Evidence-Based Management of Acute Heart Failure

2024 update in heart failure

In the last years, major progress has occurred in heart failure (HF) management. The 2023 ESC focused update of the 2021 HF guidelines introduced new key recommendations based on the results of the last years of science. First, two drugs, sodium-glucose co-transporter-2 (SGLT2) inhibitors and finerenone, a novel nonsteroidal, selective mineralocorticoid receptor antagonist (MRA), are recommended for the prevention of HF in patients with diabetic chronic kidney disease (CKD). Second, SGLT2 inhibitors are now recommended for the treatment of HF across the entire left ventricular ejection fraction spectrum. The benefits of quadruple therapy in patients with HF with reduced ejection fraction (HFrEF) are well established. Its rapid and early up-titration along with a close follow-up with frequent clinical and laboratory re-assessment after an episode of acute HF (the so-called 'high-intensity care' strategy) was associated with better outcomes in the STRONG-HF trial. Patients experiencing an episode of worsening HF might require a fifth drug, vericiguat. In the STEP-HFpEF-DM and STEP-HFpEF trials, semaglutide 2.4 mg once weekly administered for 1 year decreased body weight and significantly improved quality of life and the 6 min walk distance in obese patients with HF with preserved ejection fraction (HFpEF) with or without a history of diabetes. Further data on safety and efficacy, including also hard endpoints, are needed to support the addition of acetazolamide or hydrochlorothiazide to a standard diuretic regimen in patients hospitalized due to acute HF. In the meantime, PUSH-AHF supported the use of natriuresis-guided diuretic therapy. Further options and most recent evidence for the treatment of HF, including specific drugs for cardiomyopathies (i.e., mavacamten in hypertrophic cardiomyopathy and tafamidis in transthyretin cardiac amyloidosis), device therapies, cardiac contractility modulation and percutaneous treatment of valvulopathies, with the recent finding from the TRILUMINATE Pivotal trial, are also reviewed in this article.

Inflammation in acute heart failure

Acute heart failure (AHF) represents a common clinical scenario that requires prompt evaluation and therapy and that is characterized by a high risk of mortality or subsequent rehospitalizations. The pathophysiology leading to AHF decompensation is still not fully understood. Significant activation of inflammatory pathways has been identified in patients with AHF, particularly in its most severe forms, and it has been hypothesized that systemic inflammation has a role in AHF pathogenesis. Several inflammatory mediators and cytokines, such as high sensitivity C-reactive protein, tumor necrosis factor-α, interleukin-6, interleukin-1, soluble suppression of tumorigenicity 2 and galectin-3, have been shown to play a role in the pathogenesis, development and worsening of this condition with an independent prediction of adverse outcomes. This manuscript reviews the prevalence and prognostic value of systemic inflammation in AHF, as well as the potential role of anti-inflammatory therapies, focusing on available evidence from clinical trials and ongoing studies.

Examining predictors for 6-month mortality and healthcare utilization for patients admitted for heart failure in the acute care setting

BACKGROUND

Acute heart failure (AHF) is a leading cause of mortality and hospitalization. Past studies reported increased healthcare spending in the last year of life in high-income countries, and this has been characterized as inappropriate healthcare resource utilization. The study aimed to examine potentially (in)appropriate healthcare utilization by comparing healthcare utilization patterns across predicted and observed 6-month mortality among patients admitted for HF.

METHODS

We conducted a retrospective cohort study among patients presenting at the emergency department (ED) of a tertiary hospital with HF as primary diagnosis and admitted after their ED discharge. We used LASSO Cox proportional hazards models to predict 6-month mortality, and estimated healthcare utilization patterns of predicted and observed mortality across inpatient healthcare services.

RESULTS

3946 patients were admitted into the emergency department with a primary diagnosis of HF. From 57 candidate variables, 17 were retained in the final 6- month mortality model (C-statistic 0.66). Patients who died within 6-months of ED admission had longer length of stay (LOS) and less inpatient surgeries than those who survived. Patients with a greater predicted mortality risk were admitted to the ICU more often and had a longer LOS than those with a lower predicted mortality risk.

CONCLUSIONS

There were significant differences in healthcare resource utilization in patients admitted for AHF across predicted versus actual mortality. Lack of information on patients' preferences prevents the estimation of (in)appropriateness. Future studies should account for these considerations to estimate inappropriate healthcare utilization among these patients.

Relationship Between Symptom Burden and Self-Management Among Patients with Chronic Heart Failure: A Cross-Sectional Study

Background

Chronic heart failure (CHF) is a cardiovascular disease that seriously jeopardizes global human health. Studies indicate that good self-management can be effective in controlling disease symptoms. However, there is still insufficient evidence on the association between self-management and symptom burden among CHF patients. This study aimed to observe and assess the correlation of the self-management with the symptom burden and each dimension status in patients with CHF.

Methods

This was a cross-sectional study. Data were collected in-hospital using convenience sampling, and 128 patients with CHF were included. A general data questionnaire was used to collect demographic and disease-related data. The Memorial Symptom Assessment Scale-Heart Failure was used to measure patients' symptom burdens. The Heart Failure Self-Management Scale was used to measure the self-management level of patients. The correlation between self-management and symptom burden was analyzed using the Spearman correlation.

Results

The total scores for symptom burden and self-management were 1.26 ± 0.49 and 49.97 ± 7.14, respectively. The total score of self-management was negatively correlated with that of symptom burden. The univariate linear regression analysis indicated that age, place of residence, smoking, residence status, New York Heart Association grade of cardiac function, and attitude toward the disease were risk factors for symptom burden. The multiple linear regression analysis indicated that the regression model with symptom burden as a dependent variable included three variables: drug management, symptom management, and attitude toward the disease.

Conclusion

Hospitalized patients with CHF had heavy overall symptom burdens, and their self-management levels were moderate to low. There was a negative correlation between the total self-management score and each dimension of symptom burden.

Impact of heart failure on outcomes in patients with sepsis: A systematic review and meta-analysis

BACKGROUND

Heart failure (HF) often affects the progress of sepsis patients, although its impact on outcomes is inconsistent and inconclusive.

AIM

To conduct a systematic review and meta-analysis of the impact of HF on mortality in patients with sepsis.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library databases were searched to compare the outcomes of sepsis patients with HF. A random effect model was used to summarize the mortality data, and the odds ratio (OR) and 95% confidence interval (CI) were calculated as effect indicators.

RESULTS

Among 18001 records retrieved in the literature search, 35712 patients from 10 separate studies were included. The results showed that sepsis patients with HF were associated with increased total mortality (OR = 1.80, 95%CI: 1.34-2.43; I² = 92.1%), with high heterogeneity between studies. Significant subgroup differences according to age, geographical location, and HF patient sample were observed. HF did not increase the 1-year mortality of patients (OR = 1.11, 95%CI: 0.75-1.62; I² = 93.2%), and the mortality of patients with isolated right ventricular dysfunction (OR=2.32, 95%CI: 1.29-4.14; I² = 91.5%) increased significantly.

CONCLUSION

In patients with sepsis, HF is often associated with adverse outcomes and mortality. Our results call for more high-quality research and strategies to improve outcomes for sepsis patients with HF.

Outcomes after implementing a heart failure diuretic pathway in an emergency department setting

BACKGROUND

Among patients with acute decompensated heart failure (HF), national and international loop diuretic therapy recommendations may not be followed in the emergency department (ED).

OBJECTIVES

To examine if loop diuretic treatment and patient disposition from the ED differed after implementing a clinical pathway based on national HF guidelines.

METHODS

Using an observational, pre- and post-intervention design, after clinical pathway implementation, loop diuretic medications and clinical outcomes were retrieved from medical records. Analyses included Pearson's Chi-square or Fisher's exact test, 2-sample T-test or Wilcoxon rank sum test.

RESULTS

Of 182 pre- and 122 post-intervention patients, mean (SD) patient age was 67.9 (13.4) years and 44.2% were Caucasian. There were no between-group differences in pre-ED visit loop diuretic prescription or dosages. More post-intervention ED patients received at least one dose of loop diuretic (94.3% vs. 81.9%, p = 0.010); however, the overall dose (mg) across groups was lower than the home dose and was not based on national guideline expectations. Doses from home to ED decreased less in the post-intervention group for patients who received doses at both time points and for all patients: p = 0.047 and p = 0.048, respectively. There was no between-group differences in short-stay unit (SSU) admissions, p = 0.33. Post-intervention patients were hospitalized from the ED (p = 0.050) and SSU (p = 0.005) less often than pre-intervention patients. Discharge to home from the ED or SSU increased in the post-intervention period; 16.4% vs. 4.9%, p = 0.009.

CONCLUSIONS

Among ED patients treated for HF, diuretic dosing was non-optimized. New interventions are needed to enhance adherence to national guidelines.

Clinical effect of Danshen decoction in patients with heart failure: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The incidence of heart failure (HF) is increasing year by year, posing a great threat to human health. Although pharmacotherapy has been able to significantly prolong patient survival, pharmacotherapy for HF still has limitations due to its complex pathogenesis and considerable individual variability, there is a great need to explore complementary and alternative therapies to slow down the progression of HF. Danshen decoction is used to treat several cardiovascular diseases including HF, but the efficacy of stabilization is uncertain. This meta-analysis evaluated the clinical efficacy of Danshen Decoction for the treatment of HF.

METHODS

The registration number assigned to this meta-analysis on the PROSPERO platform is CRD42022351918. Four databases were searched, and randomized controlled trials (RCTs) of Danshen decoction combined with conventional treatment (CT) of HF were screened, CT included medical treatments other than Danshen Decoction to which the patient was treated (including but not limited to angiotensin converting enzyme inhibitor, angiotensin receptor blocker, angiotensin receptor neprilysin inhibitors, β-blockers, diuretics, mineralcorticoid recept antagonist etc.). The clinical efficacy rate (CER), left ventricular ejection fraction (LVEF), left ventricular end-diastolic dimension (LVEDD), left ventricular end-systolic diameter (LVESD), brain natriuretic peptide (BNP), N-terminal pro-B type natriuretic peptide (NT-proBNP) and hypersensitive C-reactive protein (hs-CRP) were included as outcome indicators. The GRADE grading scale was used to grade the above indicators. The Cochrane risk-of-bias tool and the Jadad quality scale were used to assess the methodological quality of RCTs. Finally, RevMan V.4.5 software was used for data synthesis, 95% confidence intervals (CI) for dichotomous data, risk ratios (RR), and mean differences (MD) for continuous variables were calculated, Chi-square and I2 were used for heterogeneity assessment.

RESULTS

Nine RCTs with a total of 855 patients were included in this study, and all included RCTs had a low overall quality risk of bias and high quality of reported information. The results of the meta-analysis showed that compared with the use of CT, CER (%) was significantly improved due to Danshen decoction combined with CT (MD = 3.95, 95% CI [2.58, 6.04], P < 0.00001), LVEF (%) was significantly improved (MD = 5.46, 95% CI [5.32, 5.60], P < 0.00001), LVEDD (mm) was significantly reduced (MD = -5.27, 95% CI [-6.21, -4.32], P < 0.00001), LVESD (mm) was significantly reduced (MD = -4.60, 95% CI [-5.87, -3.32], P < 0.00001), BNP (pg/mL) was significantly reduced (MD = -88.61, 95% CI [-121.98, -55.24], P < 0.00001), NT-proBNP (pg/mL) was significantly decreased (SMD = -3.33, 95% CI [-5.92, -0.73], P = 0.01), hs-CRP (mg/L) was significantly decreased (MD = -2.73, 95% CI [-4.11, -1.34], P = 0.0001). The quality of the GRADE evidence for all outcomes was moderate to low and no RCTs reported adverse events.

CONCLUSION

Our research demonstrates that Danshen decoction is an effective and safe treatment option for HF. Nevertheless, considering the limitations of methodological and the quality of RCTs, more rigorous, large-scale, multicenter randomized clinical trials are needed to further evaluate the efficacy and safety of Danshen decoction in the treatment of HF patients.

Updates in heart failure: sodium glucose co-transporter 2 inhibitors and beyond – major changes are coming

Prevalence of heart failure is increasing worldwide mainly due to the ageing of the population and the improvement in diagnosis and treatment. In recent years, huge progress has been made in the management of heart failure patients. A new definition of chronic heart failure based on left ventricular ejection fraction and its possible trajectories has been reported. New drug classes have been introduced for the treatment of chronic heart failure. In particular, the prognostic benefit of sodium glucose co-transporter 2 inhibitors was demonstrated across all the heart failure phenotypes. Therapies for patients with advanced heart failure (long-term mechanical circulatory supports and heart transplantation) are now indicated also in the case of mild-to-moderate symptoms but with high risk of progression. In patients with acute heart failure, monitoring of urinary sodium and the use of acetazolamide may lead to better decongestion. Importantly, pre- and postdischarge assessment should lead to optimal treatment. Devices and telemonitoring can also be of help. Cardiovascular and noncardiovascular comorbidities are major determinants of the clinical course and need proper management. This review will summarize these important advances.

Heart failure: an update from the last years and a look at the near future

In the last years, major progress occurred in heart failure (HF) management. Quadruple therapy is now mandatory for all the patients with HF with reduced ejection fraction. Whilst verciguat is becoming available across several countries, omecamtiv mecarbil is waiting to be released for clinical use. Concurrent use of potassium-lowering agents may counteract hyperkalaemia and facilitate renin-angiotensin-aldosterone system inhibitor implementations. The results of the EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Preserved Ejection Fraction (EMPEROR-Preserved) trial were confirmed by the Dapagliflozin in Heart Failure with Mildly Reduced or Preserved Ejection Fraction (DELIVER) trial, and we now have, for the first time, evidence for treatment of also patients with HF with preserved ejection fraction. In a pre-specified meta-analysis of major randomized controlled trials, sodium-glucose co-transporter-2 inhibitors reduced all-cause mortality, cardiovascular (CV) mortality, and HF hospitalization in the patients with HF regardless of left ventricular ejection fraction. Other steps forward have occurred in the treatment of decompensated HF. Acetazolamide in Acute Decompensated Heart Failure with Volume Overload (ADVOR) trial showed that the addition of intravenous acetazolamide to loop diuretics leads to greater decongestion vs. placebo. The addition of hydrochlorothiazide to loop diuretics was evaluated in the CLOROTIC trial. Torasemide did not change outcomes, compared with furosemide, in TRANSFORM-HF. Ferric derisomaltose had an effect on the primary outcome of CV mortality or HF rehospitalizations in IRONMAN (rate ratio 0.82; 95% confidence interval 0.66-1.02; P = 0.070). Further options for the treatment of HF, including device therapies, cardiac contractility modulation, and percutaneous treatment of valvulopathies, are summarized in this article.

Association between fluid balance and mortality for heart failure and sepsis: a propensity score-matching analysis

BACKGROUND

Fluid resuscitation is necessary to correct the sepsis-induced hypoperfusion, which is contradictory to the treatment of heart failure. This study explored the association between fluid balance (FB) of the first 24 h after ICU admission and mortality in critically ill patients with heart failure and sepsis.

METHODS

Data were extracted from the Medical Information Mart for Intensive Care database. The locally weighted scatterplot smoothing (Lowess) method was used to demonstrate the relationship between FB and in-hospital mortality. Groups were divided into high FB (≥ 55.85 ml/kg) and low FB (< 55.85 ml/kg) according to the cut-off value of FB using Receiver operating characteristic analysis and Youden index method. The primary outcome was in-hospital mortality. Subgroup analyses, multivariable logistic regression analyses, and Kaplan-Meier curves were used to detect the association and survival difference between groups. Inverse probability treatment weighting (IPTW) and propensity score matching (PSM) were performed to minimize the bias of confounding factors and facilitate the comparability between groups.

RESULTS

A total of 936 patients were included. The Lowess curve showed an approximate positive linear relationship for FB and in-hospital mortality. In the multivariable logistic regression adjusted model, high FB showed strong associations with in-hospital mortality (OR 2.53, 95% CI 1.60-3.99, p < 0.001) as compared to the low FB group. In IPTW and PSM models, high FB consistently showed higher in-hospital mortality (IPTW model: OR 1.94, 95% CI 1.52-2.49, p < 0.001; PSM model: OR 2.93, 95% CI 1.75-4.90, p < 0.001) and 30-day mortality (IPTW model: OR 1.65, 95% CI 1.29-2.10, p < 0.001; PSM model: OR 2.50, 95% CI 1.51-4.15, p < 0.001), compared with the low FB group.

CONCLUSION

For critically ill patients with heart failure and sepsis, high FB within the first 24 h after ICU admission could serve as an independent risk factor for in-hospital mortality and 30-day mortality. The avoidance of fluid overload exerts important effects on reducing mortality in such patients.

Effect of Hypertonic Saline Solution Combined with Furosemide on Acute Heart Failure: A Meta-Analysis

Background

The efficacy of hypertonic saline solution (HSS) combined with furosemide in treating acute heart failure is controversial. This meta-analysis explores the efficacy of HSS combined with furosemide for the treatment of acute heart failure.

Methods

Literature were searched from databases, including PubMed, Web of Knowledge, Embase, Central, CMKI, Wanfang, and VIP. The inclusion criteria were as follows: (1) subjects: patients with acute heart failure; (2) the experimental group and the control group were properly set up; (3) intervention measures: patients in the experimental group were treated with HSS + furosemide, and patients in the control group were treated with furosemide; (4) the outcomes included at least one of the following indicators: readmission rate, mortality, 24 h urine volume, weight loss, and serum creatinine; and (5) randomized controlled trial (RCT). The method recommended by Cochrane Collaboration Network was used to evaluate the risk bias. The heterogeneity among the studies was evaluated through the chi-square test, and the publication bias was assessed by the Egger test. The results were described using risk ratio (RR), mean difference (MD), and 95% confidence interval (CI).

Results

The readmission rate in the HSS + furosemide group was lower than that in the furosemide group (RR = 0.53, 95% CI [0.46, 0.60], P < 0.00001), with no heterogeneity among the literature (P = 0.21, I² = 29%). Patients in the HSS + furosemide group had a lower mortality rate than that in the furosemide group (RR = 0.55, 95% CI [0.46, 0.65], P < 0.00001). The chi-square test result indicated no heterogeneity among the literature (P = 0.25, I² = 23%). Furthermore, the 24 h urine volume of patients in the HSS + furosemide group was higher than that in the furosemide group (MD = 497.29, 95% CI [457.61, 536.96], P < 0.00001). There was no heterogeneity among the literature (P = 0.58, I² = 0%). In contrast, patients in the HSS + furosemide group demonstrated a lower serum creatinine level than those in the furosemide group (MD = −0.45, 95% CI [-0.51, -0.39], P < 0.00001). However, heterogeneity was observed among the literature (P < 0.00001, I² = 81%). The weight loss in the HSS + furosemide group was higher than that in the furosemide group (MD = 1.83, 95% CI [1.51, 2.15], P < 0.00001). There was no heterogeneity among the literature (P = 0.42, I² = 2%). Egger test showed no publication bias among the literature (P > 0.05).

Conclusion

Despite the heterogeneity and bias in our study, the combination of HSS with furosemide is promising in patients with acute heart failure. However, further research is still needed to confirm.

Impact of dapagliflozin treatment on renal function and diuretics use in acute heart failure: a pilot study

OBJECTIVE

To determine the impact of sodium-dependent glucose type 2 cotransporter inhibitors on the renal function in acute heart failure.

METHODS

In a single-centre, controlled, randomised study, patients were prescribed dapagliflozin in addition to standard therapy, or were in receipt of standard therapy. The prespecified outcome was renal function deterioration; the secondary outcomes were the development of resistance to diuretics, weight loss, death during hospitalisation and the rehospitalisation or death for any reason within 30 days following discharge.

RESULTS

102 patients were included (73.4±11.7 years, 57.8% men). The average left ventricular ejection fraction was 44.9%±14.7%, the average N-terminal prohormone of brain natriuretic peptide (NT-proBNP) was 4706 (1757; 11 244) pg/mL, the average estimated glomerular filtration rate (eGFR) was 51.6±19.5 mL/min. eGFR decreased 48 hours after randomisation in the dapagliflozin group (-4.2 (-11.03; 2.28) mL/min vs 0.3 (-6; 6) mL/min; p=0.04) but did not differ between the groups on discharge (54.71±19.18 mL/min and 58.92±24.65 mL/min; p=0.36). The incidence of worsening renal function did not differ (34.4% vs 15.2%; p=0.07). In the dapagliflozin group, there was less tendency to increase the dose of loop diuretics (14% vs 30%; p=0.048), lower average doses of loop diuretics (78.46±38.95 mg/day vs 102.82±31.26 mg/day; p=0.001) and more significant weight loss (4100 (2950; 5750) g vs 3000 (1380; 4650) g; p=0.02). In-hospital mortality was 7.8% (4(8%) in the dapagliflozin and 4 (7.7%) in the control group (p=0.95). The number of deaths within 30 days following discharge in the dapagliflozin group and in the control group was 9 (19%) and 12 (25%), p=0.55; the number of rehospitalisations was 14 (29%) and 17 (35%), respectively (p=0.51).

CONCLUSION

The use of dapagliflozin was associated with a more pronounced weight loss and less need to increase diuretic therapy without significant deterioration of the renal function. Dapagliflozin did not improve the in-hospital and 30-day prognosis after discharge.

TRIAL REGISTRATION NUMBER

N04778787.

Advanced heart failure: guideline-directed medical therapy, diuretics, inotropes, and palliative care

Heart failure (HF) is a major cause of mortality, hospitalizations, and reduced quality of life and a major burden for the healthcare system. The number of patients that progress to an advanced stage of HF is growing. Only a limited proportion of these patients can undergo heart transplantation or mechanical circulatory support. The purpose of this review is to summarize medical management of patients with advanced HF. First, evidence-based oral treatment must be implemented although it is often not tolerated. New therapeutic options may soon become possible for these patients. The second goal is to lessen the symptomatic burden through both decongestion and haemodynamic improvement. Some new treatments acting on cardiac function may fulfil both these needs. Inotropic agents acting through an increase in intracellular calcium have often increased risk of death. However, in the recent Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure (GALACTIC-HF) trial, omecamtiv mecarbil was safe and effective in the reduction of the primary outcome of cardiovascular death or HF event compared with placebo (hazard ratio, 0.92; 95% confidence interval, 0.86-0.99; P = 0.03) and its effects were larger in those patients with more severe left ventricular dysfunction. Patients with severe HF who received omecamtiv mecarbil experienced a significant treatment benefit, whereas patients without severe HF did not (P = 0.005 for interaction). Lastly, clinicians should take care of the end of life with an appropriate multidisciplinary approach. Medical treatment of advanced HF therefore remains a major challenge and a wide open area for further research.

A year in heart failure: an update of recent findings

Major changes have occurred in these last years in heart failure (HF) management. Landmark trials and the 2021 European Society of Cardiology guidelines for the diagnosis and treatment of HF have established four classes of drugs for treatment of HF with reduced ejection fraction: angiotensin‐converting enzyme inhibitors or an angiotensin receptor‐neprilysin inhibitor, beta‐blockers, mineralocorticoid receptor antagonists, and sodium‐glucose co‐transporter 2 inhibitors, namely, dapagliflozin or empagliflozin. These drugs consistently showed benefits on mortality, HF hospitalizations, and quality of life. Correction of iron deficiency is indicated to improve symptoms and reduce HF hospitalizations. AFFIRM‐AHF showed 26% reduction in total HF hospitalizations with ferric carboxymaltose vs. placebo in patients hospitalized for acute HF (P = 0.013). The guanylate cyclase activator vericiguat and the myosin activator omecamtiv mecarbil improved outcomes in randomized placebo‐controlled trials, and vericiguat is now approved for clinical practice. Treatment of HF with preserved ejection fraction (HFpEF) was a major unmet clinical need until this year when the results of EMPEROR‐Preserved (EMPagliflozin outcomE tRial in Patients With chrOnic HFpEF) were issued. Compared with placebo, empagliflozin reduced by 21% (hazard ratio, 0.79; 95% confidence interval, 0.69 to 0.90; P < 0.001), the primary outcome of cardiovascular death or HF hospitalization. Advances in the treatment of specific phenotypes of HF, including atrial fibrillation, valvular heart disease, cardiomyopathies, cardiac amyloidosis, and cancer‐related HF, also occurred. Coronavirus disease 2019 (COVID‐19) pandemic still plays a major role in HF epidemiology and management. All these aspects are highlighted in this review.