Impact of clinical ultrasound in patients with heart failure treated in home

BACKGROUND AND OBJECTIVE

In Spain, more than 10% of patients discharged with acute heart failure (AHF) are readmitted in the first 30 days. This study is designed to assess whether the treatment of AHF guided by clinical ultrasound (CU) in the setting of hospitalization at home (HAH) reduces the incidence of readmission and mortality compared to the standard care (SC).

PATIENTS AND METHODS

A randomized, open, parallel, single-center and controlled clinical trial (RCT) was designed (NT05042752). Patients >18 years of age admitted for AHF to HAD from January 2021 to April 2021 at the Reina Sofía Hospital in Tudela were consecutively included. The patients were randomized to the UG-ultrasound group (SC and CU performed) and the CG-control group (SC). The diuretic treatment was tailored according to the findings of the SC together with the CU or according to the findings of the SC respectively. The main variables were the relative risk of readmission and mortality from AHF.

RESULTS

A total of 79 patients were randomized, 39 to UG and 40 to CG. Of these, only 35 of the UG and 35 of the CG completed the intervention. The risk of readmission due to AHF was reduced by 60% in UG compared to CG (RR 0.4; 95% CI: 0.1-1) and mortality by 30% (RR 0.7; 95% CI: 0.2-2.2). Despite the relevant magnitude of the effect found, the results did not reach statistical significance due to lack of power.

CONCLUSION

Our results suggest that in HAH, a CE guided strategy for AHF could reduce the risk of readmission and mortality compared to SC alone. However, studies with greater statistical power are needed to confirm these results.

Original articleAnalysis of the effectiveness and safety of short-stay units in the hospitalization of patients with acute heart failure. Propensity Score SSU-EAHFE

OBJECTIVES

This work aims to analyze if hospitalization in short-stay units (SSU) of patients diagnosed in the emergency department with acute heart failure (AHF) is effective in terms of the length of hospital stay and if it is associated with differences in short-term progress.

METHOD

Patients from the EAHFE registry diagnosed with AHF who were admitted to the SSU (SSU group) were included and compared to those hospitalized in other departments (non-SSU group) from all hospitals (comparison A) and, separately, those from hospitals with an SSU (comparison B) and without an SSU (comparison C). For each comparison, patients in the SSU/non-SSU groups were matched by propensity score. The length of hospital stay (efficacy), 30-day mortality, and post-discharge adverse events at 30 days (safety) were compared.

RESULTS

A total of 2,003 SSU patients and 12,193 non-SSU patients were identified. Of them, 674 pairs of patients were matched for comparison A, 634 for comparison B, and 588 for comparison C. The hospital stay was significantly shorter in the SSU group in all comparisons (A: median 4 days (IQR = 2-5) versus 8 (5-12) days, p < 0.001; B: 4 (2-5) versus 8 (5-12), p < 0.001; C: 4 (2-5) versus 8 (6-12), p < 0.001). Admission to the SSU was not associated with differences in mortality (A: HR = 1.027, 95%CI = 0.681-1.549; B: 0.976, 0.647-1.472; C: 0.818, 0.662-1.010) or post-discharge adverse events (A: HR = 1.002, 95%CI = 0.816-1.232; B: 0.983, 0.796-1.215; C: 1.135, 0.905-1.424).

CONCLUSION

The hospitalization of patients with AHF in the SSU is associated with shorter hospital stays but there were no differences in short-term progress.

Prognosis of acute heart failure based on clinical data of congestion

BACKGROUND AND OBJECTIVES

This work aims to assess whether symptoms/signs of congestion in patients with acute heart failure (AHF) evaluated in hospital emergency departments (HED) allows for predicting short-term progress.

PATIENTS AND METHODS

The study group comprised consecutive patients diagnosed with AHF in 45 HED from EAHFE Registry. We collected clinical variables of systemic congestion (edema in the lower extremities, jugular vein distention, hepatomegaly) and pulmonary congestion (dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, and pulmonary crackles) and analysed their individual and group association with all-cause 30-day of mortality crudely and adjusted for differences between groups.

RESULTS

We analysed 18,120 patients (median = 83 years, interquartile range [IQR] = 76-88; women = 55.7%). Of them, 44.6% had > 3 congestive symptoms/signs. Individually, the 30-day adjusted risk of death increased 14% for jugular vein distention (hazard ratio [HR] = 1.14, 95% confidence interval [95%CI] = 1.01-1.28) and 96% for dyspnea on exertion (HR = 1.96, 95% CI = 1.55-2.49). Assessed jointly, the risk progressively increased with the number of symptoms/signs present; compared to patients without symptoms/signs of congestion, the risk increased by 109%, 123 %, and 156% in patients with 1-2, 3-5, and 6-7 symptoms/signs, respectively. These associations did not show interaction with the final disposition of the patient after their emergency care (discharge/hospitalization) with the exception of edema in the lower extremities, which had a better prognosis in discharged patients (HR = 0.66, 95% CI = 0.49-0.89) than hospitalised patients (HR = 1.01, 95% CI = 0.65-1.57; interaction p < 0.001).

CONCLUSION

The presence of a greater number of congestive symptoms/signs was associated with greater all-cause 30-day mortality. Individually, jugular vein distention and dyspnea on exertion were associated with higher short-term mortality.

Prognostic implications of hypo and hyperkalaemia in acute heart failure with reduced ejection fraction. Analysis of cardiovascular mortality and hospital readmissions

BACKGROUND AND OBJECTIVES

Potassium alterations constitute a major clinical problem in decompensated heart failure (HF). This study aims to assess the prognostic implications of hypo and hyperkalaemia on admission for acute HF in cardiovascular mortality and hospital readmissions.

MATERIAL AND METHOD

From January 2016 to June 2020, 1,397 cases with a diagnosis of acute HF were admitted. Admission programmed for study, elective therapies, and patients with LVEF> 40% were excluded. The study was carried out on 689 patients, 45 with K⁺ <3.5 mmol/L, 49K ⁺>5.0 mmol/L and 595K+3.5-5.0 mmol/L. Medical history, baseline clinical profile, drug therapy, and potassium levels obtained upon admission were analysed.

RESULTS

Annual mortality due to hypokalaemia (K+<3.5mmol/L) was 37.8% (HR 2.4; 95% CI: 1.3-4.7; P<.007); for hyperkalaemia 40.8% (HR: 1.9; 95% CI: 0.98-3.51; P<.055). Creatinine level and age were variables associated with mortality in both the hyperkalaemic and hypokalaemic cohorts. Hospital readmissions did not show statistical association with these electrolyte disorders.

CONCLUSIONS

In patients admitted for decompensated HF, both hyperkalaemia and hypokalaemia determined at admission have a negative prognostic impact on survival. Creatinine and age are other independent factors associated with mortality. The effect on the probability of hospital readmission at one year is not demonstrated in this study.

Comparison between CA125 and NT-proBNP for evaluating congestion in acute heart failure

BACKGROUND

Carbohydrate antigen 125 (CA125) and B-type natriuretic peptides are surrogate markers of congestion in patients with acute heart failure (AHF). The aim of the study was to assess the association between CA125 and NT-proBNP and congestion parameters in patients with AHF.

METHODS AND RESULTS

Prospective multicentre observational study that included 191 patients hospitalised for AHF. We recorded the presence of pleural effusion, peripheral oedema and inferior vena cava (IVC) diameter during the first 24-48 hours after admission and evaluated their independent association with CA125 concentrations and the amino-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP). The mean age was 73.4 ± 12 years, 79 (41.4%) were women, and 127 (66.5%) had left ventricular ejection fraction ≥ 50%. The median of CA125, NT-proBNP and IVC diameter was 58 (22.7-129) U/mL, 3,985 (1,905-9,775) pg/mL and 21 (17-25) mm, respectively. Multivariate analysis showed that CA125 was positively and independently associated with the presence of peripheral oedema, pleural effusion and elevated IVC levels. NT-proBNP was associated with pleural effusion and IVC diameter but not with oedema. The addition of CA125 increased the discriminatory capacity of the baseline model to identify peripheral oedema and pleural effusion, but not NT-proBNP. The most important predictor of ICV dilation was CA125 (R² = 48.3%).

CONCLUSION

In patients with AHF, serum CA125 levels are associated more significantly than NT-proBNP with a state of congestion.

Consensus on improving the comprehensive care of patients with acute heart failure

The latest acute heart failure consensus document from the Spanish Society of Cardiology, Spanish Society of Internal Medicine, and Spanish Society of Emergency Medicine was published in 2015, which made an update covering the main novelties regarding acute heart failure from the last few years necessary. These include publication of updated European guidelines on heart failure in 2016, new studies on the pharmacological treatment of patients during hospitalization, and other recent developments regarding acute heart failure such as early treatment, intermittent treatment, advanced heart failure, and refractory congestion. This consensus document was drafted with the aim of updating all aspects related to acute heart failure and to create a document that comprehensively describes the diagnosis, treatment, and management of this disease.

Consensus on improving the comprehensive care of patients with acute heart failure

The latest acute heart failure (AHF) consensus document from the Spanish Society of Cardiology (SEC, for its initials in Spanish), Spanish Society of Internal Medicine (SEMI), and Spanish Society of Emergency Medicine (SEMES) was published in 2015, which made an update covering the main novelties regarding AHF from the last few years necessary. These include publication of updated European guidelines on HF in 2016, new studies on the pharmacological treatment of patients during hospitalization, and other recent developments regarding AHF such as early treatment, intermittent treatment, advanced HF, and refractory congestion. This consensus document was drafted with the aim of updating all aspects related to AHF and to create a document that comprehensively describes the diagnosis, treatment, and management of this disease.

Consensus for improving the comprehensive care of patients with acute heart failure: summarised version

The purpose of this consensus document was to reach an agreement among experts on the multidisciplinary care of patients with acute heart failure. Starting with a narrative review of the care provided to these patients and a critical analysis of the healthcare procedures, we identified potential shortcomings and improvements and formalised a document on recommendations for optimising the clinical and therapeutic approach for acute heart failure. This document was validated through an in-person group session guided using participatory techniques. The process resulted in a set of 36 recommendations formulated by experts of the Spanish Society of Cardiology, the Spanish Society of Internal Medicine and the Spanish Society of Urgent and Emergency Care. The recommendations are designed to optimise the healthcare challenge presented by the care of patients with acute heart failure in the context of Spain's current National Health System.

[Diagnosis of acute heart failure and relevance of biomarkers in elderly patients]

Diagnosis of acute heart failure (HF) is difficult in elderly patients with multiple comorbidities. Risk scales and classification criteria based exclusively on clinical manifestations, such as the Framingham scales, lack sufficient specificity. In addition to clinical manifestations, diagnosis should be based on two key factors: natriuretic peptides and echocardiographic study. When there is clinical suspicion of acute HF, a normal natriuretic peptide level will rule out this process. When a consistent clinical suspicion is present, an echocardiographic study should also be performed. Diagnosis of HF with preserved ejection fraction (HF/pEF) requires detection of an enlarged left atrium or the presence of parameters of diastolic dysfunction. Elevation of cardiac biomarkers seems to be due to myocardial injury and the compensatory mechanisms of the body against this injury (hormone and inflammatory response and repair mechanisms). Elevation of markers of cardiac damage (troponins and natriuretic peptides) have been shown to be useful both in the diagnosis of acute HF and in prediction of outcome. MMP-2 could be useful in the diagnosis of HF/pEF. In addition to biomarkers with diagnostic value, other biomarkers are helpful in prognosis in the acute phase of HF, such as biomarkers of renal failure (eGFR, cystatin and urea), inflammation (cytokines and CRP), and the cell regeneration marker, galectin-3. A promising idea that is under investigation is the use of panels of biomarkers, which could allow more accurate diagnosis and prognosis of acute HF.

[Acute heart failure: precipitating factors and prevention]

Acute heart failure episodes, whether onset or decompensation of a chronic form, are most often precipitated by a concurrent process or disease, described as precipitating factors of heart failure. In this article, we review these precipitating factors, their proportions and clinical relevance in general and in subgroups of patients, their relationship with prognosis, and their possible prevention.

[Organ-protection therapy. A new therapeutic approach for acute heart failure?]

Unlike the prolonged benefit produced by the treatment of chronic heart failure, newer drugs tested for the treatment of acute heart failure in the last decade have failed to provide evidence of clinical benefit beyond some improvement in symptom relief. In particular, no drug has shown the ability to reduce the higher medium- and long-term risk of morbidity and mortality in these patients after an episode of decompensation. Current understanding of the pathophysiology of acute heart failure and its consequences has led to the hypothesis that, beyond symptom control, effective therapies for this syndrome should target not only the hemodynamic changes of the initial phase of the syndrome but should also "protect" the organism from the activation of neurohumoral and inflammatory pathways triggered by the decompensation episode, which persist in time and confer a risk of deleterious effects in several organs and tissues. Serelaxin, a new drug related to the peptidic endogenous hormones of the relaxin family, has recently been shown to provide multiple beneficial effects in terms of "organ protection" - not only in the cardiovascular and renal systems - from these acute heart failure-related deleterious changes. This drug has already been tested in acute heart failure patients with encouraging results in terms of medium-term clinical benefit, rendering serelaxin as a serious candidate for first-line, prognosis-modifying therapy in this syndrome.

[Acute heart failure: acute cardiogenic pulmonary edema and cardiogenic shock]

Acute cardiogenic pulmonary edema and cardiogenic shock are two of the main forms of presentation of acute heart failure. Both entities are serious, with high mortality, and require early diagnosis and prompt and aggressive management. Acute pulmonary edema is due to the passage of fluid through the alveolarcapillary membrane and is usually the result of an acute cardiac episode. Correct evaluation and clinical identification of the process is essential in the management of acute pulmonary edema. The initial aim of treatment is to ensure hemodynamic stability and to correct hypoxemia. Other measures that can be used are vasodilators such as nitroglycerin, loop diuretics and, in specific instances, opioids. Cardiogenic shock is characterized by sustained hypoperfusion, pulmonary wedge pressure > 18 mmHg and a cardiac index < 2.2l/min/m(2). The process typically presents with hypotension (systolic blood pressure < 90 mmHg or a decrease in mean arterial pressure > 30 mmHg) and absent or reduced diuresis (< 0.5 ml/kg/h). The most common cause is left ventricular failure due to acute myocardial infarction. Treatment consists of general measures to reverse acidosis and hypoxemia, as well as the use of vasopressors and inotropic drugs. Early coronary revascularization has been demonstrated to improve survival in shock associated with ischaemic heart disease.

[Vasoactive and inotropic drugs in acute heart failure]

Vasoactive and inotropic drugs provide effective symptomatic and hemodynamic relief in the short term but can increase mortality in the long-term. Consequently, their use should be restricted to the indications described in clinical practice guidelines. The present article reviews the main drugs and the available evidence on their use.