Serum Osmolality and Postdischarge Outcomes After Hospitalization for Heart Failure

Heart failure related fatigue: An exploratory analysis of serum osmolality from the national health and nutrition examination survey

BACKGROUND

Fatigue is a prominent symptom of heart failure (HF). However, underlying mechanisms remain poorly understood. Fluid volume status has been suggested as a physiologic mechanism of HF-related fatigue. Serum osmolality may fluctuate with changes in volume status associated with neurohormonal dysregulation. The relationship of fatigue to serum osmolality has not been assessed in adults with HF.

OBJECTIVES

Describe the relationship between serum osmolality and fatigue in adults with HF.

METHODS

We analyzed two waves of cross-sectional data from the National Health and Nutrition Examination Survey (2015-2016 and 2017-2018). Adults who self-reported having HF without select co-morbid conditions known to contribute to fatigue were included. Data were weighted to provide US national estimates, and complex sample design used for analyses. Sequential logistic regression was used to isolate the effect of serum osmolality on the odds of having fatigue.

RESULTS

Data from the sample represented 1.4 million Americans with HF (58.5 % male; median age 68 years), of whom 1,001,589 (67.9 %) reported fatigue. Participants with fatigue had lower serum osmolality compared to those without fatigue (t = -3.04, p = .009). Higher serum osmolality was associated with 8.8 % lower odds of experiencing fatigue when controlling for sex and body mass index (OR = 0.912, p = .007, CI 0.857 - 0.972).

CONCLUSIONS

HF-related fatigue is associated with lower serum osmolality. Low serum osmolality may indicate excess volume and the presence of a heightened neurohormonal response, both of which may influence fatigue. Alternatively, serum osmolality may directly affect other physiologic changes that may contribute to fatigue.

Arrhythmogenic Potential of Myocardial Edema: The Interstitial Osmolality Induces Spiral Waves and Multiple Excitation Wavelets

Myocardial edema is a common symptom of pathological processes in the heart, causing aggravation of cardiovascular diseases and leading to irreversible myocardial remodeling. Patient-based studies show that myocardial edema is associated with arrhythmias. Currently, there are no studies that have examined how edema may influence changes in calcium dynamics in the functional syncytium. We performed optical mapping of calcium dynamics on a monolayer of neonatal rat cardiomyocytes with Fluo-4. The osmolality of the solutions was adjusted using the NaCl content. The initial Tyrode solution contained 140 mM NaCl (1T) and the hypoosmotic solutions contained 105 (0.75T) and 70 mM NaCl (0.5T). This study demonstrated a sharp decrease in the calcium wave propagation speed with a decrease in the solution osmolality. The successive decrease in osmolality also showed a transition from a normal wavefront to spiral wave and multiple wavelets of excitation with wave break. Our study demonstrated that, in a cellular model, hypoosmolality and, as a consequence, myocardial edema, could potentially lead to fatal ventricular arrhythmias, which to our knowledge has not been studied before. At 0.75T spiral waves appeared, whereas multiple wavelets of excitation occurred in 0.5T, which had not been recorded previously in a two-dimensional monolayer under conditions of cell edema without changes in the pacing protocol.

Risk Factors for All-Cause Mortality in Patients Diagnosed with Advanced Heart Failure: A Scoping Review

Introduction: Identifying the evolving needs of patients with advanced heart failure (AdHF) and triaging those at high risk of death can facilitate timely referrals to palliative care and advance patient-centered individualized care. There are limited models specific for patients with end-stage HF. We aim to identify risk factors associated with up to three-year all-cause mortality (ACM) and describe prognostic models developed or validated in AdHF populations. Methods: Frameworks proposed by Arksey, O'Malley, and Levac were adopted for this scoping review. We searched the Medline, EMBASE, PubMed, CINAHL, Cochrane library, Web of Science and gray literature databases for articles published between January 2010 and September 2020. Primary studies that included adults aged ≥ 18 years, diagnosed with AdHF defined as New York Heart Association class III/IV, American Heart Association/American College of Cardiology Stage D, end-stage HF, and assessed for risk factors associated with up to three-year ACM using multivariate analysis were included. Studies were appraised using the Quality of Prognostic Studies tool. Data were analyzed using a narrative synthesis approach. Results: We reviewed 167 risk factors that were associated with up to three-year ACM and prognostic models specific to AdHF patients across 65 articles with low-to-moderate bias. Studies were mostly based in Western and/or European cohorts (n = 60), in the acute care setting (n = 56), and derived from clinical trials (n = 40). Risk factors were grouped into six domains. Variables related to cardiovascular and overall health were frequently assessed. Ten prognostic models developed/validated on AdHF patients displayed acceptable model performance [area under the curve (AUC) range: 0.71-0.81]. Among the ten models, the model for end-stage-liver disease (MELD-XI) and acute decompensated HF with N-terminal pro b-type natriuretic peptide (ADHF/proBNP) model attained the highest discriminatory performance against short-term ACM (AUC: 0.81). Conclusions: To enable timely referrals to palliative care interventions, further research is required to develop or validate prognostic models that consider the evolving landscape of AdHF management.

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

Background

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

Methods

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

Results

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

Conclusion

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

The U-shaped association between serum osmolality and 28-day mortality in patients with sepsis: a retrospective cohort study

BACKGROUND

Sepsis is a recognized global health challenge that places a considerable disease burden on countries. Although there has been some progress in the study of sepsis, the mortality rate of sepsis remains high. The relationship between serum osmolality and the prognosis of patients with sepsis is unclear.

METHOD

Patients with sepsis who met the criteria in the Medical Information Mart for Intensive Care IV database were included in the study. Hazard ratios (HRs) and 95% confidence intervals (CIs) were determined using multivariable Cox regression. The relationship between serum osmolality and the 28-day mortality risk in patients with sepsis was investigated using curve fitting, and inflection points were calculated.

RESULTS

A total of 13,219 patients with sepsis were enrolled in the study; the mean age was 65.1 years, 56.9 % were male, and the 28-day mortality rate was 18.8 %. After adjusting for covariates, the risk of 28-day mortality was elevated by 99% (HR 1.99, 95%CI 1.74-2.28) in the highest quintile of serum osmolality (Q5 >303.21) and by 59% (HR 1.59, 95%CI 1.39-1.83) in the lowest quintile (Q1 ≤285.80), as compared to the reference quintile (Q3 291.38-296.29). The results of the curve fitting showed a U-shaped relationship between serum osmolality and the risk of 28-day mortality, with an inflection point of 286.9 mmol/L.

CONCLUSION

There is a U-shaped relationship between serum osmolality and the 28-day mortality risk in patients with sepsis. Higher or lower serum osmolality is associated with an increased risk of mortality in patients with sepsis. Patients with sepsis have a lower risk of mortality when their osmolality is 285.80-296.29 mmol/L.

Mechanisms of Myocardial Edema Development in CVD Pathophysiology

Myocardial edema is the excess accumulation of fluid in the myocardial interstitium or cardiac cells that develops due to changes in capillary permeability, loss of glycocalyx charge, imbalance in lymphatic drainage, or a combination of these factors. Today it is believed that this condition is not only a complication of cardiovascular diseases, but in itself causes aggravation of the disease and increases the risks of adverse outcomes. The study of molecular, genetic, and mechanical changes in the myocardium during edema may contribute to the development of new approaches to the diagnosis and treatment of this condition. This review was conducted to describe the main mechanisms of myocardial edema development at the molecular and cellular levels and to identify promising targets for the regulation of this condition based on articles cited in Pubmed up to January 2024.

Serum osmolality was non-linearly associated with the risk of all-cause and cardiovascular mortality in patients with diabetes

AIMS

This study aimed to evaluate the relationship between both low and high osmolarity and the risk of all-cause and cause-specific mortality in diabetic population.

METHODS

All participants were included from the National Health and Nutrition Examination Survey 1999-2014. Baseline serum osmolality was determined from laboratory tests and cause of death from national death records. HRs and 95% CIs for all-cause mortality and cardiovascular mortality in diabetes were estimated using Cox proportional regression analysis. The non-linear relationship was explored using restricted cubic splines regression.

RESULTS

Among 7622 individuals with diabetes, 1983 (12.4%) died during a total of 3.26 thousand person-years of follow-up. Compared with the reference category (281-284 mmol/kg), the multivariable-adjusted HRs and 95% CIs for all-cause mortality were 1.27 (1.16-1.40; p<0.001) in the lowest osmolality category (<201 mmol/kg) and 1.18 (1.09-1.28; p<0.001) in the highest osmolality category (>312 mmol/kg). Restricted cubic splines results showed that serum levels of osmolality had a U-shaped association with the risk of all-cause mortality, and L-shaped relationship with the risk of cardiovascular death.

CONCLUSIONS

Both low osmolality and high osmolality were predictive of increased all-cause mortality in patients with diabetes, supporting a U-shaped relationship. Also, a lower serum osmolality increased the risk of cardiovascular mortality.

Association of serum osmolality with all-cause and cardiovascular mortality in US adults: A prospective cohort study

BACKGROUND AND AIMS

The association between serum osmolality, an effective indicator of body hydration status, and long-term mortality in the general population remains undetermined. The present study aimed to investigate the association of serum osmolality with long-term all-cause and cardiovascular mortality among adults in the United States.

METHODS AND RESULTS

This cohort study used data from the National Health and Nutrition Examination Survey (NHANES) 2007-2014. Participants were linked to National Death Index mortality data from the survey date through December 31, 2019. Cox proportional hazards regression model was used to calculate hazard ratios (HRs) and 95% CIs, and restricted cubic spline (RCS) regression was conducted. A total of 18312 US adults were included. During a median follow-up of 8.7 years, 1353 total deaths occurred, including 379 cardiovascular deaths. After multivariable adjustments, compared with the 3rd quartile (Q3) of serum osmolality, participants in the 1st (Q1) and 4th (Q4) quartiles were at a significantly higher risk of all-cause mortality (HR 1.41 [95% CI, 1.14-1.75] and 1.29 [95% CI, 1.04-1.61], respectively). RCS revealed a nonlinear relationship of serum osmolality to all-cause and cardiovascular mortality, with an inflection point of 278 mmol/kg.

CONCLUSION

In the nationally representative cohort of US adults, serum osmolality was nonlinearly associated with all-cause and cardiovascular mortality. The risk of mortality was lowest around an osmolality of 278 mmol/kg. These findings suggest the importance of serum osmolality management for long-term health outcomes.

Serum Osmolarity and Vasopressin Concentration in Acute Heart Failure-Influence on Clinical Course and Outcome

Neurohormone activation plays an important role in Acute Heart Failure (AHF) pathophysiology. Serum osmolarity can affect this activation causing vasopressin excretion. The role of serum osmolarity and vasopressin concentration and its interaction remain still unexplored in AHF. The objective of our study was to evaluate the relationship of serum osmolarity with clinical parameters, vasopressin concentration, in-hospital course, and outcomes in AHF patients. The study group consisted of 338 AHF patients (male (76.3%), mean age of 68 ± 13 years) with serum osmolarity calculated by the equation: 1.86 × sodium [mmol/L] + (glucose [mg/dL]/18) + (urea [mg/dL]/2.8) + 9 and divided into osmolarity quartiles marked as: low: <287 mOsm/L, intermediate low: 287−294 mOsm/L, intermediate high: 295−304 mOsm/L, and high: >304 mOsm/L. There was an increasing age gradient in the groups and patients differed in the occurrence of comorbidities and baseline clinical and laboratory parameters. Importantly, analysis revealed that vasopressin presented a linear correlation with osmolarity (r = −0.221, p = 0.003) and its concentration decreased with quartiles (61.6 [44.0−81.0] vs. 57.8 [50.0−77.3] vs. 52.7 [43.1−69.2] vs. 45.0 [30.7−60.7] pg/mL, respectively, p = 0.034). This association across quartiles was observed among de novo AHF (63.6 [55.3−94.5] vs. 58.0 [50.7−78.6] vs. 52.0 [46.0−58.0] vs. 38.0 [27.0−57.0] pg/mL, respectively, p = 0.022) and was not statistically significant in patients with acute decompensated heart failure (ADHF) (59.5 [37.4−80.0] vs. 52.0 [38.0−74.5] vs. 57.0 [38.0−79.0] vs. 50.0 [33.0−84.0] pg/mL, respectively, p = 0.849). The worsening of renal function episodes were more frequent in quartiles with higher osmolarity (4 vs. 2 vs. 13 vs. 11%, respectively, p = 0.018) and patients that belonged to the quartiles with low and high osmolarity were characterized more often by incidence of worsening heart failure (20 vs. 9 vs. 10 vs. 22%, respectively, p = 0.032). There was also a U-shape distribution in relation to one-year mortality (31 vs. 19 vs. 23 vs. 37%, respectively, p = 0.022). In conclusion, there was an association of serum osmolarity with clinical status and both in-hospital and out-of-hospital outcomes. Moreover, the linear dependence between vasopressin concentration and serum osmolarity in the AHF population was identified and was driven mainly by patients with de novo AHF which suggests different pathophysiological paths in ADHF and AHF de novo.

The Association Between Plasma Osmolarity and In-hospital Mortality in Cardiac Intensive Care Unit Patients

Objectives: Plasma osmolarity is a common marker used for evaluating the balance of fluid and electrolyte in clinical practice, and it has been proven to be related to prognosis of many diseases. The purpose of this study was to identify the association between plasma osmolarity and in-hospital mortality in cardiac intensive care unit (CICU) patients.

Method: All of the patients were divided into seven groups stratified by plasma osmolarity, and the group with 290–300 mmol/L osmolarity was used as a reference group. Primary outcome was in-hospital mortality. The local weighted regression (Lowess) smoothing curve was drawn to determine the “U”-shaped relationship between plasma osmolarity and in-hospital mortality. Binary logistic regression analysis was performed to determine the effect of plasma osmolarity on the risk of in-hospital mortality.

Result: Overall, 7,060 CICU patients were enrolled. A “U”-shaped relationship between plasma osmolarity and in-hospital mortality was observed using the Lowess smoothing curve. The lowest in-hospital mortality (7.2%) was observed in the reference group. whereas hyposmolarity (<280 mmol/L vs. 290–300 mmol/L: 13.0 vs. 7.2%) and hyperosmolarity (≥330 mmol/L vs. 290–300 mmol/L: 31.6 vs. 7.2%) had higher in-hospital mortality. After adjusting for possible confounding variables with binary logistic regression analysis, both hyposmolarity (<280 mmol/L vs. 290–300 mmol/L: OR, 95% CI: 1.76, 1.08–2.85, P = 0.023) and hyperosmolarity (≥330 mmol/L vs. 290–300 mmol/L: OR, 95% CI: 1.65, 1.08–2.52, P = 0.021) were independently associated with an increased risk of in-hospital mortality. Moreover, lengths of CICU and hospital stays were prolonged in patients with hyposmolarity or hyperosmolarity.

Conclusion: A “U”-shaped relationship between plasma osmolarity and in-hospital mortality was observed. Both hyposmolarity and hyperosmolarity were independently associated with the increased risk of in-hospital mortality.

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

Low Predialysis Plasma Calculated Osmolality Is Associated with Higher All-Cause Mortality: The Japanese Dialysis Outcomes and Practice Patterns Study (J-DOPPS)

INTRODUCTION

Patients undergoing hemodialysis (HD) have higher predialysis plasma osmolality. Several studies have suggested lower osmolality to be associated with worse outcomes in patients not undergoing HD. However, no studies have examined the association between osmolality and mortality among patients undergoing HD.

OBJECTIVE

We aimed to examine the association between predialysis plasma calculated osmolality and all-cause mortality.

METHODS

This was a prospective cohort study of 1,240 patients undergoing HD participating in the Japanese Dialysis Outcomes and Practice Patterns Study phase 5 (2012-2015). The exposure was predialysis plasma osmolality, calculated as 2 × (serum sodium concentration [mmol/L]) + (serum urea nitrogen [mg/dL])/2.8 + (serum glucose [mg/dL])/18. The primary outcome was all-cause mortality. The secondary outcome was the change in systolic blood pressure (SBP) during HD. We used a marginal structural model with stabilized weights to estimate the association between calculated osmolality and all-cause mortality in the presence of time-varying confounders affected by prior exposure.

RESULTS

Mean baseline plasma calculated osmolality was 306.8 ± 8.6 mOsm/kg. Low predialysis calculated osmolality was associated with higher mortality (adjusted hazard ratio 1.52, 95% confidence interval [CI]: 1.30-1.78 by each 10 mOsm/L lower osmolality). The association was consistent across clinically relevant subgroups. Predialysis osmolality was significantly associated with intradialytic SBP change (mean difference 0.96 [95% CI: 0.05-1.88] mm Hg per each 10 mOsm/L lower osmolality).

CONCLUSIONS

Low predialysis calculated osmolality was an independent risk factor of all-cause mortality.

Hepatorenal dysfunction identifies high-risk patients with acute heart failure: insights from the RELAX-AHF trial

AIMS

Episodes of acute heart failure (AHF) may lead to end-organ dysfunction. In this post hoc analysis of the Relaxin in Acute Heart Failure trial, we used the MELD-XI (Model of End-Stage Liver Dysfunction) score to examine hepatorenal dysfunction in patients with AHF.

METHODS AND RESULTS

On admission, the MELD-XI score was elevated (abnormal) in 918 (82%) patients, with 638 (57%) having isolated renal dysfunction (creatinine > 1 mg/dL), 73 (6.5%) isolated liver dysfunction (bilirubin > 1 mg/dL), and 207 (18.5%) coexisting dysfunction of the kidneys and the liver (both creatinine and bilirubin > 1 mg/dL). The percentage of patients with elevated MELD-XI score remained constant through a 60 day follow-up, as we observed a gradual decrease of liver dysfunction prevalence, counterbalanced by an increase in renal dysfunction. Serelaxin treatment was associated with a lower MELD-XI score on Day 2 and Day 5 (both P < 0.05), but this difference vs. placebo disappeared during longer follow-up. In the multivariable model, an elevated MELD-XI score on admission was associated with higher 180 day mortality: hazard ratios (95% confidence interval) for cardiovascular death were 3.10 (1.22-7.87), and for all-cause death 2.47 (1.19-5.15); both P < 0.05. The addition of the MELD-XI score to a prespecified prognostic model increased the discrimination of the model for all-cause death, but the increment in the C-index was only modest: 0.013 (P = 0.02).

CONCLUSIONS

In patients with AHF, hepatorenal dysfunction is prevalent and related to poor outcome. The MELD-XI score is a useful prognosticator in AHF.

Therapeutic Advances in the Management of Acute Decompensated Heart Failure

BACKGROUND

Acute decompensated heart failure (ADHF) is the most common presenting phenotype of acute heart failure (AHF). The main goal of this article was to review the contemporary management strategies in these patients and to describe how future clinical trials may address unmet clinical needs.

AREAS OF UNCERTAINTY

The current pathophysiologic understanding of AHF is incomplete. The guideline recommendations for the management of ADHF are based only on algorithms provided by expert consensus guided by blood pressure and/or clinical signs of congestion or hypoperfusion. The lack of adequately conducted trials to address the unmet need for evidence therapy in AHF has not yet been surpassed, and at this time, there is no evidence-based strategy for targeted decongestive therapy to improve outcomes. The precise time point for initiation of guideline-directed medical therapies (GDMTs), as respect to moment of decompensation, is also unknown.

DATA SOURCES

The available data informing current management of patients with ADHF are based on randomized controlled trials, observational studies, and administrative databases.

THERAPEUTIC ADVANCES

A major step-forward in the management of ADHF patients is recognizing congestion, either clinical or hemodynamic, as a major trigger for heart failure (HF) hospitalization and most important target for therapy. However, a strategy based exclusively on congestion is not sufficient, and at present, comprehensive assessment during hospitalization of cardiac and noncardiovascular substrate with identification of potential therapeutic targets represents "the corner-stone" of ADHF management. In the last years, substantial data have emerged to support the continuation of GDMTs during hospitalization for HF decompensation. Recently, several clinical trials raised hypothesis of "moving to the left" concept that argues for very early implementation of GDMTs as potential strategy to improve outcomes.

CONCLUSIONS

The management of ADHF is still based on expert consensus documents. Further research is required to identify novel therapeutic targets, to establish the precise time point to initiate GDMTs, and to identify patients at risk of recurrent hospitalization.

Calculated Serum Osmolality, Acute Kidney Injury, and Relationship to Mortality after Percutaneous Coronary Intervention

BACKGROUND

Data on the associations between serum osmolality (sOsmo) and acute kidney injury (AKI) as well as short- and long-term mortality in patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI) are limited.

OBJECTIVES

To investigate the association between sOsmo and development of AKI and clinical outcomes in patients undergoing PCI.

METHODS

We investigated 1,927 consecutive patients undergoing PCI from the registry of a single center. Patients were divided into quartiles according to sOsmo at admission (Q1-Q4). sOsmo was calculated using the following equation: (1.86 × serum sodium [mmol/L]) + (glucose [mg/dL] / 18) + (blood urea nitrogen [mg/dL] / 2.8) + 9. The primary endpoint was AKI, per Kidney Disease: Improving Global Outcomes (KDIGO) definition. The secondary endpoints were 30-day and 1-year all-cause mortality.

RESULTS

Patients with the highest sOsmo (Q4) were older and more likely female, with significantly more cardiovascular risk factors and comorbidities compared to those with lower sOsmo (Q1-Q3). Incidence of AKI was highest in Q4 and lowest in Q2. In the multivariate logistic regression model, high sOsmo independently predicted the development of AKI (OR 2.00, 95% CI 1.26-3.19, p = 0.003). Patients with Q4 had a higher risk of 1-year mortality compared to patients with Q2 (HR 2.11, 95% CI 1.10-4.15; p = 0.031), but not after adding AKI to the multivariate model (HR 1.71, 95% CI 0.87-3.39; p = 0.12).

CONCLUSION

sOsmo is a valid and easily obtainable predictor of AKI after PCI. High sOsmo is associated with increased risk of AKI and 1-year mortality in patients undergoing PCI. Further research is warranted to clarify whether the use of an sOsmo-directed hydration protocol might reduce the incidence of AKI in patients undergoing PCI.

Detection of Glycemia and Osmolarity Changes Using Eye Examinations

Background: Glycated hemoglobin (HbA1c) is an index of the average blood glucose level over the preceding 2-3 months. In experimental studies, the lens responded to changes in osmolarity by forming vacuoles. By observing the vacuoles of the lens during eye examination, can we detect changes in osmolarity and glycemia over the last 6 months through HbA1c levels? Methods: In total, 400 patients (mean age, 67.7 ± 9.8 years), including those with diabetes mellitus, hypertension, and heart failure, were included in the study. The control group contained 70 patients matched in terms of age and sex and who had no prior disease (mean age, 67.8 ± 9.4 years). Monthly Na, glucose, and blood urea nitrogen values were used to calculate changes in osmolarity over 6 months. HbA1c values were also recorded. Biomicroscopy was used to evaluate lens vacuolation; all vacuoles were digitally photographed and converted to ImageJ format. Results: The sensitivity and specificity of using large vacuoles to detect HbA1c ≥10% were 88.0% (95% confidence interval [CI]: 68.8-97.4) and 82.6% (95% CI: 74.1-89.2), respectively. The sensitivity and specificity of detecting a 10 mOsm/kg change in osmolarity were 61% (95% CI: 48.9-72.4) and 94.5% (95% CI: 91.5-96.7), respectively. Conclusions: Lens vacuoles, which can be observed with a simple and quick examination, can be used to detect HbA1c levels and osmolarity changes over the last 6 months. Because of their relationship to the severity of retinopathy, vacuoles can also be used as a weak control indicator.

Association between the Serum Sodium Levels and the Response to Tolvaptan in Liver Cirrhosis Patients with Ascites and Hyponatremia

Objective Hyponatremia is closely associated with the pathophysiology of cirrhosis. However, the association between the serum sodium level and the response to tolvaptan is unclear. This study evaluated the factors related to the tolvaptan response and the prognosis in cirrhosis patients with ascites and hyponatremia. Methods We retrospectively reviewed the clinical records of cirrhosis patients hospitalized for treatment with tolvaptan. The associations of patient baseline characteristics with the tolvaptan response after one week and of the characteristics after one-month tolvaptan treatment with the prognosis were analyzed. Results We analyzed 83 cirrhosis patients with ascites, including 34 patients with hyponatremia. The response rates to tolvaptan in patients with serum sodium <130 mEq/L, 130-135 mEq/L, and >135 mEq/L were 20%, 66%, and 58%, respectively (p=0.22). The serum sodium level was associated with the response to tolvaptan [odds ratio=1.18; 95% confidence interval (CI) =1.02-1.37; p=0.029]. In patients with hyponatremia, the serum sodium level after 1-month tolvaptan treatment was increased compared to baseline (132 mEq/L vs. 136 mEq/L, p=0.006), and an increasing serum sodium level was associated with a lower risk of mortality (hazard ratio=0.85; 95% CI=0.75-0.97; p=0.016). The survival rate was higher in patients with an increase in the serum sodium level after 1 month than in patients with a decreased serum sodium level (p=0.023). Conclusion Tolvaptan treatment was effective in cirrhosis patients with ascites and hyponatremia, but a low serum sodium level was associated with non-responsiveness to tolvaptan. An increased serum sodium level after one-month tolvaptan treatment may positively influence the mortality risk in cirrhosis patients with hyponatremia.

Hyponatremia in Acute Heart Failure in Relation to Hematocrit Levels: Clinical Relevance and Prognostic Implication

BACKGROUND

Hyponatremia is the most common electrolyte abnormality found in hospitalized patients with acute heart failure (AHF) and is related to poor prognosis. This study sought to evaluate: (1) the different prognostic impact of dilutional versus depletional hyponatremia, evaluating short- and long-term outcome; (2) the relationship between both types of hyponatremia and intravenous furosemide dose, renal function changes, and persistent congestion at discharge.

METHODS

This retrospective single-center study included 233 consecutive patients with a primary diagnosis of AHF. Hyponatremia was defined as serum sodium < 135 mEq/L, which could be either dilutional (hematocrit < 35%) or depletional (hematocrit ≥35%). Persistent congestion was defined as a congestion score ≥2 at discharge. Patients were followed 180 days for occurrence of death or rehospitalization for AHF.

RESULTS

Hyponatremia was present in 68/233 patients with 27 cases classified as dilutional hyponatremia versus 41 as depletional. The proportion of patients with persistent congestion was higher in the dilutional hyponatremia group, but similar in the depletional hyponatremia group (52 vs. 81 vs. 58%; p = 0.02). After adjustment for important baseline characteristics, dilutional hyponatremia was significantly associated with the risk of death or rehospitalization for AHF at 60 days (HR 2.17 [1.08-4.37]; p = 0.03) and 180 days (HR 1.88 [1.10-3.21]; p = 0.02). In contrast, depletional hyponatremia was only significantly associated with the same endpoint at 180 days (HR 1.64 [1.05-2.57]; p = 0.03).

CONCLUSIONS

Low hematocrit levels in AHF patients with hyponatremia characterize a population that is more difficult to decongest and has poor clinical outcome. In contrast, patients with hyponatremia but normal hematocrit are better decongested and have better short-term outcome.

Sudden Death After Hospitalization for Heart Failure With Reduced Ejection Fraction (from the EVEREST Trial)

Patients with chronic heart failure with reduced ejection fraction (HFrEF) benefit from medical and device therapies targeting sudden cardiac death (SCD). Contemporary estimates of SCD risk after hospitalization for heart failure are limited. We describe the incidence, timing, and clinical predictors of SCD after hospitalization for HFrEF (≤40%) in the EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan) trial. Multiple logistic regression analyses tested >30 baseline covariates (including treatment randomization, demographics, comorbid conditions, natriuretic peptides, ejection fraction, and medical and device therapies) to identify predictors of 1-year SCD. Of the 4,024 trial patients discharged alive (97%), there were 268 who experienced SCD (7%) and 703 who experienced non-SCD (17%) during median follow-up of 9.9 months. Implantable cardioverter defibrillator use at baseline was 14.5%. Estimates of SCD at 1, 3, 6, and 12 months were 0.8%, 2.3%, 4.1%, and 7.4%, respectively. Most patients were readmitted before SCD (n = 147, 55%). Male gender, black race, diabetes mellitus, and angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use were potential predictors of 1-year SCD after hospitalization for HFrEF (all p <0.10); however, this final model demonstrated poor discrimination (C-statistic 0.57). In conclusion, in the EVEREST trial, patients hospitalized for HFrEF faced risks of 1-year postdischarge SCD of 7%, which accrued gradually over time, and were balanced with high competing risks of nonsudden death (17%). Traditional clinical characteristics fail to adequately predict SCD risk. Further data are needed to identify patients at greatest relative risk for SCD (compared with non-SCD) after hospitalization for HFrEF.

Predictors of Post-discharge Mortality Among Patients Hospitalized for Acute Heart Failure

Acute Heart Failure (AHF) is a " multi-event disease" and hospitalisation is a critical event in the clinical course of HF. Despite relatively rapid relief of symptoms, hospitalisation for AHF is followed by an increased risk of death and re-hospitalisation. In AHF, risk stratification from clinically available data is increasingly important in evaluating long-term prognosis. From the perspective of patients, information on the risk of mortality and re-hospitalisation would be helpful in providing patients with insight into their disease. From the perspective of care providers, it may facilitate management decisions, such as who needs to be admitted and to what level of care (i.e. floor, step-down, ICU). Furthermore, risk-stratification may help identify patients who need to be evaluated for advanced HF therapies (i.e. left-ventricle assistance device or transplant or palliative care), and patients who need early a post-discharge follow-up plan. Finally, risk stratification will allow for more robust efforts to identify among risk markers the true targets for therapies that may direct treatment strategies to selected high-risk patients. Further clinical research will be needed to evaluate if appropriate risk stratification of patients could improve clinical outcome and resources allocation.