Considerations for initial therapy in the treatment of acute heart failure

The Effect of Hypoxia on Irisin Expression in HL-1 Cardiomyocytes

BACKGROUND/AIM

Cardiovascular diseases (CVD) are the leading cause of death worldwide. In 2019, 523 million people were diagnosed with CVD, with 18.6 million deaths. Improved treatment and diagnostics could reduce CVD's impact. Irisin (Ir) is crucial for heart function and may be a biomarker for heart attack. Ir is a glycoprotein with sugar residues attached to its protein structure. This glycosylation affects Ir stability, solubility, and receptor interactions on target cells. Its secondary structure includes a fibronectin type III domain, essential for its biological functions. Ir helps cardiomyocytes to respond to hypoxia and protects mitochondria. The aim of the study was to determine the FNDC5 gene expression level and the Ir level in HL-1 cardiomyocytes subjected to hypoxia.

MATERIALS AND METHODS

We examined the effect of hypoxia on the expression levels of the FNDC5 gene and those of Ir in mouse cardiomyocytes of the HL-1 cell line. Real-time PCR (RT-PCR) was used to estimate the expression levels of the FNDC5 gene. Western blot and immunofluorescence methods were used to analyze the Ir protein levels.

RESULTS

Analyses showed an increased Ir level in HL-1 cardiomyocytes in response to hypoxia. This is the first study to confirm the presence of Ir in HL-1 cells.

CONCLUSION

The observed increase in Ir expression in murine cardiomyocytes is associated with the hypoxic environment and can be potentially used to diagnose hypoxia and CVD.

The Role of FNDC5/Irisin in Cardiovascular Disease

Disorders of cardiomyocyte metabolism play a crucial role in many cardiovascular diseases, such as myocardial infarction, heart failure and ischemia-reperfusion injury. In myocardial infarction, cardiomyocyte metabolism is regulated by mitochondrial changes and biogenesis, which allows energy homeostasis. There are many proteins in cells that regulate and control metabolic processes. One of them is irisin (Ir), which is released from the transmembrane protein FNDC5. Initial studies indicated that Ir is a myokine secreted mainly by skeletal muscles. Further studies showed that Ir was also present in various tissues. However, its highest levels were observed in cardiomyocytes. Ir is responsible for many processes, including the conversion of white adipose tissue (WAT) to brown adipose tissue (BAT) by increasing the expression of thermogenin (UCP1). In addition, Ir affects mitochondrial biogenesis. Therefore, the levels of FNDC5/Ir in the blood and myocardium may be important in cardiovascular disease. This review discusses the current knowledge about the role of FNDC5/Ir in cardiovascular disease.

Clinical presentation and outcomes of acute heart failure in the critically ill patient: A prospective, observational, multicentre study

AIMS

To assess the clinical profile and factors associated with 30-day mortality in patients with acute heart failure (AHF) admitted to the intensive care unit (ICU).

DESIGN

Prospective, multicentre cohort study.

SCOPE

Thirty-two Spanish ICUs.

PATIENTS

Adult patients admitted to the ICU between April and June 2017.

INTERVENTION

Patients were classified into three groups according to AHF status: without AHF (no AHF); AHF as the primary reason for ICU admission (primary AHF); and AHF developed during the ICU stay (secondary AHF).

MAIN VARIABLES OF INTEREST

Incidence of AHF and 30-day mortality.

RESULTS

A total of 4330 patients were included. Of these, 627 patients (14.5%) had primary (n=319; 7.4%) or secondary (n=308; 7.1%) AHF. Among the main precipitating factors, fluid overload was more common in the secondary AHF group than in the primary group (12.9% vs 23.4%, p<0.001). Patients with AHF had a higher risk of 30-day mortality than those without AHF (OR 2.45; 95% CI: 1.93-3.11). APACHE II, cardiogenic shock, left ventricular ejection fraction, early inotropic therapy, and diagnostic delay were independently associated with 30-day mortality in AHF patients. Diagnostic delay was associated with a significant increase in 30-day mortality in the secondary group (OR 6.82; 95% CI 3.31-14.04).

CONCLUSIONS

The incidence of primary and secondary AHF was similar in this cohort of ICU patients. The risk of developing AHF in ICU patients can be reduced by avoiding modifiable precipitating factors, particularly fluid overload. Diagnostic delay was associated with significantly higher mortality rates in patients with secondary AHF.

Early cardiac rehabilitation for acute decompensated heart failure safely improves physical function (PEARL study): a randomized controlled trial

BACKGROUND

Improvements in the Short Physical Performance Battery (SPPB) rather than exercise tolerance reportedly lead to favorable prognosis in elderly patients with acute decompensated heart failure (ADHF). However, about 50% of heart failure shows heart failure with preserved ejection fraction, safe and effective interventions to improve SPPB for these types remain unclear. In addition, although a standard cardiac rehabilitation (CR) program for heart failure is widely used in Japan, whether this is sufficient to improve SPPB in elderly patients with ADHF remains unclear.

AIM

This study was to evaluate whether the addition of multidisciplinary physical interventions to the standard CR program would prove effective for improving SPPB among elderly patients with ADHF regardless types of heart failure.

DESING

Randomized, prospective study.

SETTING

Patients admitted to our hospital due to ADHF in Japan.

POPULATION

Elderly patients with ADHF between March 2019 and March 2020 were randomized to two groups, an Intervention group and a Control group.

METHODS

The Control group performed standard CR. The Intervention group received balance training and resistance training and used a cycling ergometer in addition to the standard CR program. The primary outcome was the improvement in SPPB after CR.

RESULTS

Seventy-five patients with ADHF were divided into the two groups (Intervention group, n=36; Control group, n=39). At baseline, both groups showed low physical performance and a high prevalence of frailty. Intervention size effect was an improvement in SPPB score of +2.2 (+3.7±1.1 vs. +1.5±1.7; p<0.001). Of the 3 components of SPPB, both gait speed and timed repeated chair rise were significantly improved in the Intervention group compared to the Control group, with intervention size effect of +0.76 and +0.94, respectively (p<0.001). Subgroup analysis of heart failure with preserved ejection fraction showed significant improvement in SPPB score in the Intervention group compared to the Control group (p<0.001).No adverse events were observed during the study period.

CONCLUSIONS

A multi-faceted intervention in addition to standard CR improved physical performance among elderly patients with ADHF regardless types of heart failure.

CLINICAL REHABILITATION IMPACT

We believe that use of a cycling ergometer and loadspecific resistance training provide specific CR for patients with ADHF during acute hospitalization and highlight the need for active intervention.

Dynamics of growth differentiation factor 15 in acute heart failure

Aims

Risk stratification in acute heart failure (HF) patients can help to decide therapies and time for discharge. The potential of growth differentiation factor 15 (GDF‐15) in HF has been previously shown. We aimed to study the importance of GDF‐15‐level variations in acute HF patients.

Methods and results

We retrospectively evaluated a cohort of patients hospitalized due to acute HF. GDF‐15 was measured both at admission and on the discharge day. Patients were followed‐up during a 3 year period. The endpoint under analysis was all‐cause mortality. GDF‐15 variation is equal to [(admission GDF‐15 − discharge GDF‐15)∕admission GDF‐15] × 100. Variation was categorized in levels of increase or decrease of GDF‐15. Patients were cross‐classified according to admission and discharge GDF‐15 cut‐off points. A Cox regression analysis was used to assess the prognostic impact of GDF‐15 variation and the impact of both admission and discharge GDF‐15 according to the cross‐classification. We studied a group of 249 patients with high co‐morbidity burden. Eighty‐one patients died at 1 year and 147 within 3 years. There was a modest decrease in GDF‐15 during hospitalization from a median value of 4087 to 3671 ng/mL (P = 0.02). No association existed between GDF‐15 variation and mortality. In multivariate analysis, patients with admission GDF‐15 ≥ 3500 ng/mL and discharge GDF‐15 ≥ 3000 ng/mL had a significantly higher 1 year death risk when compared with the remaining—hazard ratio = 2.59 (95% confidence interval: 1.41–4.76)—and a 3 year 1.76 (95% confidence interval: 1.08–2.87) higher death risk compared with those with both values below the cut‐off.

Conclusions

Growth differentiation factor 15 decreased during an acute HF hospitalization, but its variation had no prognostic implications. The knowledge of both admission and discharge GDF‐15 added meaningful information to patients' risk stratification.

Characteristics and Outcomes of Pediatric Heart Failure-Related Emergency Department Visits in the United States: A Population-Based Study

OBJECTIVES

To describe the frequency, characteristics, and outcomes of heart failure-related emergency department (ED) visits in pediatric patients. We aimed to test the hypothesis that these visits are associated with higher admission rates, mortality, and resource utilization.

STUDY DESIGN

A retrospective analysis of the Nationwide Emergency Department Sample for 2010 of patients ≤18 years of age was performed to describe ED visits with and without heart failure. Cases were identified using International Classification of Disease, Ninth Revision, Clinical Modification codes and assessed for factors associated with admission, mortality, and resource utilization.

RESULTS

Among 28.6 million pediatric visits to the ED, there were 5971 (0.02%) heart failure-related cases. Heart failure-related ED patients were significantly more likely to be admitted (59.8% vs 4.01%; OR 35.3, 95% CI 31.5-39.7). Among heart failure-related visits, admission was more common in patients with congenital heart disease (OR 5.0, 95% CI 3.3-7.4) and in those with comorbidities including respiratory failure (OR 78.3, 95% CI 10.4-591) and renal failure (OR 7.9, 95% CI 1.7-36.3). Heart failure-related cases admitted to the hospital had a higher likelihood of death than nonheart failure-related cases (5.9% vs 0.32%, P < .001). Factors associated with mortality included respiratory failure (OR 4.5, 95% CI 2.2-9.2) and renal failure (OR 7.8, 95% CI 2.9-20.7). Heart failure-related ED visits were more expensive than nonheart failure-related ED visits ($1460 [IQR $861-2038] vs $778 [IQR $442-1375] [P < .01].) CONCLUSIONS: Heart failure-related visits represent a minority of pediatric ED visits but are associated with increased hospital admission and resource utilization.

Troponin Testing in Patients Without Chest Pain or Electrocardiographic Ischemic Changes

BACKGROUND

Although often recommended by experts, it is unclear if elevated troponin measurements have clinical utility in patients without chest pain or ischemic electrocardiographic changes.

OBJECTIVES

The objective of this study was to determine clinical utility, and downstream testing in patients with elevated troponin values but without chest pain or electrocardiographic changes.

METHODS

We selected all patients aged 30-100 years hospitalized in cardiology and internal medicine departments from July 1, 2013 until July 31, 2016. We chose a subgroup of 723 consecutive subjects with elevated troponin values for chart review to determine the proportion of patients without chest pain or ischemic electrocardiographic changes, and resultant differential treatment and downstream testing. Clinical utility was defined as coronary artery interventions or treatment of life-threatening arrhythmias.

RESULTS

Troponin measurements were sent in 52.5% of all hospitalized patients (16,519/31,448), and were elevated in 29.9% (4938/16,519). Nearly two-thirds of the patients reviewed had neither chest pain nor ischemic electrocardiographic changes (63.3% [458/723]), and the elevated troponin values did not result in coronary artery interventions or treatment of life-threatening arrhythmias. The elevated troponin values were the sole reason for hospitalization in 2.0% (n = 9), for cardiac monitoring in 6.1% (n = 28), for cardiac consultations in 11.1% (n = 51), and for left heart catheterization in 0.7% (n = 3) of the patients.

CONCLUSION

Most of the elevated troponin test results were in patients without chest pain or ischemic electrocardiographic changes, had no clinical utility, and resulted in downstream testing.

Cardiovascular Conditions in the Observation Unit: Beyond Chest Pain

The first emergency department observation units (EDOUs) focused on chest pain and potential acute coronary syndromes. However, most EDOUs now cover multiple other conditions that lend themselves to protocolized, aggressive diagnostic and therapeutic regimens. In this article, the authors discuss the management of 4 cardiovascular conditions that have been successfully deployed in EDOUs around the country.

Expert consensus document: Echocardiography and lung ultrasonography for the assessment and management of acute heart failure

Echocardiography is increasingly recommended for the diagnosis and assessment of patients with severe cardiac disease, including acute heart failure. Although previously considered to be within the realm of cardiologists, the development of ultrasonography technology has led to the adoption of echocardiography by acute care clinicians across a range of specialties. Data from echocardiography and lung ultrasonography can be used to improve diagnostic accuracy, guide and monitor the response to interventions, and communicate important prognostic information in patients with acute heart failure. However, without the appropriate skills and a good understanding of ultrasonography, its wider application to the most acutely unwell patients can have substantial pitfalls. This Consensus Statement, prepared by the Acute Heart Failure Study Group of the ESC Acute Cardiovascular Care Association, reviews the existing and potential roles of echocardiography and lung ultrasonography in the assessment and management of patients with acute heart failure, highlighting the differences from established practice where relevant.

The impact of emergency medical services in acute heart failure

BACKGROUND

Real-life data on the role of emergency medical services (EMS) in acute heart failure (AHF) are scarce. Our aim was to describe prehospital treatment of AHF and to compare patients using EMS with self-presented, non-EMS patients.

METHODS

Data were collected retrospectively from three university hospitals in Helsinki metropolitan area between July 1, 2012 and July 31, 2013. According to the use of EMS, patients were divided into EMS and non-EMS groups.

RESULTS

The study included 873 AHF patients. One hundred were (11.5%) EMS and 773 (88.5%) non-EMS. EMS patients more often had comorbidities. Initial heart rate (HR) and peripheral oxygen saturation (SpO₂) differed between EMS and non-EMS patients; mean HR 89.2 (SD 22.5) vs. 83.7 (21.5)/min (p=0.02) and SpO₂ 90.3 (8.6) vs. 92.9 (6.6)% (p=0.01). However, on presentation to ED EMS patients' vital signs were similar to non-EMS patients'. On presentation to ED 46.0% were normotensive and 68.2% "warm and wet". Thirty-four percentage of EMS patients received prehospital medication. In-hospital mortality was 6.0% and 7.1% (p=0.84) and length of stay (LOS) 7.7 (7.0) and 8.5 (7.9) days (p=0.36) in EMS and non-EMS groups.

CONCLUSION

The use of EMS and administration of prehospital medication was low. EMS patients had initially worse HR and SpO₂ than non-EMS patients. However, EMS patients' signs improved and were similar on presentation to ED. There were no differences in in-hospital mortality and LOS. This underscores the need for equal attention to any AHF patient independent of the arrival mode.