Acute decompensated heart failure update

Temporal trends in acute decompensated heart failure outcomes: A single-center 11-year retrospective analysis

Background

Acute Decompensated Heart Failure (ADHF) is associated with frequent hospitalizations, posing a significant health and economic burden globally. Despite advancements in heart failure management, studies delineating temporal trends in ADHF outcomes are sparse.Methods: in this retrospective analysis, ADHF patients admitted to Shamir Medical Center from 2007 to 2017 were categorized into two cohorts: early (2007-2011) and recent (2012-2017). Clinical characteristics, in-hospital interventions, and outcomes were compared. Survival analysis was performed using Kaplan-Meier methods with log-rank tests.

Results

8332 admitted patients were analyzed, 4366 (52.4 %) in the early period, and 3966 (47.6 %) in the recent period. In the recent cohort, ischemic heart disease decreased significantly (from 45.2 % to 34.7 %), while hypertension and smoking rates increased. Additionally, a significant increase in coronary artery bypass grafting (from 0.8 % to 3.5 %) and beta-blockers prescription (from 45.5 % to 63.4 %) post-discharge was observed. However, no substantial improvement in in-hospital mortality (8.9 % in early vs. 8.0 % in recent), 30-day (3.2 % in early vs. 3.1 % in recent), 1-year (23.3 % in early vs. 23.8 % in recent), or 5-year survival rates was noted between cohorts. A subset analysis of patients admitted to cardiology departments showed a significant reduction in in-hospital mortality in the recent cohort (12.3 % in early vs. 6.3 % in recent), yet without a corresponding long-term survival benefit.

Conclusions

Advancements in heart failure management over the 11-year study period did not demonstrate an improvement in clinical outcomes for ADHF patients, highlighting the challenge of translating advancements in the medical care of ADHF patients into long-term survival benefits.

The Use of Drugs that Should be Avoided or Used with Caution in Patients Hospitalized for Acute Decompensated Heart Failure

BACKGROUND

Heart failure (HF) is a pervasive global health concern, with acute decompensated heart failure (ADHF) contributing significantly to morbidity and mortality. Medications used in patients with HF may exacerbate HF or prolong the QT interval, posing additional risks.

OBJECTIVE

The objective is to assess the prevalence and utilization patterns of medications known to cause or exacerbate HF and prolong the QT interval among patients with ADHF. Understanding these patterns is crucial for optimizing patient care and minimizing potential risks.

METHODS

A retrospective chart review was conducted at Huntsville Hospital, Huntsville, USA, covering 602 patients with ADHF over a 40-month period. Inclusion criteria involved age ≥ 18 years, a history of HF, and ADHF admission. The 2016 American Heart Association Scientific Statement was used to identify drugs that may cause or exacerbate HF and those that could prolong the QT interval RESULTS: Among the 602 patients, 57.3% received medications causing or exacerbating HF, notably albuterol (34.9%) and diabetes medications (20.4%), primarily metformin, followed by urologic agents (14.3%), mostly tamsulosin, and nonsteroidal anti-inflammatory drugs (NSAIDs) (6.1%). Moreover, 82.9% were on medications prolonging the QT interval, with loop diuretics, amiodarone, ondansetron, and famotidine most prevalent. Furthermore, 42.1% of the patients received more than two concomitant medications that prolong the QT interval, which can further exacerbate the risk of torsades de pointes.

CONCLUSION

This study underscores the high prevalence of HF-causing or HF-exacerbating medications and QT-prolonging drugs in patients with ADHF. Healthcare professionals must be cognizant of these patterns, advocating for safer prescribing practices to optimize patient outcomes and reduce the burden of HF-related hospitalizations.

Nitroxyl donating and visualization with a coumarin-based fluorescence probe

Nitroxyl (HNO), the single-electron reduction product of nitric oxide (NO), has attracted great interest in the treatment of congestive heart failure in clinical trials. In this paper, we describe the first coumarin-based compound N-hydroxy-2-oxo-2H-chromene-6-sulfonamide (CD1) as a dualfunctional HNO donor, which can release both an HNO signaling molecule and a fluorescent reporter. Under physiological conditions (pH 7.4 and 37 °C), the CD1 HNO donor can readily decompose with a half-life of ∼90 min. The corresponding stoichiometry HNO from the CD1 donor was confirmed using both Vitamin B12 and phosphine compound traps. In addition to HNO releasing, specifically, the degradation product 2-oxo-2H-chromene-6-sulfinate (CS1) was generated as a fluorescent marker during the decomposition. Therefore, the HNO amount released in situ can be accurately monitored through fluorescence generation. As compared to the CD1 donor, the fluorescence intensity increased by about 4.9-fold. The concentration limit of detection of HNO releasing was determined to be ∼0.13 μM according to the fluorescence generation of CS1 at physiological conditions. Moreover, the bioimaging of the CD1 donor was demonstrated in the cell culture of HeLa cells, where the intracellular fluorescence signals were observed, inferring the site of HNO release. Finally, we anticipate that this novel coumarin-based CD1 donor opens a new platform for exploring the biology of HNO.

Considering Adverse Effects of Common Antihypertensive Medications in the ED

PURPOSE OF REVIEW

To evaluate the adverse effects of common antihypertensive agents utilized or encountered in the Emergency Department.

RECENT FINDINGS

All categories of antihypertensive agents may manifest adverse effects, inclusive of adverse drug reactions (ADRs), drug-to-drug interactions, or accidental overdose. Adverse effects, and specifically ADRs, may be stratified into the organ systems affected, might require specific time-sensitive interventions, could pose particular risks to vulnerable populations, and may result in significant morbidity, and potential mortality. Adverse effects of common antihypertensive agents may be encountered in the ED, necessitating that ED systems of care are poised to prevent, recognize, and intervene when adverse effects arise.

Clinical Efficacy of Beta-1 Selective Beta-Blockers Versus Propranolol in Patients With Thyroid Storm: A Retrospective Cohort Study

OBJECTIVES

Thyroid storm is the most severe manifestation of thyrotoxicosis. Beta-blockers are among the standard treatment regimens for this condition, with propranolol being the historically preferred option. However, 2016 guidelines issued by the Japan Thyroid Association and the Japan Endocrine Society recommend the use of beta-1 selective beta-blockers over nonselective beta-blockers, such as propranolol. Nevertheless, evidence supporting this recommendation is limited. Herein, we aimed to investigate the in-hospital mortality of patients with thyroid storms based on the choice of beta-blockers.

DESIGN

Retrospective cohort study.

SETTING

The Diagnosis Procedure Combination database, a national inpatient database in Japan.

PATIENTS

Patients hospitalized with thyroid storm between April 2010 and March 2022.

INTERVENTIONS

Propensity-score overlap weighting was performed to compare in-hospital mortality between patients who received beta-1 selective beta-blockers and those who received propranolol. Subgroup analysis was also conducted, considering the presence or absence of acute heart failure.

MEASUREMENTS AND MAIN RESULTS

Among the 2462 eligible patients, 1452 received beta-1 selective beta-blockers and 1010 received propranolol. The crude in-hospital mortality rates were 9.3% for the beta-1 selective beta-blocker group and 6.2% for the propranolol group. After adjusting for baseline variables, the use of beta-1 selective beta-blockers was not associated with lower in-hospital mortality (6.3% vs. 7.4%; odds ratio, 0.85; 95% CI, 0.57-1.26). Furthermore, no significant difference in in-hospital mortality was observed in patients with acute heart failure.

CONCLUSIONS

In patients with thyroid storm, the choice between beta-1 selective beta-blockers and propranolol did not affect in-hospital mortality, regardless of the presence of acute heart failure. Therefore, both beta-1 selective beta-blockers and propranolol can be regarded as viable treatment options for beta-blocker therapy in cases of thyroid storm, contingent upon the clinical context.

Azobenzene-based colorimetric and fluorometric chemosensor for nitroxyl releasing

The precise release and characterization of nitroxyl (HNO) gas signaling molecule remain a challenge due to its short lifetime to date. To solve this issue, an azobenzene-based HNO donor (Azo-D1) was proposed as a colorimetric and fluorometric chemosensor for HNO releasing, to release both HNO and an azobenzene fluorescent reporter together. Specifically, the Azo-D1 has an HNO release half-life of ∼68 min under physiological conditions. The characteristic color change from the original orange to the yellow color indicated the decomposition of the donor molecule. In addition, the stoichiometry release of HNO was qualitatively and quantitatively verified through the classical phosphine compound trap. As compared with the donor molecule by itself, the decomposed product demonstrates a maximum fluorescence emission at 424 nm, where the increase of fluorescence intensity by 6.8 times can be applied to infer the real-time concentration of HNO. Moreover, cellular imaging can also be achieved using this Azo-D1 HNO donor through photoexcitation at 405 and 488 nm, where the real-time monitoring of HNO release was achieved without consuming the HNO source. Finally, the Azo-D1 HNO donor would open a new platform in the exploration of the biochemistry and the biology of HNO.

Predicting One-Year Mortality after Discharge Using Acute Heart Failure Score (AHFS)

Background: Acute heart failure (AHF) represents a leading cause of unscheduled hospital stays, frequent rehospitalisations, and mortality worldwide. The aim of our study was to develop a bedside prognostic tool, a multivariable predictive risk score, that is useful in daily practice, thus providing an early prognostic evaluation at admission and an accurate risk stratification after discharge in patients with AHF. Methods: This study is a subanalysis of the STADE HF study, which is a single-centre, prospective, randomised controlled trial enrolling 123 patients admitted to hospital for AHF. Here, 117 patients were included in the analysis, due to data exhaustivity. Regression analysis was performed to determine predictive variables for one-year mortality and/or rehospitalisation after discharge. Results: During the first year after discharge, 23 patients died. After modellisation, the variables considered to be of prognostic relevance in terms of mortality were (1) non-ischaemic aetiology of HF, (2) elevated creatinine levels at admission, (3) moderate/severe mitral regurgitation, and (4) prior HF hospitalisation. We designed a linear model based on these four independent predictive variables, and it showed a good ability to score and predict patient mortality with an AUC of 0.84 (95%CI: 0.76-0.92), thus denoting a high discriminative ability. A risk score equation was developed. During the first year after discharge, we observed as well that 41 patients died or were rehospitalised; hence, while searching for a model that could predict worsening health conditions (i.e., death and/or rehospitalisation), only two predictive variables were identified: non-ischaemic HF aetiology and previous HF hospitalisation (also included in the one-year mortality model). This second modellisation showed a more discrete discriminative ability with an AUC of 0.67 (95% C.I. 0.59-0.77). Conclusions: The proposed risk score and model, based on readily available predictive variables, are promising and useful tools to assess, respectively, the one-year mortality risk and the one-year mortality and/or rehospitalisations in patients hospitalised for AHF and to assist clinicians in the management of patients with HF aiming at improving their prognosis.

Evaluating the applicability of ivabradine in acute heart failure

BACKGROUND

While ivabradine has demonstrated benefits in heart rate control and prognosis for chronic heart failure patients, its application in acute decompensated heart failure remains underexplored.

HYPOTHESIS

For patients with acute decompensated heart failure with reduced ejection fraction (HFrEF) who are intolerant to β-blockers or unable to further titrate their dosage, the use of ivabradine is hypothesized to be effective and safe is improving outcomes.

METHODS

This retrospective, multicenter database analysis included patients with hospitalized decompensated heart failure with a left ventricular ejection fraction of ≤40% from June 1, 2015 to December 31, 2020. The exclusion criteria were a baseline heart rate of <70 bpm, previous use of ivabradine, mortality during admission, existing atrial fibrillation, or atrial flutter. The primary outcome was the composite of cardiovascular death and hospitalization for heart failure.

RESULTS

Of the 4163 HFrEF patients analyzed, 684 (16.4%) were administered ivabradine during their index admission. After matching, there were 617 patients in either group. The results indicated that ivabradine use was not significantly associated with the risk of the primary composite outcome (hazard ratio: 1.10; 95% confidence interval: 0.94-1.29). Similarly, the risk of secondary outcomes and adverse renal events did not significantly differ between the ivabradine and non-ivabradine cohorts (all p > .05).

CONCLUSION

For hospitalized acute decompensated heart failure patients who are intolerant to β-blockers or cannot further titrate them, ivabradine offers a consistent therapeutic effect. No significant disparities were noted between the ivabradine and non-ivabradine groups in heart failure hospitalization and cardiovascular death.

The impact of geriatric nutritional risk index on one-year outcomes in hospitalized elderly patients with heart failure

Background

Strategies that accurately predict outcomes in elderly heart failure (HF) patients have not been sufficiently established. In previous reports, nutritional status, ability to perform activities of daily living (ADL), and lower limb muscle strength are known prognostic factors associated with cardiac rehabilitation (CR). In the present study, we investigated which CR factors can accurately predict one-year outcomes in elderly patients with HF among the above factors.

Methods

Hospitalized patients with HF over 65 years of age from January 2016 to January 2022 were retrospectively enrolled in the Yamaguchi Prefectural Grand Medical (YPGM) Center. They were consequently recruited to this single-center retrospective cohort study. Nutritional status, ADL, and lower limb muscle strength were assessed by geriatric nutritional risk index (GNRI), Barthel index (BI), and short physical performance battery (SPPB) at discharge, respectively. One year after discharge, the primary and secondary outcomes were evaluated by all-cause death or HF readmission and major adverse cardiac and cerebrovascular events (MACCE), respectively.

Results

Overall, 1,078 HF patients were admitted to YPGM Center. Of those, 839 (median age 84.0, 52% female) met the study criteria. During the follow-up of 228.0 days, 72 patients reached all-cause death (8%), 215 experienced HF readmission (23%), and 267 reached MACCE (30%: 25 HF death, six cardiac death, and 13 strokes). A multivariate Cox proportional hazard regression analysis revealed that the GNRI predicted the primary outcome (Hazard ratio [HR]: 0.957; 95% confidence interval [CI]: 0.934-0.980; p < 0.001) and the secondary outcome (HR: 0.963; 95%CI: 0.940-0.986; p = 0.002). Furthermore, a multiple logistic regression model using the GNRI most accurately predicted the primary and secondary outcomes compared to those with the SPPB or BI models.

Conclusion

A nutrition status model using GNRI provided a better predictive value than ADL ability or lower limb muscle strength. It should be recognized that HF patients with a low GNRI at discharge may have a poor prognosis at one year.

Epidemiology and Outcomes of Aortic Stenosis in Acute Decompensated Heart Failure: The ARIC Study

BACKGROUND

Few studies characterize the epidemiology and outcomes of aortic stenosis (AS) in acute decompensated heart failure (ADHF). This study investigates the significance of AS in contemporary patients who have experienced an ADHF hospitalization.

METHODS

The ARIC study (Atherosclerosis Risk in Communities) surveilled ADHF hospitalizations for residents ≥55 years of age in 4 US communities. ADHF cases were stratified by left ventricular ejection fraction (LVEF). Demographic differences in AS burden and the association of varying AS severities with mortality were estimated using multivariable logistic regression.

RESULTS

From 2005 through 2014, there were 3597 (weighted n=16 692) ADHF hospitalizations of which 48.6% had an LVEF <50% and 51.4% an LVEF ≥50%. AS prevalence was 12.1% and 18.7% in those with an LVEF <50% and ≥50%, respectively. AS was less likely in Black than White patients regardless of LVEF: LVEF <50% (odds ratio [OR], 0.34 [95% CI, 0.28-0.42]); LVEF ≥50% (OR, 0.51 [95% CI, 0.44-0.59]). Higher AS severity was independently associated with 1-year mortality in both LVEF subgroups: LVEF <50% (OR, 1.16 [95% CI, 1.04-1.28]); LVEF ≥50% (OR, 1.40 [95% CI, 1.28-1.54]). Sensitivity analyses excluding severe AS patients detected that mild/moderate AS was independently associated with 1-year mortality in both LVEF subgroups: LVEF <50% (OR, 1.23 [95% CI, 1.02-1.47]); LVEF ≥50% (OR, 1.31 [95% CI, 1.14-1.51]).

CONCLUSIONS

Among patients who have experienced an ADHF hospitalization, AS is prevalent and portends poor mortality outcomes. Notably, mild/moderate AS is independently associated with 1-year mortality in this high-risk population.

Acute Heart Failure: Diagnostic-Therapeutic Pathways and Preventive Strategies-A Real-World Clinician's Guide

Acute heart failure (AHF) is the most frequent cause of unplanned hospital admission in patients of >65 years of age and it is associated with significantly increased morbidity, mortality, and healthcare costs. Different AHF classification criteria have been proposed, mainly reflecting the clinical heterogeneity of the syndrome. Regardless of the underlying mechanism, peripheral and/or pulmonary congestion is present in the vast majority of cases. Furthermore, a marked reduction in cardiac output with peripheral hypoperfusion may occur in most severe cases. Diagnosis is made on the basis of signs and symptoms, laboratory, and non-invasive tests. After exclusion of reversible causes, AHF therapeutic interventions mainly consist of intravenous (IV) diuretics and/or vasodilators, tailored according to the initial hemodynamic status with the addition of inotropes/vasopressors and mechanical circulatory support if needed. The aim of this review is to discuss current concepts on the diagnosis and management of AHF in order to guide daily clinical practice and to underline the unmet needs. Preventive strategies are also discussed.

Association between the Length of Hospital Stay and 30-Day Outcomes in Patients Admitted with Acute Decompensated Heart Failure

Method

This study is performed in the context of the Persian Registry of Cardiovascular Disease/Heart Failure (PROVE/HF). We included all patients admitted with ADHF regardless of the etiology of heart failure (HF). LOS was classified in tertiles (<4 days, >4 and <6 days, and >6 days). Our outcomes were 30-day all-cause mortality and rehospitalization. Baseline characteristics and outcomes are reported according to the tertiles of LOS. A binary logistic regression and cox regression analysis were performed to evaluate the association between LOS and rehospitalization and death, respectively.

Results

Between April 2019 and March 2020, 385 patients with ADHF were registered in our study. The mean length of hospitalization was 6.35 ± 5.46 days, varying from a minimum of 0 days to a maximum of 47 days. One hundred patients had a hospital stay lower than 4 days; 151 individuals had an intermediate LOS (4-6 days); and 134 were hospitalized for more than 6 days. Our analysis indicated no association between LOS and 30-day rehospitalization and death in multivariable or univariable models.

Conclusion

This study found no association between LOS and rehospitalization or death in patients admitted with ADHF; however, further investigations are warranted.

Early administration of ivabradine in patients admitted for acute decompensated heart failure

BACKGROUND

Heart rate (HR) control is important in heart failure (HF) patients with reduced ejection fraction, and ivabradine is indicated for patients with chronic HF and sinus rhythm. However, ivabradine is limited in initiation of ivabradine at acute stage of HF.

MATERIALS AND METHODS

This multi-institutional retrospective study enrolled 30,639 patients who were admitted for HF from January 01, 2013 to December 31, 2018 at Chang Gung Memorial Hospitals. After applying selection criteria, the eligible patients were divided into ivabradine and non-ivabradine groups according to the initiation of ivabradine at the index hospitalization. HR, clinical outcomes including HF hospitalization, all-cause hospitalization, mortality, the composite of cardiovascular (CV) death or HF hospitalization and newly developed atrial fibrillation, and left ventricular ejection fraction (LVEF) and left atrium size were compared between the ivabradine and non-ivabradine groups after inverse probability of treatment weighting (IPTW) analysis after 12 months.

RESULTS

The HR at admission in the ivabradine group (n = 433) was 99.04 ± 20.69/min, compared to 86.99 ± 20.34/min in the non-ivabradine group (n = 9,601). After IPTW, HR was lower in the ivabradine group than that in the non-ivabradine group after 12 months (74.14 ± 8.53 vs. 81.23 ± 16.79 bpm, p = 0.079). However, there were no significant differences in HF hospitalization (HR = 1.02; 95% CI, 0.38-2.79), all-cause hospitalization (HR = 0.95; 95% CI, 0.54-1.68), mortality (HR = 0.87; 95% CI, 0.69-1.08), the composite of CV death or HF hospitalization (HR = 0.87; 95% CI, 0.69-1.08) and newly developed AF between the two groups. In addition, LVEF increased with time in both groups, but there were no significant differences during the observation period.

CONCLUSION

Ivabradine was beneficial in controlling HR when initiated in patients with acute stage of HF, but it did not seem to provide any benefits in reducing HF hospitalization, all-cause hospitalization, and mortality in 1 year after discharge.

Meprin A in Patients with Acute Decompensation of Heart Failure

Plasma levels of meprin A, IL-6, and IL-18 were measured in 68 patients with acute decompensated heart failure at the time of admission to the hospital and after 1 year. The patients were assigned to groups depending on renal function disorder which was assessed by glomerular filtration rate (GFR). During hospital stay, the plasma levels of meprin A in patients with normal GFR (≥90 ml/min/1.73 m²) were considerably higher than in patients with reduced GFR (<90 ml/min/1.73 m²): 1.80 (0.86; 2.65) and 1.04 (0.56; 1.60) ng/ml, respectively. The levels of IL-6 and IL-18 did not differ significantly. After 1 year, plasma levels of meprin A and interleukins markedly decreased in patients with normal GFR (0.33 (0.20; 0.86) ng/ml) and remained high in patients with reduced GFR (0.92 (0.39; 1.33) ng/ml). Thus, the dynamics of meprin A levels in patients with acute decompensated heart failure depends on functional state of the kidneys, which may affect the course of heart failure.

Safety and efficacy of ultrafiltration versus diuretics in patients with decompensated heart failure: A systematic review and meta-analysis

BACKGROUND

Ultrafiltration (UF) is used for fluid removal patients with acute decompensated heart failure with reduced ejection fraction (HFrEF) refractory to diuretics. However, data on the relative merits of UF and diuretics are limited.

METHODS

Online databases were queried to identify clinical trials on the comparison of UF and diuretics. The major adverse cardiovascular (MACE) and its components (mortality and re-hospitalizations) were compared using the random-effects model to calculate the unadjusted odds ratio (OR) with its 95% confidence interval (CI).

RESULTS

A total of 10 clinical trials comprising 838 patients (413 UF, 425 diuretics) were included in the analysis. At a median follow-up of 90 days, there was no significant difference in the odds of MACE (OR 0.71, 95% CI 0.47-1.07) and all-cause mortality (OR 1.08, 95% CI 0.77-1.52) between patients undergoing UF compared with those receiving diuretics therapy. The need for emergency department visits (OR 1.05, 95% CI 0.38-2.90), all-cause admissions (OR 0.97, 95% CI 0.72-1.30) and heart failure-related re-hospitalization (OR 0.47, 95% CI 0.21-1.02) was also similar between the two groups. The in-hospital risk for hypotension (OR 0.49, 0.23-1.04) and post-therapy creatinine rise&gt;0.3 mg/dL (OR 1.18, 95% CI 0.74-1.89) was also not significantly different between the UF and diuretics arms. A sensitivity analysis of MACE and mortality did not show any deviation from the pooled outcomes.

CONCLUSIONS

In patients with HFrEF, UF appears to be safe but might not provide significant benefits in terms of reducing the risk of mortality or readmission rates compared with those treated with diuretics.

Levosimendan Administration May Provide More Benefit for Survival in Patients with Non-Ischemic Cardiomyopathy Experiencing Acute Decompensated Heart Failure

Background: Acute decompensated heart failure (ADHF) is a life-threatening condition with a high mortality rate. Levosimendan is an effective inotropic agent used to maintain cardiac output and a long-lasting effect. However, only few studies have compared the clinical outcomes, after levosimendan therapy, among etiologies of ADHF. Methods: Between July 2014 and December 2019, 184 patients received levosimendan therapy for ADHF at our hospital. A total of 143 patients had ischemic cardiomyopathy (ICM), and 41 patients had non-ICM (NICM). Data on comorbidities, echocardiographic findings, laboratory findings, use of mechanical devices, consumption of other inotropic or vasopressor agents, frequency of HF hospitalization, cardiovascular (CV) mortality, and all-cause mortality were compared between the ICM and NICM groups. Results: Patients with ICM were older with higher prevalence of diabetes mellitus when compared to patients with NICM. Patients with NICM had a poorer left ventricular ejection fraction (LVEF) and higher left ventricular end-systolic volume when compared to patients with ICM. At the 30 day follow-up period, a lower CV mortality (ICM vs. NICM: 20.9% vs. 5.1%; log-rank p = 0.033) and lower all-cause mortality (ICM vs. NICM: 28.7% vs. 9.8%; log-rank p = 0.018) was observed in the NICM patients. A significantly lower all-cause mortality was noted at 180 day (ICM vs. NICM: 39.2% vs. 22.0%; log-rank p = 0.043) and 1 year (ICM vs. NICM: 41.3% vs. 24.4%; log-rank p = 0.046) follow up in the NICM subgroup. NICM (hazard ratio (HR): 0.303, 95% confidence interval (CI): 0.108–0.845; p = 0.023) and ECMO use (HR: 2.550, 95% CI: 1.385–4.693; p = 0.003) were significant predictors of 30 day all-cause mortality. Conclusions: In our study on levosimendan use for ADHF patients, better clinical outcomes were noted in the NICM population when compared to the ICM population. In the patients with cardiogenic shock or ventilator use, significantly lower incidence of 30 day mortality presented in the NICM population when compared with the ICM population.

Prognostic role of diuretic failure in determining mortality for patients hospitalized with acute decompensated heart failure

BACKGROUND

Worsening heart failure (WHF) is defined as persistent or worsening symptoms of heart failure that require an escalation in intravenous therapy or initiation of mechanical and ventilatory support during hospitalization. We assessed a simplified version of WHF called diuretic failure (DF), defined as an escalation of loop diuretic dosing after 48 h, and assessed its effects on mortality and rehospitalizations at 60-days.

METHODS

We conducted a multicenter retrospective study between December 1, 2017 and January 1, 2020. We identified 1389 patients of which 6.4% experienced DF.

RESULTS

There was a significant relationship between DF and cumulative rates of 60-day mortality and 60-day rehospitalizations (p = 0.0002 and p = 0.0214). After multivariate adjustment, DF was associated with longer hospital stay (p < 0.0001), increased rate of 60-day mortality (p = 0.026), 60-day rehospitalizations (p = 0.036), and a composite outcome of 60-day mortality and 60-day cardiac rehospitalizations (p = 0.018).

CONCLUSIONS

DF has a strong relationship with adverse heart failure outcomes suggesting it is a simple yet robust prognostic indicator which can be used in real time to identify high-risk patients during hospitalization and beyond.

Effect of carperitide on the 1 year prognosis of patients with acute decompensated heart failure

Aims

Acute heart failure (AHF) is a clinical syndrome with a poor prognosis and a major public health concern worldwide. The aim of this study was to investigate whether carperitide administration improves the 1 year prognosis of patients with AHF and to check whether there is an optimal dose of the drug.

Methods and results

We analysed the data of COOPERATE‐HF‐J (the Consortium for Pooled Data Analysis regarding Hospitalized Patients with Heart Failure in Japan), combining two cohorts (NARA‐HF and REALITY‐AHF), which included 2435 patients with acute decompensated heart failure. The patients were divided into no carperitide (NO‐ANP, n = 1098); very low‐dose carperitide (VLD‐ANP, <0.02 μg/kg/min, n = 593); and low‐dose carperitide groups (LD‐ANP, ≥0.02 μg/kg/min, n = 744). The primary endpoint was cardiovascular mortality within 1 year after admission. The secondary endpoints were all‐cause mortality and rehospitalization due to worsening heart failure within 1 year after admission. The median carperitide doses in the VLD‐ANP and LD‐ANP groups were 0.013 and 0.025 μg/kg/min, respectively. Kaplan–Meier analysis showed that cardiovascular mortality and all‐cause mortality were significantly lower in the LD‐ANP group than in the NO‐ANP and VLD‐ANP groups (P < 0.001 and P = 0.002, respectively). Multivariable Cox regression analysis for cardiovascular and all‐cause mortality revealed that LD‐ANP was significantly associated with lower cardiovascular and all‐cause mortality within 1 year after admission, even after adjusting other covariates (hazard ratio: 0.696 and 0.791, 95% confidence interval: 0.513–0.944 and 0.628–0.997, P = 0.020 and 0.047, respectively).

Conclusions

Low‐dose carperitide was significantly associated with lower cardiovascular and all‐cause mortality within 1 year after admission. Our results suggest the necessity for well‐designed randomized controlled trials to determine the doses of carperitide that could improve clinical outcomes in patients with AHF.

Frequency of Atrial Fibrillation in Patients Presenting With Decompensated Heart Failure

Background

Atrial fibrillation (AF) is a common concern in patients with heart disease, especially those with acute decompensated heart failure (ADHF). We conducted a cross-sectional study to determine the frequency of AF and associated risk factors among patients with ADHF at a tertiary care hospital in Peshawar, Pakistan.

Methods

We conducted a cross-sectional analytical study of hospitalized patients with ADHF treated in a tertiary care hospital in Peshawar, Pakistan, from June 5 to October 30, 2021. The study's primary outcome was the proportion of patients with ADHF who had AF, and our secondary outcome was examining the risk factors for AF. The College of Physicians and Surgeons Pakistan provided ethical approval of the study design. Data were analyzed using IBM SPSS Statistics for Windows version 24.0 (IBM Corp., Armonk, NY, USA). We applied the chi-square test to compare the proportion of AF concerning risk factors (i.e., comorbidities).

Results

One hundred ninety-four patients with ADHF were included in the study; 54.6% were male and 45.4% female. Most (56.7%) were older than 60, and 38.1% were aged 40-60. The prevalence of AF was 38.1%. Diabetes, hypertension, previous stroke, myocardial infarction (MI), and chronic obstructive pulmonary disease (COPD) were the most common comorbidities. All patients with ADHF with AF also had MI and hypertension. Patients of known coronary artery disease (CAD) but without MI, previous percutaneous coronary intervention (PCI), or coronary artery bypass graft (CABG) surgery were less associated with AF than other comorbidities.

Conclusions

We conducted this study to determine the incidence of AF among patients with ADHF. AF occurs in a significant amount of patients with ADHF, and the risk factors associated with AF in these patients include hypertension, history of MI, diabetes, and COPD. Healthcare professionals should screen patients with ADHF for AF, especially those with common risk factors.

Percutaneous Mitral Valve Repair in Patients with Severe Mitral Regurgitation and Acute Decompensated Heart Failure

The role of percutaneous mitral valve repair (PMVr) in management of high-risk patients with severe mitral regurgitation (MR) and acute decompensated heart failure (ADHF) is undetermined. We screened all patients who underwent PMVr between October 2015 and March 2020. We evaluated immediate, 30-day, and 1-year outcomes in patients who underwent PMVr during hospitalization due to ADHF as compared to elective patients. From a cohort of 237 patients, we identified 46 patients (19.4%) with severe MR of either functional or degenerative etiology who underwent PMVr during index hospitalization due to ADHF, including 17 (37%) critically ill patients. Patients' mean age was 75.2 ± 9.8 years, 56% were males. There were no differences in background history between ADHF and elective patients. Patients with ADHF were at higher risk for surgery, reflected in higher mean EuroSCORE II, compared with elective patients. After PMVr, we observed higher 30-day mortality rate in ADHF patients as compared to the elective group (10.9% vs. 3.1%, respectively, p = 0.042). One-year mortality rate was similar between the groups (21.7% vs. 17.9%, p = 0.493). Clinical and echocardiographic follow-up showed improvement of NYHA functional class and sPAP reduction in both groups ((54 ± 15 mmHg to 50 ±15 in the elective group (p = 0.02), 58 ± 13 mmHg to 52 ± 12 in the ADHF group (p = 0.02)). PMVr could be an alternative option for treatment of patients with severe MR and ADHF.

The Effect of Rehospitalization and Emergency Department Visits on Subsequent Adherence to Weight Telemonitoring

BACKGROUND

Weight telemonitoring may be an effective way to improve patients' ability to manage heart failure and prevent unnecessary utilization of health services. However, the effectiveness of such interventions is dependent upon patient adherence.

OBJECTIVE

The purpose of this study was to determine how adherence to weight telemonitoring changes in response to 2 types of events: hospital readmissions and emergency department visits.

METHODS

The Better Effectiveness After Transition-Heart Failure trial examined the effectiveness of a remote telemonitoring intervention compared with usual care for patients discharged to home after hospitalization for decompensated heart failure. Participants were followed for 180 days and were instructed to transmit weight readings daily. We used Poisson regression to determine the within-person effects of events on subsequent adherence.

RESULTS

A total of 625 events took place during the study period. Most of these events were rehospitalizations (78.7%). After controlling for the number of previous events and discharge to a skilled nursing facility, the rate for adherence decreased by nearly 20% in the 2 weeks after a hospitalization compared with the 2 weeks before (adjusted rate ratio, 0.81; 95% confidence interval: 0.77-0.86; P < .001).

CONCLUSIONS

Experiencing a rehospitalization had the effect of diminishing adherence to daily weighing. Providers using telemonitoring to monitor decompensation and manage medications should take advantage of the potential "teachable moment" during hospitalization to reinforce the importance of adherence.

Risk of Thrombus Formation in Patients on Mechanical Circulatory Support with POLVAD-MEV

BACKGROUND Congestive heart failure is a challenging problem due to increasing prevalence in developed countries. Patients admitted due to decompensated congestive heart failure symptoms who do not respond to medical treatment require mechanical circulatory support. Patients with biventricular failure are at particularly high mortality risk. MATERIAL AND METHODS We analyzed the function of 49 pumps (POLVAD-MEV, FRK Intra-cordis, Poland) implanted to rescue INTERMACS 1 and 2 profile patients referred to our department due to severe congestive heart failure. All patients were waiting for heart transplantation and were readmitted due to acute decompensations of congestive biventricular heart failure with resistance to medical therapy. RESULTS During the observational period, there were no technical problems in pump function. The mean duration of pump therapy was 30.6±8.3 (5-49) days. The risk for right-sided pump complications included clots formation on the following parts of the pump: outflow tract (1, 2%), membrane (13, 27%), dome (6, 12.5%), and periphery (1, 2%). The overall risk for device thrombosis was 41%. The risk for thromboembolic complications was CRP-dependent regarding conglomerates of fibrin and platelets formation (p<0.05). The risk for left-sided pump complications included clots formation on the outflow tract (1, 2%), membrane (9, 19%) and dome (3, 6%). The overall risk for device thrombosis was 27%. The risk for clots formation on the membrane (P<0.05) and dome of the pump depended on time (P<0.07). CONCLUSIONS Mechanical circulatory support with a paracorporeal pump is a safe option for biventricular heart dysfunction as a bridge to heart transplantation. The risk for thrombi formation is relatively high but acceptable within 30 days after implantation.

External validation of the ACUTE HF score in patients hospitalized for acute decompensated heart failure

OBJECTIVE

Recently, the ACUTE HF score has been developed as a new tool for predicting short and long term mortality in patients with acute heart failure (AHF). However, this. score has not yet been validated externally. The present study aimed to investigate the prognostic value of ACUTE HF score in a different patient cohort.

METHODS

We retrospectively enrolled all consecutive adult patients hospitalized due to AHF between January 2016 and January 2019. The ACUTE HF score is calculated by 7 different variables including age, creatinine, non-invasive ventilation, history of stroke or transient ischemic attack, left ventricular systolic function, mitral regurgitation and history of hospitalization.The primary endpoint of the study was in-hospital mortality.

RESULTS

A total of 418 AHF patients (mean age 70.2 ± 11.3 years, 52% male) were included, and 26 (6.2%) patients died during the in-hospital course. Patients in the study were divided into three groups according to ACUTE HF score: low-risk (<1.5, n = 210), intermediate-risk (1.5-3, n = 50), and high-risk groups (>3, n = 158). The multivariate analysis showed that the ACUTE HF score was an independent predictor of in-hospital mortality(OR: 2.15; 95% CI, 0.94-4.34; p < 0.001).

CONCLUSION

The ACUTE HF score was a useful prognostic score for the prediction of in-hospital mortality in patients with AHF. Further validation studies in different regions of the world and with different AHF populations are needed to determine its generalisability.

Continuing versus suspending angiotensin-converting enzyme inhibitors and angiotensin receptor blockers: Impact on adverse outcomes in hospitalized patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)--The BRACE CORONA Trial

Angiotensin-converting enzyme-2 (ACE2) expression may increase due to upregulation in patients using angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARBs). Because renin-angiotensin system blockers increase levels of ACE2, a protein that facilitates coronavirus entry into cells, there is concern that these drugs could increase the risk of developing a severe and fatal form of COVID-19. The impact of discontinuing ACEI and ARBs in patients with COVID-19 remains uncertain. DESIGN: BRACE CORONA is a pragmatic, multicenter, randomized, phase IV, clinical trial that aims to enroll around 500 participants at 34 sites in Brazil. Participants will be identified from an ongoing national registry of suspected and confirmed cases of COVID-19. Eligible patients using renin-angiotensin system blockers (ACEI/ARBs) with a confirmed diagnosis of COVID-19 will be randomized to a strategy of continued ACEI/ARB treatment versus temporary discontinuation for 30 days. The primary outcome is the median days alive and out of the hospital at 30 days. Secondary outcomes include progression of COVID-19 disease, all-cause mortality, death from cardiovascular causes, myocardial infarction, stroke, transient ischemic attack, new or worsening heart failure, myocarditis, pericarditis, arrhythmias, thromboembolic events, hypertensive crisis, respiratory failure, hemodynamic decompensation, sepsis, renal failure, and troponin, B-type natriuretic peptide (BNP), N-terminal-proBNP, and D-dimer levels. SUMMARY: BRACE CORONA will evaluate whether the strategy of continued ACEI/ARB therapy compared with temporary discontinuation of these drugs impacts clinical outcomes among patients with COVID-19.

In-Hospital Management of Sleep Apnea During Heart Failure Hospitalization: A Randomized Controlled Trial

BACKGROUND

Obstructive sleep apnea (OSA) is associated with increased mortality and readmissions in patients with heart failure (HF). The effect of in-hospital diagnosis and treatment of OSA during decompensated HF episodes remains unknown.

METHODS AND RESULTS

A single-site, randomized, controlled trial of hospitalized patients with decompensated HF (n = 150) who were diagnosed with OSA during the hospitalization was undertaken. All participants received guideline-directed therapy for HF decompensation. Participants were randomized to an intervention arm which received positive airway pressure (PAP) therapy during the hospitalization (n = 75) and a control arm (n = 75). The primary outcome was discharge left ventricular ejection fraction (LVEF). The LVEF changed in the PAP arm from 25.5 ± 10.4 at baseline to 27.3 ± 11.9 at discharge. In the control group, LVEF was 27.3 ± 11.7 at baseline and 28.8 ± 10.5 at conclusion. There was no significant effect on LVEF of in-hospital PAP compared with controls (P = .84) in the intention-to-treat analysis. The on-treatment analysis in the intervention arm showed a significant increase in LVEF in participants who used PAP for ≥3 hours per night (n = 36, 48%) compared with those who used it less (P = .01). There was a dose effect with higher hours of use associated with more improvement in LVEF. Follow-up of readmissions at 6 months after discharge revealed a >60% decrease in readmissions for patients who used PAP ≥3 h/night compared with those who used it <3 h/night (P < .02) and compared with controls (P < .04).

CONCLUSIONS

In-hospital treatment with PAP was safe but did not significantly improve discharge LVEF in patients with decompensated HF and newly diagnosed OSA. An exploratory analysis showed that adequate use of PAP was associated with higher discharge LVEF and decreased 6 months readmissions.

Lung ultrasound-guided therapy reduces acute decompensation events in chronic heart failure

OBJECTIVE

Pulmonary congestion is the main cause of hospital admission in patients with heart failure (HF). Lung ultrasound (LUS) is a useful tool to identify subclinical pulmonary congestion. We evaluated the usefulness of LUS in addition to physical examination (PE) in the management of outpatients with HF.

METHODS

In this randomised multicentre unblinded study, patients with chronic HF and optimised medical therapy were randomised in two groups: 'PE+LUS' group undergoing PE and LUS and 'PE only' group. Diuretic therapy was modified according to LUS findings and PE, respectively. The primary endpoint was the reduction in hospitalisation rate for acute decompensated heart failure (ADHF) at 90-day follow-up. Secondary endpoints were reduction in NT-proBNP, quality-of-life test (QLT) and cardiac mortality at 90-day follow-up.

RESULTS

A total of 244 patients with chronic HF and optimised medical therapy were enrolled and randomised in 'PE+LUS' group undergoing PE and LUS, and in 'PE only' group. Thirty-seven primary outcome events occurred. The hospitalisation for ADHF at 90 day was significantly reduced in 'PE+LUS' group (9.4% vs 21.4% in 'PE only' group; relative risk=0.44; 95% CI 0.23 to 0.84; p=0.01), with a reduction of risk for hospitalisation for ADHF by 56% (p=0.01) and a number needed to treat of 8.4 patients (95% CI 4.8 to 34.3). At day 90, NT-proBNP and QLT score were significantly reduced in 'PE+LUS' group, whereas in 'PE only' group both were increased. There were no differences in mortality between the two groups.

CONCLUSIONS

LUS-guided management reduces hospitalisation for ADHF at mid-term follow-up in outpatients with chronic HF.

Analyzing Medical Research Results Based on Synthetic Data and Their Relation to Real Data Results: Systematic Comparison From Five Observational Studies

Background

Privacy restrictions limit access to protected patient-derived health information for research purposes. Consequently, data anonymization is required to allow researchers data access for initial analysis before granting institutional review board approval. A system installed and activated at our institution enables synthetic data generation that mimics data from real electronic medical records, wherein only fictitious patients are listed.

Objective

This paper aimed to validate the results obtained when analyzing synthetic structured data for medical research. A comprehensive validation process concerning meaningful clinical questions and various types of data was conducted to assess the accuracy and precision of statistical estimates derived from synthetic patient data.

Methods

A cross-hospital project was conducted to validate results obtained from synthetic data produced for five contemporary studies on various topics. For each study, results derived from synthetic data were compared with those based on real data. In addition, repeatedly generated synthetic datasets were used to estimate the bias and stability of results obtained from synthetic data.

Results

This study demonstrated that results derived from synthetic data were predictive of results from real data. When the number of patients was large relative to the number of variables used, highly accurate and strongly consistent results were observed between synthetic and real data. For studies based on smaller populations that accounted for confounders and modifiers by multivariate models, predictions were of moderate accuracy, yet clear trends were correctly observed.

Conclusions

The use of synthetic structured data provides a close estimate to real data results and is thus a powerful tool in shaping research hypotheses and accessing estimated analyses, without risking patient privacy. Synthetic data enable broad access to data (eg, for out-of-organization researchers), and rapid, safe, and repeatable analysis of data in hospitals or other health organizations where patient privacy is a primary value.

A Phase 1 Randomized Study of Single Intravenous Infusions of the Novel Nitroxyl Donor BMS-986231 in Healthy Volunteers

Nitroxyl (HNO) is a reactive nitrogen molecule that has potential therapeutic benefits for patients with acute heart failure. The results of the first‐in‐human study for BMS‐986231, a novel HNO donor, are reported. The aim of this sequential cohort study was to evaluate the safety, tolerability, and pharmacokinetic profile of BMS‐986231 after 24‐ and 48‐hour intravenous infusions in healthy volunteers. Eighty subjects were randomized and dosed. Seven cohorts (stratum A) received BMS‐986231 0.1, 0.33, 1, 3, 5, 10, and 15 μg/kg/min or placebo, infused over 24 hours. An additional cohort (stratum B) received 10 μg/kg/min or placebo, infused over 48 hours. Adverse events (AEs) were reported for 30 days after completion of infusion. Blood/urine samples were collected at regular intervals; other parameters (blood pressure, heart rate/rhythm, cardiac index) were also assessed. Headaches were the most commonly reported drug‐related AE (48%) in those who received BMS‐986231, although their severity was reduced by hydration. No other significant drug‐related AEs were noted. BMS‐986231 was associated with dose‐dependent and well‐tolerated reductions in systolic and diastolic blood pressure versus baseline; cardiac index, as measured noninvasively, was increased. BMS‐986231 had no clinically significant effect on heart rate/rhythm or laboratory parameters. Its mean elimination half‐life was 0.7‐2.5 hours. BMS‐986231 was safe and well‐tolerated for up to 24 hours (15 μg/kg/min) or 48 hours (10 μg/kg/min), with a favorable hemodynamic profile observed. Ongoing studies continue to evaluate the potential benefit of BMS‐986231 in patients with acute heart failure.

Cough

Pharmacists play an important role in the assessment and management of patients with cough. By obtaining a focused clinical history from the patient, they can identify patients who need to be referred to their physician or to the emergency room, as well as which patients can be managed at home. Red flags that prompt referral include severe systemic illness, respiratory distress, hemoptysis, and altered level of consciousness. Patients with underlying chronic illnesses such as chronic obstructive pulmonary disease, asthma, and heart failure who present with cough should be assessed for possible exacerbation of their illness and should be referred if this is suspected. Determining the duration of cough is an important step, as this helps identify possible etiologies. Cough <3-week duration is categorized as acute, 3- to 8-week duration is subacute, and > 8-week duration is a chronic cough. Patients with cough lasting >3 weeks should generally be referred for further evaluation and management. Acute cough is often infectious but can also be due to exacerbation of underlying illness or could be medication-related. Upper airway cough syndrome (UACS) is one of the most common causes of subacute and chronic cough. Several different etiologies lead to UACS, which is thought to be caused by postnasal drip ± sensitization of cough receptors in the respiratory tract. First-generation antihistamines or decongestants are therapeutic options when UACS is suspected. It is important to note that antitussive medications such as dextromethorphan can actually prolong illness in patients with a productive cough and are thus not recommended. Monitoring parameters and frequency of follow-up depend on underlying cause, severity of illnesses, past medical history, as well as medication changes.

Effects of Widespread Inotrope Use in Acute Heart Failure Patients

Current guidelines recommend that inotropes should not be used in patients with normal systolic blood pressure (SBP). However, this is not supported with concrete evidence. We aimed to evaluate the effect of inotropes in acute heart failure (HF) patients from a nationwide HF registry. A total of 5625 patients from the Korean Acute Heart Failure (KorAHF) registry were analyzed. The primary outcomes were in-hospital adverse events and 1-month mortality. Among the total population, 1703 (31.1%) received inotropes during admission. Inotrope users had a higher event rate than non-users (in-hospital adverse events: 13.3% vs. 1.4%, p < 0.001; 1-month mortality: 5.5% vs. 2.5%, p < 0.001), while inotrope use was an independent predictor for clinical outcomes (in-hospital adverse events: OR_adjusted 5.459, 95% CI 3.622–8.227, p < 0.001; 1-month mortality: HR_adjusted 1.839, 95% CI 1.227–2.757, p = 0.003). Subgroup analysis showed that inotrope use was an independent predictor for detrimental outcomes only in patients with normal initial SBP (≥90 mmHg) (in-hospital adverse events: OR_adjusted 5.931, 95% CI 3.864–9.104, p < 0.001; 1-month mortality: HR_adjusted 3.584, 95% CI 1.280–10.037, p = 0.015), and a propensity score-matched population showed consistent results. Clinicians should be cautious with the usage of inotropes in acute heart failure patients, especially in those with a normal SBP.

Wearable Water Content Sensor Based on Ultrasound and Magnetic Sensing

Fluid accumulation in the lower extremities is an early indicator of disease deterioration in cardiac failure, chronic venous insufficiency and lymphedema. At-home wearable monitoring and early detection of fluid accumulation can potentially lead to prompt medical intervention and avoidance of hospitalization. Current methods of fluid accumulation monitoring either suffer from lack of specificity and sensitivity or are invasive and cost-prohibitive to use on a daily basis. Ultrasound velocity in animal and human tissue has been found to change with water content. However, previous prototype fluid monitoring sensors based on ultrasound are cumbersome and not wearable. Hence, in this research a compact water content sensor based on a wearable instrumented elastic band is proposed. A novel integration of magnetic sensing and ultrasonic sensing is utilized, where the magnetic sensor provides distance measurement and the ultrasonic sensor produces time-of-flight measurement. Magnetic field modeling with a Kalman filter and least squares linear fitting algorithms are employed to ensure robust sensor performance on a wearable device. The combination of the two measurements yields ultrasound velocity measurement in tissue. The water content sensor prototype was tested on a tissue phantom, on animal tissue and on a human leg. The error in velocity measurement is shown to be small enough for early detection of tissue edema.

New Medications in the Treatment of Acute Decompensated Heart Failure

Acute decompensated heart failure is a sudden worsening of heart failure symptoms, typically resulting in peripheral edema and dyspnea as a result of pulmonary congestion. Acute decompensated heart failure is responsible for over 1 million hospitalizations every year. Current pharmacologic therapy is limited in its options. Despite an improved survival rate, statistic still suggests that about 50% of patients die within 5 years of diagnosis. New pharmacologic agents aim to improve efficacy by targeting previously unexplored physiological pathways.

Cardiovascular Outcomes With Minute Ventilation-Targeted Adaptive Servo-Ventilation Therapy in Heart Failure: The CAT-HF Trial

BACKGROUND

Sleep apnea is common in hospitalized heart failure (HF) patients and is associated with increased morbidity and mortality.

OBJECTIVES

The CAT-HF (Cardiovascular Improvements With MV-ASV Therapy in Heart Failure) trial investigated whether minute ventilation (MV) adaptive servo-ventilation (ASV) improved cardiovascular outcomes in hospitalized HF patients with moderate-to-severe sleep apnea.

METHODS

Eligible patients hospitalized with HF and moderate-to-severe sleep apnea were randomized to ASV plus optimized medical therapy (OMT) or OMT alone (control). The primary endpoint was a composite global rank score (hierarchy of death, cardiovascular hospitalizations, and percent changes in 6-min walk distance) at 6 months.

RESULTS

126 of 215 planned patients were randomized; enrollment was stopped early following release of the SERVE-HF (Adaptive Servo-Ventilation for Central Sleep Apnea in Systolic Heart Failure) trial results. Average device usage was 2.7 h/night. Mean number of events measured by the apnea-hypopnea index decreased from 35.7/h to 2.1/h at 6 months in the ASV group versus 35.1/h to 19.0/h in the control group (p < 0.0001). The primary endpoint did not differ significantly between the ASV and control groups (p = 0.92 Wilcoxon). Changes in composite endpoint components were not significantly different between ASV and control. There was no significant interaction between treatment and ejection fraction (p = 0.10 Cox model); however, pre-specified subgroup analysis suggested a positive effect of ASV in patients with HF with preserved ejection fraction (p = 0.036).

CONCLUSIONS

In hospitalized HF patients with moderate-to-severe sleep apnea, adding ASV to OMT did not improve 6-month cardiovascular outcomes. Study power was limited for detection of safety signals and identifying differential effects of ASV in patients with HF with preserved ejection fraction, but additional studies are warranted in this population. (Cardiovascular Improvements With MV ASV Therapy in Heart Failure [CAT-HF]; NCT01953874).

Advances in chemical pharmacotherapy for managing acute decompensated heart failure

INTRODUCTION

Acute decompensated heart failure (ADHF) contributes largely to the burden of heart failure and is associated with a poorer prognosis. Although numerous clinical trials evaluated the benefit of newer medications for ADHF, most of them were not successful. Areas covered: This review focusses on the updates on recent developments in chemical pharmacotherapy for the management of ADHF. A MEDLINE search for relevant review articles and original investigations on newer drugs for ADHF provided us with necessary literature. Expert opinion: Currently, popular therapies like diuretics, vasodilators, and inotropes offer symptomatic relief but do not provide survival benefit. Although multiple medications targeting novel pathways in ADHF were studied extensively, they failed to show either symptomatic or mortality benefit in available randomized trials. Improving our understanding of the complex pathophysiology of ADHF along with designing studies which include patients who are more representative of the real-world heart failure population, standardizing methods for endpoint assessment, and evaluating the role on novel biomarkers of organ dysfunction is important to improve ADHF research. Enhancing preventive strategies like improving baseline therapy in chronic heart failure patients and developing strategies for early identification of ADHF are important as our quest for innovative ADHF pharmacotherapy continues.

Trends in health care expenditure in U.S. adults with diabetes: 2002-2011

OBJECTIVE

Direct medical cost of diabetes in the U.S. has been estimated to be 2.3 times higher relative to individuals without diabetes. This study examines trends in health care expenditures by expenditure category in U.S. adults with diabetes between 2002 and 2011.

RESEARCH DESIGN AND METHODS

We analyzed 10 years of data representing a weighted population of 189,013,514 U.S. adults aged ≥18 years from the Medical Expenditure Panel Survey. We used a novel two-part model to estimate adjusted mean and incremental medical expenditures by diabetes status, while adjusting for demographics, comorbidities, and time.

RESULTS

Relative to individuals without diabetes ($5,058 [95% CI 4,949-5,166]), individuals with diabetes ($12,180 [11,775-12,586]) had more than double the unadjusted mean direct expenditures over the 10-year period. After adjustment for confounders, individuals with diabetes had $2,558 (2,266-2,849) significantly higher direct incremental expenditures compared with those without diabetes. For individuals with diabetes, inpatient expenditures rose initially from $4,014 in 2002/2003 to $4,183 in 2004/2005 and then decreased continuously to $3,443 in 2010/2011, while rising steadily for individuals without diabetes. The estimated unadjusted total direct expenditures for individuals with diabetes were $218.6 billion/year and adjusted total incremental expenditures were approximately $46 billion/year.

CONCLUSIONS

Our findings show that compared with individuals without diabetes, individuals with diabetes had significantly higher health expenditures from 2002 to 2011 and the bulk of the expenditures came from hospital inpatient and prescription expenditures.