The predictive value of transaminases at admission in patients hospitalized for heart failure: findings from the RO-AHFS registry

De Ritis Ratio to Predict Clinical Outcomes of Intermediate- and High-Risk Pulmonary Embolisms

Background: Abnormal liver function tests can identify severe cardiopulmonary failure. The aspartate transaminase/alanine transaminase (AST/ALT) ratio, or the De Ritis ratio, is commonly used to evaluate acute liver damage. However, its prognostic value in pulmonary embolism (PE) is unknown. Methods: Two cohorts, including patients with intermediate- and high-risk PEs, were established: one with an abnormal baseline AST/ALT ratio (>1) and another with a normal baseline AST/ALT ratio (<1). The primary outcome was a 60-day mortality. Secondary outcomes included peak N-terminal pro-brain-natriuretic-peptide (NT-proBNP) levels, complications, and the need for critical care treatment. To assess the effect of abnormal AST/ALT ratios, inverse probability weighted (IPW) analyses were performed. Results: In total, 230 patients were included in the analysis, and 52 (23%) had an abnormal AST/ALT ratio. After the IPW correction, patients with an abnormal AST/ALT ratio had a significantly higher mortality rate and peak NT-proBNP levels. The relative risks of 60-day mortality, shock development, use of inotropes/vasopressors, mechanical ventilation, and extracorporeal life support were 9.2 (95% confidence interval: 3.3-25.3), 10.1 (4.3-24), 2.7 (1.4-5.2), 2.3 (1.4-3.7), and 5.7 (1.4-23.1), respectively. Conclusions: The baseline AST/ALT ratio can be a predictor of shock, multiorgan failure, and mortality in patients with a pulmonary embolism.

Prognostic importance of improving hepatorenal function during hospitalization in acute decompensated heart failure

AIMS

The Model for End-stage Liver Disease eXcluding International normalized ratio (MELD-XI) is an established scoring system that reflects hepatorenal function. However, little is known about the prognostic value of changes in MELD-XI score during hospitalization in acute decompensated heart failure (ADHF).

METHODS AND RESULTS

We prospectively analysed 536 patients admitted for ADHF between January 2018 and December 2019. In the MELD-XI, 9.44 is the lowest possible score and considered to be normal, and values above 9.44 are classified as high. We calculated MELD-XI scores at admission and discharge and used them to divide patients into four groups depending on whether the score was high (>9.44) or normal (9.44) at each time point as follows: normal score at both measurements (persistently normal group, n = 99), high score at admission and normal score at discharge (high-to-normal group, n = 108), normal score at admission and high score at discharge (normal-to-high group, n = 24), and high score at both measurements (persistently high group, n = 305). The persistently high group had higher blood urea nitrogen, creatinine, and N-terminal pro-brain natriuretic peptide levels at both admission and discharge and significantly higher left ventricular end-diastolic, left atrial, right ventricular end-diastolic, and maximal inferior vena cava diameters at discharge. During the median follow-up period of 369 days (Q1, Q3: 97, 576), 231 (43.1%) patients reached the primary endpoint (a composite of all-cause death or re-hospitalization for heart failure). The Kaplan-Meier analysis revealed a significantly higher composite event rate in the persistently high group than in the persistently normal and high-to-normal groups (log-rank test, P < 0.001). Compared with the persistently high group, the high-to-normal group remained significantly associated with lower composite event risk after multivariate adjustment (hazard ratio, 0.30; 95% CI, 0.12-0.69; P = 0.004).

CONCLUSIONS

Our study suggests that changes in hepatorenal function during hospitalization are associated with the severity of heart failure and systemic congestion and that they provide useful information for predicting clinical outcomes in patients with ADHF.

Prognostic value of the MELD-XI score in patients undergoing cardiac resynchronization therapy

Aims

Multi‐organ dysfunction was recently reported to be a common condition in patients with heart failure (HF). The Model for End‐stage Liver Disease eXcluding International normalized ratio (MELD‐XI) score reflects liver and kidney function. The prognostic relevance of this score has been reported in patients with a variety of cardiovascular diseases who are undergoing interventional therapies. However, the relationship between the severity of hepatorenal dysfunction assessed by the MELD‐XI score and the long‐term clinical outcomes of HF patients receiving cardiac resynchronization therapy (CRT) has not been evaluated.

Methods and results

Clinical records of 283 patients who underwent CRT implantation between March 2003 and October 2020 were retrospectively evaluated (mean age 67 ± 12, 22.6% female). Blood samples were collected before CRT implantation. Patients were divided into three groups based on tertiles of the MELD‐XI score: first tertile (MELD‐XI = 9.44, n = 95), second tertile (9.44 < MELD‐XI < 13.4, n = 94), and third tertile (MELD‐XI ≥ 13.4, n = 94). The primary endpoint was all‐cause mortality. Compared with the other groups, the third tertile group exhibited significantly older age, higher prevalence of diabetes mellitus and hypertension, lower haemoglobin level, and higher N‐terminal pro‐brain natriuretic peptide level (all P < 0.05). The functional CRT response rate was also significantly lower in the third tertile group (P = 0.011). During a median follow‐up of 30 months (inter‐quartile range, 9–67), 105 patients (37.1%) died. Kaplan–Meier analysis revealed that patients with a higher MELD‐XI score had a greater risk of all‐cause mortality (log‐rank test: P < 0.001). Even after adjustment for clinically relevant factors and a conventional risk score, the MELD‐XI score was still associated with mortality (adjusted hazard ratio: 1.04, 95% confidence interval: 1.00–1.07, P = 0.014, and adjusted hazard ratio: 1.04, 95% confidence interval: 1.01–1.09, P = 0.005, respectively). A higher MELD‐XI score was associated with a greater risk of all‐cause mortality than a lower MELD‐XI score regardless of whether a pacemaker or defibrillator was implanted (log‐rank test: P = 0.010 and P < 0.001, respectively).

Conclusions

Impaired hepatorenal function assessed by the MELD‐XI score was associated with older age, higher prevalence of multiple co‐morbidities, severity of HF, lower CRT response rates, and subsequent all‐cause mortality in HF patients undergoing CRT implantation. These results suggest that the MELD‐XI score can provide additional prognostic information and may be useful for improving risk stratification in this population.

Preoperative Liver Function Test Abnormalities Were Associated With Short-Term and Long-Term Prognosis in Cardiac Surgery Patients Without Liver Disease

Aims: To explore the value of preoperative liver function tests (LFTs) for the prognosis of cardiac surgery patients without liver disease.

Methods: The Medical Information Mart for Intensive Care III (MIMIC-III) database was used to extract the clinical data. Adult cardiac patients (≥18 years) without liver disease in the database were enrolled. The association of LFTs with the time of hospital stay and ICU stay was analyzed with the Spearman correlation. Survival curves were estimated using the Kaplan-Meier method and compared by the log-rank test. Multivariable logistic regression was used to identify LFTs that were independent prognostic factors of mortality.

Results: A total of 2,565 patients were enrolled in this study. Albumin (ALB) was negatively associated with the time of hospital stay and ICU stay, while alanine transaminase (ALT), aspartate aminotransferase (AST), and total bilirubin were positively associated with the time of hospital stay and ICU stay (all p < 0.001). Abnormal ALB, ALT, AST, and total bilirubin were associated with lower 90-day and 4-year survival (all p < 0.001) and could be used as independent risk factors for hospital mortality and 90-day mortality. However, only ALB and total bilirubin were independent risk factors for 4-year mortality.

Conclusion: Preoperative LFT abnormalities were associated with short-term and long-term prognosis of cardiac surgery patients without liver disease.

Liver stiffness as measured by transient elastography is a predictor of outcomes in patients with chronic heart failure with reduced, mid-range, and recovered left-ventricular ejection fraction

Background

Transient elastography is a noninvasive method for assessing liver stiffness (LS), which can reflect right-sided filling pressure associated with passive liver congestion in patients with HF.

Methods

A prospective, single-center observational study in which LS was measured in consecutive ambulatory patients with heart failure with reduced, mid-range, and recovered left ventricular ejection fraction, between March 2018 and June 2019. Mean follow up was 219 ± 86 days. The primary endpoint was time to first event, which was defined as a composite of cardiovascular death or HF hospitalization.

Results

Eighty-five patients were included in the final analysis. Mean age was 62 ± 10 and 68% were male. Mean ejection fraction and median NT-proBNP were, respectively, 38.7 ± 14.3% and 1140 pg/mL (interquartile range 224.3-2810.3). The median LS for the entire population was 6.3 (2.5-41.2) kPa. LS correlated with NT-proBNP (r = 0.46; p < 0.0001), total bilirubin (r = 0.47; p < 0.001), direct bilirubin (r = 0.43; p = 0.0001), gama-glutamyl-transpeptidase (r = 0.54; p < 0.0001), and alkaline phosphatase (r = 0.39; p = 0.0004). A Receiver Operating Characteristic (ROC) curve was performed and a cut point of 5.9 kPa showed sensitivity of 80% and specificity of 64.1% with area under the curve of 0.73. Using Cox proportional hazard model (independent variables: LS as a continuous variable, age, gender, NT-proBNP, LVEF, and creatinine), only LS was independently associated with the primary endpoint (hazard ratio 1.05, 95% confidence interval 1.01-1.09; for each increment of one unit of LS).

Conclusion

LS correlates with biomarkers of myocardial stretch and several liver function tests and is an independent predictor of outcomes in ambulatory patients with HF.

Machine learning prediction models for prognosis of critically ill patients after open-heart surgery

We aimed to build up multiple machine learning models to predict 30-days mortality, and 3 complications including septic shock, thrombocytopenia, and liver dysfunction after open-heart surgery. Patients who underwent coronary artery bypass surgery, aortic valve replacement, or other heart-related surgeries between 2001 and 2012 were extracted from MIMIC-III databases. Extreme gradient boosting, random forest, artificial neural network, and logistic regression were employed to build models by utilizing fivefold cross-validation and grid search. Receiver operating characteristic curve, area under curve (AUC), decision curve analysis, test accuracy, F1 score, precision, and recall were applied to access the performance. Among 6844 patients enrolled in this study, 215 patients (3.1%) died within 30 days after surgery, part of patients appeared liver dysfunction (248; 3.6%), septic shock (32; 0.5%), and thrombocytopenia (202; 2.9%). XGBoost, selected to be our final model, achieved the best performance with highest AUC and F1 score. AUC and F1 score of XGBoost for 4 outcomes: 0.88 and 0.58 for 30-days mortality, 0.98 and 0.70 for septic shock, 0.88 and 0.55 for thrombocytopenia, 0.89 and 0.40 for liver dysfunction. We developed a promising model, presented as software, to realize monitoring for patients in ICU and to improve prognosis.

Serum levels of gamma-glutamyltransferase predict outcome in heart failure with preserved ejection fraction

Previous studies suggested an association between heart failure (HF) and hepatic disorders. Liver function parameters have been shown to predict outcome in HF with reduced ejection fraction, but their impact in HF with preserved ejection fraction (HFpEF) has not yet been investigated. Between January 2011 and February 2017, 274 patients with confirmed HFpEF were enrolled (age 71.3 ± 8.4 years, 69.3% female) in a prospective registry. During a median follow-up of 21.5 ± 18.6 months, 97 patients (35.4%) reached the combined endpoint defined as hospitalization due to HF and/ or death from any cause. By multivariable cox regression, serum gamma-glutamyltransferase (GT) was independently associated with outcome (Hazard Ratio (HR) 1.002, p = 0.004) along with N-terminal pro brain natriuretic peptide (HR 2.213, p = 0.001) and hemoglobin (HR 0.840, p = 0.006). Kaplan-Meier analysis showed that patients with serum gamma-GT levels above a median of 36 U/L had significantly more events as compared to the remainder of the group (log-rank p = 0.012). By multivariable logistic regression, higher early mitral inflow velocity/ mitral peak velocity of late filling (Odds Ratio (OR) 2.173, p = 0.024), higher right atrial (RA) pressure (OR 1.139, p < 0.001) and larger RA diameter (OR 1.070, p = 0.001) were independently associated with serum gamma-GT > 36 U/L. Serum levels of gamma-GT are associated with both left and right-sided cardiac alterations and may serve as a simple tool for risk prediction in HFpEF, especially when further diagnostic modalities are not available.

Relationship of Liver Stiffness With Congestion in Patients Presenting With Acute Decompensated Heart Failure

OBJECTIVE

The significance of liver stiffness (LS) in the setting of cardiovascular congestion during the course of acute decompensated heart failure (ADHF) is under investigation. The aim of this study was to assess LS with the use of transient elastography (TE) and its associations with volume overload as determined by means of bioimpedance vector analysis (BIVA) in ADHF.

METHODS AND RESULTS

TE (Fibroscan 502; Echosens) and BIVA (ABC-01, Medass) were performed in the first 48 hours of admission and on the day of discharge in 149 ADHF patients without known primary chronic liver disease or acute hepatitis. During hospitalization the median value of LS decreased from 12.2 kPa (interquartile range 6.3-23.6) to 8.7 (5.9-14.4) kPa (P < .001). Changes in LS correlated (P < .001) with changes in weight and BIVA parameters. LS was compared with histologic features of livers of ADHF patients who died (n = 7). Liver fibrosis 2B-4 was observed but was not associated with LS. LS at discharge was associated with increased risk of 12-month all-cause death, HF readmission, and the combined end point.

CONCLUSIONS

There was a moderate association between LS with clinical congestion and volume overload according to BIVA and no correlation with degree of histologic liver fibrosis. LS may be a marker of negative HF outcomes.

Usefulness of the Direct and/or Total Bilirubin to Predict Adverse Outcomes in Patients With Acute Decompensated Heart Failure

Abnormal liver function test results are often observed in acute decompensated heart failure (ADHF). However, the prognostic value of bilirubin fractionation has not been elucidated. The prognostic value of direct bilirubin (DB), in comparison with total bilirubin (TB), was examined in 556 consecutive patients with ADHF. Patients with elevated DB showed mostly similar patient characteristics including signs of elevated right-sided pressure (frequent hepatomegaly, jugular venous distention, dilated inferior vena cava, and elevated gamma-glutamyltransferase) and decreased cardiac output (cold extremities, decreased pulse pressure, and lower blood pressure) and other parameters of heart failure (HF) severity (increased plasma renin activity, decreased sodium, total cholesterol, and ejection fraction) to elevated TB; however, only patients with elevated DB showed a significant difference in the frequency of HF history and alkaline phosphatase value. Kaplan-Meier analysis showed that patients with elevated DB had a significantly higher rate of the composite end point of all-cause mortality or HF readmission (p = 0.021) compared with those with normal DB, whereas patients with elevated TB did not show a statistically significant difference compared with those with normal TB (NS). A multivariate Cox hazards model showed that DB was an independent predictor of adverse events (adjusted hazard ratio 1.052, 95% confidence interval 1.001 to 1.099, p = 0.034), whereas TB was not (adjusted hazard ratio 1.017, 95% confidence interval 0.985 to 1.046, p = 0.27). Adding DB to existing prognostic variables resulted in higher C-statistics than adding TB (C-statistics: 0.670 to 0.675, 0.670 to 0.674, respectively). In conclusion, elevated DB in ADHF was an independent prognostic predictor that was superior to TB. DB may be useful for further risk stratification in ADHF.

Predictors of Post-discharge Mortality Among Patients Hospitalized for Acute Heart Failure

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.

Characteristics of Intensive Care in Patients Hospitalized for Heart Failure in Europe

Patients hospitalized for acute heart failure (AHF) may clinically decompensate and experience life-threatening complications. Regional differences in intensive care unit (ICU) admission rates have been reported by European registries. Variations regarding ICU bed and facilities availability may contribute to these geographic differences. ICU triage decision requires cautious clinical judgment to balance between clinical benefit of ICU care and associated risk and cost. In Europe, despite large variations in treatment practices, in-hospital mortality of AHF patients managed in ICUs is similar, suggesting that high-risk characteristics of AHF patients admitted to ICUs, rather than geographic variation in intensity of therapies, may be the principal determinant of prognosis.

Effect of minor liver function test abnormalities and values within the normal range on survival in heart failure

Liver function test (LFT) abnormalities are often observed in patients with heart failure (HF). However, the relation of LFTs with outcomes has not been well described. Patients of the VA Palo Alto Health Care System (3 inpatient facilities and 7 community clinics) with a complete set of LFTs in the 60 days before a first HF diagnosis were included in the analysis from January 2005 to April 2013. A total of 2,096 patients met inclusion criteria. Patients were a mean of 71 ± 12 years old, 97% were men, 57% had a previous diagnosis of ischemic heart disease, and the mean left ventricular ejection fraction was 51 ± 12%. The median (twenty fifth and seventy fifth) values were albumin 3.6 g/dl (3.3, 3.9), alanine transaminase 21 IU/L (16, 30), aspartate transaminase 24 IU/L (20,31), AP 70 IU/L (57, 87), and total bilirubin 0.8 mg/dl (0.6, 1.0). There were 851 deaths (41%) over a mean duration of 41 ± 27 months. Mortality significantly increased with lower values of albumin and alanine transaminase and higher levels of aspartate transaminase and AP. The association with total bilirubin was not significant. In conclusion, many LFT values in the "normal" range are independently associated with decreased survival beyond traditional risk factors for mortality in HF.

Cardiac amyloidosis: a challenging diagnosis

Cardiovascular involvement of amyloidosis is present in 90% of cases, which is frequently associated with the primary form of the disease (AL amyloidosis). Clinical manifestations are represented by heart failure due to restrictive myocardiopathy and electrical impulse conduction abnormalities, which are clinically remarkable in up to 50% of the cases. The prognosis of patients with systemic amyloidosis is directly associated with the presence of cardiac involvement, such that survival does not usually exceed 4 months after the onset of heart failure signs and symptoms. The authors report a case of primary systemic amyloidosis, diagnosed only at autopsy, with severe cardiac involvement.