Concept Of Heart Failure Research Articles

New concepts in heart failure with preserved ejection fraction and hypertension.

Hypertension (HTN) remains the most common and strongest contributing factor to the development of heart failure with preserved ejection fraction (HFpEF). In this review, we aim to summarize the pathophysiological processes linking HTN to HFpEF and highlight novel concepts in medical and device-based management of HFpEF and HTN. Despite the global increase in the prevalence of HFpEF, there has been limited benefit in current medication and device-based therapy for this complex syndrome. The hallmark of HFpEF is an elevated left intra-atrial and ventricular pressure and exertional dyspnea. Traditional medications used for treating HTN in patients with reduced left ventricular ejection fraction have unclear benefits in patients with HFpEF. Careful analysis of emerging medications such as angiotensin receptor-neprilysin inhibitor and sodium-glucose co-transporter-2 inhibitors showed benefit in reducing not only blood pressure but also hospitalizations in patients with HFpEF. Current data on device-based therapy aims to reduce left intra-atrial pressure, ventricular pressure and stimulate baroreceptors to lower blood pressure; however, needs further investigation. The nexus of HTN and HFpEF remains strong and complex. Although traditional medications for treating HFrEF did not affect long-term outcomes, novel therapies with angiotensin receptor neprilysin-inhibitor and sodium-glucose co-transporter-2 inhibitor offer promising results. Many device-based interventions in the HFpEF population are being developed with the aim to reduce left intra-atrial and ventricular pressure; however, their role in HFpEF hypertensive patients needs to be further investigated.

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.

Late mortality with a 3-year follow-up of hospitalized patients with heart failure with normal, mid-range or reduced ejection fraction

Abstract Introduction In 2016, the European Society of Cardiology published a new concept of heart failure (HF) inbetween HF with reduced ejection fraction (EF) (HFrEF; EF<40%) and HF with preserved EF (HFpEF; EF>50%), the HF with mid-range EF (HFmrEF; EF between 40% and 49%). There are few studies evaluating its distinct clinical characteristics, especially in Latin America. Objective To compare clinical, laboratory and mortality characteristics in individuals with HFpEF, HFmrEF and HFrEF. Method Retrospective analysis in a prospective database of Brazilian coronary care unit admissions of patients clinically diagnosed with decompensated HF associated with serum cerebral natriuretic peptide (BNP) levels above 400 mg/dL, between September 2011 and June 2019. The clinical and laboratory characteristics of the patients, as well as the HF classification into HFpEF, HFmrEF and HFrEF, were evaluated with the first echocardiogram of the hospitalization. Analysis of variance (ANOVA) to compare means, the chi-square test for categorical variables, and the Cox regression for survival analysis were performed, with a significance level of 5%. Results The analysis included 519 patients (mean age, 74.46±12.75 years; men, 59.6%). Post-discharge follow-up was 2.94±2.55 years. Late mortality according to EF did not statistically differ between groups (53.8% x 52.1% x 57.9%, p=0.5). Multivariate analysis with Cox regression showed the following main predictors of late mortality: age (aHR 1.03; 95% CI: 1.02–1.04) and dementia (aHR 1.85; 95% CI: 1.31–2.62). The HFpEF group (aHR 1.63; 95% CI: 1.08–2.94) had higher mortality as compared to the HFmrEF (aHR 0.59; 95% CI: 0.36–0.97) and the HFrEF (aHR 0.63; 95% CI: 0.32–1.2) groups. Conclusion Factors associated with aging, such as dementia, were predictors of higher late mortality. The multivariate analysis of survival, regardless of the risk factors studied, showed a higher 3-year mortality in the HFpEF group as compared to that of the HFmrEF and HFrEF groups. Funding Acknowledgement Type of funding source: None

Pediatric cardiac transplantation

Heart transplantation in pediatric patients generally arises as a treatment option of last resort, that is, the indication is for patients with heart failure of various etiologies, with potential or actual end-organ dysfunction, in whom there are no reasonable, long-term options for life-prolonging therapy. The concept of heart failure is complex in a pediatric population, particularly those with congenital heart disease. While heart failure may refer simply to systolic dysfunction leading to low cardiac output, it can also encompass: diastolic dysfunction in restrictive cardiomyopathy; single ventricle physiology without an option for stable palliation. A good candidate should have a predicted life expectancy less than the median lifetime of a transplanted heart. Significant improvement in survival has been observed over time with 1- and 5-year survival approximately 90% and 80% in the contemporary era.

Clinical Care for the Patient with Heart Failure: A Nursing Care Perspective

Providing clinical nursing care to a patient with a heart disease requires the application of the knowledge of disease process which informs the nursing intervention. This paper presents a discussion on some priority aspects of clinical care for the patient with heart failure from the perspective of nursing care as summarized in the figure below. A brief summative overview of the disease process and the central concept in heart failure as fundamental to the conceptualization of clinical care needs for a patient with heart failure was presented. Application of the framework of the nursing process in providing clinical nursing care for a patient with a heart disease and the application of ethical principles were discussed. Thus, competent and therefore safe clinical care for a patient with heart failure requires comprehensive nursing care which embraces both the scientific approach and ethics of care.

Protein post-translational modifications and misfolding: new concepts in heart failure.

A new concept in the field of heart-failure (HF) research points to a role of misfolded proteins, forming preamyloid oligomers (PAOs), in cardiac toxicity. This is largely based on few studies reporting the presence of PAOs, similar to those observed in neurodegenerative diseases, in experimental and human HF. As the majority of proteinopathies are sporadic in nature, protein post-translational modifications (PTMs) likely play a major role in this growing class of diseases. In fact, PTMs are known regulators of protein folding and of the formation of amyloid species in well-established proteinopathies. Proteomics has been instrumental in identifying both chemical and enzymatic PTMs, with a potential impact on protein mis-/folding. Here we provide the basics on how proteins fold along with a few examples of PTMs known to modulate protein misfolding and aggregation, with particular focus on the heart. Due to its innovative content and the growing awareness of the toxicity of misfolded proteins, an "Alzheimer's theory of HF" is timely. Moreover, the continuous innovations in proteomic technologies will help pinpoint PTMs that could contribute to the process. This nuptial between biology and technology could greatly assist in identifying biomarkers with increased specificity as well as more effective therapies.

Heart failure: a complex clinical process interpreted by systems biology approach and network medicine

Systems biology is founded on the principles of integrative computational analysis and on the data from genetic and molecular components. The integration of biological components produces interacting networks, modules and phenotypes with remarkable applications in the field of clinical medicine. The evolving concept of network medicine gives a more precise picture of the intrinsic complexity of failing myocardium and its clinical consequences. The present review is focused on the impact of network cardiology in explaining the progressive nature of the clinical syndrome of heart failure. The failing myocardium and the subsequent clinical syndrome of heart failure disclose a dynamical and non-linear system with a progressive picture of clinical deterioration. The classical description of heart failure is based on tissue pathology and clinical presentation, and lately on specific genetic and molecular modifications. This characterization of heart failure has significant limitations to recognize preclinical disease features and to explain the progressive nature of the syndrome. Systems biology detects and evaluates specific networks from molecular, cellular and tissue elements, and assesses their influence on the appearance of clinical phenotypes. The classical reductive concept of heart failure is inadequate to provide data for molecular dysfunctions or defective coordination of the interconnected network components that are central to the genesis and clinical deterioration of heart failure. In heart failure, the recognition of molecular targets within the complex networks will increase the conceptual basis of pharmacology and the identification of novel biomarkers and at the same time will accelerate the discovery of new drugs.

Simulation model for cost estimation of integrated care concepts of heart failure patients

BackgroundAs a direct result of the population growing older the total number of chronic illnesses increases. The future expenditure for care of chronically ill patients is an ever-present challenge for the health care system. New solutions based on integrated care or the inclusion of telemedical systems in the treatment procedure can be essential for reducing the future financial burden. Therefore a detailed economic model was developed, which enables the comparison of health and cost outcomes for conventional medical care and different integrated care concepts in heart failure treatment.MethodsF0r modelling, the discrete event technique was used. The model takes outpatient care as well as inpatient care into account to estimate the total occurring costs. It enables the treatment of patients by a physician, a specialist or a clinical ambulance for the simulation of the outpatient care. For inpatient care the model considers the total-costs of the hospitalization and rate of re-admission and furthermore the costs which occur because of special medical treatments or necessary stay at intensive care units. To rate the severity of symptoms patients can be classified using NYHA groups. To outline some of the potential model results, two scenarios have been simulated to compare both methods of care regarding overall costs.ResultsThe developed simulation model allows comparing health and cost outcomes of different integrated care concepts for the treatment of heart failure patients. Additionally to the simulation of standard outpatient and inpatient care procedures in Austria the approach of a telemedical monitoring system for heart failure patients was implemented in this economic model. With the simulated scenarios it could be shown that under the given simulation parameters the telemedical system can lead to cost savings of up to 8% within the first three years.ConclusionsThe developed model represents a comprehensive tool, which opens a wide field of possible simulation scenarios for the treatment of heart failure patients with special focus on overall cost estimations and reimbursement strategies. The simulated scenarios show that telemedical care has the potential of improved health outcomes and economic benefits.

Heart failure patients’ attitudes, beliefs, expectations and experiences of self-management strategies: A qualitative synthesis

To develop a model of heart failure patients' attitudes, beliefs, expectations, and experiences based on published qualitative research that could influence the development of self-management strategies. A synthesis of 19 qualitative research studies using the method of meta-ethnography. This synthesis offers a conceptual model of the attitudes, beliefs, and expectations of patients with heart failure. Patients experienced a sense of disruption before developing a mental model of heart failure. Patients' reactions included becoming a strategic avoider, a selective denier, a well-intentioned manager, or an advanced self-manager. Patients responded by forming self-management strategies and finally assimilated the strategies into everyday life seeking to feel safe. This conceptual model suggests that there are a range of interplaying factors that facilitate the process of developing self-management strategies. Interventions should take into account patients' concepts of heart failure and their subsequent reactions.

Heart Failure Management: The Present and the Future

Clinical heart failure has been defined for a long time as a clinical syndrome with symptoms and signs including shortness of breath, cyanosis, ascites, and edema. However, in recent years, with the thought of promoting early diagnosis and heart-failure prevention, the concept of heart failure has often been defined simply as a subject with severe LV dysfunction and a dilated left ventricle, or by some, defined by evidence of increased circulating levels of molecular markers of cardiac dysfunction, such as ANP and BNP. Heart failure has been considered an irreversible clinical end point. Current medical management for heart failure only relieves symptoms, slows deterioration, and prolongs life modestly. However, in the recent years, rejuvenation of the failing myocardium began to seem possible as the accumulating preclinical studies demonstrated that rejuvenating the myocardium at the molecular and cellular level can be achieved by gene therapy or stem cell transplantation. Here, we review selected novel modalities that have been shown in preclinical studies to exert beneficial effects in animal models of severe LV dysfunction and seem to have the potential to make an impact in the clinical practice of heart-failure management.

Comment évaluer et traiter l’insuffisance cardiaque à fraction d’éjection préservée

The concept of heart failure with preserved left ventricular ejection fraction has replaced that of diastolic heart failure. It is today the most frequent presentation of heart failure because of the progressive aging of the population. Its prognosis appears to be similar to that of heart failure with reduced systolic function. B type natriuretic peptide dosing as well as doppler-echocardiography are useful for the diagnosis. Today, no treatment has revealed effective but clinical trials have been scarce. Renin-angiotensin system antagonists have promising properties but haven't shown efficacy. This article reviews the epidemiologic, diagnostic, pathophysiologic and therapeutic aspects of the disease.

Ancient Egyptian Medicine and the Concept of Heart Failure

Background The cardiac glosses of the Ebers papyrus comprise the concepts and notions of the Egyptian physicians about the heart and its diseases. We sought to analyze some of the cardiac glosses of the Ebers papyrus, focusing on those which may describe early concepts of the syndrome of heart failure. Methods and Results Review of Joachim's German translation and both Bryan's and Ghalioungui's English translations of the Ebers papyrus. One clinical scenario describes patients with “weakness of the heart” or “cardiac dysfunction:” “His heart is bored,” “The heart weakens,” “This means that the heart does not speak or that the vessels of the heart are dumb. Its information under your hands normally appears because of the air with which they are filled is missing….” Debility that has arisen in the heart.” The other clinical scenario supplies information about patients with heart failure and “fluid retention” or “congestion”: “His heart is flooded. This is the liquid of the mouth. His body parts are all together weak”…“His heart is over flooded….” Conclusion Whether or not Egyptian medicine and the contents of the papyri paved the way for future knowledge, the clinical scenarios included in the Ebers papyrus may represent one of the earliest documented observations of the syndrome of heart failure.

Medical Therapy in Heart Failure – Is Polypharmacy Necessary?

The concept of heart failure has undergone several paradigm shifts in the past few decades. Therapeutic targets directed at the heart pump have shifted to circulatory haemodynamics to the current neurohormonal model.

Management of heart failure in children

B dvances in our understanding of the pathophysiology and molecular basis of diseases offer new, challenging, controversial, and sometimes, counterintuitive forms of therapy. This is especially true with regard to the syndrome of heart failure. Therapeutic approaches to heart failure in adults have evolved rapidly during the past decade. Unfortunately, as with many other aspects of medicine, our concepts of heart failure in the pediatric population have been reduced to a simple extrapolation of the adult model. Pediatricians know that a child is not a small adult. Consequently, heart failure is perhaps a far more complex entity in the pediatric population with regard to pathophysiology and the possible courses of action. In this review we summarize recent advances in heart failure research in adults and attempt to integrate these findings in a pediatric context. The basic paradigm of hemodynamic derangement and the consequent symptoms have dominated our approach to congestive heart failure for most of this century (Fig 1). Despite constraint by this narrow viewpoint, the normalization of hemodynamics has an immediate positive effect on symptomatic improvement. Multiple clinical trials were conducted in the adult population with a variety of pharmacologic strategies aimed at enhancing systolic performance only. The clinical outcome of these trials was disappointing because of adverse effects on the heart in the long term, since the initial improvement in the standard measures of heart failure severity (such as exercise tolerance, symptoms, and hemodynamics) was not sustained. 1,2 Application of information available from recent heart failure research enables us to go beyond the concept of the heart as a simple pump and formulate a more comprehensive understanding of the syndrome of heart failure (Fig 2). We are now beginning to recognize the

Post-infarction myocardial remodelling: why does it happen?

Myocardial remodelling is currently the subject of intense investigative interest. The question "Why does it happen?' is not clearly answerable by today's methods; however, the work of many basic scientists and clinicians has allowed an improved understanding of the process. Multiple mechanisms are probably operative in the cardiac remodelling process, including cell drop-out, myocyte slippage, collagen replacement and growth, and myocyte hypertrophy. The concept of heart failure as primarily a structural problem rather than the result of a specific biochemical "defect' is advanced. There is now direct evidence that cardiac myocytes are enlarged in both experimental and clinical left ventricular remodelling. Possible signal processing cascades are potential pathways to myocyte remodelling. Although not proven, the enlarged and elongated cardiac myocyte may be at a structural disadvantage, thus contributing functionally to the clinical syndrome of heart failure. Reversal of established cardiomegaly--regression of myocardial remodelling--is an unusual but occasional event in patients with cardiomyopathy that can be observed experimentally.

The Concept of Heart Failure From Avicenna to Albertini

In this scholarly work, Dr Jarcho has sought to illustrate and discuss the concepts held by physcians of a remote era about the nature, causes, and treatment of what is today termed "congestive heart failure." By limiting his study to a period from about 1000 AD to roughly 1748 AD, he has undertaken a very difficult task. Although this period extends more than 100 years beyond the publication of William Harvey's epochal description of the nature of the circulation (<i>De Motu Cordis</i>, 1628), these physiological concepts had not diffused significantly into clinical thought during the period under discussion. Consequently none of the approximately 19 physicians, whose writings Dr Jarcho has analyzed, was really aware of the function of the heart, and most did not even mention the possibility of cardiac malfunction as a cause of symptoms. There really was no concept of failure of the heart during those times, and

The Use of Digitalis Glycosides in Sinus Rhythm

Historical perspective Throughout the last 200 years the use of digitalis glycosides has constantly revealed the weakness of the contemporary understanding of congestive heart failure; in consequence the reputation of these drugs has either soared or slumped according to physicians’ prejudices. Withering (1 785) identified Digitalis purpurea as the diuretic ingredient of the Shropshire woman’s herbal brew and in his study of 160 patients he showed that it could relieve dropsy in most of his cases. Although he knew that the drug ‘influenced the pulse’, the concept of heart failure was not recognized, and the primary cardiac action of the drug was not then known. The indications for its use were ill-defined and with more widespread prescription many patients, with little prospect of improvement, were exposed to serious risk from toxic side-effects. Withering knew of no other agent with comparable properties, and he succeeded where many other failed by adopting a reliable dosage regimen and using an experimental approach in each case. He was conscious of the questions that were to inhibit the sustained use of the drug for over 100 years. How does digitalis work? What identifies patients who will benefit? How can the clinical response be measured? How may the risks of treatment be avoided? All are lively questions even today!

Starling and the Concept of Heart Failure

Starling and the Concept of Heart Failure