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Fudim M, Kittipibul V, Molinger J, Yaranov DM, Miller WL. Patient Sex Impacts Volume Phenotypes and Hemodynamics in Chronic Heart Failure: A Multicenter Analysis. J Card Fail 2024:S1071-9164(24)00201-X. [PMID: 38880247 DOI: 10.1016/j.cardfail.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 04/22/2024] [Accepted: 05/13/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Quantitative methods have shown clinically significant heterogeneity in blood volume (BV) profiles in patients with chronic heart failure (HF). How patients' sex might impact this volume heterogeneity and its relationship to cardiac hemodynamics remains to be defined. METHODS Retrospective analysis of clinical and quantitative BV, plasma volume (PV) and red blood cell (RBC) mass data was undertaken across 3 medical centers. BV was quantitated using nuclear medicine I-131-labeled plasma albumin indicator-dilution methodology with cardiac hemodynamics obtained within 24 hours. RESULTS In an analysis of 149 males and 106 females, absolute BV was greater, on average, in males (6.9 ± 1.7 vs 5.0 ± 1.2 liters; P < 0.001); however, a wide range in BVs was demonstrated in both sexes (2.9-14.5 liters). Male sex was associated with higher prevalence of large (+ 25% of normal) BV and PV expansions (36% vs 15% and 51% vs 21%, respectively; both P < 0.001). In contrast, female sex was associated with higher prevalence of normal total BV (44% vs 27%; P = 0.005), PV (54% vs 27%; P < 0.001), hypovolemia (23% vs 11%; P = 0.005), and true anemia (42% vs 26%; P < 0.001). Cardiac hemodynamics differed by sex, but only modest associations were demonstrated between volume profiles and cardiac filling pressures. CONCLUSIONS Findings support unique intravascular volume profiles reflecting sex-specific differences in the prevalence and distributions of total BV, PV and RBC mass profiles in patients with chronic HF. This underscores the importance of recognizing patients' sex as a significant factor influencing volume homeostasis, which needs to be taken into account to individualize volume-management strategies effectively.
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Affiliation(s)
- Marat Fudim
- Department of Medicine, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC.
| | - Veraprapas Kittipibul
- Department of Medicine, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Jeroen Molinger
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Dmitry M Yaranov
- Department of Cardiology, Baptist Memorial Hospital, Memphis, TN
| | - Wayne L Miller
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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2
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Miller WL, Grill DE, Mullan BP. Comparison of Blood Volume Profiles in Heart Failure With Preserved and Reduced Ejection Fractions: Sex Makes a Difference. Circ Heart Fail 2024; 17:e010906. [PMID: 38842508 DOI: 10.1161/circheartfailure.123.010906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 04/10/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Blood volume (BV) profiles vary markedly in patients with heart failure (HF), but how HF phenotypes and patient sex impact volume profiles remain to be explored. The aim of the study was to differentiate BV, plasma volume, and red blood cell mass profiles by phenotypes of preserved and reduced left ventricular ejection fractions and assess the impact of patient sex on profile heterogeneity. METHODS Retrospective analysis of clinical and BV data was undertaken in patients with chronic New York Heart Association II-III heart failure. BV was quantitated using the nuclear medicine indicator-dilution methodology. RESULTS A total of 530 BV analyses (360 HF with reduced ejection fraction and 170 HF with preserved ejection fraction) were identified in 395 unique patients. Absolute BV was greater in HF with reduced ejection fraction (6.7±1.8 versus 5.9±1.6 liters: P<0.001); however, large variability in frequency distribution of volume profiles was observed in both phenotypes (-22% deficit to +109% excess relative to normal volumes). HF with reduced ejection fraction was characterized by a higher prevalence of BV expansion ≥+25% of normal (39% versus 26%; P=0.003), and HF with preserved ejection fraction was characterized a by more frequent normal BV (42% versus 24%; P<0.001). Male sex in both phenotypes was associated with a larger absolute BV (7.0±1.6 versus 5.1±1.3 liters; P<0.001) and higher frequency of large BV and plasma volume expansions above normal (both P<0.001), while females in both phenotypes demonstrated a higher prevalence of normal BV and plasma volume (both P<0.001). CONCLUSIONS Findings support significant differences in BV, plasma volume, and red blood cell mass profile distributions between heart failure phenotypes, driven in large part by sex-specific factors. This underscores the importance of identifying and distinguishing individual patient volume profiles to help guide volume management strategies.
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Affiliation(s)
- Wayne L Miller
- Department of Cardiovascular Medicine (W.L.M.), Mayo Clinic, Rochester, MN
| | - Diane E Grill
- Department of Biomedical Statistics and Informatics (D.E.G.), Mayo Clinic, Rochester, MN
| | - Brian P Mullan
- Division of Diagnostic Radiology and Nuclear Medicine (B.P.M.), Mayo Clinic, Rochester, MN
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Chen H, Zhen Z, Dong Y, Liu C, Dong B, Xue R. Hemoglobin to red cell distribution width ratio: A predictor of clinical outcome and diuretic response in patients with acute heart failure. Int J Cardiol 2024; 394:131368. [PMID: 37739043 DOI: 10.1016/j.ijcard.2023.131368] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/11/2023] [Accepted: 09/15/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Hemoglobin to Red Cell Distribution Width Ratio (HRR) is a novel inflammatory marker in the prognostic assessment of tumors. Nevertheless, its focus on the cardiovascular field is relatively limited, particularly regarding its correlation with diuretic responses and clinical outcomes. METHODS This is a secondary analysis of the Renal Optimization Strategies Evaluation (ROSE AHF) clinical trial. The outcomes of interest included all-cause death, rehospitalization and diuretic responses. Multivariable Cox proportional hazard regression and linear regression models were performed, respectively. Prognostic outcomes and diuretic response were further evaluated in ejection fraction (EF) subgroups (preserved EF ≥ 50% and reduced EF<50%). RESULTS A total of 351 patients were included in the present study and further categorized according to HRR median (0.7131) value at admission: low HRR group (n = 176) and high HRR group (n = 175). High HRR were found to be independently associated with decreased risk of all-cause death (HR = 0.51; 95% CI,0.30-0.87, P = 0.013), reduced risk of developing all-caused death or rehospitalization (HR = 0.62; 95% CI,0.39-0.98, P = 0.039). Furthermore, high HRR indicated lower cumulative urine output (OR: -992.33, P = 0.004) and less weight loss (OR: 3.08, P < 0.001) within 72 h after diuresis. Subgroup analysis revealed no significant interaction effect between EF and HRR in prognostic impact or diuretic responses, and HRR was negatively correlated with plasma volume. CONCLUSION High HRR demonstrated a lower risk of developing adverse clinical outcomes and a poorer diuretic response that might be due to less volume overload in AHF patients.
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Affiliation(s)
- Hao Chen
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, PR China; NHC Key Laboratory of Assisted Circulation and Vascular Diseases, Sun Yat-sen University, Guangzhou 510080, PR China; National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou 510080, PR China
| | - Zhe Zhen
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, PR China; NHC Key Laboratory of Assisted Circulation and Vascular Diseases, Sun Yat-sen University, Guangzhou 510080, PR China; National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou 510080, PR China
| | - Yugang Dong
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, PR China; NHC Key Laboratory of Assisted Circulation and Vascular Diseases, Sun Yat-sen University, Guangzhou 510080, PR China; National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou 510080, PR China
| | - Chen Liu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, PR China; NHC Key Laboratory of Assisted Circulation and Vascular Diseases, Sun Yat-sen University, Guangzhou 510080, PR China; National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou 510080, PR China
| | - Bin Dong
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, PR China; NHC Key Laboratory of Assisted Circulation and Vascular Diseases, Sun Yat-sen University, Guangzhou 510080, PR China; National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou 510080, PR China.
| | - Ruicong Xue
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, PR China; NHC Key Laboratory of Assisted Circulation and Vascular Diseases, Sun Yat-sen University, Guangzhou 510080, PR China; National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou 510080, PR China.
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Scicchitano P, Iacoviello M, Massari A, De Palo M, Potenza A, Landriscina R, Abruzzese S, Tangorra M, Guida P, Ciccone MM, Caldarola P, Massari F. Anaemia and Congestion in Heart Failure: Correlations and Prognostic Role. Biomedicines 2023; 11:biomedicines11030972. [PMID: 36979951 PMCID: PMC10046168 DOI: 10.3390/biomedicines11030972] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/13/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
The aim of this study was to evaluate the relationship between anaemia and biomarkers of central/peripheral congestion in heart failure (HF) and the impact on mortality. We retrospectively evaluated 434 acute/chronic HF (AHF/CHF) patients. Anaemia was defined as haemoglobin levels <12 g/dL (women) or <13 g/dL (men). The brain natriuretic peptide (BNP) and hydration index (HI) were measured. The endpoint of the study was all-cause mortality. Anaemia occurred in 59% of patients with AHF and in 35% with CHF (p < 0.001) and showed a significant correlation with the NYHA functional class and renal function. BNP and HI were significantly higher in patients with anaemia than in those without anaemia. Independent predictors of anaemia included BNP, estimated creatinine clearance (eCrCL), and HI. The all-cause mortality rate was 21%, which was significantly higher in patients with anaemia than in those without anaemia (30% vs. 14%, p < 0.001; hazard ratio: 2.6). At multivariate Cox regression analysis, BNP, eCrCL, and HI were independent predictors for mortality (Hazard ratios: 1.0002, 0.97, and 1.05, respectively), while anaemia was not. Anaemia correlates with HF status, functional class, renal function, BNP, and HI. Anaemia was not an independent predictor for mortality, acting as a disease severity marker in congestive patients rather than as a predictor of death.
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Affiliation(s)
- Pietro Scicchitano
- Cardiology Section, Hospital "F. Perinei" Altamura, 70022 Altamura, Italy
| | - Massimo Iacoviello
- Cardiology Unit, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy
| | | | - Micaela De Palo
- Cardiac Surgery Unit, Policlinic University Hospital, 70124 Bari, Italy
| | - Angela Potenza
- Cardiology Section, Hospital "F. Perinei" Altamura, 70022 Altamura, Italy
| | | | - Silvia Abruzzese
- Cardiology Section, Hospital "F. Perinei" Altamura, 70022 Altamura, Italy
| | - Maria Tangorra
- Cardiology Section, Hospital "F. Perinei" Altamura, 70022 Altamura, Italy
| | - Piero Guida
- Ospedale Generale Regionale "F. Miulli", 70021 Acquaviva delle Fonti, Italy
| | - Marco Matteo Ciccone
- Cardiology Unit, Policlinic University Hospital, Piazza Giulio Cesare 11, 70124 Bari, Italy
| | | | - Francesco Massari
- Cardiology Section, Hospital "F. Perinei" Altamura, 70022 Altamura, Italy
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5
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Miller WL. Fluid Volume Homeostasis in Heart Failure: A Tale of 2 Circulations. J Am Heart Assoc 2022; 11:e026668. [PMID: 36073644 DOI: 10.1161/jaha.122.026668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Fluid volume homeostasis in health and heart failure (HF) requires a complex interaction of 2 systems, the intravascular and interstitial-lymphatic circulations. With the development of HF both the intravascular and interstitial compartments undergo variable degrees of volume remodeling which can include significant expansion. This reflects the impact of multiple pathophysiologic mechanisms on both fluid compartments which initially play a compensatory role to stabilize intravascular circulatory integrity but with progression in HF can evolve to produce the various manifestations of volume overload and clinical HF congestion. The intent of this review is to help enhance recognition of the pathophysiologic and clinical importance of the interlinked roles of these 2 circulatory systems in volume regulation and chronic HF. It would also be hoped that a better understanding of the interacting functions of the intravascular and interstitial-lymphatic fluid compartments can potentially aid development of novel management strategies particularly addressing the generally undertargeted interstitial-lymphatic system and help bring such approaches forward through a more integrated view of these 2 circulatory systems.
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Affiliation(s)
- Wayne L Miller
- Division of Circulatory Failure, Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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6
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Comparison of device-based therapy options for heart failure with preserved ejection fraction: a simulation study. Sci Rep 2022; 12:5761. [PMID: 35388023 PMCID: PMC8987034 DOI: 10.1038/s41598-022-09637-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/25/2022] [Indexed: 12/29/2022] Open
Abstract
Successful therapy of heart failure with preserved ejection fraction (HFpEF) remains a major unmet clinical need. Device-based treatment approaches include the interatrial shunt device (IASD), conventional assist devices pumping blood from the left ventricle (LV-VAD) or the left atrium (LA-VAD) towards the aorta, and a valveless pulsatile assist device with a single cannula operating in co-pulsation with the native heart (CoPulse). Hemodynamics of two HFpEF subgroups during rest and exercise condition were translated into a lumped parameter model of the cardiovascular system. The numerical model was applied to assess the hemodynamic effect of each of the four device-based therapies. All four therapy options show a reduction in left atrial pressure during rest and exercise and in both subgroups (> 20%). IASDs concomitantly reduce cardiac output (CO) and shift the hemodynamic overload towards the pulmonary circulation. All three mechanical assist devices increase CO while reducing sympathetic activity. LV-VADs reduce end-systolic volume, indicating a high risk for suction events. The heterogeneity of the HFpEF population requires an individualized therapy approach based on the underlying hemodynamics. Whereas phenotypes with preserved CO may benefit most from an IASD device, HFpEF patients with reduced CO may be candidates for mechanical assist devices.
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7
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Sharma AK, Kumar H, Razi MM, Sinha SK, Pandey U, Shukla P, Thakur R, Verma CM, Bansal RK, Krishna V. To determine the correlation between echocardiographic diastolic parameters and invasively measured left ventricular end diastolic pressure in patients with heart failure with preserved ejection fraction- an observational, descriptive study. (CEAL-HFpEF study). Indian Heart J 2021; 73:470-475. [PMID: 34474760 PMCID: PMC8424284 DOI: 10.1016/j.ihj.2021.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/18/2021] [Accepted: 06/27/2021] [Indexed: 12/28/2022] Open
Abstract
Objectives Though invasive monitoring is the most accurate to estimate diastolic dysfunction but it has its own risk. The purpose of this study was to find out any standardized correlation between invasive and non -invasive parameters. Methods It is an observational, descriptive study comprising of a total of 500 patients. The primary objective of the study was to determine the correlation between echocardiographic diastolic parameters and invasively measured left ventricular end diastolic pressure (LVEDP). Results On studying correlation of different invasive and non-invasive data it was reported that there was a weak correlation between peak E velocity (r = 0.14, p = 0.631), Peak A velocity (r = 0.67, p = 0.59), IVRT (r = −0.35, p = 0.178), Mitral deceleration time (DT) (r = −0.06, p = 0.842), pulmonary venous peak systolic (r = −0.02, p = 0.966) and diastolic flows (r = 0.47, p = 0.201) to LVEDP. There was a good positive correlation between elevated LVEDP and difference in duration of pulmonary venous and mitral flow at atrial contraction (A-Ard) and E/Ea at all four longitudinal segments of the left ventricle. The sensitivity and specificity for detecting an elevated LVEDP of more than 12 mm Hg, using a cut off value of E/Ea< 8, were 89% and 90%.Lateral E/Ea ≥ 12, LAVI ≥34 mL/m2, and Ard–Ad > 30 msec have the greatest diagnostic value for diagnosing diastolic dysfunction in HFpEF patients. Conclusion Lateral E/Ea ≥ 12, LAVI ≥34 mL/m2, and Ard–Ad > 30 msec have the greatest diagnostic value for diagnosing diastolic dysfunction in HFpEF patients and have good correlation with invasively measured LVEDP.
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Affiliation(s)
- Awadhesh Kumar Sharma
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India.
| | - Hitender Kumar
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
| | - M M Razi
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
| | - Santosh Kumar Sinha
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
| | - Umeshwar Pandey
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
| | - Praveen Shukla
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
| | - Ramesh Thakur
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
| | - C M Verma
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
| | - R K Bansal
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
| | - Vinay Krishna
- Department of Cardiothoracic Surgury, LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, 208019, India
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He X, Dong B, Xue R, Zhao J, Wu Z, Wu Y, Zhou Y, Wu D, Dong Y, He J, Liu C. Effect of aggressive diuresis in acute heart failure with reduced and preserved ejection fraction. ESC Heart Fail 2021; 8:3248-3256. [PMID: 34076960 PMCID: PMC8318499 DOI: 10.1002/ehf2.13453] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 05/11/2021] [Accepted: 05/21/2021] [Indexed: 01/11/2023] Open
Abstract
Aims Heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF) had distinct haemodynamic characteristics in the setting of acute heart failure. The aim of our study is to evaluate the differential response to aggressive diuresis in HFrEF and HFpEF. Methods and results Patients in the Diuretic Optimization Strategies Evaluation trial with left ventricular ejection fraction measurement were included (n = 300) and classified into HFrEF [left ventricular ejection fraction (LVEF) < 40%] (n = 193) and HFpEF (LVEF ≥ 40%) (n = 107). Effect of high‐dose vs. low‐dose furosemide strategy was compared separately in HFrEF and HFpEF. In HFrEF, high‐dose strategy did not increase change in creatinine or cystatin C at 72 h [treatment difference: −0.05, 95% confidence interval (CI): −0.14 to 0.03 mg/dL; P = 0.23 for creatinine, and treatment difference: −0.06, 95% CI: −0.15 to 0.02 mg/dL; P = 0.15 for cystatin C] compared with low‐dose strategy, but there were significantly more net fluid loss, weight loss, and congestion‐free patients at 72 h in high‐dose group. It was also associated with a significantly lower risk of composite clinical outcome of death, total hospitalizations, and unscheduled visits due to heart failure. In HFpEF, high‐dose strategy significantly increased change in creatinine and cystatin C at 72 h (treatment difference: 0.16; 95% CI: 0.02–0.30 mg/dL; P = 0.03 for creatinine, and treatment difference: 0.26; 95% CI: 0.09–0.43 mg/dL; P = 0.003 for cystatin C), but did not significantly affect net fluid loss, weight loss, proportion of congestion‐free patients at 72 h, and risk of the composite clinical outcome. Conclusions Acute heart failure on the basis of HFrEF and HFpEF responded differently to aggressive diuresis. Future trials should be designed separately for HFrEF and HFpEF.
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Affiliation(s)
- Xin He
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Bin Dong
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Ruicong Xue
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Jingjing Zhao
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Zexuan Wu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Yuzhong Wu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Yuanyuan Zhou
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Dexi Wu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Yugang Dong
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Jiangui He
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
| | - Chen Liu
- Department of Cardiology, the First Affiliated Hospital of Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, China.,National - Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, China
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9
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Liang W, He X, Wu D, Xue R, Dong B, Owusu-Agyeman M, Zhao J, Cai L, You Z, Dong Y, Liu C. Prognostic Implication of Liver Function Tests in Heart Failure With Preserved Ejection Fraction Without Chronic Hepatic Diseases: Insight From TOPCAT Trial. Front Cardiovasc Med 2021; 8:618816. [PMID: 34055924 PMCID: PMC8153182 DOI: 10.3389/fcvm.2021.618816] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 03/29/2021] [Indexed: 02/04/2023] Open
Abstract
Background: Liver dysfunction is prevalent in patients with heart failure (HF), but the prognostic significance of liver function tests (LFTs) remains controversial. Heart failure with preserved ejection fraction (HFpEF) had been introduced for some time, but no previous study had focused on LFTs in HFpEF. Thus, we aim to evaluate the prognostic significance of LFTs in well-defined HFpEF patients. Methods and Results: We conveyed a post-hoc analysis of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial (TOPCAT). The primary outcome was the composite of cardiovascular mortality, HF hospitalization, and aborted cardiac arrest, and the secondary outcomes were cardiovascular mortality and HF hospitalization. In Cox proportional hazards models, aspartate transaminase (AST) and alanine transaminase (ALT) were not associated with any of the outcomes. On the contrary, increases in total bilirubin (TBIL) and alkaline phosphatase (ALP) were associated with increased risks of the primary outcome [TBIL: adjusted hazard ratio (HR), 1.17; 95% confidence interval (CI) 1.08-1.26; ALP: adjusted HR, 1.12; 95% CI 1.04-1.21], cardiovascular mortality (TBIL: adjusted HR, 1.16; 95% CI 1.02-1.31; ALP: adjusted HR, 1.16; 95% CI 1.05-1.28), and HF hospitalization (TBIL: adjusted HR, 1.22; 95% CI 1.12-1.33; ALP: adjusted HR, 1.12; 95% CI 1.03-1.23). Conclusion: Elevated serum cholestasis markers TBIL and ALP were significantly associated with a poor outcome in HFpEF patients without chronic hepatic diseases, while elevated ALT and AST were not.
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Affiliation(s)
- Weihao Liang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Xin He
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Dexi Wu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Ruicong Xue
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Bin Dong
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Marvin Owusu-Agyeman
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Jingjing Zhao
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Linnuan Cai
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Zhiyao You
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Yugang Dong
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Chen Liu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
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10
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Wilshaw J, Stein M, Lotter N, Elliott J, Boswood A. The effect of myxomatous mitral valve disease severity on packed cell volume in dogs. J Small Anim Pract 2021; 62:428-436. [PMID: 33599987 DOI: 10.1111/jsap.13308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 12/16/2020] [Accepted: 01/09/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this study was to examine whether associations between disease severity and packed cell volume exist in dogs with myxomatous mitral valve disease. MATERIALS AND METHODS Data were selected from 289 dogs that had been examined at a research clinic (2004-2017) on multiple occasions (n=1465). American College of Veterinary Internal Medicine stage and echocardiographic measurements were entered in separate multivariable linear mixed effects models with packed cell volume as the dependent variable. Age, breed, sex, weight and blood urea nitrogen concentrations were additionally tested in these analyses to control for patient characteristics. RESULTS Packed cell volume (% whole blood) in stages B1 and B2 (B1: 42.62 ±0.27, P=0.001; B2: 41.77± 0.42, P < 0.001) was lower than stage A (44.57 ±0.53). In stage C, packed cell volume was greater than both preclinical stages (C: 43.84 ±0.46). When the administration of loop diuretics was included in statistical models, packed cell volume was inversely related to normalised left ventricular internal diameters (β: -2.37; 95% confidence intervals: -3.49, -1.25; P < 0.001). CLINICAL SIGNIFICANCE Dogs with myxomatous mitral valve disease may develop reductions in packed cell volume as their disease progresses. Although this finding was statistically significant at a population level, it should be noted that the differences described are relatively small. This, along with other causes of variation in packed cell volume, means that changes would be challenging to appreciate within individual patients. Plasma volume depletion following diuretic administration may explain why findings differed in stage C.
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Affiliation(s)
- J Wilshaw
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, Herts, AL9 7TA, UK
| | - M Stein
- Department of Companion Animals, Atlantic Veterinary College, Charlottetown, Prince Edward Island, C1A 4P3, Canada
| | - N Lotter
- Department of Comparative Biomedical Science, Royal Veterinary College, Royal College Street, London, NW1 OTU, UK
| | - J Elliott
- Department of Comparative Biomedical Science, Royal Veterinary College, Royal College Street, London, NW1 OTU, UK
| | - A Boswood
- Department of Clinical Science and Services, Royal Veterinary College, Hatfield, Herts, AL9 7TA, UK
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11
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Ye SD, Wang SJ, Wang GG, Li L, Huang ZW, Qin J, Li CS, Yu XZ, Shen H, Yang LP, Fu Y, Zheng YA, Zhao B, Yu DM, Qin FJ, Zhou DG, Li Y, Liu FJ. Association between anemia and outcome in patients hospitalized for acute heart failure syndromes: findings from Beijing Acute Heart Failure Registry (Beijing AHF Registry). Intern Emerg Med 2021; 16:183-192. [PMID: 32356137 DOI: 10.1007/s11739-020-02343-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 04/11/2020] [Indexed: 10/24/2022]
Abstract
Whether the anemia increases the risk of mortality in patients with acute heart failure (AHF) remains unclear. This study aims to explore the relationship between anemia and outcomes in patients with AHF including subgroup analysis. This study included 3279 patients with hemoglobin available from the Beijing Acute Heart Failure Registry (Beijing AHF Registry) study. The primary endpoint was all-cause mortality in 1 year, and the secondary endpoint was 1-year all-cause events including all-cause death and readmission. Logistic regression models were applied to describe related variables of anemia in patients with AHF. Multivariate Cox proportional hazards models described associations of anemia with clinical outcomes in the overall cohort and subgroups. 45.4% of the patients were found anemic. They were older and had more comorbidities than non-anemic patients. Variables including older age, female, chronic kidney dysfunction (CKD), lower hematocrit, lower albumin, with loop diuretics applied, without beta-blockers, angiotensin-converting enzyme inhibitors /angiotensin receptor blockers (ACEIs/ARBs) and spironolactone applied in the emergency department (ED) were associated with anemia in AHF patients. Anemic patients had higher 1-year mortality (38.4% vs. 27.2%, p < 0.0001) and 1-year events rates (63.2% vs. 56.7%, p < 0.0001). After adjusted for covariates, anemia was associated with the increase of 1-year mortality (hazard ratio [HR] 1.278; 95% confidence interval [CI] 1.114-1.465; p = 0.0005) and 1-year events (HR 1.136; 95% CI 1.025-1.259; p = 0.0154). The severer anemia patients had higher risks both of 1-year mortality and events. In the subgroup analysis, the independent associations of anemia with 1-year mortality were shown in the subgroups including age < 75 years, male, body mass index < 25 kg/m2 and BMI ≥ 25 kg/m2, New York Heart Association (NYHA) functional class I-II and NYHA functional class III-IV, with and without cardiovascular ischemia, heart rate (HR) < 100 bpm and HR ≥ 100 bpm, systolic blood pressure (SBP) < 120 mmHg and SBP ≥ 120 mmHg, left ventricular ejection fraction (LVEF) < 40% and LVEF ≥ 40%, serum creatinine (Scr) < 133 umol/l, and with diuretics use, with and without beta-blockers use, without ACEIs/ARBs use in the ED. Anemia is associated with older age, female, CKD, volume overload, malnutrition, with loop diuretics, without beta-blockers, ACEIs/ARBs and spironolactone administration, and higher mortality and readmission in AHF. The risk associations are particular significantly obvious in younger, male, overweight, preserved LVEF, lower Scr, with diuretics and beta-blockers, without ACEIs/ARBs administration subgroups.Clinical trial No. ChiCTR-RIC-17014222.
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Affiliation(s)
- Shao-Dong Ye
- National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
| | - Si-Jia Wang
- National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
- Department of Emergency, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Guo-Gan Wang
- National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
| | - Lin Li
- National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Zhi-Wei Huang
- National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Jian Qin
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Chun-Sheng Li
- Department of Emergency, Beijing Chao Yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Xue-Zhong Yu
- Department of Emergency, Peking Union Medical College Hospital, Beijing, 100032, China
| | - Hong Shen
- Department of Emergency, Chinese People's Liberation Army General Hospital, Medical School of Chinese People's Liberation Army, Beijing, 100853, China
| | - Li-Pei Yang
- Department of Emergency, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, China
| | - Yan Fu
- Department of Emergency, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Ya-An Zheng
- Department of Emergency, Peking University Third Hospital, Beijing, 100083, China
| | - Bin Zhao
- Department of Emergency, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Dong-Min Yu
- Department of Emergency, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Fu-Jun Qin
- Department of Emergency, Liangxiang Hospital of Fangshan District, Beijing, 102400, China
| | - De-Gui Zhou
- Department of Emergency, Shunyi District Hospital, Beijing, 101300, China
| | - Ying Li
- Department of Emergency, People's Hospital of Beijing Daxing District, Beijing, 102600, China
| | - Fu-Jun Liu
- Department of Emergency, Beijing Luhe Hospital, Capital Medical University, Beijing, 101100, China
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12
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Montero D, Haider T, Barthelmes J, Goetze JP, Cantatore S, Sudano I, Ruschitzka F, Flammer AJ. Hypovolemia and reduced hemoglobin mass in patients with heart failure and preserved ejection fraction. Physiol Rep 2020; 7:e14222. [PMID: 31724335 PMCID: PMC6854115 DOI: 10.14814/phy2.14222] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 08/08/2019] [Accepted: 08/12/2019] [Indexed: 01/28/2023] Open
Abstract
A fundamental tenet of heart failure (HF) pathophysiology hinges on a propensity for fluid retention leading to blood volume (BV) expansion and hemodilution. Whether this can be applied to heart failure patients with preserved ejection fraction (HFpEF) remains uncertain. The present study sought to determine BV status and key hormones regulating fluid homeostasis and erythropoiesis in HFpEF patients. BV and hemoglobin mass (Hbmass) were determined with high‐precision, automated carbon monoxide (CO) rebreathing in 20 stable HFpEF patients (71.5 ± 7.3 years, left ventricular ejection fraction = 55.7 ± 4.0%) and 15 healthy age‐ and sex‐matched control individuals. Additional measurements comprised key circulating BV‐regulating hormones such as pro‐atrial natriuretic peptide (proANP), copeptin, aldosterone and erythropoietin (EPO), as well as central hemodynamics and arterial stiffness via carotid–femoral pulse wave velocity (PWV). Carotid–femoral PWV was increased (+20%) in HFpEF patients versus control individuals. With respect to hematological variables, plasma volume (PV) did not differ between groups, whereas BV was decreased (−14%) in HFpEF patients. In consonance with the hypovolemic status, Hbmass was reduced (−27%) in HFpEF patients, despite they presented more than a twofold elevation of circulating EPO (+119%). Plasma concentrations of BV‐regulating hormones, including proANP (+106%), copeptin (+99%), and aldosterone (+62%), were substantially augmented in HFpEF patients. HFpEF patients may present with hypovolemia and markedly reduced Hbmass, underpinned by a generalized overactivation of endocrine systems regulating fluid homeostasis and erythropoiesis. These findings provide a novel perspective on the pathophysiological basis of the HFpEF condition.
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Affiliation(s)
- David Montero
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Haider
- Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Jens Barthelmes
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Jens P Goetze
- Department of Clinical Biochemistry, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Silviya Cantatore
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Isabella Sudano
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Frank Ruschitzka
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Andreas J Flammer
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
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13
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Oeun B, Nakatani D, Hikoso S, Kojima T, Dohi T, Kitamura T, Okada K, Sunaga A, Kida H, Yamada T, Uematsu M, Yasumura Y, Higuchi Y, Mano T, Nagai Y, Fuji H, Mizuno H, Sakata Y. Factors Associated With Elevated N-Terminal Pro B-Type Natriuretic Peptide Concentrations at the Convalescent Stage and 1-Year Outcomes in Patients With Heart Failure With Preserved Ejection Fraction. Circ Rep 2020; 2:400-408. [PMID: 33693261 PMCID: PMC7819653 DOI: 10.1253/circrep.cr-20-0051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background: Little is known about factors associated with elevated N-terminal pro B-type natriuretic peptide (NT-proBNP) at the convalescent stage and their effects on 1-year outcomes in patients with heart failure with preserved ejection fraction (HFpEF). Methods and Results: This study included 469 patients with HFpEF. Elevated NT-proBNP was defined as the highest quartile. The first 3 quartiles (Q1-Q3) were combined together for comparison with the fourth quartile (Q4). Median NT-proBNP concentrations in Q1-Q3 and Q4 were 669 and 3,504 pg/mL, respectively. Multivariate logistic regression analysis revealed that low albumin (odds ratio [OR] 2.44; 95% confidence interval [CI] 1.35-4.39; P=0.003), low estimated glomerular filtration rate (OR 5.83; 95% CI 3.46-9.83; P<0.001), high C-reactive protein (OR 2.09; 95% CI 1.21-3.63; P=0.009), and atrial fibrillation at discharge (OR 2.33; 95% CI 1.40-3.89; P=0.001) were associated with elevated NT-proBNP. Cumulative rates of all-cause mortality and heart failure rehospitalization were significantly higher in Q4 than in Q1-Q3 (P=0.001 and P<0.001, respectively). Incidence and hazard ratios of these adverse events increased when the number of associated factors for elevated NT-proBNP clustered together (P<0.001 and P=0.002, respectively). Conclusions: In addition to atrial fibrillation, extracardiac factors (malnutrition, renal impairment and inflammation) were associated with elevated NT-proBNP at the convalescent stage, and led to poor prognosis in patients with HFpEF.
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Affiliation(s)
- Bolrathanak Oeun
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Suita Japan
| | - Daisaku Nakatani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Suita Japan
| | - Shungo Hikoso
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Suita Japan
| | - Takayuki Kojima
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Suita Japan
| | - Tomoharu Dohi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Suita Japan
| | - Tetsuhisa Kitamura
- Department of Environmental Medicine and Population Sciences, Osaka University Graduate School of Medicine Suita Japan
| | - Katsuki Okada
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Suita Japan
| | - Akihiro Sunaga
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Suita Japan
| | - Hirota Kida
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Suita Japan
| | - Takahisa Yamada
- Division of Cardiology, Osaka General Medical Center Osaka Japan
| | - Masaaki Uematsu
- Division of Cardiology, National Hospital Organization, Osaka National Hospital Osaka Japan
| | - Yoshio Yasumura
- Division of Cardiology, Amagasaki Chuo Hospital Amagasaki Japan
| | | | - Toshiaki Mano
- Division of Cardiology, Kansai Rosai Hospital Amagasaki Japan
| | - Yoshiyuki Nagai
- Division of Cardiology, Rinku General Medical Center Izumisano Japan
| | - Hisakazu Fuji
- Division of Cardiology, Kobe Ekisaikai Hospital Kobe Japan
| | - Hiroya Mizuno
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Suita Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine Suita Japan
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14
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Prognostic impact of plasma volume estimated from hemoglobin and hematocrit in heart failure with preserved ejection fraction. Clin Res Cardiol 2020; 109:1392-1401. [PMID: 32253507 DOI: 10.1007/s00392-020-01639-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 03/24/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Plasma volume (PV) estimated from Duarte's formula (based on hemoglobin/hematocrit) has been associated with poor prognosis in patients with heart failure (HF). There are, however, limited data regarding the association of estimated PV status (ePVS) derived from hemoglobin/hematocrit with clinical profiles and study outcomes in patients with HF and preserved ejection fraction (HFpEF). METHODS AND RESULTS Patients from North and South America enrolled in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial (TOPCAT) with available hemoglobin/hematocrit data were studied. The association between ePVS (Duarte formula and Hakim formula) and the composite of cardiovascular mortality, HF hospitalization, or aborted cardiac arrest was assessed. Among 1747 patients (age 71.6 years; males 50.1%), mean ePVS derived from Duarte formula was 4.9 ± 1.0 mL/g. Higher Duarte-derived ePVS was associated with prior HF admission, diabetes, more severe congestion, poor renal function, higher natriuretic peptide level, and E/e'. After adjustment for potential covariates including natriuretic peptide, higher Duarte-derived ePVS was associated with an increased rate of the primary outcome [highest vs. lowest ePVS quartile: adjusted-HR (95%CI) = 1.79 (1.28-2.50), p < 0.001]. Duarte-derived ePVS improved prognostic performance on top of clinical and routine variables (including natriuretic peptides) (NRI = 11, p < 0.001), whereas Hakim-derived ePVS did not (p = 0.59). The prognostic value of Duarte-derived ePVS was not modified by renal function (P interaction > 0.10 for all outcomes). CONCLUSION ePVS from Duarte's formula was associated with congestion status and improved risk stratification regardless of renal function. Our findings suggest that Duarte-derived ePVS is a useful congestion variable in patients with HFpEF.
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15
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Diaz-Canestro C, Haider T, Lundby C, Montero D. Relationship between plasma volume and essential blood constituents in patients with heart failure and preserved ejection fraction. Clin Physiol Funct Imaging 2019; 40:131-138. [PMID: 31823430 DOI: 10.1111/cpf.12614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 12/04/2019] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Notwithstanding recent progress on molecular mechanisms underlying heart failure with preserved ejection fraction (HFpEF), multiple pathophysiological aspects of this condition including the basis of anaemia and other haematological disorders remain unresolved. In this study, we sought to determine the relationship of plasma volume (PV), a plausible confounding factor for the concentration of solutes in blood, with key haematological markers in HFpEF patients. METHODS Total circulating PV was determined with high precision, automated carbon monoxide rebreathing in 24 stable HFpEF patients (70 ± 8 years, left ventricular ejection fraction = 55±5%) and 18 healthy age- and sex-matched control (HC) individuals. Linear regression analyses were performed to determine the association of PV with a comprehensive set of haematological variables. RESULTS Haematocrit (40·1 ± 4·9 versus 43·6 ± 2·7%, P = 0·004) and haemoglobin concentration (131 ± 16 versus 142 ± 7 g l-1 , P = 0·003) were reduced in HFpEF patients compared with HC individuals. In regression analyses, PV was negatively associated with haematocrit (r = -0·45, P = 0·029) and haemoglobin concentration (r = -0·44, P = 0·030) in HFpEF patients, whereas these variables were not associated with PV in HC individuals (P≥0·198). Regarding blood electrolytes, PV was negatively associated with K+ (r = -0·43, P = 0·036) and Ca2+ (r = -0·44, P = 0·032) in HFpEF patients but not in HC individuals (P≥0·734). None of the above associations were detected in HFpEF patients when using ideal instead of measured PV. CONCLUSION The blood concentration of routine markers of anaemia and electrolyte balance is specifically and linearly associated with PV in HFpEF patients. Excess or deficit of circulating PV may confound clinical diagnosis in this population.
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Affiliation(s)
- Candela Diaz-Canestro
- Faculty of Kinesiology, Cumming School of Medicine, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Thomas Haider
- University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Carsten Lundby
- Inland Norway University of Applied Sciences, Lillehammer, Norway
| | - David Montero
- Faculty of Kinesiology, Cumming School of Medicine, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
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16
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Prognostic Impact of Worsening Renal Function in Hospitalized Heart Failure Patients With Preserved Ejection Fraction: A Report From the JASPER Registry. J Card Fail 2019; 25:631-642. [DOI: 10.1016/j.cardfail.2019.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 03/17/2019] [Accepted: 04/16/2019] [Indexed: 01/09/2023]
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17
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National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart Lung Circ 2018; 27:1123-1208. [DOI: 10.1016/j.hlc.2018.06.1042] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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18
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Abstract
Background Despite multiple factors correlating with the high prevalence of anaemia in heart failure, the prevailing mechanisms have yet to be established. The purpose of this study is to systematically review the literature and determine whether low circulating haemoglobin is primarily underlain by erythropoietin resistance or defective production in heart failure. Design and methods We conducted a systematic search of MEDLINE since its inception until May 2017 for articles reporting erythropoietin and haemoglobin concentrations in heart failure patients not treated with erythropoietin-stimulating agents. The primary outcome was the mean difference in observed/predicted (O/P) erythropoietin ratio between heart failure patients and normal reference values. Meta-regression analyses assessed the influence of potential moderating factors. Results Forty-one studies were included after systematic review, comprising a total of 3137 stable heart failure patients with mean age and left ventricular ejection fraction ranging from 52 years to 80 years and 21% to 59%. The O/P erythropoietin ratio was below reference values in 24 of 25 studies in anaemic heart failure patients ( n = 1094, range = 0.49–1.05), whereas only one out of 16 studies in non-anaemic heart failure patients presented a low O/P erythropoietin ratio ( n = 2043, range = 0.91–1.97). In studies comparing anaemic versus non-anaemic heart failure patients ( n = 1531), the mean O/P erythropoietin ratio was consistently reduced in anaemic heart failure patients (mean difference = –0.68, 95% confidence interval = −0.78, −0.57; p < 0.001). In meta-regression, the O/P erythropoietin ratio was negatively associated with age, female sex, left ventricular ejection fraction, inflammation and disease severity. Conclusion Anaemia in heart failure is overwhelmingly characterized by impaired erythropoietin production, which is exacerbated with age, female sex, left ventricular ejection fraction, inflammation and disease severity.
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Affiliation(s)
- David Montero
- Department of Cardiology, University Hospital Zurich, Switzerland
| | - Thomas Haider
- Zurich Centre for Integrative Human Physiology (ZIHP), Institute of Physiology, University of Zurich, Switzerland
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19
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Bistola V, Polyzogopoulou E, Ikonomidis I, Parissis J. Congestion in acute heart failure with reduced vs. preserved left ventricular ejection fraction: differences, similarities and remaining gaps. Eur J Heart Fail 2017; 20:748-750. [PMID: 29251810 DOI: 10.1002/ejhf.1115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 11/18/2017] [Accepted: 11/20/2017] [Indexed: 12/11/2022] Open
Affiliation(s)
- Vasiliki Bistola
- Heart Failure Unit, Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Eftihia Polyzogopoulou
- Emergency Medicine Department, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Ignatios Ikonomidis
- Heart Failure Unit, Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - John Parissis
- Heart Failure Unit, Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Emergency Medicine Department, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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20
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Guazzi M, Bandera F, Ozemek C, Systrom D, Arena R. Cardiopulmonary Exercise Testing: What Is its Value? J Am Coll Cardiol 2017; 70:1618-1636. [PMID: 28935040 DOI: 10.1016/j.jacc.2017.08.012] [Citation(s) in RCA: 258] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 08/02/2017] [Indexed: 02/07/2023]
Abstract
Compared with traditional exercise tests, cardiopulmonary exercise testing (CPET) provides a thorough assessment of exercise integrative physiology involving the pulmonary, cardiovascular, muscular, and cellular oxidative systems. Due to the prognostic ability of key variables, CPET applications in cardiology have grown impressively to include all forms of exercise intolerance, with a predominant focus on heart failure with reduced or with preserved ejection fraction. As impaired cardiac output and peripheral oxygen diffusion are the main determinants of the abnormal functional response in cardiac patients, invasive CPET has gained new popularity, especially for diagnosing early heart failure with preserved ejection fraction and exercise-induced pulmonary hypertension. The most impactful advance has recently come from the introduction of CPET combined with echocardiography or CPET imaging, which provides basic information regarding cardiac and valve morphology and function. This review highlights modern CPET use as a single or combined test that allows the pathophysiological bases of exercise limitation to be translated, quite easily, into clinical practice.
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Affiliation(s)
- Marco Guazzi
- University of Milan, Cardiology University Department, Heart Failure Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.
| | - Francesco Bandera
- University of Milan, Cardiology University Department, Heart Failure Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Cemal Ozemek
- Department of Physical Therapy, Department of Kinesiology and Nutrition, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - David Systrom
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Heart and Vascular Center, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ross Arena
- Department of Physical Therapy, Department of Kinesiology and Nutrition, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois
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21
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Otto JM, Plumb JOM, Clissold E, Kumar SB, Wakeham DJ, Schmidt W, Grocott MPW, Richards T, Montgomery HE. Hemoglobin concentration, total hemoglobin mass and plasma volume in patients: implications for anemia. Haematologica 2017; 102:1477-1485. [PMID: 28596281 PMCID: PMC5685237 DOI: 10.3324/haematol.2017.169680] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 06/06/2017] [Indexed: 11/09/2022] Open
Abstract
In practice, clinicians generally consider anemia (circulating hemoglobin concentration < 120 g.l-1 in non-pregnant females and < 130 g.l-1 in males) as due to impaired hemoglobin synthesis or increased erythrocyte loss or destruction. Rarely is a rise in plasma volume relative to circulating total hemoglobin mass considered as a cause. But does this matter? We explored this issue in patients, measuring hemoglobin concentration, total hemoglobin mass (optimized carbon monoxide rebreathing method) and thereby calculating plasma volume in healthy volunteers, surgical patients, and those with inflammatory bowel disease, chronic liver disease or heart failure. We studied 109 participants. Hemoglobin mass correlated well with its concentration in the healthy, surgical and inflammatory bowel disease groups (r=0.687-0.871, P<0.001). However, they were poorly related in liver disease (r=0.410, P=0.11) and heart failure patients (r=0.312, P=0.16). Here, hemoglobin mass explained little of the variance in its concentration (adjusted R2=0.109 and 0.052; P=0.11 and 0.16), whilst plasma volume did (R2 change 0.724 and 0.805 in heart and liver disease respectively, P<0.0001). Exemplar patients with identical (normal or raised) total hemoglobin masses were diagnosed as profoundly anemic (or not) depending on differences in plasma volume that had not been measured or even considered as a cause. The traditional inference that anemia generally reflects hemoglobin deficiency may be misleading, potentially resulting in inappropriate tests and therapeutic interventions to address 'hemoglobin deficiency' not 'plasma volume excess'. Measurement of total hemoglobin mass and plasma volume is now simple, cheap and safe, and its more routine use is advocated.
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Affiliation(s)
- James M Otto
- Division of Surgery and Interventional Science, University College London, UK
| | - James O M Plumb
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, UK.,Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK
| | - Eleri Clissold
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, UK.,Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK
| | - Shriya B Kumar
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, UK.,Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK
| | - Denis J Wakeham
- School of Sport, Physiology and Health Group, Cardiff Metropolitan University, UK
| | - Walter Schmidt
- Department of Sports Medicine/Sports Physiology, University of Bayreuth, Germany
| | - Michael P W Grocott
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, UK.,Critical Care Research Area, Southampton NIHR Respiratory Biomedical Research Unit, Southampton, UK
| | - Toby Richards
- Division of Surgery and Interventional Science, University College London, UK
| | - Hugh E Montgomery
- Centre for Human Health and Performance/Institute of Sport, Exercise and Health, University College London, and NIHR University College London Hospitals Biomedical Research Centre, UK
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22
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Afsar B, Rossignol P, van Heerebeek L, Paulus WJ, Damman K, Heymans S, van Empel V, Sag A, Maisel A, Kanbay M. Heart failure with preserved ejection fraction: a nephrologist-directed primer. Heart Fail Rev 2017; 22:765-773. [DOI: 10.1007/s10741-017-9619-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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23
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Montero D, Lundby C, Ruschitzka F, Flammer AJ. True Anemia―Red Blood Cell Volume Deficit―in Heart Failure. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003610. [DOI: 10.1161/circheartfailure.116.003610] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 03/29/2017] [Indexed: 01/08/2023]
Abstract
Background—
Anemia in heart failure (HF) is commonly diagnosed according to hemoglobin concentration [Hb], hence may be the result of hemodilution or true red blood cell volume (RBCV) deficit. Whether true (nonhemodilutional) anemia in HF can or cannot be generally inferred by [Hb] measurements and clinical correlates remains unclear. The purpose of this study was to systematically review the literature and investigate the status and correlates of RBCV in patients with HF.
Methods and Results—
MEDLINE, Scopus, and Web of Science were searched since their inceptions until April 2016 for articles directly reporting or allowing the calculation of intravascular volumes (RBCV, plasma volume) in patients with HF according to the International Council for Standardization in Hematology. Eighteen studies were included after systematic review, comprising a total of 368 patients with HF (limits for mean age=49–80 years, sex=0%–92% females, left ventricular ejection fraction=26%–61%). Mean RBCV was reduced (limits=67%–88% of normal) in all studies including HF patients with anemia (low [Hb]) (7 studies, n=127), whereas only 2 of 10 studies in nonanemic patients with HF presented lower than normal mean RBCV (90% and 96%). In metaregression analyses, RBCV was positively associated with [Hb] (
B
=6.10, SE=1.44) and negatively associated with age (
B
=−1.14, SE=0.23), % females (
B
=−0.38, SE=0.04), left ventricular ejection fraction (
B
=−0.81, SE=0.20), and body mass index (
B
=−3.55, SE=0.46;
P
<0.001).
Conclusions—
Presence or absence of true anemia in patients with HF as determined by RBCV status mainly concurs with diagnosis based on [Hb] and presents negative relationships with age, female sex, left ventricular ejection fraction, and body mass index.
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Affiliation(s)
- David Montero
- From the University Heart Center, Department of Cardiology, University Hospital Zurich, Switzerland (D.M., F.R., A.J.F.); and Zurich Center for Integrative Human Physiology (ZIHP), Oxygen Transport and Utilization, Institute of Physiology, University of Zurich, Switzerland (C.L.)
| | - Carsten Lundby
- From the University Heart Center, Department of Cardiology, University Hospital Zurich, Switzerland (D.M., F.R., A.J.F.); and Zurich Center for Integrative Human Physiology (ZIHP), Oxygen Transport and Utilization, Institute of Physiology, University of Zurich, Switzerland (C.L.)
| | - Frank Ruschitzka
- From the University Heart Center, Department of Cardiology, University Hospital Zurich, Switzerland (D.M., F.R., A.J.F.); and Zurich Center for Integrative Human Physiology (ZIHP), Oxygen Transport and Utilization, Institute of Physiology, University of Zurich, Switzerland (C.L.)
| | - Andreas J. Flammer
- From the University Heart Center, Department of Cardiology, University Hospital Zurich, Switzerland (D.M., F.R., A.J.F.); and Zurich Center for Integrative Human Physiology (ZIHP), Oxygen Transport and Utilization, Institute of Physiology, University of Zurich, Switzerland (C.L.)
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24
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Montero D, Lundby C. Reduced arteriovenous oxygen difference in heart failure with preserved ejection fraction patients: Is the muscle oxidative phenotype certainly involved? Eur J Prev Cardiol 2017; 24:1157-1160. [DOI: 10.1177/2047487317706587] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- David Montero
- Department of Cardiology, University Hospital Zurich, Switzerland
| | - Carsten Lundby
- Centre for Physical Activity Research, Rigshospitalet, Denmark
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25
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Montero D, Flammer AJ. Exercise intolerance in heart failure with preserved ejection fraction: time to scrutinize diuretic therapy? Eur J Heart Fail 2017; 19:971-973. [DOI: 10.1002/ejhf.811] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Revised: 02/03/2017] [Accepted: 02/08/2017] [Indexed: 12/28/2022] Open
Affiliation(s)
- David Montero
- University Heart Centre; University Hospital Zurich; Zurich Switzerland
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26
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Hudson SR, Chan D, Ng LL. Change in plasma volume and prognosis in acute decompensated heart failure: an observational cohort study. J R Soc Med 2017; 109:337-46. [PMID: 27609799 DOI: 10.1177/0141076816661316] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES This study aimed to develop an inexpensive, readily available prognostic indicator in acute decompensated heart failure patients to guide management and improve outcome. Prognostic biomarkers for heart failure exist but are expensive and not routinely performed. Increasing plasma volume has been associated with worse outcomes. SETTING UK University Teaching Hospital. DESIGN Observational Cohort study. PARTICIPANTS 967 patients with acute decompensated heart failure. METHODS Haemoglobin and haematocrit were measured at admission and discharge and were used to calculate the plasma volume change using the Strauss-Davis-Rosenbaum formula. MAIN OUTCOME MEASURES Endpoints were death and the composite of death and/or heart failure hospitalisation. Change in plasma volume was added to ADHERE scoring to determine predictive value. RESULTS During follow-up, 536 died and 626 died or were hospitalised with heart failure. Multivariable Cox models showed change in plasma volume was an independent predictor of mortality (hazard ratio (HR) [95% confidence interval (CI)]: 1.150 [1.031-1.283], p = 0.012) and death or heart failure hospitalisation (HR: 1.138 [1.029-1.259], p = 0.012). Kaplan-Meier analysis of change in plasma volume tertiles for outcome measures showed significant difference for the top tertile compared to the lower two. Multivariable analysis of change in plasma volume with ADHERE scoring showed change in plasma volume change remained an independent predictor of death (HR: 1.138 [1.026-1.261], p = 0.015) and death or heart failure hospitalisation (HR: 1.129 [1.025-1.243], p = 0.014). CONCLUSIONS Change in plasma volume over an admission can be used for prognostication and adds value to the ADHERE score. Change in plasma volume can be easily and inexpensively calculated from routine blood tests. Clinically, this may facilitate targeted treatment of acute decompensated heart failure patients at greatest risk.
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Affiliation(s)
- Sarah R Hudson
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE3 9QP, UK NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, Leicester LE3 9QP, UK
| | - Daniel Chan
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE3 9QP, UK NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, Leicester LE3 9QP, UK
| | - Leong L Ng
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE3 9QP, UK NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, University of Leicester, Leicester LE3 9QP, UK
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27
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Plasma Volume Is Normal but Heterogeneously Distributed, and True Anemia Is Highly Prevalent in Patients With Stable Heart Failure. J Card Fail 2017; 23:138-144. [DOI: 10.1016/j.cardfail.2016.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 08/03/2016] [Accepted: 08/19/2016] [Indexed: 11/20/2022]
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28
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Tim Goodnough L, Comin-Colet J, Leal-Noval S, Ozawa S, Takere J, Henry D, Javidroozi M, Hohmuth B, Bisbe E, Gross I, Shander A. Management of anemia in patients with congestive heart failure. Am J Hematol 2017; 92:88-93. [PMID: 27779769 DOI: 10.1002/ajh.24595] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/19/2016] [Accepted: 10/23/2016] [Indexed: 12/21/2022]
Abstract
Anemia is an independent risk factor for adverse patient outcomes. There are no guidelines for management of anemia in patients with congestive heart failure (CHF), despite its high incidence. Four objectives were defined by the International Anemia Management and Clinical Outcomes Expert Panel (AMCO), a multinational group of interdisciplinary experts identified by the Society for the Advancement of Blood Management (SABM) to: determine the prevalence of anemia in outpatients; to determine the prevalence of hospital-acquired anemia; to assess the impact of anemia management on clinical outcomes such as quality of life and functional status; and to provide recommendations for primary care physicians and specialists for the diagnosis, evaluation, and management of anemia in patients with CHF. Anemia and iron deficiency were confirmed to be highly prevalent in patients with CHF. Intravenous iron therapy improves anemia, cardiac function and exercise tolerance, leading to improvement in quality of life. Anemia management has been demonstrated to be cost-effective. Clinical care pathways to manage anemia in patients with CHF are recommended as best practices in order to improve patient outcomes. Am. J. Hematol. 92:88-93, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Josep Comin-Colet
- Department of Cardiology; Heart Failure Program, Bellvitge University Hospital and Biomedical Research Institute, Hospitalet de Liobregat; Barcelona Spain
| | - Santiago Leal-Noval
- Department of Critical Care, Critical Care Division; University Hospital “Virgen delRocío” Avda Manuel Siurot s/n; Seville Spain
| | - Sherri Ozawa
- Institute for Patient Blood Management and Bloodless Medicine and Surgery; Englewood Hospital and Medical Center; Englewood New Jersey
| | - Jacqueline Takere
- Department of Pharmacy, ASHP Pharmacy Residency Program, Investigation Drug Services; Clinical Coordinator for Pharmacy and Therapeutics/Oncology Services; Englewood New Jersey
| | - David Henry
- Department of Medicine; Penn Hematology/Oncology Abramson Cancer Center, Pennsylvania Hospital; Philadelphia Pennsylvania
| | - Mazyar Javidroozi
- Department of Anesthesiology; Englewood Hospital and Medical Center; Englewood New Jersey
| | - Benjamin Hohmuth
- Department of Hospital Medicine; Temple University School of Medicine, Representing Society of Hospital Medicine; Philadelphia Pennsylvania
| | - Elvira Bisbe
- Department of Anaesthesiology and Reanimation; Hospital Universitaridel Mar; Barcelona Spain
- Perioperative Medicine Research Group; Hospital del Mar Medical Research Institute. IMIM Coordination of Anemia Working Group España; Spain
| | - Irwin Gross
- Senior medical director; Accumen LLC; San Diego California
| | - Aryeh Shander
- Medicine and Surgery, Icahn School of Medicine; New York New York
- Department of Anesthesiology, Critical Care, Pain and Hyperbaric medicine, Englewood Hospital and Medical Center; TeamHealth Research Institute; Englewood New Jersey
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29
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Kajimoto K, Sato N, Takano T. Association of anemia and renal dysfunction with in-hospital mortality among patients hospitalized for acute heart failure syndromes with preserved or reduced ejection fraction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 5:89-99. [PMID: 26124457 DOI: 10.1177/2048872615593387] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the association of anemia and renal dysfunction with in-hospital outcomes in acute heart failure syndromes patients with preserved or reduced ejection fraction. METHODS AND RESULTS Of the 4842 patients enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry, 4693 patients were evaluated to investigate the association among anemia, renal dysfunction, a preserved or reduced ejection fraction and in-hospital mortality. They were divided into four groups based on hemoglobin and estimated glomerular filtration rate at admission. The in-hospital mortality rate was 5.9% and 6.9% of the preserved and reduced ejection fraction groups, respectively. After adjustment for multiple comorbidities, there was no association of either anemia or renal dysfunction alone with in-hospital mortality in preserved ejection fraction patients, but the combination of anemia and renal dysfunction was associated with a somewhat higher risk of in-hospital mortality than that without either condition (odds ratio (OR), 2.75; 95% confidence interval (CI), 0.72-10.41; p=0.137). In reduced ejection fraction patients, adjusted analysis showed that a significantly higher risk of in-hospital mortality was associated with anemia alone (OR, 2.56; 95% CI, 1.10 -5.94; p=0.029) and with anemia plus renal dysfunction (OR, 2.34; 95% CI, 1.09-5.03; p=0.029) relative to the risk without either condition. CONCLUSIONS Our findings demonstrate that anemia combined with renal dysfunction is not a risk factor for in-hospital mortality in patients with a preserved ejection fraction, whereas anemia is an independent predictor of in-hospital mortality risk in reduced ejection fraction patients regardless of renal dysfunction.
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Affiliation(s)
| | - Naoki Sato
- 2 Internal Medicine, Cardiology, and Intensive Care Unit, Nippon Medical School Musashi-Kosugi Hospital, Kanagawa, Japan
| | - Teruo Takano
- 3 Department of Internal Medicine, Nippon Medical School, Tokyo, Japan
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30
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Abstract
Volume regulation, assessment, and management remain basic issues in patients with heart failure. The discussion presented here is directed at opening a reassessment of the pathophysiology of congestion in congestive heart failure and the methods by which we determine volume overload status. Peer-reviewed historical and contemporary literatures are reviewed. Volume overload and fluid congestion remain primary issues for patients with chronic heart failure. The pathophysiology is complex, and the simple concept of intravascular fluid accumulation is not adequate. The dynamics of interstitial and intravascular fluid compartment interactions and fluid redistribution from venous splanchnic beds to central pulmonary circulation need to be taken into account in strategies of volume management. Clinical bedside evaluations and right heart hemodynamic assessments can alert clinicians of changes in volume status, but only the quantitative measurement of total blood volume can help identify the heterogeneity in plasma volume and red blood cell mass that are features of volume overload in patients with chronic heart failure and help guide individualized, appropriate therapy—not all volume overload is the same.
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Affiliation(s)
- Wayne L. Miller
- From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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31
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Katz SD. Blood Vessels Behaving Badly: Targeting Hypertension in Acute Decompensated Heart Failure. J Card Fail 2016; 22:628-30. [PMID: 27327971 DOI: 10.1016/j.cardfail.2016.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 06/16/2016] [Accepted: 06/16/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Stuart D Katz
- Leon H. Charney Division of Cardiology, New York University School of Medicine, New York, New York.
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32
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Miller WL, Mullan BP. Volume Overload Profiles in Patients With Preserved and Reduced Ejection Fraction Chronic Heart Failure. JACC-HEART FAILURE 2016; 4:453-9. [DOI: 10.1016/j.jchf.2016.01.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 01/12/2016] [Accepted: 01/13/2016] [Indexed: 12/17/2022]
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33
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Samson R, Jaiswal A, Ennezat PV, Cassidy M, Le Jemtel TH. Clinical Phenotypes in Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2016; 5:e002477. [PMID: 26811159 PMCID: PMC4859363 DOI: 10.1161/jaha.115.002477] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Rohan Samson
- Tulane University Heart and Vascular InstituteTulane University School of MedicineNew OrleansLA
| | - Abhishek Jaiswal
- Tulane University Heart and Vascular InstituteTulane University School of MedicineNew OrleansLA
| | - Pierre V. Ennezat
- Department of CardiologyCentre Hospitalier Universitaire de GrenobleGrenoble Cedex 09France
| | - Mark Cassidy
- Tulane University Heart and Vascular InstituteTulane University School of MedicineNew OrleansLA
| | - Thierry H. Le Jemtel
- Tulane University Heart and Vascular InstituteTulane University School of MedicineNew OrleansLA
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34
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Miller WL, Mullan BP. Peripheral Venous Hemoglobin and Red Blood Cell Mass Mismatch in Volume Overload Systolic Heart Failure: Implications for Patient Management. J Cardiovasc Transl Res 2015; 8:404-10. [DOI: 10.1007/s12265-015-9650-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 08/27/2015] [Indexed: 10/23/2022]
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35
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Takei M, Kohsaka S, Shiraishi Y, Goda A, Izumi Y, Yagawa M, Mizuno A, Sawano M, Inohara T, Kohno T, Fukuda K, Yoshikawa T. Effect of estimated plasma volume reduction on renal function for acute heart failure differs between patients with preserved and reduced ejection fraction. Circ Heart Fail 2015; 8:527-32. [PMID: 25737498 DOI: 10.1161/circheartfailure.114.001734] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 02/27/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND The prognostic relevance of plasma volume reduction (PVR) in acute heart failure patients remains unclear because of the confounding hemodynamic effect of left ventricular ejection fraction impairment on kidney function. METHODS AND RESULTS Subjects enrolled in the West Tokyo Heart Failure Registry were examined. The PV at admission and discharge was estimated from the subjects' body weight and its deviation from the ideal body weight. Patients in the top tertile of estimated PVR were classified as PVR+. Of the 381 patients with acute heart failure, 181 (47.5%) had heart failure with preserved ejection fraction (HFpEF). Estimated PVR was associated with worsening renal function in the HFpEF (odds ratio, 3.28; 95% confidence interval, 1.55-6.96; P=0.002) but not in the heart failure with reduced ejection fraction cohort (odds ratio, 1.22; 95% confidence interval, 0.61-2.42; P=0.57). This association in the HFpEF cohort remained significant after adjusting for a history of hypertension and diabetes mellitus and the estimated glomerular filtration rate (odds ratio, 3.34; 95% confidence interval, 1.52-7.33; P=0.003). The use of intravenous diuretics was a significant predictor of PVR in the HFpEF and heart failure with reduced ejection fraction groups. CONCLUSIONS The effect of estimated PVR differs by HF type, and the estimated PVR during hospitalization is a predictor of worsening renal function in patients with HFpEF but not in heart failure with reduced ejection fraction. CLINICAL TRIAL REGISTRATION URL: http://www.umin.ac.jp/ctr/index-j.html. Unique identifier: UMIN000001549.
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Affiliation(s)
- Makoto Takei
- From the Department of Cardiology, Keio University School of Medicine, Shinjukuku, Tokyo, Japan (M.T., S.K., Y.S., M.S., T.I., T.K., K.F.); Department of Cardiology, St. Luke's International Hospital, Chuouku, Tokyo, Japan (A.M.); Second Department of Internal Medicine, Division of Cardiology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan (A.G.); and Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan (Y.I., M.Y., T.Y.)
| | - Shun Kohsaka
- From the Department of Cardiology, Keio University School of Medicine, Shinjukuku, Tokyo, Japan (M.T., S.K., Y.S., M.S., T.I., T.K., K.F.); Department of Cardiology, St. Luke's International Hospital, Chuouku, Tokyo, Japan (A.M.); Second Department of Internal Medicine, Division of Cardiology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan (A.G.); and Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan (Y.I., M.Y., T.Y.).
| | - Yasuyuki Shiraishi
- From the Department of Cardiology, Keio University School of Medicine, Shinjukuku, Tokyo, Japan (M.T., S.K., Y.S., M.S., T.I., T.K., K.F.); Department of Cardiology, St. Luke's International Hospital, Chuouku, Tokyo, Japan (A.M.); Second Department of Internal Medicine, Division of Cardiology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan (A.G.); and Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan (Y.I., M.Y., T.Y.)
| | - Ayumi Goda
- From the Department of Cardiology, Keio University School of Medicine, Shinjukuku, Tokyo, Japan (M.T., S.K., Y.S., M.S., T.I., T.K., K.F.); Department of Cardiology, St. Luke's International Hospital, Chuouku, Tokyo, Japan (A.M.); Second Department of Internal Medicine, Division of Cardiology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan (A.G.); and Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan (Y.I., M.Y., T.Y.)
| | - Yuki Izumi
- From the Department of Cardiology, Keio University School of Medicine, Shinjukuku, Tokyo, Japan (M.T., S.K., Y.S., M.S., T.I., T.K., K.F.); Department of Cardiology, St. Luke's International Hospital, Chuouku, Tokyo, Japan (A.M.); Second Department of Internal Medicine, Division of Cardiology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan (A.G.); and Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan (Y.I., M.Y., T.Y.)
| | - Mayuko Yagawa
- From the Department of Cardiology, Keio University School of Medicine, Shinjukuku, Tokyo, Japan (M.T., S.K., Y.S., M.S., T.I., T.K., K.F.); Department of Cardiology, St. Luke's International Hospital, Chuouku, Tokyo, Japan (A.M.); Second Department of Internal Medicine, Division of Cardiology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan (A.G.); and Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan (Y.I., M.Y., T.Y.)
| | - Atsushi Mizuno
- From the Department of Cardiology, Keio University School of Medicine, Shinjukuku, Tokyo, Japan (M.T., S.K., Y.S., M.S., T.I., T.K., K.F.); Department of Cardiology, St. Luke's International Hospital, Chuouku, Tokyo, Japan (A.M.); Second Department of Internal Medicine, Division of Cardiology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan (A.G.); and Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan (Y.I., M.Y., T.Y.)
| | - Mitsuaki Sawano
- From the Department of Cardiology, Keio University School of Medicine, Shinjukuku, Tokyo, Japan (M.T., S.K., Y.S., M.S., T.I., T.K., K.F.); Department of Cardiology, St. Luke's International Hospital, Chuouku, Tokyo, Japan (A.M.); Second Department of Internal Medicine, Division of Cardiology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan (A.G.); and Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan (Y.I., M.Y., T.Y.)
| | - Taku Inohara
- From the Department of Cardiology, Keio University School of Medicine, Shinjukuku, Tokyo, Japan (M.T., S.K., Y.S., M.S., T.I., T.K., K.F.); Department of Cardiology, St. Luke's International Hospital, Chuouku, Tokyo, Japan (A.M.); Second Department of Internal Medicine, Division of Cardiology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan (A.G.); and Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan (Y.I., M.Y., T.Y.)
| | - Takashi Kohno
- From the Department of Cardiology, Keio University School of Medicine, Shinjukuku, Tokyo, Japan (M.T., S.K., Y.S., M.S., T.I., T.K., K.F.); Department of Cardiology, St. Luke's International Hospital, Chuouku, Tokyo, Japan (A.M.); Second Department of Internal Medicine, Division of Cardiology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan (A.G.); and Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan (Y.I., M.Y., T.Y.)
| | - Keiichi Fukuda
- From the Department of Cardiology, Keio University School of Medicine, Shinjukuku, Tokyo, Japan (M.T., S.K., Y.S., M.S., T.I., T.K., K.F.); Department of Cardiology, St. Luke's International Hospital, Chuouku, Tokyo, Japan (A.M.); Second Department of Internal Medicine, Division of Cardiology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan (A.G.); and Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan (Y.I., M.Y., T.Y.)
| | - Tsutomu Yoshikawa
- From the Department of Cardiology, Keio University School of Medicine, Shinjukuku, Tokyo, Japan (M.T., S.K., Y.S., M.S., T.I., T.K., K.F.); Department of Cardiology, St. Luke's International Hospital, Chuouku, Tokyo, Japan (A.M.); Second Department of Internal Medicine, Division of Cardiology, Kyorin University School of Medicine, Mitaka, Tokyo, Japan (A.G.); and Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan (Y.I., M.Y., T.Y.)
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Bugrova IA, Kalyuta TY, Korsunova EN, Shvartz YG. RED BLOOD VALUES CHANGES IN CARDIOVASCULAR PATIENTS — EPIDEMIOLOGY, PROGNOSIS AND TREATMENT APPROACHES. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2014. [DOI: 10.15829/1728-8800-2014-6-62-67] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The review highlights a significance of anemic syndrome in cardiovascular patients, which is certainly negatively related to life quality and prognosis of patients. The main causes for its development are discussed, of those the main are hemodilution, inflammatory cytokines, iron deficiency. Also anemia correction is discussed and the main trials of this field are mentioned. The U-shaped relation is discussed for hemoglobin concentration and cardiovascular morbidity and mortality which reflect that higher levels of hemoglobin and hematocrit are associated with poorer outcome. There is lack of information on the prevalence and influence of hemoconcentration on prognosis in cardiological patients, as the data available is usually controversial. The conclusion is made that at the moment the problem of target hemoglobin and hematocrit levels definition for anemia treatment in cardiological patients, as also the data on the hemoconcentration influence of course and prognosis of cardiovascular diseases remains open.
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Caughey MC, Avery CL, Ni H, Solomon SD, Matsushita K, Wruck LM, Rosamond WD, Loehr LR. Outcomes of patients with anemia and acute decompensated heart failure with preserved versus reduced ejection fraction (from the ARIC study community surveillance). Am J Cardiol 2014; 114:1850-4. [PMID: 25438912 DOI: 10.1016/j.amjcard.2014.09.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 09/14/2014] [Accepted: 09/14/2014] [Indexed: 11/19/2022]
Abstract
Anemia is associated with poor prognosis in patients hospitalized with acute decompensated heart failure (ADHF). Whether the impact of anemia differs by heart failure with preserved ejection fraction (HFpEF) or heart failure with reduced ejection fraction (HFrEF) is uncertain. We examined hospital surveillance data captured by the Atherosclerosis Risk in Communities Study from January 1, 2005, to December 31, 2010. Diagnoses of ADHF were validated by standardized physician review of the medical record. Anemia was classified using the World Health Organization criteria (<12 g/dl for women and <13 g/dl for men), and HF type was determined by the ejection fraction (<40% for HFrEF and ≥40% for HFpEF). Hospital length of stay and 1-year mortality outcomes were analyzed by multivariable regression, weighted to account for the sampling design, and adjusted for demographics and clinical covariates. Over 6 years, 15,461 (weighted) hospitalized events for ADHF (59% HFrEF) occurred in the catchment of the Atherosclerosis Risk in Communities, based on 3,309 sampled events. Anemia was associated with a mortality hazard ratio of 2.1 (95% confidence interval [CI] 1.6 to 2.7) in patients classified with HFpEF and 1.4 (95% CI 1.1 to 1.7) in those with HFrEF; p for interaction = 0.05. The mean increase in length of hospital stay associated with anemia was 3.5 days (95% CI 3.4 to 3.6) for patients with HFpEF, compared with 1.8 days (95% CI 1.7 to 1.9) for those with HFrEF; p for interaction <0.0001. In conclusion, the incremental risks of death and lengthened hospital stay associated with anemia are more pronounced in ADHF patients classified with HFpEF than HFrEF.
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Affiliation(s)
- Melissa C Caughey
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Christy L Avery
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Hanyu Ni
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard University; Boston, Massachusetts
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lisa M Wruck
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Wayne D Rosamond
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Laura R Loehr
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Palazzuoli A, Ruocco G, Pellegrini M, De Gori C, Del Castillo G, Giordano N, Nuti R. The role of erythropoietin stimulating agents in anemic patients with heart failure: solved and unresolved questions. Ther Clin Risk Manag 2014; 10:641-50. [PMID: 25143739 PMCID: PMC4137997 DOI: 10.2147/tcrm.s61551] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Anemia is a common finding in congestive heart failure (CHF) and is associated with an increased mortality and morbidity. Several conditions can cause depression of erythroid progenitor cells: reduction of iron absorption and reuptake, decreased bone marrow activity, reduced endogenous erythropoietin production, and chronic inflammatory state. Anemia's etiology in CHF is complex and partially understood; it involves several systems including impaired hemodynamic condition, reduced kidney and bone perfusion, increased inflammatory activity, and neurohormonal overdrive. The use of erythropoiesis stimulating agents (ESAs) such as erythropoietin and its derivatives is recently debated; the last interventional trial seems to demonstrate a neutral or negative effect in the active arm with darbepoetin treatment. The current data is opposite to many single blind studies and previous meta-analysis showing an improvement in quality of life, New York Heart Association class, and exercise tolerance using ESA therapy. These contrasting data raise several concerns regarding the target of hemoglobin levels needing intervention, the exact anemia classification and categorization, and the standardization of hematocrit cutoffs. Some cardiac and systemic conditions (ie, hypertension, atrial fibrillation, prothrombotic status) may predispose to adverse events, and ESA administration should be avoided. To prevent the negative effects, high-dosage and chronic administration should be avoided. Clarification of these items could probably identify patients that may benefit from additional iron or ESA treatment. In this review, we discuss the interventional trials made in anemic heart failure patients, the underlying mechanism of anemia in CHF, and the potential role of ESA in this setting.
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Affiliation(s)
- Alberto Palazzuoli
- Department of Internal Medicine and Metabolic Diseases, Cardiology Section, Le Scotte Hospital, University of Siena, Siena, Italy
| | - Gaetano Ruocco
- Department of Internal Medicine and Metabolic Diseases, Cardiology Section, Le Scotte Hospital, University of Siena, Siena, Italy
| | - Marco Pellegrini
- Department of Internal Medicine and Metabolic Diseases, Cardiology Section, Le Scotte Hospital, University of Siena, Siena, Italy
| | - Carmelo De Gori
- Department of Internal Medicine and Metabolic Diseases, Cardiology Section, Le Scotte Hospital, University of Siena, Siena, Italy
| | - Gabriele Del Castillo
- Department of Internal Medicine and Metabolic Diseases, Cardiology Section, Le Scotte Hospital, University of Siena, Siena, Italy
| | - Nicola Giordano
- Department of Internal Medicine and Metabolic Diseases, Cardiology Section, Le Scotte Hospital, University of Siena, Siena, Italy
| | - Ranuccio Nuti
- Department of Internal Medicine and Metabolic Diseases, Cardiology Section, Le Scotte Hospital, University of Siena, Siena, Italy
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Differences in blood volume components between hyporesponders and responders to erythropoietin alfa: the heart failure with preserved ejection fraction (HFPEF) anemia trial. J Card Fail 2014; 19:685-91. [PMID: 24125107 DOI: 10.1016/j.cardfail.2013.08.508] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 08/14/2013] [Accepted: 08/27/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Hyporesponders to erythropoietin-stimulating agents (ESAs) have been associated with an increased subsequent risk of death or cardiovascular events. We hypothesized that subjects who are hyporesponsive to erythropoietin alfa would have higher plasma volumes and lower red cell deficits than subjects who are responsive to therapy. METHODS As part of a prospective, single blind, randomized, placebo-controlled study comparing erythropoietin alfa with placebo in older adults (n = 56) with heart failure and a preserved ejection fraction (HFPEF), we performed blood volume analysis with the use of an indicator dilution technique with (131)iodine-labeled albumin. We evaluated differences in plasma volumes and red cell volumes in hyporesponders (eg, <1 g/dL increase in hemoglobin within the first 4 weeks of treatment with erythropoetin alfa) compared with subjects who were responders and controls. RESULTS Nine of 28 subjects (32%) assigned to ESA were hyporesponders. Hyporesponders did not differ from responders nor control subjects by any baseline demographic, clinical, or laboratory parameter, including hemoglobin. Hyporesponders had a greater total blood volume expansion (1,264.7 ± 387 vs 229 ± 206 mL; P = .02) but less of a red cell deficit (-96.2 ± 126 vs -402.5 ± 80.6 mL; P = .04) and a greater plasma volume expansion (+1,360.8 ± 264.5 vs +601.1 ± 165.5 mL; P = .01). Among responders, the increase in hemoglobin with erythropoietin alfa was associated primarily with increases in red cell volume (r = 0.91; P < .0001) as well as a decline in plasma volume (r = -0.55; P = .06). CONCLUSIONS Among older adults with HFPEF and anemia, hyporesponders to erythropoietin alfa had a hemodilutional basis of their anemia, suggesting that blood volume analysis can identify a cohort likely to respond to therapy.
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Hong N, Youn JC, Oh J, Lee HS, Park S, Choi D, Kang SM. Prognostic value of new-onset anemia as a marker of hemodilution in patients with acute decompensated heart failure and severe renal dysfunction. J Cardiol 2013; 64:43-8. [PMID: 24368094 DOI: 10.1016/j.jjcc.2013.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 10/16/2013] [Accepted: 11/06/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In patients with acute decompensated heart failure (ADHF), the prognostic value of new-onset anemia with regard to renal function has not been investigated. METHODS AND SUBJECTS Consecutive 299 ADHF patients (162 men, 62 ± 14 years) were enrolled. Cardiovascular (CV) events composite of CV mortality and rehospitalization occurred in 113 patients (37.8%) during 2 years of follow-up. RESULTS Baseline anemia was prevalent (n = 124, 41.5%) and 43 patients (14.4%) had new-onset anemia at 1 month after discharge. Baseline anemia was strongly associated with CV events risk in overall [hazard ratio (HR): 1.79, 95% CI: 1.17-2.74, p = 0.006] and those with preserved renal function [estimated glomerular filtration rate (eGFR)≥ 45 mL/min/1.73 m(2)] (HR: 1.81, 95% CI: 1.05-3.12, p = 0.031). In patients with severe renal dysfunction (eGFR<45 mL/min/1.73 m(2)), new-onset anemia independently predicted CV events (HR: 2.72, 95% CI: 1.09-6.76, p = 0.031) whereas baseline anemia did not (HR: 1.28, 95% CI: 0.61-2.65, p = 0.505). New-onset anemia was significantly associated with hemodilution, which may reflect inadequate decongestion in ADHF patients. CONCLUSIONS Baseline anemia was an independent prognostic factor in overall ADHF patients and those with preserved renal function. New-onset anemia as a surrogate for hemodilution better predicted CV events than baseline anemia in ADHF patients with severe renal dysfunction.
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Affiliation(s)
- Namki Hong
- Cardiology Division, Severance Cardiovascular Hospital and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong-Chan Youn
- Cardiology Division, Severance Cardiovascular Hospital and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jaewon Oh
- Cardiology Division, Severance Cardiovascular Hospital and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Sun Lee
- Department of Biostatistics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sungha Park
- Cardiology Division, Severance Cardiovascular Hospital and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Donghoon Choi
- Cardiology Division, Severance Cardiovascular Hospital and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seok-Min Kang
- Cardiology Division, Severance Cardiovascular Hospital and Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Maurer MS, Teruya S, Chakraborty B, Helmke S, Mancini D. Treating anemia in older adults with heart failure with a preserved ejection fraction with epoetin alfa: single-blind randomized clinical trial of safety and efficacy. Circ Heart Fail 2012; 6:254-63. [PMID: 23258574 DOI: 10.1161/circheartfailure.112.969717] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Anemia is a common comorbidity in older adults with heart failure and a preserved ejection fraction and is associated with worse outcomes. We hypothesized that treating anemia with subcutaneous epoetin alfa would be associated with reverse ventricular remodeling and improved exercise capacity and health status compared with placebo. METHODS AND RESULTS Prospective, randomized, single-blind, 24-week study with blinded end point assessment among anemic (average hemoglobin of 10.4±1 g/dL) older adult patients (n=56; 77±11 years; 68% women) with heart failure and a preserved ejection fraction (ejection fraction=63±15%; B-type natriuretic peptide=431±366 pg/mL) was conducted. Treatment with epoetin alfa resulted in significant increases in hemoglobin (P<0.0001). Changes in end-diastolic volume (-6±14 versus -4±16 mL; P=0.67) at 6 months did not differ between epoetin alfa and placebo, but declines in stroke volume (-5±8 versus 2±10 mL; P=0.09) without significant changes in left ventricular mass were observed. Changes in 6-minute walk distance (16±11 versus 5±12 m; P=0.52) did not differ. Although quality of life improved by the Kansas City Cardiomyopathy Questionnaire and the Minnesota Living with Heart Failure Questionnaire in both cohorts, there were no significant differences between groups. CONCLUSIONS Administration of epoetin alfa to older adult patients with heart failure and a preserved ejection fraction compared with placebo did not change left ventricular end-diastolic volume and left ventricular mass nor did it improve submaximal exercise capacity or quality of life. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. UNIQUE IDENTIFIER: NCT00286182.
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Bernard S, Maurer MS. Heart Failure With a Normal Ejection Fraction: Treatments for a Complex Syndrome? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2012; 14:305-18. [DOI: 10.1007/s11936-012-0187-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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MacIver DH, Dayer MJ, Harrison AJI. A general theory of acute and chronic heart failure. Int J Cardiol 2012; 165:25-34. [PMID: 22483252 DOI: 10.1016/j.ijcard.2012.03.093] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2012] [Revised: 03/07/2012] [Accepted: 03/08/2012] [Indexed: 12/13/2022]
Abstract
Current concepts of heart failure propose multiple heterogeneous pathophysiological mechanisms. Recently a theoretical framework for understanding chronic heart failure was suggested. This paper develops this framework to include acute heart failure syndromes. We propose that all acute heart failure syndromes may be understood in terms of a relative fall in left ventricular stroke volume. The initial compensatory mechanism is frequently a tachycardia often resulting in a near normal cardiac output. In more severe forms a fall in cardiac output causes hypotension or cardiogenic shock. In chronic heart failure the stroke volume and cardiac output is returned to normal predominantly through ventricular remodeling or dilatation. Ejection fraction is simply the ratio of stroke volume and end-diastolic volume. The resting stroke volume is predetermined by the tissue's needs; therefore, if the ejection fraction changes, the end-diastolic volume must change in a reciprocal manner. The potential role of the right heart in influencing the presentation of left heart disease is examined. We propose that acute pulmonary edema occurs when the right ventricular stroke volume exceeds left ventricular stroke volume leading to fluid accumulation in the alveoli. The possible role of the right heart in determining pulmonary hypertension and raised filling pressures in left-sided heart disease are discussed. Different clinical scenarios are presented to help clarify these proposed mechanisms and the clinical implications of these theories are discussed. Finally an alternative definition of heart failure is proposed.
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Affiliation(s)
- David H MacIver
- Department of Cardiology, Taunton & Somerset Hospital, Musgrove Park, Taunton TA1 5DA, UK.
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Guglin M, Win CM, Darbinyan N, Wu Y. Predictors of right ventricular systolic dysfunction in compensated and decompensated heart failure. ACTA ACUST UNITED AC 2012; 18:278-83. [PMID: 22994442 DOI: 10.1111/j.1751-7133.2012.00289.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Current understanding of the mechanisms of right ventricular (RV) systolic dysfunction in heart failure (HF) is limited. The authors analyzed a limited access dataset from the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) provided by the National Heart, Lung, and Blood Institute (NHLBI). RV systolic function was measured by echocardiography at baseline and at 3-month follow-up using fractional area change. Univariate and multivariate analysis was performed with linear regression. Of 433 patients enrolled in the ESCAPE trial, 190 had RV systolic function measured at baseline (decompensated HF) and 147 had it measured at 3-month follow-up. On both occasions, parameters of congestion were associated with RV systolic function. Interestingly, lower hematocrit level was also associated with better RV systolic function. In multivariate analysis, only wedge pressure remained a statistically significant predictor of RV dysfunction. In summary, cardiac diastolic pressures and corresponding echocardiographic parameters, as well as hematocrit level, predicted RV systolic function in both compensated and decompensated systolic HF.
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Affiliation(s)
- Maya Guglin
- Department of Cardiology, University of South Florida, Tampa, FL 33606, USA.
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MacIver DH, Dayer MJ. An alternative approach to understanding the pathophysiological mechanisms of chronic heart failure. Int J Cardiol 2012; 154:102-10. [DOI: 10.1016/j.ijcard.2011.05.075] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2010] [Revised: 03/16/2011] [Accepted: 05/13/2011] [Indexed: 11/29/2022]
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Guglin M, Darbinyan N. Relationship of Hemoglobin and Hematocrit to Systolic Function in Advanced Heart Failure. Cardiology 2012; 122:187-94. [DOI: 10.1159/000339536] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Accepted: 05/15/2012] [Indexed: 11/19/2022]
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Liu M, Chan CP, Yan BP, Zhang Q, Lam YY, Li RJ, Sanderson JE, Coats AJS, Sun JP, Yip GWK, Yu CM. Albumin levels predict survival in patients with heart failure and preserved ejection fraction. Eur J Heart Fail 2011; 14:39-44. [PMID: 22158777 DOI: 10.1093/eurjhf/hfr154] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
AIMS Low serum albumin is common in patients with systolic heart failure and is associated with increased mortality. However, the relationship between albumin and outcome in patients with heart failure and preserved ejection fraction (HFPEF) is not known. The aim of this study was to investigate the effect of serum albumin level on survival in patients with HFPEF. METHODS AND RESULTS We studied 576 consecutive HFPEF patients (left ventricular ejection fraction ≥50%) admitted to our hospital from 2006 to 2009. Standard demographics, transthoracic echocardiography, and routine blood testing including albumin levels were obtained shortly after admission. Outcome was assessed at 1 year after admission. Hypoalbuminaemia (≤34 g/L) was detected in 160 (28%) at admission; and all patients were then divided into hypoalbuminaemia and non-hypoalbuminaemia groups. In the hypoalbuminaemia group, the prevalence of chronic renal failure history, serum creatinine, and urea nitrogen levels were higher when compared with those without hypoalbuminaemia (all P < 0.05). Kaplan-Meier analysis showed that patients with hypoalbuminaemia had a significantly lower survival rate (53% vs. 84%, log-rank χ(2) = 53.3, P < 0.001) and a higher rate of cardiovascular death (21.8% vs. 8.9%, log-rank χ(2) = 19.7, P < 0.001) when compared with those without hypoalbuminaemia. Cox regression further revealed that hypoalbuminaemia, a history of cerebrovascular disease, and older age were the most powerful independent predictors of all-cause mortality in HFPEF patients at 1 year. CONCLUSIONS Hypoalbuminaemia is common in HFPEF patients and is associated with increased risk of death. Renal dysfunction may be the main pathophysiological mechanism underlying hypoalbuminaemia in HFPEF patients.
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Affiliation(s)
- Ming Liu
- Institute of Vascular Medicine and Division of Cardiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Shatin, N.T., Hong Kong
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Davila C, Reyentovich A, Katz SD. Clinical correlates of hemoconcentration during hospitalization for acute decompensated heart failure. J Card Fail 2011; 17:1018-22. [PMID: 22123365 DOI: 10.1016/j.cardfail.2011.08.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 07/28/2011] [Accepted: 08/03/2011] [Indexed: 12/01/2022]
Abstract
BACKGROUND Hemoconcentration has been proposed as a putative biomarker of effective decongestion therapy in heart failure patients. The prevalence and clinical correlates of hemoconcentration in hospitalized patients with acute decompensated heart failure (ADHF) have not been previously described. METHODS AND RESULTS We retrospectively reviewed paired values of hemoglobin at admission and discharge to identify evidence of hemoconcentration in 295 subjects hospitalized with ADHF and determined the association between hemoconcentration and risk of worsening renal function and survival. Subjects with hemoconcentration (n = 75) received higher diuretic doses and demonstrated greater weight loss during hospitalization when compared with subjects without hemoconcentration (median [IQR] loop diuretic dose 180 (120) versus 160 (150) mg, P = .014; mean ± SD weight loss 4.0 ± 3.1 versus 2.2 ± 3.1 kg, P < .001). In univariate analysis, hemoconcentration was associated with increased risk of worsening renal function (odds ratio 2.34, 95% CI 1.27-4.30, P = .006), but decreased risk of all-cause mortality (hazard ratio 0.53, 95% CI 0.29-0.96, P = .035). In multivariate analysis, hemoconcentration remained independently associated with worsening renal function, but not mortality. CONCLUSIONS Hemoconcentration is significantly associated with increased diuretic dose, greater weight loss, and increased risk of worsening renal function during hospitalization. Hemoconcentration was significantly associated with mortality in univariate analysis, but not in multivariate analysis.
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Affiliation(s)
- Carlos Davila
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Langone Medical Center, New York, NY, USA
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Altincatal A, Macarthur RB, Teruya S, Helmke S, Maurer MS. A dosing algorithm for erythropoietin alpha in older adults with heart failure and a preserved ejection fraction. Cardiovasc Ther 2011; 31:92-9. [PMID: 21884028 DOI: 10.1111/j.1755-5922.2011.00295.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
AIMS Erythropoietin stimulating agents (ESAs) is an active area of clinical investigation in heart failure (HF) but can cause hypertension and higher hemoglobin concentrations (Hb) that have been associated with adverse outcomes. We evaluated a dosing algorithm and potential confounders' effect on Hb and blood pressure (BP) in a clinical trial. METHODS In an ongoing randomized, placebo controlled, single blind clinical trial of ESA (epoetin alfa) in anemic patients with HF and a preserved ejection fraction (HFPEF), Hb was measured weekly as was BP, weight and concomitant medical therapy. A repeated measure mixed model evaluated determinants of weekly changes in Hb and BP. RESULTS Among 45 subjects (78 ± 11 years, 67% women, EF = 57 ± 9%) with a total of 780 repeated weekly Hb measures, Hb significantly increased over time in those assigned to ESA (β = 0.933, P < 0.0001), compared to placebo. Dose (β = -0.108, P < 0.0001), patient weight (β = -0.016, P = 0.0037), diuretic use (β = -0.124, P = 0.0389), and time (β = 0.003, P = 0.0331), were all significantly associated with Hb change. Increased diuretic dose and weight change were significantly inversely associated with changes in Hb. ESA administration and dose were not significant determinants of absolute BP or changes in BP from baseline. DISCUSSION In addition to ESA dose and duration of therapy, factors indicative of volume status including weight and diuretic use are determinants of hemoglobin levels in HF subjects. CONCLUSION The currently employed dosing algorithm, which adjusts the administration of ESA based on the absolute hemoglobin and weekly change in hemoglobin increases Hb with relatively a low weekly dose of ESA without significant effects on BP.
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50
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Noumi B, Teruya S, Salomon S, Helmke S, Maurer MS. Blood volume measurements in patients with heart failure and a preserved ejection fraction: implications for diagnosing anemia. ACTA ACUST UNITED AC 2011; 17:14-8. [PMID: 21272222 DOI: 10.1111/j.1751-7133.2010.00208.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Racial differences in the prevalence of anemia in patients with heart failure have been noted. The diagnosis of anemia in heart failure patients can be confounded by many factors. Plasma volume expansion is one of the most prominent confounders. The authors investigated the difference of anemia prevalence using two different diagnostic techniques: peripheral hemoglobin recommended by the World Health Organization criteria and blood volume (BV) analysis. Racial disparities in the prevalence of anemia using both measures were compared. Sixty patients with heart failure and preserved ejection fraction (HFPEF) underwent measurement of BV by a radio-labeled albumin technique. Anemia was defined by both WHO criteria and by measured red blood cell volume (RBCV) >10% below ideal. Anemia was found in 67% of patients by the peripheral hemoglobin technique with no racial disparity. Only 35% of the patients had anemia by the BV analysis, with a 2-fold higher prevalence among Hispanics compared with whites and blacks. In patients with HFPEF, the diagnosis of anemia based on hemoglobin is confounded by plasma volume derangements resulting in significant overdiagnosis in this cohort. Racial differences in the rate of anemia were found. Such data could have important implications for the diagnosis and management of anemia in ethnic minorities with HFPEF.
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Affiliation(s)
- Bassel Noumi
- Clinical Cardiovascular Research Laboratory for the Elderly, Columbia University Medical Center, Allen Hospital of New York Presbyterian, 5141 Broadway, New York, NY 10034, USA
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