Acute Heart Failure Management

The role of tolvaptan add-on therapy in patients with acute heart failure: a systematic review and network meta-analysis

Background

Several conflicting reviews have concluded that the use of loop diuretics is associated with poorer clinical and safety outcomes. Therefore, this study aimed to investigate the efficacy and safety of tolvaptan as an adjunct to conventional diuretic therapy in patients with acute heart failure (AHF).

Methods

A comprehensive search was conducted on PubMed, Embase, ProQuest, EBSCO, and Cochrane Library until 24 May 2023 to identify randomized controlled trials that compared the effects of tolvaptan with conventional therapy and placebo in patients with AHF. The quality assessment of the included trials was conducted using the Cochrane risk of bias. A network meta-analysis (NMA) was conducted to examine the dosage effect of tolvaptan.

Result

A total of 17 studies with 18 reports, involving 10,039 patients, were selected. The tolvaptan add-on therapy significantly alleviated dyspnea [24 h: RR 1.16 (1.04, 1.29), 48 h: RR 1.18 (1.04, 1.33)], reduced body weight within 48 h [Asian group, MD -0.93 (-1.48, -0.38); non-Asian group, MD -2.76 (-2.88, -2.65)], reduced edema [RR 1.08 (1.02, 1.15)], increased serum sodium [non-Asian group, MD 3.40 (3.02, 3.78)], and resulted in a change in serum creatinine [MD -0.10 (-0.18, -0.01)]. No significant differences were observed in mortality and rehospitalization. The NMA suggested that an intermediate dosage (15 mg/day) might offer the best efficacy in reducing dyspnea within 24 h, reducing edema, increasing serum sodium, and lowering the incidence of worsening renal function (WRF).

Conclusion

In conclusion, the meta-analysis showed that tolvaptan contributed to the short-term alleviation of congestive symptoms, elevated sodium levels, and a lower incidence of WRF. However, no significant benefits were observed in long-term symptoms, rehospitalization rates, and mortality. An intermediate dosage of tolvaptan might be considered the optimal choice for various clinical outcomes.

Systematic Review Registration

https://www.crd.york.ac.uk/, PROSPERO (CRD42023420288).

Critical Insights Into the Management of Postpartum Left Main Spontaneous Coronary Artery Dissection: Current Strategies and Future Directions

This review article delves into the multifaceted realm of postpartum left main spontaneous coronary artery dissection (PLMSCAD), an infrequent yet critical condition affecting women during the postpartum period. Through a comprehensive exploration of its pathophysiology, clinical presentation, diagnosis, management strategies, and future directions, this review provides a holistic understanding of PLMSCAD's complexities. The article highlights challenges in diagnosis due to overlapping symptoms and underscores the significance of prompt recognition and tailored interventions. Current management strategies, encompassing medical and interventional approaches, are analysed in the context of their short-term and long-term impact on patient outcomes. Ethical considerations and the role of patient education and support networks are explored, shedding light on the broader psychosocial dimensions of PLMSCAD management. As emerging research reveals insights into genetic influences, hormonal dynamics, and the prognosis of affected individuals, this review emphasises the necessity of collaborative research endeavours and data sharing to enhance our understanding and guide future strategies. Ultimately, this review underscores the urgency of addressing the unique needs of women experiencing PLMSCAD, urging ongoing research, multidisciplinary collaboration, and a patient-centred approach to optimise maternal health outcomes and well-being.

Effect of Hypertonic Saline Solution Combined with Furosemide on Acute Heart Failure: A Meta-Analysis

Background

The efficacy of hypertonic saline solution (HSS) combined with furosemide in treating acute heart failure is controversial. This meta-analysis explores the efficacy of HSS combined with furosemide for the treatment of acute heart failure.

Methods

Literature were searched from databases, including PubMed, Web of Knowledge, Embase, Central, CMKI, Wanfang, and VIP. The inclusion criteria were as follows: (1) subjects: patients with acute heart failure; (2) the experimental group and the control group were properly set up; (3) intervention measures: patients in the experimental group were treated with HSS + furosemide, and patients in the control group were treated with furosemide; (4) the outcomes included at least one of the following indicators: readmission rate, mortality, 24 h urine volume, weight loss, and serum creatinine; and (5) randomized controlled trial (RCT). The method recommended by Cochrane Collaboration Network was used to evaluate the risk bias. The heterogeneity among the studies was evaluated through the chi-square test, and the publication bias was assessed by the Egger test. The results were described using risk ratio (RR), mean difference (MD), and 95% confidence interval (CI).

Results

The readmission rate in the HSS + furosemide group was lower than that in the furosemide group (RR = 0.53, 95% CI [0.46, 0.60], P < 0.00001), with no heterogeneity among the literature (P = 0.21, I² = 29%). Patients in the HSS + furosemide group had a lower mortality rate than that in the furosemide group (RR = 0.55, 95% CI [0.46, 0.65], P < 0.00001). The chi-square test result indicated no heterogeneity among the literature (P = 0.25, I² = 23%). Furthermore, the 24 h urine volume of patients in the HSS + furosemide group was higher than that in the furosemide group (MD = 497.29, 95% CI [457.61, 536.96], P < 0.00001). There was no heterogeneity among the literature (P = 0.58, I² = 0%). In contrast, patients in the HSS + furosemide group demonstrated a lower serum creatinine level than those in the furosemide group (MD = −0.45, 95% CI [-0.51, -0.39], P < 0.00001). However, heterogeneity was observed among the literature (P < 0.00001, I² = 81%). The weight loss in the HSS + furosemide group was higher than that in the furosemide group (MD = 1.83, 95% CI [1.51, 2.15], P < 0.00001). There was no heterogeneity among the literature (P = 0.42, I² = 2%). Egger test showed no publication bias among the literature (P > 0.05).

Conclusion

Despite the heterogeneity and bias in our study, the combination of HSS with furosemide is promising in patients with acute heart failure. However, further research is still needed to confirm.

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.

A Novel Paradigm Based on ST2 and Its Contribution towards a Multimarker Approach in the Diagnosis and Prognosis of Heart Failure: A Prospective Study during the Pandemic Storm

Background: Acute heart failure (HF) represents an increasingly common and challenging presentation in the emergency room, also inducing a great socio-economic burden. Extensive research was conducted toward finding an ideal biomarker of acute HF, both in terms of sensitivity and specificity, but today practicians’ interest has shifted towards a more realistic multimarker approach. Natriuretic peptides (NPs) currently represent the gold standard for diagnosing HF in routine clinical practice, but novel molecules, such as sST2, emerge as potentially useful biomarkers, providing additional diagnostic and prognostic value. Methods: We conducted a prospective, single-center study that included 120 patients with acute HF and 53 controls with chronic HF. Of these, 13 patients (eight with acute HF, five from the control group) associated the coronavirus-19 disease (COVID-19). The diagnosis of HF was confirmed by a complete clinical, biological and echocardiographic approach. Results: The serum levels of all studied biomarkers (sST2, NT-proBNP, cardiac troponin) were significantly higher in the group with acute HF. By area under the curve (AUC) analysis, we noticed that NT-proBNP (AUC: 0.976) still had the best diagnostic performance, closely followed by sST2 (AUC: 0.889). However, sST2 was a significantly better predictor of fatal events, showing positive correlations for both in-hospital and at 1-month mortality rates. Moreover, sST2 was also associated with other markers of poor prognosis, such as the use of inotropes or high lactate levels, but not with left ventricle ejection fraction, age, body mass index or mean arterial pressure. sST2 levels were higher in patients with a positive history of COVID-19 as compared with non-COVID-19 patients, but the differences were statistically significant only within the control group. Bivariate regression showed a positive and linear relationship between NT-proBNP and sST2 (r(120) = 0.20, p < 0.002). Conclusions: we consider that sST2 has certain qualities worth integrating in a future multimarker test kit alongside traditional biomarkers, as it provides similar diagnostic value as NT-proBNP, but is emerging as a more valuable prognostic factor, with a better predictive value of fatal events in patients with acute HF.

The Potential of Oxygenation-Sensitive CMR in Heart Failure

PURPOSE OF REVIEW

Cardiac magnetic resonance imaging (CMR) use in the context of heart failure (HF) has increased over the last decade as it is able to provide detailed, quantitative information on function, morphology, and myocardial tissue composition. Furthermore, oxygenation-sensitive CMR (OS-CMR) has emerged as a CMR imaging method capable of monitoring changes of myocardial oxygenation without the use of exogenous contrast agents.

RECENT FINDINGS

The contributions of OS-CMR to the investigation of patients with HF includes not only a fully quantitative assessment of cardiac morphology, function, and tissue characteristics, but also high-resolution information on both endothelium-dependent and endothelium-independent vascular function as assessed through changes of myocardial oxygenation. In patients with heart failure, OS-CMR can provide deep phenotyping on the status and important associated pathophysiology as a one-stop, needle-free diagnostic imaging test.

Integrating Palliative Care Into Heart Failure Management

BACKGROUND

The World Health Organization defines palliative care as an approach that improves the quality of life of patients and their families through the prevention and relief of suffering by assessment and treatment of physical, psychosocial, and spiritual problems. Any patient with chronic debilitating disease, including heart failure, is a candidate for interdisciplinary palliative care to manage their complex physical and psychosocial needs.

CLINICAL RELEVANCE

The philosophy of palliative care has evolved to include a vision of holistic care extended to all individuals with serious illness and their families or caregivers that should be integrated throughout the continuum of care, including the acute phase. The critical care nurse will likely encounter patients with heart failure who are receiving or are eligible to receive palliative care at various time points during their illness. Critical care nurses therefore play a pivotal role in symptom palliation affecting the heart failure patient's quality of life.

PURPOSE

To review the models of palliative care and the role that the critical care nurse plays in symptom palliation and preparation of the patient and their family for transition to other levels and settings of care.

CONTENT COVERED

This review addresses the principles and models of palliative care along with how to integrate these principles into all phases of the heart failure disease continuum. Also included are recommendations for palliation of symptoms specific to heart failure patients as well as a discussion of the role of the critical care nurse and the importance of shared decision-making.

Heart failure and sepsis: practical recommendations for the optimal management

Acute heart failure (AHF) is a common clinical challenge that a wide spectrum of physicians encounters in every practice. In many cases, AHF is due to decompensation of chronic heart failure. This decompensation may be triggered by various reasons, with sepsis being a notable one. Sepsis is defined as a life-threatening organ dysfunction caused by the dysregulated host response to infection and is associated with a very high mortality, which may reach 25%. Alarmingly, the increase in the mortality rate of patients with combined cardiac dysfunction and sepsis is extremely high (may reach 90%). Thus, these patients need urgent intervention. Management of patients with AHF and sepsis is challenging since cornerstone interventions for AHF may be contraindicated in sepsis and vice versa (e.g., diuretic treatment). Unfortunately, no relevant guidelines are yet available, and treatment remains empirical. This review attempts to shed light on the intricacies of the available interventions and suggests routes of action based on the existing bibliography.

Efficacy and safety of spironolactone for the treatment of patients with acute heart failure: A protocol for systematic review

BACKGROUND

This study will investigate the efficacy and safety of spironolactone for the treatment of acute heart failure (AHF).

METHODS

The following electronic databases will be retrieved in PUBMED, EMBASE, Cochrane Library, Web of Science, CINAHL, CBM, CNKI, and VIP database from inception through present. Two researchers will independently screen and assess the obtained literatures and extract outcome data. All study methodological quality will be assessed using Cochrane risk of bias tool, and all statistical analysis will be performed by RevMan 5.3 software. Additionally, we will undertake a narrative synthesis if it is possible.

RESULTS

This study will sum-marize most recent evidence to investigate the efficacy and safety of spironolactone for the treatment of AHF.

CONCLUSION

This study will seek to assess the efficacy and safety of spironolactone for treating AHF.

SYSTEMATIC REVIEW REGISTRATION

INPLASY202070053.

A narrative review on the management of Acute Heart Failure in Emergency Medicine Department

The main urgent symptom presented to an emergency department is acute heart failure (AHF). In that considerable risksof morbidity and mortality, it is important to plan precision medicine to achieve the most suitable outcomes. The object of this review is to provide a summary of contemporary management procedures of emergency medicine in a department of acute heart failure. Heart failure could be presented with a broad range of symptoms, in particular a sudden worsening of those of Chronic Obstructive Pulmonary Disease. The treatment should focus on acute and chronic underlying disorders with instructions focusing on haemodynamics and blood pressure status. Treatment of patients suffering with worsening symptoms of AHF mainly focuses on intravenous diuretics. In emergency situations, patients suffering with AHF with low blood pressure must receive emergency consultation and a primary fluid bolus therapy (range 250-500 mL) followed by inotropic therapy with or without antihypotensive agents. For treatment of severe heart failure and cardiogenic shock in patients treated with noradrenalin, when blood pressure support is required, a direct-acting inotropic agent, dobutamine, could be applied effectively. When non-invasive positive pressure ventilation is needed, suppliers must track for any possibility of sudden worsening, i.e., for acute decompensated heart failure. When cardiac output is high the disorder could be treated with vasopressors.

A study of the predictive factors of mortality in acute poisoning with aluminum phosphide with special reference to echocardiography and SOFA score

Aluminum phosphide (AlP) is considered now one of the most common causes of poisoning among agricultural pesticides. Poisoning with AlP is extremely toxic to humans with high mortality rate. The aim of this work was to evaluate the prognostic factors and outcome of acute aluminum phosphide poisoning in Alexandria Main University Hospital during a period of 6 months from 1 November 2017 until the end of April 2018, highlighting the role of SOFA score and echocardiography in predicting the mortality. The prospective study was conducted on all patients admitted with acute AlP poisoning to Alexandria Main University Hospital for those 6 months. Patients' data were collected in a special sheet and included biosocial data, medical history, poisoning history, complete medical examination, investigations, duration of hospital stay, and the outcome. All patients were assessed according to SOFA score on admission. Thirty patients were admitted during the period of the current study. Females outnumbered males in all age groups with a sex ratio of 2.75:1. The mean age of patients was 22.77 ± 12.79 years. 96.6% of patients came from rural areas. 93.3% of the cases were exposed to poisoning at home, where suicidal poisoning accounted for (86.7%) of cases. 43.3% of patients died (n = 13), and the median value of SOFA score among non-survivors was 10, versus 1 among survivors. The median value of ejection fraction among non-survivors (25%) was half its value in survivors (50%). Although there were many predictors of severity of AlP poisoning, SOFA score was the most predictive factor of mortality detected by multivariate analysis.

Efficacy of urapidil for the treatment of patients with senile hypertension and acute heart failure

BACKGROUND

Previous clinical studies have reported that urapidil can effectively treat patients with senile hypertension (SH) and acute heart failure (AHF). However, no studies have systematically assessed the efficacy and safety of urapidil for patients with SH and AHF. Thus, this study will investigate the efficacy and safety of urapidil for SH and AHF.

METHODS

In this study, we will search the following electronic databases from inception to the June 30, 2019: MEDLINE, EMBASE, Cochrane Library, Google scholar, Springer, WANGFANG, and China Knowledge Resource Integrated Database. We will search all these electronic databases without language limitations. We will also search grey records to avoid missing potential literature. In this study, only randomized controlled trials on assessing efficacy and safety of urapidil for SH and AHF will be considered. We will use RevMan 5.3 software and STATA 15.0 software to carry out statistical analysis.

RESULTS

This study will evaluate the efficacy and safety of urapidil for SH and AHF by assessing all-cause mortality, change in body weight, urine output, change in serum sodium; and incidence of all adverse events.

CONCLUSION

This study will provide latest evidence of the efficacy and safety of urapidil for patients with SH and AHF.

DISSEMINATION AND ETHICS

This study will only analyze published data; therefore, no ethical approval is needed. The findings of this study will be published at peer-reviewed journals.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019139344.

Update on heart failure management and future directions

Heart failure (HF) is an important cardiovascular disease because of its increasing prevalence, significant morbidity, high mortality, and rapidly expanding health care cost. The number of HF patients is increasing worldwide, and Korea is no exception. There have been marked advances in definition, diagnostic modalities, and treatment of HF over the past four decades. There is continuing effort to improve risk stratification of HF using biomarkers, imaging and genetic testing. Newly developed medications and devices for HF have been widely adopted in clinical practice. Furthermore, definitive treatment for end-stage heart failure including left ventricular assist device and heart transplantation are rapidly evolving as well. This review summarizes the current state-of-the-art management for HF and the emerging diagnostic and therapeutic modalities to improve the outcome of HF patients.

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.