1
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de la Espriella R, Núñez-Marín G, Codina P, Núñez J, Bayés-Genís A. Biomarkers to Improve Decision-making in Acute Heart Failure. Card Fail Rev 2023; 9:e13. [PMID: 37942188 PMCID: PMC10628997 DOI: 10.15420/cfr.2023.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/19/2023] [Indexed: 11/10/2023] Open
Abstract
Acute heart failure (AHF) is a complex clinical syndrome that requires prompt diagnosis, risk stratification and effective treatment strategies to reduce morbidity and mortality. Biomarkers are playing an increasingly important role in this process, offering valuable insights into the underlying pathophysiology and facilitating personalised patient management. This review summarises the significance of various biomarkers in the context of AHF, with a focus on their clinical applications to stratify risk and potential for guiding therapy choices.
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Affiliation(s)
| | - Gonzalo Núñez-Marín
- Department of Cardiology, Hospital Clínico Universitario de ValenciaValencia, Spain
| | - Pau Codina
- Heart Institute, Hospital Universitari Germans Trias i PujolBarcelona, Spain
| | - Julio Núñez
- Department of Cardiology, Hospital Clínico Universitario de ValenciaValencia, Spain
- Department of Medicine, Universitat de ValènciaValencia, Spain
- Centro de Investigación Biomédica en Red en Enfermedades CardiovascularesMadrid, Spain
| | - Antoni Bayés-Genís
- Heart Institute, Hospital Universitari Germans Trias i PujolBarcelona, Spain
- Centro de Investigación Biomédica en Red en Enfermedades CardiovascularesMadrid, Spain
- Department of Medicine, Universitat Autònomoa de BarcelonaBarcelona, Spain
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2
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Light MP, Kreitinger KY, Lee E, DeYoung PN, Lakhani A, Siegel B, Daniels LB, Malhotra A, Owens RL. The impact of sleep disordered breathing on cardiac troponin in acutely decompensated heart failure. Sleep Breath 2023; 27:553-560. [PMID: 35641808 PMCID: PMC9708937 DOI: 10.1007/s11325-022-02646-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/05/2022] [Accepted: 05/17/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Sleep disordered breathing in decompensated heart failure has physiological consequences (e.g., intermittent hypoxemia) that may predispose to subclinical myocardial injury, yet a temporal relationship between sleep apnea and troponin elevation has not been established. METHODS We assessed the feasibility of performing respiratory polygraphy and measuring overnight high-sensitivity cardiac troponin T change in adults admitted to the hospital with acutely decompensated heart failure. Repeat sleep apnea tests (SATs) were performed to determine response to optimal medical heart failure therapy. Multivariable logistic regression was used to identify associations between absolute overnight troponin change and sleep apnea characteristics. RESULTS Among the 19 subjects with acutely decompensated heart failure, 92% of SATs demonstrated sleep disordered breathing (apnea-hypopnea index [AHI] > 5 events/h). For those with repeat SATs, AHI increased in 67% despite medical management of heart failure. Overnight troponin increase was associated with moderate to severe sleep apnea (vs. no to mild sleep apnea, odds ratio (OR = 18.4 [1.51-224.18]), central apnea index (OR = 1.11 [1.01-1.22]), and predominantly central sleep apnea (vs. obstructive, OR = 22.9 [1.29-406.32]). CONCLUSIONS Sleep apnea severity and a central apnea pattern may be associated with myocardial injury. Respiratory polygraphy with serial biomarker assessment is feasible in this population, and combining this approach with interventions (e.g., positive airway pressure) may help establish if a link exists between sleep apnea and subclinical myocardial injury.
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Affiliation(s)
- Matthew P Light
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), 9300 Campus Point Drive #7381, La Jolla, CA, 92037, USA.
| | - Kimberly Y Kreitinger
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), 9300 Campus Point Drive #7381, La Jolla, CA, 92037, USA
| | - Euyhyun Lee
- Altman Clinical and Translational Research Institute, University of California San Diego, La Jolla, CA, USA
| | - Pamela N DeYoung
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), 9300 Campus Point Drive #7381, La Jolla, CA, 92037, USA
| | - Avni Lakhani
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), 9300 Campus Point Drive #7381, La Jolla, CA, 92037, USA
| | - Brent Siegel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), 9300 Campus Point Drive #7381, La Jolla, CA, 92037, USA
| | - Lori B Daniels
- Division of Cardiology, Department of Medicine, University of California San Diego (UCSD), La Jolla, CA, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), 9300 Campus Point Drive #7381, La Jolla, CA, 92037, USA
| | - Robert L Owens
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), 9300 Campus Point Drive #7381, La Jolla, CA, 92037, USA
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3
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Koniari I, Artopoulou E, Velissaris D, Ainslie M, Mplani V, Karavasili G, Kounis N, Tsigkas G. Biomarkers in the clinical management of patients with atrial fibrillation and heart failure. J Geriatr Cardiol 2021; 18:908-951. [PMID: 34908928 PMCID: PMC8648548 DOI: 10.11909/j.issn.1671-5411.2021.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Atrial fibrillation (AF) and heart failure (HF) are two cardiovascular diseases with an increasing prevalence worldwide. These conditions share common pathophysiologiesand frequently co-exit. In fact, the occurrence of either condition can 'cause' the development of the other, creating a new patient group that demands different management strategies to that if they occur in isolation. Regardless of the temproral association of the two conditions, their presence is linked with adverse cardiovascular outcomes, increased rate of hospitalizations, and increased economic burden on healthcare systems. The use of low-cost, easily accessible and applicable biomarkers may hasten the correct diagnosis and the effective treatment of AF and HF. Both AF and HF effect multiple physiological pathways and thus a great number of biomarkers can be measured that potentially give the clinician important diagnostic and prognostic information. These will then guide patient centred therapeutic management. The current biomarkers that offer potential for guiding therapy, focus on the physiological pathways of miRNA, myocardial stretch and injury, oxidative stress, inflammation, fibrosis, coagulation and renal impairment. Each of these has different utility in current clinincal practice.
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Affiliation(s)
- Ioanna Koniari
- Manchester Heart Institute, Manchester University Foundation Trust, Manchester, United Kingdom
| | - Eleni Artopoulou
- Department of Internal Medicine, University Hospital of Patras, Patras, Greece
| | | | - Mark Ainslie
- Manchester Heart Institute, Manchester University Foundation Trust, Manchester, United Kingdom
- Division of Cardiovascular Sciences, University of Manchester
| | - Virginia Mplani
- Department of Cardiology, University Hospital of Patras, Patras, Greece
| | - Georgia Karavasili
- Manchester Heart Institute, Manchester University Foundation Trust, Manchester, United Kingdom
| | - Nicholas Kounis
- Department of Cardiology, University Hospital of Patras, Patras, Greece
| | - Grigorios Tsigkas
- Department of Cardiology, University Hospital of Patras, Patras, Greece
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4
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Berg DD, Docherty KF, Sattar N, Jarolim P, Welsh P, Jhund PS, Anand IS, Chopra V, de Boer RA, Kosiborod MN, Nicolau JC, O'Meara E, Schou M, Hammarstedt A, Langkilde AM, Lindholm D, Sjöstrand M, McMurray JJV, Sabatine MS, Morrow DA. Serial Assessment of High-Sensitivity Cardiac Troponin and the Effect of Dapagliflozin in Patients with Heart Failure with Reduced Ejection Fraction: An Analysis of the DAPA-HF Trial. Circulation 2021; 145:158-169. [PMID: 34743554 DOI: 10.1161/circulationaha.121.057852] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Circulating high-sensitivity cardiac troponin T (hsTnT) predominantly reflects myocardial injury, and higher levels are associated with a higher risk of worsening heart failure (HF) and death in patients with HF with reduced ejection fraction (HFrEF). Less is known about the prognostic significance of changes in hsTnT over time, the effects of dapagliflozin on clinical outcomes in relation to baseline hsTnT levels, and the effect of dapagliflozin on hsTnT levels. Methods: DAPA-HF was a randomized, double-blind, placebo-controlled trial of dapagliflozin (10 mg daily) in patients with NYHA class II-IV symptoms and left ventricular ejection fraction ≤40% (median follow-up = 18.2 months). hsTnT (Roche Diagnostics) was measured at baseline in 3,112 patients and at 1 year in 2,506 patients. The primary endpoint was adjudicated worsening HF or cardiovascular death. Clinical endpoints were analyzed according to baseline hsTnT and change in hsTnT from baseline to 1 year. Comparative treatment effects on clinical endpoints with dapagliflozin vs. placebo were assessed by baseline hsTnT. The effect of dapagliflozin on hsTnT was explored. Results: Median baseline hsTnT concentration was 20.0 (25th-75th percentile, 13.7 to 30.2) ng/L. Over 1 year, 67.9% of patients had a ≥10% relative increase or decrease in hsTnT concentrations, and 43.5% had a ≥20% relative change. A stepwise gradient of higher risk for the primary endpoint was observed across increasing quartiles of baseline hsTnT concentration (adjusted hazard ratio [aHR] Q4 vs. Q1, 5.10; 95% CI, 3.67-7.08). Relative and absolute increases in hsTnT over 1 year were associated with higher subsequent risk of the primary endpoint. The relative reduction in the primary endpoint with dapagliflozin was consistent across quartiles of baseline hsTnT (p-interaction = 0.55), but patients in the top quartile tended to have the greatest absolute risk reduction (absolute risk difference, 7.5%; 95% CI, 1.0% - 14.0%). Dapagliflozin tended to attenuate the increase in hsTnT over time compared to placebo (relative least squares mean reduction, -3% [-6% to 0%]; p=0.076). Conclusions: Higher baseline hsTnT and greater increase in hsTnT over 1 year are associated with worse clinical outcomes. Dapagliflozin consistently reduced the risk of the primary endpoint, irrespective of baseline hsTnT levels. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique Identifier: NCT03036124.
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Affiliation(s)
- David D Berg
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kieran F Docherty
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Naveed Sattar
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Paul Welsh
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Pardeep S Jhund
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | | | - Vijay Chopra
- Max Superspeciality Hospital, Saket, New Delhi, India
| | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City, MO
| | - Jose C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Eileen O'Meara
- Department of Cardiology, Montreal Heart Institute and Université de Montréal, Montreal, Canada
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte University Hospital, Herlev, Denmark
| | | | | | | | | | - John J V McMurray
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - David A Morrow
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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5
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Meijers WC, Bayes-Genis A, Mebazaa A, Bauersachs J, Cleland JGF, Coats AJS, Januzzi JL, Maisel AS, McDonald K, Mueller T, Richards AM, Seferovic P, Mueller C, de Boer RA. Circulating heart failure biomarkers beyond natriuretic peptides: review from the Biomarker Study Group of the Heart Failure Association (HFA), European Society of Cardiology (ESC). Eur J Heart Fail 2021; 23:1610-1632. [PMID: 34498368 PMCID: PMC9292239 DOI: 10.1002/ejhf.2346] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 08/13/2021] [Accepted: 09/07/2021] [Indexed: 12/18/2022] Open
Abstract
New biomarkers are being evaluated for their ability to advance the management of patients with heart failure. Despite a large pool of interesting candidate biomarkers, besides natriuretic peptides virtually none have succeeded in being applied into the clinical setting. In this review, we examine the most promising emerging candidates for clinical assessment and management of patients with heart failure. We discuss high-sensitivity cardiac troponins (Tn), procalcitonin, novel kidney markers, soluble suppression of tumorigenicity 2 (sST2), galectin-3, growth differentiation factor-15 (GDF-15), cluster of differentiation 146 (CD146), neprilysin, adrenomedullin (ADM), and also discuss proteomics and genetic-based risk scores. We focused on guidance and assistance with daily clinical care decision-making. For each biomarker, analytical considerations are discussed, as well as performance regarding diagnosis and prognosis. Furthermore, we discuss potential implementation in clinical algorithms and in ongoing clinical trials.
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Affiliation(s)
- Wouter C Meijers
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, CIBERCV, Barcelona, Spain
| | - Alexandre Mebazaa
- Inserm U942-MASCOT; Université de Paris; Department of Anesthesia and Critical Care, Hôpitaux Saint Louis & Lariboisière; FHU PROMICE, Paris, France.,Université de Paris, Paris, France.,Department of Anesthesia and Critical Care, Hôpitaux Saint Louis & Lariboisière, Paris, France.,FHU PROMICE, Paris, France
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow; National Heart & Lung Institute, Imperial College London, London, UK
| | - Andrew J S Coats
- Monash University, Melbourne, Australia.,University of Warwick, Coventry, UK
| | | | | | | | - Thomas Mueller
- Department of Clinical Pathology, Hospital of Bolzano, Bolzano, Italy
| | - A Mark Richards
- Christchurch Heart Institute, Christchurch, New Zealand.,Cardiovascular Research Institute, National University of Singapore, Singapore
| | - Petar Seferovic
- Faculty of Medicine, Belgrade University, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgarde, Serbia
| | | | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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6
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Nuzzi V, Merlo M, Specchia C, Lombardi CM, Carubelli V, Iorio A, Inciardi RM, Bellasi A, Canale C, Camporotondo R, Catagnano F, Dalla Vecchia LA, Giovinazzo S, Maccagni G, Mapelli M, Margonato D, Monzo L, Oriecuia C, Peveri G, Pozzi A, Provenzale G, Sarullo F, Tomasoni D, Ameri P, Gnecchi M, Leonardi S, Agostoni P, Carugo S, Danzi GB, Guazzi M, La Rovere MT, Mortara A, Piepoli M, Porto I, Volterrani M, Senni M, Metra M, Sinagra G. The prognostic value of serial troponin measurements in patients admitted for COVID-19. ESC Heart Fail 2021; 8:3504-3511. [PMID: 34236135 PMCID: PMC8426962 DOI: 10.1002/ehf2.13462] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/14/2021] [Accepted: 05/23/2021] [Indexed: 01/06/2023] Open
Abstract
Aims Myocardial injury (MI) in coronavirus disease‐19 (COVID‐19) is quite prevalent at admission and affects prognosis. Little is known about troponin trajectories and their prognostic role. We aimed to describe the early in‐hospital evolution of MI and its prognostic impact. Methods and results We performed an analysis from an Italian multicentre study enrolling COVID‐19 patients, hospitalized from 1 March to 9 April 2020. MI was defined as increased troponin level. The first troponin was tested within 24 h from admission, the second one between 24 and 48 h. Elevated troponin was defined as values above the 99th percentile of normal values. Patients were divided in four groups: normal, normal then elevated, elevated then normal, and elevated. The outcome was in‐hospital death. The study population included 197 patients; 41% had normal troponin at both evaluations, 44% had elevated troponin at both assessments, 8% had normal then elevated troponin, and 7% had elevated then normal troponin. During hospitalization, 49 (25%) patients died. Patients with incident MI, with persistent MI, and with MI only at admission had a higher risk of death compared with those with normal troponin at both evaluations (P < 0.001). At multivariable analysis, patients with normal troponin at admission and MI injury on Day 2 had the highest mortality risk (hazard ratio 3.78, 95% confidence interval 1.10–13.09, P = 0.035). Conclusions In patients admitted for COVID‐19, re‐test MI on Day 2 provides a prognostic value. A non‐negligible proportion of patients with incident MI on Day 2 is identified at high risk of death only by the second measurement.
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Affiliation(s)
- Vincenzo Nuzzi
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Via Valdoni 7, Trieste, 34100, Italy
| | - Marco Merlo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Via Valdoni 7, Trieste, 34100, Italy
| | - Claudia Specchia
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Carlo Mario Lombardi
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Valentina Carubelli
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Annamaria Iorio
- Cardiology Unit, Cardiovascular Department, Papa Giovanni XXIII Hospital-Bergamo, Bergamo, Italy
| | - Riccardo Maria Inciardi
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Antonio Bellasi
- Innovation and Brand Reputation Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Claudia Canale
- Department of Internal Medicine, IRCCS Ospedale Policlinico San Martino-IRCCS Italian Cardiovascular Network, University of Genova, Genoa, Italy
| | - Rita Camporotondo
- Intensive Cardiac Care Unit, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | | | - Laura Adelaide Dalla Vecchia
- Dipartimento di Cardiologia, Istituti Clinici Scientifici Maugeri, IRCCS, Istituto Scientifico di Milano, Milan, Italy
| | - Stefano Giovinazzo
- Department of Internal Medicine, IRCCS Ospedale Policlinico San Martino-IRCCS Italian Cardiovascular Network, University of Genova, Genoa, Italy
| | - Gloria Maccagni
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Division of Cardiology, Ospedale di Cremona, Cremona, Italy
| | - Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | | | - Luca Monzo
- Istituto Clinico Casal Palocco, Rome, Italy.,Policlinico Casilino, Rome, Italy
| | - Chiara Oriecuia
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy.,Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giulia Peveri
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Andrea Pozzi
- Cardiology Unit, Cardiovascular Department, Papa Giovanni XXIII Hospital-Bergamo, Bergamo, Italy
| | - Giovanni Provenzale
- Division of Cardiology, Ospedale San Paolo, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Filippo Sarullo
- Cardiovascular Rehabilitation Unit, Buccheri La Ferla Fatebenefratelli Hospital, Palermo, Italy
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Pietro Ameri
- Department of Internal Medicine, IRCCS Ospedale Policlinico San Martino-IRCCS Italian Cardiovascular Network, University of Genova, Genoa, Italy
| | - Massimiliano Gnecchi
- Intensive Cardiac Care Unit, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy.,Department of Molecular Medicine, Cardiology Unit, University of Pavia, Pavia, Italy
| | - Sergio Leonardi
- Intensive Cardiac Care Unit, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy.,Department of Molecular Medicine, Cardiology Unit, University of Pavia, Pavia, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Stefano Carugo
- Division of Cardiology, Ospedale San Paolo, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | | | - Marco Guazzi
- Heart Failure Unit, Cardiology Department, University of Milan, Milan, Italy.,IRCCS Policlinico San Donato, Milan, Italy
| | - Maria Teresa La Rovere
- Dipartimento di Cardiologia, Istituti Clinici Scientifici Maugeri, IRCCS, Istituto Scientifico di Montescano, Pavia, Italy
| | - Andrea Mortara
- Cardiology Department, Policlinico di Monza, Monza, Italy
| | - Massimo Piepoli
- Heart Failure Unit, Guglielmo da Saliceto Hospital, AUSL Piacenza, Piacenza, Italy.,Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Italo Porto
- Department of Internal Medicine, IRCCS Ospedale Policlinico San Martino-IRCCS Italian Cardiovascular Network, University of Genova, Genoa, Italy
| | - Maurizio Volterrani
- Department of Cardiovascular and Respiratory Sciences, IRCCS, San Raffaele Pisana Rome, Rome, Italy
| | - Michele Senni
- Cardiology Unit, Cardiovascular Department, Papa Giovanni XXIII Hospital-Bergamo, Bergamo, Italy
| | - Marco Metra
- Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Via Valdoni 7, Trieste, 34100, Italy
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7
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Wettersten N, Horiuchi Y, van Veldhuisen DJ, Ix JH, Mueller C, Filippatos G, Nowak R, Hogan C, Kontos MC, Cannon CM, Müeller GA, Birkhahn R, Taub P, Vilke GM, Duff S, McDonald K, Mahon N, Nuñez J, Briguori C, Passino C, Maisel A, Murray PT. Decongestion discriminates risk for one-year mortality in patients with improving renal function in acute heart failure. Eur J Heart Fail 2021; 23:1122-1130. [PMID: 33788989 DOI: 10.1002/ejhf.2179] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/19/2021] [Accepted: 03/23/2021] [Indexed: 01/28/2023] Open
Abstract
AIMS Improving renal function (IRF) is paradoxically associated with worse outcomes in acute heart failure (AHF), but outcomes may differ based on response to decongestion. We explored if the relationship of IRF with mortality in hospitalized AHF patients differs based on successful decongestion. METHODS AND RESULTS We evaluated 760 AHF patients from AKINESIS for the relationship between IRF, change in B-type natriuretic peptide (BNP), and 1-year mortality. IRF was defined as a ≥20% increase in estimated glomerular filtration rate (eGFR) relative to admission. Adequate decongestion was defined as a ≥40% decrease in last measured BNP relative to admission. IRF occurred in 22% of patients who had a mean age of 69 years, 58% were men, 72% were white, and median admission eGFR was 49 mL/min/1.73 m2 . IRF patients had more severe heart failure reflected by lower admission eGFR, higher blood urea nitrogen, lower systolic blood pressure, lower sodium, and higher use of inotropes. IRF patients had higher 1-year mortality (25%) than non-IRF patients (15%) (P < 0.01). However, this relationship differed by BNP trajectory (P-interaction = 0.03). When stratified by BNP change, non-IRF patients and IRF patients with decreasing BNP had lower 1-year mortality than either non-IRF and IRF patients without decreasing BNP. However, in multivariate analysis, IRF was not associated with mortality [adjusted hazard ratio (HR) 1.0, 95% confidence interval (CI) 0.7-1.5] while BNP was (adjusted HR 0.5, 95% CI 0.3-0.7). When IRF was evaluated as transiently occurring or persisting at discharge, again only BNP change was significantly associated with mortality. CONCLUSION Improving renal function is associated with mortality in AHF but not independent of other variables and congestion status. Achieving adequate decongestion, as reflected by lower BNP, in AHF is more strongly associated with mortality than IRF.
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Affiliation(s)
- Nicholas Wettersten
- Division of Cardiovascular Medicine, Veterans Affairs San Diego Healthcare System, San Diego, CA, USA.,Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA
| | - Yu Horiuchi
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Joachim H Ix
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego and Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Gerasimos Filippatos
- Department of Cardiology, Athens University Hospital Attikon, University of Athens, Athens, Greece
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Hospital System, Detroit, MI, USA
| | - Christopher Hogan
- Division of Emergency Medicine and Acute Care Surgical Services, VCU Medical Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Michael C Kontos
- Division of Cardiology, VCU Medical Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Chad M Cannon
- Department of Emergency Medicine, University of Kansas Medical Center, Kansas City, MO, USA
| | - Gerhard A Müeller
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, University of Göttingen, Göttingen, Germany
| | - Robert Birkhahn
- Department of Emergency Medicine, New York Methodist, Brooklyn, NY, USA
| | - Pam Taub
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA
| | - Gary M Vilke
- Department of Emergency Medicine, University of California San Diego, La Jolla, CA, USA
| | - Stephen Duff
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Kenneth McDonald
- Department of Cardiology, Mater Misericordiae University Hospital, University College Dublin, Dublin, Ireland.,Department of Cardiology, St. Vincent's University Hospital, Dublin, Ireland
| | - Niall Mahon
- Department of Cardiology, Mater Misericordiae University Hospital, University College Dublin, Dublin, Ireland
| | - Julio Nuñez
- Department of Cardiology, Hospital Clínico Universitario Valencia, INCLIVA, University of Valencia, Valencia, Spain.,CIBER in Cardiovascular Diseases, Madrid, Spain
| | - Carlo Briguori
- Department of Cardiology, Interventional Cardiology, Mediterranea Cardiocentro, Naples, Italy
| | - Claudio Passino
- Department of Cardiology and Cardiovascular Medicine, Fondazione Gabriele Monasterio, Pisa, Italy
| | - Alan Maisel
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA
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8
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Biomarkers in Acute Heart Failure: Diagnosis, Prognosis, and Treatment. INTERNATIONAL JOURNAL OF HEART FAILURE 2021; 3:81-105. [PMID: 36262882 PMCID: PMC9536694 DOI: 10.36628/ijhf.2020.0036] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 12/28/2020] [Accepted: 01/11/2021] [Indexed: 01/16/2023]
Abstract
Heart failure is a global health problem. An episode of acute heart failure (AHF) is a period of substantial morbidity and mortality with few advances in the management of an episode that have improved outcomes. The measurement of multiple biomarkers has become an integral adjunctive tool for the management of AHF. Many biomarkers are now well established in their ability to assist with diagnosis and prognostication of an AHF patient. There are also emerging biomarkers that are showing significant promise in the areas of diagnosis and prognosis. For improving the management of AHF, both established and novel biomarkers may assist in guiding medical therapy and subsequently improving outcomes. Thus, it is important to understand the different abilities and limitations of established and emerging biomarkers in AHF so that they may be correctly interpreted and integrated into clinical practice for AHF. This knowledge may improve the care of AHF patients. This review will summarize the evidence of both established and novel biomarkers for diagnosis, prognosis and management in AHF so that the treating clinician may become more comfortable incorporating these biomarkers into clinical practice in an evidence-based manner.
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9
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Redón P, Shahzad A, Iqbal T, Wijns W. Benefits of Home-Based Solutions for Diagnosis and Treatment of Acute Coronary Syndromes on Health Care Costs: A Systematic Review. SENSORS (BASEL, SWITZERLAND) 2020; 20:E5006. [PMID: 32899338 PMCID: PMC7506920 DOI: 10.3390/s20175006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 08/29/2020] [Accepted: 09/01/2020] [Indexed: 01/06/2023]
Abstract
Diagnosing and treating acute coronary syndromes consumes a significant fraction of the healthcare budget worldwide. The pressure on resources is expected to increase with the continuing rise of cardiovascular disease, other chronic diseases and extended life expectancy, while expenditure is constrained. The objective of this review is to assess if home-based solutions for measuring chemical cardiac biomarkers can mitigate or reduce the continued rise in the costs of ACS treatment. A systematic review was performed considering published literature in several relevant public databases (i.e., PUBMED, Cochrane, Embase and Scopus) focusing on current biomarker practices in high-risk patients, their cost-effectiveness and the clinical evidence and feasibility of implementation. Out of 26,000 references screened, 86 met the inclusion criteria after independent full-text review. Current clinical evidence highlights that home-based solutions implemented in primary and secondary prevention reduce health care costs by earlier diagnosis, improved patient outcomes and quality of life, as well as by avoidance of unnecessary use of resources. Economical evidence suggests their potential to reduce health care costs if the incremental cost-effectiveness ratio or the willingness-to-pay does not surpass £20,000/QALY or €50,000 limit per 20,000 patients, respectively. The cost-effectiveness of these solutions increases when applied to high-risk patients.
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Affiliation(s)
- Pau Redón
- CÚRAM Center for Research in Medical Devices, H91 W2TY Galway, Ireland;
- Smart Sensor Lab, School of Medicine, National University of Ireland, Galway (NUIG), H91 TK33 Galway, Ireland; (A.S.); (T.I.)
| | - Atif Shahzad
- Smart Sensor Lab, School of Medicine, National University of Ireland, Galway (NUIG), H91 TK33 Galway, Ireland; (A.S.); (T.I.)
| | - Talha Iqbal
- Smart Sensor Lab, School of Medicine, National University of Ireland, Galway (NUIG), H91 TK33 Galway, Ireland; (A.S.); (T.I.)
| | - William Wijns
- CÚRAM Center for Research in Medical Devices, H91 W2TY Galway, Ireland;
- Smart Sensor Lab, School of Medicine, National University of Ireland, Galway (NUIG), H91 TK33 Galway, Ireland; (A.S.); (T.I.)
- Saolta University Healthcare Group, University Hospital Galway, Newcastle Road, H91 YR71 Galway, Ireland
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10
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Sweda R, Sabti Z, Strebel I, Kozhuharov N, Wussler D, Shrestha S, Flores D, Badertscher P, Lopez‐Ayala P, Zimmermann T, Michou E, Gualandro DM, Häberlin A, Tanner H, Keller DI, Nowak A, Pfister O, Breidthardt T, Mueller C, Reichlin T. Diagnostic and prognostic values of the QRS-T angle in patients with suspected acute decompensated heart failure. ESC Heart Fail 2020; 7:1817-1829. [PMID: 32452635 PMCID: PMC7373892 DOI: 10.1002/ehf2.12746] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 04/08/2020] [Accepted: 04/20/2020] [Indexed: 01/06/2023] Open
Abstract
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.
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Affiliation(s)
- Romy Sweda
- Department of Cardiology, Inselspital, University Hospital BernUniversity of BernBernSwitzerland
- sitem Center for Translational Medicine and Biomedical EntrepreneurshipUniversity of BernBernSwitzerland
| | - Zaid Sabti
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB)University Hospital BaselBaselSwitzerland
| | - Ivo Strebel
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB)University Hospital BaselBaselSwitzerland
| | - Nikola Kozhuharov
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB)University Hospital BaselBaselSwitzerland
| | - Desiree Wussler
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB)University Hospital BaselBaselSwitzerland
| | - Samyut Shrestha
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB)University Hospital BaselBaselSwitzerland
| | - Dayana Flores
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB)University Hospital BaselBaselSwitzerland
| | - Patrick Badertscher
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB)University Hospital BaselBaselSwitzerland
| | - Pedro Lopez‐Ayala
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB)University Hospital BaselBaselSwitzerland
| | - Tobias Zimmermann
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB)University Hospital BaselBaselSwitzerland
| | - Eleni Michou
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB)University Hospital BaselBaselSwitzerland
| | - Danielle M. Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB)University Hospital BaselBaselSwitzerland
| | - Andreas Häberlin
- Department of Cardiology, Inselspital, University Hospital BernUniversity of BernBernSwitzerland
- sitem Center for Translational Medicine and Biomedical EntrepreneurshipUniversity of BernBernSwitzerland
| | - Hildegard Tanner
- Department of Cardiology, Inselspital, University Hospital BernUniversity of BernBernSwitzerland
| | | | - Albina Nowak
- Department of Endocrinology and Clinical NutritionUniversity Hospital ZurichZurichSwitzerland
| | - Otmar Pfister
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB)University Hospital BaselBaselSwitzerland
| | - Tobias Breidthardt
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB)University Hospital BaselBaselSwitzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB)University Hospital BaselBaselSwitzerland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, University Hospital BernUniversity of BernBernSwitzerland
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB)University Hospital BaselBaselSwitzerland
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11
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Nikhanj A, Nichols BM, Wang K, Siddiqi ZA, Oudit GY. Evaluating the Diagnostic and Prognostic Value of Biomarkers for Heart Disease and Major Adverse Cardiac Events in Patients With Muscular Dystrophy. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 7:564-573. [PMID: 32687175 DOI: 10.1093/ehjqcco/qcaa059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/10/2020] [Accepted: 07/14/2020] [Indexed: 12/17/2022]
Abstract
AIMS Heart disease is recognized as the leading cause of morbidity and mortality in patients with muscular dystrophy (MD). Our study demonstrates the clinical utility of cardiac biomarkers to improve the diagnosis of cardiomyopathy and prognostication of major adverse cardiac events (MACE) in these vulnerable patients. METHODS AND RESULTS We prospectively followed 117 patients (median age, 42 (interquartile range [IQR], 26-50) years; 49 [41.9%] women) at the Neuromuscular Multidisciplinary clinic diagnosed with a dystrophinopathy, limb-girdle MD, type 1 myotonic dystrophy, or facioscapulohumeral MD. We determined that B-type natriuretic peptide (BNP) and high-sensitive troponin I (hsTnI) were effective diagnostic markers of cardiomyopathy (area under the curve [AUC], 0.64; P=0.017; and AUC, 0.69; P=0.001, respectively). Patient risk stratification for MACE was based on cutoff values of BNP and hsTnI defined a priori as 30.5000 pg/mL and 7.6050 ng/L, respectively. Over a median follow-up period of 2.09 (IQR, 1.17-2.81) years there were 36 confirmed MACE. Multivariate regression analyses showed that patients with BNP and hsTnI levels above the respective cutoff values had a 3.70-fold (P=0.001) and 3.24-fold (P=0.002) greater risk of MACE, respectively, compared to patients with biomarker levels below. Furthermore, patients with biomarker levels above both cutoff values had a 4.08-fold (P=0.001) greater risk of MACE. Inflammatory biomarkers did not show clinical utility for heart disease in these patients. CONCLUSION Our study demonstrates important diagnostic and prognostic value of BNP and hsTnI as part of a comprehensive cardiac assessment to augment the management and treatment of heart disease in patients with MD.
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Affiliation(s)
- Anish Nikhanj
- Division of Cardiology, University of Alberta, Edmonton, Canada.,Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Bailey Miskew Nichols
- Division of Cardiology, University of Alberta, Edmonton, Canada.,Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Kaiming Wang
- Division of Cardiology, University of Alberta, Edmonton, Canada.,Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Zaeem A Siddiqi
- Division of Neurology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Gavin Y Oudit
- Division of Cardiology, University of Alberta, Edmonton, Canada.,Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
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12
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Lombardi C, Peveri G, Cani D, Latta F, Bonelli A, Tomasoni D, Sbolli M, Ravera A, Carubelli V, Saccani N, Specchia C, Metra M. In-hospital and long-term mortality for acute heart failure: analysis at the time of admission to the emergency department. ESC Heart Fail 2020; 7:2650-2661. [PMID: 32588981 PMCID: PMC7524058 DOI: 10.1002/ehf2.12847] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 05/28/2020] [Accepted: 06/02/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS Acute heart failure (AHF) leads to a drastic increase in mortality and rehospitalization. The aim of the study was to identify prognostic variables in a real-life population of AHF patients admitted to the emergency department with acute shortness of breath. METHODS AND RESULTS We evaluated potential predictors of mortality in 728 consecutive patients admitted to the emergency department with AHF. Possible predictors of all-cause and cardiovascular (CV) mortality were investigated by Cox and Fine and Gray models at multivariable analysis. Among the 728 patients, 256 died during the entire follow-up, 142 of these due to CV cause. The 1 year mortality rate was 20%, with the highest risk of death during the index hospitalization (with 8% estimate in-hospital mortality at 30 days). A higher risk of events during the index hospitalization was more evident for the CV deaths, for which we found a cumulative 1 year incidence of 12% with a cumulative incidence in the first 30 days of hospitalization of about 5%. At multivariable analysis, age (P < 0.001), New York Heart Association (NYHA) class IV vs. I-II-III (P = 0.001), systolic blood pressure (P < 0.001), non-cardiac co-morbidities (≥3 vs. 0, P = 0.05), oxygen saturation (P = 0.03), serum creatinine (P < 0.001), and left ventricular ejection fraction (LVEF) (40-49% vs. <40%, P = 0.004; ≥50% vs. <40%, P = 0.003) were independent predictors of all-cause mortality during the entire follow-up. Age (P = 0.03), systolic blood pressure (P = 0.01), oxygen saturation (P = 0.03), serum creatinine (P = 0.02), and LVEF (40-49% vs. <40%, P = 0.03; ≥50% vs. <40%, P = 0.004) were independent predictors of CV mortality during the entire follow-up. NYHA class IV vs. I-II-III (P < 0.001), serum creatinine (P = 0.01), and LVEF (40-49% vs. <40%, P = 0.02; ≥50% vs. <40%, P < 0.001) remained independent predictors for in-hospital death, while only serum creatinine (P = 0.04), LVEF (40-49% vs. <40%: 0.32, P = 0.04; ≥50% vs. <40%, P < 0.001), and NYHA class vs. I-II-III (P = 0.02) remained predictors for in-hospital CV mortality. CONCLUSIONS In this real-life cohort of patients with AHF, the results showed a similar mortality rate comparing with other analysis and with the most important registries. Age, NYHA class IV, systolic blood pressure, creatinine levels, sodium levels, and ejection fraction were independent predictors of 1 year mortality, while LVEF <40% was the only predictor of both all-cause mortality and CV mortality.
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Affiliation(s)
- Carlo Lombardi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, University of Brescia Spedali Civili of Brescia, Brescia, Italy
| | - Giulia Peveri
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Dario Cani
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, University of Brescia Spedali Civili of Brescia, Brescia, Italy
| | - Federica Latta
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, University of Brescia Spedali Civili of Brescia, Brescia, Italy
| | - Andrea Bonelli
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, University of Brescia Spedali Civili of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, University of Brescia Spedali Civili of Brescia, Brescia, Italy
| | - Marco Sbolli
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, University of Brescia Spedali Civili of Brescia, Brescia, Italy
| | - Alice Ravera
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, University of Brescia Spedali Civili of Brescia, Brescia, Italy
| | - Valentina Carubelli
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, University of Brescia Spedali Civili of Brescia, Brescia, Italy
| | - Nicola Saccani
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, University of Brescia Spedali Civili of Brescia, Brescia, Italy
| | - Claudia Specchia
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health University, University of Brescia Spedali Civili of Brescia, Brescia, Italy
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13
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Borah P, Deka S, Mailavaram RP, Deb PK. P1 Receptor Agonists/Antagonists in Clinical Trials - Potential Drug Candidates of the Future. Curr Pharm Des 2020; 25:2792-2807. [PMID: 31333097 DOI: 10.2174/1381612825666190716111245] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 07/03/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Adenosine mediates various physiological and pathological conditions by acting on its four P1 receptors (A1, A2A, A2B and A3 receptors). Omnipresence of P1 receptors and their activation, exert a wide range of biological activities. Thus, its modulation is implicated in various disorders like Parkinson's disease, asthma, cardiovascular disorders, cancer etc. Hence these receptors have become an interesting target for the researchers to develop potential therapeutic agents. Number of molecules were designed and developed in the past few years and evaluated for their efficacy in various disease conditions. OBJECTIVE The main objective is to provide an overview of new chemical entities which have crossed preclinical studies and reached clinical trials stage following their current status and future prospective. METHODS In this review we discuss current status of the drug candidates which have undergone clinical trials and their prospects. RESULTS Many chemical entities targeting various subtypes of P1 receptors are patented; twenty of them have crossed preclinical studies and reached clinical trials stage. Two of them viz adenosine and regadenoson are approved by the Food and Drug Administration. CONCLUSION This review is an attempt to highlight the current status, progress and probable future of P1 receptor ligands which are under clinical trials as promising novel therapeutic agents and the direction in which research should proceed with a view to come out with novel therapeutic agents.
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Affiliation(s)
- Pobitra Borah
- Pratiksha Institute of Pharmaceutical Sciences, Panikhaiti, Chandrapur Road, Guwahati, Assam, India
| | - Satyendra Deka
- Pratiksha Institute of Pharmaceutical Sciences, Panikhaiti, Chandrapur Road, Guwahati, Assam, India
| | - Raghu Prasad Mailavaram
- Department of Pharmaceutical Chemistry, Shri Vishnu College of Pharmacy, Vishnupur (Affiliated to Andhra University), Bhimavaram, W.G. Dist., AP, India
| | - Pran Kishore Deb
- Faculty of Pharmacy, Philadelphia University, Amman, PO Box-1, 19392, Jordan
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14
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Fudim M, Ambrosy AP, Sun JL, Anstrom KJ, Bart BA, Butler J, AbouEzzeddine O, Greene SJ, Mentz RJ, Redfield MM, Reddy YNV, Vaduganathan M, Braunwald E, Hernandez AF, Borlaug BA, Felker GM. High-Sensitivity Troponin I in Hospitalized and Ambulatory Patients With Heart Failure With Preserved Ejection Fraction: Insights From the Heart Failure Clinical Research Network. J Am Heart Assoc 2019; 7:e010364. [PMID: 30561266 PMCID: PMC6405612 DOI: 10.1161/jaha.118.010364] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background We sought to study the prevalence of high-sensitivity troponin and its association with cardiac structure and outcomes in ambulatory and hospitalized patients with heart failure with a preserved ejection fraction ( HF p EF ). Methods and Results A post hoc analysis utilized data from HF p EF patients: DOSE (Diuretic Optimization Strategies Evaluation) and CARRESS - HF (Cardiorenal Rescue Study in Acute Decompensated Heart Failure) enrolled patients hospitalized with acute HF p EF , and RELAX (Phosphodiesterase-5 Inhibition to Improve Clinical Status and Exercise Capacity in Heart Failure With Preserved Ejection Fraction) enrolled ambulatory patients with HF p EF . High-sensitivity troponin I (hs-TnI) was measured in hospitalized patients at baseline, at 72 to 96 hours, on day 7, and on day 60. In ambulatory patients hs-TnI was measured at baseline and at week 24. In the ambulatory cohort, correlations between hs-TnI and cardiac structure and function were assessed. The association between hs-TnI and a 60-day composite of emergency room visits, readmissions, and death was assessed for hospitalized patients using multivariable Cox proportional hazard models. The study population included 139 hospitalized and 212 ambulatory patients with HF p EF and hs-TnI measured at baseline. The median (25th, 75th percentiles) baseline troponin was 17.6 (11.1, 41.0) ng/L in hospitalized patients and 9.5 (5.3, 19.7) ng/L in ambulatory patients ( P<0.001). The prevalence of elevated hs-TnI (>99% percentile upper reference limit was 86% in hospitalized patients and 53% among ambulatory patients, with stable elevation in ambulatory patients during follow-up. HF p EF patients with a hs-TnI above the median were older with worse left ventricular hypertrophy and diastolic dysfunction. Continuously valued hs-TnI (per doubling) was associated with increased risk of composite end point (adjusted hazard ratio 1.20, 95% confidence interval 1.00-1.43; P=0.042). Conclusions Hs-TnI is commonly elevated among both hospitalized and ambulatory patients with HF p EF . Increased hs-TnI levels are associated with worse cardiac structure and increased risk of adverse events.
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Affiliation(s)
- Marat Fudim
- 1 Duke Clinical Research Institute and Division of Cardiology Duke University Medical Center Durham NC
| | - Andrew P Ambrosy
- 1 Duke Clinical Research Institute and Division of Cardiology Duke University Medical Center Durham NC
| | - Jie-Lena Sun
- 1 Duke Clinical Research Institute and Division of Cardiology Duke University Medical Center Durham NC
| | - Kevin J Anstrom
- 1 Duke Clinical Research Institute and Division of Cardiology Duke University Medical Center Durham NC
| | - Bradley A Bart
- 2 Division of Cardiology Hennepin County Medical Center Minneapolis MN
| | - Javed Butler
- 3 Division of Cardiology Stony Brook University Stony Brook NY
| | | | - Stephen J Greene
- 1 Duke Clinical Research Institute and Division of Cardiology Duke University Medical Center Durham NC
| | - Robert J Mentz
- 1 Duke Clinical Research Institute and Division of Cardiology Duke University Medical Center Durham NC
| | | | - Yogesh N V Reddy
- 4 Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | - Muthiah Vaduganathan
- 5 Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School Boston MA
| | - Eugene Braunwald
- 5 Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School Boston MA
| | - Adrian F Hernandez
- 1 Duke Clinical Research Institute and Division of Cardiology Duke University Medical Center Durham NC
| | - Barry A Borlaug
- 4 Department of Cardiovascular Diseases Mayo Clinic Rochester MN
| | - G Michael Felker
- 1 Duke Clinical Research Institute and Division of Cardiology Duke University Medical Center Durham NC
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15
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Biegus J, Demissei B, Postmus D, Cotter G, Davison BA, Felker GM, Filippatos G, Gimpelewicz C, Greenberg B, Metra M, Severin T, Teerlink JR, Voors AA, Ponikowski P. Hepatorenal dysfunction identifies high-risk patients with acute heart failure: insights from the RELAX-AHF trial. ESC Heart Fail 2019; 6:1188-1198. [PMID: 31568696 PMCID: PMC6989278 DOI: 10.1002/ehf2.12477] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 05/09/2019] [Accepted: 05/21/2019] [Indexed: 12/26/2022] Open
Abstract
AIMS Episodes of acute heart failure (AHF) may lead to end-organ dysfunction. In this post hoc analysis of the Relaxin in Acute Heart Failure trial, we used the MELD-XI (Model of End-Stage Liver Dysfunction) score to examine hepatorenal dysfunction in patients with AHF. METHODS AND RESULTS On admission, the MELD-XI score was elevated (abnormal) in 918 (82%) patients, with 638 (57%) having isolated renal dysfunction (creatinine > 1 mg/dL), 73 (6.5%) isolated liver dysfunction (bilirubin > 1 mg/dL), and 207 (18.5%) coexisting dysfunction of the kidneys and the liver (both creatinine and bilirubin > 1 mg/dL). The percentage of patients with elevated MELD-XI score remained constant through a 60 day follow-up, as we observed a gradual decrease of liver dysfunction prevalence, counterbalanced by an increase in renal dysfunction. Serelaxin treatment was associated with a lower MELD-XI score on Day 2 and Day 5 (both P < 0.05), but this difference vs. placebo disappeared during longer follow-up. In the multivariable model, an elevated MELD-XI score on admission was associated with higher 180 day mortality: hazard ratios (95% confidence interval) for cardiovascular death were 3.10 (1.22-7.87), and for all-cause death 2.47 (1.19-5.15); both P < 0.05. The addition of the MELD-XI score to a prespecified prognostic model increased the discrimination of the model for all-cause death, but the increment in the C-index was only modest: 0.013 (P = 0.02). CONCLUSIONS In patients with AHF, hepatorenal dysfunction is prevalent and related to poor outcome. The MELD-XI score is a useful prognosticator in AHF.
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Affiliation(s)
- Jan Biegus
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.,Department of Cardiology, Centre for Heart Diseases, Clinical Military Hospital, Wroclaw, Poland
| | - Biniyam Demissei
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Douwe Postmus
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gad Cotter
- Momentum Research, Inc., Durham, NC, USA
| | | | | | - Gerasimos Filippatos
- School of Medicine, University of Cyprus, Nicosia, Cyprus.,School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | | | | | - Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Thomas Severin
- Novartis Pharmaceuticals Corporation, New Hanover, NJ, USA
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Adriaan A Voors
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.,Department of Cardiology, Centre for Heart Diseases, Clinical Military Hospital, Wroclaw, Poland
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16
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Pang PS, Fermann GJ, Hunter B, Levy P, Lane KA, Li X, Cole M, Collins SP. TACIT (High Sensitivity Troponin T Rules Out Acute Cardiac Insufficiency Trial). Circ Heart Fail 2019; 12:e005931. [PMID: 31288565 PMCID: PMC6719714 DOI: 10.1161/circheartfailure.119.005931] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/09/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Identifying low-risk acute heart failure patients safe for discharge from the emergency department is a major unmet need. METHODS AND RESULTS A prospective, observational, multicenter pilot study targeting lower risk acute heart failure patients to determine whether hsTnT (high-sensitivity troponin T) identifies emergency department acute heart failure patients at low risk for rehospitalization and mortality. hsTnT was drawn at baseline and 3 hours. Phone follow-up occurred at 30 and 90 days. The primary end point composite of all-cause mortality, rehospitalization, and emergency department visits at 90 days (changed from 30 days because of lack of mortality events), analyzed using logistic regression. Secondary end points: 30- and 90-day all-cause mortality. hsTnT values less than the 99th percentile were defined as low hsTnT. Out of 527 enrolled patients, 499 comprised the initial analysis set. Of these, 332 had both 0- and 3-hour hsTnT drawn, of whom 319 completed 30 day follow-up. The average age was 62, 60% male, and 57% black. Median hsTnT was 26.4 ng/L (interquartile range, 15.1-44.3). There were 99 (21%) 30-day composite events, 13 (2.7%) deaths at 30 days, and 25 deaths (8.2%) at 90 days. Serial hsTnT values below the 99th percentile were not associated with a lower risk for the 90-day primary composite end point (odds ratio, 0.79; 95% CI, 0.42-1.50; P=0.4736). However, no deaths occurred in the low hsTnT group at 30 days with 1 death at 90 days. CONCLUSIONS hsTnT did not identify patients at low risk for the primary outcome of rehospitalization, emergency department visits, and mortality at 90 days. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT02592135.
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Affiliation(s)
- Peter S. Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gregory J. Fermann
- Department of Emergency Medicine, University of Cincinnati College of Medicine
| | - Benton Hunter
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Phillip Levy
- Department of Emergency Medicine, Wayne State University School of Medicine
| | - Kathleen A. Lane
- Department of Biostatistics, Indiana University School of Medicine
| | - Xiaochun Li
- Department of Biostatistics, Indiana University School of Medicine
| | - Mette Cole
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sean P. Collins
- Department of Emergency Medicine, Vanderbilt University School of Medicine
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17
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18
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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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19
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Palazzuoli A, Evangelista I, Ruocco G, Lombardi C, Giovannini V, Nuti R, Ghio S, Ambrosio G. Early readmission for heart failure: An avoidable or ineluctable debacle? Int J Cardiol 2018; 277:186-195. [PMID: 30262226 DOI: 10.1016/j.ijcard.2018.09.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 08/30/2018] [Accepted: 09/10/2018] [Indexed: 12/18/2022]
Abstract
Early hospital readmission after an episode of Acute Decompensated Heart Failure (ADHF) is an emerging issue that is causing a relevant clinical and economic burden. Although there might be several reasons for early readmissions, in many cases these might be effectively prevented by a more adequate post-discharge management, including recommendations on lifestyle and rehabilitation programs. However, almost half of hospitalizations are unrelated to specific cardiac causes and thus increases the difficulty in analyzing risks prediction. Many episodes are related to social environment, poor familiar assistance and inadequate followup program. In addition, the national and insurance companies constantly quest for a reduction of costs that could lead to inappropriately shortened hospital stays. Therefore, the suitability of early re-hospitalization as a correct target for good medical practice is highly debated. Nevertheless, the post-discharge phase after episodes of ADHF remains poorly analyzed in clinical trials and specific investigations should be considered during the transition period from acute to chronic status. A validated program, which focuses on an appropriate risk algorithm including cardiac and extracardiac precipitating factors is lacking. This is a necessary and it should become one of the most important targets to aim for in HF management and strategy.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Internal Medicine, University of Siena, Siena, Italy.
| | - Isabella Evangelista
- Cardiovascular Diseases Unit, Department of Internal Medicine, University of Siena, Siena, Italy
| | - Gaetano Ruocco
- Cardiovascular Diseases Unit, Department of Internal Medicine, University of Siena, Siena, Italy
| | - Carlo Lombardi
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Valtere Giovannini
- Azienda Ospedaliera Universitaria Senese, Le Scotte Hospital, Siena, Italy
| | - Ranuccio Nuti
- Cardiovascular Diseases Unit, Department of Internal Medicine, University of Siena, Siena, Italy
| | - Stefano Ghio
- Division of Cardiology, Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy
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20
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GRODIN JUSTINL, BUTLER JAVED, METRA MARCO, FELKER GMICHAEL, VOORS ADRIAANA, MCMURRAY JOHNJ, ARMSTRONG PAULW, HERNANDEZ ADRIANF, O'CONNOR CHRISTOPHER, STARLING RANDALLC, TANG WWILSON. Circulating Cardiac Troponin I Levels Measured by a Novel Highly Sensitive Assay in Acute Decompensated Heart Failure: Insights From the ASCEND-HF Trial. J Card Fail 2018; 24:512-519. [DOI: 10.1016/j.cardfail.2018.06.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 06/02/2018] [Accepted: 06/28/2018] [Indexed: 12/23/2022]
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21
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Collins SP, Levy PD, Fermann GJ, Givertz MM, Martindale JM, Pang PS, Storrow AB, Diercks DD, Michael Felker G, Fonarow GC, Lanfear DJ, Lenihan DJ, Lindenfeld JM, Frank Peacock W, Sawyer DM, Teerlink JR, Butler J. What's Next for Acute Heart Failure Research? Acad Emerg Med 2018; 25:85-93. [PMID: 28990334 DOI: 10.1111/acem.13331] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 09/29/2017] [Accepted: 10/01/2017] [Indexed: 12/11/2022]
Abstract
Each year over one million patients with acute heart failure (AHF) present to a United States emergency department (ED). The vast majority are hospitalized for further management. The length of stay and high postdischarge event rate in this cohort have changed little over the past decade. Therapeutic trials have failed to yield substantive improvement in postdischarge outcomes; subsequently, AHF care has changed little in the past 40 years. Prior research studies have been fragmented as either "inpatient" or "ED-based." Recognizing the challenges in identification and enrollment of ED patients with AHF, and the lack of robust evidence to guide management, an AHF clinical trials network was developed. This network has demonstrated, through organized collaboration between cardiology and emergency medicine, that many of the hurdles in AHF research can be overcome. The development of a network that supports the collaboration of acute care and HF researchers, combined with the availability of federally funded infrastructure, will facilitate more efficient conduct of both explanatory and pragmatic trials in AHF. Yet many important questions remain, and in this document our group of emergency medicine and cardiology investigators have identified four high-priority research areas.
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Affiliation(s)
- Sean P. Collins
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN
| | - Phillip D. Levy
- Department of Emergency Medicine Wayne State University Detroit MI
| | - Gregory J. Fermann
- Department of Emergency Medicine University of Cincinnati Medical Center Cincinnati OH
| | | | | | - Peter S. Pang
- Department of Emergency Medicine Indiana University School of Medicine & Indianapolis EMS Indianapolis IN
| | - Alan B. Storrow
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN
| | - Deborah D. Diercks
- Department of Emergency Medicine University of Texas Southwestern Medical Center Dallas TX
| | | | - Gregg C. Fonarow
- Division of Cardiology University of California Los Angeles Ronald Reagan Medical Center Los AngelesCA
| | | | - Daniel J. Lenihan
- Division of Cardiology Vanderbilt University Medical Center Nashville TN
| | | | - W. Frank Peacock
- Department of Emergency Medicine Baylor University Medical Center Houston TX
| | | | - John R. Teerlink
- Division of Cardiology University of California San Francisco and the San Francisco VA San Francisco CA
| | - Javed Butler
- Division of Cardiology Stony Brook University Medical Center Stony BrookNY
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22
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Greene SJ, Butler J, Fonarow GC, Subacius HP, Ambrosy AP, Vaduganathan M, Triggiani M, Solomon SD, Lewis EF, Maggioni AP, Böhm M, Chioncel O, Nodari S, Senni M, Zannad F, Gheorghiade M. Pre-discharge and early post-discharge troponin elevation among patients hospitalized for heart failure with reduced ejection fraction: findings from the ASTRONAUT trial. Eur J Heart Fail 2017; 20:281-291. [PMID: 29044915 DOI: 10.1002/ejhf.1019] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 07/20/2017] [Accepted: 08/28/2017] [Indexed: 12/19/2022] Open
Abstract
AIMS Troponin levels are commonly elevated among patients hospitalized for heart failure (HF), but the prevalence and prognostic significance of early post-discharge troponin elevation are unclear. This study sought to describe the frequency and prognostic value of pre-discharge and post-discharge troponin elevation, including persistent troponin elevation from the inpatient to outpatient settings. METHODS AND RESULTS The ASTRONAUT trial (NCT00894387; http://www.clinicaltrials.gov) enrolled hospitalized HF patients with ejection fraction ≤40% and measured troponin I prior to discharge (i.e. study baseline) and at 1-month follow-up in a core laboratory (elevation defined as >0.04 ng/mL). This analysis included 1469 (91.0%) patients with pre-discharge troponin data. Overall, 41.5% and 29.9% of patients had elevated pre-discharge [median: 0.09 ng/mL; interquartile range (IQR): 0.06-0.19 ng/mL] and 1-month (median: 0.09 ng/mL; IQR: 0.06-0.15 ng/mL) troponin levels, respectively. Among patients with pre-discharge troponin elevation, 60.4% had persistent elevation at 1 month. After adjustment, pre-discharge troponin elevation was not associated with 12-month clinical outcomes. In contrast, 1-month troponin elevation was independently predictive of increased all-cause mortality [hazard ratio (HR) 1.59, 95% confidence interval (CI) 1.18-2.13] and cardiovascular mortality or HF hospitalization (HR 1.28, 95% CI 1.03-1.58) at 12 months. Associations between 1-month troponin elevation and outcomes were similar among patients with newly elevated (i.e. normal pre-discharge) and persistently elevated levels (interaction P ≥ 0.16). The prognostic value of 1-month troponin elevation for 12-month mortality was driven by a pronounced association among patients with coronary artery disease (interaction P = 0.009). CONCLUSIONS In this hospitalized HF population, troponin I elevation was common during index hospitalization and at 1-month follow-up. Elevated troponin I level at 1 month, but not pre-discharge, was independently predictive of increased clinical events at 12 months. Early post-discharge troponin I measurement may offer a practical means of risk stratification and should be investigated as a therapeutic target.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Javed Butler
- Division of Cardiology, Stony Brook University, Stony Brook, NY, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Haris P Subacius
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Andrew P Ambrosy
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical Center, Boston, MA, USA
| | - Marco Triggiani
- Cardiology Section, Department of Clinical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Scott D Solomon
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical Center, Boston, MA, USA
| | - Eldrin F Lewis
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical Center, Boston, MA, USA
| | - Aldo P Maggioni
- Italian Association of Hospital Cardiologists, ANMCO Research Center, Florence, Italy
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Ovidiu Chioncel
- Institute of Emergency for Cardiovascular Diseases Professor C. C. Iliescu, University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Savina Nodari
- Cardiology Section, Department of Clinical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Michele Senni
- Division of Cardiology 1, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Faiez Zannad
- Inserm, Clinical Investigation Center CIC 1433, Université de Lorraine and CHRU Nancy, France
| | - Mihai Gheorghiade
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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23
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Ambrosy AP, Butler J, Gheorghiade M. Clinical trials in acute heart failure: beginning of the end or end of the beginning? Eur J Heart Fail 2017; 19:1358-1360. [PMID: 28656635 DOI: 10.1002/ejhf.925] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 04/19/2017] [Accepted: 05/29/2017] [Indexed: 12/28/2022] Open
Affiliation(s)
- Andrew P Ambrosy
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Javed Butler
- Stony Brook Heart Institute, Stony Brook, NY, USA
| | - Mihai Gheorghiade
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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24
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Streng KW, Ter Maaten JM, Cleland JG, O'Connor CM, Davison BA, Metra M, Givertz MM, Teerlink JR, Ponikowski P, Bloomfield DM, Dittrich HC, Hillege HL, van Veldhuisen DJ, Voors AA, van der Meer P. Associations of Body Mass Index With Laboratory and Biomarkers in Patients With Acute Heart Failure. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003350. [PMID: 28069685 DOI: 10.1161/circheartfailure.116.003350] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 12/06/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Plasma concentrations of natriuretic peptides decline with obesity in patients with heart failure. Whether this is true for other biomarkers is unknown. We investigated a wide range of biomarker profiles in acute heart failure across the body mass index (BMI) spectrum. METHODS AND RESULTS A total of 48 biomarkers, assessing multiple pathophysiological pathways, were measured in 2033 patients included in PROTECT (Placebo-Controlled Randomized Study of the Selective A1 Adenosine Receptor Antagonist Rolofylline for Patients Hospitalized With Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function), a trial comparing the effects of rolofylline to placebo in patients with acute heart failure. Patients were classified into 4 groups according to BMI (<25, 25-30, 30-35, and >35 kg/m2). Of 2003 patients with known weight and height, mean age was 70±12 years and 67% were men. Patients with a higher BMI (>35 kg/m2) had higher blood pressures, were younger, and were more often women. Median levels of brain natriuretic peptide were 550 pg/mL in patients with a BMI <25 kg/m2 and 319 pg/mL in patients with a BMI >35 kg/m2 (P<0.001). Multivariable regression revealed that brain natriuretic peptide (β=-0.250; P<0.001) and receptor for advanced glycation endproducts (β=-0.095; P<0.007) were inversely correlated to BMI, whereas higher levels of uric acid (β=0.164; P<0.001), proadrenomedullin (β=0.171; P<0.001), creatinine (β=0.118; P=0.003), sodium (β=0.101; P=0.006), and bicarbonate (β=0.094; P=0.009) were associated with higher BMI. No significant interaction was seen between these 7 biomarkers and BMI on 180-day mortality. CONCLUSIONS The plasma concentrations of several biomarkers are either positively or negatively influenced by BMI. These findings suggest that these markers should be interpreted with caution in patients with obesity. Although concentrations differ, their prognostic value for mortality up to 180 days did not differ. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00354458.
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Affiliation(s)
- Koen W Streng
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (K.W.S., J.M.t.M., H.L.H., D.J.v.V., A.A.V., P.v.d.M.); National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom (J.G.C.); Inova Heart and Vascular Institute, Falls Church, VA (C.M.O'C.); Momentum Research, Durham, NC (B.A.D.); University of Brescia, Italy (M.M.); Brigham and Women's Hospital, Boston, MA (M.M.G.); University of California at San Francisco and San Francisco Veterans Affairs Medical Center (J.R.T.); Medical University, Clinical Military Hospital, Wroclaw, Poland (P.P.); Merck Research Laboratories, Rahway, NJ (D.M.B.); and University of Iowa Carver College of Medicine Cardiovascular Research Center (H.C.D.)
| | - Jozine M Ter Maaten
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (K.W.S., J.M.t.M., H.L.H., D.J.v.V., A.A.V., P.v.d.M.); National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom (J.G.C.); Inova Heart and Vascular Institute, Falls Church, VA (C.M.O'C.); Momentum Research, Durham, NC (B.A.D.); University of Brescia, Italy (M.M.); Brigham and Women's Hospital, Boston, MA (M.M.G.); University of California at San Francisco and San Francisco Veterans Affairs Medical Center (J.R.T.); Medical University, Clinical Military Hospital, Wroclaw, Poland (P.P.); Merck Research Laboratories, Rahway, NJ (D.M.B.); and University of Iowa Carver College of Medicine Cardiovascular Research Center (H.C.D.)
| | - John G Cleland
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (K.W.S., J.M.t.M., H.L.H., D.J.v.V., A.A.V., P.v.d.M.); National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom (J.G.C.); Inova Heart and Vascular Institute, Falls Church, VA (C.M.O'C.); Momentum Research, Durham, NC (B.A.D.); University of Brescia, Italy (M.M.); Brigham and Women's Hospital, Boston, MA (M.M.G.); University of California at San Francisco and San Francisco Veterans Affairs Medical Center (J.R.T.); Medical University, Clinical Military Hospital, Wroclaw, Poland (P.P.); Merck Research Laboratories, Rahway, NJ (D.M.B.); and University of Iowa Carver College of Medicine Cardiovascular Research Center (H.C.D.)
| | - Christopher M O'Connor
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (K.W.S., J.M.t.M., H.L.H., D.J.v.V., A.A.V., P.v.d.M.); National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom (J.G.C.); Inova Heart and Vascular Institute, Falls Church, VA (C.M.O'C.); Momentum Research, Durham, NC (B.A.D.); University of Brescia, Italy (M.M.); Brigham and Women's Hospital, Boston, MA (M.M.G.); University of California at San Francisco and San Francisco Veterans Affairs Medical Center (J.R.T.); Medical University, Clinical Military Hospital, Wroclaw, Poland (P.P.); Merck Research Laboratories, Rahway, NJ (D.M.B.); and University of Iowa Carver College of Medicine Cardiovascular Research Center (H.C.D.)
| | - Beth A Davison
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (K.W.S., J.M.t.M., H.L.H., D.J.v.V., A.A.V., P.v.d.M.); National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom (J.G.C.); Inova Heart and Vascular Institute, Falls Church, VA (C.M.O'C.); Momentum Research, Durham, NC (B.A.D.); University of Brescia, Italy (M.M.); Brigham and Women's Hospital, Boston, MA (M.M.G.); University of California at San Francisco and San Francisco Veterans Affairs Medical Center (J.R.T.); Medical University, Clinical Military Hospital, Wroclaw, Poland (P.P.); Merck Research Laboratories, Rahway, NJ (D.M.B.); and University of Iowa Carver College of Medicine Cardiovascular Research Center (H.C.D.)
| | - Marco Metra
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (K.W.S., J.M.t.M., H.L.H., D.J.v.V., A.A.V., P.v.d.M.); National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom (J.G.C.); Inova Heart and Vascular Institute, Falls Church, VA (C.M.O'C.); Momentum Research, Durham, NC (B.A.D.); University of Brescia, Italy (M.M.); Brigham and Women's Hospital, Boston, MA (M.M.G.); University of California at San Francisco and San Francisco Veterans Affairs Medical Center (J.R.T.); Medical University, Clinical Military Hospital, Wroclaw, Poland (P.P.); Merck Research Laboratories, Rahway, NJ (D.M.B.); and University of Iowa Carver College of Medicine Cardiovascular Research Center (H.C.D.)
| | - Michael M Givertz
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (K.W.S., J.M.t.M., H.L.H., D.J.v.V., A.A.V., P.v.d.M.); National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom (J.G.C.); Inova Heart and Vascular Institute, Falls Church, VA (C.M.O'C.); Momentum Research, Durham, NC (B.A.D.); University of Brescia, Italy (M.M.); Brigham and Women's Hospital, Boston, MA (M.M.G.); University of California at San Francisco and San Francisco Veterans Affairs Medical Center (J.R.T.); Medical University, Clinical Military Hospital, Wroclaw, Poland (P.P.); Merck Research Laboratories, Rahway, NJ (D.M.B.); and University of Iowa Carver College of Medicine Cardiovascular Research Center (H.C.D.)
| | - John R Teerlink
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (K.W.S., J.M.t.M., H.L.H., D.J.v.V., A.A.V., P.v.d.M.); National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom (J.G.C.); Inova Heart and Vascular Institute, Falls Church, VA (C.M.O'C.); Momentum Research, Durham, NC (B.A.D.); University of Brescia, Italy (M.M.); Brigham and Women's Hospital, Boston, MA (M.M.G.); University of California at San Francisco and San Francisco Veterans Affairs Medical Center (J.R.T.); Medical University, Clinical Military Hospital, Wroclaw, Poland (P.P.); Merck Research Laboratories, Rahway, NJ (D.M.B.); and University of Iowa Carver College of Medicine Cardiovascular Research Center (H.C.D.)
| | - Piotr Ponikowski
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (K.W.S., J.M.t.M., H.L.H., D.J.v.V., A.A.V., P.v.d.M.); National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom (J.G.C.); Inova Heart and Vascular Institute, Falls Church, VA (C.M.O'C.); Momentum Research, Durham, NC (B.A.D.); University of Brescia, Italy (M.M.); Brigham and Women's Hospital, Boston, MA (M.M.G.); University of California at San Francisco and San Francisco Veterans Affairs Medical Center (J.R.T.); Medical University, Clinical Military Hospital, Wroclaw, Poland (P.P.); Merck Research Laboratories, Rahway, NJ (D.M.B.); and University of Iowa Carver College of Medicine Cardiovascular Research Center (H.C.D.)
| | - Daniel M Bloomfield
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (K.W.S., J.M.t.M., H.L.H., D.J.v.V., A.A.V., P.v.d.M.); National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom (J.G.C.); Inova Heart and Vascular Institute, Falls Church, VA (C.M.O'C.); Momentum Research, Durham, NC (B.A.D.); University of Brescia, Italy (M.M.); Brigham and Women's Hospital, Boston, MA (M.M.G.); University of California at San Francisco and San Francisco Veterans Affairs Medical Center (J.R.T.); Medical University, Clinical Military Hospital, Wroclaw, Poland (P.P.); Merck Research Laboratories, Rahway, NJ (D.M.B.); and University of Iowa Carver College of Medicine Cardiovascular Research Center (H.C.D.)
| | - Howard C Dittrich
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (K.W.S., J.M.t.M., H.L.H., D.J.v.V., A.A.V., P.v.d.M.); National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom (J.G.C.); Inova Heart and Vascular Institute, Falls Church, VA (C.M.O'C.); Momentum Research, Durham, NC (B.A.D.); University of Brescia, Italy (M.M.); Brigham and Women's Hospital, Boston, MA (M.M.G.); University of California at San Francisco and San Francisco Veterans Affairs Medical Center (J.R.T.); Medical University, Clinical Military Hospital, Wroclaw, Poland (P.P.); Merck Research Laboratories, Rahway, NJ (D.M.B.); and University of Iowa Carver College of Medicine Cardiovascular Research Center (H.C.D.)
| | - Hans L Hillege
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (K.W.S., J.M.t.M., H.L.H., D.J.v.V., A.A.V., P.v.d.M.); National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom (J.G.C.); Inova Heart and Vascular Institute, Falls Church, VA (C.M.O'C.); Momentum Research, Durham, NC (B.A.D.); University of Brescia, Italy (M.M.); Brigham and Women's Hospital, Boston, MA (M.M.G.); University of California at San Francisco and San Francisco Veterans Affairs Medical Center (J.R.T.); Medical University, Clinical Military Hospital, Wroclaw, Poland (P.P.); Merck Research Laboratories, Rahway, NJ (D.M.B.); and University of Iowa Carver College of Medicine Cardiovascular Research Center (H.C.D.)
| | - Dirk J van Veldhuisen
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (K.W.S., J.M.t.M., H.L.H., D.J.v.V., A.A.V., P.v.d.M.); National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom (J.G.C.); Inova Heart and Vascular Institute, Falls Church, VA (C.M.O'C.); Momentum Research, Durham, NC (B.A.D.); University of Brescia, Italy (M.M.); Brigham and Women's Hospital, Boston, MA (M.M.G.); University of California at San Francisco and San Francisco Veterans Affairs Medical Center (J.R.T.); Medical University, Clinical Military Hospital, Wroclaw, Poland (P.P.); Merck Research Laboratories, Rahway, NJ (D.M.B.); and University of Iowa Carver College of Medicine Cardiovascular Research Center (H.C.D.)
| | - Adriaan A Voors
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (K.W.S., J.M.t.M., H.L.H., D.J.v.V., A.A.V., P.v.d.M.); National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom (J.G.C.); Inova Heart and Vascular Institute, Falls Church, VA (C.M.O'C.); Momentum Research, Durham, NC (B.A.D.); University of Brescia, Italy (M.M.); Brigham and Women's Hospital, Boston, MA (M.M.G.); University of California at San Francisco and San Francisco Veterans Affairs Medical Center (J.R.T.); Medical University, Clinical Military Hospital, Wroclaw, Poland (P.P.); Merck Research Laboratories, Rahway, NJ (D.M.B.); and University of Iowa Carver College of Medicine Cardiovascular Research Center (H.C.D.)
| | - Peter van der Meer
- From the Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (K.W.S., J.M.t.M., H.L.H., D.J.v.V., A.A.V., P.v.d.M.); National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom (J.G.C.); Inova Heart and Vascular Institute, Falls Church, VA (C.M.O'C.); Momentum Research, Durham, NC (B.A.D.); University of Brescia, Italy (M.M.); Brigham and Women's Hospital, Boston, MA (M.M.G.); University of California at San Francisco and San Francisco Veterans Affairs Medical Center (J.R.T.); Medical University, Clinical Military Hospital, Wroclaw, Poland (P.P.); Merck Research Laboratories, Rahway, NJ (D.M.B.); and University of Iowa Carver College of Medicine Cardiovascular Research Center (H.C.D.).
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25
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Chow SL, Maisel AS, Anand I, Bozkurt B, de Boer RA, Felker GM, Fonarow GC, Greenberg B, Januzzi JL, Kiernan MS, Liu PP, Wang TJ, Yancy CW, Zile MR. Role of Biomarkers for the Prevention, Assessment, and Management of Heart Failure: A Scientific Statement From the American Heart Association. Circulation 2017; 135:e1054-e1091. [PMID: 28446515 DOI: 10.1161/cir.0000000000000490] [Citation(s) in RCA: 358] [Impact Index Per Article: 51.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND PURPOSE Natriuretic peptides have led the way as a diagnostic and prognostic tool for the diagnosis and management of heart failure (HF). More recent evidence suggests that natriuretic peptides along with the next generation of biomarkers may provide added value to medical management, which could potentially lower risk of mortality and readmissions. The purpose of this scientific statement is to summarize the existing literature and to provide guidance for the utility of currently available biomarkers. METHODS The writing group used systematic literature reviews, published translational and clinical studies, clinical practice guidelines, and expert opinion/statements to summarize existing evidence and to identify areas of inadequacy requiring future research. The panel reviewed the most relevant adult medical literature excluding routine laboratory tests using MEDLINE, EMBASE, and Web of Science through December 2016. The document is organized and classified according to the American Heart Association to provide specific suggestions, considerations, or contemporary clinical practice recommendations. RESULTS A number of biomarkers associated with HF are well recognized, and measuring their concentrations in circulation can be a convenient and noninvasive approach to provide important information about disease severity and helps in the detection, diagnosis, prognosis, and management of HF. These include natriuretic peptides, soluble suppressor of tumorgenicity 2, highly sensitive troponin, galectin-3, midregional proadrenomedullin, cystatin-C, interleukin-6, procalcitonin, and others. There is a need to further evaluate existing and novel markers for guiding therapy and to summarize their data in a standardized format to improve communication among researchers and practitioners. CONCLUSIONS HF is a complex syndrome involving diverse pathways and pathological processes that can manifest in circulation as biomarkers. A number of such biomarkers are now clinically available, and monitoring their concentrations in blood not only can provide the clinician information about the diagnosis and severity of HF but also can improve prognostication and treatment strategies.
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26
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Takashio S, Nagai T, Sugano Y, Honda S, Okada A, Asaumi Y, Aiba T, Noguchi T, Kusano KF, Ogawa H, Yasuda S, Anzai T. Persistent increase in cardiac troponin T at hospital discharge predicts repeat hospitalization in patients with acute decompensated heart failure. PLoS One 2017; 12:e0173336. [PMID: 28379962 PMCID: PMC5381770 DOI: 10.1371/journal.pone.0173336] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 02/20/2017] [Indexed: 01/09/2023] Open
Abstract
Background High-sensitive cardiac troponin T (hsTnT) is a sensitive biomarker of myocardial damage and predictor of acute decompensated heart failure (ADHF). However, there is little information on changes over time in hsTnT level during ADHF management. The aim of this prospective study was to evaluate changes in hsTnT levels between admission and at discharge in patients with ADHF, and identify factors that determine such levels and their prognostic significance. Methods and results We evaluated 404 ADHF patients with abnormal hsTnT levels (≥0.0135 ng/ml) on admission. The median (interquartile ranges) hsTnT levels on admission, at discharge, and percent changes in hsTnT levels were 0.038 (0.026 to 0.065), 0.032 (0.021 to 0.049) ng/ml, and -12.0 (-39.8 to 7.4) % respectively. The numbers of patients with falling (hsTnT decrease > -15%), stable (hsTnT change between -15 and +15%) and rising (hsTnT increase > +15%) hsTnT level at discharge were 190, 146, and 68, respectively. The percent change in B-type natriuretic peptide (BNP) levels was greater in the falling group, compared to the stable (p<0.001) and rising groups (p<0.001). Changes in hsTnT levels correlated significantly with changes in BNP levels (ρ = 0.22, p<0.001). Multivariate Cox regression analysis identified rising or stable hsTnT at discharge as a significant predictor of heart failure-related rehospitalization (hazard ratio: 1.69; 95% confidence interval: 1.06 to 2.70; p = 0.03). Conclusions Persistent increase in hsTnT levels at discharge correlated with inadequate decrease of BNP levels, and was a predictor of poor clinical outcome, with repeat heart failure hospitalizations.
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Affiliation(s)
- Seiji Takashio
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yasuo Sugano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satoshi Honda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Atsushi Okada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kengo F. Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hisao Ogawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
- * E-mail:
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27
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Cleland JG, Teerlink JR, Davison BA, Shoaib A, Metra M, Senger S, Milo O, Cotter G, Bourge RC, Parker JD, Jondeau G, Krum H, O'Connor CM, Torre-Amione G, van Veldhuisen DJ, McMurray JJ. Measurement of troponin and natriuretic peptides shortly after admission in patients with heart failure-does it add useful prognostic information? An analysis of the Value of Endothelin Receptor Inhibition with Tezosentan in Acute heart failure Studies (V. Eur J Heart Fail 2017; 19:739-747. [DOI: 10.1002/ejhf.786] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 12/01/2016] [Accepted: 12/04/2016] [Indexed: 12/28/2022] Open
Affiliation(s)
- John G.F. Cleland
- University of Hull, Kingston upon Hull; UK
- National Heart and Lung Institute; Royal Brompton and Harefield Hospitals NHS Trust, Imperial College; London UK
| | - John R. Teerlink
- University of California, San Francisco and the San Francisco Veterans Affairs Medical Center; San Francisco CA USA
| | | | | | - Marco Metra
- University of Brescia, Piazza Spedali Civili; Brescia Italy
| | | | - Olga Milo
- Momentum Research, Inc.; Durham NC USA
| | | | | | - John D. Parker
- Division of Cardiology; Mount Sinai Hospital; Toronto Ontario Canada
| | | | - Henry Krum
- Monash Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine; Alfred Hospital, Monash University; Melbourne Australia (deceased 28 November 2015)
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Escribano D, Santas E, Miñana G, Mollar A, García-Blas S, Valero E, Payá A, Chorro F, Sanchis J, Núñez J. High-sensitivity troponin T and the risk of recurrent readmissions after hospitalization for acute heart failure. Rev Clin Esp 2017. [DOI: 10.1016/j.rceng.2016.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Escribano D, Santas E, Miñana G, Mollar A, García-Blas S, Valero E, Payá A, Chorro F, Sanchis J, Núñez J. Troponina T de alta sensibilidad y riesgo de hospitalizaciones recurrentes tras un ingreso por insuficiencia cardíaca aguda. Rev Clin Esp 2017; 217:63-70. [DOI: 10.1016/j.rce.2016.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/24/2016] [Accepted: 10/18/2016] [Indexed: 11/28/2022]
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30
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Anguita M. Troponinas de alta sensibilidad y pronóstico de la insuficiencia cardíaca. Rev Clin Esp 2017; 217:95-96. [DOI: 10.1016/j.rce.2016.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 11/29/2016] [Indexed: 10/20/2022]
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Elevated troponin I level assessed by a new high-sensitive assay and the risk of poor outcomes in patients with acute heart failure. Int J Cardiol 2017; 230:646-652. [PMID: 28069251 DOI: 10.1016/j.ijcard.2017.01.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 12/30/2016] [Accepted: 01/03/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND The interpretation and clinical usefulness of elevated levels of cardiac troponins in acute heart failure (AHF) remain controversial. We aimed to characterize the relationship between changes in cardiac troponin I (measured using a new high-sensitive immunoassay by single-molecule counting technology, Singulex, Alameda, USA; hs-TnI) during first 48h of hospital stay and patients' characteristics and the outcomes. METHODS AND RESULTS We measured hs-TnI at baseline, after 24 and 48h in 130 AHF patients (mean age: 65±13years, 77% men). The percentage of patients with elevated hs-TnI (i.e., above the upper reference limit [URL]>10.19pg/mL) were: on admission - 59%, after 24h - 61%, and after 48h - 58%. Elevated baseline level of hs-TnI was associated with more severe dyspnoea on admission but neither peak level nor changes in hs-TnI during first 48h were related to the dyspnoea severity or magnitude of dyspnoea relief. During 1-year follow-up there were 32 (25%) cardiovascular deaths. Neither absolute baseline nor peak values of hs-TnI predicted cardiovascular mortality. Only changes in hs-TnI were independently associated with cardiovascular mortality with the strongest relationship seen in peak change in hs-TnI: patients with an increase vs. remaining patients - hazard ratio (95% confidence interval): 3.22 (1.52-6.82)p=0.002. CONCLUSIONS Using the new assay (proved to be more sensitive that the other available troponin assays) we observed that approximately 60% of patients with AHF presented elevated hs-TnI above URL during first 48h of hospital stay. Only significant increase in hs-TnI predicted cardiovascular mortality.
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Chioncel O, Collins SP, Greene SJ, Pang PS, Ambrosy AP, Antohi EL, Vaduganathan M, Butler J, Gheorghiade M. Predictors of Post-discharge Mortality Among Patients Hospitalized for Acute Heart Failure. Card Fail Rev 2017; 3:122-129. [PMID: 29387465 DOI: 10.15420/cfr.2017:12:1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Acute Heart Failure (AHF) is a " multi-event disease" and hospitalisation is a critical event in the clinical course of HF. Despite relatively rapid relief of symptoms, hospitalisation for AHF is followed by an increased risk of death and re-hospitalisation. In AHF, risk stratification from clinically available data is increasingly important in evaluating long-term prognosis. From the perspective of patients, information on the risk of mortality and re-hospitalisation would be helpful in providing patients with insight into their disease. From the perspective of care providers, it may facilitate management decisions, such as who needs to be admitted and to what level of care (i.e. floor, step-down, ICU). Furthermore, risk-stratification may help identify patients who need to be evaluated for advanced HF therapies (i.e. left-ventricle assistance device or transplant or palliative care), and patients who need early a post-discharge follow-up plan. Finally, risk stratification will allow for more robust efforts to identify among risk markers the true targets for therapies that may direct treatment strategies to selected high-risk patients. Further clinical research will be needed to evaluate if appropriate risk stratification of patients could improve clinical outcome and resources allocation.
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Affiliation(s)
- Ovidiu Chioncel
- Carol Davila University of Medicine and Pharmacy, Emergency Institute for Cardiovascular Diseases,Bucharest, Romania
| | | | - Stephen J Greene
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center,Durham, NC, USA
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine,Indiana, IN, USA
| | - Andrew P Ambrosy
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center,Durham, NC, USA
| | - Elena-Laura Antohi
- Carol Davila University of Medicine and Pharmacy, Emergency Institute for Cardiovascular Diseases,Bucharest, Romania
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School,Boston, MA, USA
| | | | - Mihai Gheorghiade
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine,Chicago, IL, USA
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33
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Teerlink JR, Felker GM, McMurray JJV, Ponikowski P, Metra M, Filippatos GS, Ezekowitz JA, Dickstein K, Cleland JGF, Kim JB, Lei L, Knusel B, Wolff AA, Malik FI, Wasserman SM. Acute Treatment With Omecamtiv Mecarbil to Increase Contractility in Acute Heart Failure: The ATOMIC-AHF Study. J Am Coll Cardiol 2016; 67:1444-1455. [PMID: 27012405 DOI: 10.1016/j.jacc.2016.01.031] [Citation(s) in RCA: 167] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/04/2016] [Accepted: 01/05/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Omecamtiv mecarbil (OM) is a selective cardiac myosin activator that increases myocardial function in healthy volunteers and in patients with chronic heart failure. OBJECTIVES This study evaluated the pharmacokinetics, pharmacodynamics, tolerability, safety, and efficacy of OM in patients with acute heart failure (AHF). METHODS Patients admitted for AHF with left ventricular ejection fraction ≤40%, dyspnea, and elevated plasma concentrations of natriuretic peptides were randomized to receive a double-blind, 48-h intravenous infusion of placebo or OM in 3 sequential, escalating-dose cohorts. RESULTS In 606 patients, OM did not improve the primary endpoint of dyspnea relief (3 OM dose groups and pooled placebo: placebo, 41%; OM cohort 1, 42%; cohort 2, 47%; cohort 3, 51%; p = 0.33) or any of the secondary outcomes studied. In supplemental, pre-specified analyses, OM resulted in greater dyspnea relief at 48 h (placebo, 37% vs. OM, 51%; p = 0.034) and through 5 days (p = 0.038) in the high-dose cohort. OM exerted plasma concentration-related increases in left ventricular systolic ejection time (p < 0.0001) and decreases in end-systolic dimension (p < 0.05). The adverse event profile and tolerability of OM were similar to those of placebo, without increases in ventricular or supraventricular tachyarrhythmias. Plasma troponin concentrations were higher in OM-treated patients compared with placebo (median difference at 48 h, 0.004 ng/ml), but with no obvious relationship with OM concentration (p = 0.95). CONCLUSIONS In patients with AHF, intravenous OM did not meet the primary endpoint of dyspnea improvement, but it was generally well tolerated, it increased systolic ejection time, and it may have improved dyspnea in the high-dose group. (Acute Treatment with Omecamtiv Mecarbil to Increase Contractility in Acute Heart Failure [ATOMIC-AHF]; NCT01300013).
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Affiliation(s)
- John R Teerlink
- School of Medicine, University of California San Francisco, San Francisco, California; Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, California.
| | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Piotr Ponikowski
- Department of Heart Diseases, Medical University, Clinical Military Hospital, Wroclaw, Poland
| | - Marco Metra
- Division of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | | | - Kenneth Dickstein
- Cardiology Division, University of Bergen, Bergen, Norway; Cardiology Division, Stavanger University Hospital, Stavanger, Norway
| | - John G F Cleland
- National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom
| | - Jae B Kim
- Amgen, Inc., Thousand Oaks, California
| | - Lei Lei
- Amgen, Inc., Thousand Oaks, California
| | | | | | - Fady I Malik
- Cytokinetics, Inc., South San Francisco, California
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Gencer E, Doğan V, Öztürk MT, Nadir A, Musmul A, Cavuşoğlu Y. Comparison of the Effects of Levosimendan Dobutamine and Vasodilator Therapy on Ongoing Myocardial Injury in Acute Decompensated Heart Failure. J Cardiovasc Pharmacol Ther 2016; 22:153-158. [PMID: 27390145 DOI: 10.1177/1074248416657612] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cardiac troponins (cTn) are reliable and the most sensitive biomarker in the setting of acute decompensated heart failure (ADHF). Acute decompensated heart failure is usually associated with worsening chronic heart failure, and it may be caused by ongoing minor myocardial cell damage that may occur without any reported precipitating factors. METHODS We compared the short-term effect of levosimendan (LEV), dobutamine (DOB), and vasodilator treatment (nitroglycerin [NTG]) on myocardial injury with hemodynamic, neurohumoral, and inflammatory indicators. One hundred twenty-two patients with a mean age of 66 ± 9 years were treated with LEV (n = 40), DOB (n = 42), and NTG (n = 40) and examined retrospectively. Blood samples (cTnI, N-terminal probrain natriuretic peptide [NT-proBNP], highly sensitive C-reactive protein [HsCRP], and others), left ventricular ejection fraction (LVEF), systolic pulmonary artery pressure (sPAP), and 6-minute walk distance (6MWD) were compared before and after treatment. RESULTS At admission, detectable levels of cTnI were observed in 53% of patients (≥0.05 ng/mL). Serial changes in the mean cTnI levels were not significantly different between the groups (LEV 0.04 ± 0.01 to 0.03 ± 0.01 ng/mL; DOB 0.145 ± 0.08 to 0.08 ± 0.03 ng/mL; NTG 0.1 ± 0.03 to 0.09 ± 0.02 ng/mL; overall P = .859). Favourable effects on the NT-proBNP, sPAP values, LVEF, 6MWD, and HsCRP were observed overall, especially in the LEV groups. CONCLUSION Beneficial effects of short-term use of LEV, DOB, and NTG on ongoing myocardial injury were demonstrated. These findings can be attributed to the anti-ischemic properties as well as the hemodynamic, neurohumoral, and functional benefits from the positive inotropes, especially LEV, in patients with ADHF.
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Affiliation(s)
- Erkan Gencer
- 1 Department of Cardiology, Cardiology Clinic, Kilis State Hospital, Kilis, Turkey
| | - Volkan Doğan
- 2 Department of Cardiology, Mugla Sıtkı Kocman University, Mugla, Turkey
| | - Müjgan Tek Öztürk
- 3 Department of Cardiology, Cardiology Clinic, Kecioren Education and Research Hospital, Ankara, Turkey
| | - Aydın Nadir
- 4 Department of Cardiology, Cardiology Clinic, Bozuyuk State Hospital, Bilecik, Turkey
| | - Ahmet Musmul
- 5 Department of Biostatistics, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Yüksel Cavuşoğlu
- 6 Department of Cardiology, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
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Dunbar-Yaffe R, Stitt A, Lee JJ, Mohamed S, Lee DS. Assessing Risk and Preventing 30-Day Readmissions in Decompensated Heart Failure: Opportunity to Intervene? Curr Heart Fail Rep 2016; 12:309-17. [PMID: 26289741 PMCID: PMC4768253 DOI: 10.1007/s11897-015-0266-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Heart failure (HF) patients are at high risk of hospital readmission, which contributes to substantial health care costs. There is great interest in strategies to reduce rehospitalization for HF. However, many readmissions occur within 30 days of initial hospital discharge, presenting a challenge for interventions to be instituted in a short time frame. Potential strategies to reduce readmissions for HF can be classified into three different forms. First, patients who are at high risk of readmission can be identified even before their initial index hospital discharge. Second, ambulatory remote monitoring strategies may be instituted to identify early warning signs before acute decompensation of HF occurs. Finally, strategies may be employed in the emergency department to identify low-risk patients who may not need hospital readmission. If symptoms improve with initial therapy, low-risk patients could be referred to specialized, rapid outpatient follow-up care where investigations and therapy can occur in an outpatient setting.
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Affiliation(s)
- Richard Dunbar-Yaffe
- Institute for Clinical Evaluative Sciences, University of Toronto, 2075 Bayview Avenue, Room G-106, Toronto, ON, M4N 3M5, Canada
| | - Audra Stitt
- Institute for Clinical Evaluative Sciences, University of Toronto, 2075 Bayview Avenue, Room G-106, Toronto, ON, M4N 3M5, Canada
| | - Joseph J Lee
- Institute for Clinical Evaluative Sciences, University of Toronto, 2075 Bayview Avenue, Room G-106, Toronto, ON, M4N 3M5, Canada
| | - Shanas Mohamed
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Douglas S Lee
- Institute for Clinical Evaluative Sciences, University of Toronto, 2075 Bayview Avenue, Room G-106, Toronto, ON, M4N 3M5, Canada. .,Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada. .,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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Biegus J, Hillege HL, Postmus D, Valente MA, Bloomfield DM, Cleland JG, Cotter G, Davison BA, Dittrich HC, Fiuzat M, Givertz MM, Massie BM, Metra M, Teerlink JR, Voors AA, O'Connor CM, Ponikowski P. Abnormal liver function tests in acute heart failure: relationship with clinical characteristics and outcome in the PROTECT study. Eur J Heart Fail 2016; 18:830-9. [DOI: 10.1002/ejhf.532] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 02/19/2016] [Accepted: 02/23/2016] [Indexed: 12/18/2022] Open
Affiliation(s)
- Jan Biegus
- Department of Heart Diseases; Medical University; Wroclaw Poland
- Department of Cardiology, Centre for Heart Diseases; Clinical Military Hospital; Wroclaw Poland
| | - Hans L. Hillege
- Department of Cardiology, University of Groningen; University Medical Centre Groningen; Groningen the Netherland
| | - Douwe Postmus
- Department of Cardiology, University of Groningen; University Medical Centre Groningen; Groningen the Netherland
| | - Mattia. A.E. Valente
- Department of Cardiology, University of Groningen; University Medical Centre Groningen; Groningen the Netherland
| | | | - John G.F. Cleland
- National Heart and Lung Institute, Imperial College London (Royal Brompton and Harefield Hospitals) Department of Cardiology, Castle Hill Hospital; University of Hull; UK
| | | | | | - Howard C. Dittrich
- University of Iowa Carver College of Medicine Cardiovascular Research Center; Iowa City IA USA
| | - Mona Fiuzat
- Duke Clinical Research Institute, Division of Cardiovascular Medicine; Duke University Medical Center; Durham NC USA
| | - Michael M. Givertz
- Cardiovascular Division; Brigham and Women's Hospital, Harvard Medical School; Boston MA USA
| | - Barry M. Massie
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine; University of California San Francisco; San Francisco CA USA
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health; University of Brescia; Brescia Italy
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine; University of California San Francisco; San Francisco CA USA
| | - Adriaan A. Voors
- Department of Cardiology, University of Groningen; University Medical Centre Groningen; Groningen the Netherland
| | - Christopher M. O'Connor
- Duke Clinical Research Institute, Division of Cardiovascular Medicine; Duke University Medical Center; Durham NC USA
| | - Piotr Ponikowski
- Department of Heart Diseases; Medical University; Wroclaw Poland
- Department of Cardiology, Centre for Heart Diseases; Clinical Military Hospital; Wroclaw Poland
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Pang PS, Teerlink JR, Voors AA, Ponikowski P, Greenberg BH, Filippatos G, Felker GM, Davison BA, Cotter G, Kriger J, Prescott MF, Hua TA, Severin T, Metra M. Use of High-Sensitivity Troponin T to Identify Patients With Acute Heart Failure at Lower Risk for Adverse Outcomes: An Exploratory Analysis From the RELAX-AHF Trial. JACC-HEART FAILURE 2016; 4:591-599. [PMID: 27039129 DOI: 10.1016/j.jchf.2016.02.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 02/10/2016] [Accepted: 02/22/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The aim of this study was to determine if a baseline high-sensitivity troponin T (hsTnT) value ≤99th percentile upper reference limit (0.014 μg/l ["low hsTnT"]) identifies patients at low risk for adverse outcomes. BACKGROUND Approximately 85% of patients who present to emergency departments with acute heart failure are admitted. Identification of patients at low risk might decrease unnecessary admissions. METHODS A post-hoc analysis was conducted from the RELAX-AHF (Serelaxin, Recombinant Human Relaxin-2, for Treatment of Acute Heart Failure) trial, which randomized patients within 16 h of presentation who had systolic blood pressure >125 mm Hg, mild to moderate renal impairment, and N-terminal pro-brain natriuretic peptide ≥1,600 ng/l to serelaxin versus placebo. Linear regression models for continuous endpoints and Cox models for time-to-event endpoints were used. RESULTS Of the 1,076 patients with available baseline hsTnT values, 107 (9.9%) had low hsTnT. No cardiovascular (CV) deaths through day 180 were observed in the low-hsTnT group compared with 79 CV deaths (7.3%) in patients with higher hsTnT. By univariate analyses, low hsTnT was associated with lower risk for all 5 primary outcomes: 1) days alive and out of the hospital by day 60; 2) CV death or rehospitalization for heart failure or renal failure by day 60; 3) length of stay; 4) worsening heart failure through day 5; and 5) CV death through day 180. After multivariate adjustment, only 180-day CV mortality remained significant (hazard ratio: 0.0; 95% confidence interval: 0.0 to 0.736; p = 0.0234; C-index = 0.838 [95% confidence interval: 0.798 to 0.878]). CONCLUSIONS No CV deaths through day 180 were observed in patients with hsTnT levels ≤0.014 μg/l despite high N-terminal pro-brain natriuretic peptide levels. Low baseline hsTnT may identify patients with acute heart failure at very low risk for CV mortality.
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Affiliation(s)
- Peter S Pang
- Indiana University School of Medicine and Regenstrief Institute, Indianapolis, Indiana.
| | - John R Teerlink
- University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, San Francisco, California
| | | | | | | | | | - G Michael Felker
- Duke University School of Medicine and the Duke Clinical Research Institute, Durham, North Carolina
| | | | - Gad Cotter
- Momentum Research, Durham, North Carolina
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Parikh KS, Felker GM, Metra M. Mode of Death After Acute Heart Failure Hospitalization - A Clue to Possible Mechanisms. Circ J 2015; 80:17-23. [PMID: 26511229 DOI: 10.1253/circj.cj-15-1006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Heart failure continues to be a leading cause of hospitalization worldwide, and acute heart failure (AHF) carries significant risk for short-term morbidity and mortality. Despite many trials of potential new therapies for AHF, there have been very few advances over the recent decades. In this review, we will examine mortality during and after AHF hospitalization, with an emphasis on available data on mode of death (MOD). We will also review data on the timing of different MOD after AHF and the effect of specific therapies, as well as what is known about the contribution of specific pathophysiological mechanisms. Finally, we discuss the potential utility of further study of MOD data for AHF and its application to drug development, risk stratification, and therapeutic tailoring to improve short- and long-term outcomes in AHF.
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Felker GM, Mentz RJ, Teerlink JR, Voors AA, Pang PS, Ponikowski P, Greenberg BH, Filippatos G, Davison BA, Cotter G, Prescott MF, Hua TA, Lopez-Pintado S, Severin T, Metra M. Serial high sensitivity cardiac troponin T measurement in acute heart failure: insights from the RELAX-AHF study. Eur J Heart Fail 2015; 17:1262-70. [DOI: 10.1002/ejhf.341] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 06/30/2015] [Accepted: 07/02/2015] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Robert J. Mentz
- Duke Clinical Research Institute; DUMC Box 3850 Durham NC 27710 USA
| | - John R. Teerlink
- University of California-San Francisco and San Francisco Veterans Affairs Medical Center; San Francisco CA USA
| | | | - Peter S. Pang
- Indiana University School of Medicine; Indianapolis IN USA
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Pang PS, Collins SP, Miró Ò, Bueno H, Diercks DB, Di Somma S, Gray A, Harjola VP, Hollander JE, Lambrinou E, Levy PD, Papa A, Möckel M. Editor's Choice-The role of the emergency department in the management of acute heart failure: An international perspective on education and research. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2015; 6:421-429. [PMID: 26265736 DOI: 10.1177/2048872615600096] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Emergency departments are a major entry point for the initial management of acute heart failure (AHF) patients throughout the world. The initial diagnosis, management and disposition - the decision to admit or discharge - of AHF patients in the emergency department has significant downstream implications. Misdiagnosis, under or overtreatment, or inappropriate admission may place patients at increased risk for adverse events, and add costs to the healthcare system. Despite the critical importance of initial management, data are sparse regarding the impact of early AHF treatment delivered in the emergency department compared to inpatient or chronic heart failure management. Unfortunately, outcomes remain poor, with nearly a third of patients dying or re-hospitalised within 3 months post-discharge. In the absence of robust research evidence, consensus is an important source of guidance for AHF care. Thus, we convened an international group of practising emergency physicians, cardiologists and advanced practice nurses with the following goals to improve outcomes for AHF patients who present to the emergency department or other acute care setting through: (a) a better understanding of the pathophysiology, presentation and management of the initial phase of AHF care; (b) improving initial management by addressing knowledge gaps between best practices and current practice through education and research; and
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Affiliation(s)
- Peter S Pang
- 1 Department of Emergency Medicine, Indiana University School of Medicine and the Regenstrief Institute, USA
| | - Sean P Collins
- 2 Department of Emergency Medicine, Vanderbilt University and The Veterans Health Administration, USA
| | - Òscar Miró
- 3 Emergency Department, Hospital Clínic, Spain
| | - Hector Bueno
- 4 Department of Cardiology, Hospital General Universitario Gregorio Marañón, Spain
| | - Deborah B Diercks
- 5 Department of Emergency Medicine, University of Texas Southwestern, USA
| | - Salvatore Di Somma
- 6 Department of Medical-Surgery Sciences and Translational Research, University Sapienza Rome, Italy
| | - Alasdair Gray
- 7 Emergency Medicine Research Group, Royal Infirmary of Edinburgh, UK
| | - Veli-Pekka Harjola
- 8 Department of Emergency Care, Helsinki University and Helsinki University Hospital, Finland
| | - Judd E Hollander
- 9 Sidney Kimmel Medical College and the National Academic Center for Telehealth, Thomas Jefferson University, USA
| | | | - Phillip D Levy
- 11 Department of Emergency Medicine and Cardiovascular Research Institute, Wayne State University School of Medicine, USA
| | | | - Martin Möckel
- 13 Department of Cardiology, Charité-Universitätsmedizin Berlin, Germany
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Brown K, Chee J, Kyung S, Vettichira B, Papadimitriou L, Butler J. Mineralocorticoid Receptor Antagonism in Acute Heart Failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015. [PMID: 26199117 DOI: 10.1007/s11936-015-0402-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OPINION STATEMENT Heart failure (HF) remains a tremendous burden to health care systems and patients worldwide. The cornerstone neurohormonal disruption that leads to the debilitating sequelae in HF patients revolves primarily around aldosterone and the renin-angiotensin-aldosterone system (RAAS). Aldosterone plays a detrimental role in tissue remodeling by inducing inflammation and fibrosis within the cardiovascular and renal systems, leaving mineralocorticoid receptor antagonists (MRAs) as key pharmacological tools to slow pathogenesis and improve patient outcomes. The role of MRA in improving morbidity and mortality in outpatients with chronic HF and low ejection fraction is well established and supported by large randomized controlled trials. However, evidence-based data relating to the use of MRA in acute HF (AHF) remain somewhat limited, and therefore, the use of MRA is not ubiquitously considered in the acute setting. Current studies for the use of MRA in AHF are limited by small sample size as well as safety concerns relating to the dose-dependent effects on electrolyte homeostasis and renal function. Here, we discuss the imperative need for additional trials elucidating the potential benefits of MRA in AHF as an adjunct diuretic therapy. We not only discuss the role of MRA in neurohormonal regulation of aldosterone but also highlight a potential dose-dependent role for MRA in natriuresis. Furthermore, we showcase existing and recent evidence-based data demonstrating the effectiveness of MRA in AHF and on long-term outcomes. Finally, we look at several treatment strategies and safety concerns as they relate to MRA use so as to aid in avoidance of MRA-related complications while facilitating achievement of treatment goals.
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Affiliation(s)
- Kemar Brown
- Division of Cardiology, Health Sciences Center, Stony Brook University, T-16, Room 080, Stony Brook, NY, 11794, USA
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Frea S, Bovolo V, Pidello S, Canavosio FG, Botta M, Bergerone S, Gaita F. Clinical and prognostic role of ammonia in advanced decompensated heart failure. The cardio-abdominal syndrome? Int J Cardiol 2015; 195:53-60. [PMID: 26022800 DOI: 10.1016/j.ijcard.2015.05.061] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 04/29/2015] [Accepted: 05/08/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Advanced heart failure is associated with end-organ damage. Recent literature suggested an intriguing crosstalk between failing heart, abdomen and kidneys. Venous ammonia, as a by-product of the gut, could be a marker of abdominal injury in heart failure patients. The aim of the study was to investigate the clinical and prognostic role of ammonia in patients with advanced decompensated heart failure (ADHF). METHODS & RESULTS 90 patients admitted with ADHF were prospectively studied. The prognostic role of ammonia at admission was evaluated. Primary end-points were: a composite of cardiac death, urgent heart transplantation and mechanical circulatory support at 3 months and need for renal replacement therapies (RRT). In the study cohort (age 59.0 ± 12.0 years, FE 21.6 ± 9.0%, INTERMACS profile 3.7 ± 0.9, creatinine 1.71 ± 0.95 mg/dl) 27 patients (30%) underwent the cardiac composite endpoint, while 9 patients (10%) needed RRT. At ROC curve analysis ammonia ≥ 130 μg/dl (abdominal damage) showed the best diagnostic accuracy. At multivariate analysis abdominal damage predicted the cardiac composite endpoint. Abdominal damage further increased risk among patient with cold profile at admission (HR 2.7, 95% CI 1.1-7.0, p = 0.046). At multivariate analysis abdominal damage also predicted need for RRT (OR 10.8, 95% CI 1.5-75.8, p = 0.017). The combined use of estimated right atrial pressure and ammonia showed the highest diagnostic accuracy and a very high specificity in prediction of need for RRT. CONCLUSION In a selected population admitted for ADHF ammonia, as a marker of abdominal derangement, predicted adverse cardiac events and need for RRT.
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Affiliation(s)
- Simone Frea
- Cardiovascular and Thoracic Department, Division of Cardiology, Città della Salute e della Scienza University Hospital of Torino, Italy
| | - Virginia Bovolo
- Cardiovascular and Thoracic Department, Division of Cardiology, Città della Salute e della Scienza University Hospital of Torino, Italy
| | - Stefano Pidello
- Cardiovascular and Thoracic Department, Division of Cardiology, Città della Salute e della Scienza University Hospital of Torino, Italy.
| | - Federico G Canavosio
- Cardiovascular and Thoracic Department, Division of Cardiology, Città della Salute e della Scienza University Hospital of Torino, Italy
| | - Michela Botta
- Cardiovascular and Thoracic Department, Division of Cardiology, Città della Salute e della Scienza University Hospital of Torino, Italy
| | - Serena Bergerone
- Cardiovascular and Thoracic Department, Division of Cardiology, Città della Salute e della Scienza University Hospital of Torino, Italy
| | - Fiorenzo Gaita
- Cardiovascular and Thoracic Department, Division of Cardiology, Città della Salute e della Scienza University Hospital of Torino, Italy
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Abstract
Heart failure is a commonly encountered condition associated with increased morbidity, mortality, and healthcare cost. For years, its management has been strongly influenced by the use of B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide biomarkers. In some cases, this approach does not always identify patients with heart failure accurately and may not provide the best prognostic assessment, particularly in the presence of comorbidities. Biomarkers that help refine diagnosis and risk stratification are needed. Soluble ST2, a peptide belonging to the interleukin-1 receptor family, is secreted when cardiomyocytes and cardiac fibroblasts are subjected to mechanical strain. Although preliminary results on this novel biomarker are encouraging, additional and more comprehensive studies are clearly needed to establish its role in the management of patients with heart failure. The purpose of this chapter is to provide an overview of data currently available.
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Affiliation(s)
- Silvia Lupu
- Department of Cardiovascular Disease and Transplant Institute, University of Medicine and Pharmacy of Targu Mures, Targu Mures, Romania; Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Lucia Agoston-Coldea
- Department of Cardiovascular Disease and Transplant Institute, University of Medicine and Pharmacy of Targu Mures, Targu Mures, Romania; Department of Internal Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
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Collins SP, Pang PS, Butler J, Fonarow G, Metra M, Gheorghiade M. Revisiting cardiac injury during acute heart failure: further characterization and a possible target for therapy. Am J Cardiol 2015; 115:141-6. [PMID: 25456864 DOI: 10.1016/j.amjcard.2014.09.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 09/25/2014] [Accepted: 09/26/2014] [Indexed: 11/17/2022]
Affiliation(s)
- Sean P Collins
- Vanderbilt University College of Medicine, Nashville, TN
| | - Peter S Pang
- Indiana University School of Medicine, Indianapolis, IN
| | - Javed Butler
- Emory University School of Medicine, Atlanta, GA
| | - Gregg Fonarow
- University of California Los Angeles Medical Center, Los Angeles, CA
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Abstract
Cardiac troponin (cTn) is the primary biomarker for the diagnosis of myocardial necrosis in an acute coronary syndrome (ACS). cTn levels can also be elevated in many other conditions, including heart failure, with significant prognostic value. An elevated cTn level can be found in both acute and chronic heart failure and its presence is believed to be due to multiple different pathophysiological processes. In acute decompensated heart failure (AHF), an elevated cTn level has been repeatedly shown to correlate with increased short- and long-term mortality and, to a lesser extent, readmission rates. These associations have been demonstrated with both I and T isoforms of cTn, as well as when troponin is measured with conventional assays or new high-sense assays. In multimarker models, cTn has repeatedly been found to be an independent predictive variable enhancing prognostic ability of the model. cTn is therefore an important biomarker for prognosis in AHF.
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Affiliation(s)
| | - Alan Maisel
- Veterans Affairs San Diego Healthcare System, La Jolla, CA, USA
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Biomarkers in cardiology--part 1--in heart failure and specific cardiomyopathies. Arq Bras Cardiol 2014; 103:451-9. [PMID: 25590924 PMCID: PMC4290735 DOI: 10.5935/abc.20140184] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 09/30/2014] [Indexed: 02/02/2023] Open
Abstract
Cardiovascular diseases are the leading causes of mortality and morbidity in Brazil.
The primary and secondary preventions of those diseases are a priority for the health
system and require multiple approaches to increase their effectiveness. Biomarkers
are tools used to more accurately identify high-risk individuals, to speed the
diagnosis, and to aid in treatment and prognosis determination. This review aims to
highlight the importance of biomarkers in clinical cardiology practice, and to raise
relevant points of their use and the promises for the coming years. This document was
divided into two parts, and this first one discusses the use of biomarkers in
specific cardiomyopathies and heart failure.
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Cohen-Solal A, Laribi S, Ishihara S, Vergaro G, Baudet M, Logeart D, Mebazaa A, Gayat E, Vodovar N, Pascual-Figal DA, Seronde MF. Prognostic markers of acute decompensated heart failure: the emerging roles of cardiac biomarkers and prognostic scores. Arch Cardiovasc Dis 2014; 108:64-74. [PMID: 25534886 DOI: 10.1016/j.acvd.2014.10.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 09/25/2014] [Accepted: 10/02/2014] [Indexed: 12/12/2022]
Abstract
Rapidly assessing outcome in patients with acute decompensated heart failure is important but prognostic factors may differ from those used routinely for stable chronic heart failure. Multiple plasma biomarkers, besides the classic natriuretic peptides, have recently emerged as potential prognosticators. Furthermore, prognostic scores that combine clinical and biochemical data may also be useful. However, compared with the scores used in chronic heart failure, scores for acute decompensated heart failure have not been validated. This article reviews potential biomarkers, with a special focus on biochemical biomarkers, and possible prognostic scores that could be used by the clinician when assessing outcome in patients with acute heart failure.
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Affiliation(s)
- Alain Cohen-Solal
- UMR-S 942 "Biomarqueurs et Insuffisances Cardiaques", Paris, France; Université Paris Diderot, Sorbonne Paris Cité, Paris, France; Cardiology department, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, 2, rue Ambroise-Paré, 75010 Paris, France; DHU FIRE, Sorbonne Paris Cité, Paris, France.
| | - Said Laribi
- UMR-S 942 "Biomarqueurs et Insuffisances Cardiaques", Paris, France; Emergency department, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Shiro Ishihara
- UMR-S 942 "Biomarqueurs et Insuffisances Cardiaques", Paris, France; Cardiology department, Steel Memorial Yawata Hospital, Kitakyushu, Japan
| | - Giuseppe Vergaro
- UMR-S 942 "Biomarqueurs et Insuffisances Cardiaques", Paris, France; Cardiology and cardiovascular medicine division, Fondazione Toscana Gabriele Monasterio per la Ricerca Medica e di Sanità Pubblica, CNR-Regione Toscana, Pisa, Italy
| | - Mathilde Baudet
- Cardiology department, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, 2, rue Ambroise-Paré, 75010 Paris, France
| | - Damien Logeart
- UMR-S 942 "Biomarqueurs et Insuffisances Cardiaques", Paris, France; Université Paris Diderot, Sorbonne Paris Cité, Paris, France; Cardiology department, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, 2, rue Ambroise-Paré, 75010 Paris, France; DHU FIRE, Sorbonne Paris Cité, Paris, France
| | - Alexandre Mebazaa
- UMR-S 942 "Biomarqueurs et Insuffisances Cardiaques", Paris, France; Université Paris Diderot, Sorbonne Paris Cité, Paris, France; DHU FIRE, Sorbonne Paris Cité, Paris, France; Anaesthesia-ICU department, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Etienne Gayat
- UMR-S 942 "Biomarqueurs et Insuffisances Cardiaques", Paris, France; Université Paris Diderot, Sorbonne Paris Cité, Paris, France; DHU FIRE, Sorbonne Paris Cité, Paris, France; Anaesthesia-ICU department, hôpital Lariboisière, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Nicolas Vodovar
- UMR-S 942 "Biomarqueurs et Insuffisances Cardiaques", Paris, France
| | - Domingo A Pascual-Figal
- Cardiology department, hospital Virgen de la Arrixaca, school of medicine, university of Murcia, Murcia, Spain
| | - Marie-France Seronde
- UMR-S 942 "Biomarqueurs et Insuffisances Cardiaques", Paris, France; Cardiology department, CHU de Besançon, Besançon, France
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Palazzuoli A, Masson S, Ronco C, Maisel A. Clinical relevance of biomarkers in heart failure and cardiorenal syndrome: the role of natriuretic peptides and troponin. Heart Fail Rev 2014; 19:267-84. [PMID: 23563622 DOI: 10.1007/s10741-013-9391-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
In recent years, numerous biomarkers have been studied in heart failure to improve diagnostic accuracy and identify patients at higher risk. The overall outcome remains fairish despite improvements in therapy, with mean survival after first hospitalization, around 5 years. We therefore need surrogate end points to better understand the pathogenetic mechanisms of the disease, including interplays with other organs. The kidney plays an important role in the initiation and progression of HF, and around one-third of patients with HF show some degree of renal dysfunction. In addition, treatment for HF often worsens renal function, consequently to hemodynamic and clinical improvement do not correspond an effective improvement in HF prognosis. Association between HF and renal impairment (RI) is now classified as cardiorenal syndrome (CRS) pointing out the bidirectional nature of this vicious circle leading to a mutual and progressive damage of both organs. The clinicians can rely on circulating biomarkers that give insights into the underlying pathogenetic mechanisms and help in risk stratification. Recently, a multimarker strategy including biomarker tool to traditional risk scores has been purposed and applied: Although each biomarker provided incremental outcome benefit, the combination of multiple biomarkers should offer the greatest improvement in risk prediction. Natriuretic peptides (NP) and cardiac troponins (TN) are the two biomarkers most studied in this setting, probably because of their organ-specific nature. However, both NP and TN cutoffs in presence of renal dysfunction need to be revised and discussed in relation to age, gender and stage of RI. In this context, the biomarkers are a unique opportunity to elucidate pathophysiological mechanisms, tailor clinical management to the single patient and improve outcomes. Specific studies about the exact role of biomarkers as in HF as in CRS should be planned and considered for future trials.
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Affiliation(s)
- Alberto Palazzuoli
- Department of Internal Medicine and Metabolic Diseases, Cardiology Section, Le Scotte Hospital, University of Siena, Viale Bracci, 53100, Siena, Italy,
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