Timing on echocardiography and blood laboratory test is important for future outcome association in hospitalized heart failure patients

Left ventricular systolic function affects right atrial pressure as prognosticator in patients with heart failure

The effect of the left ventricular ejection fraction (LVEF) on the prognostic impact of the right atrial pressure (RAP) in patients with heart failure (HF) requires clarification. We aimed to investigate whether LVEF affects the prognostic impact of RAP estimated from inferior vena cava (IVC) measurements in patients hospitalized with HF. Initially, this observational study included 1349 consecutive patients urgently hospitalized with HF. After patient exclusions, 506 and 484 patients with reduced (< 40%) and with non-reduced (≥ 40%) LVEF, respectively, were assigned according to maximum IVC diameter and its collapsibility, to the Normal-RAP (diameter ≤ 2.1 cm; collapsibility ≥ 50%), High-RAP (diameter > 2.1 cm; collapsibility < 50%), and Intermediate-RAP (others) groups. The endpoint comprised cardiovascular death after discharge and hospitalization for HF recurrence. During the observation period, 247 (49%) patients with LVEF < 40% and 178 (37%) patients with LVEF ≥ 40% experienced the endpoint. The patient subgroups with LVEF < 40% had comparable event rates (ptrend = 0.10). The High-RAP subgroup with LVEF ≥40% had a higher event rate than the other subgroups (p < 0.001). The RAP independently predicted the endpoint in patients with LVEF ≥ 40% (hazard ratio: 1.26; 95% confidence interval: 1.01-1.59). The interaction between the RAP groups and LVEF regarding the primary endpoint was significant (pinteraction = 0.007). Stratifying patients with HF according to IVC measurements may predict the post-discharge cardiovascular prognoses of patients with non-reduced LVEF, but not that of patients with reduced LVEF.

Prognostic impact of right ventricular function affected by pulmonary hypertension in hospitalized heart failure patients

BACKGROUND

Pulmonary hypertension (PH) may affect right ventricular (RV) function; however, the prognostic implications of RV function in patients with heart failure and PH remain unclear. We aimed to investigate the impact of RV function on the prognosis of hospitalized heart failure patients with and without PH.

METHODS

This observational study initially included 1,349 consecutive hospitalized heart failure patients. After excluding patients who died in hospital, whose left ventricular (LV) function was preserved, and whose echocardiography data were incomplete, 573 patients with heart failure and reduced LV ejection fractions (HFrEF) were analyzed. The patients were grouped according to RV dysfunction that was defined as an RV-tissue Doppler imaging systolic velocity (RV-TDI s') of ≤9.5 cm/s. The primary endpoint was a composite of cardiovascular death and rehospitalization as a consequence of heart failure.

RESULTS

Overall, the patients with reduced RV function had significantly higher event rates than those with preserved RV function (log-rank test p = 0.01). This prognostic impact was observed in the patients with PH (p = 0.001) and was not evident among the patients without PH (p = 0.39). In the patients with PH, reduced RV function independently predicted the prognosis after adjusting for the covariates (adjusted hazard ratio: 3.12; 95% confidence interval: 1.44 to 6.73).

CONCLUSION

RV dysfunction that was estimated during hospitalization using the RV-TDI s', which is a simply determined index, may predict clinical outcomes in hospitalized patients with HFrEF and PH after discharge, but not in those without PH.

Prognosticators of All-Cause Mortality in Patients With Heart Failure With Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) represents ∼50% of all cases of congestive heart failure (CHF) with prevalence expected to increase with aging of the population. We performed an observational study of all patients admitted to 3 hospitals in the ExcelaHealth care system, Greensburg, PA, with a primary diagnosis of HFpEF heart failure exacerbation between January 2014 and January 2017. Demographic data, laboratory results, and echocardiograms performed closest to index hospitalization were collected. A total of 487 patients were admitted with a primary diagnosis of CHF exacerbation and HFpEF, with a mean age of 80.5 years (±10.9), 62% women and predominantly Caucasian (98.8%). Over a median follow-up of 21.7 months, 246 patients died with an all-cause mortality rate of 51.3%. Receiver operator curves were generated for multiple continuous variables to identify optimal cut-off values Kaplan-Meir survival curves were then generated. Clinical factors were tested by univariate Cox regression modeling, with significant factors entered into a step-wise multivariate model. Our modeling identified age>80 years, serum albumin level<3.2 g/dl, N-terminal pro-brain natriuretic peptide (NT-proBNP) >5,000 pg/mL and medial E/e'≥20 as significant, independent predictors of all-cause mortality (p-value <0.0001). Surprisingly, lack of a diagnosis of hypertension was associated with significantly increased mortality risk. In a community-based sample of HFpEF patients, we identified multiple factors that were strong, independent predictors of all-cause mortality that can be easily applied in a clinical setting.

The risk factors for delayed recovery in patients with cardiopulmonary bypass: Why should we care?

Cardiopulmonary bypass (CPB) is very commonly performed among the cardiovascular surgeries, and delayed recovery (DR) is a kind of serious complications in patients with CPB. It is necessary to assess the risk factors for DR in patients with CPB, to provide evidence into the management of CPB patients.Patients undergoing CPB in our hospital from January 2018 to March 2020 were included. Cases that consciousness has not recovered 12 hours after anesthesia were considered as DR. The preoperative and intraoperative variables of CPB patients were collected and analyzed. Logistic regressions were conducted to analyze the potential influencing factor.A total of 756 CPB patients were included, and the incidence of DR was 9.79%. There were significant differences on the age, aspartate aminotransferase (AST), glutamic pvruvic transaminase (ALT), blood urea nitrogen (BUN), and serum creatinine (SCr) between patients with and without DR (all P < .05); there were no significant differences in the types of surgical procedure (all P > .05); there were significant differences on the duration of CPB, duration of aortic cross clamp (ACC), duration of surgery, minimum nasopharyngeal temperature, and transfusion of packed red blood cells between patients with and without DR (all P < .05). Logistic regression analysis indicated that duration of CPB ≥132 minutes (odds ratio [OR] 4.12, 1.02-8.33), BUN ≥9 mmol/L (OR 4.05, 1.37-8.41), infusion of red blood cell suspension (OR 3.93, 1.25-7.63), duration of surgery ≥350 minutes (OR 3.17, 1.24-5.20), age ≥6 (OR 3.01, 1.38-6.84) were the independent risk factors for DR in patients with CPB (all P < .05).Extra attention and care are needed for those CPB patients with duration of CPB ≥132 minutes, BUN ≥9 mmol/L, infusion of red blood cell suspension, duration of surgery ≥350 minutes, and age ≥60.

Optimal timing of echocardiography for heart failure inpatients in Japanese institutions: OPTIMAL Study

AIMS

Guidelines for the diagnosis and treatment of acute and chronic heart failure (HF) provided by the European Society of Cardiology state that echocardiography is recommended for the assessment of the myocardial structure and function of subjects with suspected HF including HF with reduced (HFrEF), mid-range (HFmrEF), and preserved ejection fraction (HFpEF) as class I of recommendation and level C of evidence. However, the impact of timing of echocardiography on survival for hospitalized HF patients or the prevalence of echocardiography during their stay has not yet been fully investigated. Therefore, we designed and conducted a prospective multicentre study, Optimal Timing of Echocardiography for Heart Failure Inpatients in Japanese Institutions (OPTIMAL) study, to investigate and evaluate the prevalence of echocardiography during the in-hospital stay of HF patients, and the impact of timing of echocardiography on their survival.

METHODS AND RESULTS

OPTIMAL was based on a nationwide, prospective, multicentre registry at 10 institutions in Japan endorsed by the Japanese Society of Echocardiography. A total of 601 patients hospitalized with HF were enrolled between August 2016 and July 2018 at the participating centres. Their mean age was 73.9 ± 13.0 years, left ventricular ejection fraction was 37.0% (26.0-50.0), and 256 patients (42.6%) were female. Admission echocardiography (admission echo) was categorized as either standard or point-of-care echocardiography performed within 3 days of admission, as was pre-discharge echocardiography (pre-discharge echo) within 3 days of discharge. The primary endpoint was defined as cardiovascular death over a median follow-up period of 18.9 months (9.3-26.5 months). Admission echo was performed for 476 patients (79.2%) and pre-discharge echo for 216 patients (35.9%). The primary endpoint of cardiovascular death occurred in 65 patients (10.8%). Kaplan-Meier curve findings indicated that survival of patients with pre-discharge echo was significantly better than that of patients without it (log-rank P < 0.001), and the same findings were obtained for patients with HFrEF, HFmrEF, and HFpEF. However, survival of patients with and without admission echo was similar (log-rank P = 0.33).

CONCLUSIONS

This OPTIMAL study prospectively showed the importance of pre-discharge echo for hospitalized HF patients. Careful attention is needed regarding the haemodynamic status of HF patients by administering pre-discharge echo to avoid HF re-hospitalization after discharge, and pre-discharge echo may provide additional information for deciding the appropriate discharge time. Our findings may thus offer a new insight into the management of hospitalized HF patients.

[Why not integrate the spectral tissue Doppler E/(e'xs') in the multiparametric assessment of cardiovascular diseases by transthoracic Doppler echocardiography?]

Assessment of left ventricular diastolic function by transthoracic Doppler echocardiography is based on a multiparametric approach which includes the spectral tissue Doppler-derived E/e'. Recently, a new Doppler index, E/(e'xs'), which combines E/e' with a spectral tissue Doppler-derived marker of systolic function, s', has been proposed in noninvasive assessment of left ventricular myocardial dysfunction. Current literature provides evidence that E/(e'xs') has good correlation with NT proBNP levels and invasive left ventricular end-diastolic pressure, both used as markers of left ventricular myocardial dysfunction, irrespective of left ventricular ejection fraction and wall motion abnormalities. More specifically, E/(e'xs') has good diagnostic accuracy in patients with intermediate values for E/e' (8 to 15). Average E/(e'xs')>1.6 is reported to predict invasive left ventricular end-diastolic pressure>15mmHg with a sensitivity of 86% and a specificity of 85%. Current literature provides evidence that E/(e'xs') could offer better prognostic information than E/e' in patients with systolic heart failure and heart failure with normal ejection fraction, as well as in patients with asymptomatic heart disease. A few clinical studies also suggest that E/(e'xs') could predict recurrence of atrial fibrillation after cardioversion and left ventricular remodeling after acute myocardial infarction. Further experimental and clinical investigation is critically needed to determine the role of this under-recognized tissue Doppler index in noninvasive assessment of cardiovascular diseases, in particular heart failure with normal ejection fraction.