Acute Heart Failure Syndromes Research Articles

Potential association between fentanyl, propofolinduced acute heart failure and Kounis syndrome: A case report and review of the literature

Potential association between fentanyl, propofolinduced acute heart failure and Kounis syndrome: A case report and review of the literature

C25 TEMPORAL TREND MORTALITY AND IN–HOSPITAL MORTALITY PREDICTORS IN AN ISCHEMIC CARDIOGENIC SHOCK POPULATION: A 10 YEARS SINGLE–CENTRE RETROSPECTIVE STUDY

Abstract Background Cardiogenic shock (CS) after acute myocardial infarction (AMI) represents the most severe form of acute heart failure (AHF) syndromes with an high rate of in–hospital mortality. Purpose describe predictors of in–hospital mortality; evaluate ten years mortality temporal trend in our CICU; assess the feasibility of CARDSHOCK risk score; elaborate a simpler version of CARDSHOCK risk score. Methods All consecutive patients with CS after AMI admitted at our CICU from March 2012 to July 2021 were included in this single–centre retrospective study. Results We included 167 patients [males 67%; age 71 years] with ischemic CS. Patients had severe LV dysfunction in 66%. Baseline serum lactate was 5,2 mmol/L. All patients required inotropes: 71% required dopamine, 65% noradrenaline, 32% dobutamine; 32% adrenalina,17,4% received levosimendan alone. Mechanical cardiac support (MCS) was pursued in 91,1% [65% IABP, 23% Impella CP, 4% VA–ECMO]. From March 2012 to July 2021 we observed a significative temporal trend mortality reduction (p=0.0015) from 57% of first time–quartile to 29% of the fourth quartile (fig1). In addition we noted a significant increase in Impella catheter use (p=0,0005) with a consequent reduction of IABP (p=0,01), a reduction in dopamine administration (p=0,007) and a greater use of inotropic drugs with vasodilatory action (p=0,015 and p=0,001). In our population of AMI–CS patients CARDSHOCK risk score was a reliable in–hospital mortality predictor tool (p=0.00011). After the multivariate analysis only EF at baseline (p=0,009), lactate level at presentation (p=0,015) and presence of three–vessels CAD (p=0,0038) resulted to be in–hospital mortality predictors. A new prediction model composed by those three variables was created and it exhibited better predictive performance for in–hospital mortality than Cardshock risk score (AUC 0,94 vs 0,72 respectively, p=0,015) (fig2). Conclusions In our retrospective single–centre study a significant reduction of mortality through the years is observed, probably due to more extensive use of micro axial pumps and a greater use of inodilators drug therapies. Cardshock risk score represents a feasible tool to predict in–hospital mortality also in our sample composed only of ischemic CS patients. A new prediction model composed by three clinical variables demonstrates at least the same predictive performance but future validation in a larger population could be advisable to validate the simplified score.

Successful Resuscitation of Neonatal Kittens Delivered by a Perimortem Cesarean Section Following Maternal Cardiopulmonary Arrest.

A 9 yr old, unknown weight, intact female domestic shorthair presented for evaluation of dystocia with dyspnea. En route to the hospital for treatment, the owners noted the queen stopped breathing. On presentation, cardiopulmonary arrest was confirmed. The exact cause was unknown but suspected to be secondary to acute fulminant congestive heart failure or acute respiratory distress syndrome due to a large volume of serosanguineous fluid within the mouth and nose. Cardiopulmonary resuscitation (CPR) was immediately started. After 2 min of CPR without return of spontaneous circulation, the owners consented to perimortem Cesarean section. Two kittens were removed via emergency hysterotomy within 3-4 min. Both kittens were successfully resuscitated. CPR efforts were continued on the queen for 2 min after delivery of the kittens, at which time the owners elected to stop further resuscitative efforts. Both kittens were discharged from the hospital and were alive at last follow-up, 2 yr and 4 mo after birth. There are no previous reports regarding the use of a perimortem Cesarean section to deliver neonates in small animal medicine. Therefore, this report represents a novel treatment approach that can be considered in the case of maternal arrest during dystocia.

Kidney function changes in acute heart failure: a practical approach to interpretation and management.

Worsening kidney function (WKF) is common in patients with acute heart failure (AHF) syndromes. Although WKF has traditionally been associated with worse outcomes on a population level, serum creatinine concentrations vary greatly during episodes of worsening heart failure, with substantial individual heterogeneity in terms of their clinical meaning. Consequently, interpreting such changes within the appropriate clinical context is essential to unravel the pathophysiology of kidney function changes and appropriately interpret their clinical meaning. This article aims to provide a critical overview of WKF in AHF, aiming to provide physicians with some tips and tricks to appropriately interpret kidney function changes in the context of AHF.

Use of VA-ECMO successfully rescued a trauma patient with fat embolism syndrome complicated with acute heart failure and acute respiratory distress syndrome

Use of VA-ECMO successfully rescued a trauma patient with fat embolism syndrome complicated with acute heart failure and acute respiratory distress syndrome

Telemedicine Consult for Shortness of Breath Due to Sympathetic Crashing Acute Pulmonary Edema.

This simulation is appropriate for senior and junior emergency medicine residents. Shortness of breath is a very common presentation in the emergency department and can range from mild to severe as well as a chronic or acute onset. In sympathetic crashing acute pulmonary edema (SCAPE), patients typically present with acute onset of dyspnea occurring within minutes to hours and have significantly elevated blood pressure.1 The condition of SCAPE falls into the spectrum of acute heart failure syndromes such as fluid overload pulmonary edema and congestive heart failure exacerbation.1. At the completion of the simulation and debriefing, the learner will be able to: 1) recognize the physical exam findings and presentation of SCAPE, 2) utilize imaging and laboratory results to further aid in the diagnosis of SCAPE, 3) initiate treatments necessary for the stabilization of SCAPE, 4) demonstrate the ability to assist with the stabilization and disposition of a patient via tele-medicine as determined by the critical action checklist and assessment tool below, 5) interpret the electrocardiogram (EKG) as atrial fibrillation with rapid ventricular response (AFRVR), and 6) recognize that SCAPE is the underlying cause of AFRVR and continue to treat the former. This simulation was performed using a high-fidelity mannequin. In order to simulate the telemedicine aspect, the learner evaluated the patient using a video conferencing interface while the two confederates were present with the high-fidelity mannequin. A debriefing session was held immediately after the simulation. The educational content was evaluated by debriefing and verbal feedback provided immediately after the case. Additionally, a survey was emailed to participants and observers of the case to provide qualitative feedback. Post-simulation feedback was overall positive with participants and observers. Participants and observers felt this was a safe and realistic simulation of SCAPE and provided them with the opportunity to practice rapid recognition and treatment of this condition. Sympathetic crashing acute pulmonary edema falls into the spectrum of acute heart failure disorders, and rapid recognition and stabilization is vital for the patient's survival. This simulation case provided learners of all levels the chance to assess and treat a life-threatening condition with limited information in a safe and effective learning environment. The telemedicine component was used while conducting weekly didactics via zoom during the COVID-19 pandemic. Simulation is a large component of our didactic curriculum and implementing the telemedicine component into this case was worth the effort. It is important to familiarize our residents with telemedicine since we expect that it will become a larger part of the practice of emergency medicine in the future, allowing board-certified emergency medicine physicians to assist in providing care in rural emergency departments and smaller hospitals that may be staffed with less experienced providers. Medical simulation, tele-medicine, pulmonary edema, respiratory distress, cardiac emergencies, resuscitation.

438 INCIDENT HYPOCHLOREMIA AMONG PATIENTS WITH TAKOTSUBO SYNDROME: SHORT- AND LONG-TERM OUTCOME. RESULTS FROM A MULTICENTER PROSPECTIVE REGISTRY.

Abstract Background Takotsubo syndrome (TTS) is an acute heart failure syndrome featured by a reversible left ventricular systolic dysfunction with significant rate of in- and out-of-hospital mayor cardiac adverse events (MACE). Aim of the study To evaluate the possible role of hypochloremia as prognostic marker at short- and long-term follow-up in subjects with TTS. Methods 305 consecutive patients were enrolled in a multicenter international registry. Clinical, laboratory and echocardiographic evaluations were performed at admission and during hospitalization. Incident hypochloremia (serum chloride level below 97 mEq/l) during hospitalization was recorded. In-hospital MACE, short- and long-term mortality was recorded. Results Mean admission serum chloride levels were 102±5 mEq/l. 97 out of 305 (37%) patients experienced incident hypochloremia. Patients with incident hypochloremia were older (78±10 vs 73±12 years, p=0.01), had lower admission LVEF (34±8% vs 37±8%, p=0.009), and longer hospital stay (9±4 vs 7±4 days, p=0.0003). During hospitalization patients with incident hypochloremia had higher rates of complication (45% vs 32%, p=0.01), lower levels of natremia and azotemia at admission and discharge. At long term follow-up incident hypochloremia was associated with increased risk of MACE (49% vs 32%, p=0.005) and death (42% vs 24%, p=0.002, log rank p<0.01). Conclusion Incident hypochloremia is a common finding among hospitalized patients with TTS, associated with higher risk of in-hospital events and long-term MACE and death.

391 NEUROLOGICAL DISORDERS AND TAKOTSUBO SYNDROME: CLINICAL FEATURES AND OUTCOMES. RESULTS FROM A MULTICENTER PROSPECTIVE EUROPEAN REGISTRY OF 2300 PATIENTS.

Abstract Background and aims Takotsubo syndrome (TTS) is an acute heart failure syndrome featured by a reversible left ventricular systolic dysfunction. However, few data have been reported about prevalence of non-cardiovascular comorbidities as chronic neurological disorders in TTS patients. Aim of this study was to compare clinical features, short- and long-term outcome among TTS patients with history of neurological disorder. Methods 2301 patients with TTS were enrolled in a multicenter prospective European registry from July 2002 to November 2021. Clinical features, in- and out-of-hospital MACE, laboratory and imaging data were collected and a long-term follow-up was performed. Results Prevalence of history of neurological disorder was 17% (n= 400 pts). Most represented neurological conditions were previous cerebrovascular disorders (ischemic stroke and transient ischemic attack, 36.2%), followed by neurodegenerative disorders (30.7%, including cognitive disorders and motion disorders), tensive migraine (10%) and epilepsy (9.5%). Neurological Patients developed TTS more frequently after a physical trigger (46.2% vs 33.8%, p<0.01). Sepsis (10%), acute neurological trigger (9.5%) and extreme activity/trauma (8.5%) where the type of physical trigger more prevalent. During hospitalization neurological patients had longer in-hospital stay (10±11 days vs 8±8 days, p<0.01) and experienced more often in-hospital complications (27% vs 16%, p=0.0001) mainly driven by cardiogenic shock and in-hospital death (12% vs 7.6%; 6.5% vs 2.8%, respectively p<0.01). Long-term mortality was higher in patients with history of neurological disorders (23.5% vs 10%, p<0.01), with a mean follow up of 2.5 ± 5.8 years. Conclusions Patients with history of neurological disorders and TTS have different clinical features and worse prognosis with higher short-term and long-term mortality.

Rationale and design of BROKEN-SWEDEHEART: a registry-based, randomized, parallel, open-label multicenter trial to test pharmacological treatments for broken heart (takotsubo) syndrome

Takotsubo syndrome (TS) is a life-threatening acute heart failure syndrome without any evidence-based treatment options. No treatment for TS has been examined in a randomized trial. BROKEN-SWEDEHEART is a multicenter, randomized, open-label, registry-based 2×2 factorial clinical trial in patients with TS designed to test whether treatment with adenosine and dipyridamole accelerates cardiac recovery and improves clinical outcomes compared to standard care (study 1); and apixaban reduces the risk of thromboembolic events compared to no treatment with antithrombotic drugs (study 2). The trial will enroll 1,000 patients. Study 1 (adenosine hypothesis) will evaluate 2 coprimary end points: (1) wall motion score index at 48 to 96 hours (evaluated in the first 200 patients); and (2) the composite of death, cardiac arrest, need for mechanical assist device or heart failure hospitalization within 30 days or left ventricular ejection fraction <50% at 48 to 96 hours (evaluated in 1,000 patients). The primary end point in study 2 (apixaban hypothesis) is the composite of death or thromboembolic events within 30 days or the presence of intraventricular thrombus on echocardiography at 48 to 96 hours. BROKEN-SWEDEHEART will be the first prospective randomized multicenter trial in patients with TS. It is designed as 2 parallel studies to evaluate whether adenosine accelerates cardiac recovery and improves cardiac function in the acute phase and the efficacy of anticoagulation therapy for preventing thromboembolic complications in TS. If either of its component studies is successful, the trial will provide the first evidence-based treatment recommendation in TS. The trial has been approved by the Swedish Medicinal Product Agency and the Swedish Ethical Board and is registered at ClinicalTrials.gov (NCT04666454).

Readmission in patients undergoing percutaneous patent foramen ovale closure in the United States

Current estimates suggest that a patent foramen ovale (PFO) may exist in up to 25% of the general population and is a potential risk factor for embolic, ischemic stroke. PFO closure complications include bleeding, need for procedure-related surgical intervention, pulmonary emboli, device malpositioning, new onset atrial arrhythmias, and transient atrioventricular block. Rates of PFO closure complications at a national level in the Unites States remain unknown. To address this, we performed a contemporary nationwide study using the 2016 and 2017 Nationwide Readmissions Database (NRD) to identify patterns of readmissions after percutaneous PFO closure. In conclusion, our study showed that following PFO closure, the most common complications were atrial fibrillation/atrial flutter followed by acute heart failure syndrome, supraventricular tachycardia and acute myocardial infarction.

Orexin/hypocretin system dysfunction in patients with Takotsubo syndrome: A novel pathophysiological explanation.

Takotsubo syndrome (TTS) is an acute heart failure syndrome. Emotional or physical stressors are believed to precipitate TTS, while the pathophysiological mechanism is not yet completely understood. During the coronavirus disease (COVID-19) pandemic, an increased incidence of TTS has been reported in some countries; however, the precise pathophysiological mechanism for developing TTS with acute COVID-19 infection is unknown. Nevertheless, observing the symptoms of COVID-19 might lead to new perspectives in understanding TTS pathophysiology, as some of the symptoms of the COVID-19 infection could be assessed in the context of an orexin/hypocretin-system dysfunction. Orexin/hypocretin is a cardiorespiratory neuromodulator that acts on two orexin receptors widely distributed in the brain and peripheral tissues. In COVID-19 patients, autoantibodies against one of these orexin receptors have been reported. Orexin-system dysfunction affects a variety of systems in an organism. Here, we review the influence of orexin-system dysfunction on the cardiovascular system to propose its connection with TTS. We propose that orexin-system dysfunction is a potential novel explanation for the pathophysiology of TTS due to direct or indirect dynamics of orexin signaling, which could influence cardiac contractility. This is in line with the conceptualization of TTS as a cardiovascular syndrome rather than merely a cardiac abnormality or cardiomyopathy. To the best of our knowledge, this is the first publication to present a plausible connection between TTS and orexin-system dysfunction. We hope that this novel hypothesis will inspire comprehensive studies regarding orexin's role in TTS pathophysiology. Furthermore, confirmation of this plausible pathophysiological mechanism could contribute to the development of orexin-based therapeutics in the treatment and prevention of TTS.

Das Takotsubo-Syndrom

TTS is an acute heart failure syndrome that usually affects postmenopausal women. The Syndrome is often preceded by an emotional or physical trigger. TTS strongly resembles acute myocardial infarction from a clinical standpoint and also exhibits ECG changes in the same proportion. There are specific patterns of wall motion abnormalities, based on which, the syndrome can be divided into four types. Neurological and/or psychiatric comorbidities are common in TTS patients. Therapy is based on the hemodynamic state and the presence of left ventricular outflow tract obstruction or cardiogenic shock. TTS has a comparable mortality to acute myocardial infarction. Pathophysiologically, the activation of the brain-heart axis with acute catecholamine storm seems to inherit a central role.

Glycocalyx Disruption Triggers Human Monocyte Activation in Acute Heart Failure Syndromes.

Acute heart failure (AHF) syndromes manifest increased inflammation and vascular dysfunction; however, mechanisms that integrate the two in AHF remain largely unknown. The glycocalyx (GAC) is a sugar-based shell that envelops all mammalian cells. Much GAC research has focused on its role in vascular responses, with comparatively little known about how the GAC regulates immune cell function. In this study, we sought to determine if GAC degradation products are elevated in AHF patients, how these degradation products relate to circulating inflammatory mediators, and whether the monocyte GAC (mGAC) itself modulates monocyte activation. Inflammatory markers and GAC degradation products were profiled using ELISAs. Flow cytometry was used to assess the mGAC and RNA-seq was employed to understand the role of the mGAC in regulating inflammatory activation programs. In a cohort of hospitalized AHF patients (n = 17), we found that (1) the GAC degradation product heparan sulfate (HS) was elevated compared with age-matched controls (4396 and 2903ng/mL; p = 0.01) and that (2) HS and soluble CD14 (a marker of monocyte activation) levels were closely related (Pearson's r = 0.65; p = 0.002). Mechanistically, Toll-like receptor (TLR) activation of human monocytes results in GAC remodeling and a decrease in the mGAC (71% compared with no treatment; p = 0.0007). Additionally, we found that ex vivo enzymatic removal of HS and disruption of the mGAC triggers human monocyte activation and amplifies monocyte inflammatory responses. Specifically, using RNA-seq, we found that enzymatic degradation of the mGAC increases transcription of inflammatory (IL6, CCL3) and vascular (tissue factor/F3) mediators. These studies indicate that the mGAC is dynamically remodeled during monocyte activation and that mGAC remodeling itself may contribute to the heightened inflammation associated with AHF.

Molecular Mechanisms of Takotsubo Syndrome.

Takotsubo syndrome (TTS) is a severe but reversible acute heart failure syndrome that occurs following high catecholaminergic stress. TTS patients are similar to those with acute coronary syndrome, with chest pain, dyspnoea and ST segment changes on electrocardiogram, but are characterised by apical akinesia of the left ventricle, with basal hyperkinesia in the absence of culprit coronary artery stenosis. The pathophysiology of TTS is not completely understood and there is a paucity of evidence to guide treatment. The mechanisms of TTS are thought to involve catecholaminergic myocardial stunning, microvascular dysfunction, increased inflammation and changes in cardiomyocyte metabolism. Here, we summarise the available literature to focus on the molecular basis for the pathophysiology of TTS to advance the understanding of the condition.

The new 2022 ESC Guidelines on Cardio-oncology and their impact on the Acute Cardiovascular Care Society.

In this perspective piece on the recently published ESC Guidelines on Cardio-oncology and the Consensus Statements from the Acute Cardiovascular Care Association, we summarize key learning points regarding the management of acute cardiovascular disease in patients with cancer. This document outlines where other pre-existing ESC Guidelines can be applied to the management of acute cardiovascular disease in patients with cancer while simultaneously highlighting important gaps in knowledge that require further research. Cancer and cardiovascular disease share common risk factors and often co-exist, especially in older patients. In addition, patients with cancer undergoing active treatment are exposed to multiple, potentially cardiotoxic drugs, which may manifest as a variety of cardiovascular events, including left-ventricular systolic dysfunction and heart failure, arrhythmias, hypertension, or acute venous and arterial vascular events. Knowledge about potential causative cancer therapeutics is necessary for rapid recognition and management to improve cardiovascular outcomes and guide ongoing cancer treatment. Specifically, the importance of rapidly interrupting culprit cancer drugs is highlighted, as well as instituting standard guideline-based therapies for conditions such as acute heart failure and acute coronary syndromes [ST-elevation myocardial infarction and high-risk non-ST-elevation acute coronary syndrome (ACS)]. Given the high prevalence of thrombocytopenia and increased bleeding risk in patients with cancer, we are provided with platelet cut-offs for the use of different antiplatelet agents and anticoagulants for patients with ACS and atrial arrhythmias. In contrast, given the hypercoagulable milieu of cancer, we are provided information regarding types of anticoagulants, drug-drug interactions, and duration of anticoagulation in patients with acute venous thromboembolism, as well as for atrial fibrillation. They also discuss the diagnostic and treatment strategies for the unique cardiotoxicities seen with novel cancer therapeutics such as immune checkpoint inhibitors and chimeric receptor antigen T-cell therapy. Last, but not least, the authors emphasize that the care of these patients requires close collaboration between cardiology and oncology to maximize both cardiovascular and cancer outcomes.

Vasodilators for acute heart failure-A protocol for a systematic review of randomized clinical trials with meta-analysis and Trial Sequential Analysis.

BackgroundAbove one million annual hospitalizations occur with a primary diagnosis of acute heart failure in the US, with comparable numbers in Europe. Within 1 year, over a third of patients have died or been re‐hospitalized. Most patients have acutely elevated systemic and/or intra‐cardiac blood pressures as part of the acute heart failure syndrome. Most clinical trials of acute heart failure have aimed at reducing preload and/or afterload through drug‐induced vasodilation. However, recent European guidelines downgraded the treatment recommendation of vasodilators. We aim to assess the beneficial and harmful effects of vasodilators in the treatment of acute heart failure.MethodsThis protocol for a systematic review was undertaken using the recommendations of The Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis Protocols. We plan to include all randomized clinical trials assessing the use of vasodilators in the treatment of AHF. The systematic review will be conducted based on a systematic search of relevant major medical databases without date restrictions, including MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) in addition to clinical trial registries. We will begin the searches in August 2022. All included trials will be assessed and classified at low risk of bias or at high risk of bias. Our conclusions will be based on the results from the primary outcomes with concomitant low risk of bias. Extracted data will be analyzed using Trial Sequential Analysis 0.9.5.10, Review Manager 5.3, and SAS. We will assess the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation. We will register this systematic review at Prospero and aim to update it when new trials are published.DiscussionThis protocol defines the detailed methodology and approach used for a systematic review on whether vasodilation for acute heart failure improves patient outcome. This systematic review will potentially aid clinicians in deciding the optimal treatment of patients admitted with acute heart failure. Furthermore, this review will explore gaps in our knowledge and thus guide future research within acute heart failure.

Rate of 30-day Readmission & Economic Burden of Patients with Acute Congestive Heart Failure with Co-existing Metabolic Syndrome

<h3>Lead Author's Financial Disclosures</h3> Nothing to disclose. <h3>Study Funding</h3> None. <h3>Background/Synopsis</h3> Heart failure (HF) and meta-bolic syndrome (MetS) are commonly co- exist. MetS are known to be one of the risk factors of HF, and it can also act as a comorbidity in HF. Mets is an independent risk factor for cardiovascular disease, however its impact on HF outcomes is incompletely understood. <h3>Objective/Purpose</h3> We sought to determine the 30-Day Readmission rate (30-DRr) of patients with Acute Congestive Heart Failure (aCHF) & Co-existing Metabolic Syndrome (MetS) & its impact on mortality, clinical outcomes & healthcare utilization in the United States. <h3>Methods</h3> Using the 2017 & 2018 National Readmission Database, we conducted a retrospective analysis of patient discharges with aCHF as a principal diagnosis & MetS as a secondary diagnosis according to ICD-10 codes. Readmission was defined as the first admission to any hospital for any non-trauma diagnosis within 30 days of the index admission. Same-day admissions & discharges were excluded. The primary outcome was 30DRr, while secondary outcomes were readmission mortality rate, most common diagnoses (MCD's) for readmission, & resource utilization defined by length of stay (LOS), Average & Total Patient Charge (TPC), & Average and Total Hospital Cost (THC). <h3>Results</h3> A total of 530 index hospitalization for aCHF with co-existing MetS. Index vs. Readmission Cohorts had a mean age of 62.2 years vs. 60.6 years, Males (51.6% vs. 61.1%). In- hospital mortality rate for index admission was 1.7%, while 30-DRr was 13.6% (Figure 1). Among this group of readmitted patients, in-hospital mortality rate was 2.2%, compared to index admission (2.2% vs. 1.7%, adjusted p-value=0.1). The total hospital days associated with readmission were 460 days, with a THC of $1,144,028 & TPC of $3,555,453. <h3>Conclusions</h3> In patients with aCHF & MetS, we observed a high readmission rate of ∼1 in 7 readmitted. There was subsequent higher mortality with the readmitted patient, but this was not statistically significant. Heart Failure, Acute Kidney Injury, Atrial Fibrillation, ASCVD were the most common reasons for readmission and were associated with a higher economic health care burden. A higher risk for hypertensive heart failure among MetS patients & a more significant proportion of patients with CKD & AF may indicate a higher risk for HFpEF. Comprehensive management involving a multidisciplinary team is necessary for managing patients with metabolic syndrome and heart failure to help alleviate the health care burden. Further research focusing on the HF subtypes among MetS & HF is needed to help understand specific patient populations at risk & thereby help alleviate the health care burden.

Neutrophil-Albumin Ratio as a Predictor of in-Hospital Mortality in Patients with Cardiogenic Shock

Intoduction: Cardiogenic shock (SK) is the most severe phase of the acute heart failure syndrome. One of the most widely studied inflammatory mediators in cardiogenic shock is neutrophils. Albumin has several functions, including in pressure regulation, plays a role as an antioxidant and anti-inflammatory agent. Several studies have shown the association of albumin levels with mortality in patients with cardiogenic shock.&#x0D; Purpose: This study aimed to evaluate the utilization of neutrophil-albumin ratio (NAR) in predicting in-hospital mortality in patients with cardiogenic shock (CS)&#x0D; Patients and methods: This study was an observational study with cross sectional design conducted at the Department of Cardiovascular, Harapan Kita Cardiovascular Hospital. The data were collected from the patient registry (January 2018 to April 2020). The study participants were all patients with cardiogenic shock admitted to our hospital. The endpoint was in-hospital mortality in CS patients. Predictors of hospital mortality were identified using multivariable logistic regression, followed by receiver operator characteristic (ROC) curve analysis and cut-off value for optimal NAR level.&#x0D; Results: A total of 130 patients hospitalized with CS were enrolled in this study, In-hospital mortality was found in 75 (57,7%) patients, among which 102 (78,5%) were male and 101 (77,7%) patients had acute coronary syndrome. There was a significant positive correlation between NAR levels and in-hospital mortality. The multivariate logistic regression showed that NAR was independently associated with increased risk of in-hospital mortality with odd ratio (OR) of 5,81, 95% confidence interval (CI) 2,303 - 14,692, P &lt;0,001. NAR had a prognostic value in predicting in-hospital mortality of CS based on ROC curve analysis (AUC 0,802), with an optimal NAR cut-off value of 25.&#x0D; Conclusion: NAR is independently associated with in-hospital mortality in patients with CS&#x0D; Keywords: Neutropil-albumin ratio, cardiogenic Shock, mortality predictor

Biomarkers in Acute Heart Failure Syndromes: An Update.

Heart failure is one of the leading healthcare problems in the world. Clinical data lacks sensitivity and specificity in the diagnosis of heart failure. Laboratory biomarkers are a non-invasive method of assessing suspected decompensated heart failure. Biomarkers such as natriuretic peptides have shown promising results in the management of heart failure. The literature does not provide comprehensive guidance in the utilization of biomarkers in the setting of acute heart failure syndrome. Many conditions that manifest with similar pathophysiology as acute heart failure syndrome may demonstrate positive biomarkers. The following is a review of biomarkers in heart failure, enlightening their role in diagnosis, prognosis and management of heart failure.

Sodium-glucose Co-transporter 2 Inhibitors in Acute Heart Failure: A Review of the Available Evidence and Practical Guidance on Clinical Use.

Sodium-glucose co-transporter 2 (SGLT2) inhibitors were initially conceived as glucose-lowering agents. However, striking renal and cardiovascular benefits were observed in type 2 diabetes trials. This led to evaluate it in dedicated studies in chronic heart failure (HF) and chronic kidney disease, which also showed remarkable clinical results. Given this findings, and taking into account the multiple mechanisms of action, the use of SGLT2 inhibitors in acute heart failure seemed promising. Sotagliflozin was the first SGLT2 inhibitor to reduce heart failure hospitalizations within the acute setting in the SOLOIST-WHF trial. Only type 2 diabetes patients were included, with a preserved and reduced ejection fraction. In slightly less than half of the cohort, this medication was started when the diuretic therapy was transitioned from intravenous to oral, during the hospital admission. In the rest of the patients, sotagliflozin was started early after discharge. Empagliflozin proved to be safe, well-tolerated, increased diuresis, and reduced a combined clinical endpoint (worsening HF, rehospitalization for HF, or death at 60 days) when administered within the first 24 hours of an acute heart failure hospitalization in the EMPA-RESPONSE-AHF trial. More recently, empagliflozin showed a reduction in a composite primary endpoint of death, heart failure events, and quality of life compared to placebo in the EMPULSE trial. Empagliflozin was started after the initial stabilization phase, but while patients were still admitted and receiving intravenous loop diuretics. Less than half of the patients were diabetic and two-thirds had a left ventricular ejection fraction below 40%. Dapagliflozin is currently being tested in the DAPA ACT HF-TIMI 68 trial, which plans to enroll 2400 patients admitted with acute heart failure and reduced ejection fraction. We envision SGLT2 inhibitors as a useful tool in acute heart failure syndrome given the additive diuretic effect, and minimal impact on blood pressure, kidney function, and electrolytes. Its dosage schedule is simple and can help initiation and tolerance of other medical therapy. However, there is an increased risk of genital infections and euglycaemic ketoacidosis. Notwithstanding, once critically ill and fasting patients are excluded, early administration of SGLT2 inhibitors is safe. This review summarizes the development of SGLT2 inhibitors and the available evidence supporting their use during an acute heart failure admission. We also propose a practical guideline for in-hospital initiation and monitoring.