Diagnosis and management of heart failure from hospital admission to discharge: A practical expert guidance

Heart failure (HF) has high event rates, mortality, and is challenging to manage in clinical practice. Clinical management is complicated by complex therapeutic strategies in a population with a high prevalence of comorbidity and general frailty. In the last four years, an abundance of research has become available to support multidisciplinary management of heart failure from within the hospital through to discharge and primary care as well as supporting diagnosis and comorbidity management. Within the hospital setting, recent evidence supports sacubitril-valsartan combination in frail, deteriorating or de novo patients with LVEF≤40%. Furthermore, new strategies such as SGLT2 inhibitors and vericiguat provide further benefit for patients with decompensating HF. Studies with tafamidis report major clinical benefits specifically for patients with ATTR cardiac amyloidosis, a remaining underdiagnosed and undertreated disease. New evidence for medical interventions supports his bundle pacing to reduce QRS width and improve haemodynamics as well as ICD defibrillation for non-ischemic cardiomyopathy. The Mitraclip reduces hospitalisations and mortality in patients with symptomatic, secondary mitral regurgitation and ablation reduces mortality and hospitalisations in patients with paroxysmal and persistent atrial fibrillation. In end-stage HF, the 2018 French Heart Allocation policy should improve access to heart transplants for stable, ambulatory patients and, mechanical circulatory support should be considered to avoid deteriorating on the waiting list. In the community, new evidence supports that improving discharge education, treatment and patient support improves outcomes. The authors believe that this review fills the gap between the guidelines and clinical practice and provides practical recommendations to improve HF management.

Characteristics and prognosis of patients with acute heart failure without troponin determination: The EAHFE-TROPICA3 study

BACKGROUND

The absence of cardiac troponin (cTn) determination in an episode of acute heart failure (AHF) is frequent. The characteristics of these patients are not well known; nor is it known whether they have a better prognosis than patients in whom cTn is determined.

AIM

The objective of the EAHFE-TROPICA3 study was to analyse the characteristics of patients consulting for AHF in whom cTn was not determined (nocTn), and to evaluate the relationship of cTn determination (wcTn) with patient outcomes.

METHODS

This was an analysis of the multipurpose prospective EAHFE registry of patients with AHF consulting at the emergency departments of 34 Spanish hospitals.

RESULTS

Data from 8850 patients with AHF were analysed; cTn was not determined in 4216 of these patients (47.6%), who had a lower prevalence of ischaemic heart disease, more frequent use of loop diuretics at baseline, a greater rate of oedema in the acute episode, more frequent history of heart failure, and less use of angiotensin-converting enzyme inhibitors or aldosterone receptor antagonists and beta-blockers at baseline. Compared with the wcTn group, the nocTn group had the same in-hospital mortality (adjusted odds ratio [OR] 1.21, 95% confidence interval [CI] 0.98-1.50), mortality at 30 days (adjusted OR 1.07, 95% CI 0.90-1.28) and reconsultation at 30 days (adjusted OR 0.90, 95% CI 0.80-1.02).

CONCLUSIONS

Patients presenting with AHF with and without cTn determination have different characteristics. These differences are not related to a better prognosis.

Dynamic iron status after acute heart failure

BACKGROUND

Iron deficiency (ID) is common in heart failure (HF), and is associated with unfavourable clinical outcomes. Although it is recommended to screen for ID in HF, there is no clear consensus on the optimal timing of its assessment.

AIM

To analyse changes in iron status during a short-term follow-up in patients admitted for acute HF.

METHODS

Iron status (serum ferritin concentration and transferrin saturation) was determined in 110 consecutive patients (median age: 81 years) admitted to a referral centre for acute HF, at three timepoints (admission, discharge and 1 month after discharge). ID was defined according to the guidelines.

RESULTS

The prevalence rates of ID at admission, discharge and 1 month were, respectively, 75% (95% confidence interval [CI] 67-83%), 61% (95% CI: 52-70%), and 70% (95% CI: 61-79%) (P=0.008). Changes in prevalence were significant between admission and discharge (P=0.0018). Despite a similar ID prevalence at admission and 1 month (P=0.34), iron status changed in 25% of patients. Between admission and discharge, variation in C-reactive protein correlated significantly with that of ferritin (ρ=0.30; P=0.001). Advanced age, anaemia, low ferritin concentration and low creatinine clearance were associated with the persistence of ID from admission to 1 month.

CONCLUSIONS

Iron status is dynamic in patients admitted for acute HF. Although ID was as frequent at admission as at 1 month after discharge, iron status varied in 25% of patients.

Mechanical circulatory support in patients with cardiogenic shock in intensive care units: A position paper of the "Unité de Soins Intensifs de Cardiologie" group of the French Society of Cardiology, endorsed by the "Groupe Athérome et Cardiologie Interventionnelle" of the French Society of Cardiology

Cardiogenic shock (CS) is a major challenge in contemporary cardiology. Despite a better understanding of the pathophysiology of CS, its management has only improved slightly. The prevalence of CS has remained stable over the past decade, but its outcome has seen few improvements, with the 1-month mortality rate still in the range of 40-60%. Inotropes and vasopressors are the first-line therapies for CS, but they are associated with significant hazards, and have well-known deleterious effects. Furthermore, a significant number of patients develop refractory CS with haemodynamic instability, causing critical organ hypoperfusion and/or pulmonary congestion, despite increasing doses of catecholamines. A major change has resulted from the recent advent and availability of potent mechanical circulatory support (MCS) devices. These devices, which ensure sustained blood flow, provide a great and long-awaited opportunity to improve the prognosis of CS. Several efficient MCS devices are now available, including left ventricle-to-aorta circulatory support devices and full pulmonary and circulatory support with venoarterial extracorporeal membrane oxygenation. However, evidence to support their indications, the timing of implantation and the selection of patients and devices is scarce. Because these devices are gaining momentum and are becoming readily available, the "Unité de Soins Intensifs de Cardiologie" group of the French Society of Cardiology aims to propose practical algorithms for the use of these devices, to help intensive care unit and cardiac care unit physicians in this complex area, where evidence is limited.

Impact of the time-to-treatment concept on the outcome of acute heart failure: A pilot study

BACKGROUND

An optimal maximum time of 60minutes has been recommended in recent guidelines for the first evaluation and treatment of patients with acute heart failure (AHF); however, this has not been tested prospectively.

AIM

To analyze the impact of a time-to-treatment (TTT) strategy of <60minutes on the in-hospital outcome of patients with AHF.

METHODS

During a single 1-month period, we consecutively enrolled all patients hospitalized with AHF in a prospective cohort. In this pilot study, TTT was defined as the time between the first medical contact to the onset of the first medical intervention. The primary outcome was a composite including in-hospital death or worsening AHF.

RESULTS

Of the 74 patients included, 23 (31%) had a TTT of <60minutes. Although these patients were more likely to have a more severe episode of AHF, the primary outcome occurred only in patients with a TTT of ≥60minutes. The primary outcome was significantly associated with a TTT of ≥60minutes (P=0.036), low systolic blood pressure (P<0.01), rales more than halfway up the lung fields (P=0.02), infectious precipitating factor (P=0.04) and high serum concentrations of B-type natriuretic peptide (P<0.01) and urea (P=0.03). No significant differences were observed in the rate of treatment-induced acute renal insufficiency or in the long-term rates of death or rehospitalization for heart failure according to TTT.

CONCLUSIONS

This study suggests that the recently recommended TTT strategy of <60minutes in the setting of AHF might be associated with a better prognosis during hospitalization. Further large prospective works are needed to confirm these preliminary results, and to define more precisely which types of AHF could benefit from this strategy.

[Usefulness of natriuretic peptide testing and Doppler echocardiography at bedside in the diagnosis of acute heart failure]

Acute heart failure is a common condition that leads to hospital admission, with important mortality and readmission rates. A prompt and accurate diagnosis of this condition by hospitalists is essential for an early and tailored medical management. The use of natriuretic peptide testing (BNP and NT-proBNP) through a two cut-point strategy is currently recommended as the first-line diagnostic complement to the initial clinical evaluation in the acute care setting. Transthoracic Doppler echocardiography is an other noninvasive method that can be used at bedside, especially in patients with intermediate, inconclusive natriuretic peptides levels. In this regard, left ventricular ejection fraction and several simple Doppler indexes (restrictive mitral filling pattern, spectral tissue Doppler E/e' ratio), have been validated in the emergency diagnosis of acute heart failure. The aim of the present review is to overview the respective contribution of natriuretic peptides and Doppler echocardiography at bedside to the diagnosis of acute heart failure in the acute care setting.

[Optimization of the management of acute heart failure. New concept of fast-track]

The acute heart failure generates a very important number of hospitalizations for a high cost. A recent reflection on optimizing its management is ongoing, based on the fastest management in the emergency department, with a distinction between which patient should remain and who returns at home, and under what conditions, allowing to limit the number of hospitalizations. It will require a reorganization of emergency department and updating of decision algorithms and new guidelines of care.

Prehospital and in-hospital course of care for patients with acute heart failure: Features and impact on prognosis in "real life"

BACKGROUND

Acute heart failure (AHF) is a life-threatening medical emergency for which no new effective therapies have emerged in recent decades. No previous study has exhaustively described the entire course of care of AHF patients from first medical contact to hospital discharge or assessed its impact on prognosis.

AIM

To fully describe the course of care and analyze its influence on outcomes in patients hospitalized with an AHF syndrome in an academic university center.

METHODS

One hundred and nineteen adults with AHF from three public academic university hospitals were consecutively enrolled in a multicenter prospective observational cohort study. All of the emergency departments, intensive care units, coronary care units, cardiology wards and other medical wards participated in the study.

RESULTS

The composite primary outcome (6-month rate of cardiovascular death, readmission for acute heart failure, acute coronary syndrome or stroke) occurred in 59% of patients. This rate was high and similar regardless of first medical contact, type of transport, first medical department of admission and number of medical departments involved in the course of care. A cardiologist was involved in management in 80% of cases. The global median hospital stay was shorter with cardiology vs non-cardiology management (7 days [interquartile range 4-11] vs 10 days [interquartile range 7-18]; P=0.003). History of hypertension (P=0.004), need for non-invasive ventilation (P=0.023) and Lee prognostic score (P=0.028) were independently associated with the primary outcome.

CONCLUSIONS

Morbimortality and readmissions were high regardless of the course of care in patients admitted for AHF in real life. The reduction in hospital stay when cardiologists were involved in management encourages the creation of "mobile AHF cardiology teams".

Temporal trends in nitrate utilization for acute heart failure in elderly emergency patients: A single-centre observational study

BACKGROUND

We previously conducted a pilot study that reported the safety of isosorbide dinitrate boluses for elderly emergency patients with acute heart failure syndrome.

AIMS

To assess the temporal trend in the rate of elderly patients treated with isosorbide dinitrate, and to evaluate subsequent outcome differences.

METHODS

This was a single-centre study. We compared patients aged>75 years who attended the emergency department with a primary diagnosis of acute pulmonary oedema in the years 2007 and 2014. The primary endpoint was the rate of patients who received isosorbide dinitrate boluses in the emergency department. Secondary endpoints included in-hospital mortality, need for intensive care and length of stay.

RESULTS

We analysed 368 charts, 232 from patients included in 2014 (63%) and 136 in 2007 (37%). The mean age was 85±6 years in both groups. There was a significant rise in the rate of patients treated with isosorbide dinitrate between 2007 and 2014: 97 patients (42%) in 2014 vs. 24 patients (18%) in 2007 (P<0.01). Comparing the two periods, we report similar in-hospital mortality rates (8% vs. 11%; P=0.5), rates of admission to the intensive care unit (13% vs. 17%; P=0.3) and lengths of stay (10 days in both groups).

CONCLUSION

We observed a significant rise in the rate of elderly patients treated with isosorbide dinitrate boluses for acute heart failure. However, we did not observe any significant improvement in outcomes.

Management of acute heart failure in elderly patients

Acute heart failure (AHF) is the most common cause of unplanned hospital admissions, and is associated with high mortality rates. Over the next few decades, the combination of improved cardiovascular disease survival and progressive ageing of the population will further increase the prevalence of AHF in developed countries. New recommendations on the management of AHF have been published recently, but as elderly patients are under-represented in clinical trials, and scientific evidence is often lacking, the diagnosis and management of AHF in this population is challenging. The clinical presentation of AHF, especially in patients aged>85years, differs substantially from that in younger patients, with unspecific symptoms, such as fatigue and confusion, often overriding dyspnoea. Older patients also have a different risk profile compared with younger patients: often heart failure with preserved ejection fraction, and infection as the most frequent precipitating factor of AHF. Moreover, co-morbidities, disability and frailty are common, and increase morbidity, recovery time, readmission rates and mortality; their presence should be detected during a geriatric assessment. Diagnostics and treatment for AHF should be tailored according to cardiopulmonary and geriatric status, giving special attention to the patient's preferences for care. Whereas many elderly AHF patients may be managed similarly to younger patients, different strategies should be applied in the presence of relevant co-morbidities, disability and frailty. The option of palliative care should be considered at an early stage, to avoid unnecessary and harmful diagnostics and treatments.

[High pressure trap]

Pheochromocytoma is a rare tumor potentially life-threatening and associated with non specific and diverse symptomatology. Cardiac symptoms may mislead diagnosis; they could manifest as myocardial sideration concomitant to a hypertensive peak or supraventricular arythmia. We report a case of pheochromocytoma associated with hypokaliemia revealed by a myocardial ischemia with acute cardiac failure and severe left ventricular depression and complete reversal after surgery.

Prognostic markers of acute decompensated heart failure: the emerging roles of cardiac biomarkers and prognostic scores

Rapidly assessing outcome in patients with acute decompensated heart failure is important but prognostic factors may differ from those used routinely for stable chronic heart failure. Multiple plasma biomarkers, besides the classic natriuretic peptides, have recently emerged as potential prognosticators. Furthermore, prognostic scores that combine clinical and biochemical data may also be useful. However, compared with the scores used in chronic heart failure, scores for acute decompensated heart failure have not been validated. This article reviews potential biomarkers, with a special focus on biochemical biomarkers, and possible prognostic scores that could be used by the clinician when assessing outcome in patients with acute heart failure.

Be careful about abdominal discomfort in adult patients with muscular dystrophy

Muscular dystrophies are genetic muscular disease with disability. Heart failure is a classical complication mainly in Duchenne muscular dystrophy (DMD). We report 2 cases of severe acute heart failure revealed by abdominal discomfort in a patient with DMD and in a patient with gamma-sarcoglycanopathy.