Chronic Heart Failure Outpatients Research Articles

Somatic symptom profile in patients with chronic heart failure with and without depressive comorbidity.

Patients with chronic heart failure (CHF) frequently suffer from depressive comorbidity. CHF and depressive comorbidity can cause somatic symptoms. The correct attribution of somatic symptoms is important. Thus, we aimed to assess potential differences in somatic symptom severity between CHF patients with and without depressive comorbidity. We evaluated depressive comorbidity using the Patient Health Questionnaire-9 (PHQ-9), somatic symptom severity with the Patient Health Questionnaire-15 (PHQ-15), and sociodemographic and medical variables in 308 CHF outpatients. To compare somatic symptom severity between CHF patients with and without depressive comorbidity, we conducted item-level analyses of covariance. Of the 308 participating patients, 93 (30.3%) met the PHQ-9 criteria for depressive comorbidity. These patients did not differ from those without depressive comorbidity with regard to age, sex, left ventricular function, and multimorbidity. Patients with depressive comorbidity scored significantly higher on ten out of thirteen PHQ-15 items than patients without depressive comorbidity. The largest effect sizes (0.71-0.80) were shown for symptoms of headache, chest pain, shortness of breath, and palpitations, and the latter three were potentially attributable to heart failure. Among patients with CHF, somatic symptoms are more pronounced in those with depressive comorbidity than those without depressive comorbidity. This finding is especially true for cardiac symptoms independent of CHF severity. The potential interpretation of somatic symptoms as correlates of depressive comorbidity must be recognized in clinical practice.

Relationship between BMI and prognosis of chronic heart failure outpatients in Vietnam: a single-center study

BackgroundInsufficient data exists regarding the relationship between body mass index (BMI) and the prognosis of chronic heart failure (CHF) specifically within low- and middle-income Asian countries. The objective of this study was to evaluate the impact of BMI on adverse outcomes of ambulatory patients with CHF in Vietnam.MethodsBetween 2018 and 2020, we prospectively enrolled consecutive outpatients with clinically stable CHF in an observational cohort, single-center study. The participants were stratified according to Asian-specific BMI thresholds. The relationships between BMI and adverse outcomes (all-cause death and all-cause hospitalization) were analyzed by Kaplan–Meier survival curves and Cox proportional-hazards model.ResultsAmong 320 participants (age 63.5 ± 13.3 years, 57.9% male), the median BMI was 21.4 kg/m2 (IQR 19.5–23.6), and 10.9% were underweight (BMI <18.50 kg/m2). Over a median follow-up time of 32 months, the cumulative incidence of all-cause mortality and hospitalization were 5.6% and 19.1%, respectively. After multivariable adjustment, underweight patients had a significantly higher risk of all-cause mortality than patients with normal BMI (adjusted hazard ratios = 3.03 [95% CI: 1.07–8.55]). Lower BMI remained significantly associated with a worse prognosis when analyzed as a continuous variable (adjusted hazard ratios = 1.27 [95% CI: 1.03–1.55] per 1 kg/m2 decrease for all-cause mortality). However, BMI was not found to be significantly associated with the risk of all-cause hospitalization (p > 0.05).ConclusionIn ambulatory patients with CHF in Vietnam, lower BMI, especially underweight status (BMI < 18.5 kg/m2), was associated with a higher risk of all-cause mortality. These findings suggest that BMI should be considered for use in risk classification, and underweight patients should be managed by a team consisting of cardiologists, nutritionists, and geriatricians.

Long-Term Trajectories of Biomarkers, Functional, and Echocardiographic Parameters in Patients with Chronic Heart Failure from Dilated or Ischaemic Cardiomyopathy

Introduction: The long-term evolution of clinical, echocardiographic, and laboratory parameters of cardiac function in patients with chronic heart failure (HF) with either reduced (HFrEF) or mildly reduced (HFmrEF) left ventricular ejection fraction (LVEF) is incompletely characterised. Methods: We identified patients with chronic stable HF who presented at least twice to a university HF outpatient clinic between 1995 and 2021. Trajectories of NYHA functional class, LVEF, left ventricular internal end-diastolic diameter (LVIDD), NT-proBNP concentrations, and HF treatment over 10 years of follow-up were analysed using fractional polynomials. Analyses were repeated after stratifying patients according to aetiology (ischaemic vs. dilated) or HF category (HFrEF vs. HFmrEF). Results: A total of 2,132 patients were included, of whom 51% had ischaemic and 49% had dilated HF. Eighty six percent and 14% were classified as HFrEF and HFmrEF, respectively. Mean LVEF was 28 ± 10%, and median NT-proBNP and estimated glomerular filtration rate values were 1,170 (385–3,176) pmol/L and 81 (62–100) mL/min/1.73 m², respectively. Median follow-up was 5.2 (2.6–9.2) years. Overall, NYHA functional class and LVIDD trajectories were U-shaped, whereas LVEF and NT-proBNP concentrations markedly improved during the first year and remained stable thereafter. However, the evolution of HF parameters significantly differed with respect to HF category and aetiology, with greater improvements seen in patients with HFrEF of non-ischaemic origin. Improvements in HF variables were associated with optimization of HF therapy, notably with initiation and up-titration of renin-angiotensin-system blockers. Conclusion: This study provides insights into the natural history of HF in a large cohort of well-treated chronic HF outpatients with respect to subgroups of HF and different aetiologists.

P273 THE RATIO BETWEEN LEFT ATRIAL RESERVOIR AND SEPTAL E/E’: A NEW PARAMETER REFLECTING ATRIO–VENTRICULAR FUNCTION WHICH IS ASSOCIATED WITH A WORSE OUTCOME AMONG HEART FAILURE OUTPATIENTS

Abstract Background Two–dimensional speckle tracking (2D–ST) analysis allows to evaluate both atrial and ventricular function. Recently, it has been demonstrated that the ratio between left atrial reservoir (LAr) assessed by 2D–ST and the E/e’ ratio could allow a more accurate estimation of left ventricular filling pressure. Aim of the study. To evaluate if the ratio between LAr and E/e’ is also associated with heart failure progression among chronic heart failure (CHF) outpatients. Methods All patients enrolled underwent a medical visit, an ECG and an echocardiographic examination. LAr was assessed by 2D–ST. The early diastolic peak at pulsed Doppler (E) and at the level of septal (e’s) and lateral (e’l) mitral annulus by Tissue Doppler Imaging (TDI) were also evaluated. Then the ratio between E and e’s (E/es) and between E and the mean of e’s and e’l (E/em) were also calculated. Finally, the ratio between LAr and E/es (LAr/Ees) and E/em (LAr/Eem) were computed. During follow–up the progression of heart failure, defined as heart failure hospitalization or death, were evaluated. Results Among 256 patients, LAr/Eem and LA/Ees were available in 191 patients (age 64±13 years,80 % males, mean LVEF 39±11%, NYHA class 2.3±0.5). All patients were in conventional medical therapy (sacubitril/valsartan or ACE–inhibitors or Angiotensin II receptor blockers in 85%, beta–blockers in 94%, mineralcorticoid receptor antagonists in 73%, diuretics in 81%, SGLT2 inhibitors in 21%). During a mean follow–up of 13±7 months, 25 patients experienced death (9) and/or hospitalization (21) for heart failure worsening. At univariate Cox univariate regression analysis, both LAr/Eem (HR 0.61; 95%CI: 0.43–0.87; p:0.006) and LAr/Ees (HR 0.43; 95%CI: 0.25–0.71; p:0.001) were associated with the events. However, LAr/Ees showed a greater accuracy than LAr/Eem (C–index 0.76 vs. 0.73) and remained significantly associated with the events at multivariate analysis after correction for age, LVEF, NYHA class and estimated glomerular filtration rate (HR: 0.55; 95%CI: 0.33–0.92; p:0.22). Figure shows Kaplan–Meier curves according with the median value of LAr/Eem (panel A) and LAr/Ees (panel B). Conclusions The ratio between LAr and E/es is a new echocardiographic parameter able to reflect both left ventricular filling pressure and worse prognosis among patients affected by CHF. Further studies should evaluate its incremental value in stratifying patients’ prognosis.

Chất lượng cuộc sống của người bệnh suy tim mạn tính tại bệnh viện đa Khoa Vùng Tây Nguyên năm 2021

Objective: the study aims to describe the health-related quality of life and identify some associated factors to the quality of life of chronic heart failure out-patients at Central Highlands Regional General hospital. Methods: The study used cross-sectional study on 194 chronic heart failure patients who were aged 18 years old or older at cardiology clinic of the Central Highlands Regional General Hospital and they had a stable medical condition for at least one month before. SF-36 questionaire was used. Main findings: Mean score of health-related quality of life among chronic heart failure patients was medium-good (50.40±18.78). The mean score of quality of life about physical health and mental health was medium–poor (41.14±22.50) and medium–good (59.66±19.48), respectively. Female patients (p=0.044), NYHA classification that was greater than or equal to 3 (p<0,001), having chronic comorbidities (p=0.010) had a lower physical health score than the others. Patients who had higher classification of NYHA (p<0.001) had poorer metal health score than others. Patients who had higher classification of NYHA (p<0.001) and had more comorbidities (p<0.031) had worse health-related quality of life score than others. Conclusion: Quality of life should be assessed periodically during the outpatient treatment of chronic heart failure patients. It is necessary to optimally control the number of chronic comorbidities, improve the NYHA classification to improve the quality of life of patients with chronic heart failure. Keywords: chronic heart failure; health-related quality of life; SF-36.

Association Between Illness Perception and Care-Seeking Intention in Patients With Chronic Heart Failure.

This study aimed to investigate the association between illness perception and care-seeking intention in Japanese patients with chronic heart failure (CHF). A cross-sectional study was conducted on 160 CHF outpatients with reference to the framework of the Common-Sense Model. Illness perception was measured using the Brief Illness Perception Questionnaire (B-IPQ). Care-seeking intention was assessed based on the intent to consult medical care at the onset of varying symptoms. Association between illness perception and the care-seeking intention was analyzed by logistic regression analysis after univariate analysis. In the univariate analysis, illness perception was only associated with care-seeking intention at the onset of dyspnea at rest. Treatment control, which means the expected effectiveness of treatment in B-IPQ, was associated with care-seeking intention at the onset of dyspnea at rest (OR: 1.261, 95% CI [1.025-1.550]). It may be necessary to assess the patients' perceptions of their treatment and explain its effects.

Combining echo-derived haemodynamic phenotypes and myocardial strain for risk stratification of chronic heart failure with reduced ejection fraction.

Echocardiography has shown to categorize heart failure (HF) patients according to haemodynamic profiles. Whether left ventricular (LV) global longitudinal strain (LV-GLS) could integrate echo-derived haemodynamic profiles to risk stratify chronic HF patients is still unknown. Chronic HF outpatients with LV ejection fraction (LV-EF) <50% (n = 351) and LV-GLS assessment were evaluated and divided according to four haemodynamic phenotypes based on LV stroke volume index (SVI), LV filling pressure (LVFP), and right ventricular (RV) function: normal output-normal LVFP (NO-NP), normal output-high LVFP (NO-HP), low output-no RV dysfunction (LO-NRVD), and low output-RV dysfunction (LO-RVD). RV function was defined using the tricuspid annular plane systolic excursion and RV free-wall longitudinal strain. The median follow-up duration was 3.3 years. The combination of all-cause mortality and HF hospitalization was the primary endpoint. Secondary endpoints were all-cause mortality and cardiovascular mortality. The prevalence of NO-NP, NO-HP, LO-NRVD, and LO-RVD were 38%, 22%, 30%, and 10%, respectively. The haemodynamic model independently predicted primary and secondary outcomes, with incremental prognostic information over LV-EF (all P-values <0.001 for C-statistics). When univariate Cox regression analysis was performed to assess the prognostic stratification capability of LV-GLS in different haemodynamic subgroups, we observed a reduction in LV-GLS hazard ratios from the NO-NP to the LO-RVD for every endpoint. There was a continuum in LV-GLS impairment across the spectrum of haemodynamic phenotypes and its prognostic value resulted variable depending on the types of chronic HF patients. The highest prognostic information added by LV-GLS was in patients with normal SVI.

Tendencias temporales en las características, tratamiento y resultados de la insuficiencia cardiaca en octogenarios durante dos décadas

Introduction and objectivesOctogenarians represent the most rapidly expanding population segment in Europe. The prevalence of heart failure (HF) in this group exceeds 10%. We assessed changes in clinical characteristics, therapy, and 1-year outcomes over 2 decades in chronic HF outpatients aged ≥ 80 years enrolled in a nationwide cardiology registry. MethodsWe included 2520 octogenarians with baseline echocardiographic ejection fraction measurements and available 1-year follow-up, who were recruited at 138 HF outpatient clinics (21% of national hospitals with cardiology units), across 3 enrolment periods (1999-2005, 2006-2011, 2012-2018). ResultsAt recruitment, over the 3 study periods, there was an increase in age, body mass index, ejection fraction, the prevalence of obesity, diabetes, dyslipidemia, pre-existing hypertension, and atrial fibrillation history. The proportion of patients with preserved ejection fraction rose from 19.4% to 32.7% (P for trend <.0001). Markers of advanced disease became less prevalent. Prescription of beta-blockers and mineralocorticoid receptor antagonists increased over time. During the 1-year follow-up, 308 patients died (12.2%) and 360 (14.3%) were admitted for cardiovascular causes; overall, 591 (23.5%) met the combined primary endpoint of all-cause mortality or cardiovascular hospitalization. On adjusted multivariable analysis, enrolment in 2006 to 2011 (HR, 0.70; 95%CI, 0.55-0.90; P=.004) and 2012 to 2018 (HR, 0.61; 95%CI, 0.47-0.79; P=.0002) carried a lower risk of the primary outcome than recruitment in 1999 to 2005. ConclusionsAmong octogenarians, over 2 decades, risk factor prevalence increased, management strategies improved, and survival remained stable, but the proportion hospitalized for cardiovascular causes declined. Despite increasing clinical complexity, in cardiology settings the burden of hospitalizations in the oldest old with chronic HF is declining.

Temporal trends in characteristics, treatment, and outcomes of heart failure in octogenarians over two decades

Introduction and objectivesOctogenarians represent the most rapidly expanding population segment in Europe. The prevalence of heart failure (HF) in this group exceeds 10%. We assessed changes in clinical characteristics, therapy, and 1-year outcomes over 2 decades in chronic HF outpatients aged ≥ 80 years enrolled in a nationwide cardiology registry. MethodsWe included 2520 octogenarians with baseline echocardiographic ejection fraction measurements and available 1-year follow-up, who were recruited at 138 HF outpatient clinics (21% of national hospitals with cardiology units), across 3 enrolment periods (1999-2005, 2006-2011, 2012-2018). ResultsAt recruitment, over the 3 study periods, there was an increase in age, body mass index, ejection fraction, the prevalence of obesity, diabetes, dyslipidemia, pre-existing hypertension, and atrial fibrillation history. The proportion of patients with preserved ejection fraction rose from 19.4% to 32.7% (P for trend <.0001). Markers of advanced disease became less prevalent. Prescription of beta-blockers and mineralocorticoid receptor antagonists increased over time. During the 1-year follow-up, 308 patients died (12.2%) and 360 (14.3%) were admitted for cardiovascular causes; overall, 591 (23.5%) met the combined primary endpoint of all-cause mortality or cardiovascular hospitalization. On adjusted multivariable analysis, enrolment in 2006 to 2011 (HR, 0.70; 95%CI, 0.55-0.90; P=.004) and 2012 to 2018 (HR, 0.61; 95%CI, 0.47-0.79; P=.0002) carried a lower risk of the primary outcome than recruitment in 1999 to 2005. ConclusionsAmong octogenarians, over 2 decades, risk factor prevalence increased, management strategies improved, and survival remained stable, but the proportion hospitalized for cardiovascular causes declined. Despite increasing clinical complexity, in cardiology settings the burden of hospitalizations in the oldest old with chronic HF is declining.

Comprehensive Palliative Care Needs in Outpatients with Chronic Heart Failure: A Japanese Cross-Sectional Study.

Background:The type and frequency of palliative care needs of chronic heart failure (CHF) patients have not been determined in Japan.Objectives:The aim of this study was to comprehensively assess the prevalence and characteristics of palliative care needs of CHF outpatients.Methods:Patients were recruited for this cross-sectional study from June 1 to August 31, 2020, at the Kobe University Hospital. An Integrated Palliative care Outcome Scale (IPOS) and an original questionnaire developed by multidisciplinary experts were answered once by patients themselves or with the assistance of their family.Results:A total of 101 patients (63 males and 38 females) were included. The most common distressing symptoms were dyspnea (29%; 95% confidence interval [CI] 21–39]), drowsiness (29%; 95% CI 21–39), poor mobility (25%; 95% CI 17–35), insomnia (25%; 95% CI 17–35), and anxiety (24%; 95% CI 17–35). Eighty percent (95% CI 70–87) of patients were willing to have an end-of-life (EOL) discussion. When we compared New York Heart Association class I/II with III/IV patients, the frequency of distressing symptoms was associated with the severity of the disease, but both groups exhibited a willingness for having an EOL discussion or knowing the future course of their diseases.Conclusions:Dyspnea, drowsiness, insomnia, and anxiety were frequent symptoms in CHF outpatients in Japan. Beyond distressing symptoms, most ambulatory heart failure patients have a need for EOL discussion, which was not associated with disease stage. Assessing comprehensive and multidimensional palliative care needs, including needs for EOL discussion, is advisable among outpatients with CHF.

Cardiac cycle time-corrected electromechanical activation time greater than 15% is an independent risk factor for major adverse cardiovascular events in chronic heart failure outpatients.

Objectives:This study aimed to investigate the predictive value of cardiac cycle time-corrected electromechanical activation time (EMATc) for major adverse cardiovascular events (MACEs) in outpatients with chronic heart failure (CHF) in comparison with other clinic indexes.Methods:This prospective observational study at Beijing Anzhen Hospital from January 01, 2015 to January 01 2018 enrolled 120 CHF patients who were admitted for acute onset of CHF and followed up after discharge for 616.5 days (range: 202.75–875.25 days). Based on the different endpoints, cardiogenic death, all-cause death, and HF-related readmission, patients were assigned to the following groups: cardiogenic death and non-cardiogenic death groups, all-cause death and survival groups, and HF readmission and non-readmission groups. EMATc and other clinic indexes were measured and compared between these groups. Cox regression analysis was used to identify independent risk factors for MACEs.Results:The hazard ratio for EMATc>15% for cardiogenic death was 3.493 (P=0.046), suggesting that an EMATc>15% was an independent risk factor for cardiogenic death in CHF patients. The hazard ratios for B-type natriuretic peptide (BNP) >400 ng/L for all-cause death and CHF readmission were 3.810 (P=0.008) and 2.764 (P=0.031), respectively. Thus, BNP >400 ng/L was an independent risk factor for all-cause death and readmission for CHF. EF<40% was not found to be a significant risk factor for MACEs.Conclusions:BNP level can predict the risk for poor prognosis in CHF patients. EMATc>15% is an independent risk factor for cardiogenic death and should be considered as a supplement to serum BNP level and other clinical indexes for predicting cardiogenic death in CHF outpatients.

Prognostic Role of Subclinical Congestion in Heart Failure Outpatients: Focus on Right Ventricular Dysfunction.

Background: subclinical pulmonary and peripheral congestion is an emerging concept in heart failure, correlated with a worse prognosis. Very few studies have evaluated its prognostic impact in an outpatient setting and its relationship with right-ventricular dysfunction. The study aims to investigate subclinical congestion in chronic heart failure outpatients, exploring the close relationship between the right heart-pulmonary unit and peripheral congestion. Materials and methods: in this observational study, 104 chronic HF outpatients were enrolled. The degree of congestion and signs of elevated filling pressures of the right ventricle were evaluated by physical examination and a transthoracic ultrasound to define multiparametric right ventricular dysfunction, estimate the right atrial pressure and the pulmonary artery systolic pressure. Outcome data were obtained by scheduled visits and phone calls. Results: ultrasound signs of congestion were found in 26% of patients and, among this cohort, half of them presented as subclinical, affecting their prognosis, revealing a linear correlation between right ventricular/arterial coupling, the right-chambers size and ultrasound congestion. Right ventricular dysfunction, TAPSE/PAPS ratio, clinical and ultrasound signs of congestion have been confirmed to be useful predictors of outcome. Conclusions: subclinical congestion is widespread in the heart failure outpatient population, significantly affecting prognosis, especially when right ventricular dysfunction also occurs, suggesting a strict correlation between the heart-pulmonary unit and volume overload.

Age-related changes in clinical characteristics and outcomes of chronic heart failure outpatients in a cardiology setting. A report from the Italian Network on Heart Failure

AimsAgeing and comorbidities are increasing frailty/complexity of heart failure (HF) patients globally. We assessed evolving trends over two decades according to patients' age and time of recruitment in a nationwide cardiology setting in Italy. Methods and resultsChronic HF outpatients recruited between 1999 and 2018 (N = 14,823) were divided into 3 cohorts: 1999–2005 (N = 5404); 2006–2011 (N = 3971); 2012–2018 (N = 5448). We analyzed temporal changes in clinical characteristics, therapies, and outcome (1-year all-cause mortality/cardiovascular hospitalization), overall and by age group: <65 (n = 5465); 65–79 (n = 6838); ≥80 (n = 2520) years old. Across enrolment epochs, comorbidities (atrial fibrillation, hypertension, obesity) increased by both epoch/age groups (p < 0.001), whereas the prevalence of ischemic etiology declined among patients ≥65 years (p = 0.05). Accordingly, the preserved LVEF phenotype (HFpEF) increased in all age categories (p < 0.001) over time. Moreover, the use of betablockers, mineralocorticoid-receptor antagonists and loop-diuretics rose by enrolment epoch in all age groups (p < 0.05). In parallel with these epidemiologic/treatment changes, age-adjusted survival free from cardiovascular hospitalization improved over time (p < 0.0001). However, divergent trends in the end-point components were apparent according to age groups: mortality decreased in patients<80 years, although hospitalizations remained stable in the youngest group, while subjects ≥65 years were less likely to be admitted for cardiovascular causes (all p < 0.005). ConclusionsOver two decades in a cardiology outpatient setting, the prevalence of comorbid HFpEF increased in all age categories. Mortality improved among patients<80 years and cardiovascular hospitalizations decreased in patients≥65 years. These findings point to the value of cardiologist’ input in the management of adult chronic HF patients at all ages.

Lung ultrasound in outpatients with heart failure: the wet-to-dry HF study.

AimsIn ambulatory patients with chronic heart failure (HF), congestion and decongestion assessment may be challenging. The aim of this study is to assess the value of lung ultrasound (LUS) in outpatients with HF in characterizing decompensation and recompensation, and in outcomes prediction.Methods and resultsHeart failure outpatients attended to establish HF decompensation were included. LUS was blindly performed at baseline (LUS1) and at clinical recompensation (LUS2). B‐lines were counted in eight scanned areas. Diagnosis of no HF decompensation vs. right‐sided, left‐sided, or global HF decompensation, and patients' management were performed by physicians blinded to LUS1. Outcome was the composite of all‐cause death or HF‐related hospitalization. Two hundred and thirty‐three suspicions of HF decompensation were included in 187 patients (71.4 ± 11.3 years, 66.8% men). Mean B‐line (LUS1) was 17.6 ± 11.2 vs. 3.7 ± 4.5 for episodes with and without HF decompensation, respectively (P < 0.001). Global HF decompensation showed the highest number of B‐lines (20.6 ± 11), followed by left‐sided (19.7 ± 11.6) and right‐sided (13.5 ± 9.8). B‐lines declined to 6.9 ± 6.7 (LUS2) (P < 0.001 vs. LUS1) after treatment, within a mean time of 24.2 ± 23.7 days [median 13.5 days (interquartile range 6–40)]. B‐lines were significantly associated with the composite endpoint at 30 days (hazard ratio [HR] 1.04 [95% confidence interval 1.01–1.07], P = 0.02), but not at 60 (P = 0.22) or 180 days (P = 0.54). In multivariable analysis, B‐line number remained as an independent predictor of the composite endpoint at 30 days, [HR 1.04 (1.01–1.07), P = 0.014], with a 4% increase risk per B‐line added. B‐lines correlated significantly with CA125 (R = 0.30, P = 0.001).ConclusionsLung ultrasound supports the diagnostic work‐up of congestion and decongestion in chronic HF outpatients and identifies patients at high risk of short‐term events.

Prevalence of Thiamine Deficiency in Chronic Heart Failure Patients: Ramathibodi Cardiology Clinic Experience

Objective: Thiamine deficiency is still a public health concern in developing countries including Thailand. Heart failure is associated with thiamine deficiency especially in patients receiving diuretic therapy. Therefore, we sought to find the prevalence of thiamine deficiency in chronic heart failure outpatients. Materials and Methods: A cross-sectional descriptive epidemiological study in 50 heart failure patients scheduled for regular follow-up visits at Ramathibodi Cardiology Clinic, Mahidol University, Bangkok, Thailand. Thiamine pyrophosphate effect was used to identify thiamine deficiency. Review of electrical medical records were made in order to collect variable clinical and demographic data. Results: The mean age was 60&plusmn;2.1 years, 54% were male. The mean left ventricular ejection fraction was 37&plusmn;2.5%. The prevalence of thiamine deficiency in a chronic heart failure outpatient was 6% (n=3). Thiamine status was negatively associated with left ventricular ejection fraction (r=-0.283, p=0.047) and thiamine status was positively associated with left ventricular dimension (r=0.462, p=0.001). However, there was no association between the dose of diuretic and thiamine status (r=0.024, p=0.882), duration of heart failure and thiamine status (r=-0.012, p=0.945). In patients with severe thiamine deficiency, there were subsequent serious adverse cardiovascular outcomes (one had cardiac arrest and underwent left ventricular assist device). Conclusion: We found that the prevalence of thiamine deficiency in chronic heart failure outpatients is low in an urban outpatient setting. Keywords: Thiamine deficiency; Heart failure; Prevalence

TSH Variations in Chronic Heart Failure Outpatients: Clinical Correlates and Outcomes.

Hypothyroidism is a frequently observed comorbidity in patients with chronic heart failure (CHF), possibly giving rise to unfavorable outcomes. The aim of the study was to evaluate the impact of TSH changes over time on cardiac function and prognosis of outpatients with CHF. Patients underwent clinical, electrocardiographic, and echocardiographic evaluations at baseline and after 12 months. Moreover, blood chemistry tests were performed to evaluate renal function, cardiac biomarkers, fT3, fT4, and TSH levels. Based on TSH serum levels, patients were retrospectively classified into four categories: Group 1, patients with improved thyroid function at one-year follow up vs. baseline; Group 2, patients with stable and mildly high TSH values (3.74 - 10 mUI/L); Group 3, patients with worsening thyroid function; Euthyroid patients Group, TSH levels within the normal range of reference at baseline as well as at 12 months follow-up. We considered as end-points: one-year changes of laboratory and echocardiographic parameters; hospitalizations due to worsening of HF (acute decompensated heart failure - ADHF); death for all causes. Among 257 patients, 174 (67.7%) were euthyroid at baseline and after 12 months. Group 1 patients (n. 22, 8.6%) showed a significant improvement in systolic and diastolic function, filling pressures, NT-proBNP and Galectin-3. Group 2 patients (n. 34, 13.2%) did not exhibit significant modifications in studied parameters. Group 3 patients (n. 27, 10.5%) showed worsening of diastolic function and NT-proBNP and a greater risk of ADHF (HR: 2.12; 95%CI: 1.20-3.74; p: 0.009) and death (HR: 4.05; 95%CI: 2.01-8.15; p<0.001). In patients with CHF, changes in thyroid function over time influenced echocardiographic parameters and biomarkers reflecting modifications of cardiac function and prognosis, thus suggesting the clinical relevance of thyroid deficiency screening and correction.

Interrelationship between renin-angiotensin-aldosterone system and oxidative stress in chronic heart failure patients with or without renal impairment

We investigated oxidative stress and RAAS biomarkers, as well as their association, in chronic heart failure (CHF) patients on optimized medical therapy, stratified by disease severity or by renal function. Since vitamin D has been shown to attenuate RAAS activation and oxidative stress, we further evaluated the relationship between vitamin D, RAAS and oxidative stress in CHF patients with or without renal impairment. Sixty CHF outpatients were included and stratified by disease severity or by renal function. We quantified urinary hydrogen peroxide, plasma and urinary isoprostanes, plasma total antioxidant status, urinary angiotensinogen (intrarenal RAAS activation biomarker) and plasma angiotensinogen, plasma renin and aldosterone concentration, serum angiotensin-converting enzyme (ACE) activity, plasma angiotensin peptides, and serum total 25-hydroxyvitamin D (S-total 25(OH)D). Severe CHF patients had higher urinary isoprostanes (p = 0.002) and lower S-total 25(OH)D (p = 0.006) compared to mild-to-moderate patients, but no differences were observed for other redox or RAAS biomarkers. Patients with impaired renal function (iRF) had higher urinary angiotensinogen (p = 0.003) and lower S-total 25(OH)D (p = 0.028) compared to those with normal renal function (nRF), while no differences were observed for the remaining RAAS and redox parameters. Several positive correlations between oxidative stress and RAAS biomarkers were detected in iRF patients, while in patients with nRF these correlations were primarily inverse. In CHF-iRF patients, S-25(OD)D was inversely associated with urinary isoprostanes, which in turn were positively associated with plasma angiotensinogen and serum ACE. In conclusion, CHF patients with renal function impairment have increased intrarenal RAAS activation and lower vitamin D values and might benefit from the combination of RAAS blockers with vitamin D and/or antioxidants.

Baseline and incident hypochloremia in chronic heart failure outpatients: Clinical correlates and prognostic role

BackgroundElectrolyte serum disorders are associated with poor outcome in chronic heart failure. The aim of this study sought to identify the main driver of incident hypochloremia in chronic HF (CHF) outpatients and to determine the prognostic value of baseline and incident hypochloremia. MethodsConsecutive CHF outpatients were enrolled and clinical, laboratoristic and echocardiographic evaluations were performed at baseline and repeated yearly in a subgroup of patients. Baseline and incident hypochloremia were evaluated. During an up to 5-year follow-up, all-cause mortality was the primary end-point for outcome. ResultsAmong 506 patients enrolled, 120 patients died during follow-up. At baseline, hypochloremia was present in 10% of patients and it was associated with mortality at univariate (HR: 3.25; 95%CI: 2.04–5.18; p<0.001) and at multivariate analysis (HR 2.14; 95%CI: 1.23–3.63; p: 0.005) after correction for well-established CHF prognostic markers. Among patients with repeated evaluations and without baseline hypochloremia, in 13% of these, incident hypochloremia occurred during follow-up and furosemide equivalent daily dose was its first determinant (HR for 1 mg/die: 1.008; 95%CI: 1.004–1.013; p<0.001) at forward stepwise logistic regression analysis. Finally, incident hypochloremia was associated with mortality at univariate (HR: 4.69; 95%CI: 2.69–8.19; p<0.001) as well as at multivariate analysis (HR: 2.97; 95%CI: 1.48–5.94; p: 0.002). ConclusionsIn CHF outpatients baseline and incident hypochloremia are independently associated with all-cause mortality, thus highlighting the prognostic role of serum chloride levels which are generally unconsidered. Future studies should evaluate if the strict monitoring and correction of hypochloremia could exert a beneficial effect on prognosis.

Pre-existing type 2 diabetes is associated with increased all-cause death independently of echocardiographic predictors of poor prognosis only in ischemic heart disease

Background and aimsIt is unknown whether the prognostic role of diabetes (T2DM) in outpatients with chronic heart failure (CHF) is independent of the most important echocardiographic markers of poor prognosis. The aims of this analysis were to evaluate whether T2DM modifies the risk of mortality in CHF patients stratified by etiology of disease or by right-ventricular to pulmonary arterial coupling at echocardiography and to evaluate how T2DM interacts with the prognostic role of cardiac plasma biomarkers. Methods and resultsThis is a retrospective analysis of 1627 CHF outpatients who underwent a complete echocardiographic examination. During a median follow-up period of 63 months 255 patients died. Poor right-ventricular to pulmonary arterial coupling and reduced left ventricular ejection fraction were independent predictors of outcome, whereas ischemic etiology and T2DM were not. T2DM interacted with etiology increasing the risk of mortality by 32% among patients with ischemic disease (p = 0.003). Elevated hsTNI plasma levels were associated with poor survival in T2DM but not in non-diabetic patients. ConclusionT2DM signals a worse outcome in ischemic CHF patients regardless of the echocardiographic phenotype. High plasma levels of hsTNI are stronger predictors of mortality in CHF patients with T2DM than in patients without diabetes.

Thyroid Disorders and Prognosis in Chronic Heart Failure: A Long-Term Follow-Up Study.

Thyroid disorders may have a negative impact on the prognosis of patients affected by chronic heart failure (CHF). The aim of the current study was to evaluate the prognostic role of all thyroid disorders over a long term follow-up in a single centre large sample of CHF outpatients. In all patients, the function of the thyroid was evaluated at the enrolment and during the follow- up. On the basis of free triiodothyronine (T3), free thyroxine (fT4) and thyroid-stimulating hormone (TSH) serum levels, patients were classified into one of the following four categories: euthyroid subjects, patients affected by hypothyroidism, low T3 (LT3) syndrome and hyperthyroidism. During the follow-up, death for all causes was assessed as primary end-point, whereas time to the first hospitalization for heart failure worsening was the secondary end-point analyzed. Among 762 patients, 190 patients were affected by hypothyroidism (Hypo). LT3 syndrome was diagnosed in 15 patients and 59 patients were affected by hyperthyroidism (Hyper). During a long term follow-up (5.1±3.7 years), 303 patients died. Patients with Hypo showed an increased risk of death as well as of hospitalization due to heart failure worsening at univariate regression analysis. At multivariate regression analysis, Hypo remained associated with hospitalization after correction for age >75 years, ischemic aetiology, diabetes, therapy with ACE-inhibitors or ARBs, therapy with betablockers and with aldosterone antagonists, NYHA class 3, systolic arterial pressure <95 mmHg, left ventricular ejection fraction <30%, estimated glomerular filtration rate <60 ml/min, hyponatremia and NTproBNP> 1000 pg/ml. At multivariate analysis, the independent association with death was significant only for the subgroup of patients with TSH >10 mIU/L. LT3 was independently associated with both heart failure hospitalization and death, whereas Hyper was not associated with any of the two considered end-points. Hypo is associated with a worse prognosis over a long-term follow-up. The association with heart failure hospitalization is not dependent on the baseline TSH levels, whereas the association with death is significant only when TSH >10 mIU/L. Finally, Hyper does not have any association with a worse prognosis.