Initial management of patients with acute heart failure

Time from admission to randomization and the effect of empagliflozin in acute heart failure: A post-hoc analysis from EMPULSE

AIMS

Patients hospitalized for acute heart failure (HF) could be enrolled in EMPULSE (NCT04157751) upon haemodynamic stabilization and between 24 h and 5 days after hospital admission. The timing of treatment initiation may influence the efficacy and safety of drugs such as empagliflozin. The aim of this study was to evaluate patient characteristics, clinical events, and treatment effects according to time from admission to randomization.

METHODS AND RESULTS

The EMPULSE population was dichotomized by median time from hospital admission to randomization (1-2 days vs. 3-5 days). The primary outcome was a hierarchical composite endpoint of time to all-cause death, number of HF events, time to first HF event, and a ≥5-point difference in Kansas City Cardiomyopathy Questionnaire total symptom score change from baseline after 90 days, analysed using the win ratio (WR) method. Patients randomized later (3-5 days, average time 3.9 days; n = 312) had a higher risk of experiencing clinical events than patients randomized earlier (1-2 days, average time 1.7 days; n = 215). The treatment effect favoured empagliflozin versus placebo in patients randomized later (3-5 days: WR 1.69, 95% confidence interval [CI] 1.26-2.25) but was attenuated in patients randomized earlier (1-2 days: WR 1.04, 95% CI 0.74-1.44) (interaction p = 0.029). A similar pattern was observed for the composite of HF hospitalization or cardiovascular death and all-cause hospitalizations (interaction p < 0.1 for both). The reduction of N-terminal pro-B-type natriuretic peptide levels was more pronounced with empagliflozin among patients randomized later than in patients randomized earlier (interaction p = 0.004).

CONCLUSIONS

Among patients hospitalized for acute HF enrolled in EMPULSE, those randomized later after hospital admission (3-5 days) experienced greater clinical benefit with empagliflozin than those randomized earlier (1-2 days). These findings should be confirmed in future studies before clinical application.

Therapeutic effects of intravenous urapidil in elderly patients with hypertension and acute decompensated heart failure: A pilot clinical trial

Urapidil has been proposed to be an effective vasodilator for the treatment of acute decompensated heart failure (ADHF); however, its effect on cardiac function, as compared with that of nitroglycerin, in elderly patients with hypertension and ADHF has yet to be determined. In the present study, a multicenter, open-label clinical trial was performed, in which 120 elderly patients with hypertension and ADHF were randomly assigned to the treatment (50–400 µg/min intravenous urapidil) or control group (5–40 µg/min intravenous nitroglycerin). The dosages of the medications were adjusted according to the blood pressure of the patients. The systolic and diastolic blood pressure, heart rate and serum level of N-terminal pro B-type natriuretic peptide (NT-proBNP) were evaluated at hospital admission and at days 1, 2, 3 and 7 after treatment. In addition, the left ventricular function was assessed by measuring the left ventricular ejection fraction (LVEF) and left ventricular end-diastolic volume at hospital admission and at days 2 and 7 after treatment. The results indicated that intravenous administration of urapidil and nitroglycerin were effective in lowering the blood pressure and heart rate within 7 days, with no significant differences observed between the two groups (P>0.05). By contrast, greater reduction in the serum NT-proBNP level (2,410.4±546.1 vs. 4,234.1±876.4 pg/ml; P<0.05) and greater improvement in the LVEF (55.3±3.4 vs. 45.2±2.4%; P<0.05) were observed in the urapidil-treated group, as compared with the nitroglycerin-treated group. No adverse events were reported during the treatment period in the two groups. The clinical outcomes at 6 months following discharge were evaluated and were not found to be significantly different between the two groups. In conclusion, the present results of the present study suggested that urapidil was as effective as nitroglycerin in controlling blood pressure and heart rate and was more effective in improving cardiac systolic function in elderly patients with hypertension and ADHF.

Respiratory Collapse of the Inferior Vena Cava Reflects Volume Shift and Subsequent Fluid Refill in Acute Heart Failure Syndrome

BACKGROUND

Fluid redistribution rather than fluid accumulation plays an important role in the development of acute heart failure (HF) syndrome. Patients with fluid redistribution develop acute HF without prominent volume overload. We investigated volume status by measuring the diameter of the inferior vena cava (IVC) and examining variations in hemoglobin and hematocrit.

METHODS AND RESULTS

Seventy-four consecutive patients admitted for acute HF syndrome were analyzed. Blood tests and measurement of IVC diameter after stabilization of respiratory distress were performed on admission and were repeated after 24 h. IVC collapsibility index (IVC-CI) was calculated as (maximum IVC-minimum IVC)/maximum IVC. According to the initial IVC-CI, the patients were divided into the collapse group (IVC-CI ≥0.5: n=34) and the non-collapse group (IVC-CI <0.5: n=40). Initial blood pressure was higher in the collapse group (P<0.001). Although 24-h urine volume did not differ between the groups, hemoglobin (P<0.001) and hematocrit (P<0.001) decreased significantly in the collapse group but not in the non-collapse group after 24 h. Furthermore, IVC-CI significantly decreased in the collapse group after 24 h (P=0.003).

CONCLUSIONS

In acute HF syndrome, IVC-CI ≥0.5 on admission suggests a volume shift from the central vein into the pulmonary vasculature. Fluid refill occurs within 24 h after admission. This observation could be helpful in selecting strategies for diuretic use. (Circ J 2016; 80: 1171-1177).

Plasma bioactive adrenomedullin as a prognostic biomarker in acute heart failure

OBJECTIVE

The objective was to evaluate the prognostic performance of a new biomarker, plasma bioactive adrenomedullin (bio-ADM), for short-term clinical outcomes in acute heart failure.

METHODS

A multicenter prospective cohort study of adult emergency department (ED) patients suspected of having acute heart failure was conducted to evaluate the association between plasma bio-ADM concentration and clinical outcomes. The primary outcome was a composite of the following within 30 days: death, cardiac arrest with resuscitation, respiratory failure, emergency dialysis, acute coronary syndrome, hospitalization >5 days, and repeat ED visit or hospitalization. Prognostic accuracy was evaluated with a nonparametric receiver operating characteristic curve. In addition, a multivariable logistic regression model was constructed to assess the additive prognostic performance of bio-ADM while adjusting for other biomarkers routinely used clinically, including B-type natriuretic peptide, cardiac troponin I, creatinine, and sodium concentration.

RESULTS

Two hundred forty-six patients were enrolled, including 85 (34.6%) patients with the primary outcome. Plasma bio-ADM concentrations were higher among patients who experienced the primary outcome (median, 80.5 pg/mL; interquartile range [IQR], 53.7-151.5 pg/mL) compared with those who did not (median, 54.4 pg/mL; IQR, 43.4-78.4 pg/mL) (P < .01). Area under the receiver operating characteristic curve was 0.70 (95% confidence interval, 0.63-0.75). After adjusting for the other biomarkers, plasma bio-ADM remained a strong predictor of the primary outcome (adjusted odds ratio per IQR change, 2.68; 95% confidence interval, 1.60-4.51).

CONCLUSIONS

Bioactive adrenomedullin concentrations at the time of ED evaluation for acute heart failure were predictive of clinically important 30-day outcomes, suggesting that bio-ADM is a promising prognostic marker for further study.

Role of the acute care nurse in managing patients with heart failure using evidence-based care

Acute heart failure is a major US public health problem, accounting for more than 1 million hospitalizations each year. As part of the health care team, nurses play an important role in the evaluation and management of patients presenting to the emergency department with acute decompensated heart failure. Once acute decompensation is controlled, nurses also play a critical role in preparing patients for hospital discharge and educating patients and caregivers about strategies to improve long-term outcomes and prevent future decompensation and rehospitalization. Nurses' assessment skills and comprehensive knowledge of acute and chronic heart failure are important to optimize patient care and improve outcomes from initial emergency department presentation through discharge and follow-up. This review presents an overview of current heart failure guidelines, with the goal of providing acute care cardiac nurses with information that will allow them to better use their knowledge of heart failure to facilitate diagnosis, management, and education of patients with acute heart failure.

Drug Therapy for Acute Heart Failure

Acute heart failure is globally one of most frequent reasons for hospitalization and still represents a challenge for the choice of the best treatment to improve patient outcome. According to current international guidelines, as soon as patients with acute heart failure arrive at the emergency department, the common therapeutic approach aims to improve their signs and symptoms, correct volume overload, and ameliorate cardiac hemodynamics by increasing vital organ perfusion. Recommended treatment for the early management of acute heart failure is characterized by the use of intravenous diuretics, oxygen, and vasodilators. Although these measures ameliorate the patient's symptoms, they do not favorably impact on short- and long-term mortality. Consequently, there is a pressing need for novel agents in acute heart failure treatment with the result that research in this field is increasing worldwide.