Multiparametric approach to congestion for predicting long-term survival in heart failure

Cardiac power output associated with hospitalization and mortality in coronary artery disease patients at stage B heart failure

Background

Cardiac power output (CPO) predicts outcomes in advanced heart failure (HF) and cardiogenic shock, but its role in early HF stages is unclear. This study assessed the prognostic value of CPO in coronary artery disease patients with asymptomatic left ventricular systolic dysfunction (ALVSD) at stage B HF.

Methods

We conducted a retrospective analysis of coronary artery disease patients who underwent coronary and pulmonary artery catheterization between 2006 and 2016. Stage B HF with ALVSD was defined as left ventricular ejection fraction < 50 %, without HF symptoms, signs, or prior HF hospitalization. CPO was derived from invasive hemodynamic parameters. Endpoints included HF hospitalization, cardiovascular mortality, and all-cause mortality over a 5-year follow-up.

Results

A total of 783 coronary artery disease patients with ALVSD at stage B HF were enrolled. Incidence rates (per 1000 person-years) were 13.9 for HF hospitalization, 14.5 for cardiovascular mortality, and 23.7 for all-cause mortality.Multivariate analysis adjusting for covariates demonstrated that CPO was independent associated with all endpoints. Patients with a low CPO (<0.97 Watts) were at significantly higher risk for HF hospitalization (adjusted hazard ratio [HR]: 4.04; 95 % CI: 1.53 - 10.6; p = 0.005), cardiovascular mortality (adjusted HR: 2.73; 95 % CI: 1.19 - 6.27; p = 0.018), and all-cause mortality (adjusted HR: 1.86; 95 % CI: 1.05 - 3.30; p = 0.035) compared to those with higher CPO, regardless of subgroup classification.

Conclusion

Resting CPO in patients with ALVSD is significantly associated with adverse events, including HF hospitalization and mortality, highlighting its value in early-stage HF management.

Noninvasive biometric monitoring technologies for patients with heart failure

Heart failure remains one of the leading causes of mortality and hospitalizations in the US that not only impacts quality of life but also poses a significant public health burden. The majority of affected patients are admitted with signs and symptoms of congestion. Despite the initial enthusiasm, traditional remote monitoring strategies focusing primarily on weight gain failed to improve clinical outcomes. Implantable pulmonary artery pressure sensors provide earlier and actionable data, but most patients would favor forgoing an invasive procedure in favor of an alternative, non-invasive monitoring platform. Several devices utilizing different combinations of multiparameter monitoring to reliably detect congestion have recently been developed and are undergoing testing in the clinical setting. Combining these sensors with the power of artificial intelligence and machine learning has the potential to revolutionize remote patient monitoring and early congestion detection and to facilitate timely interventions by the care team to prevent hospitalization. This manuscript provides an objective review of novel, noninvasive, multiparameter remote monitoring platforms that may be tailored to individual heart failure phenotypes, aiming to improve quality of life and survival.

Facilities in Molecular Biomarkers in Cardiology

This Special Issue of Biomolecules, entitled "Molecular Biomarkers in Cardiology 2022-2023", presents a comprehensive collection of research and reviews exploring the rapidly evolving field of cardiovascular biomarkers [...].

Bioelectrical impedance vector analysis is different according to the comorbidity burden in post-acute myocardial infarction

BACKGROUND

The prevalence of a high comorbidity burden in patients who suffered an acute myocardial infarction (AMI) is increasing with the aging population, and the nutrition status also may be a predictor of clinical outcomes for these patients. This study aimed to investigate the relationship between the comorbidity burden and the characteristics of the bioelectrical impedance vector analysis (BIVA) in patients post-AMI.

METHODS

This prospective observational cohort study was conducted with adult patients who were hospitalized with AMI. Pre-existing comorbidities were assessed by the Charlson comorbidity index (CCI) adjusted by age, and anthropometric and BIVA characteristics were evaluated after the hemodynamic stabilization. All patients were followed-up until hospital discharge, and their length of stay was observed.

RESULTS

A total of 184 patients (75% were males; mean age, 60.2 ± 12.3 years) were included. The most common comorbidities were dyslipidemia (73.9%), hypertension (62%), and type 2 diabetes (34.2%). A higher CCI (≥3) was associated with sex (P = 0.008) and age (P < 0.001). Regarding BIVA, statistically significant differences were detected between sex (P < 0.001), age (P < 0.001), and CCI (P = 0.003), with longer vectors in female, older adults, and those with CCI ≥ 3.

CONCLUSION

Finding a relationship between BIVA and CCI suggests the first identified coherent differences, potentially correlated with diseases, representing a first contribution to support this type of assessment. Therefore, with BIVA, healthcare professionals may monitor abnormalities and adopt preventive nutrition care measures on patients post-AMI to improve their clinical status.

The Worsening of Heart Failure with Reduced Ejection Fraction: The Impact of the Number of Hospital Admissions in a Cohort of Patients

BACKGROUND

Worsening heart failure (WFH) includes heart failure (HF) hospitalisation, representing a strong predictor of mortality in patients with heart failure with reduced ejection fraction (HFrEF). However, there is little evidence analysing the impact of the number of previous HF admissions. Our main objective was to analyse the clinical profile according to the number of previous admissions for HF and its prognostic impact in the medium and long term.

METHODS

A retrospective study of a cohort of patients with HFrEF, classified according to previous admissions: cohort-1 (0-1 previous admission) and cohort-2 (≥2 previous admissions). Clinical, echocardiographic and therapeutic variables were analysed, and the medium- and long-term impacts in terms of hospital readmissions and cardiovascular mortality were assessed. A total of 406 patients were analysed.

RESULTS

The mean age was 67.3 ± 12.6 years, with male predominance (73.9%). Some 88.9% (361 patients) were included in cohort-1, and 45 patients (11.1%) were included in cohort-2. Cohort-2 had a higher proportion of atrial fibrillation (49.9% vs. 73.3%; p = 0.003), chronic kidney disease (36.3% vs. 82.2%; p < 0.001), and anaemia (28.8% vs. 53.3%; p = 0.001). Despite having similar baseline ventricular structural parameters, cohort-1 showed better reverse remodelling. With a median follow-up of 60 months, cohort-1 had longer survival free of hospital readmissions for HF (37.5% vs. 92%; p < 0.001) and cardiovascular mortality (26.2% vs. 71.9%; p < 0.001), with differences from the first month.

CONCLUSIONS

Patients with HFrEF and ≥2 previous admissions for HF have a higher proportion of comorbidities. These patients are associated with worse reverse remodelling and worse medium- and long-term prognoses from the early stages, wherein early identification is essential for close follow-up and optimal intensive treatment.

Blood urea nitrogen to creatinine ratio and long-term survival in patients with chronic heart failure

OBJECTIVES

To explore the correlation between Blood urea nitrogen to creatinine ratio (BUN/Scr ratio) and prognosis of patients with chronic heart failure complicated with renal injury.

METHODS

A retrospective analysis of 504 patients hospitalized in Guang 'anmen Hospital, Chinese Academy of Traditional Chinese Medicine from March 2006 to June 2014 was conducted. The baseline data were analyzed, and the cutoff value was obtained by receiver operator characteristic curve (ROC) analysis, according to the cutoff value, all the participants were divided into two groups, BUN/Scr < 19.37 group (280 cases) and BUN/Scr ≥ 19.37 group (224 cases). The main end point was defined as all-cause death. The long-term mortality of the two groups was evaluated, and Kaplan-Meier survival curve was drawn. Univariate analysis was performed on all the variables affecting the patient's prognosis, and the variables with P < 0.05 were put into Cox regression model, and subgroup analysis was performed on the variables that might affect the patient's prognosis.

RESULTS

The baseline data of 504 patients were analyzed and found that the median follow up was 683. Through ROC analysis of 504 subjects, the cutoff value of BUN/Scr was 19.37. The results of Kaplan-Meier survival curve showed that the mortality rate of patients with ratio ≥ 19.37 was higher than that of patients with ratio < 19.37. After multivariate analysis, COX regression model showed that the mortality of patients with BUN/Scr ≥ 19.37 was 1.885 times that of patients with BUN/Scr < 19.37 [HR = 1.885 (1.298-2.737), P = 0.001]. Subgroup analysis showed that the relationship between BUN/Scr and the prognosis of CHF was influenced by NYHA and eGRF (P < 0.05).

CONCLUSIONS

BUN/Scr ratio is related to the poor prognosis of patients with CHF, and is an independent predictor of all-cause death.

Practical Recommendations for the Use of Angiotensin Receptor-Neprilysin Inhibitors (ARNI) in Heart Failure: Insights from Indian Cardiologists

Heart failure is a significant public health concern characterized by notable rates of morbidity and mortality. Despite the presence of guideline-directed medical therapy (GDMT), its utilization remains inadequate. This practical recommendation paper focuses on the utilization of angiotensin receptor-neprilysin inhibitor (ARNI) as a pivotal treatment for heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), and heart failure with improved ejection fraction (HFimpEF). The recommendations presented in this paper have been developed by a group of cardiologists in India who convened six advisory board meetings to discuss the utilization of ARNI in the management of heart failure. The paper emphasizes the importance of accurate biomarkers for diagnosing heart failure, particularly N-terminal pro-B-type natriuretic peptide (NT-proBNP) and B-type natriuretic peptide (BNP), which are commonly used. Additionally, the paper advocates the use of imaging, specifically echocardiography, in diagnosing and monitoring heart failure patients. Moreover, the paper highlights the role of ARNI in heart failure management, with numerous clinical trials that have demonstrated its effectiveness in reducing cardiovascular death or heart failure hospitalization, enhancing quality of life, and diminishing the risk of ventricular arrhythmias. This practical recommendation paper offers valuable insights into the utilization of ARNI in the management of heart failure, aiming to enhance the implementation of GDMT and ultimately alleviate the burden of heart failure on society.

Implanted haemodynamic telemonitoring devices to guide management of heart failure: a review and meta-analysis of randomised trials

BACKGROUND AND AIMS

Congestion is a key driver of morbidity and mortality in heart failure. Implanted haemodynamic monitoring devices might allow early identification and management of congestion. Here, we provide a state-of-the-art review of implanted haemodynamic monitoring devices for patients with heart failure, including a meta-analysis of randomised trials.

METHODS AND RESULTS

We did a systematic search for pre-print and published trials in Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) on the 22nd of September 2021. We included randomised trials that compared management with or without information from implanted haemodynamic monitoring devices for patients with heart failure. Outcomes selected were hospitalisation for heart failure and all-cause mortality. Changes in treatment associated with haemodynamic monitoring resulted in only a small reduction in mean pulmonary artery pressure (typically < 1 mmHg as a daily average), which generally remained much greater than 20 mmHg. Haemodynamic monitoring reduced hospitalisations for heart failure (HR 0.75; 95% CI 0.58-0.96; p = 0.03) but not mortality (RR 0.92; 95% CI 0.68-1.26; p = 0.48).

CONCLUSIONS

Haemodynamic monitoring for patients with heart failure may reduce the risk of hospitalization for heart failure but this has not yet translated into a reduction in mortality, perhaps because the duration of trials was too short or the reduction in pulmonary artery pressure was not sufficiently large. The efficacy and safety of aiming for larger reductions in pulmonary artery pressure should be explored. After selecting key words, a systematic review for implanted haemodynamic telemonitoring devices was performed in different dataset and 4 randomised clinical trials were identified and included in this meta-analysis. Three different devices (Chronicle, Chronicle/ICD and CardioMEMS) were tested. All-cause mortality and total heart failure hospitalisations were selected as outcomes. No reduction in all-cause mortality rate was reported but a potential benefit on total heart failure hospitalisation was identified.

Hepatic Venous Stasis Index Reflects Hepatic Congestion and Predicts Adverse Outcomes in Patients With Heart Failure

Background It has been reported that the hepatic vein waveforms determined by abdominal ultrasonography can assess hepatic congestion in patients with heart failure (HF). However, the parameter that quantifies hepatic vein waveforms has not been established. We suggest the hepatic venous stasis index (HVSI) as the novel indicator to evaluate hepatic congestion quantitatively. To examine the clinical significance of HVSI in patients with HF, we aimed to clarify the associations of HVSI with the parameters of cardiac function and right heart catheterization, as well as that with prognosis, in patients with HF. Methods and Results We performed abdominal ultrasonography, echocardiography, and right heart catheterization in patients with HF (n=513). The patients were divided into 3 groups based on HVSI as follows: HVSI 0 (HVSI=0, n=253), low HVSI (HVSI 0.01-0.20, n=132), and high HVSI (HVSI>0.20, n=128). We examined the associations of HVSI with parameters of cardiac function and right heart catheterization and followed up for cardiac events defined as cardiac death or worsening HF. There was a significant increase in level of B-type natriuretic peptide, inferior vena cava diameter, and mean right atrial pressure with increasing HVSI. During the follow-up period, cardiac events occurred in 87 patients. In the Kaplan-Meier analysis, cardiac event rate increased across increasing HVSI (log-rank, P=0.002). Conclusions HVSI assessed by abdominal ultrasonography reflects hepatic congestion and right-sided HF and is associated with adverse prognosis in patients with HF.

The role of bioelectrical phase angle in patients with heart failure

The most challenging feature of heart failure (HF) still remains the evaluation of congestion. Residual congestion at discharge and the difficulties in perfectly dosing therapies in order to balance the hydration status of the patient are the most worrisome issues when dealing with HF.The use of bioimpedance vector analysis (BIVA) might promote a different approach in the general management of patients with HF. BIVA is a reliable, fast, bedside tool able to assess the congestion status. It proved to be helpful to physicians for diagnosing congestive status, managing therapies, and providing prognostic information in the setting of HF.Bioelectrical Phase Angle (PhA) - as derived from equations related to the parameters of BIVA - recently surged as a possible biomarker for patients with HF. Studies provided data about the application of PhA in the clinical management and in the overall risk stratification of HF patients.Basically, the use of PhA might be considered as a holistic evaluation of patients with HF which includes the need for a multiparametric approach able to effectively depict the clinical status of patients. There is no definite biomarker able to comprehensively describe and identify all the features of HF patient, but scores based on molecules/techniques able to explore the different pathogenetic mechanisms of HF are desirable.The aim of this review was to provide a comprehensive evaluation of literature related to PhA role in HF and the impact of this biomarker on clinical management and risk stratification of HF patients.

A Current Review of the Uses of Bioelectrical Impedance Analysis and Bioelectrical Impedance Vector Analysis in Acute and Chronic Heart Failure Patients: An Under-valued Resource?

BACKGROUND

There is a need to detect and prevent fluid overload and malnutrition in heart failure. Bioelectrical impedance analysis and bioelectrical impedance vector analysis are medical instruments that can advance heart failure management by generating values of body composition and body water, assisting clinicians to detect fluid and nutritional status. However, there is a lack of evidence to summarise how they have been used among heart failure patients.

METHOD

A systematic search was conducted.

RESULT

Two hundred and four papers were screened. Forty-eight papers were reviewed, and 46 papers were included in this review. The literature shows that bioelectrical impedance analysis and bioelectrical impedance vector analysis were mostly used to assess fluid and nutritional status, together with diagnostic and prognostic values. Contraindication of using BIA and implications for practice are also demonstrated.

CONCLUSION

The findings suggest that bioelectrical impedance vector analysis is superior to bioelectrical impedance analysis when assessing hydration/nutritional status in heart failure. Assessing a patient using bioelectrical impedance analysis /bioelectrical impedance vector analysis, together with natriuretic peptide -heart failure biomarkers, increases the diagnostic accuracy of heart failure. Further studies are required to examine the cost effectiveness of using these instruments in clinical practice.

Bioimpedance Indices of Fluid Overload and Cardiorenal Outcomes in Heart Failure and Chronic Kidney Disease: a Systematic Review

BACKGROUND

Bioimpedance-based estimates of fluid overload have been widely studied and systematically reviewed in populations of those undergoing dialysis, but data from populations with heart failure or nondialysis chronic kidney disease (CKD) have not.

METHODS AND RESULTS

We conducted a systematic review of studies using whole-body bioimpedance from populations with heart failure and nondialysis CKD that reported associations with mortality, cardiovascular outcomes and/or CKD progression. We searched MEDLINE, Embase databases and the Cochrane CENTRAL registry from inception to March 14, 2022. We identified 31 eligible studies: 20 heart failure and 11 CKD cohorts, with 2 studies including over 1000 participants. A wide range of various bioimpedance methods were used across the studies (heart failure: 8 parameters; CKD: 6). Studies generally reported positive associations, but between-study differences in bioimpedance methods, fluid overload exposure definitions and modeling approaches precluded meta-analysis. The largest identified study was in nondialysis CKD (Chronic Renal Insufficiency Cohort, 3751 participants), which reported adjusted hazard ratios (95% confidence intervals) for phase angle < 5.59 vs ≥ 6.4 of 2.02 (1.67-2.43) for all-cause mortality; 1.80 (1.46-2.23) for heart failure events; and 1.78 (1.56-2.04) for CKD progression.

CONCLUSIONS

Bioimpedance indices of fluid overload are associated with risk of important cardiorenal outcomes in heart failure and CKD. Facilitation of more widespread use of bioimpedance requires consensus on the optimum device, standardized analytical methods and larger studies, including more detailed characterization of cardiac and renal phenotypes.

Plasma Levels of Intact Parathyroid Hormone and Congestion Burden in Heart Failure: Clinical Correlations and Prognostic Role

Circulating parathyroid hormone (PTH) concentrations increase in heart failure (HF) and are related to disease severity. The relationship between PTH and congestion is still a matter of debate. The objective of this analysis was to evaluate the role of PTH as a marker of congestion and prognosis in HF. We enrolled 228 patients with HF. Intact PTH concentrations and HYDRA score (constituted by: B-type natriuretic peptide, blood urea nitrogen−creatinine ratio, estimated plasma volume status, and hydration status) were evaluated. The study endpoint was all-cause mortality. PTH levels were higher in acute compared with chronic HF and in patients with clinical signs of congestion (i.e., peripheral oedema and orthopnea). PTH concentrations significantly correlated with NYHA class and HYDRA score. At multivariate analysis of HYDRA score, estimated glomerular filtration rate (eGFR), and corrected serum calcium were independently determinants of PTH variability. Fifty patients (22%) died after a median follow-up of 408 days (interquartile range: 283−573). Using univariate Cox regression analysis, PTH concentrations were associated with mortality (hazard ratio [HR]: 1.003, optimal cut-off: >249 pg/mL—area under-the-curve = 0.64). Using multivariate Cox regression analysis, PTH was no longer associated with death, whereas HYDRA score, left ventricular ejection fraction, and eGFR acted as independent predictors for mortality (HR: 1.96, 0.97, and 0.98, respectively). Our study demonstrated that intact PTH was related to clinical and subclinical markers of congestion. However, intact PTH did not act as an independent determinant of all-cause death in HF patients.

Brain Natriuretic Peptide Biomarkers in Current Clinical and Therapeutic Scenarios of Heart Failure

Brain natriuretic peptide (BNP) and its inactive N-terminal fragment, NT-proBNP, are serum biomarkers with key roles in the management of heart failure (HF). An increase in the serum levels of these peptides is closely associated with the pathophysiological mechanisms underlying HF such as the presence of structural and functional cardiac abnormalities, myocardial stretch associated with a high filling pressure and neuro-hormonal activation. As BNP and NT-proBNP measurements are possible, several studies have investigated their clinical utility in the diagnosis, prognostic stratification, monitoring and guiding therapy of patients with HF. BNP and NT-proBNP have also been used as criteria for enrollment in randomized trials evaluating the efficacy of new therapeutic strategies for HF. Nevertheless, the use of natriuretic peptides is still limited in clinical practice due to the controversial aspect of their use in different clinical settings. The purpose of this review is to discuss the main issues associated with using BNP and NT-proBNP serum levels in the management of patients with HF under current clinical and therapeutic scenarios.

Respiratory failure and bioelectrical phase angle are independent predictors for long-term survival in acute heart failure

Background. The assessment of long-term mortality in acute decompensated heart failure (ADHF) is challenging. Respiratory failure and congestion play a fundamental role in risk stratification of ADHF patients. The aim of this study was to investigate the impact of arterial blood gases (ABG) and congestion on long-term mortality in patients with ADHF. Methods and results. We enrolled 252 patients with ADHF. Brain natriuretic peptide (BNP), blood urea nitrogen (BUN), phase angle as assessed by means of bioimpedance vector analysis, and ABG analysis were collected at admission. The endpoint was all-cause mortality. At a median follow-up of 447 d (interquartile range [IQR]: 248-667), 72 patients died 1-840 d (median 106, IQR: 29-233) after discharge. Respiratory failure types I and II were observed in 78 (19%) and 53 (20%) patients, respectively. The ROC analyses revealed that the cut-off points for predicting death were: BNP > 441 pg/mL, BUN > 1.67 mmol/L, partial pressure in oxygen (PaO₂) ≤69.7 mmHg_, and phase angle ≤4.9°. Taken together, these four variables proved to be good predictors for long-term mortality in ADHF (area under the curve [AUC] 0.78, 95% CI 0.72-0.78), thus explaining 60% of all deaths. A multiparametric score based on these variables was determined: each single-unit increase promoted a 2.2-fold augmentation of the risk for death (hazard ratio [HR] 2.2, 95% CI 1.8-2.8, p< .0001). Conclusions. A multiparametric approach based on measurements of BNP, BUN, PaO_2, and phase angle is a reliable approach for long-term prediction of mortality risk in patients with ADHF.

Renal Venous Stasis Index Reflects Renal Congestion and Predicts Adverse Outcomes in Patients With Heart Failure

Background

It has been recently reported that the renal venous stasis index (RVSI) assessed by renal Doppler ultrasonography provides information to stratify pulmonary hypertension that can lead to right-sided heart failure (HF). However, the clinical significance of RVSI in HF patients has not been sufficiently examined. We aimed to examine the associations of RVSI with parameters of cardiac function and right heart catheterization (RHC), as well as with prognosis, in patients with HF.

Methods

We performed renal Doppler ultrasonography, echocardiography and RHC in hospitalized patients with HF (n = 388). RVSI was calculated as follows: RVSI = (cardiac cycle time-venous flow time)/cardiac cycle time. The patients were classified to three groups based on RVSI: control group (RVSI = 0, n = 260, 67%), low RVSI group (0 &lt; RVSI ≤ 0.21, n = 63, 16%) and high RVSI group (RVSI &gt; 0.21, n = 65, 17%). We examined associations of RVSI with parameters of cardiac function and RHC, and followed up for cardiac events defined as cardiac death or worsening HF.

Results

There were significant correlations of RVSI with mean right atrial pressure (mRAP; R = 0.253, P &lt; 0.001), right atrial area (R = 0.327, P &lt; 0.001) and inferior vena cava diameter (R = 0.327, P &lt; 0.001), but not with cardiac index (R = −0.019, P = 0.769). During the follow-up period (median 412 days), cardiac events occurred in 60 patients. In the Kaplan–Meier analysis, the cumulative cardiac event rate increased with increasing RVSI (log-rank, P = 0.001). In the multivariate Cox proportional hazard analysis, the cardiac event rate was independently associated with RVSI (high RVSI group vs. control group: hazard ratio, 1.908; 95% confidence interval, 1.046–3.479, P = 0.035).

Conclusion

RVSI assessed by renal Doppler ultrasonography reflects right-sided overload and is associated with adverse prognosis in HF patients.

Predictive Value of Blood Urea Nitrogen to Albumin Ratio in Long-Term Mortality in Intensive Care Unit Patients with Acute Myocardial Infarction: A Propensity Score Matching Analysis

Background

Blood urea nitrogen to albumin ratio (BAR) has been implicated in predicting outcomes of various inflammatory-related diseases. However, the predictive value of BAR in long-term mortality in patients with acute myocardial infarction (AMI) has not yet been evaluated.

Methods

In this retrospective cohort study, the patients were recruited from the Medical Information Mart for Intensive Care III (MIMIC III) database and categorized into two groups by a cutoff value of BAR. Kaplan–Meier (K-M) analysis and Cox proportional hazard model were performed to determine the predictive value of BAR in long-term mortality following AMI. In order to adjust the baseline differences, a 1:1 propensity score matching (PSM) was carried out and the results were further validated.

Results

A total of 1827 eligible patients were enrolled. The optimal cutoff value of BAR for four-year mortality was 7.83 mg/g. Patients in the high BAR group tended to have a longer intensive care unit (ICU) stay and a higher rate of one-, two-, three- and four-year mortality (all p<0.001) compared with those in the low BAR group. K-M curves indicated a significant difference in four-year survival (p<0.001) between low and high BAR groups. The Cox proportional hazards model showed that higher BAR (>7.83) was independently associated with increased four-year mortality in the entire cohort, with a hazard ratio (HR) of 1.478 [95% CI (1.254–1.740), p<0.001]. After PSM, the baseline characteristics of 312 pairs of patients in the high and low BAR groups were well balanced, and similar results were observed in K-M curve (p=0.003).

Conclusion

A higher BAR (>7.83) was associated with four-year mortality in patients with AMI. As an easily available biomarker, BAR can predict the long-term mortality in AMI patients independently.

Sex Differences in the Evaluation of Congestion Markers in Patients with Acute Heart Failure

The impact of sex on the assessment of congestion in acute heart failure (AHF) is still a matter of debate. The objective of this analysis was to evaluate sex differences in the evaluation of congestion at admission in patients hospitalized for AHF. We consecutively enrolled 494 AHF patients (252 female). Clinical congestion assessment, B-type natriuretic peptide levels analysis, blood urea nitrogen to creatinine ratio (BUN/Cr), plasma volume status estimate (by means of Duarte or Kaplam-Hakim PVS), and hydration status evaluation through bioimpedance analysis were performed. There was no difference in medications between men and women. Women were older (79 ± 9 yrs vs. 77 ± 10 yrs, p = 0.005), and had higher left ventricular ejection fraction (45 ± 11% vs. 38 ± 11%, p < 0.001), and lower creatinine clearance (42 ± 25 mL/min vs. 47 ± 26 mL/min, p = 0.04). The prevalence of peripheral oedema, orthopnoea, and jugular venous distention were not significantly different between women and men. BUN/Cr (27 ± 9 vs. 23 ± 13, p = 0.04) and plasma volume were higher in women than men (Duarte PVS: 6.0 ± 1.5 dL/g vs. 5.1 ± 1.5 dL/g, p < 0.001; Kaplam−Hakim PVS: 7.9 ± 13% vs. −7.3 ± 12%, p < 0.001). At multivariate logistic regression analysis, female sex was independently associated with BUN/Cr and PVS. Female sex was independently associated with subclinical biomarkers of congestion such as BUN/Cr and PVS in patients with AHF. A sex-guided approach to the correct evaluation of patients with AHF might become the cornerstone for the correct management of these patients.

Predictive value of plasma volume status for contrast-induced nephropathy in patients with heart failure undergoing PCI

AIMS

Contrast-induced nephropathy remains a common complication of coronary procedure and increases poor outcomes, especially in patients with heart failure. Plasma volume expansion relates to worsening prognosis of heart failure. We hypothesized that calculated plasma volume status (PVS) might provide predictive utility for contrast-induced nephropathy in patients with heart failure undergoing elective percutaneous coronary intervention (PCI).

METHODS AND RESULTS

We enrolled 441 patients with heart failure undergoing elective PCI from 2012 to 2018. Pre-procedural estimated PVS by the Duarte's formula (Duarte-ePVS) and Kaplan-Hakim formula (KH-ePVS) were calculated for all patients. CIN was defined as an absolute serum creatinine (SCr) increase ≥0.5 mg/dL or a relative increase ≥25% compared with the baseline value within 48 h of contrast medium exposure. We assessed the association between PVS and CIN in patients with heart failure undergoing elective PCI. In 441 patients, 28 (6.3%) patients developed CIN. The median Duarte-ePVS was 4.44 (3.87, 5.13) and the median KH-ePVS was -0.03 (-0.09, 0.05). The best cutoff values for Duarte-ePVS and KH-ePVS to predict CIN were 4.64 (with 78.6% sensitivity and 61.7% specificity) and 0.04 (with 64.5% sensitivity and 75.5% specificity), respectively. After adjusting for potential confounding variables, KH-ePVS > 0.04 [odds ratio (OR) 2.685, 95% confidence interval (CI) 1.012-7.123, P = 0.047] remained significantly associated with CIN whereas Duarte-ePVS was not.

CONCLUSIONS

Pre-procedural KH-ePVS is an independent risk factor for CIN in patients with heart failure undergoing elective PCI. The best cutoff point of KH-ePVS for predicting CIN was 0.04.

Bioimpedance Vector Analysis for Heart Failure: Should We Put It on the Agenda?

Heart failure is a clinical syndrome, resulting in increased intracardiac pressure and/or decreased cardiac output under rest or stress. In acute decompensated heart failure, volume assessment is essential for clinical diagnosis and management. More and more evidence shows the advantages of bioimpedance vector analysis in this issue. Here, we critically present a brief review of bioimpedance vector analysis in the prediction and management of heart failure to give a reference to clinical physicians and guideline makers.

The Prognostic Impact of Estimated Creatinine Clearance by Bioelectrical Impedance Analysis in Heart Failure: Comparison of Different eGFR Formulas

The estimation of glomerular filtration rate (eGFR) provides prognostic information in patients with heart failure (HF). Bioelectrical impedance analysis may calculate eGFR (Donadio formula). The aim of this study was to evaluate the impact of the Donadio formula in predicting all-cause mortality in patients with HF as compared to Cockroft-Gault, MDRD-4 (Modification of Diet in renal Disease Study), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas. Four-hundred thirty-six subjects with HF (52% men; mean age 75 ± 11 years; 42% acute HF) were enrolled. Ninety-two patients (21%) died during the follow-up (median 463 days, IQR 287-669). The area under the receiver operator characteristic curve for eGFR, as estimated by Cockroft-Gault formula (AUC = 0.75), was significantly higher than those derived from Donadio (AUC = 0.72), MDRD-4 (AUC = 0.68), and CKD-EPI (AUC = 0.71) formulas. At multivariate analysis, all eGFR formulas were independent predictors of death; 1 mL/min/1.73 m2 increase in eGFR-as measured by Cockroft-Gault, Donadio, MDRD-4, and CKD-EPI formulas-provided a 2.6%, 1.5%, 1.2%, and 1.6% increase, respectively, in mortality rate. Conclusions. eGFR, as calculated with the Donadio formula, was an independent predictor of mortality in patients with HF as well as the measurements derived from MDRD4 and CKD-EPI formulas, but less accurate than Cockroft-Gault.

Prognostic association of medication trajectories with 3-year mortality in heart failure and preserved ejection fraction: findings from the EPICAL2 cohort study

PURPOSE

The aims of this study were to describe combinations of beta-blockers (BB), renin-angiotensin system (RAS) blockers, and mineralocorticoid receptor antagonist (MRA) prescriptions and their trajectories in heart failure with preserved ejection fraction (HFpEF) patients, and to assess their effect on the three-year all-cause and cardiovascular (CV)-mortality.

METHODS

We used data from the EPICAL2 cohort of 689 hospitalized HFpEF patients. Medication prescriptions were collected at hospital discharge and at 6, 12, and 24 months after discharge. A multi-trajectory approach was used to conjointly model groups of individuals following similar trajectories over medications prescriptions. We used Cox and Fine-Gray models, to evaluate respectively the associations between 3-year all-cause mortality and CV-mortality and the trajectory groups.

RESULTS

Multi-trajectory modelling revealed five distinct trajectory groups: group1 (N = 232, 33.6%) stable ACEI/ARB and BB prescriptions, group 2 (N = 199, 28.8%) stable ACEI/ARB prescription, group 3 (N = 133, 19.3%) stable BB prescriptions, group 4 (N = 78, 11.3%) stable prescriptions of none of the medications, and group 5 (N = 47, 6.8%) stable ACEI/ARB, BB, and MRA prescriptions. As compared to the group 4 of patients receiving none of the three medications, patients receiving a stable prescription of one or a combination of two or the three medications over 2 years) had a lower overall mortality over 3-year follow-up, i.e., group 1 (HR = 0.5, 95% CI 0.4-0.8), group 2 (HR = 0.6, 95% CI:0.4-0.8), group 3 (HR = 0.5, 95% CI:0.4-0.7), and group 5 (HR = 0.5, 95% CI:0.3-0.9). However, none of these trajectory groups was associated with a lower CV-mortality over 3 years.

CONCLUSION

In an unselected population-based sample of HFpEF patients, the long-term stable use of the combination ACEI/ARB and BB, BB exclusively, ACEI/ARB exclusively, or the combination ACEI/ARB and BB and MRAs was associated with reduced three-year all-cause mortality.

Comparison of the prognosis and outcome of heart failure with reduced ejection fraction patients treated with sacubitril/valsartan according to age

The treatment with sacubitril/valsartan in patients suffering from chronic heart failure with reduced ejection fraction increases left ventricular ejection fraction and decreases the risk of sudden cardiac death. We conducted a retrospective analysis regarding the impact of age differences on the treatment outcome of sacubitril/valsartan in patients with chronic heart failure with reduced ejection fraction. Patients were defined as adults if ≤65 years (n = 51) and older if >65 years of age (n = 76). The incidence of ventricular arrhythmias at 1-year follow-up was comparable in both groups (30.8 vs 26.5%; p = 0.71). The mortality rate in adult patients is significantly lower as compared with older patients (2 vs 14.5%; log-rank = 0.04). Older patients may suffer remarkably more side effects than adult patients (21.1 vs 11.8%; p = 0.03).

Prognostic value of estimated plasma volume in patients with chronic systolic heart failure

Assessing congestion is challenging but important to patients with chronic heart failure (CHF). However, there are limited data regarding the association between estimated plasma volume status (ePVS) determined using hemoglobin/hematocrit data and outcomes in patients with stable CHF. We prospectively analyzed 231 patients; the median follow-up period was 35.6 months. We calculated ePVS at admission using the Duarte and Strauss formula, derived from hemoglobin and hematocrit ratios and divided patients into three groups. The primary outcome was a composite of all-cause mortality or heart failure rehospitalization. Among 274 patients (61.98 years of age, 2.3% male), the mean ePVS was 3.98±0.90 dL/g. The third ePVS tertile had a higher proportion of primary outcome (71.4%) than the first or second tertile (48.1% and 59.7%, respectively; p=0.013). On multivariable Cox analysis, after adjusting for potential confounders, higher ePVS remained significantly associated with increased rate of primary outcome (adjusted HR 1.567, 95% CI 1.267 to 1.936; p<0.001). Kaplan-Meier survival analyses showed that the occurrence of primary outcome, all-cause mortality and rehospitalization increased progressively from first to third tertiles (p=0.006, 0.014 and 0.001; respectively). In receiver operating characteristic analysis, the area under the curve of ePVS for primary outcome was 0.645. ePVS determined using hemoglobin and hematocrit was independently associated with clinical outcomes for patients with stable CHF. Our study thus further strengthens the evidence that ePVS has important prognostic value in patients with stable CHF.

Trial registration number ChiCTR-ONC-14004463.

Estimated plasma volume status in heart failure: clinical implications and future directions

Congestion is one of the main predictors of poor outcome in patients with heart failure (HF). Assessing and monitoring congestion is essential for optimizing HF therapy. Among the various available methods, serial measurements of estimated plasma volume (ePVS) using routine blood count and/or body weight (e.g., the Strauss, Duarte, Hakim formulas) may be useful in HF management. Further prospective study is warranted to determine whether ePVS can help optimize decongestion therapy (loop diuretics, mineralocorticoid receptor antagonists, SGLT2i) in various HF settings. This narrative review summarizes the recent evidence supporting the association of ePVS with clinical congestion and outcome(s) and discusses future directions for monitoring ePVS in HF.

Decline in eGFR over time and incidence of cardiovascular events: Shinken database analysis

BACKGROUND

It has been reported that a large decline in estimated glomerular filtration rate (eGFR) over time is associated with increased incidence of cardiovascular disease. We investigated whether this association differs according to the baseline eGFR.

METHODS

A total of 4666 patients (male 71%) with measurements of eGFR at both baseline and 1 year and that had no cardiovascular events at 1-year follow-up were retrieved from the Shinken Database between June 2004 and March 2015. The study population was divided into three groups by baseline eGFR (mL/min/1.73 m²): high (≥60, n = 1650), intermediate (45-59, n = 1947), and low (<45, n = 1069) eGFR groups. Each eGFR group was further divided into two groups by eGFR slope (change at 1 year, <-10 and ≥-10 mL/min/1.73 m²). The patient characteristics and the incidences of cardiovascular events within 3 years (after 1-year follow-up) were compared between the negatively large eGFR slope (<-10) and others (≥-10) in each eGFR group.

RESULTS

A total of 187 cardiovascular events occurred during the mean follow-up of 2.8 ± 0.6 years. The adjusted hazard ratios of eGFR slope (<-10 with reference to ≥-10) were 2.37 (95% CI, 1.28-4.40), 3.10 (95% CI, 1.78-5.40), and 2.66 (95% CI, 1.15-6.13) in the high, middle, and low eGFR groups, respectively. Similar results were found in patients with structural heart disease, but not in those without.

CONCLUSIONS

Decline in eGFR was associated with an increase in cardiovascular events, and this effect was consistent regardless of the baseline eGFR.

Cardiac Cachexia: A Well-Known but Challenging Complication of Heart Failure

Heart failure (HF) is a common complication of various cardiac diseases, and its incidence constantly increases. This is caused mainly by aging of populations and improvement in the treatment of coronary artery disease. As HF patients age, they tend to develop comorbidities, creating new problems for health-care professionals. Sarcopenia, defined as the loss of muscle mass and function, and cachexia, defined as weight loss due to an underlying illness, are muscle wasting disorders of particular relevance in the heart failure population, but they go mostly unrecognized. The coexistence of chronic HF and metabolic disorders facilitates the development of cachexia. Cachexia, in turn, significantly worsens a patient’s prognosis and quality of life. The mechanisms underlying cachexia have not been explained yet and require further research. Understanding its background is crucial in the development of treatment strategies to prevent and treat tissue wasting. There are currently no specific European guidelines or recommended therapy for cachexia treatment in HF (“cardiac cachexia”).

Blood Urea Nitrogen to Creatinine Ratio and Long-Term Mortality in Patients with Acute Heart Failure: A Prospective Cohort Study and Meta-Analysis

OBJECTIVE

To further explore the relationship between the blood urea nitrogen to creatinine (BUN/Cr) ratio and the prognosis of patients with acute heart failure (AHF), a two-part study consisting of a prospective cohort study and meta-analysis were conducted.

METHODS

A total of 509 hospitalized patients with AHF were enrolled and followed up. Cox proportional hazards regression was used to analyze the relationship between the BUN/Cr ratio and the long-term prognosis of patients with AHF. Meta-analysis was also conducted regarding the topic by searching PubMed and Embase for relevant studies published up to October 2019.

RESULTS

During a median follow-up of 2.8 years, 197 (42.6%) deaths occurred. The cumulative survival rate of patients with a BUN/Cr ratio in the bottom quartile was significantly lower than in the other 3 groups (log-rank test: p = 0.003). In multivariate Cox regression models, the mortality rate of AHF patients with a BUN/Cr ratio in the bottom quartile was significantly higher than in the top quartile (adjusted HR 1.52; 95% CI 1.03-2.24). For the meta-analysis, we included 8 studies with 4,700 patients, consisting of 7 studies from the database and our cohort study. The pooled analysis showed that the highest BUN/Cr ratio category was associated with an 77% higher all-cause mortality than the lowest category (pooled HR 1.77; 95% CI 1.52-2.07).

CONCLUSIONS

Elevated BUN/Cr ratio is associated with poor prognosis in patients with AFH and is an independent predictor of all-cause mortality.

Relationship among Activities of Daily Living, Nutritional Status, and 90 Day Readmission in Elderly Patients with Heart Failure

Purpose: This investigation aimed to examine the relationship among activities of daily living (ADL), nutritional status and 90-day hospital readmission in elderly heart failure (HF) patients. Methods: Participants were selected from 634 HF patients consecutively hospitalized at one institution. We investigated patient characteristics, ADL (motor and cognitive items of Functional Independence Measure (FIM)) and nutritional status (Geriatric Nutritional Risk Index (GNRI)). Data were analyzed using unpaired t-test, χ² test, Cox proportional hazard model, and Kaplan-Meier method. Results: The 169 participants that met inclusion criteria were divided into two groups based on hospital readmission within 90 days of discharge. Body mass index (BMI) (p = 0.03), hemoglobin (p = 0.047), GNRI (p = 0.02) and motor-FIM (p = 0.007) were significantly different between the readmission (n = 31) and non-readmission (n = 138) groups. After Cox proportional hazard model analysis, GNRI (HR: 0.96; p = 0.048) and motor-FIM (HR: 0.97; p = 0.03) scores remained statistically significant. Participants were then classified into four groups based on a previous study’s cut-off values of prognosis for GNRI and motor-FIM. Readmission avoidance rate was significantly lower (p = 0.002) in the group with GNRI <92 and motor FIM <75. Conclusions: This study showed that motor-FIM and GNRI scores for hospitalized elderly HF patients were predictors of readmission within 90 days of discharge.