3.5 %) and beta-blockers prescription (from 45.5 % to 63.4 %) post-discharge was observed. However, no substantial improvement in in-hospital mortality (8.9 % in early vs. 8.0 % in recent), 30-day (3.2 % in early vs. 3.1 % in recent), 1-year (23.3 % in early vs. 23.8 % in recent), or 5-year survival rates was noted between cohorts. A subset analysis of patients admitted to cardiology departments showed a significant reduction in in-hospital mortality in the recent cohort (12.3 % in early vs. 6.3 % in recent), yet without a corresponding long-term survival benefit.

Conclusions

Advancements in heart failure management over the 11-year study period did not demonstrate an improvement in clinical outcomes for ADHF patients, highlighting the challenge of translating advancements in the medical care of ADHF patients into long-term survival benefits.

A Review of the Role of Statins in Heart Failure Treatment

BACKGROUND

Heart failure is a common medical problem in the world, which has a high prevalence in both developed and developing countries. Today, among the medications used for the heart failure treatment, there are many medications with a positive cardiac contraction effect (positive inotropic such as digital glycosides, adrenergic receptor stimulants, and phosphodiesterase inhibitors), a large number of cardiac diluents (such as Angiotensin-Converting Enzyme (ACE) inhibitor group), and a few other types of drugs whose final effects are still under review. Statins are valuable drugs that are broadly prescribed in hyperlipidemia and cardiovascular patients due to their multiple properties, such as cholesterol reduction, endothelial function improvement, antioxidative, anti-inflammatory, neovascularization, and immunomodulatory activities.

METHODS

There is evidence that the therapeutic role of statins in HF, due to myocardial hypertrophy, show reduction in cardiomyocyte loss in the apoptosis process, oxidative stress, inflammation, and also the return of neurohormonal imbalance. However, the fact that these drugs have no sideeffects has not been confirmed in all studies, as statins prevent the production of particular beneficial and protective factors, such as coenzyme Q10 (CoQ10), while inhibiting the production of specific proteins involved in pathologic mechanisms.

RESULTS

Recently, it has been hypothesized that, despite the positive effects reported, high doses of statins in patients with long-term heart failure lead to progress in heart failure by inhibiting CoQ10 synthesis and intensifying hypertrophy.

CONCLUSION

Thus, it can be stated that the advantage of using statins depends on factors, such as stroke fraction, and the existence of other standard indications such as atherosclerotic diseases or high Low-Density Lipoprotein-C (LDL-C).

L'insuffisance cardiaque aiguë aux urgences : présentations cliniques, diagnostic et prise en charge thérapeutique

L’insuffisance cardiaque (IC) est une maladie fréquente dont l'incidence croît dans tous les pays développés et dont la morbimortalité est effroyable. Devant une dyspnée aiguë, maître symptôme de la décompensation, le diagnostic d’insuffisance cardiaque aiguë (ICA) reste difficile aux urgences. En effet, les connaissances ayant permis de comprendre les mécanismes physiopathologiques, le concept nosologique d’une seule entité clinique a évolué vers la notion de syndromes d’ICA (SICA) intégrant plusieurs cadres nosographiques de la décompensation d’une IC chronique au tableau de détresse respiratoire aiguë dans l’œdème aigu du poumon cardiogénique, voire au choc cardiogénique. Afin de poser le diagnostic devant ces différentes formes de décompensations aiguës, l'urgentiste a recours à des examens complémentaires qui permettent de déterminer l'étiologie de l'épisode d'IC. Si la réalisation de l'électrocardiogramme et celle de la radiographie thoracique restent indispensables, l’utilisation de biomarqueurs cardiaques, au premier rang desquels les peptides natriurétiques se sont imposés, fait aujourd'hui partie intégrante des outils nécessaires à l'élaboration de la démarche diagnostique. Par ailleurs, la généralisation progressive de l'échographie clinique au sein des services d'urgences permet aujourd'hui d'améliorer la démarche diagnostique et de proposer une approche thérapeutique plus rapide. Ainsi, le concept moderne de « Time-to-therapy » prend-il tout son sens aux urgences où l'utilisation optimisée des différents traitements médicamenteux doit s'associer aux supports d'oxygénothérapie souvent nécessaires à la prise en charge de la dyspnée aiguë. Cet article se propose de faire une revue de la littérature et des recommandations actuelles afin d'assurer une prise en charge optimale des SICA aux urgences et en extrahospitalier.

Proposal for heart failure progression based on the 'chloride theory': worsening heart failure with increased vs. non-increased serum chloride concentration

AIMS

Chloride (Cl) is an established key electrolyte for the activation of the renin-angiotensin-aldosterone system. Recent studies have shown the serum Cl as a key electrolyte for the regulation of body fluid distribution in heart failure (HF) patients. The clinical differences of worsening HF status according to the changes in serum Cl concentration are unclear.

METHODS AND RESULTS

Data from 47 chronic HF patients were analysed. Upon worsening HF, each patient exhibited at least two HF-related signs. Blood tests included haemoglobin (Hb), haematocrit (Ht), mean red blood cell volume (MCV), albumin, serum solutes, and b-type natriuretic peptide. The relative change in the plasma volume (%PV) from stable to worsening HF was estimated as follows: 100 × {Hb (stable) × [1 - Ht (worse)]}/{Hb (worse) × [1 - Ht (stable)]} - 100. When patients were divided into two groups based on changes in serum Cl concentration from stable to worsening HF, the pathophysiologic features of the patients with increased Cl (range 1-23 mEq/L; n = 31) included a greater increase in serum sodium (2.94 ± 4.15 vs. -0.69 ± 3.75 mEq/L, P = 0.005), higher vascular expansion (12 ± 11.1 vs. 4.81 ± 7.94%, P = 0.026), a tendency towards a greater MCV (1.23 ± 2.36 vs. -0.06 ± 1.88 fL, P = 0.065), and preserved renal function defined by the absence of an increase of serum creatinine (-0.24 ± 0.39 vs. -0.05 ± 0.12 mg/dL, P = 0.057) compared to patients with non-increased Cl (range -9 to 0 mEq/L; n = 16). Clinically, the increased Cl group had fewer HF signs (2.65 ± 0.71 vs. 3.31 ± 0.79, P = 0.005) although the change in symptoms did not differ between groups (48% vs. 63%, P = 0.54).

CONCLUSIONS

The present study suggests a new clinical entity of worsening HF status, that is, HF with increased vs. non-increased serum Cl concentration from clinical stability to worsening HF.

β-Blockers on Discharge From Acute Atrial Fibrillation Are Associated With Decreased Mortality and Lower Cerebrovascular Accidents in Patients With Heart Failure and Reduced Ejection Fraction

The benefits of β-blockers in patients with heart failure (HF) with reduced ejection fraction (HFrEF) and atrial fibrillation (AF) are controversial. The Gulf Survey of Atrial Fibrillation Events was a prospective, multinational, observational registry of consecutive patients with AF recruited from the emergency department (ED). We studied the incidence of 6- and 12-month mortality, hospitalization for HF or AF, and stroke/transient ischemic attacks (TIAs) in patients with HFrEF, in relation to β-blockers on discharge from the ED or the subsequent hospital stay. Of the 344 patients with HFrEF and AF in the GULF-SAFE, 177 patients (53%) were discharged on β-blockers. Mortality was lower in those patients compared with the non-β-blockers group at 6 and 12 months (odds ratios [ORs] 0.31, 95% CI [0.16-0.61]; OR 0.30, 95% CI [0.16-0.55]; P = .001 for both, respectively), so was the risk of stroke/TIAs. However, hospitalizations for AF increased in the β-blockers group. Even after adjustment for several risk variables in 2 different models, the beneficial effect of β-blockers on mortality persisted, at the cost of more hospitalization for AF.

Non-withdrawal of beta blockers in acute decompensated chronic and de novo heart failure with reduced ejection fraction in a prospective multicentre study of patients with acute heart failure in the Middle East

OBJECTIVES

Beta blockers reduce mortality in heart failure (HF). However, it is not clear whether they should be temporarily withdrawn during acute HF.

DESIGN

Analysis of prospectively collected data.

SETTING

The Gulf aCute heArt failuRe rEgistry is a prospective multicentre study of patients hospitalised with acute HF in seven Middle Eastern countries.

PARTICIPANTS

5005 patients with acute HF.

OUTCOME MEASURES

We studied the effect of beta blockers non-withdrawal on intrahospital, 3-month and 12-month mortality and rehospitalisation for HF in patients with acute decompensated chronic heart failure (ADCHF) and acute de novo heart failure (ADNHF) and a left ventricular ejection fraction (LVEF) <40%.

RESULTS

44.1% of patients were already on beta blockers on inclusion. Among those, 57.8% had an LVEF <40%. Further, 79.9% were diagnosed with ADCHF and 20.4% with ADNHF. Mean age was 61 (SD 13.9) in the ADCHF group and 59.8 (SD 13.8) in the ADNHF group. Intrahospital mortality was lower in patients whose beta blocker therapy was not withdrawn in both the ADCHF and ADNHF groups. This protective effect persisted after multivariate analysis (OR 0.05, 95% CI 0.022 to 0.112; OR 0.018, 95% CI 0.003 to 0.122, respectively, p<0.001 for both) and propensity score matching even after correcting for variables that remained significant in the new model (OR 0.084, 95% CI 0.015 to 0.468, p=0.005; OR 0.047, 95% CI 0.013 to 0.169, p<0.001, respectively). At 3 months, mortality was still lower only in patients with ADCHF in whom beta blockers were maintained during initial hospitalisation. However, the benefit was lost after correcting for confounding factors. Interestingly, rehospitalisation for HF and length of hospital stay were unaffected by beta blockers discontinuation in all patients.

CONCLUSION

In summary, non-withdrawal of beta blockers in acute decompensated chronic and de novo heart failure with reduced ejection fraction is associated with lower intrahospital mortality but does not influence 3-month and 12-month mortality, rehospitalisation for heart failure,and the length of hospital stay.

TRIAL REGISTRATION NUMBER

NCT01467973; Post-results.

Comparison of metoprolol succinate versus carvedilol in time to cardiovascular admission in a Veterans Affairs healthcare system: An observational study

OBJECTIVE

To determine if metoprolol succinate or carvedilol is more effective in delaying the time to first cardiovascular disease hospital admission in systolic heart failure patients. As a secondary objective, to determine the most effective dose of each agent in delaying first cardiovascular disease hospital admission, including but not limited to heart failure exacerbation, myocardial infarction, ischemic heart disease, cardiac arrhythmias, or death.

METHODS

This study was a retrospective chart review of 272 veterans at the VA Boston Healthcare System newly started on metoprolol succinate (n = 157) or carvedilol (n = 115) between January 2000 and December 2008. After an 8-week study medication titration period, subjects were subcategorized into low-, medium-, and high-dose ranging groups and followed until the first cardiovascular disease hospitalization, death, or 365 days. The main outcome measure was time to first cardiovascular hospitalization or death.

RESULTS

The mean age (69.9 years vs. 67.9 years) and ejection fraction (26% vs. 25%) were comparable between study arms at baseline. Mean time to first cardiovascular disease hospitalization was significantly different (p = 0.001) between study groups with 330.6 days with in metoprolol succinate group vs. 282.6 days in the carvedilol groups. High-dose carvedilol significantly delayed time to first hospitalization in comparison to medium or low carvedilol doses (p = 0.015, p = 0.005). Low- and high-dose metoprolol succinate were not significantly different (p = 0.509) in time to first event, and both dosing groups fared better compared to medium dose metoprolol succinate (p = 0.046).

CONCLUSION

In this veteran patient population in need of additional heart failure treatments, metoprolol succinate use resulted in a delayed time to first cardiovascular disease hospitalization or death compared to carvedilol. Both low and high doses of metoprolol succinate showed a significant delay of time to first cardiovascular hospitalization compared to medium doses of metoprolol succinate. Higher doses of carvedilol showed a significant delay of time to cardiovascular hospitalization than lower carvedilol doses.

First clinical experience with TRV027: pharmacokinetics and pharmacodynamics in healthy volunteers

TRV027 is a novel β-arrestin biased peptide ligand of the angiotensin II type 1 receptor (AT1R). The compound antagonizes G protein coupling while simultaneously stimulating β-arrestin-mediated signaling. In preclinical studies, TRV027 reversibly reduced blood pressure while preserving renal function in a dog tachypaced heart failure model and stimulating cardiomyocyte contractility in vitro. This profile suggests that TRV027 may have unique benefits in acute heart failure, a condition associated with renin-angiotensin system activation. A first-time-in-human study was conducted with ascending doses of TRV027 to explore its tolerability, pharmacokinetics and pharmacodynamics in healthy volunteers. Subjects' salt intake was restricted to stimulate RAS activation. In this study TRV027 was safe and well tolerated with a short-half-life (ranging between 2.4 and 13.2 minutes) and dose-proportional increases in systemic exposure. Consistent with the pre-clinical findings, TRV027 reduced blood pressure to a greater degree in subjects with RAS activation, measured as elevated plasma renin activity, than in those with normal PRA levels. This study in sodium-restricted healthy subjects suggests that TRV027 will successfully target a core mechanism of acute heart failure pathophysiology. Further clinical studies with TRV027 in patients with heart failure are underway.

Cinaciguat, a soluble guanylate cyclase activator, unloads the heart but also causes hypotension in acute decompensated heart failure

AIMS

Cinaciguat (BAY 58-2667) is a novel soluble guanylate cyclase activator. This study evaluated the haemodynamic effect and safety of cinaciguat added to standard therapy in patients with acute decompensated heart failure (ADHF).

METHODS AND RESULTS

In this placebo-controlled, phase IIb study (NCT00559650), 139 patients admitted with ADHF, pulmonary capillary wedge pressure (PCWP) ≥18 mmHg, left ventricular ejection fraction <40%, and a pre-existing need for invasive haemodynamic monitoring were randomized 2:1 to cinaciguat:placebo (continuous i.v. infusion). The dose was titrated for 8 h and maintained for 16-40 h (starting dose: 100 μg/h). At 8 h, mean PCWP changed from 25.7 ± 5.0 mmHg by -7.7 mmHg with cinaciguat and from 25.0 ± 5.3 mmHg by -3.7 mmHg with placebo (P < 0.0001). The mean right atrial pressure changed from 12.4 ± 5.3 mmHg by -2.7 mmHg with cinaciguat and from 11.8 ± 4.9 mmHg by -0.6 mmHg with placebo (P= 0.0019). Cinaciguat also decreased the pulmonary and systemic vascular resistance and the mean arterial pressure, and increased the cardiac index (all P < 0.0001 vs. placebo). Systolic blood pressure changed by -21.6 ± 17.0 mmHg with cinaciguat and -5.0 ± 14.5 mmHg with placebo. Adverse events were experienced by 71 and 45% of patients receiving cinaciguat and placebo, respectively. No adverse effects on the 30-day mortality were seen; however, the trial was stopped prematurely due to an increased occurrence of hypotension at cinaciguat doses ≥200 µg/h.

CONCLUSION

Cinaciguat unloaded the heart in patients with ADHF. However, high doses were associated with hypotension.

The biological effect of pharmacological treatment on dimethylaminohydrolases (DDAH-1) and cationic amino acid transporter-1 (CAT-1) expression in patients with acute congestive heart failure

AIM

Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of nitric oxide (NO) which plays an important role in controlling vascular tone and regulates the contractile properties of cardiac myocytes. The aim of this study was to investigate the effect of pharmacological treatment on symmetric dimethylarginine (SDMA), ADMA and arginine plasma concentrations in patients with acute congestive heart failure (ACHF) through the evaluation of type-1 system cationic amino acid transporter-1/type 1 dimethylarginine dimethylaminohydrolases-1 (CAT-1/DDAH-1).

METHODS AND RESULTS

25 hospitalized cardiology patients with symptomatic acute congestive HF (NYHA Class III-IV) and impaired left ventricular (LV) function (ejection fraction<35%) were included in the study. ADMA, SDMA, and arginine plasma concentrations were assessed before and after pharmacological treatment by high performance liquid chromatography. All patients received an adequate pharmacological treatment for ACHF. ADMA and SDMA plasma levels were significantly higher after pharmacological treatment respect to baseline values (pre-treatment) (0.75 vs 0.48; 1.31 vs 1.03; p<0.01). Arginine plasma concentration was significantly lower after therapy respect to baseline values (0.78 vs 0.99; p<0.01). This is associated more with the modulation of DDAH-1 protein than with of CAT-1 system transport.

CONCLUSIONS

In patients with ACHF, acute renal impairment function and the modulation of metabolism and extracellular transport by the DDAH-1/CAT-1 system determine high ADMA and SDMA levels after therapy for acute congestive heart failure.

Validation of extravascular lung water measurement by single transpulmonary thermodilution: human autopsy study

Introduction

Gravimetric validation of single-indicator extravascular lung water (EVLW) and normal EVLW values has not been well studied in humans thus far. The aims of this study were (1) to validate the accuracy of EVLW measurement by single transpulmonary thermodilution with postmortem lung weight measurement in humans and (2) to define the statistically normal EVLW values.

Methods

We evaluated the correlation between pre-mortem EVLW value by single transpulmonary thermodilution and post-mortem lung weight from 30 consecutive autopsies completed within 48 hours following the final thermodilution measurement. A linear regression equation for the correlation was calculated. In order to clarify the normal lung weight value by statistical analysis, we conducted a literature search and obtained the normal reference ranges for post-mortem lung weight. These values were substituted into the equation for the correlation between EVLW and lung weight to estimate the normal EVLW values.

Results

EVLW determined using transpulmonary single thermodilution correlated closely with post-mortem lung weight (r = 0.904, P < 0.001). A linear regression equation was calculated: EVLW (mL) = 0.56 × lung weight (g) - 58.0. The normal EVLW values indexed by predicted body weight were approximately 7.4 ± 3.3 mL/kg (7.5 ± 3.3 mL/kg for males and 7.3 ± 3.3 mL/kg for females).

Conclusions

A definite correlation exists between EVLW measured by the single-indicator transpulmonary thermodilution technique and post-mortem lung weight in humans. The normal EVLW value is approximately 7.4 ± 3.3 mL/kg.

Trial registration

UMIN000002780.

Lung ultrasound: a new tool for the emergency physician

Patients with dyspnea are routinely assessed with physical examination, lung auscultation and chest X-rays. Auscultation and bedside radiography have a low accuracy in the critically ill. Chest X-ray images remain suboptimal in more than one-third of cases and are poorly correlated to lung CT images. Lung ultrasound is invaluable as a bedside diagnostic tool of the dyspneic patient since, in a few minutes, it may help distinguish the typical features of most common causes of dyspnea. The lung has been improperly considered to be poorly accessible using ultrasound, because air prevents the progression of the ultrasound beam with production of reverberation artifacts under the lung surface. This article reviews the scanning technique, and the normal and pathological findings of lung ultrasound, and underscores its utility in providing the emergency physician with a new, fast and reliable diagnostic tool.

Spectroscopic diagnosis of myocardial infarction and heart failure by Fourier transform infrared spectroscopy in serum samples

Cardiovascular disease is the leading cause of death in Western civilization. In this pilot study we evaluated a new method for the diagnosis of myocardial infarction and heart failure by determining the typical fingerprint in the infrared (IR) spectrum of 1 microL of a dried patient serum sample by Fourier transform IR spectroscopy. For classification, cluster analysis and artificial neural networks (ANN) were applied. In this study 567 subjects were enrolled, comprising 225 controls (Co) and 342 patients with myocardial infarction (MI) (n = 157) and heart failure (HF) (n = 185). By applying artificial neural network algorithms, the following sensitivities and specificities of the same spectra were determined: MI versus Co (98%, 97%), HF versus Co (98%, 100%), MI versus HF (100%, 100%), and MI plus HF versus Co (100%, 100%). Based on our data, mid-IR spectroscopy appears to be a promising new method to diagnose heart diseases from serum samples. Artificial neural network algorithms proved to be superior to cluster analysis for correct prediction.

Cinaciguat (BAY 58-2667) improves cardiopulmonary hemodynamics in patients with acute decompensated heart failure

BACKGROUND

Cinaciguat (BAY 58-2667) is the first of a new class of soluble guanylate cyclase activators in clinical development for acute decompensated heart failure. We aimed to assess the hemodynamic effects, safety, and tolerability of intravenous cinaciguat in patients with acute decompensated heart failure (pulmonary capillary wedge pressure > or =18 mm Hg).

METHODS AND RESULTS

After initial dose finding (part A; n=27), cinaciguat was evaluated in the nonrandomized, uncontrolled proof-of-concept part of the study (part B; n=33) using a starting dose of 100 microg/h, which could be titrated depending on hemodynamic response. Patients were categorized as responders if their pulmonary capillary wedge pressure decreased by > or =4 mm Hg compared with baseline. Final doses of cinaciguat after 6 hours of infusion in part B were 50 microg/h (n=2), 200 microg/h (n=12), and 400 microg/h (n=16). Compared with baseline, a 6-hour infusion of cinaciguat led to significant reductions in pulmonary capillary wedge pressure (-7.9 mm Hg), mean right atrial pressure (-2.9 mm Hg), mean pulmonary artery pressure (-6.5 mm Hg), pulmonary vascular resistance (-43.4 dynes . s . cm(-5)), and systemic vascular resistance (-597 dynes . s . cm(-5)), while increasing heart rate by 4.4 bpm and cardiac output by 1.68 L/min. The responder rate was 53% after 2 hours, 83% after 4 hours, and 90% after 6 hours. Cinaciguat was well tolerated, with 13 of 60 patients reporting 14 drug-related treatment-emergent adverse events of mild to moderate intensity, most commonly hypotension.

CONCLUSIONS

Cinaciguat has potent preload- and afterload-reducing effects, increasing cardiac output. Further investigation of cinaciguat for acute decompensated heart failure is warranted.

Twelve tips for teaching avoidance of diagnostic errors

BACKGROUND

Despite an increasing emphasis on patient safety on the part of healthcare systems worldwide, diagnostic error remains common. Errors frequently result in significant clinical consequences and persist despite remarkable advances in diagnostic technology. Most medical students and physician trainees receive little instruction regarding both the root causes of diagnostic errors and how to avoid such errors.

AIMS

This installment of the '12 tips' series discusses how to familiarize the learner with the cognitive underpinnings of diagnostic error. It also describes how to teach several approaches to the diagnostic process that may lessen the likelihood of error.

METHODS

Specific educational practices are discussed in detail. Emphasis is placed on describing meta-cognitive techniques, promoting the value of the clinical examination, and employing simple diagnostic strategies, including 'diagnostic time-outs' and the practice of 'worst-case scenario' medicine.

CONCLUSIONS

Clinical educators may help learners avoid diagnostic errors by employing several of the educational techniques described herein.

Effects of horsefly (Tabanidae) salivary gland extracts on isolated perfused rat heart

The speed with which horseflies (Diptera: Tabanidae) obtain a bloodmeal suggests they have potent vasodilators. We used isolated perfused rat heart to examine the vasoactivity of salivary gland extracts (SGEs) of three horsefly species, Hybomitra bimaculata Macquart, Tabanus bromius Linnaeus and Tabanus glaucopis Meigen. Administration of horsefly SGEs to the heart produced biphasic coronary responses: a decrease and subsequent increase in coronary flow (CF), characterized by initial vasoconstriction followed by prolonged vasodilation of coronary vessels. However, although SGEs of H. bimaculata induced a significant decrease in left ventricular pressure (LVP), the effect on changes in CF was not significant except at the highest dose tested. The ability to reduce LVP without significantly lowering CF, or affecting heart rate and rhythm, represents a unique set of properties that have considerable therapeutic potential if they can be reproduced by a single molecule.