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Sokolska JM, Sokolski M, Zymliński R, Biegus J, Siwołowski P, Nawrocka-Millward S, Swoboda K, Gajewski P, Jankowska EA, Banasiak W, Ponikowski P. Distinct clinical phenotypes of congestion in acute heart failure: characteristics, treatment response, and outcomes. ESC Heart Fail 2020; 7:3830-3840. [PMID: 32909684 PMCID: PMC7754722 DOI: 10.1002/ehf2.12973] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 12/29/2022] Open
Abstract
Aims Patients with acute heart failure (AHF) are included into clinical trials regardless of differences in baseline clinical characteristics. The aim of this study was to assess patients with AHF according to the presence of central and/or peripheral congestion at hospital admission and evaluate treatment response and outcomes in studied phenotypes. Methods and results We investigated retrospectively 352 patients (mean age: 68 ± 13 years, 77% men) hospitalized due to AHF with the signs of congestion on admission. Patients were divided according to the type of signs of congestion into three groups: A, isolated pulmonary congestion (n = 52, 15%); B, isolated peripheral congestion (n = 31, 9%); and C, signs of mixed (peripheral and central) congestion (n = 269, 76%). Patients from Group A had lower concentration of urea, bilirubin, and gamma‐glutamyl transferase whereas higher level of haematocrit, albumin, and leukocytes on admission. The highest baseline N‐terminal pro‐B‐type natriuretic peptide level (median: 4113 vs. 3634 vs. 6093 pg/mL) and percentage of patients with chronic heart failure (56 vs. 58 vs. 74%; A vs. B. vs. C, respectively, all P < 0.01) were observed in Group C. There were no differences in terms of demographics, co‐morbidities, left ventricular ejection fraction, and applied treatment between studied groups. Patients from Group A had the highest systolic blood pressure on admission (145 ± 37 vs. 122 ± 20 vs. 130 ± 29 mmHg) and the biggest decrease in systolic blood pressure [−22 (−45 to −4) vs. −2 (−13 to 2) vs. −10 (−25 to 0) mmHg] and heart rate [−16 (−35 to −1.5) vs. −1 (−10 to 5) vs. −7 (−20 to 0) b.p.m.] with the lowest weight change [−1.0 (−1.0 to 0) vs. −2.9 (−3.8 to −0.9) vs. −2.0 (−3.0 to −1.0) kg; all P < 0.01] after 48 h of hospitalization. There were differences in short‐term and long‐term outcomes with favourable results in Group A. Group A experienced less frequent in‐hospital heart failure worsening during the first 48 h (4 vs. 23 vs. 7%), had shorter length of hospital stay [6 (5–8) vs. 7 (5–11) vs. 7 (6–11) days], and had lower 1 year all‐cause mortality (12 vs. 28 vs. 29%; all P < 0.05). Presence of peripheral congestion on admission was independent predictor for all‐cause mortality within 1 year [hazard ratio (95% confidence interval): 2.68 (1.06–6.79); P = 0.04]. Conclusions Patterns of congestion in AHF are associated with differences in clinical characteristics, treatment response, and outcomes. It needs to be considered once planning clinical trials in AHF.
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Affiliation(s)
- Justyna Maria Sokolska
- Department of Heart Diseases, Wroclaw Medical University, ul. Borowska 213, Wrocław, 50-556, Poland.,Department of Cardiology, University Heart Center, University Hospital Zurich, Zürich, Switzerland
| | - Mateusz Sokolski
- Department of Heart Diseases, Wroclaw Medical University, ul. Borowska 213, Wrocław, 50-556, Poland.,Centre for Heart Diseases, University Hospital, Wrocław, Poland
| | - Robert Zymliński
- Department of Heart Diseases, Wroclaw Medical University, ul. Borowska 213, Wrocław, 50-556, Poland.,Centre for Heart Diseases, University Hospital, Wrocław, Poland
| | - Jan Biegus
- Department of Heart Diseases, Wroclaw Medical University, ul. Borowska 213, Wrocław, 50-556, Poland.,Centre for Heart Diseases, University Hospital, Wrocław, Poland
| | - Paweł Siwołowski
- Department of Heart Diseases, Wroclaw Medical University, ul. Borowska 213, Wrocław, 50-556, Poland.,Centre for Heart Diseases, Clinical Military Hospital, Wrocław, Poland
| | | | - Katarzyna Swoboda
- Centre for Heart Diseases, Clinical Military Hospital, Wrocław, Poland
| | - Piotr Gajewski
- Department of Heart Diseases, Wroclaw Medical University, ul. Borowska 213, Wrocław, 50-556, Poland.,Centre for Heart Diseases, University Hospital, Wrocław, Poland
| | - Ewa Anita Jankowska
- Department of Heart Diseases, Wroclaw Medical University, ul. Borowska 213, Wrocław, 50-556, Poland.,Centre for Heart Diseases, University Hospital, Wrocław, Poland
| | - Waldemar Banasiak
- Centre for Heart Diseases, Clinical Military Hospital, Wrocław, Poland
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, ul. Borowska 213, Wrocław, 50-556, Poland.,Centre for Heart Diseases, University Hospital, Wrocław, Poland
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Sokolska JM, Sokolski M, Zymliński R, Biegus J, Siwołowski P, Nawrocka‐Millward S, Jankowska EA, Todd J, Banasiak W, Ponikowski P. Patterns of dyspnoea onset in patients with acute heart failure: clinical and prognostic implications. ESC Heart Fail 2018; 6:16-26. [PMID: 30426729 PMCID: PMC6351893 DOI: 10.1002/ehf2.12371] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 09/06/2018] [Accepted: 09/08/2018] [Indexed: 12/21/2022] Open
Abstract
Aims Despite attempts to improve the management of patients with acute heart failure (HF), virtually all therapeutic agents investigated in large clinical trials failed to show any consistent reduction in mortality and morbidity. Complexity of the clinical syndrome of acute HF seems to be likely an underlying explanation. Traditionally, clinical trials studied mixed patient populations with acute HF, and only recently, better clinical characterization of patients has been proposed. Dyspnoea is the most common presenting symptom related to hospital admission for acute HF. Whether in patients with acute HF, the pattern of symptoms onset preceding hospital admission is associated with clinical characteristics, and the outcomes have not yet been established. Methods and results We investigated 137 patients (mean age: 65 ± 13 years; 80% men) hospitalized due to acute HF with dyspnoea as major reported symptom, who were divided according to the time of its onset into those with acute (n = 98) vs. subacute (n = 39) onset (i.e. within 7 days vs. >7 days preceding hospital admission, respectively). On admission, the former group presented higher blood pressure (138 ± 33 vs. 121 ± 32 mmHg), more often moderate–severe pulmonary congestion (33 vs. 8%), and lower bilirubin level [1.07 (0.72–1.60) vs. 1.27 (0.87–2.06); P < 0.05 in all comparisons]. There were no other differences in baseline clinical characteristics and laboratory indices. Higher percentage of patients with an acute dyspnoea onset reported marked/moderate dyspnoea relief after 6 (18% vs. 7%), 24 (59% vs. 24%), and 48 h (80% vs. 46% assessed as an improvement of at least 5 points in self‐reported 10‐point Likert scale; P < 0.05 in all time points). In patients with an acute onset of dyspnoea after 48 h, a decrease of N‐terminal pro BNP was more frequently observed (83% vs. 65%), and the levels of endothelin‐1 were more reduced [−1.1 (−2.9–0.03) vs 0.4 (−2.2–1.4); all P < 0.05]. Patients with acute onset experienced less in‐hospital HF worsening (13% vs. 40%, P = 0.001), and 1 year cardiovascular mortality was significantly lower (20% vs. 41%, P = 0.01). On the multivariable analysis, subacute pattern of dyspnoea was independent predictor of 12 month cardiovascular mortality in patients with acute HF after adjusting for other prognostic factors: systolic blood pressure, urea, and HF de novo [hazard ratio (95% confidence interval): 2.32 (1.13–4.75), P = 0.02]. Conclusions In patients with acute HF, the pattern of symptoms onset is associated with baseline differences in clinical characteristics, biomarker profile, response to standard treatment, and the long‐term outcomes. This is relevant information for planning future clinical trials.
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Affiliation(s)
- Justyna Maria Sokolska
- Department of Heart DiseasesWroclaw Medical UniversityWroclawPoland
- Department of Cardiology, Military HospitalCentre for Heart DiseasesWroclawPoland
| | - Mateusz Sokolski
- Department of Heart DiseasesWroclaw Medical UniversityWroclawPoland
- Department of Cardiology, Military HospitalCentre for Heart DiseasesWroclawPoland
| | - Robert Zymliński
- Department of Heart DiseasesWroclaw Medical UniversityWroclawPoland
- Department of Cardiology, Military HospitalCentre for Heart DiseasesWroclawPoland
| | - Jan Biegus
- Department of Heart DiseasesWroclaw Medical UniversityWroclawPoland
- Department of Cardiology, Military HospitalCentre for Heart DiseasesWroclawPoland
| | - Paweł Siwołowski
- Department of Cardiology, Military HospitalCentre for Heart DiseasesWroclawPoland
| | | | - Ewa Anita Jankowska
- Department of Cardiology, Military HospitalCentre for Heart DiseasesWroclawPoland
- Laboratory for Applied Research on Cardiovascular System, Department of Heart DiseasesWroclaw Medical UniversityWroclawPoland
| | - John Todd
- Singulex, California Inc.AlamedaCAUSA
| | - Waldemar Banasiak
- Department of Cardiology, Military HospitalCentre for Heart DiseasesWroclawPoland
| | - Piotr Ponikowski
- Department of Heart DiseasesWroclaw Medical UniversityWroclawPoland
- Department of Cardiology, Military HospitalCentre for Heart DiseasesWroclawPoland
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