Use of Biomarkers to Predict Readmission for Congestive Heart Failure

Cardiac Magnetic Resonance Imaging as a Risk Stratification Tool in COVID-19 Myocarditis

The aim of this retrospective study was to identify myocardial injury after COVID-19 inflammation and explore whether myocardial damage could be a possible cause of the persistent symptoms following COVID-19 infection in previously healthy individuals. This study included 139 patients who were enrolled between January and June 2021, with a mean age of 46.7 ± 15.2 years, of whom 68 were men and 71 were women without known cardiac or pulmonary diseases. All patients underwent clinical work-up, laboratory analysis, cardiac ultrasound, and CMR on a 1.5 T scanner using a recommended protocol for morphological and functional assessment before and after contrast media application with multi-parametric sequences. In 39% of patients, late gadolinium enhancement (LGE) was found as a sign of myocarditis. Fibrinogen was statistically significantly higher in patients with LGE than in those without LGE (4.3 ± 0.23 vs. 3.2 ± 0.14 g/L, p < 0.05, respectively), as well as D-dimer (1.8 ± 0.3 vs. 0.8 ± 0.1 mg/L FEU). Also, troponin was statistically significantly higher in patients with myocardial LGE (13.1 ± 0.4 ng/L) compared to those with normal myocardium (4.9 ± 0.3 ng/L, p < 0.001). We demonstrated chest pain, fatigue, and elevated troponin to be independent predictors for LGE. Septal LGE was shown to be a predictor for arrhythmias. The use of CMR is a potential risk stratification tool in evaluating outcomes following COVID-19 myocarditis.

Diagnostic Value of Serum Concentration of Galectin-3 in Patients With Heart Failure With Preserved Ejection Fraction

BACKGROUND

Although the predictive value of galectin-3 for heart failure with preserved ejection fraction has been demonstrated, the diagnostic value remains unclear. The present study was performed to address this issue.

HYPOTHESIS

Galectin-3 has diagnostic value for heart failure with preserved ejection fraction.

METHODS

This is a diagnostic experiment. We conducted an observational study of 223 patients with combined symptoms of heart failure and diseases that can lead to heart failure with preserved ejection fraction. Patients were grouped into the heart failure group and control group in accordance with the 2016 European Society of Cardiology heart failure guidelines for heart failure with preserved ejection fraction. Baseline information and serum galectin-3 concentration were assessed within 24 h after admission.

RESULTS

Serum galectin-3 concentration was significantly higher in the heart failure group compared with the control group. Binary logistic regression analysis showed that higher galectin-3 concentration was associated with the occurrence of heart failure with preserved ejection fraction. The area under the curve of galectin-3 was 0.763, indicating that galectin-3 has moderate diagnostic value for heart failure with preserved ejection fraction. Galectin-3 >15.974 ng/mL identified heart failure with preserved ejection fraction with 76.0% sensitivity and 71.9% specificity.

CONCLUSIONS

There was a correlation between galectin-3 and heart failure with preserved ejection fraction, and galectin-3 was an independent predictor of heart failure with preserved ejection fraction. The diagnostic value of galectin-3 for heart failure with preserved ejection fraction was moderate (AUC: 0.763, 95% CI: 0.696-0.821, P < 0.01, and the sensitivity is 76.0% while the specificity is 71.9% at the threshold 15.974 ng/mL) and was higher than that of interventricular septal thickness or E/A ratio.

Urine albumin-to-creatinine ratio on admission predicts early rehospitalization in patients with acute decompensated heart failure

Detecting high-risk patients for early rehospitalization is crucial in heart failure patient care. An association of albuminuria with cardiovascular events is well known. However, its predictive impact on rehospitalization for acute decompensated heart failure (ADHF) remains unknown. In this study, 190 consecutive patients admitted due to ADHF between 2017 and April 2019 who underwent urinalysis were enrolled. Among them, 140 patients from whom urine albumin-to-creatinine ratio (UACR) was measured with spot urine samples on admission were further analyzed. The association between UACR and rehospitalization due to HF during 1 year after discharge was evaluated. The mean age of 140 participants was 77.6 years and 55% were men. Only 18% (n = 25) of patients presented with normoalbuminuria (UACR < 30 mg/g∙creatinine), whereas 59% (n = 83) and 23% (n = 32) showed microalbuminuria (UACR 30-300 mg/g·creatinine) and macroalbuminuria (UACR > 300 mg/g·creatinine), respectively. The level of UACR on admission was correlated with the risk of subsequent rehospitalization due to HF (p = 0.017). The receiver operating characteristic analysis indicated that the best cut-off values for the UACR and B-type natriuretic peptide (BNP) levels to predict ADHF rehospitalization were 50 mg/g·creatinine and 824 pg/ml, respectively. When the patients were divided into four groups using both cut-off values, the individual predictive impacts of UACR and BNP on rehospitalization were comparable. Patients with both elevated UACR and BNP levels had a higher rate of HF rehospitalization than those with elevated BNP levels alone (p < 0.05). The combination of both values enabled more accurate prediction of HF rehospitalization than BNP levels alone. In conclusion, UACR could be a new useful biomarker to predict HF rehospitalization in patients with ADHF, especially in combination with the levels of BNP, and should be further evaluated in a prospective study.

HIGH-SENSITIVITY TROPONIN T FOR THE RISK ASSESSMENT OF PATIENTS WITH ACUTE ATRIAL FIBRILLATION

Elevations of high-sensitivity troponin T (Hs-TnT) in the setting of acute atrial fibrillation (AF) are not clearly understood. This study evaluated factors associated with these elevations and its prognostic implication. We prospectively included 413 consecutive patients who presented to our institution with acute AF. The median Hs-TnT on admission was 12 ng/l and 39.4% had values above the 99th percentile. At one-year, AF recurrence occurred in 38.3% of patients and MACE in 5.6%. Hs-TnT levels were not associated with AF reversion (p 0.869) or with one-year AF recurrence (p 0.132) but they were with MACE (12 vs 24 ng/l, p 0.001). Thus, Hs-TnT was a strong predictor of MACE (HR 3.486, 95% CI 1.256-5.379, p 0.009) in this population. In conclusion, Hs-TnT elevation was frequently observed in patients with acute AF, and although it was not associated with AF reversion or recurrence, it was highly predictive of MACE at one-year.

Reappraisal of Inflammatory Biomarkers in Heart Failure

PURPOSE OF REVIEW

Inflammation has been shown to be an important factor in the development and progression of heart failure (HF), regardless of the etiology. There have been many studies that demonstrated roles of inflammatory biomarkers in diagnosis, prognosis of chronic and acute HF patients, and also markers of cardiotoxicity from chemotherapy. These cytokines are high-sensitivity C-reactive protein (hsCRP), myeloperoxidase (MPO), soluble growth stimulation expressed gene 2 (sST2), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNFα), growth differentiation factor-15 (GDF-15), endothelin-1 (ET-1), and galectin-3. In this review, we discuss the past and present insights of those inflammatory biomarkers in order to gain more understanding in pathogenesis of HF, risk stratification of HF patients, and early detection of cardiotoxicity from cancer therapy.

RECENT FINDINGS

Many inflammatory cytokines have been shown to be associated with mortality of both chronic and acute HF patients, and some of them are able to track treatment responses, especially sST2 and galectin-3, which are the only two inflammatory biomarkers recommended to use in clinical setting by the recent standard HF guidelines, while some studies described ET-1 and MPO as potential predictors of cardiotoxicity from cancer drugs. The prognostic implications of inflammatory biomarkers in HF patients have been demonstrated more consistently in chronic than acute HF, with some suggestions of ET-1 and MPO in patients receiving chemotherapy. However, further studies are necessary for the use of inflammatory biomarkers in routine clinical practice.

Biomedical, Socioeconomic and Demographic Predictors of Heart Failure Readmissions: A Systematic Review

AIMS

To identify the biomedical, socioeconomic and demographic predictors of heart failure (HF) related readmissions in adult patients with HF.

METHODS

This systematic review was conducted in March 2020 using the databases EMBASE, CINAHL and Medline to identify publications between 2015-2020. The resulting articles were systematically reviewed according to the PRISMA guidelines.

RESULTS

Eighteen (18) studies were included in this review. Unemployment (HR=1.09; 95%CI=1.05-1.14; p=0.03) was the only socioeconomic factor predictive of HF-readmissions. Socio-Economic Indexes for Areas (SEIFA) scores did not predict HF readmissions in adults with HF (p>0.05). All patients included in the studies had pre-existing HF. Based on the included studies, Indigenous status was identified as a risk factor for HF readmissions in 1 study (p<0.05), and age or sex did not affect HF readmission patterns (p>0.05). New York Heart Association (NYHA) class, brain natriuretic peptide (BNP) levels, and heart rate were also predictive of HF readmission (p<0.05). Left ventricular ejection fraction and blood pressure, however, were non-significant risk factors of HF readmissions (p>0.05).

CONCLUSIONS

This review identified unemployment, Indigenous status, NYHA class, heart rate, and BNP levels to predict HF related readmissions in adult patients with HF. Adding demographic and socioeconomic variables to readmission risk models has the potential to more accurately target patients at risk of readmissions.

Biomarkers in Acute Heart Failure: Diagnosis, Prognosis, and Treatment

Heart failure is a global health problem. An episode of acute heart failure (AHF) is a period of substantial morbidity and mortality with few advances in the management of an episode that have improved outcomes. The measurement of multiple biomarkers has become an integral adjunctive tool for the management of AHF. Many biomarkers are now well established in their ability to assist with diagnosis and prognostication of an AHF patient. There are also emerging biomarkers that are showing significant promise in the areas of diagnosis and prognosis. For improving the management of AHF, both established and novel biomarkers may assist in guiding medical therapy and subsequently improving outcomes. Thus, it is important to understand the different abilities and limitations of established and emerging biomarkers in AHF so that they may be correctly interpreted and integrated into clinical practice for AHF. This knowledge may improve the care of AHF patients. This review will summarize the evidence of both established and novel biomarkers for diagnosis, prognosis and management in AHF so that the treating clinician may become more comfortable incorporating these biomarkers into clinical practice in an evidence-based manner.

Prognostic Value of Troponin in Patients with Atrial Fibrillation Admitted to an Emergency Department: Review and Meta-Analysis

Introduction

Elevated levels of cardiac troponin (cTn) indicate underlying heart disease and is known to predict adverse events in multiple conditions. Its role in atrial fibrillation (AF) in the acute setting is still not conclusive. We aimed to assess the prognostic value of c-Tn in patients with AF admitted to an emergency department (ED).

Methods

Systematic searches were conducted using PubMed and the Cochrane Library and the International Clinical Trials Registry Platform to identify studies from year 2009 to October 2019 reporting on the prognostic value of cTn on all-cause mortality or major adverse cardiac events (MACE) in adult patients with AF in the ED. We pooled hazard ratio (HR) and 95% confidence interval (CI) using fixed and random effects models according the heterogeneity. We planned to conduct a sensitivity and subgroup analyses.

Results

Five studies involving 5750 patients were identified. The mean follow-up ranged from 12 to 35 months. An increase in mortality was observed in the elevated cTn group compared to the controls, HR=2.7 (95% CI 1.55-4.72), P for effect<0.001, I2=80%). For MACE, the pooled HR was 2.17 (95%CI 1.60-2.94), P for effect<0.001, I2=0%). In the subgroup analysis we found no significant difference in type of troponin used and study design.

Conclusions

The elevation of cardiac troponin was significantly associated with higher mortality and major adverse cardiac events in patients with AF admitted to an ED. In this setting the use of c-Tn could provide prognostic information.

The therapeutic effect of B-type natriuretic peptides in acute decompensated heart failure

B-type natriuretic peptide (BNP) exhibits roles in natriuresis and diuresis, making it an ideal drug that may aid in diuresing a fluid-overloaded patient with poor or worsening renal function. Several randomized clinical trials have tested the hypothesis that infusions of pharmacological doses of BNP to acute heart failure (HF) patients may enhance decongestion and preserve renal function in this clinical setting. Unfortunately, none of these have demonstrated beneficial outcomes. The current challenge for BNP research in acute HF lies in addressing a failure of concept and a reluctance to abandon an ineffective research model. Future success will necessitate a detailed understanding of the mechanism of action of BNP, as well as better integration of basic and clinical science.

Electronic medical record-based model to predict the risk of 90-day readmission for patients with heart failure

BACKGROUND

Several heart failure (HF) risk models exist, however, most of them perform poorly when applied to real-world situations. This study aimed to develop a convenient and efficient risk model to identify patients with high readmission risk within 90 days of HF.

METHODS

A multivariate logistic regression model was used to predict the risk of 90-day readmission. Data were extracted from electronic medical records from January 1, 2017 to December 31, 2017 and follow-up records of patients with HF within 3 months after discharge. Model performance was evaluated using a receiver operating characteristic curve. All statistical analysis was done using R version 3.5.0.

RESULTS

A total of 350 patients met the inclusion criterion of being readmitted within in 90 days. All data sets were randomly divided into derivation and validation cohorts at a 7/3 ratio. The baseline data were fairly consistent among the derivation and validation cohorts. The variables most clearly related to readmission were logarithm of serum N-terminal pro b-type natriuretic peptide (NT-proBNP) level, red cell volume distribution width (RDW-CV), and Charlson comorbidity index (CCI). The model had good discriminatory ability (C-statistic = 0.73).

CONCLUSIONS

We developed and validated a multivariate logistic regression model to predict the 90-day readmission risk for Chinese patients with HF. The predictors included in the model are derived from electronic medical record (EMR) admission data, making it easier for physicians and pharmacists to identify high-risk patients and tailor more intensive precautionary strategies.

An update on the use and discovery of prognostic biomarkers in acute decompensated heart failure

Introduction: Acute decompensated heart failure (ADHF) remains a significant health care burden as evidenced by high readmission rates and mortality. Over the years, the care of patients with ADHF has been transformed by the use of biomarkers, specifically to aid in the diagnosis and prognosis. Patients with HF follow a variable course given the complex and heterogenous pathophysiological processes, thus it is imperative for clinicians to have tools to predict short and long-term outcomes in order to educate patients and optimize management. Areas Covered: The natriuretic peptides, including B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide, are considered the gold standard biomarkers. Yet, other emerging biomarkers such as suppression of tumerogenicity-2, cardiac troponin, galectin-2, mid-regional pro-adrenomedullin, copeptin, cystatin, and neutrophil gelatinase-associated lipocalin have increasingly shown promise in evaluating prognosis in patients with ADHF. This article reviews the pathophysiology and utility of both established and emerging biomarkers for the prognostication of patients with ADHF. Expert Opinion: As of 2019, the most validated biomarkers for use in decompensated heart failure include natriuretic peptides, high sensitivity troponin, and sST2. These biomarkers are involved in the underlying pathophysiology of disease and as such provide added information to that of exam, x-ray, and echocardiography.

Clinical and Socioeconomic Predictors of Heart Failure Readmissions: A Review of Contemporary Literature

Heart failure represents a clinical syndrome that results from a constellation of disease processes affecting myocardial function. Although recent studies have suggested a declining or stable incidence of heart failure, patients with heart failure continue to have high hospitalization and readmission rates, resulting in a substantial economic and public health burden. We searched PubMed and Google Scholar to identify published literature from 1998 through 2018 using the following keywords: heart failure, readmissions, predictors, prediction models, and interventions. Cited references were also used to identify relevant literature. Developments in the diagnosis and management of patients with heart failure have improved hospitalization and readmission rates in the past few decades. However, heart failure remains the most common cause of hospitalization in persons older than 65 years. As a result, given the enormous clinical and financial burden associated with heart failure readmissions on health care, there has been growing interest in the investigation of mechanisms aimed at improving outcomes and curtailing associated costs of care. Herein, we review the current literature on clinical and socioeconomic predictors of heart failure readmissions, briefly discussing limitations of existing strategies and providing an overview of current technology aimed at reducing hospitalizations.

The Impact of Physiological Factors on 30-day Unplanned Rehospitalization in Adults with Heart Failure

Heart failure (HF) patients have high rates of 30-day unplanned rehospitalization. This study assessed the impact of physiological factors on 30-day HF unplanned rehospitalization.

METHODS

The cross-sectional study used secondary data from electronic medical records of 270 patients.

RESULTS

Findings revealed several factor types were related to 30-day HF unplanned rehospitalization such as chronic kidney disease (p = 0.001), the use of CPAP machine (p = 0.028), and B-type natriuretic peptide (p = 0.050).

CONCLUSION

Many physiological factors were associated with 30-day HF unplanned rehospitalization. Identifying these factors will help health care providers to plan a variety of interventions that reduce 30-day HF unplanned rehospitalization.

Use of levosimendan in acute heart failure

As a calcium sensitizer and inodilator that augments cardiac contractility without increasing myocardial oxygen demand or exacerbating ischaemia, levosimendan may be well configured to deliver inotropic support in cases of acute heart failure (AHF). Other factors favouring levosimendan in this setting include its extended duration of action due to the formation of an active metabolite and the lack of any attenuation of effect in patients treated with beta-blockers. Effects of levosimendan on systemic haemodynamics include its significant, dose-dependent increases in cardiac output, stroke volume and heart rate, and decreases in right and left ventricular filling and total peripheral resistance. Rapid and sustained reduction in levels of natriuretic peptides is a consistent effect of levosimendan use and potentially favourable effects on other neurohormonal indicators of cardiac distress are also observed. Levosimendan has repeatedly been shown to be effective in relief of symptoms of AHF, notably dyspnoea and fatigue, while mortality data from clinical trials and registries suggest that levosimendan is markedly less likely than catecholaminergic inotropes to worsen prognosis. The vasodilator pharmacology of levosimendan is also pertinent to the drug’s use in AHF, in which setting organ under-perfusion is often a key pathology. These considerations suggest that levosimendan may have a more favourable impact on the circumstances of the majority of AHF patients than adrenergic agents that act only or primarily as cardiac stimulants. They also suggest that levosimendan may advantageously be integrated into a comprehensive strategy of early intervention designed and intended to prevent cardiac destabilization worsening to the point where hospitalization is necessary. Levosimendan should be used with caution and with tightened haemodynamic monitoring in patients who have low baseline blood pressure (systolic blood pressure <100 mmHg; diastolic blood pressure <60 mmHg), or who are at risk of a hypotensive episode.

The Association Between Novel Biomarkers and 1-Year Readmission or Mortality After Cardiac Surgery

BACKGROUND

Novel cardiac biomarkers including soluble suppression of tumorigenicity 2, galectin-3, and the N-terminal prohormone of brain natriuretic peptide may be associated with long-term adverse outcomes after cardiac surgery. We sought to measure the association between cardiac biomarker levels and 1-year hospital readmission or mortality.

METHODS

Plasma biomarkers from 1,047 patients discharged alive after isolated coronary artery bypass graft surgery from 8 medical centers were measured in a cohort from the Northern New England Cardiovascular Disease Study Group between 2004 and 2007. We evaluated the association between preoperative and postoperative biomarkers and 1-year readmission or mortality using Kaplan-Meier estimates and Cox proportional hazards modeling, adjusting for covariates used in The Society of Thoracic Surgeons 30-day readmission model.

RESULTS

The median follow-up time was 365 days. After adjustment for established risk factors, above-median levels of postoperative galectin-3 (median 10.35 ng/mL; hazard ratio, 1.40; 95% confidence interval, 1.08 to 1.80; p = 0.010) and N-terminal prohormone of brain natriuretic peptide (median = 15.21 ng/mL, hazard ratio, 1.42; 95% confidence interval, 1.07 to 1.87; p = 0.014) were each significantly associated with 1-year readmission or mortality.

CONCLUSIONS

In patients undergoing cardiac surgery, novel cardiac biomarkers were associated with readmission or mortality independent of established risk factors. Measurement of these biomarkers may improve our ability to identify patients at highest risk for readmission or mortality before discharge. This will also allow resource allocation accordingly, while implementing strategies for personalized medicine based on the biomarker profile of the patient.

Galectin-3 in Heart Failure: An Update of the Last 3 Years

Galectin-3 plays a role in tissue inflammation, repair, and fibrosis. This article specifically focuses on heart failure (HF), in which galectin-3 has been shown to be a useful biomarker in prognosis and risk stratification, especially in HF with preserved ejection fraction. Experimental research has shown that galectin-3 directly induces pathologic remodeling of the heart, and is therefore considered a culprit protein in the development of cardiac fibrosis in HF, with potentially relevant clinical implications. In summary, galectin-3 is a biomarker and biotarget in cardiac remodeling and fibrosis and future research will target galectin-3-centered diseases.

Late In-Hospital Management of Patients Hospitalized with Acute Heart Failure

Acute Heart Failure (AHF) hospitalization presents a significant financial burden and portends a poor prognosis following discharge. As such, there has been significant emphasis on the late inpatient management of patients hospitalized with AHF to ensure successful transition to the outpatient setting and to reduce overall readmission and mortality rates. Thorough discharge planning and a multidisciplinary team approach are essential and as outlined in this review should focus on four key elements: the assessment of patients' readiness for discharge, optimization of goal directed medical therapy and appropriate device therapy, patient education and transition to the outpatient care.

The Significance Of Troponin Elevation In Atrial Fibrillation

Cardiac troponin assays have provided a significant contribution for the early diagnosis of cardiovascular events. There is significant evidence about the association between the absolute value of elevated cardiac troponin levels with the prognosis of patients with chest pain. However, it is well-known that elevated cardiac troponin levels may occur in situations other than acute coronary syndromes, as it happens with atrial fibrillation. The significance and prognosis of this elevation are not entirely clear. We review the evidence about the meaning of such elevation in the setting of atrial fibrillation.