Timing of Immunoreactive B-Type Natriuretic Peptide Levels and Treatment Delay in Acute Decompensated Heart Failure

Door-to-Diuretic Time and Outcomes in Acute Heart Failure: A Scoping Review

INTRODUCTION

Inadequate decongestion remains an unmet need in the management of patients with heart failure. The concept of door-to-diuretic (D2D) time to improve outcomes has been proposed for patients with heart failure (HF), but the trial results have been mixed.

METHODS

We utilized Preferred Reporting Instrument for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) for scoping reviews with an extensive a priori search strategy for databases: PubMed and Scopus between January 2015 and November 2023. We used the key search terms "door-to-diuretic time" OR "door-to-furosemide time" OR "acute heart failure decongestion". Early D2D time was defined as intravenous (IV) diuretic administration within 30-120 min of patient arrival to the healthcare facility. Articles were included if they met our criteria, were written in the English language, and investigated door-to-diuretic or furosemide time as a decongestive strategy to improve outcomes in patients with acute HF.

RESULTS

From 588 articles, 13 articles fulfilled the inclusion criteria after excluding duplicates and articles that did not meet our inclusion criteria. Of these studies, there was 1 meta-analysis and 12 observational cohort/registry-based studies (10 were positive trials and 2 were neutral). The most common outcomes examined were mortality and rehospitalization with early diuretic administration. First, early treatment was associated with lower in-hospital mortality and shorter hospital length of stay. Second, higher doses of furosemide were associated with improved HF symptoms and decreased hospitalization, at the cost of transiently worsening renal function. Third, the evidence is mixed for long-term mortality benefits.

CONCLUSION

Although the impact of early D2D time on HF outcomes is mixed, early diuretic administration appears to be an effective and safe strategy that warrants further investigation in large-scale pragmatic comparative effectiveness trials. Future trials should consider utilizing diuretic efficiency-guided dose escalation and augmented diuresis using high-dose or combination diuretic therapy.

Door-to-Diuretic Time and Short-term Outcomes in Acute Heart Failure: A Systematic Review and Meta-analysis

INTRODUCTION

Acute heart failure (AHF) is a leading cause of unplanned hospitalization, often associated with poor outcomes. Decongestion with intravenous loop diuretics is the mainstay of treatment. Metrics such as door-to-diuretic time, the time between presentation of AHF to the hospital, and administration of intravenous diuretics, may play an important role in faster decongestion and thereby reduce mortality. We sought to investigate whether early diuretic administration [door-to-diuretic (D2D) time 60 ≤mins] was associated with improved outcomes among hospitalized heart failure patients.

METHODS

A systematic search of PubMed and Scopus databases was performed from inception until June 2023. The primary endpoints were all-cause in-hospital and 30-day mortality. Secondary endpoints were the length of hospital stay and heart failure readmission. We used a random-effects model to calculate odds ratios (OR) for binary outcomes and mean differences for continuous data.

RESULTS

Our meta-analysis included 6 observational studies involving 19,916 patients. No significant differences ( P > 0.05) were observed between shorter D2D and delayed D2D time with respect to in-hospital mortality (OR, 0.62; 95% CI, 0.35-1.09), 30-day mortality (OR, 0.83; 95% CI, 0.51-1.33; P = 0.44), length of hospital stay (MD, -0.02; 95% CI, -0.26 to 0.22) and heart failure readmission (OR, 1.00; 95% CI, 0.86-1.20).

CONCLUSIONS

Evidence from existing literature, which is largely limited to observational comparisons, highlights comparable outcomes between the 2 treatment strategies. Early diuretic administration, particularly within 60 minutes of hospital presentation, does not demonstrate any prognostic benefits.

Contemporary management of acute heart failure in the emergency department and the potential impact of early diuretic therapy on outcomes

OBJECTIVE

Acute heart failure (AHF) is one of the most common conditions presenting to the ED and patients often require hospitalisation. Emerging evidence suggests early diagnosis and administration of diuretics are associated with improved patient outcomes. Currently, there is limited literature on the management of AHF in the Australian ED context.

METHODS

A retrospective review of consecutive AHF presentations to the ED in a metropolitan hospital. Patient demographics, clinical status and management were assessed including timeliness of diuretics administration and association with outcomes including ED length of stay (LOS) and inpatient mortality using linear regression.

RESULTS

One hundred and ninety-one presentations (median age 81 years, 50.8% male) were identified. Common cardiovascular comorbidities were prevalent. Fifty-four patients (28.3%) had ≥1 clinical high-risk feature at presentation. The median time from presentation to furosemide administration was 187 min (interquartile range 97-279 min); only 35 patients received diuretics within 60 min of presentation. Early diuretics was associated with shorter ED LOS (246 min vs 275 min, P = 0.03) and a lower but non-significant inpatient mortality (4.9% vs 6.3%, P = 0.21) and a non-significant increased rate of discharge home from ED (8.6% vs 4.7%, P = 0.15). The likelihood of discharge home was significantly more pronounced in patients receiving early diuretics without clinical high-risk features (16.7% vs 4.3%, P = 0.028).

CONCLUSION

Despite symptoms and signs being well recognised at presentation, time to diuretics was relatively long. Early diuretics administration was associated with improved patient outcomes, particularly in clinically more stable patients. Due to the limitations of the study design, results should be interpreted with caution and warrant further research to identify factors that delay timely administration of diuretics.

Awareness of heart failure, blood pressure management and self-efficacy: The Research Goes Red for Women Registry

BACKGROUND

Heart failure (HF) is increasing in the United States, and awareness is needed for prevention. Hypertension is the leading cause of HF, and adherence to antihypertensive medication is critical for reducing HF risk. Self-efficacy positively influences health-promoting behaviors.

OBJECTIVES

Assess HF awareness, test associations with antihypertensive medication adherence, and self-efficacy for managing chronic conditions.

DESIGN

We conducted a cross-sectional, observational survey research study.

METHODS

We leveraged data from participants enrolled in the American Heart Association's Research Goes Red™ registry, an online platform powered by Verily. Three surveys ascertained HF awareness, blood pressure management, and self-efficacy. Chi-squared and Wilcoxon rank sum determined associations between survey domains and participant characteristics.

RESULTS

Two thousand three hundred twenty women took the HF awareness survey, 678 the blood pressure management survey, and 755 the self-efficacy survey (response rates: 12%, 78%, and 76%, respectively). Participants were predominantly non-Hispanic White (78%), with a median age of 51 (interquartile range (IQR): 39, 62). Median HF awareness score was 4/5 (IQR: 4, 5). Participants with high HF awareness versus low were more likely to be older (p < 0.001), non-Hispanic White (p < 0.001), and less likely to smoke (p < 0.001) or have depression (p = 0.004). Nearly 90% of hypertensive participants reported medication adherence, which was not associated with HF awareness or self-efficacy. Participants with greater self-efficacy versus less were more likely to have higher HF awareness (p = 0.01), be older (p = 0.01), and less likely to have depression (p < 0.001).

CONCLUSION

Women's awareness of HF and adherence to antihypertensive medication in this cohort was high. Depression and younger age may be important factors affecting women's HF awareness and confidence in managing chronic disease medication plans.

Deciphering the Dilemma: Anticoagulation for Heart Failure With Preserved Ejection Fraction (HFpEF)

Impairment in ventricular relaxation and preserved left ventricular ejection fraction are the two main features of heart failure with preserved ejection fraction (HFpEF) a difficult clinical condition. Therapeutic choices for HFpEF patients are still scarce despite its rising frequency and negative effects on morbidity and mortality, necessitating creative methods to enhance results. The increased thromboembolic risk seen in these individuals raises questions about the relevance of anticoagulation in the therapy of HFpEF. Although anticoagulation has been shown to be beneficial in heart failure with decreased ejection fraction (HFrEF) and other high-risk cardiovascular disorders, its efficacy and safety in HFpEF present a challenging therapeutic challenge. Anticoagulants have been the subject of clinical trials in HFpEF, but the results have been conflicting, giving clinicians only a little information with which to make decisions. The decision-making process is made more difficult by worries about potential bleeding hazards, particularly in susceptible elderly HFpEF patients with other comorbidities. The link between heart failure and anticoagulant medication in HFpEF is thoroughly analyzed in this narrative review. In HFpEF, cardiac fibrosis and endothelial dysfunction create a prothrombotic milieu, as is highlighted in this passage. Also covered are recent developments in innovative biomarker research and cutting-edge imaging techniques, which may provide ways to spot HFpEF patients who might benefit from anticoagulation. This therapeutic conundrum may be resolved by using precision medicine strategies based on risk classification and individualized therapy choices. This review emphasizes the need for more research to establish the best use of anticoagulation in HFpEF within the framework of personalized therapy and shared decision-making. To successfully manage thromboembolic risk and reduce bleeding consequences in HFpEF patients, it is essential to perform well-designed clinical studies and advance our understanding of the pathophysiology of HFpEF. These developments may ultimately improve the prognosis and quality of life for people who suffer from this difficult and mysterious ailment.

Association of 48-h net fluid status with change in renal function and dyspnea among patients with decompensated heart failure: A pooled cohort analysis of three acute heart failure trials

BACKGROUND

Acute heart failure (AHF) exacerbations are a leading cause of hospitalization in the United States. Despite the frequency of AHF hospitalizations, there are inadequate data or practice guidelines on how quickly diuresis should be achieved.

OBJECTIVE

To study the association of 48-h net fluid change and (A) 72-h change in creatinine and (B) 72-h change in dyspnea among patients with acute heart failure.

DESIGNS, SETTINGS, AND PARTICIPANTS

This is a retrospective, pooled cohort analysis of patients from the DOSE, ROSE, and ATHENA-HF trials.

INTERVENTIONS

The primary exposure was 48-h net fluid status.

MAIN OUTCOMES AND MEASURES

The co-primary outcomes were 72-h change in creatinine and 72-h change in dyspnea. The secondary outcome was risk of 60-day mortality or rehospitalization.

RESULTS

Eight hundred and seven patients were included. The mean 48-h net fluid status was -2.9 L. A nonlinear association was observed with net fluid status and creatinine change, such that creatinine improved with each liter net negative up to 3.5 L (-0.03 mg/dL per liter negative [95% confidence interval [CI]: -0.06 to -0.01) and remained stable beyond 3.5 L (-0.01 [95% CI: -0.02 to 0.001], p = .17). Net fluid loss was associated with a monotonic improvement of dyspnea (1.4-point improvement per liter negative [95% CI: 0.7-2.2], p = .0002). Each liter net negative by 48 h was also associated with 12% decreased odds of 60-day rehospitalization or death (odds ratio: 0.88; 95% CI: 0.82-0.95; p = .002).

CONCLUSION

Aggressive net fluid targets within the first 48 h are associated with effective relief of patient self-reported dyspnea and improved long-term outcomes without adversely affecting renal function.

Real-World Intravenous Diuretic Use to Treat Congestion in Patients With Heart Failure - An Observational Study Using a Research Database

Background: Intravenous (IV) diuretics are key in the treatment of acute heart failure, but the time of administration can affect outcomes. Using a medical database, we assessed the real-world usage and clinical impact of IV diuretics after admission. Methods and Results: This observational study included hospitalized patients with heart failure who received IV diuretics. Relationships between IV diuretic use and clinical outcomes (duration of hospitalization, in-hospital mortality, readmission) were evaluated using analysis of variance or logistic regression. Overall, 9,653 patients (51.1% male) were assessed (mean age 80.9 years). Most (89.1%) patients had IV loop diuretic treatment initiated on Day 1 of hospitalization and 68.0% achieved the maximum dose on that day. The median duration of hospitalization was 17.0 days. In-hospital mortality was 9.2%; 13.7% of patients were readmitted within 3 months after discharge. There were prognostic relationships between IV diuretic usage and both duration of hospitalization and in-hospital mortality. On multivariable analysis, the time of maximum dose had the biggest impact on outcomes. Duration of hospitalization was prolonged and in-hospital mortality rates increased when the time of maximum dose was delayed. There was little correlation between IV diuretic use and readmission following discharge. Conclusions: Short-term outcomes (duration of hospitalization, in-hospital mortality) correlated with the time of maximum IV diuretic dose; thus, early initiation and subsequent modification of appropriate congestion treatment is critical for prognostic improvement.

Association of time-to-intravenous furosemide with mortality in acute heart failure: data from REPORT-HF

AIM

Acute heart failure can be a life-threatening medical condition. Delaying administration of intravenous furosemide (time-to-diuretics) has been postulated to increase mortality, but prior reports have been inconclusive. We aimed to evaluate the association between time-to-diuretics and mortality in the international REPORT-HF registry.

METHODS AND RESULTS

We assessed the association of time-to-diuretics within the first 24 h with in-hospital and 30-day post-discharge mortality in 15 078 patients from seven world regions in the REPORT-HF registry. We further tested for effect modification by baseline mortality risk (ADHERE risk score), left ventricular ejection fraction (LVEF) and region. The median time-to-diuretics was 67 (25th-75th percentiles 17-190) min. Women, patients with more signs and symptoms of heart failure, and patients from Eastern Europe or Southeast Asia had shorter time-to-diuretics. There was no significant association between time-to-diuretics and in-hospital mortality (p > 0.1). The 30-day mortality risk increased linearly with longer time-to-diuretics (administered between hospital arrival and 8 h post-hospital arrival) (p = 0.016). This increase was more significant in patients with a higher ADHERE risk score (p_interaction  = 0.008), and not modified by LVEF or geographic region (p_interaction  > 0.1 for both).

CONCLUSION

In REPORT-HF, longer time-to-diuretics was not associated with higher in-hospital mortality. However, we did found an association with increased 30-day mortality, particularly in high-risk patients, and irrespective of LVEF or geographic region.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02595814.

Deferral of Non-Emergency Cardiovascular Interventions Triggers Increased Cardiac Emergency Admissions-Analysis of the COVID-19 Related Lockdown

BACKGROUND

Data on the relation between non-emergency and emergency cardiac admission rates during the COVID-19 lockdown and post-lockdown period are sparse.

METHODS

Consecutive cardiac patients admitted to our tertiary heart center between 1 January and 30 June 2020 were included. The observation period of 6 months was analyzed in total and divided into three defined time periods: the pre-lockdown (1 January-19 March), lockdown (20 March-19 April), and post-lockdown (20 April-30 June) period. These were compared to the reference periods 2019 and 2022 using daily admission rates and incidence rate ratios (IRR).

RESULTS

Over the observation period from 1 January to 30 June, cardiac admissions (including non-emergency and emergency) were comparable between 2019, 2020, and 2022 (n = 2889, n = 2952, n = 2956; p = 0.845). However, when compared to the reference period 2019, non-emergency admissions decreased in 2020 (1364 vs. 1663; p = 0.02), while emergency admissions significantly increased (1588 vs. 1226; p < 0.001). Further analysis of the lockdown period revealed that non-emergency admissions dropped by 82% (IRR 0.18; 95%-CI 0.14-0.24; p < 0.001) and 42% fewer invasive cardiac interventions were performed (p < 0.001), whereas the post-lockdown period showed a 52% increase of emergency admissions (IRR 1.47; 95%-CI 1.31-1.65; p < 0.001) compared to 2019.

CONCLUSIONS

We demonstrate a drastic surge of emergency cardiac admissions post-COVID-19 related lockdown suggesting that patients who did not keep their non-emergency appointment had to be admitted as an emergency later on.

Association between focused cardiac ultrasound and time to furosemide administration in acute heart failure

BACKGROUND

Heart failure (HF) is a global health burden, and its management in the emergency department (ED) is important. This study aimed to evaluate the association between focused cardiac ultrasound (FoCUS) and early administration of diuretics in patients with acute HF admitted to the ED.

METHODS

This retrospective observational study was conducted at a tertiary academic hospital. Patients with acute HF patients who were admitted to the ED and receiving intravenous medication between January 2018 and December 2019 were enrolled. The main exposure was a FoCUS examination performed within 2 h of ED triage. The primary outcome was the time to furosemide administration.

RESULTS

Of 1154 patients with acute HF, 787 were included in the study, with 116 of them having undergone FoCUS. The time to furosemide was significantly shorter in the FoCUS group (median time (q1-q3), 112 min; range, 65-163 min) compared to the non-FoCUS group (median time, 131 min; range, 71-229 min). In the multivariable logistic regression analysis adjusting for age, sex, chief complaint, mode of arrival, triage level, shock status, and desaturation at triage, early administration of furosemide within 2 h from triage was significantly higher in the FoCUS group (adjusted odds ratio, 1.63; 95% confidence intervals, 1.04-2.55) than in the non-FoCUS group.

CONCLUSIONS

Early administration of intravenous furosemide was associated with FoCUS examination in patients with acute HF admitted to the ED. An early screening protocol could be useful for improving levels in clinical practice at EDs.

Development and validation of a decision support tool for the diagnosis of acute heart failure: systematic review, meta-analysis, and modelling study

OBJECTIVES

To evaluate the diagnostic performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) thresholds for acute heart failure and to develop and validate a decision support tool that combines NT-proBNP concentrations with clinical characteristics.

DESIGN

Individual patient level data meta-analysis and modelling study.

SETTING

Fourteen studies from 13 countries, including randomised controlled trials and prospective observational studies.

PARTICIPANTS

Individual patient level data for 10 369 patients with suspected acute heart failure were pooled for the meta-analysis to evaluate NT-proBNP thresholds. A decision support tool (Collaboration for the Diagnosis and Evaluation of Heart Failure (CoDE-HF)) that combines NT-proBNP with clinical variables to report the probability of acute heart failure for an individual patient was developed and validated.

MAIN OUTCOME MEASURE

Adjudicated diagnosis of acute heart failure.

RESULTS

Overall, 43.9% (4549/10 369) of patients had an adjudicated diagnosis of acute heart failure (73.3% (2286/3119) and 29.0% (1802/6208) in those with and without previous heart failure, respectively). The negative predictive value of the guideline recommended rule-out threshold of 300 pg/mL was 94.6% (95% confidence interval 91.9% to 96.4%); despite use of age specific rule-in thresholds, the positive predictive value varied at 61.0% (55.3% to 66.4%), 73.5% (62.3% to 82.3%), and 80.2% (70.9% to 87.1%), in patients aged <50 years, 50-75 years, and >75 years, respectively. Performance varied in most subgroups, particularly patients with obesity, renal impairment, or previous heart failure. CoDE-HF was well calibrated, with excellent discrimination in patients with and without previous heart failure (area under the receiver operator curve 0.846 (0.830 to 0.862) and 0.925 (0.919 to 0.932) and Brier scores of 0.130 and 0.099, respectively). In patients without previous heart failure, the diagnostic performance was consistent across all subgroups, with 40.3% (2502/6208) identified at low probability (negative predictive value of 98.6%, 97.8% to 99.1%) and 28.0% (1737/6208) at high probability (positive predictive value of 75.0%, 65.7% to 82.5%) of having acute heart failure.

CONCLUSIONS

In an international, collaborative evaluation of the diagnostic performance of NT-proBNP, guideline recommended thresholds to diagnose acute heart failure varied substantially in important patient subgroups. The CoDE-HF decision support tool incorporating NT-proBNP as a continuous measure and other clinical variables provides a more consistent, accurate, and individualised approach.

STUDY REGISTRATION

PROSPERO CRD42019159407.

Acute Heart Failure in the 2021 ESC Heart Failure Guidelines: a scientific statement from the Association for Acute CardioVascular Care (ACVC) of the European Society of Cardiology

The current European Society of Cardiology (ESC) Heart Failure Guidelines are the most comprehensive ESC document covering heart failure to date; however, the section focused on acute heart failure remains relatively too concise. Although several topics are more extensively covered than in previous versions, including some specific therapies, monitoring and disposition in the hospital, and the management of cardiogenic shock, the lack of high-quality evidence in acute, emergency, and critical care scenarios, poses a challenge for providing evidence-based recommendations, in particular when by comparison the data for chronic heart failure is so extensive. The paucity of evidence and specific recommendations for the general approach and management of acute heart failure in the emergency department is particularly relevant, because this is the setting where most acute heart failure patients are initially diagnosed and stabilized. The clinical phenotypes proposed are comprehensive, clinically relevant and with minimal overlap, whilst providing additional opportunity for discussion around respiratory failure and hypoperfusion.

Low-Level Elevations of Procalcitonin Are Associated with Increased Mortality in Acute Heart Failure Patients, Independent of Concomitant Infection

We aimed to evaluate the prognostic value of procalcitonin (PCT) in acute heart failure (AHF) patients, especially in those without underlying infection. We enrolled patients presenting with acute dyspnea to the emergency department (ED) of Heidelberg University Hospital and studied the prognostic role of PCT on all-cause death. Of 312 patients, AHF was diagnosed in 139 patients. Of these, 125 patients had AHF without signs of infection, and 14 had AHF complicated by respiratory or other infection. The optimal prognostic PCT cutoff value for mortality prediction was calculated by a receiver operating characteristics curve. In patients with AHF, the prognostic PCT cutoff value was 0.08 ng/mL. The Kaplan–Meier survival analysis showed that AHF patients with PCT values > 0.08 ng/mL had a higher all-cause mortality at 120 days than those with PCT values ≤ 0.08 ng/mL (log-rank p = 0.0123). Similar results could be obtained after subdivision into AHF patients with and without signs of overt infection. In both cases, mortality was higher in patients with PCT levels above the prognostic PCT cutoff than in those with values ranging below this threshold. Moreover, we show that the prognostic PCT cutoff values for mortality prediction ranged below the established PCT cutoff for the guidance of antibiotic therapy. In conclusion, the data of our study revealed that low-level elevations of PCT were associated with an increased mortality in patients with AHF, irrespective of concomitant respiratory or other infection. PCT should thus be further used as a marker in the risk stratification of AHF.

'Time is prognosis' in heart failure: time-to-treatment initiation as a modifiable risk factor

In heart failure (HF), acute decompensation can occur quickly and unexpectedly because of worsening of chronic HF or to new-onset HF diagnosed for the first time ('de novo'). Patients presenting with acute HF (AHF) have a poor prognosis comparable with those with acute myocardial infarction, and any delay of treatment initiation is associated with worse outcomes. Recent HF guidelines and recommendations have highlighted the importance of a timely diagnosis and immediate treatment for patients presenting with AHF to decrease disease progression and improve prognosis. However, based on the available data, there is still uncertainty regarding the optimal 'time-to-treatment' effect in AHF. Furthermore, the immediate post-worsening HF period plays an important role in clinical outcomes in HF patients after hospitalization and is known as the 'vulnerable phase' characterized by high risk of readmission and early death. Early and intensive treatment for HF patients in the 'vulnerable phase' might be associated with lower rates of early readmission and mortality. Additionally, in the chronic stable HF outpatient, treatments are often delayed or not initiated when symptoms are stable, ignoring the risk for adverse outcomes such as sudden death. Consequently, there is a dire need to better identify HF patients during hospitalization and after discharge and treating them adequately to improve their prognosis. HF is an urgent clinical scenario along all its stages and disease conditions. Therefore, time plays a significant role throughout the entire patient's journey. Therapy should be optimized as soon as possible, because this is beneficial regardless of severity or duration of HF. Time lavished before treatment initiation is recognized as important modifiable risk factor in HF.

Predictive Factors of 30-day Adverse Events in Acute Heart Failure after Discharge from Emergency Department; a Historical Cohort Study

Introduction:

The rates of unscheduled emergency department (ED) visits and readmissions after discharge from the ED in acute heart failure (AHF) patients are high. This study aimed to identify the predictive factors of 30-day adverse events after discharge from the ED.

Methods:

A retrospective study was conducted from 2017 to 2019 in patients diagnosed with AHF and discharged from the ED at a tertiary university hospital. Thirty-day adverse events were defined as (i) unscheduled revisit to the ED with AHF, (ii) hospital admission from AHF, and, (iii) death after discharge from the ED. The predictive factors of 30-day adverse events were examined using multivariate analyses by logistic regression.

Results:

421 patients with the median age of 73 (IQR: 63-81) years were studied (52.3% male). 81 (19.2%) patients had 30-day adverse events. Significant predictive factors of 30-day adverse events consisted of underlying valvular heart disease (OR = 2.46; 95%CI: 1.27-4.78; p = 0.008), chronic obstructive pulmonary disease (COPD) (OR = 0.08; 95%CI: 0.01-0.64; p=0.001), malignancy (OR=3.63; 95%CI: 1.17-11.24; p = 0.031), New York Heart Association functional class III (OR = 4.88; 95%CI: 0.93-25.59) and IV (OR = 7.23; 95% CI: 1.37-38.08) at the ED (p = 0.035), and serum sodium <135 mmol/L (OR = 2.20; 95%CI: 1.17-4.14; p = 0.014). Precipitating factors were anemia (OR = 2.42; 95%CI: 1.16-5.02; p = 0.021), progressive valvular heart disease (OR = 3.52; 95%CI: 1.35-7.85; p = 0.009), acute kidney injury (OR = 6.98; 95%CI: 2.32-20.96; p < 0.001), time to diuretic administration >60 minutes after ED arrival (OR = 3.89; 95%CI: 2.16-7.00; p < 0.001), and no discharge advice for follow-up (OR = 2.30; 95%CI: 1.10-4.77; p = 0.028).

Conclusion:

AHF patients who had good response to intravenous diuretics and were discharged from the ED were at high risk for 30-day adverse events. Ten factors predicted 30-day adverse events after discharge from the ED.

Delay in seeking medical care for worsening heart failure symptoms: predictors and association with cardiac events

AIMS

The association of delay in seeking medical care to subsequent cardiac events remains unknown in patients with worsening heart failure (HF) symptoms. The aims of this study were to (i) identify factors predicting care-seeking delay and (ii) examine the impact of care-seeking delay on subsequent cardiac rehospitalization or death.

METHODS AND RESULTS

We studied 153 patients hospitalized with an exacerbation of HF. Potential predictors of delay including demographic, clinical, psychosocial, cognitive, and behavioural variables were collected. Patients were followed for 3 months after discharge to determine time to the first cardiac rehospitalization or death. The median delay time was 134 h (25th and 75th percentiles 49 and 364 h). Non-linear regression showed that New York Heart Association functional class III/IV (P = 0.001), worse depressive symptoms (P = 0.004), better HF knowledge (P = 0.003), and lower perceived somatic awareness (P = 0.033) were predictors of delay time from patient perception of worsening HF to subsequent hospital admission. Cox regression revealed that patients who delayed longer (more than 134 h) had a 1.93-fold higher risk of experiencing cardiac events (P = 0.044) compared to non-delayers.

CONCLUSIONS

Care-seeking delay in patients with worsening HF symptoms was significantly associated with an increased risk of rehospitalization and mortality after discharge. Intervention strategies addressing functional status, psychological state, cognitive and behavioural factors are essential to reduce delay and thereby improve outcomes.

Determination and stability of N-terminal pro-brain natriuretic peptide in saliva samples for monitoring heart failure

Heart failure (HF) is the main cause of mortality worldwide, particularly in the elderly. N-terminal pro-brain natriuretic peptide (NT-proBNP) is the gold standard biomarker for HF diagnosis and therapy monitoring. It is determined in blood samples by the immunochemical methods generally adopted by most laboratories. Saliva analysis is a powerful tool for clinical applications, mainly due to its non-invasive and less risky sampling. This study describes a validated analytical procedure for NT-proBNP determination in saliva samples using a commercial Enzyme-Linked Immuno-Sorbent Assay. Linearity, matrix effect, sensitivity, recovery and assay-precision were evaluated. The analytical approach showed a linear behaviour of the signal throughout the concentrations tested, with a minimum detectable dose of 1 pg/mL, a satisfactory NT-proBNP recovery (95-110%), and acceptable precision (coefficient of variation ≤ 10%). Short-term (3 weeks) and long-term (5 months) stability of NT-proBNP in saliva samples under the storage conditions most frequently used in clinical laboratories (4, - 20, and - 80 °C) was also investigated and showed that the optimal storage conditions were at - 20 °C for up to 2.5 months. Finally, the method was tested for the determination of NT-proBNP in saliva samples collected from ten hospitalized acute HF patients. Preliminary results indicate a decrease in NT-proBNP in saliva from admission to discharge, thus suggesting that this procedure is an effective saliva-based point-of-care device for HF monitoring.

Relation of Decongestion and Time to Diuretics to Biomarker Changes and Outcomes in Acute Heart Failure

Prompt treatment may mitigate the adverse effects of congestion in the early phase of heart failure (HF) hospitalization, which may lead to improved outcomes. We analyzed 814 acute HF patients for the relationships between time to first intravenous loop diuretics, changes in biomarkers of congestion and multiorgan dysfunction, and 1-year composite end point of death or HF hospitalization. B-type natriuretic peptide (BNP), high sensitivity cardiac troponin I (hscTnI), urine and serum neutrophil gelatinase-associated lipocalin, and galectin 3 were measured at hospital admission, hospital day 1, 2, 3 and discharge. Time to diuretics was not correlated with the timing of decongestion defined as BNP decrease ≥ 30% compared with admission. Earlier BNP decreases but not time to diuretics were associated with earlier and greater decreases in hscTnI and urine neutrophil gelatinase-associated lipocalin, and lower incidence of the composite end point. After adjustment for confounders, only no BNP decrease at discharge was significantly associated with mortality but not the composite end point (p = 0.006 and p = 0.062, respectively). In conclusion, earlier time to decongestion but not the time to diuretics was associated with better biomarker trajectories. Residual congestion at discharge rather than the timing of decongestion predicted a worse prognosis.

The value of the inferior vena cava ultrasound in the decision to hospitalise in patients with acute decompensated heart failure; the best sonographic measurement method?

OBJECTIVES

The primary aim of this study was to determine the value of the inferior vena cava (IVC) ultrasound in the decision to hospitalise acute decompensated heart failure (ADHF) patients. Our secondary aim was to find the most successful IVC measurement method in monitoring volume status.

METHODS

ADHF patients were accepted over a 1-year period in this study. Patients' vital signs, laboratory tests and IVC measurements measured by six methods (in B- and M-mode; maximum, minimum diameter and caval index) performed on an hourly basis were recorded. The presence of any statistically significant difference between the IVC measurement methods, laboratory tests and vital parameters between the hospitalised and discharged patients was calculated. ROC curves were produced in order to determine the ability of parameters to differentiate two groups. Spearman's correlation test was used to investigate correlation between the IVC measurement methods and patients' urine outputs.

RESULTS

A total of 71 patients were included in the study; 42 of these were hospitalised and 29 were discharged. Potassium, brain natriuretic peptide, respiration rate, urine output, maximum and minimum IVC diameters differed significantly between the two groups. Minimum IVC diameter measured in M-mode was identified as a weak marker with 65% sensitivity and 64% specificity (+PPV: 73%; -NPV:54%) for hospitalisation. Change in maximum IVC diameter measured in B-mode exhibited a high degree of correlation with change in body fluid (cc: 0.802).

CONCLUSION

IVC ultrasound may have a limited value in the decision to hospitalise ADHF patients. But Maximum IVC diameter may be an ideal method for monitoring hypervolemic patients' volume status.

CLINICAL TRIALS IDENTIFIER

NCT02725151.

The FAST-FURO study: effect of very early administration of intravenous furosemide in the prehospital setting to patients with acute heart failure attending the emergency department

AIMS

The effect of early administration of intravenous (IV) furosemide in the emergency department (ED) on short-term outcomes of acute heart failure (AHF) patients remains controversial, with one recent Japanese study reporting a decrease of in-hospital mortality and one Korean study reporting a lack of clinical benefit. Both studies excluded patients receiving prehospital IV furosemide and only included patients requiring hospitalization. To assess the impact on short-term outcomes of early IV furosemide administration by emergency medical services (EMS) before patient arrival to the ED.

METHODS AND RESULTS

In a secondary analysis of the Epidemiology of Acute Heart Failure in Emergency Departments (EAHFE) registry of consecutive AHF patients admitted to Spanish EDs, patients treated with IV furosemide at the ED were classified according to whether they received IV furosemide from the EMS (FAST-FURO group) or not (CONTROL group). In-hospital all-cause mortality, 30-day all-cause mortality, and prolonged hospitalization (>10 days) were assessed. We included 12 595 patients (FAST-FURO = 683; CONTROL = 11 912): 968 died during index hospitalization [7.7%; FAST-FURO = 10.3% vs. CONTROL = 7.5%; odds ratio (OR) = 1.403, 95% confidence interval (95% CI) = 1.085-1.813; P = 0.009], 1269 died during the first 30 days (10.2%; FAST-FURO = 13.4% vs. CONTROL = 9.9%; OR = 1.403, 95% CI = 1.146-1.764; P = 0.004), and 2844 had prolonged hospitalization (22.8%; FAST-FURO = 25.8% vs. CONTROL = 22.6%; OR = 1.189, 95% CI = 0.995-1.419; P = 0.056). FAST-FURO group patients had more diabetes mellitus, ischaemic cardiomyopathy, peripheral artery disease, left ventricular systolic dysfunction, and severe decompensations, and had a better New York Heart Association class and had less atrial fibrillation. After adjusting for these significant differences, early IV furosemide resulted in no impact on short-term outcomes: OR = 1.080 (95% CI = 0.817-1.427) for in-hospital mortality, OR = 1.086 (95% CI = 0.845-1.396) for 30-day mortality, and OR = 1.095 (95% CI = 0.915-1.312) for prolonged hospitalization. Several sensitivity analyses, including analysis of 599 pairs of patients matched by propensity score, showed consistent findings.

CONCLUSION

Early IV furosemide during the prehospital phase was administered to the sickest patients, was not associated with changes in short-term mortality or length of hospitalization after adjustment for several confounders.

The Impact of Door to Diuretic Time in Acute Heart Failure on Hospital Length of Stay and In-Patient Mortality

Background Acute heart failure (AHF) can be life-threatening if not treated promptly and can significantly increase the number of annual emergency department (ED) encounters in the United States. Achieving adequate and prompt euvolemic state in AHF patients using intravenous (IV) diuretics is the cornerstone of treatment, which not only reduces in-hospital stay and mortality but also decreases healthcare expenditures. Surprisingly, the door to diuretic (D2D) time in AHF patients has always been a debatable issue among physicians worldwide, and so far, there are no set guidelines. This study examines a large cohort of AHF patients to determine the association between diuretics use within 90 minutes of ED admission and hospital length of stay (LOS) and patient mortality.  Methods Retrospective institutional data of AHF patients receiving IV diuretics following ED admission were extracted from 2016 to 2017. A total of 7,751 patients treated for AHF exacerbation were included, which were further divided into two groups based on the timing of diuretics administration (<90 minutes vs. ≥90 minutes). The primary outcomes were LOS between the two groups and hospital mortality. The standard statistical methodology was used for data analysis. Results  A total of 7,751 AHF cases receiving IV diuretics were identified. Almost 1,432 patients (18.5%) received IV diuretics within 90 minutes of ER admission (group 1) while 6,319 patients (81.5%) patients received IV diuretics after 90 minutes (group 2). Furthermore, among group 1 patients, average LOS was noted to be associated with shorter hospitalization (average of 1.423 days less as compared to group 2 patients (confidence interval (CI) =1.02-1.82; p<0.05). Finally, after controlling for other mortality risk factors, patients in group 2 were 1.435 times more likely to have died compared to patients in group 1 (CI=1.03-1.98; p<0.05). Conclusions  D2D time in AHF patients has always been a crucial judgmental decision. The current study successfully demonstrated the relation between IV diuretics administration within 90 minutes of ED admission, favorable clinical outcomes, and decreased mortality rates. More adequately powered studies are needed to validate the results of our current study further.

Time-sensitive approach in the management of acute heart failure

Acute heart failure (AHF) has become a global public health burden largely because of the associated high morbidity, mortality, and cost. The treatment options for AHF have remained relatively unchanged over the past decades. Historically, clinical congestion alone has been considered the main target for treatment of acute decompensation in patients with AHF; however, this is an oversimplification of the complex pathophysiology. Within the similar clinical presentation of congestion, significant differences in pathophysiological mechanisms exist between the fluid accumulation and redistribution. Tissue hypoperfusion is another vital characteristic of AHF and should be promptly treated with appropriate interventions. In addition, recent clinical trials of novel therapeutic strategies have shown that heart failure management is ‘time sensitive’ and suggested that treatment selection based on individual aetiologies, triggers, and risk factor profiles could lead to better outcomes. In this review, we aim to describe the specifics of the ‘time‐sensitive’ approach by the clinical phenotypes, for example, pulmonary/systemic congestion and tissue hypoperfusion, wherein patients are classified based on pathophysiological conditions. This mechanistic classification, in parallel with the comprehensive risk assessment, has become a cornerstone in the management of patients with AHF and thus supports effective decision making by clinicians. We will also highlight how therapeutic modalities should be individualized according to each clinical phenotype.

The impact of the first 24 h of loop diuretic on kidney function in acute decompensated heart failure

BACKGROUND

Because of the uncertainty in the appropriate initial loop diuretic dose in acute decompensated heart failure (ADHF), the risk of acute kidney injury (AKI) is believed to be increased with the high dose of initial intravenous (IV) loop diuretic.

AIMS

The purpose of this study is to examine the impact of the first 24-h IV diuretic on kidney function in ADHF.

METHODS

A retrospective cohort study included patients with ADHF. These patients were divided into two groups: the first group received an initial total IV diuretic dose that was equal to or 2.5 times less than the home dose in the first 24 h (low dose), while the second group received 2.5 times more than the home dose in the first 24 h (high dose). The primary outcome was the incidence of developing AKI within 48 h of first IV diuretic. The secondary outcomes were total hospital length of stay and all-cause 30-day readmission rates.

RESULTS

A total of 252 patients were available for analysis; 172 patients received a low dose in the first 24 h, while 80 patients received a high dose. The incidence of AKI was higher in the high-dose group compared to that in the low-dose group (25% vs. 9.9%, P = 0.002). There was no significant difference between the two groups in terms of hospital stay and all-cause 30-day readmission.

CONCLUSION

In patients with ADHF, the initial high dose of IV loop diuretics is associated with an increased risk of developing AKI.

Diagnostic performance of congestion score index evaluated from chest radiography for acute heart failure in the emergency department: A retrospective analysis from the PARADISE cohort

BACKGROUND

Congestion score index (CSI), a semiquantitative evaluation of congestion on chest radiography (CXR), is associated with outcome in patients with heart failure (HF). However, its diagnostic value in patients admitted for acute dyspnea has yet to be evaluated.

METHODS AND FINDINGS

The diagnostic value of CSI for acute HF (AHF; adjudicated from patients' discharge files) was studied in the Pathway of dyspneic patients in Emergency (PARADISE) cohort, including patients aged 18 years or older admitted for acute dyspnea in the emergency department (ED) of the Nancy University Hospital (France) between January 1, 2015 and December 31, 2015. CSI (ranging from 0 to 3) was evaluated using a semiquantitative method on CXR in consecutive patients admitted for acute dyspnea in the ED. Results were validated in independent cohorts (N = 224). Of 1,333 patients, mean (standard deviation [SD]) age was 72.0 (18.5) years, 686 (51.5%) were men, and mean (SD) CSI was 1.42 (0.79). Patients with higher CSI had more cardiovascular comorbidities, more severe congestion, higher b-type natriuretic peptide (BNP), poorer renal function, and more respiratory acidosis. AHF was diagnosed in 289 (21.7%) patients. CSI was significantly associated with AHF diagnosis (adjusted odds ratio [OR] for 0.1 unit CSI increase 1.19, 95% CI 1.16-1.22, p < 0.001) after adjustment for clinical-based diagnostic score including age, comorbidity burden, dyspnea, and clinical congestion. The diagnostic accuracy of CSI for AHF was >0.80, whether alone (area under the receiver operating characteristic curve [AUROC] 0.84, 95% CI 0.82-0.86) or in addition to the clinical model (AUROC 0.87, 95% CI 0.85-0.90). CSI improved diagnostic accuracy on top of clinical variables (net reclassification improvement [NRI] = 94.9%) and clinical variables plus BNP (NRI = 55.0%). Similar diagnostic accuracy was observed in the validation cohorts (AUROC 0.75, 95% CI 0.68-0.82). The key limitation of our derivation cohort was its single-center and retrospective nature, which was counterbalanced by the validation in the independent cohorts.

CONCLUSIONS

In this study, we observed that a systematic semiquantified assessment of radiographic pulmonary congestion showed high diagnostic value for AHF in dyspneic patients. Better use of CXR may provide an inexpensive, widely, and readily available method for AHF triage in the ED.

Derivation and Validation of Clinical Prediction Models for Rapid Risk Stratification for Time-Sensitive Management for Acute Heart Failure

Early and rapid risk stratification of patients with acute heart failure (AHF) is crucial for appropriate patient triage and outcome improvements. We aimed to develop an easy-to-use, in-hospital mortality risk prediction tool based on data collected from AHF patients at their initial presentation. Consecutive patients’ data pertaining to 2006–2017 were extracted from the West Tokyo Heart Failure (WET-HF) and National Cerebral and Cardiovascular Center Acute Decompensated Heart Failure (NaDEF) registries (n = 4351). Risk model development involved stepwise logistic regression analysis and prospective validation using data pertaining to 2014–2015 in the Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure Syndrome (REALITY-AHF) (n = 1682). The final model included data describing six in-hospital mortality risk predictors, namely, age, systolic blood pressure, blood urea nitrogen, serum sodium, albumin, and natriuretic peptide (SOB-ASAP score), available at the time of initial triage. The model showed excellent discrimination (c-statistic = 0.82) and good agreement between predicted and observed mortality rates. The model enabled the stratification of the mortality rates across sixths (from 14.5% to <1%). When assigned a point for each associated factor, the integer score’s discrimination was similar (c-statistic = 0.82) with good calibration across the patients with various risk profiles. The models’ performance was retained in the independent validation dataset. Promptly determining in-hospital mortality risks is achievable in the first few hours of presentation; they correlate strongly with mortality among AHF patients, potentially facilitating clinical decision-making.

UMBRELLA protocol: systematic reviews of multivariable biomarker prognostic models developed to predict clinical outcomes in patients with heart failure

BACKGROUND

Heart failure (HF) is a chronic and common condition with a rising prevalence, especially in the elderly. Morbidity and mortality rates in people with HF are similar to those with common forms of cancer. Clinical guidelines highlight the need for more detailed prognostic information to optimise treatment and care planning for people with HF. Besides proven prognostic biomarkers and numerous newly developed prognostic models for HF clinical outcomes, no risk stratification models have been adequately established. Through a number of linked systematic reviews, we aim to assess the quality of the existing models with biomarkers in HF and summarise the evidence they present.

METHODS

We will search MEDLINE, EMBASE, Web of Science Core Collection, and the prognostic studies database maintained by the Cochrane Prognosis Methods Group combining sensitive published search filters, with no language restriction, from 1990 onwards. Independent pairs of reviewers will screen and extract data. Eligible studies will be those developing, validating, or updating any prognostic model with biomarkers for clinical outcomes in adults with any type of HF. Data will be extracted using a piloted form that combines published good practice guidelines for critical appraisal, data extraction, and risk of bias assessment of prediction modelling studies. Missing information on predictive performance measures will be sought by contacting authors or estimated from available information when possible. If sufficient high quality and homogeneous data are available, we will meta-analyse the predictive performance of identified models. Sources of between-study heterogeneity will be explored through meta-regression using pre-defined study-level covariates. Results will be reported narratively if study quality is deemed to be low or if the between-study heterogeneity is high. Sensitivity analyses for risk of bias impact will be performed.

DISCUSSION

This project aims to appraise and summarise the methodological conduct and predictive performance of existing clinically homogeneous HF prognostic models in separate systematic reviews.Registration: PROSPERO registration number CRD42019086990.

Diagnostic and prognostic values of the QRS-T angle in patients with suspected acute decompensated heart failure

AIMS

The aim of this study was to investigate the diagnostic and prognostic utility of the QRS-T angle, an electrocardiogram (ECG) marker quantifying depolarization-repolarization heterogeneity, in patients with suspected acute decompensated heart failure (ADHF).

METHODS AND RESULTS

We prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of ADHF. The QRS-T angle was automatically derived from a standard 12-lead ECG recorded at presentation. The primary diagnostic endpoint was a final adjudicated diagnosis of ADHF. The primary prognostic endpoint was all-cause mortality during 2 years of follow-up. Among the 1915 patients enrolled, those with higher QRS-T angles were older, were more commonly male, and had a higher rate of co-morbidities such as arterial hypertension, coronary artery disease, or chronic kidney disease. ADHF was the final adjudicated diagnosis in 1140 (60%) patients. The QRS-T angle in patients with ADHF was significantly larger than in patients with non-cardiac causes of dyspnoea {median 110° [inter-quartile range (IQR) 46-156°] vs. median 33° [IQR 15-57°], P < 0.001}. The diagnostic accuracy of the QRS-T angle as quantified by the area under the receiver operating characteristic curve (AUC) was 0.75 [95% confidence interval (CI) 0.73-0.77, P < 0.001], which was inferior to N-terminal pro-B-type natriuretic peptide (AUC 0.93, 95% CI 0.92-0.94, P < 0.001), but similar to that of high-sensitivity troponin T (AUC 0.78, 95% CI 0.76-0.80, P = 0.09). The AUC of the QRS-T angle for discrimination between ADHF and non-cardiac dyspnoea remained similarly high in subgroups of patients known to be diagnostically challenging, including patients older than 75 years [0.71 (95% CI 0.67-0.74)], renal failure [0.79 (95% CI 0.71-0.87)], and atrial fibrillation at presentation [0.68 (95% CI 0.60-0.76)]. Mortality rates according to QRS-T angle tertiles were 4%, 6%, and 10% after 30 days (P < 0.001) and 24%, 31%, and 43% after 2 years (P < 0.001). After adjustment for clinical, laboratory, and ECG parameters, the QRS-T angle remained an independent predictor for 2 year mortality with a 4% increase in mortality for every 20° increase in QRS-T angle (P = 0.02).

CONCLUSIONS

The QRS-T angle is a readily available and inexpensive marker that can assist in the discrimination between ADHF and non-cardiac causes of acute dyspnoea and may aid in the risk stratification of these patients.

Early Point-of-Care Ultrasound Assessment for Medical Patients Reduces Time to Appropriate Treatment: A Pilot Randomized Controlled Trial

Numerous studies emphasize the diagnostic importance of point-of-care ultrasound (POCUS), but the level of evidence remains low as most data are gathered from observational studies. We conducted a pilot, randomized controlled trial to evaluate the effect of POCUS exam on medical patient's management and clinical outcomes. Patients presenting with chest pain or dyspnea were enrolled and randomly allocated to an early POCUS scan group and a control group. POCUS assessment, within 24 h of internal ward admission, was conducted only for the intervention group. The primary outcome was time to correct diagnosis. Secondary outcomes included time to appropriate treatment, POCUS-related rate of primary diagnosis alteration and new clinically relevant findings and time to hospital discharge. Sixty patients were enrolled. Thirty patients were randomly allocated to each study arm. The POCUS exam revealed clinically relevant findings among 79% of patients and led to alteration of the primary diagnosis among 28% of patients. Time to appropriate treatment was significantly shorter among patients in the POCUS group compared with the control group (median time of 5 h [95% confidence interval: 0.5-9] vs. 24 h [95% CI: 19-29] p = 0.014). The time needed to achieve correct diagnosis by the primary team was shorter in the POCUS group compared with the control group, yet it did not reach statistical significance (median time of 24 h [95% CI: 18-30] vs. 48 h [95% CI: 20-76], p = 0.12). These results indicate that POCUS assessment conducted early among patients with dyspnea or chest pain improves diagnostic accuracy and shortens significantly the time to appropriate treatment.

Impact of brain natriuretic peptide reduction on the worsening renal function in patients with acute heart failure

Aims

The prognostic impact of worsening renal function (WRF) in patients with acute heart failure (AHF) remains under debate. Successful decongestion might offset the negative impact of WRF, but little is known about indicators of successful decongestion in the very acute phase of AHF. We hypothesized that decongestion as evaluated by the percent reduction in brain natriuretic peptide (BNP) could identify relevant prognostic implications of WRF in the very acute phase of AHF.

Methods and results

Data on 907 consecutive hospitalized patients with AHF in the REALITY-AHF study (age: 78±12 years; 55.1% male) were analyzed. Creatinine and BNP were measured at baseline and 48 hours from admission. WRF was defined as an increase in creatinine >0.3 mg at 48 hours from admission. The primary endpoint was 1-year all-cause mortality. Patients were divided into four groups according to the presence/absence of WRF and a BNP reduction higher/lower than the median: no-WRF/higher-BNP-reduction (n = 390), no-WRF/lower-BNP-reduction (n = 397), WRF/higher-BNP-reduction (n = 63), and WRF/lower-BNP-reduction groups (n = 57). Kaplan-Meier curve analysis showed that the WRF/lower-BNP-reduction group had a worse prognosis than the other groups. In a Cox regression analysis, only the WRF/lower-BNP-reduction group had higher mortality compared to the no-WRF/higher-BNP-reduction group (hazard ratio: 3.34, p<0.001).

Conclusion

In the very acute phase of AHF, BNP reduction may aid in identifying relevant prognostic significance of WRF.

Improvement of hyponatremia is associated with lower mortality risk in patients with acute decompensated heart failure: a meta-analysis of cohort studies

Hyponatremia at admission is predictive of poor prognosis in patients with acute decompensated heart failure (ADHF). We performed a meta-analysis of cohort studies to evaluate whether improvement of hyponatremia is associated with improved survival in patients with ADHF and hyponatremia. Relevant studies were identified through systematic search of PubMed and Embase. A random-effect model was used to pool the results. Predefined subgroup analyses were performed to explore the source of heterogeneity. Five thousand seven hundred fourteen patients with ADHF and hyponatremia from eight cohort studies were included. Results showed that improvement of hyponatremia during hospitalization was associated with lower risk of all-cause mortality (RR = 0.65, 95% CI 0.53 to 0.80, p < 0.001) as compared with those without improvement of hyponatremia. Results of subgroup analyses indicated that improvement of hyponatremia was associated with more remarkable changes of short-term (within 3 months after discharge) mortality (RR = 0.54) as compared with long-term mortality (RR = 0.74). Other factors such as study design, sample size, and heart failure subtypes did not affect the association. This was further confirmed by the meta-analysis of studies with multivariate analysis, which also suggested an association between improved hyponatremia and lower risk of all-cause mortality in ADHF patients (adjusted RR = 0.63, 95% CI 0.43 to 0.92, p = 0.02; I² = 63%). These results suggested that improvement of hyponatremia in ADHF patients is associated with lower mortality risk during follow-up, particularly for the short-term mortality.

Emerging microRNA biomarkers for acute kidney injury in acute decompensated heart failure

Acute decompensated heart failure (ADHF) is associated with a high incidence of acute kidney injury (AKI), an abrupt loss of kidney function associated with a near doubling of mortality at 1 year. In addition to the direct threat acute HF itself poses to kidney function, the beneficial effects of commonly prescribed HF treatments must be weighed against their potentially adverse effects on glomerular perfusion. Consequently, there is an urgent need to identify early markers for AKI in ADHF to facilitate timely implementation of supportive measures to minimize kidney damage and improve outcomes. The recent recognition of the diagnostic potential of circulating microRNAs presents the potential to address this gap if microRNAs specific for AKI can be identified in serial plasma, serum and/or urine samples from well-phenotyped cohorts of ADHF patients, including a proportion with AKI. This review summarizes emerging circulating diagnostic and prognostic microRNA biomarkers (serum, plasma or urine) in HF and AKI.

Towards Point-of-Care Heart Failure Diagnostic Platforms: BNP and NT-proBNP Biosensors

Heart failure is a class of cardiovascular diseases that remains the number one cause of death worldwide with a substantial economic burden of around $18 billion incurred by the healthcare sector in 2017 due to heart failure hospitalization and disease management. Although several laboratory tests have been used for early detection of heart failure, these traditional diagnostic methods still fail to effectively guide clinical decisions, prognosis, and therapy in a timely and cost-effective manner. Recent advances in the design and development of biosensors coupled with the discovery of new clinically relevant cardiac biomarkers are paving the way for breakthroughs in heart failure management. Natriuretic neurohormone peptides, B-type natriuretic peptide (BNP) and N-terminal prohormone of BNP (NT-proBNP), are among the most promising biomarkers for clinical use. Remarkably, they result in an increased diagnostic accuracy of around 80% owing to the strong correlation between their circulating concentrations and different heart failure events. The latter has encouraged research towards developing and optimizing BNP biosensors for rapid and highly sensitive detection in the scope of point-of-care testing. This review sheds light on the advances in BNP and NT-proBNP sensing technologies for point-of-care (POC) applications and highlights the challenges of potential integration of these technologies in the clinic. Optical and electrochemical immunosensors are currently used for BNP sensing. The performance metrics of these biosensors-expressed in terms of sensitivity, selectivity, reproducibility, and other criteria-are compared to those of traditional diagnostic techniques, and the clinical applicability of these biosensors is assessed for their potential integration in point-of-care diagnostic platforms.

Pre-hospital management protocols and perceived difficulty in diagnosing acute heart failure

Aim

To illustrate the pre‐hospital management arsenals and protocols in different EMS units, and to estimate the perceived difficulty of diagnosing suspected acute heart failure (AHF) compared with other common pre‐hospital conditions.

Methods and results

A multinational survey included 104 emergency medical service (EMS) regions from 18 countries. Diagnostic and therapeutic arsenals related to AHF management were reported for each type of EMS unit. The prevalence and contents of management protocols for common medical conditions treated pre‐hospitally was collected. The perceived difficulty of diagnosing AHF and other medical conditions by emergency medical dispatchers and EMS personnel was interrogated.

Ultrasound devices and point‐of‐care testing were available in advanced life support and helicopter EMS units in fewer than 25% of EMS regions. AHF protocols were present in 80.8% of regions. Protocols for ST‐elevation myocardial infarction, chest pain, and dyspnoea were present in 95.2, 80.8, and 76.0% of EMS regions, respectively. Protocolized diagnostic actions for AHF management included 12‐lead electrocardiogram (92.1% of regions), ultrasound examination (16.0%), and point‐of‐care testings for troponin and BNP (6.0 and 3.5%). Therapeutic actions included supplementary oxygen (93.2%), non‐invasive ventilation (80.7%), intravenous furosemide, opiates, nitroglycerine (69.0, 68.6, and 57.0%), and intubation 71.5%. Diagnosing suspected AHF was considered easy to moderate by EMS personnel and moderate to difficult by emergency medical dispatchers (without significant differences between de novo and decompensated heart failure). In both settings, diagnosis of suspected AHF was considered easier than pulmonary embolism and more difficult than ST‐elevation myocardial infarction, asthma, and stroke.

Conclusions

The prevalence of AHF protocols is rather high but the contents seem to vary. Difficulty of diagnosing suspected AHF seems to be moderate compared with other pre‐hospital conditions.

Loop Diuretics-Analysis of Efficacy Data for the Perioperative Clinician

HEART FAILURE (HF) is one of the most common causes of hospitalization in the United States. Loop diuretics (LD) are the mainstay of treatment in the management of acute and chronic HF. Although they generally are effective in relieving symptoms and reducing congestion, LD have not been shown to significantly affect morbidity and mortality. The initial decongestion strategy for management of HF is likely to be an LD, with evidence suggesting that an initial "high-dose" strategy either by twice-daily bolus injection or by continuous infusion is likely to be more successful than an initial lower dose in respect to relief of symptoms but at the expense of increased worsening of renal function. This review focuses on the current state of evidence of different strategies related to the use of LD in the treatment of congestive symptoms in critically ill patients and presents a summary of the body of evidence regarding dosages, timing, and different diuretic agents.

Biomarkers in diagnosing and treatment of acute heart failure

Acute heart failure (AHF) is a complex disorder involving different pathophysiological pathways. In recent years, there is an increased focus on biomarkers that help with diagnosis, risk stratification and disease monitoring of AHF. Finding a reliable set of biomarkers not only improves morbidity and mortality but it can also potentially reveal the new targets of therapy. In this paper, we have reviewed the biomarkers found useful for the diagnosis as well as for risk stratification and prognostication in patients with AHF. We have discussed the established biomarkers for AHF including cardiac troponins and natriuretic peptides and emerging biomarkers including adiponectin, mi-RNA, sST2, Gal-3, MR-proADM, OPG, CT-proAVP and H-FABP for the purposes of making diagnosis, their use as a guide of therapy or for determination of prognosis.

Inpatient management of acute decompensated heart failure

Acute decompensated heart failure (ADHF) is the leading cause of hospital admissions in patients older than 65 years. These hospitalisations are highly risky and are associated with poor outcomes, including rehospitalisation and death. The management of ADHF is drastically different from that of chronic heart failure as inpatient treatment consists primarily of haemodynamic stabilisation, symptom relief and prevention of short-term morbidity and mortality. In this review, we will discuss the strategies put forth in the most recent American College of Cardiology/American Heart Association and Heart Failure Society of America guidelines for ADHF as well as the evidence behind these recommendations.

Diagnostic accuracy and temporal impact of ultrasound in patients with dyspnea admitted to the emergency department

OBJECTIVE

Few studies have prospectively evaluated the diagnostic accuracy and temporal impact of ultrasound in the emergency department (ED) in a randomized manner. In this study, we aimed to perform a randomized, standard therapy controlled evaluation of the diagnostic accuracy and temporal impact of a standardized ultrasound strategy, versus standard care, in patients presenting to the ED with acute dyspnea.

METHODS

The patients underwent a standardized ultrasound examination that was blinded to the team caring for the patient. Ultrasound results remained blinded in patients randomized to the treating team but were unblinded in the interventional cohort. Scans were performed by trained emergency physicians. The gold standard diagnosis (GSDx) was determined by two physicians blinded to the ultrasound results. The same two physicians reviewed all data >30 days after the index visit.

RESULTS

Fifty-nine randomized patients were enrolled. The mean±standard deviation age was 54.4±11 years, and 37 (62%) were male. The most common GSDx was acute heart failure with reduced ejection fraction in 13 (28.3%) patients and airway diseases such as acute exacerbation of asthma or chronic obstructive pulmonary disease in 10 (21.7%). ED diagnostic accuracy, as compared to the GSDx, was 76% in the ultrasound cohort and 79% in the standard care cohort (P=0.796). Compared with the standard care cohort, the final diagnosis was obtained much faster in the ultrasound cohort (mean±standard deviation: 12±3.2 minutes vs. 270 minutes, P<0.001).

CONCLUSION

A standardized ultrasound approach is equally accurate, but enables faster ED diagnosis of acute dyspnea than standard care.

Diagnosis and Management of Acute Heart Failure in Sub-Saharan Africa

PURPOSE OF REVIEW

Acute heart failure (AHF) is a common emergency presentation in Sub-Saharan Africa (SSA). In the current review, we present the most recent data on the epidemiology of AHF in SSA and discuss recommended approaches to management in resource-limited settings, with a particular focus on primary and secondary facilities (e.g., health centers and district hospitals), where these patients often present.

RECENT FINDINGS

AHF in SSA is most often due to hypertension, cardiomyopathies, and rheumatic heart disease. The etiology of AHF may be different in rural as compared with urban settings. Diagnostic tools for AHF are often lacking in SSA, especially at the first-level facilities. Point-of-care ultrasound (POCUS) and biomarker tests, such as brain natriuretic peptide (BNP), offer promise in helping to mitigate diagnostic challenges. POCUS can also help distinguish among types of heart failure and prompt the correct treatment strategy. Many of the drugs and equipment commonly used to treat AHF in resource-rich settings are lacking in SSA. However, some adaptations of commonly available materials may provide temporary alternatives. The epidemiology of AHF in SSA differs from that of high-income settings. Management of AHF at the first-level facility in SSA is an important and understudied problem. Simplified diagnostic and treatment algorithms rooted in knowledge of the local epidemiology should be developed and tested as part of broader efforts to combat cardiovascular disease in SSA.

N-Terminal Pro-B-Type Natriuretic Peptide in the Emergency Department: The ICON-RELOADED Study

BACKGROUND

Contemporary reconsideration of diagnostic N-terminal pro-B-type natriuretic peptide (NT-proBNP) cutoffs for diagnosis of heart failure (HF) is needed.

OBJECTIVES

This study sought to evaluate the diagnostic performance of NT-proBNP for acute HF in patients with dyspnea in the emergency department (ED) setting.

METHODS

Dyspneic patients presenting to 19 EDs in North America were enrolled and had blood drawn for subsequent NT-proBNP measurement. Primary endpoints were positive predictive values of age-stratified cutoffs (450, 900, and 1,800 pg/ml) for diagnosis of acute HF and negative predictive value of the rule-out cutoff to exclude acute HF. Secondary endpoints included sensitivity, specificity, and positive (+) and negative (-) likelihood ratios (LRs) for acute HF.

RESULTS

Of 1,461 subjects, 277 (19%) were adjudicated as having acute HF. The area under the receiver-operating characteristic curve for diagnosis of acute HF was 0.91 (95% confidence interval [CI]: 0.90 to 0.93; p < 0.001). Sensitivity for age stratified cutoffs of 450, 900, and 1,800 pg/ml was 85.7%, 79.3%, and 75.9%, respectively; specificity was 93.9%, 84.0%, and 75.0%, respectively. Positive predictive values were 53.6%, 58.4%, and 62.0%, respectively. Overall LR+ across age-dependent cutoffs was 5.99 (95% CI: 5.05 to 6.93); individual LR+ for age-dependent cutoffs was 14.08, 4.95, and 3.03, respectively. The sensitivity and negative predictive value for the rule-out cutoff of 300 pg/ml were 93.9% and 98.0%, respectively; LR- was 0.09 (95% CI: 0.05 to 0.13).

CONCLUSIONS

In acutely dyspneic patients seen in the ED setting, age-stratified NT-proBNP cutpoints may aid in the diagnosis of acute HF. An NT-proBNP <300 pg/ml strongly excludes the presence of acute HF.

The time-to-treatment concept in acute heart failure: Lessons and implications from REALITY-AHF

Acute heart failure (AHF) is a clinical syndrome with devastating prognosis. Despite considerable improvements in the treatment of chronic heart failure, most trials of new drugs for AHF, such as vasodilators, inotropes, and diuretics, have failed to show a prognostic benefit. Therefore, pharmacological treatment of AHF has changed very little, and loop diuretics have remained a cornerstone drug for decades. One of the emerging factors possibly playing an important role in AHF management is the time course of treatment. Several recent retrospective studies have highlighted the importance of early treatment in AHF; however, at the time, support from a prospective study with an adequate number of enrolled patients was lacking. The Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure (REALITY-AHF) was the first prospective study to specifically focus on the time course of treatment in the very acute phase and its prognostic implication in patients with AHF. Data from the REALITY-AHF revealed that early treatment with intravenous furosemide is significantly associated with lower in-hospital mortality. Although pathophysiological background of this association remains to be investigated, the time course of treatment may be a critical component of AHF treatment, and it will be important to take this factor into account in future clinical studies on AHF.

Early Treatment in Emergency Department Patients with Acute Heart Failure: Does Time Matter?

PURPOSE OF REVIEW

Acute heart failure accounts for over one million hospital discharges annually. Current guidelines suggest treatments for AHF should begin "without delay" but this time interval has not been clearly defined.

RECENT FINDINGS

Data suggest that certain treatments such as earlier treatment with diuretics and vasodilators may improve patient symptom relief, morbidity, and mortality. Secondary analyses of clinical trials of novel treatments under development have not shown similar results. The data are equivocal regarding the impact of early treatment in AHF on in-hospital and long-term morbidity and mortality. Improved clinical trial designs will help answer when and if "early" treatment should begin and whether it impacts short- and long-term outcomes in AHF.

KSHF Guidelines for the Management of Acute Heart Failure: Part II. Treatment of Acute Heart Failure

The prevalence of heart failure (HF) is on the rise due to the aging of society. Furthermore, the continuous progress and widespread adoption of screening and diagnostic strategies have led to an increase in the detection rate of HF, effectively increasing the number of patients requiring monitoring and treatment. Because HF is associated with substantial rates of mortality and morbidity, as well as high socioeconomic burden, there is an increasing need for developing specific guidelines for HF management. The Korean guidelines for the diagnosis and management of chronic HF were introduced in March 2016. However, chronic and acute HF represent distinct disease entities. Here, we introduce the Korean guidelines for the management of acute HF with reduced or preserved ejection fraction. Part II of this guideline covers the treatment of acute HF.