Chronic Compensated Heart Failure Research Articles

Sleep-disordered breathing in chronic compensated heart failure

Sleep-disordered breathing in chronic compensated heart failure

Elevated GDF-15 levels may indicate malnutrition in chronic compensated heart failure with or without diabetes mellitus

Abstract Background/Introduction Malnutrition is common in chronic heart failure (HF) and is associated with adverse outcomes. Elevated NT-proBNP may indicate increased cardiac stress, whereas growth differentiation factor 15 (GDF-15) is increased in response to tissue injury, inflammation and in diabetes mellitus (DM). GDF-15 also negatively regulates appetite, body weight and skeletal muscle homeostasis. Purpose We aim to assess the nutritional status of HF patients with or without DM, and determine if GDF-15 is associated with malnutrition. Methods We did a cross-sectional analysis on chronic HF patients in a prospective cohort study, forecAsting Heart Failure decompensation (AHF). Chronic compensated HF was defined as a state following hospital discharge for >30 days, or where there had not been hospitalisation for 30 days preceding phenotyping. Patients with a history of HF decompensation were included. Geriatric Nutritional Risk Index (GNRI), including body mass index (BMI) and serum albumin, was used to assess and categorise nutritional status. Patients were classified as being “malnourished” or “well-nourished” based on GNRI scores of <92 and ≥92, respectively. NT-proBNP and GDF-15 levels were measured and echocardiography was done. The study was approved by institutional review board and complied with Declaration of Helsinki. Results Among 73 patients (mean age 66 y, 58.9% male), 32.7% exhibited malnutrition as determined by GNRI. There was no difference in age, sex ratio and NYHA functional class between the malnourished and the well-nourished. BMI (22.1 vs 25.6, P<0.001) and levels of GDF-15 (7216.0 vs 2469.0, P<0.001) and NT-proBNP (7158.0 vs 1321.0, P=0.01) were different between the malnourished and well-nourished. Both GDF-15 and NT-proBNP were inversely correlated with GNRI (GDF-15, r=−0.39, P<0.001; NT-proBNP, r=−0.46, P<0.0001). As expected, DM HF patients had significantly higher levels of GDF-15 than non-DM HF patients. In subgroup analysis of DM HF patients, GDF-15 and NT-proBNP levels were higher in the malnourished than well-nourished (median log-[GDF-15], 9.15 vs 8.10, P<0.01; median log-[NT-proBNP], 9.44 vs 7.00, P<0.01). Whereas in non-DM HF, NT-proBNP levels were not different between the malnourished and well-nourished. Age- and sex-adjusted logistic regression model determined that per log increment in GDF-15 level there was a 5.8-fold increased risk of malnutrition (OR 5.81 [2.43–17.62], P<0.001), and for every log increment in NT-proBNP level there was a 1.8-fold increase in the risk of malnutrition (OR 1.82 [1.23–2.88], P<0.01). Conclusion(s) Malnutrition is common in chronic compensated HF patients with a history of hospitalisation, and is associated with elevated NT-proBNP and GDF-15 levels. Elevated GDF-15 levels independently predicted poor nutritional status, and with NT-proBNP may indicate a particularly high-risk HF subgroup Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): 1) Health and Medical Research Fund, Food and Health Bureau, 2) Direct Grant, Faculty of Medicine, CUHK

Angiotensin receptor neprilysin inhibitor in heart failure with reduced ejection fraction: Real-world experience from a safety perspective

Background: Angiotensin receptor neprilysin inhibitor (ARNI) reduces morbidity and mortality in patients of heart failure with reduced ejection fraction (HFrEF). However, the use of ARNI in real-world practice is limited by safety issues, especially in acute decompensated heart failure (ADHF) patients. Methods and Results: Forty-seven hospitalized ADHF inpatients and 53 chronic compensated heart failure (CCHF) outpatients were enrolled in the study. ARNI was initiated and aimed to be up-titrated to a target dose of 97 mg of sacubitril with 103 mg of valsartan twice daily. Efficacy endpoints were New York Heart Association functional class, 6-min walk distance (6MWD), change in N-terminal pro B-type natriuretic peptide (NT-pro BNP) levels and left ventricular ejection fraction (LVEF) from baseline with follow-up at 1 month, 6 months, and 2 years. Safety endpoints were the rates of worsening serum creatinine, hyperkalemia, symptomatic hypotension, angioedema, and need for drug discontinuation. Cumulative adverse drug effect was observed in 42.6% and 13.2% patients of ADHF and CCHF groups, respectively. The most common side-effect was symptomatic hypotension that occurred in 10 (21.3%) patients of ADHF group and 3 (5.7%) patients of CCHF group. Drug discontinuation rate was 19.1% in ADHF group and 3.8% in CCHF group. Significant improvement was seen in both the groups with respect to 6 MWD, functional class, change in NT-pro BNP levels and LVEF. At 2-year follow-up, 3 (6.4%) deaths occurred in ADHF group while none was reported from CCHF group. Conclusion: ARNI results in a significant clinical, biochemical, and functional improvement in HFrEF patients but at the cost of worsening renal function and hypotension especially in ADHF setting.

Serum level of apelin-13 negatively correlated with NT-proBNP in heart failure patients

Abstract Background: Apelin is a potent endogenous inotropic peptide with a major role in counteracting the aldosterone and angiotensin II and their negative effects on the cardiovascular system. The exact role of apelin in the patho-physiology of this disease is not well understood. We aimed to investigate the possible associations of apelin-13 with clinical and paraclinical characteristics in HF patients as well as studying its dynamics during the course of the heart failure. Method: We performed a prospective observational cohort single-center study. We compared the baseline serum levels of apelin-13 and NT-proBNP level in 53 heart failure patients (acute heart failure, chronic compensated heart failure and chronic decompensated heart failure). We divided the patients according to the apelin-13 level: above and below the median, and we analyzed the relationship between serum apelin-13 and the clinical, echocardiographic, electrocardiographic and biological parameters. Twenty patients were followed-up (after an average time interval of 9 months), investigating the same parameters. Results: The median of apelin-13 was 495pg/mL (IQR 276-845pg/mL). We found strong, negative correlation between the serum levels of apelin-13 and NT-proBNP (Spearman rho= −0.83, p<0.001). For the reassessed patients the median apelin level was significantly higher at follow-up (460 pg/mL, IQR 342-871 pg/mL) as compared with the baseline level (395 pg/mL, IQR 270-603 pg/mL), p=0.019, and maintained the negative correlation with NT-proBNP level (Spearman’s rho −0.7, p<0.001. The Low Apelin-13 group have higher NT-proBNP levels and also contains all the patients in NYHA IV class heart failure, 71% of the acute HF patients, and 7 of 8 patients who died before follow-up. Conclusion: Apelin-13 was negatively correlated with NT-proBNP. The Low Apelin-13 group contained the majority of the patients with a negative outcome (death before follow-up), most of the patients who presented with acute HF and all the patients in NYHA IV class.

125 - Left Ventricular Flow Vortex is Incremental to Conventional Echo-Doppler to Predict Clinical Outcomes in Patients with Chronic Compensated Heart Failure: A Quantitative Vorticity Imaging Study Using Contrast Echocardiography

125 - Left Ventricular Flow Vortex is Incremental to Conventional Echo-Doppler to Predict Clinical Outcomes in Patients with Chronic Compensated Heart Failure: A Quantitative Vorticity Imaging Study Using Contrast Echocardiography

Short term omega-3 polyunsaturated fatty acid supplementation induces favorable changes in right ventricle function and diastolic filling pressure in patients with chronic heart failure; A randomized clinical trial

IntroductionOmega-3 polyunsaturated fatty acids (omega 3-PUFAs) seem to favorably affect cardiac hemodynamics and may benefit the clinical course of heart failure patients. The role of omega 3-PUFAs supplementation on the left and right ventricular function of patients with chronic compensated systolic heart failure, under optimal treatment, was studied. Methods205 consecutive patients with chronic compensated heart failure, due to ischemic (IHF) or dilated cardiomyopathy (DCM)-NYHA classification I–III, under optimal medical treatment, were enrolled. Participants were 1-to-1 randomized on 1000mg omega 3-PUFA supplementation or no supplementation, in a non-blinded fashion. Echocardiographic assessment was performed at first visit and 6months after. Plasma BNP and serum creatinine levels were also measured. ResultsAs compared with the control group, BNP levels in omega 3-PUFA intervention group were 34.6% lower (p=0.001); end-diastolic and end-systolic left ventricle dimensions were decreased by 2.5% (p=0.047) and 3.7% (p=0.01), maximum diameter of left atrium was decreased by 8.4% (p=0.004), left atrium ejection fraction was ameliorated by 6.03% (p=0.021) and as regards tissue Doppler parameters, TDI_Etv/Atv was decreased in omega 3-PUFA intervention group by 6.3% (p=0.038). Moreover, improvement in diastolic indices was more prominent in subjects with DCM as compared to IHF patients. ConclusionOmega 3-PUFA supplementation was associated with improved left diastolic function and decreased BNP levels in patients with chronic heart failure. These findings suggest a beneficial role of omega 3-PUFAs on the hemodynamic course of patients with systolic heart failure.

Investigation of bacterial translocation in chronic ischemic heart failure in the rat.

Increased markers of systemic inflammation had been found in patients with acute heart failure. These and other findings led to the hypothesis of an increased rate of bacterial translocation in severe or acute heart failure, leading to systemic inflammation. The present study examined if bacterial translocation occurs under physiological conditions in rats and if its rate and spectrum changes in chronic compensated ischemic heart failure. Myocardial infarction (MI) was induced by proximal ligation of the left anterior descending coronary artery or a sham operation was performed. Rats were followed up for six months and mesenteric lymph nodes of the surviving animals with large MI were excised and bacterial translocation was quantified by cultivating viable bacteria. Induction of a large MI led to a significant cardiac remodelling, elevated levels of atrial natriuretic peptide, and pulmonary oedema. There was no difference in the spectrum or in the rate of bacterial translocation compared with controls, neither comparing all cultured bacteria nor predefined subgroups (e.g., intestinal bacteria). Bacterial translocation is a physiological process with no gradual increase in chronic compensated heart failure in rats.

Response to Improvement of Arterial Stiffness in the Transition From Acute Decompensated Heart Failure to Chronic Compensated Heart Failure

Kim DB et al. Clin Cardiol. 2013;36:358–362.

Response to Improvement of Arterial Stiffness in the Transition From Acute Decompensated Heart Failure to Chronic Compensated Heart Failure

Kim DB et al. Clin Cardiol. 2013;36:358–362.

QRS Prolongation in the Prediction of Clinical Cardiac Events in Patients with Acute Heart Failure: Analysis of Data from the Korean Acute Heart Failure Registry

Objectives: A prolonged QRS duration has been associated with an unfavorable prognosis in chronic compensated heart failure (HF). However, its predictive value during an admission for acute HF is limited, even in HF with a preserved ejection fraction (EF). The purpose of this study was to evaluate the prognostic utility of the QRS duration in acute HF. Methods: Analyses were performed using data from 1,489 patients with a 2-year follow-up. The patients were selected from the Korean Acute Heart Failure Registry and were divided into three groups according to QRS duration (≤80, 81-119 or ≥120 ms). The all-cause mortality and readmission for HF were assessed. Results: During the study period, 774 primary events occurred (359 deaths and 415 HF). The event frequencies were higher in patients with a prolonged QRS duration. The increased risk associated with the QRS duration was also demonstrated after adjustment for cardiac outcome variables. The prognostic significance of the QRS duration was demonstrated in patients with reduced EF but not in those with a preserved EF. Conclusions: A prolonged QRS duration could be a significant predictor of the 2-year cardiac outcome in patients with acute HF, particularly in those with a reduced EF.

Improvement of Arterial Stiffness in the Transition From Acute Decompensated Heart Failure to Chronic Compensated Heart Failure

Pulse wave velocity (PWV) is a well-established marker for aortic stiffness and may be a prognostic factor in heart failure (HF). This study investigates whether PWV changes as patients transition from acute decompensated heart failure (ADHF) to chronic compensated heart failure (CCHF). Arterial stiffness is related with the development of HF. Regional PWV was prospectively measured using noninvasive applanation tonometry in consecutive ADHF patients (n = 55). PWV measurements of 45 patients were taken at admission and 3-month follow-up (F/U). Central and upper-extremity PWV, but not lower-extremity PWVs, were found to have improved after 3 months compared with the admission PWV (central: 8.73 ± 1.17 vs 8.39 ± 0.99 m/s, P = 0.018; upper extremity: 8.59 ± 0.84 vs 8.33 ± 0.82 m/s, P = 0.028). Multivariate logistic regression analyses revealed that low-density lipoprotein cholesterol was significantly associated with the change of PWV in HF (odds ratio: 1.037, 95% confidence interval: 1.003-1.071, P = 0.030). In preserved left ventricular ejection fraction patients (n = 26) and ischemic patients (n = 31), central and upper-extremity PWVs improved over the admission PWV at 3-month F/U. The present results indicate that central and upper-extremity PWVs, but not lower-extremity PWV, are increased in ADHF and improve as patients transition from ADHF to CCHF.

488 Serial Measures of the Fractional Excretion of Urea(FEurea), Fractional Excretion of Sodium(FEna) and the Urea/Creatinine Ratio(UCr) for Predicting Changes in Renal Function in Ambulatory Heart Failure Patients

Worsening renal function often follows changes in renal perfusion and solute clearance. In patients with chronic compensated heart failure, subtle changes in renal perfusion could alter the fractional excretion of urea (FEurea) and give insight into subtle states of renal hypoperfusion. FEurea is a simple, quick and inexpensive surrogate measure of diminishing renal perfusion and renal vasoconstriction in response to the neurohormonal perturbations and functional decline in cardiac function. Furthermore, the FEurea is not affected by diuretics.

Reduced Heart Rate Variability Correlates With Anaemia and Impaired Quality of Life in Patients With Chronic Compensated Heart Failure

Reduced Heart Rate Variability Correlates With Anaemia and Impaired Quality of Life in Patients With Chronic Compensated Heart Failure

The prevalence and clinical relevance of sexual dysfunction in women and men with chronic heart failure

Sexual dysfunction is a common problem of increasing incidence that is associated with multiple co-morbid conditions and chronic diseases. In heart failure, however, exact numbers are unknown, in part secondary to under-reporting and under-interrogating by health care providers. A gender-specific questionnaire was modified from established sexual dysfunction questionnaires to correspond to a non-randomized outpatient heart failure population, to assess the prevalence and demographic distribution of sexual dysfunction and potential treatments expectations. One-hundred patients in a stable hemodynamic condition in New York Heart Association classes I-III participated. Eighty-seven percent of women were diagnosed with female sexual dysfunction compared to 84% of men with erectile dysfunction. Eighty percent of women reported reduced lubrication, which resulted in frequent unsuccessful intercourse in 76%. Thirty-six percent of patients thought that sexual activity could harm their current cardiac condition; 75% of females and 60% of men stated that no physicians ever asked about potential sexual problems. Fifty-two percent of men considered sexual activity in their current condition as an essential aspect of quality of life and 61% were interested in treatment to improve sexual function. Sexual dysfunction appears to be high in prevalence in both men and women with chronic compensated heart failure and represents a reduction in quality of life for most. Despite the fact that most patients are interested in receiving therapy to improve sexual dysfunction, treatment options are rarely discussed or initiated.

Conivaptan: A Dual Receptor Vasopressin V1a/V2 Antagonist

Several fluid retentive states such as heart failure, cirrhosis of the liver, and syndrome of inappropriate antidiuretic hormone secretion are associated with inappropriate elevation in plasma levels of arginine vasopressin (AVP), a neuropeptide that is secreted by the hypothalamus and plays a critical role in the regulation of serum osmolality and in circulatory homeostasis. The actions of AVP are mediated by three receptor subtypes V1a, V2, and V1b. The V1a receptor regulates vasodilation and cellular hypertrophy while the V2 receptor regulates free water excretion. The V1b receptor regulates adrenocorticotropin hormone release. Conivaptan is a nonpeptide dual V1a/V2 AVP receptor antagonist. It binds with high affinity, competitively, and reversibly to the V1a/V2 receptor subtypes; its antagonistic effect is concentration dependent. It inhibits CYP3A4 liver enzyme and elevates plasma levels of other drugs metabolized by this enzyme. It is approved only for short-term intravenous use. Infusion site reaction is the most common reason for discontinuation of the drug. In animals conivaptan increased urine volume and free water clearance. In heart failure models it improved hemodynamic parameters and free water excretion. Conivaptan has been shown to correct hyponatremia in euvolemic or hypervolemic patients. Its efficacy and safety for short-term use have led to the Food and Drug Administration (FDA) approval of its intravenous form for the correction of hyponatremia in euvolemic and hypervolemic states. Despite its ability to block the action of AVP on V1a receptors, no demonstrable benefit from this action was noted in patients with chronic compensated heart failure and it is not approved for this indication. Consideration should be given to further evaluation of its potential benefits in patients with acute decompensated heart failure.

Cardiovascular Profile of the Canine Torsades de Pointes Arrhythmia Model Assessed by Echocardiographic and Haemodynamic Methods

Chronic atrioventricular block dogs have been established as an in vivo model of drug-induced torsades de pointes arrhythmias. We compared the cardiovascular profile of the canine model with that of sham-operated animals using echocardiographic and haemodynamic methods. In the echocardiographic study, the larger diameters of the left atria, inferior vena cava and left ventricle in end-diastole in addition to greater fractional shortening, end-diastolic volume, stroke volume and ejection fraction were more often detected in the chronic atrioventricular block dogs than in the sham-operated animals. During haemodynamic examination, lower cardiac output and higher pulmonary capillary wedge pressure were detected in chronic atrioventricular block dogs more than in sham-operated animals; however, these changes were within the physiological limits, and the results suggest that the chronic atrioventricular block dogs have a pathophysiological profile of chronic compensated heart failure.

Risk factors for pneumonia in the elderly

purpose: To investigate the prevalence of certain chronic conditions among the elderly and to estimate the relative risk for pneumonia associated with each condition. patients and methods: Medical records of all inhabitants aged 60 years or more (4,175 persons) in one township (population 24,716) in Finland were reviewed, seeking 15 chronic conditions. Which patients had pneumonia in the same population was prospectively ascertained over a period of 3 years (185 patients). results: Hypertension was the most frequent chronic condition (36.4%) in the study population. Other common conditions were heart disease (23.7%, with chronic compensated heart failure in 96.3% of these), other cardiovascular disease (13.1%), and diabetes (13.1%). The prevalence of any other condition was less than 5%. The following conditions were significantly more common among pneumonia patients than among control subjects: heart disease (38.4% versus 23.0%), lung disease (13.0% versus 3.8%), bronchial asthma (11.9% versus 3.1%), immunosuppressive therapy (2.7% versus 0.8%), alcoholism (2.2% versus 0.3%), and institutionalization (8.6% versus 3.9%). By multivariate logistic regression analysis, independent risk factors for pneumonia were alcoholism (relative risk [RR]= 9.0, confidence interval [Cl] = 5.1 to 16.2), bronchial asthma (RR = 4.2, Cl = 3.3 to 5.4), immunosuppressive therapy (RR = 3.1, Cl = 1.9 to 5.1), lung disease (RR = 3.0, Cl = 2.3 to 3.9), heart disease (RR = 1.9, Cl = 1.7 to 2.3), institutionalization (RR = 1.8, Cl = 1.4 to 2.4), and age (70 years or more versus 60 to 69 years; RR = 1.5, Cl = 1.3 to 1.7). One third of the study population and 57% of the pneumonia patients had one or more of these risk factors. Diabetes, chronic pyelonephritis, and malignancies of sites other than the lungs were not associated with increased risk for pneumonia. conclusion: We found which elderly persons have an increased risk for pneumonia. Although the highest relative risk was associated with alcoholism, that condition was rare in this elderly population. Chronic obstructive lung diseases were more common and were also associated with a high relative risk. Heart disease had the highest public health impact because it was very common among the elderly and increased the risk of contracting pneumonia almost twofold; it also increased the risk of pneumonia-related death. These population-based data confirm and extend previous findings derived from selected patient groups and are useful for designing cost-effective pneumonia prevention programs.

The Atrial Natriuretic Factor Hormonal System in the Regulation of Sodium Excretion in Dogs With Experimental Heart Failure

In response to a meat meal containing 125 mEq of sodium, conscious dogs (n = 5) with an arteriovenous (AV) fistula and chronic compensated heart failure exhibited temporally related increases in postprandial plasma immunoreactive atrial natriuretic factor (iANF), right atrial pressure, and sodium excretion. In separate experiments, two weeks of dietary sodium restriction produced similar marked stimulation of renin and aldosterone both in normal dogs (n = 5), and in AV fistula dogs (n = 5) with chronic high circulating levels of ANF. Plasma iANF did not change (P greater than .05) in either group. These results suggest that the ANF system is involved in the postprandial regulation of sodium excretion in the AV fistula dogs with compensated heart failure. In the postabsorptive state, however, the activity of the renin-aldosterone axis is closely related to dietary sodium intake and appears to function independently of the ANF system for the prevention of sodium loss.