Acute Heart Failure Syndromes Research Articles

Dose Response Relationship of RAS Blockers and Beta-Blockers in Patients with Acute Heart Failure Syndrome: A Nationwide Prospective Cohort Study, on Behalf of KorAHF Investigators

<h3>Purpose</h3> It remains unclear if patients with acute heart failure syndrome (AHFS) need to reach the maximally tolerated doses of renin-angiotensin system blockers (RASBs) or beta-blockers (BBs) to obtain a survival benefit. This study evaluated the dose-response relationship between RASBs or BBs and survival in AHFS patients. <h3>Methods</h3> In total, 5,331 patients in the Korean Acute Heart Failure registry were analyzed based on the doses of RASBs and BBs at discharge. Also, an additional analysis of 4,613 patients with dosage information at the first post-discharge follow-up visit was done. Survival curves were constructed using the Kaplan-Meier method and compared using the log-rank test, and independent predictors of mortality were identified with the multivariable Cox proportional hazards model. <h3>Results</h3> In patients hospitalized with AHFS, RASB use at discharge was associated with a significant reduction in the risk of all-cause mortality. This effect was dose dependent for heart failure with reduced ejection fraction (HFrEF) but did not attain statistical significance for heart failure with preserved ejection fraction (HFpEF). BB use at discharge was associated with a reduction in all-cause mortality in HFrEF but not for HFpEF patients, although this was not dose dependent. At the first post-discharge follow-up visit, a significantly higher risk of all-cause mortality was associated with the maintenance or withdrawal of RASBs compared to up-titration of dose in HFrEF patients. <h3>Conclusion</h3> Using RASBs or BBs at discharge was associated with improved survival. A dose-response relationship between RASB and all-cause mortality was evident in AHFS patients with a reduced ejection fraction but not BBs. It is important to initiate and up-titrate RASBs to the maximally tolerated dose in AHFS patients during the transition period, especially for patients with a reduced ejection fraction.

Takotsubo Syndrome Presenting with Syncope and Third-Degree Atrioventricular Block Requiring Permanent Pacemaker Implantation

Takotsubo syndrome (TS) is an acute but transient heart failure syndrome and it is very uncommon for TS to present with syncope and complete atrioventricular (AV) block. In this report, we discuss a case of TS complicated by a third-degree AV block presented to the emergency department with syncope and requiring permanent pacemaker implantation. A 53-year-old female was admitted to our emergency department with complaints of syncopal episodes and chest pain. Due to ongoing chest pain, electrocardiography (ECG) findings and segmentary wall motion abnormality on the transthoracic echocardiography (TTE), she was immediately transferred to the cardiac catheterization laboratory. Coronary angiogram revealed normal coronary arteries and left ventriculography demonstrated apical ballooning and hypokinesis of the apex. Once the diagnosis of TS was established, the patient was transferred to the coronary intensive care unit (CICU). Initial ECG at CICU demonstrated complete AV block with a heart rate of 35 beats/min. On the third day of hospitalization, repeat TTE showed improved left ventricular functions with an ejection fraction of 50%. During the follow-up period in CICU, complete AV block persisted and the rhythm did not return to normal sinus rhythm after six days of monitorization. An electrophysiological study demonstrated supra-hisian atrioventricular block and atrioventricular dissociation. On the seventh day of hospitalization, TTE demonstrated recovered ventricular functions with an ejection fraction of 65%, and a dual pacemaker was then implanted. Her third-month followup was uneventful and TTE showed normal left ventricular functions but pacemaker interrogation revealed 99% of ventricular pacing. This case report demonstrated that the decision to implant a permanent pacemaker in such patients should be considered on a case-by-case basis, and an electrophysiological study could be valuable on this decision.

The Prescription Characteristics, Efficacy and Safety of Spironolactone in Real-World Patients With Acute Heart Failure Syndrome: A Prospective Nationwide Cohort Study.

BackgroundRandomized clinical trials of spironolactone showed significant mortality reduction in patients with heart failure with reduced ejection fraction. However, its role in acute heart failure syndrome (AHFS) is largely unknown.AimTo investigate the prescription characteristics, efficacy and safety of spironolactone in real-world patients with AHFS.Methods5,136 AHFS patients who survived to hospital discharge using a nationwide prospective registry in Korea were analyzed. The primary efficacy outcome was 3-year all-cause mortality.ResultsSpironolactone was prescribed in 2,402 (46.8%) at discharge: <25 mg in 890 patients (37.1%), ≥25 mg, and <50 mg in 1,154 patients (48.0%), and ≥50 mg in 358 patients (14.9%). Patients treated with spironolactone had a lower proportion of chronic renal failure and renal replacement therapy during hospitalization and had lower serum creatinine level than those who did not. In overall patients, 3-year mortality was not different in both groups (35.9 vs. 34.5%, P = 0.279). The incidence of renal injury and hyperkalemia was 2.2% and 4.3%, respectively, at the first follow-up visit. The treatment effect of spironolactone on mortality was different across subpopulations according to LVEF. The use of spironolactone was associated with a significant reduction in 3-year morality in patients with LVEF ≤ 26% (33.8 vs. 44.3%, P < 0.001; adjusted HR 0.79, 95% CI 0.64–0.97, P = 0.023), but not in patients with LVEF > 26%.ConclusionsAlthough spironolactone was frequently used at lower doses in real-world practice, use of spironolactone significantly reduced 3-year mortality in patients with severely reduced LVEF with acceptable safety profile. However, our findings remain prone to various biases and further prospective randomized controlled studies are needed to confirm these findings.

GDF-15: a novel biomarker of heart failure predicts 30-day all-cause mortality and 30-day HF rehospitalization in patients with acute heart failure syndrome

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Ratchadapiseksomphotch Fund, Faculty of Medicine, Chulalongkorn University Background Growth Differentiation Factor-15 (GDF-15) is a distant member of the transforming growth factor-β (TGF-β) cytokine super family. The increased expression of GDF-15 has been observed during various cardiac diseases include heart failure (HF) and may associated with worse outcomes. However, the relationship is still not well understood, and evidences are not existed in Thai patients. Purpose To study association between biomarker (GDF-15, NT-proBNP and hs-Troponin T) at the time of admission and discharge in patient with AFHS and their association with 30-day all-cause mortality and 30-day heart failure rehospitalization Methods This is a prospective, single center study of patients admitted for acute HF syndrome regardless of ejection fraction between December 2018 to June 2019. GDF-15 were measured within 24 hours after admission and at the time of discharge. Patient characteristics, orthoedema congestion score, biomarkers, treatment and outcome including 30-day, all-cause mortality and rehospitalization were collected. Logistic regression analysis was used to evaluate the relationship between GDF-15 level and outcomes. Results Total of 103 patients were screened and 84 patients were enrolled (mean age of 69 ± 14 years, 52.4% females). Ischemic heart diseases were reported in 38.1% and 23.1% of patients had history of HF with reduced ejection fraction. The orthoedema congestion score at the time of admission and discharge were 2.29 ± 0.1 and 0.38 ± 0.8, respectively (score from 0 to 4, with lower scores are less congestion). The GDF-15 level was significantly decrease during admission (at the time of admission 9118 ± 6010 pg/mL, at time of discharge 7107 ± 4787 pg/mL, mean differences 1528 ± 4469; p = 0.006). The 30-day all-cause mortality was 5.95%. The 30-day rehospitalization occurred in 22 (26.1%) patients (13 HF rehospitalization and 9 non-HF rehospitalization). Univariate analysis showed that the admission GDF-15 level, but not troponin or NT-proBNP, was associated with 30-days all-cause mortality (p = 0.029) and multivariate analysis showed reduction in GDF-15 level from admission to discharge was associated with lower 30-days rehospitalization (p = 0.023). Conclusion In this single center study, the rate of mortality and rehospitalization is very high in patient discharge after acute HF hospitalization. the GDF-15 levels were elevated during acute HF and improving by the time of discharge. This novel biomarker may offer additional value in predicting the risk of outcomes in patient with acute HF.

Venous Thromboembolism in Patients with Heart Failure.

Heart failure (HF) and venous thromboembolism (VTE) are common clinical entities, closely interrelated, sharing multiple pathophysiological mechanisms. Their co-incidence is associated with further worsening of the prognosis of one another. Despite their frequent co-existence, important clinical questions still remain unanswered. The risk of VTE especially in chronic HF patients appears to vary widely in clinical studies, while the VTE-associated risk in HF patients is still not well determined and cannot be accurately predicted. Although scientific guidelines recommend venous thromboprophylaxis in patients hospitalized with an acute HF syndrome, venous thromboprophylaxis has not been studied adequately in prospective trials in ambulatory HF patients. In the present review, we aimed to summarize the current knowledge on the epidemiology of VTE and HF, the risk prediction for VTE occurrence in HF patients, the impact on patient outcome, and the need for anticoagulation in certain HF subgroups to improve prognosis, while we sought to identify gaps in knowledge that need to be addressed in the future.

A dose-response relationship of renin-angiotensin system blockers and beta-blockers in patients with acute heart failure syndrome: a nationwide prospective cohort study.

It remains unclear if patients with acute heart failure syndrome (AHFS) need to reach the maximally tolerated doses of renin-angiotensin system blockers (RASBs) or beta-blockers (BBs) to obtain a survival benefit. This study evaluated the dose-response relationship between RASBs or BBs and survival in AHFS patients. In total, 5331 patients in the Korean Acute Heart Failure registry were analysed based on the doses of RASBs and BBs at discharge. In AHFS patients, RASB use at discharge was associated with a significant reduction in all-cause mortality risk. This effect was dose-dependent for heart failure with reduced ejection fraction (HFrEF) but did not attain statistical significance for heart failure with preserved ejection fraction (HFpEF). BB use at discharge was associated with reduced all-cause mortality in HFrEF patients but not in HFpEF patients. In an additional analysis of 4613 patients with dosage information at the first post-discharge follow-up visit, a significantly higher mortality risk was associated with the maintenance or withdrawal of RASBs compared with up-titrating the dose in HFrEF patients. Using RASBs or BBs at discharge was associated with improved survival. A dose-response relationship between RASBs and all-cause mortality was evident in AHFS patients with a reduced ejection fraction but not BBs. It is important to initiate and up-titrate RASBs to the maximally tolerated dose in AHFS patients during the transition period, especially for patients with a reduced ejection fraction.

Nicardipine versus nitroglycerin for hypertensive acute heart failure syndrome: a single-center observational study.

Objective: Nitroglycerin is a first-line treatment for hypertensive acute heart failure syndrome (AHFS). However, nicardipine is frequently used to treat hypertensive emergencies, including AHFS. In this study, we compared the effectiveness of nicardipine and nitroglycerin in patients with hypertensive AHFS.Patients and Methods: This single-center, retrospective, observational study was conducted at the intensive care unit of a Japanese hospital. Patients diagnosed with AHFS and systolic blood pressure 140 mmHg on arrival between April 2013 and March 2021 were included. The outcomes were the time to optimal blood pressure control, duration of continuous infusion of antihypertensive agents, duration of positive pressure ventilation, need for additional antihypertensive agents, length of hospital stay, and body weight changes. Outcomes were compared between the nicardipine and nitroglycerin groups. We also compared these outcomes between the groups after excluding patients who received renal replacement therapy.Results: Fifty-eight patients were enrolled (26 and 32 patients were treated with nitroglycerin and nicardipine, respectively). The nicardipine group had a shorter time to optimal blood pressure control (2.0 [interquartile range, 2.0–8.5] h vs. 1.0 [0.5–2.0] h), shorter duration of continuous anti-hypertensive agent infusion (3.0 [2.0–5.0] days vs. 2.0 [1.0–2.0] days), less frequent need for additional anti-hypertensive agents (1 patients [3.1%] vs. 11 patients [42.3%]), and shorter length of hospital stay (17.5 [10.0–33.0] days vs. 9.0 [5.0–15.0] days) than the nitroglycerin group. The duration of positive pressure ventilation and body weight changes were similar between the groups. The outcomes were similar after excluding patients who received renal replacement therapy.Conclusion: Nicardipine may be more effective than nitroglycerin for treating hypertensive AHFS.

Iron deficiency as an emerging therapeutic target in patients stabilized after an episode of acute heart failure

Acute heart failure (AHF) syndromes are among the most frequent causes of hospitalization in the elderly and put a heavy financial burden on healthcare systems, mainly due to high early readmission rates. The understanding of AHF has evolved over the years from a significant hemodynamic failure to a multi-organ disease in the course of which peripheral mechanisms such as dysregulated cardiorenal axis or inflammation also play essential roles. A few available observational studies investigating iron deficiency (ID) in patients hospitalized for AHF indicate that this comorbidity is more prevalent than in chronic heart failure, and iron status presents some dynamics in these subjects. ID in AHF predicts increased mortality, greater risk for early readmission and is related to prolonged hospitalization. This paper reviews the results of the first multicenter, double-blind, randomized clinical trial on ferric carboxymaltose in patients who were stabilized after an episode of AHF who had concomitant ID (AFFIRM-AHF), and potential pathophysiological links between dysregulated iron status and AHF syndromes are discussed.

285 A rare case of atypical, non-triggered takotsubo recurrence

Abstract Aims Takotsubo syndrome (TTS) is an acute and reversible heart failure syndrome that, at presentation, mimics acute myocardial infarction. The most common echocardiographic manifestation is the so-called ‘apical ballooning’, but other much less common wall motion patterns have been described. The pathophysiology of the syndrome is not fully understood, but there is considerable evidence that sympathetic stimulation plays a central role. The prevalence of this syndrome is higher in post-menopausal women and in most cases, but not invariably, precipitated by an emotional or physical triggering event. A close relation between brain and circulatory system has been observed and for this reason psychiatric and neurologic disorders are often recognized as precipitating conditions. Although many risk factor persist after the acute manifestation, Takotsubo recurrences do represent an exception, especially in the absence of a clear precipitating event. Methods and results A 70-year-old woman was admitted for anginal pain associated with ischaemic electrocardiographic alterations and elevation of cardiac biomarkers. The coronary angiography with left ventriculogram and the echocardiographic findings were consistent with a diagnosis of mid-ventricular Takotsubo. Cardiac magnetic resonance confirmed the absence of an ischaemic pattern or evidence of infectious myocarditis. This case represents a recurrence of TTS, in fact two years earlier the patient was hospitalized to our division for stress cardiomyopathy with typical apical ballooning. Also in the present occasion, she had a favorable clinical course, with a complete recovery of the cardiac function at subsequent evaluations. The unicity of this case lies above all in the absence of a clear trigger event. Although, an altered mental status was present because the patient suffered from anxiety and depression on pharmacological treatment, with periods of exacerbation but not in occasion of the recurrence. Conclusions TTS is not a benign condition, with recurrence being possible even in the absence of precipitating events. Based on registry data, annual rate of Takotsubo recurrence is 1.5–1.8% and is estimated to reach 4% in life. A variable TTS pattern at recurrence is common in up to 20% of cases. Our paper reports a unique case of recurrent Takotsubo syndrome with variable patterns of ventricular involvement, with neither physical nor psychological trigger. Nevertheless, for what concerns our case, the psychiatric condition the patient suffered from, could have played a role of permanent status of sympathetic activation, that in the end elicitates the occurrence of the syndrome. A better understanding of the pathophysiology of the syndrome is needed to find evidence-based therapeutic strategies that could prevent recurrence.

188 Disarming the bomb in AL amyloidosis: a case report

Abstract Aims Light-chain amyloidosis (AL) is a rapidly progressive systemic disease commonly involving also the myocardium, with poor outcome if lately diagnosed and treated. Clinical presentation can be widely varied, ranging from unapparent disease with soft symptoms to acute heart failure syndromes, requiring urgent therapies and supports. Methods and results A 52-year-old women came to our outpatient cardiomyopathy clinic because of hypertrophic cardiomyopathy (HCM) suspicion. Family history included a paternal cousin with diagnosis of unspecified cardiomyopathy and cardiac arrest. Her medical history was unremarkable until few months ago, when she started to complain with palpitations and asthenia. Given that both electrocardiogram and echocardiogram had previously showed signs of left ventricular (LV) hypertrophy, she was referred to us for HCM evaluation. Our physical examination was unremarkable, in particular there were no signs of central or peripheral venous congestion. Electrocardiogram showed a diffuse strain pattern with inferolateral ST-depression and T-wave inversion. Echocardiogram showed a thicked interventricular septum (17 mm), a pseudo-normal transmitral filling pattern with mild increase of LV filling pressure (E/E′ 11), a severely dilated left atrium (51 ml/mq). To complete the diagnostic path for HCM, we asked for a cardiac magnetic resonance (CMR), which two months later gave to us the diagnosis of myocardial amyloid infiltration. The diagnosis was quite surprising, because the patient was fine, 6 min walking test assessed a good functional capacity (500 m), no heart failure signs were recorded. So, we sent the patient to perform bone scintigraphy, which showed Perugini 0 uptake, and blood exam, showing, instead, rise of lambda free light chains, cardiac troponin (41.5 ng/l) and NTproBNP (5318 ng/l). Patient was urgently referred to haematologists, who using bone marrow and fat pad biopsy diagnosed a multiple myeloma with stage IV sec. Mayo AL amyloidosis. (Cy)BorD therapy was started, reaching a complete response in 4 months. Conclusions Diagnosis of AL amyloidosis is tricky due to heterogeneous clinical onset and multi-organ involvement. Cardiologist community should be aware of this condition, phenotypically mimicking HCM, but with very different management, in order to favour early diagnosis, prompt referral and treatment initiation. This case teaches that only 1. clinical awareness and 2. multidisciplinary approach can lead to disarm the bomb in AL amyloidosis.

Clinical correlates and prognostic impact of neurologic disorders in Takotsubo syndrome

Cardiac alterations are frequently observed after acute neurological disorders. Takotsubo syndrome (TTS) represents an acute heart failure syndrome and is increasingly recognized as part of the spectrum of cardiac complications observed after neurological disorders. A systematic investigation of TTS patients with neurological disorders has not been conducted yet. The aim of the study was to expand insights regarding neurological disease entities triggering TTS and to investigate the clinical profile and outcomes of TTS patients after primary neurological disorders. The International Takotsubo Registry is an observational multicenter collaborative effort of 45 centers in 14 countries (ClinicalTrials.gov, identifier NCT01947621). All patients in the registry fulfilled International Takotsubo Diagnostic Criteria. For the present study, patients were included if complete information on acute neurological disorders were available. 2402 patients in whom complete information on acute neurological status were available were analyzed. In 161 patients (6.7%) an acute neurological disorder was identified as the preceding triggering factor. The most common neurological disorders were seizures, intracranial hemorrhage, and ischemic stroke. Time from neurological symptoms to TTS diagnosis was ≤ 2 days in 87.3% of cases. TTS patients with neurological disorders were younger, had a lower female predominance, fewer cardiac symptoms, lower left ventricular ejection fraction, and higher levels of cardiac biomarkers. TTS patients with neurological disorders had a 3.2-fold increased odds of in-hospital mortality compared to TTS patients without neurological disorders. In this large-scale study, 1 out of 15 TTS patients had an acute neurological condition as the underlying triggering factor. Our data emphasize that a wide spectrum of neurological diseases ranging from benign to life-threatening encompass TTS. The high rates of adverse events highlight the need for clinical awareness.

Impella Mechanical Circulatory Support for Takotsubo Syndrome With Shock: A Retrospective Multicenter Analysis

ObjectivesTo analyze the characteristics and outcome of Impella mechanical circulatory support (MCS) for Takotsubo syndrome (TS) with cardiogenic shock. BackgroundTS is an acute heart failure syndrome characterized by transient severe reduction of left ventricular (LV) systolic function, with cardiogenic shock occurring in around 10% of patients. Since inotropes should be avoided due to their role in TS pathogenesis and aggravation of LV outflow tract obstruction, the use of MCS as treatment is a viable treatment option, however, studies are lacking. MethodsThe catheter-based ventricular assist device (cVAD) registry and local MCS databases were screened for TS patients with cardiogenic shock (TS-CS) supported with an Impella percutaneous ventricular assist device (pVAD). Patient and treatment characteristics and in-hospital outcomes were retrospectively analyzed. ResultsAt 10 US and European centers, 16 TS-CS patients supported with an Impella pVAD were identified between December 2013 and May 2018 (mean age, 61.8 ± 15.5 years; 87.5% women). LV ejection fraction (LVEF) at presentation was severely reduced (mean, 19.4 ± 8.3%). Prior to MCS, 13 patients (81.3%) were mechanically ventilated, 4 patients (25.0%) had been resuscitated, and mean serum lactate was 4.7 ± 3.5 mmol/L. Mean duration of Impella support was 1.9 ± 1.0 days (range, 1–4 days). Thirteen patients (81.3%) survived to discharge, and all survivors experienced cardiac recovery with significant improvement of LVEF at discharge compared to baseline (20.4 ± 8.8 vs. 52.9 ± 12.0, P < 0.001). ConclusionsThis is the first series of TS-CS patients supported with an Impella pVAD. Mortality was low, and LV systolic function recovered in all survivors. Prospective studies of Impella support in this special condition are warranted.

Intra-Aortic Balloon Pumping in Acute Decompensated Heart Failure With Hypoperfusion: From Pathophysiology to Clinical Practice.

Trials on intra-aortic balloon pump (IABP) use in cardiogenic shock related to acute myocardial infarction have shown disappointing results. The role of IABP in cardiogenic shock treatment remains unclear, and new (potentially more potent) mechanical circulatory supports with arguably larger device profile are emerging. A reappraisal of the physiological premises of intra-aortic counterpulsation may underpin the rationale to maintain IABP as a valuable therapeutic option for patients with acute decompensated heart failure and tissue hypoperfusion. Several pathophysiological features differ between myocardial infarction- and acute decompensated heart failure-related hypoperfusion, encompassing cardiogenic shock severity, filling status, systemic vascular resistances rise, and adaptation to chronic (if preexisting) left ventricular dysfunction. IABP combines a more substantial effect on left ventricular afterload with a modest increase in cardiac output and would therefore be most suitable in clinical scenarios characterized by a disproportionate increase in afterload without profound hemodynamic compromise. The acute decompensated heart failure syndrome is characterized by exquisite afterload-sensitivity of cardiac output and may be an ideal setting for counterpulsation. Several hemodynamic variables have been shown to predict response to IABP within this scenario, potentially guiding appropriate patient selection. Finally, acute decompensated heart failure with hypoperfusion may frequently represent an end stage in the heart failure history: IABP may provide sufficient hemodynamic support and prompt end-organ function recovery in view of more definitive heart replacement therapies while preserving ambulation when used with a transaxillary approach.

Prognostic Significance of Cardiac 123I-MIBG SPECT Imaging in Heart Failure Patients With Preserved Ejection Fraction

ObjectivesThe authors sought to elucidate the prognostic value of cardiac sympathetic nerve dysfunction as evaluated using iodine-123-labeled metaiodobenzylguanidine (123I-MIBG) single-photon emission computed tomography (SPECT) imaging in patients with heart failure (HF) with preserved left ventricular ejection fraction (HFpEF). BackgroundCardiac sympathetic nerve dysfunction assessed by 123I-MIBG imaging is associated with poor outcomes in chronic HF patients with reduced left ventricular ejection fraction (HFrEF). However, no information is available on the prognostic vale of cardiac 123I-MIBG SPECT imaging in patients with HFpEF. MethodsWe studied 148 patients admitted for acute decompensated HF (ADHF) with nonischemic HFpEF and who underwent cardiac 123I-MIBG imaging at discharge. The cardiac 123I-MIBG heart-to-mediastinum ratio (H/M) was measured on the delayed planar image (late H/M). SPECT analysis of the delayed image was conducted, and the tracer uptake in all 17 regions on the polar map was scored on a 5-point scale by comparison with a sex-matched normal control database. The total defect score (TDS) was calculated by summing the score of each of the 17 segments. The primary endpoint was the association between TDS and cardiac events (the composite of emergent HF hospitalization and cardiac death). ResultsDuring a mean follow-up period of 2.4 ± 1.6 years, 61 patients experienced cardiac events. TDS was significantly associated with cardiac events after multivariate Cox adjustment (P < 0.0001). Patients with high TDS levels had a significantly greater risk of cardiac events than those with middle or low TDS levels (63% vs 40% vs 20%, respectively; P < 0.0001; HR: 4.69; 95% CI: 2.29 to 9.61; and HR: 2.46; 95% CI: 1.14 to 5.29). C-statistic of TDS was 0.730 (95% CI: 0.651 to 0.799), which was significantly higher than that of late H/M (0.607; 95% CI: 0.524 to 0.686; P = 0.0228). ConclusionsCardiac 123I-MIBG SPECT imaging provided useful prognostic information in nonischemic ADHF patients with HFpEF. (Clinical Trial: Osaka Prefectural Acute Heart Failure Syndrome Registry [OPAR]: UMIN000015246)

Multisystem inflammatory syndrome in adult and acute heart failure: a case report

Multisystem inflammatory syndrome in adult and acute heart failure: a case report

Estimating Incidence of Acute Heart Failure Syndromes in Japan - An Analysis From the KUNIUMI Registry.

Few registries have provided precise information concerning incidence rates for acute heart failure syndrome (AHFS) in Japan. All hospitals with acute care beds in Awaji Island participated in the Kobe University heart failure registry in Awaji Medical Center (KUNIUMI Registry), a retrospective, population-based AHFS registration study, enabling almost every patient with AHFS in Awaji Island to be registered. From 1 January 2015 to 31 December 2017, 743 patients with de novo AHFS had been registered. Mean age was 82.1±11.5 years. Using the general population of Japan as of 2015 as a standard, age- and sex-adjusted incidence rates for AHFS were 133.8 per 100,000 person-years for male and 120.0 for female. In 2015, there were an estimated 159,702 new-onset patients with AHFS, which was predicted to increase to 252,153 by 2040, and reach a plateau. The proportion of patients aged >85 years accounted for 42.6% in 2015, which was predicted to increase up to 62.5% in 2040. The proportion of patients with heart failure with preserved ejection fraction was estimated at 52.0% in 2015, which was predicted to increase gradually to 57.3% in 2055. The present analysis suggested that the number of patients with de novo AHFS keeps increasing with progressive aging in Japan. Establishment of countermeasures against the expanding burden of HF is urgently required.

ОСТРАЯ И ХРОНИЧЕСКАЯ СЕРДЕЧНАЯ НЕДОСТАТОЧНОСТЬ ПОСЛЕ ИНФАРКТА МИОКАРДА: КЛИНИЧЕСКИЕ И ФУНКЦИОНАЛЬНЫЕ МАРКЕРЫ

Вackground. The last decade has seen an increase in the number of people who have had myocardial infarction (MI). This phenomenon contributes to an increase in the long-term incidence of chronic cardiovascular diseases, including chronic heart failure. Purpose of the study. To identify the most significant clinical and functional indicators characterizing acute and chronic heart failure after myocardial infarction. Patient Characterization and Research Methods. This analysis included 186 patients who had myocardial infarction from January 2019 to January 2020: 86 people, the main subgroup, with signs of CHF above FC 2 (NYHA) (mean age 64.3 g) and 100 people, the comparison subgroup, without signs of CHF or had CHF 1 FC (NYHA) (mean age 62.6 l). After 1 year, clinical outcomes were assessed: cardiovascular death, repeated hospitalizations due to decompensation of CHF, death from other causes, stroke, repeated myocardial infarction, unplanned coronary revascularization. Results. In the acute period of myocardial infarction in the main subgroup (MI + CHF more than 2cl NYHA), all patients had symptoms of acute heart failure (AHF) in the form of Killip II and Killip III. Predictors of the development of chronic heart failure were the presence of a history of ischemic heart disease, confirmed in accordance with the recommendations, before myocardial infarction; decreased fraction of the left ventricle, detected before discharge and on the 30th day of myocardial infarction; the presence of atrial fibrillation (AF). One-year unfavorable outcomes in the main group were significantly more frequent. Subanalysis of long-term drug therapy showed that cardiovascular death was significantly less common in the subgroup of patients taking ARNI than in the subgroup of enalapril. Conclusion. In the present study, we studied postinfarction myocardial remodeling, which is realized in the form of the formation of a syndrome of acute and chronic heart failure. It has been shown that immediate reperfusion and restriction of the necrosis zone, as well as long-term use of drugs that inhibit SAS and RAAS, stimulating NPP, can inhibit the development of AHF and death. The CHF problem requires further fundamental research in order to develop new approaches that can affect more subtle mechanisms, such as the expression of specific genes involved in the disease, in order to reduce the persisting excess mortality for this pathology.

Prognostic role of neoplastic markers in Takotsubo syndrome

Takotsubo syndrome (TTS) is an acute heart failure syndrome with significant rates of in and out-of-hospital mayor cardiac adverse events (MACE). To evaluate the possible role of neoplastic biomarkers [CA-15.3, CA-19.9 and Carcinoembryonic Antigen (CEA)] as prognostic marker at short- and long-term follow-up in subjects with TTS. Ninety consecutive subjects with TTS were enrolled and followed for a median of 3 years. Circulating levels of CA-15.3, CA-19.9 and CEA were evaluated at admission, after 72 h and at discharge. Incidence of MACE during hospitalization and follow-up were recorded. Forty-three (46%) patients experienced MACE during hospitalization. These patients had increased admission levels of CEA (4.3 ± 6.2 vs. 2.2 ± 1.5 ng/mL, p = 0.03). CEA levels were higher in subjects with in-hospital MACE. At long term follow-up, CEA and CA-19.9 levels were associated with increased risk of death (log rank p < 0.01, HR = 5.3, 95% CI 1.9–14.8, HR = 7.8 95% CI 2.4–25.1, respectively, p < 0.01). At multivariable analysis levels higher than median of CEA, CA-19.9 or both were independent predictors of death at long term (Log-Rank p < 0.01). Having both CEA and CA-19.9 levels above median (> 2 ng/mL, > 8 UI/mL respectively) was associated with an increased risk of mortality of 11.8 (95% CI 2.6–52.5, p = 0.001) at follow up. Increased CEA and CA-19.9 serum levels are associated with higher risk of death at long-term follow up in patients with TTS. CEA serum levels are correlated with in-hospital MACE.

Hemodynamic Collapse Caused by Cardiac Dysfunction and Abdominal Compartment Syndrome in a Patient with Mitochondrial Disease

We herein report a case of mitochondrial disease with heart and intestinal tract involvement resulting in hemodynamic collapse. A 66-year-old woman was transferred to our hospital because of cardiogenic shock. Vasopressors were administered, and a circulatory support device was deployed. However, her hemodynamics did not improve sufficiently, and we detected abdominal compartment syndrome caused by the aggravation of chronic intestinal pseudo-obstruction as a complication. Insertion of a colorectal tube immediately decreased the intra-abdominal pressure, improving the hemodynamics. Finally, we diagnosed her with mitochondrial disease, concluding that the resulting combination of acute heart failure and abdominal compartment syndrome had aggravated the hemodynamics.

Antigen carbohydrate 125 as a biomarker in heart failure: a narrative review.

Congestion explains many of the signs and symptoms of acute heart failure (AHF) and disease progression. However, accurate quantification of congestion is challenging in daily practice. Antigen carbohydrate 125 (CA125) or mucin 16 (MUC16), a large glycoprotein synthesized by mesothelial cells, has emerged as a reliable proxy of congestion and inflammation in patients with heart failure (HF). In AHF syndromes, CA125 is strongly associated with right-sided HF parameters and a higher risk of adverse clinical events beyond standard prognostic factors, including natriuretic peptides. Furthermore, CA125 has the potential for both monitoring and guide HF treatment following a decompensated HF event. The wide availability of CA125 in most clinical laboratories, together with its standardized measurement and reduced cost, makes this marker attractive for routine use in decompensated HF. Further research is required to understand better its biological role and its promising utility as a tool to guide decongestive therapy in HF.