The prognostic combined role of B-type natriuretic peptide, blood urea nitrogen and congestion signs persistence in patients with acute heart failure

Persistent Heart Failure Symptoms at Hospital Discharge Predicts 30-Day Clinical Events

Background

The relationship between heart failure (HF) symptoms at hospital discharge and 30-day clinical events is unknown. Variability in HF symptom assessment may affect ability to predict readmission risk.

Objective

The aim of this study was to describe HF symptom profiles and burden at hospital discharge. A secondary aim was to examine the relationship between symptom burden at discharge and 30-day clinical events.

Methods

An exploratory descriptive design was used. Patients with HF (n = 186) were enrolled 24 to 48 hours pre hospital discharge. The HF Somatic Perception Scale quantified 18 HF physical signs and symptoms. Scores were divided into tertiles (0-10, 11-19, and 20 and higher). The Patient Health Questionnaire-9 quantified depressive symptoms. Self-assessed health, comorbid illnesses, and 30-day clinical events were documented. Chi-square and logistic regression were used to examine clinical events.

Results

The sample (n = 186) was predominantly White (87.6%), male (59.1%), elderly (mean [SD], 74.2 [12.5]), and symptomatic (92.5%) at discharge. Heart Failure Somatic Perception Scale scores ranged from 0 to 53, with a mean (SD) of 13.7 (10.1). Symptoms reported most frequently were fatigue (67%), nocturia (62%), need to rest (53%), and inability to do usual activities due to shortness of breath (52%). Thirty-day event rate was 28%, with significant differences between Heart Failure Somatic Perception Scale tertiles (9.4% vs 37.7% in the second and third tertiles, respectively; [chi]22(N = 186) = 16.73, P < .001). Heart Failure Somatic Perception Scale tertile 2 or 3 (odds ratio [OR], 5.7; P = .003; and OR, 4.3; P = .021), self-assessed health (OR, 2.6; P = .029), and being in a relationship predicted clinical events.

Conclusions

Heart failure symptom burden at discharge predicted 30-day clinical events. Comprehensive symptom assessment is important when determining readmission risk.

Visit-to-Visit B-Type Natriuretic Peptide Variability during the Previous Year Has Independent Prognostic Value in Patients with Stable Chronic Heart Failure

BACKGROUND

There is wide variability of visit-to-visit (V2V) B-type natriuretic peptide (BNP) in patients with chronic heart failure (CHF), even when they are stable. The prognostic significance of V2V-BNP variability has not been investigated. We aimed to test whether V2V-BNP variability during the stable period of CHF has prognostic value regardless of BNP level.

METHODS

In 278 stable outpatients (75 ± 10 years, 65% male) with CHF, we studied V2V-BNP variability, which was defined as the coefficient of variance of BNP values measured during 1 year before enrollment. All-cause death and rehospitalization due to HF were considered the primary endpoint.

RESULTS

The median V2V-BNP variability was 25.7% (IQR: 19.2-34.4%). During the follow-up period (median 3.2 years), 100 patients reached the endpoint and those with high V2V-BNP variability (≥25.7%) had a significantly higher rate of events (p = 0.001). CHF severity in terms of BNP level and MAGGIC risk score was not significantly different between those with high and low V2V-BNP variability. Multivariable analysis showed that high V2V-BNP variability was independently associated with increased event rates even after adjustment for other known prognostic predictors, including BNP (hazard ratio 1.90, p = 0.003), or for MAGGIC risk score and BNP (hazard ratio 1.72, p = 0.010). The hazard for the outcome consistently increased as V2V-BNP variability increased, with a marked increase up to about 30%.

CONCLUSIONS

Even in the stable phase of CHF, V2V-BNP variability was associated with worse long-term outcomes, independent of BNP level.

Redefining biomarkers in heart failure

Heart failure (HF) is the end result of many different cardiac and non-cardiac abnormalities leading to a complex clinical entity. In this view, the use of biomarkers in HF should be deeply reconsidered; indeed, the same biomarker may carry a different significance in patients with preserved or reduced EF. The aim of this review is to reconsider the role of biomarkers in HF, based on the different clinical characteristics of this syndrome. The role of cardiac and non-cardiac biomarkers will be reviewed with respect of the different clinical manifestations of this syndrome.

Bioimpedance vector analysis predicts hospital length of stay in acute heart failure

OBJECTIVE

Congestion in acute heart failure (AHF) affects survival curves and hospital length of stay (LOS). The evaluation of congestion, however, is not totally objective. The aim of this study was to verify the accuracy of bioelectrical impedance vector analysis (BIVA) in predicting the LOS in AHF patients.

METHODS

This is a retrospective study. A total of 706 patients (367 male; mean age: 78 ± 10 y) who had been admitted to hospital with an AHF event were enrolled. All underwent anthropometric and clinical evaluation, baseline transthoracic echocardiography, and biochemical and BIVA evaluations.

RESULTS

The comparison among the clinical characteristics of congestion, LOS, and hyperhydration status revealed that the higher the hydration status, the longer the LOS (from 7.36 d [interquartile range: 7.34-7.39 d] in normohydrated patients to 9.04 d [interquartile range: 8.85- 9.19 d] in severe hyperhydrated patients; P < 0.05). At univariate analysis, brain natriuretic peptide, blood urea nitrogen, New York Heart Association class, hemoglobin, hydration index, and peripheral edema all had a statistically significant influence on LOS. At multivariate analysis, only brain natriuretic peptide (P < 0.0001), blood urea nitrogen (P = 0.011), and hydration index (P < 0.0001) were significantly associated to LOS.

CONCLUSIONS

Congestion evaluated by BIVA is an independent predictor of length of total hospital stay in HF patients with acute decompensation. The quick and reliable detection of congestion permits the administration of target therapy for AHF, thus reducing LOS and treatment costs.

Heart-Kidney Interactions in Cardiorenal Syndrome Type 1

The exact significance of kidney function deterioration during acute decompensated heart failure (ADHF) episodes is still under debate. Several studies reported a wide percentage of worsening renal function (WRF) in ADHF patients ranging from 20% to 40%. This is probably because of different populations enrolled with different baseline kidney and cardiac function, varying definition of acute kidney injury (AKI), etiology of kidney dysfunction (KD), and occurrence of transient or permanent KD over the observational period. Current cardiorenal syndrome classification does not distinguish among the mechanisms leading to cardiac and renal deterioration. Cardiorenal syndrome type 1 (CRS-1) is the result of a combination of neurohormonal activation, fluid imbalance, arterial underfilling, increased renal and abdominal pressure, and aggressive decongestive treatment. A more complete mechanistic approach to CRS-1 should include evaluation of baseline kidney function, timing, course and magnitude of KD, and introduction of specific biomarkers able to identify early kidney damage. Therefore, clinical and laboratory parameters may yield a different combination among predisposing, precipitating, and amplifying factors that may influence cardiorenal syndrome development. Thus, CRS-1 is a heterogeneous syndrome that needs to be better defined and categorized taking into account clinical status, renal condition, and treatment. The application of universal definitions for WRF/AKI definition would be the first step to achieve a clear classification.

Clinical profile of patients with heart failure can predict rehospitalization and quality of life

BACKGROUND

The aim of this retrospective study was to identify clinical, humoral and echocardiographic variables predicting rehospitalization and poor quality of life (QOL) in patients with reduced or mid-range ejection fraction heart failure.

METHODS

From 2009 to 2012, 310 patients were admitted having signs and symptoms of heart failure with reduced ejection fraction. All the patients were followed by phone, calling the patients or the referring general practitioner. The Minnesota Living with Heart Failure Questionnaire (MLHFQ) was used as the instrument to evaluate QOL: MLHFQ less than 24 is a good QOL, 24-45 is moderate QOL and more than 45 is poor QOL. The primary event was poor QOL and/or rehospitalization at 4 years.

RESULTS

Seventy-nine patients died at median time of 21 months; 4-year survival was 72 ± 3%. Rehospitalization due to heart failure was recorded in 60 cases. Among 231 survivors, MLHFQ score was good in 99 (42%), moderate in 50 (21%) and poor in 88 (37%). Four-year freedom from death, poor QOL or rehospitalization was 51 ± 3%. Multivariable analysis identified the following risk factors: heart rate at discharge at least 70 bpm, ischemic heart disease, atrial fibrillation, hypercholesterolemia, chronic pulmonary disease, N-terminal pro brain natriuretic peptide at discharge, severe tricuspid regurgitation and mitral regurgitation more than moderate.

CONCLUSION

Clinical, laboratory and echocardiographic profile is crucial to predict long-term QOL of patients admitted for heart failure.