Hospital meal intake in acute heart failure patients and its association with long-term outcomes

Background

Risk prediction for hospitalised heart failure (HF, HHF) patients remains suboptimal. We aimed to determine the prognostic value of hospital food intake (FI) immediately before discharge among HHF patients.

Method

We analysed the data of 255 HHF patients extracted from the records of a single university hospital. The FI percentage of the three meals the day before hospital discharge was averaged. Patients were stratified into adequate FI (100% consumption) and inadequate FI (less than 100% consumption) groups. The primary outcome was the composite of all-cause mortality and/or HF readmission within 1 year.

Results

Only 49.3% of HHF patients consumed 100% of their meals. Patients with inadequate FI were older; predominantly women; and had a lower body mass index, higher brain natriuretic peptide levels and Clinical Frailty Scale scores at discharge than those with adequate FI. Inadequate FI was significantly associated with adverse outcomes after adjustments (HR 2.00; 95% CI 1.09 to 3.67; p=0.026). The effect of interaction by ejection fraction (EF) was highly significant: HF with preserved EF (≥40%) was significantly associated with inadequate FI with adverse outcomes (HR 4.95; 95% CI 1.71 to 14.36; p=0.003) but HF with reduced EF (<40%) was not (HR 0.77; 95% CI 0.31 to 1.95; p=0.590).

Conclusions

The hospital FI assessment might be a simple, useful tool for predicting and stratifying risk for HHF patients.

The impact of an integrated heart failure service in a medium-sized district general hospital

Objectives

Assessing the impact of a new integrated heart failure service (IHFS) in a medium-sized district general hospital (DGH) on heart failure (HF) mortality, readmission rates, and provision of HF care.

Methods

A retrospective, observational study encompassing all patients admitted with a diagnosis of HF over two 12-month periods before (2012/2013), and after (2015/2016) IHFS establishment.

Results

Total admissions for HF increased by 40% (385 vs 540), with a greater number admitted to the cardiology ward (231 vs 121). After IHFS implementation, patients were more likely to see a cardiologist (35.1% vs 43.7%, p=0.009), undergo echocardiography (70.1% vs 81.5%, p<0.001), be initiated on all three disease modifying HF medications (angiotensin-converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB) and mineralocorticoid receptor antagonists (MRA)) in the heart failure with reduced ejection fraction (HFrEF) group (42% vs 99%, p<0.001) and receive specialist HF input (81.6% vs 85.4%, p=0.2). Both 30-day post-discharge mortality and HF related readmissions were significantly lower in patients with heart failure with preserved ejection fraction (HFpEF) (8.9% vs 3.1%, p=0.032, 58% reduction, p=0.043 respectively) with no-significant reductions in all other HF groups. In-patient mortality was similar. Length of stay in Cardiology wards increased from 8.4 to 12.7 days (p<0.001).

Conclusion

Establishment of an IHFS within a DGH with limited resources and only a modest service re-design has resulted in significantly improved provision of specialist in-patient care, use of HFrEF medications, early heart failure nurse follow-up, and is associated with a reduction in early mortality, particularly in the HFpEF cohort, and HF related readmissions.

Prognostic impacts of changes in left ventricular ejection fraction in heart failure patients with preserved left ventricular ejection fraction

Background

It has been reported that recovery of left ventricular ejection fraction (LVEF) is associated with better prognosis in heart failure (HF) patients with reduced EF (rEF). However, change of LVEF has not yet been investigated in cases of HF with preserved EF (HFpEF).

Methods and results

Consecutive 1082 HFpEF patients, who had been admitted to hospital due to decompensated HF (EF >50% at the first LVEF assessment at discharge), were enrolled, and LVEF was reassessed within 6 months in the outpatient setting (second LVEF assessment). Among the HFpEF patients, LVEF of 758 patients remained above 50% (pEF group), 138 patients had LVEF of 40%–49% (midrange EF, mrEF group) and 186 patients had LVEF of less than 40% (rEF group). In the multivariable logistic regression analysis, younger age and presence of higher levels of troponin I were predictors of rEF (worsened HFpEF). In the Kaplan-Meier analysis, the cardiac event rate of the groups progressively increased from pEF, mrEF to rEF (log-rank, p<0.001), whereas all-cause mortality did not significantly differ among the groups. In the multivariable Cox proportional hazard analysis, rEF (vs pEF) was not a predictor of all-cause mortality, but an independent predictor of increased cardiac event rates (HR 1.424, 95% CI 1.020 to 1.861, p=0.039).

Conclusion

An initial assessment of LVEF and LVEF changes are important for deciding treatment and predicting prognosis in HFpEF patients. In addition, several confounding factors are associated with LVEF changes in worsened HFpEF patients.

Electrocardiographic characteristics in patients with heart failure and normal ejection fraction: A systematic review and meta-analysis

BACKGROUND

Little is known about ECG abnormalities in patients with heart failure and normal ejection fraction (HeFNEF) and how they relate to different etiologies or outcomes.

METHODS AND RESULTS

We searched the literature for peer-reviewed studies describing ECG abnormalities in HeFNEF other than heart rhythm alone. Thirty five studies were identified and 32,006 participants. ECG abnormalities reported in patients with HeFNEF include atrial fibrillation (prevalence 12%-46%), long PR interval (11%-20%), left ventricular hypertrophy (LVH, 10%-30%), pathological Q waves (11%-18%), RBBB (6%-16%), LBBB (0%-8%), and long JTc (3%-4%). Atrial fibrillation is more common in patients with HeFNEF compared to those with heart failure and reduced ejection fraction (HeFREF). In contrast, long PR interval, LVH, Q waves, LBBB, and long JTc are more common in patients with HeFREF. A pooled effect estimate analysis showed that QRS duration ≥120 ms, although uncommon (13%-19%), is associated with worse outcomes in patients with HeFNEF.

CONCLUSIONS

There is high variability in the prevalence of ECG abnormalities in patients with HeFNEF. Atrial fibrillation is more common in patients with HeFNEF compared to those with HeFREF. QRS duration ≥120 ms is associated with worse outcomes in patients with HeFNEF. Further studies are needed to address whether ECG abnormalities correlate with different phenotypes in HeFNEF.

Non-invasive intraventricular pressure differences estimated with cardiac MRI in subjects without heart failure and with heart failure with reduced and preserved ejection fraction

Objective

Non-invasive assessment of left ventricular (LV) diastolic and systolic function is important to better understand physiological abnormalities in heart failure (HF). The spatiotemporal pattern of LV blood flow velocities during systole and diastole can be used to estimate intraventricular pressure differences (IVPDs). We aimed to demonstrate the feasibility of an MRI-based method to calculate systolic and diastolic IVPDs in subjects without heart failure (No-HF), and with HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF).

Methods

We studied 159 subjects without HF, 47 subjects with HFrEF and 32 subjects with HFpEF. Diastolic and systolic intraventricular flow was measured using two-dimensional in-plane phase-contrast MRI. The Euler equation was solved to compute IVPDs in diastole (mitral base to apex) and systole (apex to LV outflow tract).

Results

Subjects with HFpEF demonstrated a higher magnitude of the early diastolic reversal of IVPDs (−1.30 mm Hg) compared with the No-HF group (−0.78 mm Hg) and the HFrEF group (−0.75 mm Hg; analysis of variance p=0.01). These differences persisted after adjustment for clinical variables, Doppler-echocardiographic parameters of diastolic filling and measures of LV structure (No-HF=−0.72; HFrEF=−0.87; HFpEF=−1.52 mm Hg; p=0.006). No significant differences in systolic IVPDs were found in adjusted models. IVPD parameters demonstrated only weak correlations with standard Doppler-echocardiographic parameters.

Conclusions

Our findings suggest distinct patterns of systolic and diastolic IVPDs in HFpEF and HFrEF, implying differences in the nature of diastolic dysfunction between the HF subtypes.

Echocardiographic subtypes of heart failure in consecutive hospitalised patients with dyspnoea

Heart failure with preserved ejection fraction (HFpEF) involves half of hospitalised patients with heart failure (HF), but estimates vary due to unclear diagnostic criteria. We performed a prospective observational study of hospitalised patients admitted with dyspnoea. The aim was to apply contemporary guidelines to diagnose HF due to valvular disease (HFvhd), HF due to reduced ejection fraction (HFrEF), HF due to midrange EF (HFmrEF) and HFpEF in relation to presumed cardiac or non-cardiac dyspnoea.

Cornell product is an ECG marker of heart failure with preserved ejection fraction

Objective

ECG markers of heart failure (HF) with preserved ejection fraction (HFpEF) are lacking. We hypothesised that the Cornell product (CP) is a risk marker of HFpEF and has prognostic utility in HFpEF.

Methods

CP =[(amplitude of R wave in aVL+depth of S wave in V3)×QRS] was measured on baseline 12-lead ECG in a prospective Asian population-based study of 606 healthy controls (aged 55±10 years, 45% men), 221 hypertensive controls (62±9 years, 58% men) and 242 HFpEF (68±12 years, 49% men); all with EF ≥50% and followed for 2 years for all-cause mortality and HF hospitalisations.

Results

CP increased across groups from healthy controls to hypertensive controls to HFpEF, and distinguished between HFpEF and hypertension with an optimal cut-off of ≥1800 mm*ms (sensitivity 40%, specificity 85%). Age, male sex, systolic blood pressure (SBP) and heart rate were independent predictors of CP ≥1800 mm*ms, and CP was associated with echocardiographic E/e' (r=0.27, p<0.01) and left ventricular mass index (r=0.46, p<0.01). Adjusting for clinical and echocardiographic variables and log N-terminal pro B-type natriuretic peptide (NT-proBNP), CP ≥1800 mm*ms was significantly associated with HFpEF (adjusted OR 2.7, 95% CI 1.0 to 7.0). At 2-year follow-up, there were 29 deaths and 61 HF hospitalisations, all within the HFpEF group. Even after adjusting for log NT-proBNP, clinical and echocardiographic variables, CP ≥1800 mm*ms remained strongly associated with a higher composite endpoint of all-cause mortality and HF hospitalisations (adjusted HR 2.1, 95% CI 1.2 to 3.5).

Conclusion

The Cornell product is an easily applicable ECG marker of HFpEF and predicts poor prognosis by reflecting the severity of diastolic dysfunction and LV hypertrophy.

Improving risk stratification in heart failure with preserved ejection fraction by combining two validated risk scores

Introduction

The Intermountain Risk Score (IMRS) was developed and validated to predict short-term and long-term mortality in hospitalised patients using demographics and commonly available laboratory data. In this study, we sought to determine whether the IMRS also predicts all-cause mortality in patients hospitalised with heart failure with preserved ejection fraction (HFpEF) and whether it is complementary to the Get with the Guidelines Heart Failure (GWTG-HF) risk score or N-terminal pro-B-type natriuretic peptide (NT-proBNP).

Methods and results

We used the Stanford Translational Research Integrated Database Environment to identify 3847 adult patients with a diagnosis of HFpEF between January 1998 and December 2016. Of these, 580 were hospitalised with a primary diagnosis of acute HFpEF. Mean age was 76±16 years, the majority being female (58%), with a high prevalence of diabetes mellitus (36%) and a history of coronary artery disease (60%). Over a median follow-up of 2.0 years, 140 (24%) patients died. On multivariable analysis, the IMRS and GWTG-HF risk score were independently associated with all-cause mortality (standardised HRs IMRS (1.55 (95% CI 1.27 to 1.93)); GWTG-HF (1.60 (95% CI 1.27 to 2.01))). Combining the two scores, improved the net reclassification over GWTG-HF alone by 36.2%. In patients with available NT-proBNP (n=341), NT-proBNP improved the net reclassification of each score by 46.2% (IMRS) and 36.3% (GWTG-HF).

Conclusion

IMRS and GWTG-HF risk scores, along with NT-proBNP, play a complementary role in predicting outcome in patients hospitalised with HFpEF.

Elevated serum levels of cardiovascular biomarkers are associated with progression of renal cancer

Objective

Renal cell carcinoma (RCC) is a hypervascular tumour due to high constitutive production of vascular endothelial growth factor (VEGF), which is activated by hypoxia-inducible factor (HIF). Elevated levels of cardiovascular peptides, including brain natriuretic peptide (BNP), have been reported in patients with cancer, regardless of whether they have overt cardiovascular disease. Furthermore, it has been demonstrated that hypoxia stimulates BNP production by an HIF-dependent manner. However, the clinical implications of such cardiovascular peptides in patients with RCC have not been assessed.

Methods

In patients with clear cell RCC who underwent nephrectomy, we investigated the relationship between the serum level of BNP or N-terminal pro-BNP (NT-proBNP) and various clinicopathological characteristics, including serum VEGF and expression of BNP and HIF-2 alpha in the primary tumour.

Results

Elevated preoperative serum levels of BNP, NT-proBNP and VEGF, as well as increased tumour expression of HIF-2 alpha, were associated with a worse performance status, local invasion, distant metastasis and shorter overall survival. HIF-2 alpha expression showed a positive correlation with the preoperative serum VEGF level, while there was no relation between the serum levels of BNP/NT-proBNP and VEGF or tumour expression of HIF-2 alpha. BNP expression was very low in both tumour tissues and normal kidney tissues. Serum levels of BNP, NT-proBNP and VEGF all decreased significantly after nephrectomy.

Conclusions

Our findings suggested that the preoperative serum levels of BNP and NT-proBNP are markers of tumour progression, as well as indicators of subclinical functional and structural myocardial damage in patients with advanced RCC.

Can we diagnose isolated, exercise-induced heart failure with normal ejection fraction?

BACKGROUND

A significant proportion of patients with exertional dyspnea require exercise to diagnose heart failure with normal ejection fraction (HFNEF).

METHODS AND RESULTS

In this review article, we evaluate current data on the prevalence, clinical significance and specifically the establishment of a diagnosis of isolated, exercise-induced HFNEF. Despite the unquestioned clinical importance and high prevalence of exercise-induced HFNEF, there are limited and conflicting data on making a diagnosis of exercise-induced HFNEF. This mostly relies on the evidence of exercise-induced elevation in left ventricular filling pressure (LVFP). At present, there is no agreement on the ability of exercise echocardiographic parameteres to predict exercise-induced LVFP elevation. In addition, even invasively measured exercise LVFP faces the problem of defining normal exercise LVFP values. More data and probably new diagnostic approaches are necessary to reliably diagnose exercise HFNEF.

CONCLUSIONS

There are conflicting results and significant problems associated with the diagnosis of exercise HFNEF. This review hopefully will encourage further research in this difficult but clinically important area of heart failure.

Incremental prognostic significance of the elevated levels of pentraxin 3 in patients with heart failure with normal left ventricular ejection fraction

Background

Pentraxin 3 (PTX3) is a novel inflammatory marker produced by various cell types including those of the vasculature and the heart. The relationship between inflammatory markers and prognosis of patients with heart failure with normal ejection fraction (HFNEF) remains unknown. We investigated whether plasma PTX3 levels can predict future cardiovascular events in patients with HFNEF.

Methods and Results

Plasma PTX3, high‐sensitivity C‐reactive protein, and B‐type natriuretic peptide levels were measured prospectively in 360 stable patients with HFNEF. The subsequent incidence of cardiovascular events, including cardiovascular death, nonfatal myocardial infarction (MI), unstable angina pectoris, nonfatal ischemic stroke, hospitalization for heart failure decompensation, and coronary revascularization, was determined. During a mean 30‐month follow‐up, 106 patients experienced cardiovascular events. These events were more frequent in patients with high plasma PTX3 levels (>3.0 ng/mL) than low levels (≤3.0 ng/mL). Multivariable Cox hazard analysis showed that PTX3 (hazard ratio: 1.16; 95% CI: 1.05 to 1.27; P<0.01) and B‐type natriuretic peptide (hazard ratio: 1.08; 95% CI: 1.03 to 1.14; P<0.001), but not high‐sensitivity C‐reactive protein levels, were significant predictors of future cardiovascular events. Multivariable Cox analysis with the forced inclusion model, including 5 previously identified prognostic factors, found that PTX3 was a significant predictor of cardiovascular events (hazard ratio: 1.16; 95% CI: 1.06 to 1.27; P<0.01). The C‐statistics for cardiovascular events substantially increased from 0.617 to 0.683 when PTX3 was added to the 5 previously identified prognostic factors.

Conclusions

High plasma PTX3 levels, but not other inflammatory markers, are correlated with future cardiovascular events in patients with HFNEF. PTX3 may be a useful biomarker for assessment of risk stratification in HFNEF.

Clinical Trial Registration

URL: http://www.umin.ac.jp; Unique identifier: UMIN000002170.

Inactivation of Myosin binding protein C homolog in zebrafish as a model for human cardiac hypertrophy and diastolic dysfunction

Background

Sudden cardiac death due to malignant ventricular arrhythmia is a devastating manifestation of cardiac hypertrophy. Sarcomere protein myosin binding protein C is functionally related to cardiac diastolic function and hypertrophy. Zebrafish is a better model to study human electrophysiology and arrhythmia than rodents because of the electrophysiological characteristics similar to those of humans.

Methods and Results

We established a zebrafish model of cardiac hypertrophy and diastolic dysfunction by genetic knockdown of myosin binding protein C gene (mybpc3) and investigated the electrophysiological phenotypes in this model. We found expression of zebrafish mybpc3 restrictively in the heart and slow muscle, and mybpc3 gene was evolutionally conservative with sequence homology between zebrafish and human mybpc3 genes. Zebrafish with genetic knockdown of mybpc3 by morpholino showed ventricular hypertrophy with increased myocardial wall thickness and diastolic heart failure, manifesting as decreased ventricular diastolic relaxation velocity, pericardial effusion, and dilatation of the atrium. In terms of electrophysiological phenotypes, mybpc3 knockdown fish had a longer ventricular action potential duration and slower ventricular diastolic calcium reuptake, both of which are typical electrophysiological features in human cardiac hypertrophy and heart failure. Impaired calcium reuptake resulted in increased susceptibility to calcium transient alternans and action potential duration alternans, which have been proved to be central to the genesis of malignant ventricular fibrillation and a sensitive marker of sudden cardiac death.

Conclusions

mybpc3 knockdown in zebrafish recapitulated the morphological, mechanical, and electrophysiological phenotypes of human cardiac hypertrophy and diastolic heart failure. Our study also first demonstrated arrhythmogenic cardiac alternans in cardiac hypertrophy.

Positive inotropes in heart failure: a review article

Increasing myocardial contractility has long been considered a big help for patients with systolic heart failure, conferring an augmented haemodynamic profile in terms of higher cardiac output, lower cardiac filling pressure and better organ perfusion. Though concerns have been raised over the safety issues regarding the clinical trials of different inotropes in hearts with systolic dysfunction, they still stand as a main therapeutic strategy in many centres dealing with such patients. They must be used as short in duration, low in dose and stopped as early as possible. Evidence-based guidelines have provided clinicians with valuable data for better applying inotropes in heart failure patients. In this paper, the authors address clinical trials with different agents used for increasing cardiac contractility in heart failure patients. Furthermore, the authors focus on recent guidelines on making the most out of inotropes in heart failure patients.

Liver diseases in heart failure

Heart failure (HF) is a growing public health concern as a consequence of the ageing of the population and the improved survival of patients with HF. HF is defined as impaired organ perfusion and/or high filling pressure. It is a systemic and chronic disease and as such involves many organs, not least the liver and kidney. The complex vascular system of the liver and its high metabolic activity render it vulnerable to circulation disturbances and trigger many molecular and haemodynamic changes in patients. There are many studies describing the impact of liver disease on patient outcomes. Hepatic dysfunction is commonly seen in HF patients and is closely correlated with a poor outcome. Knowledge about the mechanisms and impacts of liver disease in HF helps us to know the stage of the disease and treat it properly. Moreover, many drugs and toxins that are metabolised in the liver and contribute to drug interactions should also be taken into account when prescribing medication for HF patients. In light of the above-mentioned points, the authors have compiled this review on congestive hepatopathy with the aim of providing physicians and cardiologists with a succinct and useful guide on the role of the liver in HF.