Heart failure guidelines: What’s new?

Association of serum albumin with heart failure mortality with NYHA class IV in Chinese patients: Insights from PhysioNet database (version 1.3)

BACKGROUND

Studies have proved that low albumin level is associated with increased mortality in most diseases, such as chronic kidney disease and hepatic cirrhosis. However, the relationship between albumin and all-cause death in heart failure patients in China is still unclear.

OBJECTIVES

We aimed to investigate the association between albumin level and 28-day mortality in Chinese hospitalized patients with NYHA IV heart failure.

METHODS

A total of 2008 Chinese patients were included. The correlation between serum albumin level and mortality was tested using a cox proportional hazards regression model. The smooth curve fitting was used to identify non-linear relationships between serum albumin and mortality. The Forest plot analysis was used to assess the association between albumin and 28-day mortality in different groups.

RESULTS

Compared with patients with NYHA II-III, patients with NYHA IV had lower albumin level and higher mortality within 28 days. The albumin on admission was independently and inversely associated with the endpoint risk, which remained significant (hazard ratio: 0.80; 95 % confidence interval: 0.66 to 0.96; p = 0.0196) after multivariable adjustment. The smooth curve fitting showed with the increase of albumin, the mortality within 28 days would decrease. A subgroup analysis found that the inverse association between the albumin level and risk of the mortality was consistent across the subgroup stratified by possible influence factors.

CONCLUSION

Serum albumin level is negatively associated with 28-day mortality in hospitalized heart failure patients within NYHA IV in China, which can be used as an independent predictor.

Growth differentiation factor 15 associations with clinical features of chronic heart failure with midrange ejection fraction and preserved ejection fraction depending on the history of myocardial infarction

Aim    To analyze associations between levels of the inflammatory marker, growth differentiation factor 15 (GDF-15), and echocardiographic indexes in CHF patients with mid-range and preserved left ventricular ejection fraction (LV EF) depending on the history of myocardial infarction (MI).Material and methods    This study included 34 CHF patients with preserved and mid-range LV EF after MI (group 1, n=19) and without a history of MI (group 2, n=15). Serum concentration of GDF-15 was measured with enzyme immunoassay (BioVendor, Czech Republic). Statistical analysis was performed with STATISTICA 10.0.Results    Patients of the study groups were age-matched [62 (58;67) and 64 (60;70) years, p=0.2] but differed in the gender; group 1 consisted of men only (100 %) whereas in group 2, the proportion of men was 53.3 % (p=0.001). Median concentration of GDF-15 was 2385 (2274; 2632.5) and 1997 (1534;2691) pg/ml in groups 1 and 2, respectively (p=0.09). Patients without MI showed a moderate negative correlation between LV EF and GDF-15 concentration (r= - 0.51, p=0.050) and a pronounced correlation between GDF-15 and LV stroke volume (r= -0.722, p=0.002). For patients after MI, a correlation between the level of GDF-15 and the degree of systolic dysfunction was not found (р>0.05).Conclusion    Blood concentration of the inflammatory marker, GDF-15, correlates with LV EF and stroke volume in CHF patients with preserved or mid-range LV EF and without a history of MI while no such correlations were observed for patients with a history of MI.

A metabolomic study for chronic heart failure patients based on a dried blood spot mass spectrometry approach

Objective: a dried blood spot (DBS) method integrated with direct infusion mass spectrometry (MS) focused on a metabolomic analysis was applied to detect and compare the difference of metabolites between the heart failure (HF) patients and non-HF patients in order to facilitate the early detection of heart failures, provide targeted intervention and offer prognostic insights. Methods: the method we used was an untargeted metabolic approach. The dry blood spot mass spectrometry (DBS) was used to analyze 23 types of amino acids and 26 types of carnitine in blood samples. In the current study, 49 metabolites were selected to establish the PLS-DA model to compare the differences between the 117 HF patients and 118 non-HF patients, which inclined to detect the difference between the two groups. Multiple algorithms were run for selecting different metabolites as potential biomarkers. Ten-fold cross validation method was used to verify and evaluate the selected potential biomarkers. Results: through significant analysis of the microarrays (SAM) and analysis of 9 parameters, 8 metabolites showed significant discrepancies between the HF and non-HF groups. Among these metabolites, the levels of 5 metabolites were increased, and the other 3 metabolites were decreased in the HF group compared with the non-HF group. However, 7 metabolites including Asn, C0, C14, C4DC, C5-OH, C6 and Glu were selected to distinguish the HF group from the non-HF group with specificity and sensitivity of 0.8475 and 0.8974, respectively. Conclusion: metabolomic study for chronic heart failure (CHF) patients based on the dried blood spot mass spectrometry approach would be beneficial to understand the metabolic pathway of HF, and probably work as biomarkers to predict the prognosis of HF and provide the basis for an individualized treatment.

A dried blood spot method with mass spectrometry focused on metabolomics analysis was applied to detect and compare the difference in metabolites between heart failure (HF) patients and non-HF patients in order to facilitate the early detection and treatment of heart failure.

Exercise for Preventing Hospitalization and Readmission in Adults With Congestive Heart Failure

We critically appraised all available evidence regarding exercise interventions for improving patient survival and reducing hospital admissions in adults with chronic heart failure (HF). We searched 4 databases up to April 2018 and graded the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation working group approach. We reviewed 7 meta-analyses and the publications of 48 randomized controlled trials (RCTs). In HF with reduced ejection fraction, low-quality evidence suggests that exercise prevents all-cause hospitalizations [Relative risk (RR), 0.77; 95% confidence interval (CI), 0.63 to 0.93; 1328 patients in 15 RCTs] and hospitalizations due to HF (RR, 0.57; 95% CI, 0.37 to 0.88; 1073 patients in 13 RCTs) and improves quality of life (standardized mean difference, -0.37; 95% CI, -0.60 to -0.14; 1270 patients in 25 RCTs) but has no effect on mortality. In HF with preserved ejection fraction, low-quality evidence suggests that exercise improves peak oxygen uptake (mean difference, 2.36; 95% CI, 1.16 to 3.57; 171 patients in 3 RCTs) and quality of life (mean difference, -4.65; 95% CI, -8.46 to -0.83; 203 patients in 4 RCTs). In patients after heart transplantation, low-quality evidence suggests that exercise improves peak oxygen uptake (standardized mean difference, 0.68; 95% CI, 0.43 to 0.93; 284 patients in 9 RCTs) but does not improve quality of life. In order to reduce hospitalization and improve quality of life for adults with HF and reduced ejection fraction, clinicians should recommend exercise interventions. For adults with HF and preserved ejection fraction and in those undergoing heart transplantation, clinicians may recommend exercise interventions in order to improve peak oxygen uptake.

Optimal left ventricular lead placement for cardiac resynchronization therapy in postmyocardial infarction patients

AIM

To evaluate at a 12-month follow-up, the clinical and echocardiographic outcomes in postmyocardial infarction (MI) heart failure patients who underwent cardiac resynchronization therapy (CRT) device implantation.

MATERIALS & METHODS

A total of 100 patients received a CRT device, and the study population was divided into three groups, according to the site of MI and left ventricular (LV) lead placed downstream of the ischemic area, as evaluated by echocardiography.

RESULTS

At the end of the 12-month follow-up, we reported a general improvement of LV ejection fraction from 28 ± 7% to 35 ± 9% (p < 0.001) and a significant reverse remodeling: LV end-systolic volume changed from 147 ± 54 to 125 ± 63 (p = 0.001) with a 53% of echocardiographic responders. We also observed 67% of CRT responders in the group with optimal LV lead placement compared with 38% in the remaining population (p = 0.01).

CONCLUSION

The optimal positioning of LV lead is a feasible method to improve the percentage of CRT responders in post-MI heart failure patients.

Benefits and Harms of Sacubitril in Adults With Heart Failure and Reduced Left Ventricular Ejection Fraction

The quality of evidence regarding patient-centered outcomes in adults with heart failure (HF) after sacubitril combined with valsartan has not been systematically appraised. We searched 4 databases in February 2017 and graded the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation working group approach. We reviewed 1 meta-analysis and multiple publications of 2 randomized controlled trials (RCT) and 1 unpublished RCT. In adults with HF and reduced ejection fraction, low-quality evidence from 1 RCT of 8,432 patients suggests that sacubitril combined with valsartan reduces all-cause (number needed to treat [NNT] to prevent 1 event [NNTp] = 35) and cardiovascular mortality (NNTp = 32), hospitalization (NNTp = 11), emergency visits (NNTp = 69), and serious adverse effects, leading to treatment discontinuation (NNTp = 63) and improves quality of life when compared with enalapril. In adults with HF and preserved ejection fraction, very low-quality evidence from 1 RCT of 301 patients suggests that there are no differences in mortality, morbidity, or adverse effects between sacubitril combined with valsartan and valsartan alone. In conclusion, in adults with HF and reduced ejection fraction, to reduce cardiovascular mortality and hospitalizations and improve quality of life, clinicians may recommend sacubitril combined with valsartan over angiotensin-converting enzyme inhibitors.