Vasodilators in acute heart failure - evidence based on new studies

Admission prioritization of heart failure patients with multiple comorbidities

The primary objective of this study was to enhance the operational efficiency of the current healthcare system by proposing a quicker and more effective approach for healthcare providers to deliver services to individuals facing acute heart failure (HF) and concurrent medical conditions. The aim was to support healthcare staff in providing urgent services more efficiently by developing an automated decision-support Patient Prioritization (PP) Tool that utilizes a tailored machine learning (ML) model to prioritize HF patients with chronic heart conditions and concurrent comorbidities during Urgent Care Unit admission. The study applies key ML models to the PhysioNet dataset, encompassing hospital admissions and mortality records of heart failure patients at Zigong Fourth People's Hospital in Sichuan, China, between 2016 and 2019. In addition, the model outcomes for the PhysioNet dataset are compared with the Healthcare Cost and Utilization Project (HCUP) Maryland (MD) State Inpatient Data (SID) for 2014, a secondary dataset containing heart failure patients, to assess the generalizability of results across diverse healthcare settings and patient demographics. The ML models in this project demonstrate efficiencies surpassing 97.8% and specificities exceeding 95% in identifying HF patients at a higher risk and ranking them based on their mortality risk level. Utilizing this machine learning for the PP approach underscores risk assessment, supporting healthcare professionals in managing HF patients more effectively and allocating resources to those in immediate need, whether in hospital or telehealth settings.

Acute venodilation properties of low-dose intravenous nitroglycerine in pulmonary veno-occlusive disease: a case report

Background

The use of pulmonary vasodilators for pulmonary arterial hypertension (PAH) has led to a favourable prognosis. In contrast, pulmonary veno-occlusive disease (PVOD) is characterized by the possibility of severe pulmonary oedema after specific PAH therapy. Pulmonary oedema presumably develops in association with pulmonary arterial vasodilation without concomitant pulmonary venodilation. The venous circulation maximally dilates with small amounts of nitroglycerine.

Case summary

A 59-year-old woman with advanced PVOD was referred to our hospital. We performed a right heart catheterization after administering combination therapy with selexipag and macitentan, and intravenous nitroglycerine at 0.2 and 0.4 μg/kg/min decreased pulmonary arterial wedge pressure (PAWP) and mean pulmonary arterial pressure (PAP) to minimal levels. The final dose of 1 μg/kg/min yielded an ∼20% decrease in mean PAP and pulmonary vascular resistance (PVR).

Discussion

Here, we described the acute effect of intravenous nitroglycerine on PAWP and PVR in a patient with PVOD. This case highlights the venodilation response even in advanced PVOD, suggesting the importance of further research into selective venous dilators as potent therapy.

Diallyl sulfide protects against dilated cardiomyopathy via inhibition of oxidative stress and apoptosis in mice

Cytochrome P450 family 2 subfamily E member 1 (CYP2E1) is a member of the cytochrome P450 enzyme family and catalyzes the metabolism of various substrates. CYP2E1 is upregulated in multiple heart diseases and causes damage mainly via the production of reactive oxygen species (ROS). In mice, increased CYP2E1 expression induces cardiac myocyte apoptosis, and knockdown of endogenous CYP2E1 can attenuate the pathological development of dilated cardiomyopathy (DCM). Nevertheless, targeted inhibition of CYP2E1 via the administration of drugs for the treatment of DCM remains elusive. Therefore, the present study aimed to investigate whether diallyl sulfide (DAS), a competitive inhibitor of CYP2E1, can be used to inhibit the development of the pathological process of DCM and identify its possible mechanism. Here, cTnT^R141W transgenic mice, which developed typical DCM phenotypes, were used. Following treatment with DAS for 6 weeks, echocardiography, histological analysis and molecular marker detection were conducted to investigate the DAS-induced improvement on myocardial function and morphology. Biochemical analysis, western blotting and TUNEL assays were used to detected ROS production and myocyte apoptosis. It was found that DAS improved the typical DCM phenotypes, including chamber dilation, wall thinning, fibrosis, poor myofibril organization and decreased ventricular blood ejection, as determined using echocardiographic and histopathological analyses. Furthermore, the regulatory mechanisms, including inhibition both of the oxidative stress levels and the mitochondria-dependent apoptosis pathways, were involved in the effects of DAS. In particular, DAS showed advantages in terms of improved chamber dilation and dysfunction in model mice, and the improvement occurred in the early stage of the treatment compared with enalaprilat, an angiotensin-converting enzyme inhibitor that has been widely used in the clinical treatment of DCM and HF. The current results demonstrated that DAS could protect against DCM via inhibition of oxidative stress and apoptosis. These findings also suggest that inhibition of CYP2E1 may be a valuable therapeutic strategy to control the development of heart diseases, especially those associated with CYP2E1 upregulation. Moreover, the development of DAS analogues with lower cytotoxicity and metabolic rate for CYP2E1 may be beneficial.

Protective Effect of Epigallocatechin Gallate on Endothelial Disorders in Atherosclerosis

Healthy vascular endothelial cells regulate vascular tone and permeability, prevent vessel wall inflammation, enhance thromboresistance, and contribute to general vascular health. Furthermore, they perform important functions including the production of vasoactive substances such as nitric oxide (NO) and endothelium-derived hyperpolarizing factors, as well as the regulation of smooth muscle cell functions. Conversely, vascular endothelial dysfunction leads to atherosclerosis, thereby enhancing the risk of stroke, myocardial infarction, and other cardiovascular diseases (CVDs). Observational studies and randomized trials showed that green tea intake was inversely related to CVD risk. Furthermore, evidence indicates that epigallocatechin gallate (EGCG) found in green tea might exert a preventive effect against CVDs. EGCG acts as an antioxidant, inducing NO release and reducing endothelin-1 production in endothelial cells. EGCG enhances the bioavailability of normal NO by reducing levels of the endogenous NO inhibitor asymmetric dimethylarginine. Furthermore, it inhibits the enhanced expression of adhesion molecules such as vascular cell adhesion molecule-1 and intercellular adhesion molecule-1 and attenuates monocyte adhesion. In addition, EGCG prevents enhanced oxidative stress through the Nrf2/HO-1 pathway. These effects indicate that it might prevent the production of reactive oxygen species, inhibit inflammation, and reduce endothelial cell apoptosis during the initial stages of atherosclerosis. The current review summarizes recent research in this area and discusses novel findings regarding the protective effect of EGCG on endothelial dysfunction and CVDs in general.

Impact of left ventricular dysfunction and fluid balance on the outcomes of patients with sepsis

OBJECTIVE

Left ventricular (LV) dysfunction is a predictor of mortality in patients with sepsis. However, whether the adverse impact of LV dysfunction depends on fluid balance remains unclear. We retrospectively investigated the impact of LV dysfunction and fluid balance on various outcomes of patients with sepsis.

METHODS

Critically ill patients with sepsis were classified according to their LV function: normal LV function, diastolic dysfunction (septal e' of <10 and E/e' of ≥15 with ejection fraction of ≥50%), and systolic dysfunction (ejection fraction of <50%).

RESULTS

There were 83 (51.2%) patients with normal LV function, 39 (24.1%) with diastolic dysfunction, and 40 (24.7%) with systolic dysfunction. The cumulative and daily fluid balances after intensive care unit admission did not differ. However, acute kidney injury was more prevalent in the patients with diastolic and systolic dysfunction than in those with normal LV function (82.1%, 87.5%, and 69.9%, respectively; P = 0.065). LV dysfunction lengthened the duration of renal replacement therapy, independent of baseline renal dysfunction and the daily fluid balance (P = 0.008). Moreover, both diastolic and systolic dysfunction were associated with mortality (hazard ratio: 2.7 and 3.0; P = 0.047 and P = 0.028, respectively), regardless of the daily fluid balance, which was also a significant predictor of mortality (P < 0.001).

CONCLUSIONS

LV dysfunction has an adverse impact on renal outcomes and mortality in patients with sepsis and seems to be independent of fluid balance. Additional therapeutic options to restore organ perfusion are needed for patients with sepsis who have LV dysfunction, in addition to intravenous fluid restriction.

Natriuretic Peptides in Heart Failure with Preserved Left Ventricular Ejection Fraction: From Molecular Evidences to Clinical Implications

The incidence of heart failure with preserved ejection fraction (HFpEF) is increasing and its challenging diagnosis and management combines clinical, imagistic and biological data. Natriuretic peptides (NPs) are hormones secreted in response to myocardial stretch that, by increasing cyclic guanosine monophosphate (cGMP), counteract myocardial fibrosis and hypertrophy, increase natriuresis and determine vasodilatation. While their role in HFpEF is controversial, most authors focused on b-type natriuretic peptides (BNPs) and agreed that patients may show lower levels. In this setting, newer molecules with an increased specificity, such as middle-region pro-atrial natriuretic peptide (MR-proANP), emerged as promising markers. Augmenting NP levels, either by NP analogs or breakdown inhibition, could offer a new therapeutic target in HFpEF (already approved in their reduced EF counterparts) by increasing the deficient cGMP levels found in patients. Importantly, these peptides also retain their prognostic value. This narrative review focuses on NPs' physiology, diagnosis, therapeutic and prognostic implication in HFpEF.

Clinical characteristics of hospitalized heart failure patients with preserved, mid-range, and reduced ejection fractions in Japan

Aims

There are regional differences in the patient characteristics, management, and outcomes of hospitalized patients with heart failure (HF). The aim of this study was to evaluate the clinical characteristics and outcomes of Japanese patients who are hospitalized with HF on the basis of the left ventricular ejection fraction (LVEF) stratum.

Methods and results

We retrospectively conducted a multicentre cohort study of 1245 hospitalized patients with decompensated HF between 2013 and 2014. Of these patients, 36% had an LVEF < 40% [HF with reduced ejection fraction (HFrEF), median age 72 years, 71% male], 21% had an LVEF 40–49% [HF with mid‐range EF (HFmrEF), 77 years, 56% male], and 43% had an LVEF ≥ 50% [HF with preserved EF (HFpEF), 81 years, 44% male]. The primary outcome was death from any cause, and the secondary outcomes were cardiac death and re‐hospitalization due to worsened HF after hospital discharge. There were high proportions of non‐ischaemic cardiomyopathy (32%) in HFrEF patients, coronary artery disease (44%) in HFmrEF patients, and valvular disease (39%) in HFpEF patients. The frequencies of intravenous diuretic and natriuretic peptide administration during hospitalization were 66% and 30%, respectively. The median hospital stay for the overall population was 19 days, and the length of stay was >7 days for >90% of patients. In‐hospital mortality was 7%, but was not different among the LVEF groups (HFrEF 7%, HFmrEF 6%, and HFpEF 8%). After a median follow‐up of 19 months (range, 3–26 months), 192 (17%) of the 1156 patients who were discharged alive died, and 534 (46%) were re‐hospitalized after hospital discharge. There were no significant differences in mortality after hospital discharge among the three LVEF groups (HFrEF 18%, HFmrEF 16%, and HFpEF 16%). There were no differences in cardiac death or re‐hospitalization due to worsened HF after hospital discharge among the LVEF groups (cardiac death: HFrEF 8%, HFmrEF 7%, and HFpEF 7%; re‐hospitalization due to worsened HF: HFrEF 19%, HFmrEF 16%, and HFpEF 17%). Multivariable‐adjusted analyses showed that the HFmrEF and HFrEF groups, compared with the HFpEF group, were not associated with an increased risk for in‐hospital death or death after hospital discharge. Non‐cardiac causes of death and re‐hospitalization after hospital discharge accounted for 35% and 38%, respectively.

Conclusions

Our results revealed different clinical characteristics but similar mortality rates in the HFrEF, HFmrEF, and HFpEF groups. The most common cause of death and re‐hospitalization after hospital discharge was HF, but non‐cardiac causes also contributed to their prognosis. Integrated management approaches will be required for HF patients.

Cardiorenal Syndrome: An Overview

It is well established that a large number of patients with acute decompensated heart failure present with various degrees of heart and kidney dysfunction usually primary disease of heart or kidney often involve dysfunction or injury to the other. The term cardiorenal syndrome increasingly had been used without a consistent or well-accepted definition. To include the vast array of interrelated derangements and to stress the bidirectional nature of heart-kidney interactions, a new classification of the cardiorenal syndrome with 5 subtypes that reflect the pathophysiology, the time frame, and the nature of concomitant cardiac and renal dysfunction was proposed. Cardiorenal syndrome can generally be defined as a pathophysiological disorder of the heart and kidneys, in which acute or chronic dysfunction of one organ may induce acute or chronic dysfunction to the other. Although cardiorenal syndrome was usually referred to as acute kidney dysfunction following acute cardiac disease, it is now clearly established that impaired kidney function can have an adverse impact on cardiac function.