Divergent effect of blood glucose dysregulation on long-term clinical outcome in acute decompensated heart failure: A reappraisal in contemporary practice

BACKGROUND

The prognostic implication of elevated or decreased blood glucose (BG) level in acute decompensated heart failure (ADHF) has been still controversial. Indices of stress hyperglycemia, expressed by the ratio of BG and chronic BG control, has been reported to be associated with poor outcome in different disease population. We sought to assess BG at admission and %ΔBG, an index of BG deviation from estimated average BG calculated from glycated hemoglobin (HbA1c), on the long-term outcome in ADHF patients.

METHODS AND RESULTS

The West Tokyo Heart Failure (WET-HF) Registry is a prospective multicenter registry enrolling consecutive hospitalized ADHF patients. Among the patients (N = 3078, 77 [67-84] years, male 59%), BG at admission discriminated the long-term (1000 days) incidence of ADHF rehospitalization, but not cardiac death. BG at admission showed a U-shape relationship with the long-term incidence of ADHF rehospitalization after adjustment for covariates. Especially, in patients with HbA1c ≥ 6.5%, the lowest quartile showed the highest risk of ADHF rehospitalization. On the contrary, %ΔBG showed U-shape relationship with the long-term incidence of cardiac death after discharge, rather than ADHF rehospitalization after adjustment for covariates. In addition, elevated %ΔBG was associated with the long-term risk of sudden cardiac death (SCD) even after adjustment for covariates.

CONCLUSIONS

For ADHF patients, BG at admission and %ΔBG might be a simple, useful tool for predicting and stratifying long-term risk of cardiac events. Especially, elevated %ΔBG might be an important in predicting hard events such as cardiac death or SCD.

Heart failure and its treatment from the perspective of sympathetic nerve activity

Heart failure is the end-stage phenotype of several cardiac diseases. The number of heart failure patients is increasing in accordance with an increase in the number of elderly people. The prognosis of heart failure is poor and its 5-year death rate is comparable to that of stage III cancer. It is important to understand the essential mechanism of the worsening prognosis of heart failure and to practice effective treatment from the perspective of improving the prognosis of heart failure based on its essential mechanism. Plasma noradrenaline level is a good predictor of the survival rate of heart failure patients, and sympathetic nerve activity is augmented in patients with heart failure as evidenced by a higher noradrenaline release rate (spillover) from the sympathetic nerve endings especially in the heart and kidney. Noradrenaline release is regulated by presynaptic receptors at the sympathetic nerve endings, and the kidney affects the sympathetic nerve activity. Although the short-term reflex augmentation of sympathetic nerve activity caused by reduced cardiac function may help to improve cardiac function, long-term augmentation of sympathetic nerve activity damages the heart and deteriorates the prognosis of heart failure. Currently, drugs such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, mineralocorticoid antagonists, ivabradine, angiotensin receptor-neprilysin inhibitor, and sodium-glucose transport protein 2 inhibitors, are used for the treatment of heart failure, and had a good prognosis in large randomized, controlled clinical trials. Interestingly, the same characteristics in common of these drugs is the ability to optimize excessively augmented sympathetic nerve activity. This review discusses insights into essential mechanism of heart failure that determines the prognosis of heart failure, focusing on the interaction between sympathetic nerve activity and anti-heart failure drugs currently recommended by the 2021 guidelines of the Japanese Circulation Society and the Japanese Heart Failure Society for heart failure treatment.

Sympathetic neural overdrive in congestive heart failure and its correlates: systematic reviews and meta-analysis

BACKGROUND AND OBJECTIVES

Sympathetic neural activation occurs in congestive heart failure (CHF). However, the small sample size of the microneurographic studies, heterogeneity of the patients examined, presence of comorbidities as well as confounders (including treatment) represented major weaknesses not allowing to identify the major features of the phoenomenon, particularly in mild CHF. This meta-analysis evaluated 2530 heart failure (CHF) patients recruited in 106 microneurographic studies. It was based on muscle sympathetic nerve activity (MSNA) quantification in CHF of different clinical severity, but data from less widely addressed conditions, such as ischemic vs. idiopathic, were also considered.

METHODS

Assessment was extended to the relationships of MSNA with venous plasma norepinephrine, heart rate (HR) and echocardiographic parameters of cardiac morphology [left ventricular (LV) end-diastolic diameter] and function (LV ejection fraction) as well.

RESULTS

MSNA was significantly greater (1.9 times, P < 0.001) in CHF patients as compared with healthy controls, a progressive significant increase being observed from New York Heart Association classes I-IV in unadjusted and adjusted analyses. MSNA was significantly greater in both untreated and treated CHF (P < 0.001 for both), related to left ventricular (LV) end-diastolic diameter and to a lesser extent to LV ejection fraction (r = 0.24 and -0.05, P < 0.001 and <0.01, respectively), and closely associated with HR (r = 0.66, P < 0.001) and plasma norepinephrine (r = 0.68, P < 0.001).

CONCLUSION

CHF is characterized by sympathetic overactivity which mirrors the degree of LV dysfunction independently of the stage of CHF, its cause and presence of confounders or pharmacological treatment. plasma norepinephrine and HR represent potentially valuable surrogate markers of sympathetic activation in the clinical setting.

Sympathetic overactivation predicts body weight loss in patients with heart failure

Neurohumoral activation is frequently observed in chronic heart failure (HF) patients who develop body weight (BW) loss. We therefore hypothesized that sympathetic overactivation can predict progression of BW loss in HF patients with reduced ejection fraction. We prospectively evaluated BW loss in 108 non-edematous HF in whom muscle sympathetic nerve activity (MSNA) was measured. Follow-up began on the day of first MSNA measurement. Patients with BW loss of ≥5% of baseline BW during the first year of follow-up were considered to be experiencing BW loss. Maximal BW loss (%) and time to first BW loss (i.e., ≥5%) were assessed. Primary cardiovascular endpoints included cardiovascular death and HF hospitalization. Predictors of outcomes were assessed on univariate, multivariate, and Kaplan-Meier analyses. BW loss ≥5% occurred in 14% of enrolled patients. Mean MSNA was significantly higher in the BW loss group than in the no-BW loss group (80 versus 58 bursts/100 beats; p < 0.001). Moreover, multivariate Cox proportional hazard regression analysis revealed MSNA as the only independent predictor of BW loss. Multiple linear regression analysis identified MSNA as the strongest independent marker of maximal BW loss, even after adjusting for univariate predictors. BW loss, MSNA and several variables also correlated significantly with poor outcomes in univariate analyses. However, multivariate analysis only showed MSNA and NYHA III/IV as independent prognostic predictors, while BW loss did not predict prognosis. MSNA offered the most sensitive marker of BW loss in HF patients, but MSNA, not BW loss, was an independent predictor of poor outcome.

Comparison of Canagliflozin, Dapagliflozin and Empagliflozin Added to Heart Failure Treatment in Decompensated Heart Failure Patients With Type 2 Diabetes Mellitus

Background: Three sodium-glucose cotransporter-2 inhibitors (SGLT2i), canagliflozin, dapagliflozin and empagliflozin, successfully reduced hospitalization for heart failure (HF) in patients with type 2 diabetes mellitus (T2DM). It remains unclear, however, whether the efficacy of the 3 SGLT2i for HF in T2DM patients is similar.

Methods and Results: Eighty-one T2DM patients hospitalized due to decompensated HF were enrolled. After treatment for HF, one of the 3 SGLT2i was non-randomly used, and clinical parameters for HF and T2DM were followed for 7 days. The attending physician was allowed to adjust the dose of furosemide. No differences were observed between the 3 groups in the increase of glycosuria, or in the decreases of body weight and blood pressure 7 days after SGLT2i (interaction P>0.05). Urine volume was similarly increased on day 1, and returned to the baseline on day 7 in each group. Decrease in B-type natriuretic peptide and increase in plasma renin activity were significant in each group. Plasma aldosterone concentration, however, was significantly increased in the empagliflozin and canagliflozin groups (P<0.01, respectively), but not in the dapagliflozin group. Additionally, plasma noradrenaline was significantly increased in the empagliflozin group (P<0.01), but not in the canagliflozin and dapagliflozin groups.

Conclusions: The neurohumoral responses to the 3 SGLT2i are different under similar volume correction in HF patients with T2DM.

Renal Sympathetic Denervation Improves Outcomes in a Canine Myocardial Infarction Model

BACKGROUND Myocardial infarction (MI) is the main cause of heart failure (HF), and sympathetic nerve activity is associated with prognosis chronic heart failure. Renal sympathetic denervation (RDN) is noted for its powerful effect on the inhibition of sympathetic nerve activity. This study investigated the effect of RDN on heart failure in dogs after myocardial infarction. MATERIAL AND METHODS The experimental animals were randomized into 2 groups: the MI group (n=12) and the sham operation group (n=6). In the MI group we established an MI model by permanently ligating the left anterior descending branch. After 4 weeks, the MI dogs were randomly divided into 2 groups: the MI+RDN group (MI+renal sympathetic denervation, n=6) and the simple MI group (n=6). Animals in the MI+RDN group underwent both surgical and chemical renal denervation. RESULTS Compared with sham operation group, left ventricular fraction shortening (LVFS) and left ventricular ejection fraction (LVEF) were significantly reduced in the simple MI group, while the reduction was partly reversed in the MI+RDN group. RDN reduced sympathetic nerve activity and release of B-type natriuretic peptide (BNP) and Angiotensin II (AngII) in the MI+ RDN group but not in the simple MI group. CONCLUSIONS Canine renal sympathetic denervation prevents myocardial malignant remodeling by lowering the activity of the systemic sympathetic nerve and inhibiting renin-angiotensin-aldosterone system (RASS) activation, providing a new target and method for the treatment of heart failure.

Thoracic Epidural Anesthesia Reversed Myocardial Fibrosis in Patients With Heart Failure Caused by Dilated Cardiomyopathy

OBJECTIVE

To verify that high thoracic epidural anesthesia (TEA) could reverse myocardial fibrosis in heart failure caused by dilated cardiomyopathy (DCM).

DESIGN

Hospitalized patients with DCM and heart failure.

SETTING

Harbin Medical University, Harbin, Heilongjiang, China.

PARTICIPANTS

Eight patients.

INTERVENTIONS

0.5% lidocaine was administered epidurally at the T4-T5 interspace for 4 weeks.

MEASUREMENTS AND MAIN RESULTS

Eight hospitalized patients with DCM and heart failure were enrolled into the present study. All patients received TEA plus optimal medical therapy (OMT) for 4 weeks. Echocardiograms and cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE) technique were used to evaluate cardiac function and detect myocardial fibrosis before and after treatment. The 6-minute walking distance and the level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) also were measured. The authors used before-after study to verify whether thoracic epidural anesthesia could reverse myocardial fibrosis. The left ventricular end-diastolic diameter was reduced significantly and the left ventricular ejection fraction (LVEF) was increased significantly after a 4-week treatment. Meanwhile, the 6-minute walking distance was increased dramatically. Furthermore, the level of NT-proBNP was reduced significantly after TEA plus OMT treatment. Consistent with echocardiography parameters, the LVEF measured by CMR also was increased markedly. Both total LGE volume and average LGE volume were reduced significantly after 4 weeks of TEA plus OMT treatment.

CONCLUSIONS

TEA plus OMT could reverse myocardial fibrosis and improve cardiac function in patients with heart failure caused by DCM.