Trajectories of renal biomarkers and new-onset heart failure in the general population: Findings from the PREVEND study

AIMS

Renal dysfunction is one of the most critical risk factors for developing heart failure (HF). However, the association between repeated measures of renal function and incident HF remains unclear. Therefore, this study investigated the longitudinal trajectories of urinary albumin excretion (UAE) and serum creatinine and their association with new-onset HF and all-cause mortality.

METHODS AND RESULTS

Using group-based trajectory analysis, we estimated trajectories of UAE and serum creatinine in 6881 participants from the Prevention of Renal and Vascular End-stage Disease (PREVEND) study and their association with new-onset HF and all-cause death during the 11-years of follow-up. Most participants had stable low UAE or serum creatinine. Participants with persistently higher UAE or serum creatinine were older, more often men, and more often had comorbidities, such as diabetes, a previous myocardial infarction or dyslipidaemia. Participants with persistently high UAE had a higher risk of new-onset HF or all-cause mortality, whereas stable serum creatinine trajectories showed a linear association for new-onset HF and no association with all-cause mortality.

CONCLUSION

Our population-based study identified different but often stable longitudinal patterns of UAE and serum creatinine. Patients with persistently worse renal function, such as higher UAE or serum creatinine, were at a higher risk of HF or mortality.

Massive biventricular thrombi complicating new-onset heart failure in a patient with suspected COVID-19

The World Health Organization nominated SARS-CoV-2 as the cause of the Coronavirus Disease 2019 (COVID-19) and has been granted as a pandemic. COVID-19 is an emerging threat due to the risk of microvascular, venous, and arterial thrombosis, thereby exacerbating organ injury and mortality. Although the exact mechanism of extensive thromboembolism and myocardial injury caused by SARS-CoV-2 is not illuminated, it is clear that COVID-19 related hypercoagulation increasing the fatality of the disease. Herein, we reported a patient with extensive biventricular thrombi along with the new-onset severe systolic dysfunction as an unusual catastrophic presentation of COVID-19. In our patient, there was both a right atrial "clot in transit" from his DVT as well as extensive muralized biventricular thrombus from severe global hypokinesis. We believe that the hypercoagulable state of his COVID-19 infection, along with severe systolic dysfunction, caused this unusual presentation. Although the hypercoagulable state of COVID-19 is well recognized, there have not been any reported cases of extensive de-novo intracardiac thrombus as of yet. We urge awareness of severe and potentially fatal extensive thrombosis and cardiac failure as the initial clinical presentation of possible SARS-CoV-2.

<Learning objective: Thrombotic manifestations are correlated with the high mortality rate in COVID-19; thus, strategies to prevent thrombosis have critical importance. The hypercoagulable state of COVID-19, along with cardiac injury, can lead to an extensive intracardiac thrombus and severe systolic dysfunction even in young patients who don't have previous cardiovascular comorbidities. We urge awareness of severe and potentially fatal extensive thrombosis and cardiac failure as the initial clinical presentation of COVID-19.>

Differential effect of malnutrition between patients hospitalized with new-onset heart failure and worsening of chronic heart failure

Aims

We aimed to investigate the differences in the prevalence, severity, and prognostic impact of malnutrition between patients with new‐onset heart failure (HF) and worsening of chronic HF.

Methods and results

In older (≥60 years) hospitalized patients with acute HF, malnutrition was assessed according to the Geriatric Nutritional Risk Index (GNRI). A score <92 was defined as malnutrition. The primary endpoint was a composite endpoint, including cardiac death or rehospitalization for HF. Among 210 patients, 37% (52/142) of patients with new‐onset HF and 31% (21/68) of patients with worsening of chronic HF had malnutrition (P = 0.41). The GNRI classification was comparable between the two groups. Kaplan–Meier analysis revealed a significant difference in the incidence of the composite endpoint in patients with new‐onset HF (GNRI < 92 vs. GNRI ≥ 92: 50% vs. 32%, P = 0.007), but not in patients with worsening of chronic HF (GNRI < 92 vs. GNRI ≥ 92: 67% vs. 68%, P = 0.91). The adjusted Cox proportional hazards model demonstrated that a GNRI of <92 was an independent prognostic factor for the composite endpoint in patients with new‐onset HF only.

Conclusions

Among older hospitalized patients with acute HF, the prevalence and severity of malnutrition were comparable between the two categories of patients. Malnutrition was an independent prognostic factor in patients with new‐onset HF, while clinical prognosis was poor in patients with worsening of HF, irrespective of malnutrition. The prognostic impact of malnutrition differs between new‐onset HF and worsening of chronic HF.

Diabetes mellitus and risk of new-onset and recurrent heart failure: a systematic review and meta-analysis

Despite mounting evidence of the positive relationship between diabetes mellitus (DM) and heart failure (HF), the entire context of the magnitude of risk for HF in relation to DM remains insufficiently understood. The principal reason is because new‐onset HF (HF occurring in participants without a history of HF) and recurrent HF (HF re‐occurring in patients with a history of HF) are not discriminated. This meta‐analysis aims to comprehensively and separately assess the risk of new‐onset and recurrent HF depending on the presence or absence of DM. We systematically searched cohort studies that examined the relationship between DM and new‐onset or recurrent HF using EMBASE and MEDLINE (from 1 Jan 1950 to 28 Jul 2019). The risk ratio (RR) for HF in individuals with DM compared with those without DM was pooled with a random‐effects model. Seventy‐four and 38 eligible studies presented data on RRs for new‐onset and recurrent HF, respectively. For new‐onset HF, the pooled RR [95% confidence interval (CI)] of 69 studies that examined HF as a whole [i.e. combining HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF)] was 2.14 (1.96–2.34). The large between‐study heterogeneity (I² = 99.7%, P < 0.001) was significantly explained by mean age [pooled RR (95% CI) 2.60 (2.38–2.84) for mean age < 60 years vs. pooled RR (95% CI) 1.95 (1.79–2.13) for mean age ≥ 60 years] (P < 0.001). Pooled RRs (95% CI) of seven and eight studies, respectively, that separately examined HFpEF and HFrEF risk were 2.22 (2.02–2.43) for HFpEF and 2.73 (2.71–2.75) for HFrEF. The risk magnitudes between HFpEF and HFrEF were not significantly different in studies that examined both HFpEF and HFrEF risks (P = 0.86). For recurrent HF, pooled RR (95% CI) of the 38 studies was 1.39 (1.33–1.45). The large between‐study heterogeneity (I² = 80.1%, P < 0.001) was significantly explained by the proportion of men [pooled RR (95% CI) 1.53 (1.40–1.68) for < 65% men vs. 1.32 (1.25–1.39) for ≥65% men (P = 0.01)] or the large pooled RR for studies of only participants with HFpEF [pooled RR (95% CI), 1.73 (1.32–2.26) (P = 0.002)]. Results indicate that DM is a significant risk factor for both new‐onset and recurrent HF. It is suggested that the risk magnitude is large for new‐onset HF especially in young populations and for recurrent HF especially in women or individuals with HFpEF. DM is associated with future HFpEF and HFrEF to the same extent.