Decompensated Heart Failure Research Articles

Intracardiac energy inefficiency during decompensated and compensated heart failure.

The mechanisms underlying the acute decompensation of heart failure (HF) remain unclear. The present study examined intracardiac dynamics during decompensated HF using echo-vector flow mapping. Fifty patients admitted for decompensated HF were prospectively enrolled, and intracardiac energy loss (EL) was assessed by echo-vector flow mapping at admission (decompensated HF) and discharge (compensated HF). Outcome measures were average EL in the left ventricle (LV) in decompensated and compensated HF and were compared with those in 40 stable non-HF patients with cardiovascular diseases. The mean age of HF patients was 80.8±12.4years. The prevalence of both females and atrial fibrillation was 48.0%. The prevalence of HF with a reduced ejection fraction (<40%) (HFrEF) was 34.0%. The prevalence of decompensated HF classified into clinical scenario 1 was 33.3%. Blood pressure and NT-proBNP were significantly higher in decompensated HF than in compensated HF, while the ejection fraction (EF) was significantly lower. Average EL was significantly higher in compensated HF patients than in non-HF patients (40mW/m·L vs. 26mW/m·L, P=0.047). A multivariable analysis identified age, systolic blood pressure, LVEF, and the absence of chronic obstructive pulmonary disease as independent risk factors for high LV-EL regardless of the presence of HF. Furthermore, average EL in HF patients was significantly higher under acute decompensated conditions than under compensated conditions (55mE/m·L vs. 40mE/m·L, [+18mE/m·L, P=0.03]). Higher EL under decompensated HF conditions was significant in non-HFrEF (+19mW/m·L, P=0.009) and clinical scenario 1 (+23mW/m·L, P=0.008). The multivariable analysis identified eGFR as an independent risk factor for a decrease in average LV-EL under decompensated conditions. Energy inefficiency in LV was apparent even in stable HF patients and significant under acute decompensated conditions, particularly in HF with preserved EF and clinical scenario 1.

Days Not at Home: Association of Vulnerability with Healthcare Utilization After Hospitalization for Heart Failure.

Heart failure (HF) hospitalizations are characterized by vulnerability in functioning and frequent post-discharge healthcare utilization in both acute and post-acute settings. To determine, in patients hospitalized for decompensated HF, the association of vulnerability with (1) detailed forms of post-discharge healthcare utilization, and (2) days spent away from home after initial hospital discharge. Secondary analysis of a prospective longitudinal cohort study from a single-center academic institution in the USA. Adults admitted with acute decompensated HF who were discharged alive. The Vulnerable Elders Survey 13 (VES-13) measured functional vulnerability at baseline. The primary outcome was the Highest Healthcare Utilization (HHU) 90days post-discharge, from the following ordered categories: at home, emergency room visit, skilled nursing facility stay, hospital readmission, or death. The secondary outcome was the proportion of days not at home (DNAH) within the first 90days. Analyses were performed using a partial proportional odds model with adjustment for demographics and health characteristics. A total of 806 patients were included with median age 65, interquartile range [IQR] 55-73years. Fewer than half (N = 345 [43%]) of patients remained alive and at home during 90-day follow-up. There were 286 [35%] hospital readmissions and 70 [8.7%] participants died. The median DNAH was 3 [IQR 0-16]. Increased vulnerability was associated with (1) HHU, (2) higher odds of utilizing healthcare or dying versus being at home alive 90days post-discharge (OR 1.81 [95% CI, 1.35, 2.42]), and (3) higher odds of DNAH in the first 90days (OR 1.55 [95% CI, 1.27, 1.89]). In this cohort of patients hospitalized for decompensated HF, vulnerability predicted higher levels of healthcare utilization, as well as total days not at home in the 90days following hospitalization. Vulnerability may have clinical applications to identify patients at greatest need for comprehensive, patient-centered discharge planning.

Overlap of frailty and malnutrition as prognosticators in older patients with heart failure

BackgroundPhysical frailty and malnutrition coexist in older patients with heart failure (HF) and form a vicious cycle exacerbating each other and can cause poor clinical outcomes. We aimed to clarify the association of prevalence of physical frailty and malnutrition and clinical outcomes in hospitalized patients with HF. MethodsA total of 862 hospitalized patients aged ≥65 years with HF decompensation were included in this FRAGILE-HF post-hoc sub-analysis. Patients were categorized into Neither, Either, or Both groups based on the prevalence of physical frailty and malnutrition. The primary outcome was all-cause mortality within 1 year after discharge. Prognoses among the groups were compared in the entire cohort and in subgroups with preserved ejection fraction (pEF) and reduced/mildly reduced left ventricular ejection fractions (rEF/mrEF). ResultsThe Neither, Either, and Both groups comprised 32 %, 40 %, and 28 % respectively. During a 1-year follow-up period, 101 (12 %) patients died. Kaplan–Meier analysis showed significant differences in the primary outcomes among the groups (P < 0.001). The Both group had a higher risk of mortality (HR: 2.47, 95 % CI: 1.38–4.42) than the Neither group, while the Either group showed insignificant risk increase (HR: 1.58, 95 % CI: 0.86–2.90). Similar trends were observed in the pEF and rEF/mrEF subgroups (P = 0.60). ConclusionsPhysical frailty and malnutrition coexist in approximately one-quarter of hospitalized older patients with HF and are associated with an increased risk of mortality. Assessing both conditions is crucial for risk stratification and interventions to mitigate their interplay.

Tissue inhibitor of metalloproteinase (TIMP)-1 predicts failure of recovery of ejection fraction in acute heart failure with reduced ejection fraction

BackgroundHeart failure (HF) with improved ejection fraction (HFimpEF) is a recently identified phenotype of HF, which had better cardiovascular outcomes compared with persistent HF with reduced ejection fraction (HFrEF). The...

Cardio-ocular syndrome: Retinal microvascular changes in acutely decompensated heart failure.

To investigate the changes in retinal microvasculature by contemporary imaging techniques during episodes of acute decompensated heart failure (ADHF) and following recompensation compared to age-matched controls without known cardiac or retinal disease. Adult patients hospitalized with a primary diagnosis of ADHF, regardless of left ventricular ejection fraction (LVEF) and treated with a minimum dose of 40 mg of intravenous furosemide or equivalent were included. Transthoracic echocardiography was conducted in all patients. Eye examinations were performed out within the initial 24 h after admission and after recompensation before discharge. All eyes underwent a general examination, including a best corrected visual acuity test, dilated fundoscopy, spectral-domain optical coherence tomography (OCT) as well as OCT angiography (OCT-A). In addition, 40 participants without documented cardiac or retinal diseases served as controls. Forty patients with ADHF (mean age 78.9 ± 8.8 years; 32% female) with a mean LVEF of 43 ± 12.8% were included. All patients were treated with intravenous diuretics for a median of 4.3 ± 2.8 days. There was a significant reduction in N-terminal pro-B-type natriuretic peptide from baseline up to discharge (10 396 [interquartile range 6410] vs. 6380 [interquartile range 3933] pg/ml, p ≤ 0.001) and inferior vena cava diameters (2.13 ± 0.4 vs. 1.63 ± 0.3 cm, p = 0.003). Compared to the control group, patients with ADHF showed on admission impaired visual acuity (0.15 ± 0.1 vs. 0.35 ± 0.1 logMAR, p < 0.001), reduced macular vessel density (18.0 ± 1.9 vs. 14.3 ± 3.6 mm/mm2, p < 0.001) and perfusion density (42.6 ± 3.2 vs. 35.2 ± 9.7%, p < 0.001). After recompensation, the mean overall vessel density and mean overall perfusion density were markedly increased at discharge (14.3 ± 3.6 vs. 19.7 ± 2.6 mm/mm2, p = 0.001, and 35.2 ± 9.7 vs. 39.2 ± 6.5%, p = 0.005, respectively). The mean diameter of the superior temporal retinal vein at admission was significantly larger compared to the control group (136 ± 19 vs. 124 ± 22 μm, p = 0.008) and decreased significantly to 122 ± 15 μm at discharge (p < 0.001). This analysis revealed a remarkable reversible change in retinal microvasculature after ADHF. This could provide a valuable evidence for use of OCT-A in the assessment of overall microperfusion and haemodynamic status in patients with acute heart failure.

Neurohormonal Effects of Intravenous Dopamine in Patients with Acute Heart Failure

Background/Objectives: Many clinical trials have shown beneficial effects of low-dose dopamine on renal function, diuresis and symptom relief, or cardiac function in hospitalized patients with acute decompensated heart failure (HF). The aim is to assess the neurohormonal effects and the effects on clinical outcomes of the addition of low-dose dopamine in furosemide treatment in patients hospitalized for acute decompensated HF. Methods: A total of 62 patients hospitalized for acute decompensation of HF, were randomly allocated to one of the following three groups: i. LDF (low-dose furosemide), ii. HDF (high-dose furosemide) and, iii. LDFD (low-dose furosemide and dopamine). Primary outcomes of the present analysis were biochemical and neurohormonal indices (i.e., urea, creatinine, hemoglobin, electrolytes, natriuretic peptides, troponin, renin, angiotensin, aldosterone, adrenaline, noradrenaline). Secondary endpoints included clinical outcomes (i.e., length of stay, in-hospital mortality, 2-month mortality and rehospitalization, and 1-year mortality and rehospitalization). Results: Urea and creatinine levels were similar for each day among the three groups (p &gt; 0.05). The amount of urine was similar among the three groups per measurement at 2, 4, 6 and at 8 h (p &gt; 0.05). Biochemical and neurohormonal indices as well as clinical outcomes did not differ among patients receiving different doses of furosemide, nor in patients receiving furosemide in combination with dopamine (p &gt; 0.05). Conclusions: Although the addition of low-dose dopamine to intravenous furosemide was considered to have some theoretical advantages in maintaining renal function, no significant differences in neurohormonal effects and clinical outcomes were observed in patients hospitalized for acute decompensation of HF.

Quality of Life of Patients with Heart Failure Due to Myocardial Ischemia.

Heart failure caused by myocardial ischemia is a common cause encountered in clinical practice. A significant problem in heart failure is its progressive, unfavorable course and the associated increased frequency of repeated hospitalizations, as well as a significant deterioration in the functioning of patients, leading to their inability to function independently and a significant decline in the quality of life. This study aimed to assess the quality of life of patients with heart failure due to myocardial ischemia, considering the left ventricular ejection fraction, the number of "diseased" coronary arteries, co-occurring diseases, and cardiovascular risk factors. A total of 204 patients with decompensated heart failure due to chronic myocardial ischemia were included in this study and examined twice: A: on the first day of hospitalization; A': from 4 to 8 weeks. For the individual assessment of the quality of life, the WHOQOL-BREF (The World Health Organization Quality of Life - BREF) questionnaire was used. In the group of patients with heart failure in the decompensation stage a statistically significant positive relationship was observed between the number of comorbidities and the social domain (R(A) = 0.197; p(A) = 0.005), the number of diseased coronary arteries and the mental (R(A) = 0.184; p(A) = 0.184) and environmental (R(A) = 0.149; p(A) = 0.034) domains, left ventricular ejection fraction (LVEF%) and quality of life (R(A) = 0.235; p = 0.001) and satisfaction with health (R(A) = 0.235; p = 0.001) and somatic domain (R(A) = 0.194; p = 0.005). A similar result was observed among patients in the long-term follow-up. A statistically significant negative correlation was demonstrated in the mentioned group between the LVEF% value and the social domain (R(A) = -0.235; p = 0.001), as well as in the long-term follow-up (R(A') = -0.191, p = 0.026). The level of self-assessment of quality of life and satisfaction with health was statistically significantly higher among patients with heart failure in the long-term follow-up (3.20 ± 0.62) than in patients in the decompensation stage (1.98 ± 0.69). The quality of life of the examined patients with heart failure caused by chronic myocardial ischemia was poor, although it improved to average in the long-term follow-up. It was determined by left ventricular ejection fraction, the number of "diseased" coronary arteries, comorbidities, and risk factors.

Clinical implications of admission and follow-up urea-to-creatinine ratio in patients with acute decompensated heart failure

PurposeAcute decompensated heart failure (ADHF) patients with a poor renal function have a worse prognosis. The urea-to-creatinine ratio (UCR) may be a valuable tool for assessing kidney function and stratifying patients with ADHF. We evaluated the value of an admission and follow-up UCR in predicting AKI, 28-day mortality, and rehospitalization in patients with ADHF.MethodsThis prospective research comprised sixty patients with ADHF. Based on the mean admission UCR, patients are classified into two groups: the high UCR group (UCR ≥ 42.33) and the low UCR group (UCR < 42.33). On the third day, they are categorized into high UCR and low UCR groups according to the same mean of UCR (42.33). A 28-day follow-up was implemented.ResultsThirty patients (50%) developed AKI, and nine (15%) died during follow-up. In the high UCR group, the development of AKI was considerably more significant than in the low UCR group on the 3rd day (69.2% vs. 35.2%, respectively, p = 0.010). Furthermore, the high UCR group experienced a higher death rate than the low UCR group on the 3rd day (26.9% vs. 5.8%, respectively, p = 0.024). A considerable statistical correlation was reported between UCR and eGFR on the 3rd day (p = 0.025). According to ROC, UCR on the 3rd day was a significant predictor of AKI and 28-day mortality in these patients ((AUC = 0.736 and 0.718, respectively). In contrast, UCR on admission was not a predictor of AKI or 28-day mortality (p = 0.578 and 0.305, respectively). Also, neither admission nor 3rd day UCR could predict HF readmission (p = 0.108 and 0.298, respectively). By the Kaplan–Meier curve, survival rates were highest when UCR ≤ 34.85 and reduced when UCR > 34.85 (p < 0.001).ConclusionThe follow-up UCR is a good predictor of AKI development and elevated 28-day mortality in ADHF patients. Considering its simplicity, this biomarker should be used more systematically in clinical practice.

Thoracic Fluid Content as an Indicator of High Intravenous Diuretic Requirements in Hospitalized Patients with Decompensated Heart Failure.

Background: The main cause of hospitalization in patients with heart failure is hypervolemia. Therefore, the primary treatment strategy involves diuretic therapy using intravenous loop diuretics to achieve decongestion and euvolemia. Some patients with acutely decompensated heart failure (ADHF) do not respond well to diuretic treatment, which may be due to diuretic resistance (DR). Such cases require high doses of diuretic medications and combination therapy with diuretics of different mechanisms of action. Although certain predisposing factors for diuretic resistance have been identified (such as hypotension, type 2 diabetes, impaired renal function, and hyponatremia), further research is needed to identify other pathophysiological markers of DR. Objective: This study aims to identify admission markers that can predict a high requirement for intravenous diuretics in hospitalized patients with decompensated heart failure. Methods: This study included 102 adult patients hospitalized for ADHF. At admission, patients underwent clinical assessment, laboratory parameter evaluation (including the N-terminal prohormone of brain natriuretic peptide [NT-proBNP] levels), and hemodynamic assessment using impedance cardiography (ICG). Hemodynamic profiles were based on the use of parameters such as heart rate (HR), blood pressure (BP), and thoracic fluid content (TFC) as markers of volume status. The analysis included 97 patients with documented doses of intravenous diuretic use. Patients were stratified into two groups based on median diuretic consumption (equivalent to 540 mg of intravenous furosemide): the high-loop diuretic utilization (LDU) group (n = 49) and the low-LDU group (n = 48). Results: Compared to low-LDU patients, high-LDU patients had greater thoracic fluid content at admission, both quantitatively (37.4 ± 8.1 vs. 34.1 ± 6.9 kOhm-1; p = 0.024) and qualitatively (TFC ≥ 35 kOhm-1: 59.2% vs. 33.3%; p = 0.011). Anemia was more common in the high-LDU group (67.4% vs. 43.8%; p = 0.019), as was elevated NT-proBNP (≥median of 3952 pg/mL: 60.4% vs. 37.5%; p = 0.024). High LDU was associated with a significantly longer hospitalization duration (12.9 ± 6.4 vs. 7.0 ± 2.6 days; p < 0.001). Logistic regression analysis identified anemia, elevated NT-proBNP, and high TFC as predictors of high LDU (HR: 2.65, 2.54, and 2.90, respectively). In a multifactorial model, only high TFC remained an independent predictor (HR: 2.60, 95% CI 1.04-6.49; p = 0.038). Conclusions: TFC was the sole independent admission marker of a high requirement for intravenous diuretics in patients hospitalized for decompensated heart failure. An objective assessment of volume status by impedance cardiography may support intensive personalized decongestion therapy.

Safety and Efficacy of Remogliflozin in Patients with Type 2 Diabetes Mellitus Hospitalized For Acute Decompensated Heart Failure (RemoSafe AHF)

Safety and Efficacy of Remogliflozin in Patients with Type 2 Diabetes Mellitus Hospitalized For Acute Decompensated Heart Failure (RemoSafe AHF)

Add-on multidrug treatment based on quadruple therapy successfully treated worsening heart failure caused by anthracycline-induced cardiomyopathy in a survivor of cancer as a young adult: a case report

BackgroundThe overall mortality and morbidity benefit in patients with heart failure with a reduced ejection fraction is greatest with a treatment combination of sacubitril/valsartan, beta-blockers, mineralocorticoid-receptor antagonists, and sodium-glucose transporter-2 inhibitors, termed the “fantastic four” or “quadruple therapy.” The addition of vericiguat (an oral soluble guanylate cyclase stimulator) is believed to aid in managing worsening heart failure after quadruple therapy. Among childhood and young adult cancer survivors, cardiovascular complications that develop more than 10 years after anthracycline-based chemotherapy have a poor prognosis. Therefore, this study reports the efficacy of multidrug regimen based on quadruple therapy for worsening heart failure in cancer survivors with anthracycline-induced cardiomyopathy.Case presentationA survivor of cancer as a young adult who received high-dose anthracycline chemotherapy presented with acute decompensated heart failure 20 years post-chemotherapy and worsening heart failure 1.5 years after discharge. The patient showed signs of improvement after a step-wise introduction of carvedilol, empagliflozin, sacubitril/valsartan, ivabradine, and spironolactone for worsening heart failure. Vericiguat was accelerated owing to the risk of more severe cardiovascular events associated with ongoing aortic stenosis and the poor prognosis of anthracycline-induced cardiomyopathy. Heart failure symptoms continued to improve, with significant cardiac reverse remodeling, and the patient successfully underwent aortic valve replacement for severe aortic stenosis.ConclusionsOur case highlighted that multidrug treatment with add-on vericiguat and ivabradine based on quadruple therapy can potentially treat worsening heart failure in young adult cancer survivors with severe anthracycline-induced cardiomyopathy.

Clinical and utilization outcomes with short stay units vs hospital admission for lower risk decompensated heart failure: a systematic review and meta-analysis.

With over 1 million primary heart failure (HF) hospitalizations annually, nearly 80% of patients who present to the emergency department with decompensated HF (DHF) are hospitalized. Short stay units (SSU) present an alternative to hospitalization, yet the effectiveness of the SSU strategy of care is not well known. This study is to determine the effectiveness of a SSU strategy compared with hospitalization in lower-risk patients with DHF. Our primary outcome was a composite of 30-day mortality and re-hospitalization. Key secondary outcomes included 90-day mortality and re-hospitalization, costs, and 30-day days-alive-and-out-of-hospital (DAOOH). This is a systematic review and meta-analysis, following PRISMA guidelines. MEDLINE, EMBASE, CENTRAL, CINAHL, SCOPUS, and Web of Science were searched from inception through February 2024. Either randomized trials or comparative observational studies were included if they compared outcomes between low-risk ED DHF patients admitted to an SSU (defined as an observation unit with expected stay ≤ 48h) vs. admitted to the hospital. Two authors independently screened all titles and abstracts and then identified full texts for inclusion. Data extraction and risk of bias assessments were performed by two authors in parallel. The primary outcome was a composite of death or readmission within 30days, reported as relative risk (RR), where a RR < 1 favored the SSU strategy. Secondary outcomes included 90-day mortality and re-hospitalization, costs, and 1-month days-alive-and-out-of-hospital (DAOOH). Of the 467 articles identified by our search strategy, only 3 full text articles were included. In meta-analysis for the primary outcome of 30-day death or readmission, the RR was 0.95 (95% CI = 0.56 to 1.63; I2 = 0%) for patients randomized to SSU vs hospitalization (2 studies, 241 patients). There were only 2 total deaths at 30days in the 2 studies (total N = 258) which reported 30-day mortality, both in hospitalized patients. Only one study reported 90-day outcomes, showing no significant differences. Costs were lower in the SSU arm from one study, and 30-day DAOOH also favored SSU based on a single randomized trial. Based on very limited evidence, SSU provides similar efficacy for 30-day and 90-day mortality and readmission compared to hospitalization. An SSU strategy appears safe and may be cost effective.

Atrial Fibrillation Status and Physical Rehabilitation in Older Patients With Acute Decompensated Heart Failure: An Analysis From the REHAB-HF Trial.

The REHAB-HF (Rehabilitation Therapy in Older Acute Heart Failure Patients) trial demonstrated that a transitional, tailored, progressive rehabilitation intervention improved physical function, 6-minute walk distance, frailty, quality-of-life, and depression in older patients hospitalized for acute decompensated heart failure. This analysis assessed the impact of atrial fibrillation (AF) on intervention benefits. Of 349 enrolled patients hospitalized for acute decompensated heart failure (mean age 72.7±8.1 years), 176 (50.4%) had AF. Participants were randomly assigned to 12-week rehabilitation intervention or attention control. The primary outcome was Short Physical Performance Battery score at 3 months. Participants with AF were older (74.4±8.3 versus 70.8±7.5, P<0.0001) and had higher prevalence of heart failure with preserved ejection fraction (58.5% versus 47.4%, P=0.037). Patients with and without AF had similar improvement in Short Physical Performance Battery score (mean difference between rehabilitation intervention and attention control, 1.5 [95% CI, 0.6-2.3] versus 1.5 [95% CI, 0.7-2.3]; P<0.001). Those with AF had significant improvement in 6-minute walk distance (all P<0.05) and each of the Short Physical Performance Battery domains: balance, 4-meter walk, and chair rise. Kansas City Cardiomyopathy Questionnaire score significantly improved in patients with AF (P<0.05) but not those without AF (P>0.05). Interaction P values for 3-month outcomes by AF status were not significant (P>0.1). No significant differences were observed in deaths, all-cause rehospitalizations, or heart failure hospitalizations at 6 months. In older, hospitalized patients with acute decompensated heart failure, the presence of AF did not significantly affect the benefit of the rehabilitation intervention on physical function and quality of life. The intervention appears safe and effective regardless of AF status. URL: https://www.clinicaltrials.gov; Unique Identifier: NCT02196038.

Outcomes in acute decompensated chronic heart failure patients discharged with and without ivabradine: Advantages beyond heart rate control

&lt;p&gt;&lt;strong&gt;&lt;span lang="EN-GB" style="font-size: 10.0pt; line-height: 115%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-fareast-font-family: 宋体; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-ansi-language: EN-GB; mso-fareast-language: ZH-CN; mso-bidi-language: AR-SA;"&gt;Background and Aim: &lt;/span&gt;&lt;/strong&gt;&lt;span lang="EN-GB" style="font-size: 10.0pt; line-height: 115%; font-family: 'Times New Roman',serif; mso-ascii-theme-font: major-bidi; mso-fareast-font-family: 宋体; mso-hansi-theme-font: major-bidi; mso-bidi-theme-font: major-bidi; mso-ansi-language: EN-GB; mso-fareast-language: ZH-CN; mso-bidi-language: AR-SA;"&gt;Ivabradine is indicated in chronic heart failure (HF) and reduced ejection fraction (EF) of &amp;lt; 35% and resting heart rate (HR) of &amp;gt; 70 bpm. However, role of Ivabradine in acute decompensated chronic HF (ADCHF) is not well known. The aim of this study was to evaluate one-year outcomes of ADCHF patients discharged with and without Ivabradine. &lt;strong&gt;Materials and Methods: &lt;/strong&gt;This is a prospective observational cohort study of ADCHF patients from January 2016 to January 2018. Main exclusion criteria was new onset de-novo acute HF, those with EF &amp;gt; 50% and atrial fibrillation. Data were analysed from 130 patients who were discharged with (62 patients) or without Ivabradine (68 patients). The primary end points were one-year re-hospitalization and cardiovascular mortality between two groups. &lt;strong&gt;Results:&lt;/strong&gt; The mean age of patients were 56 &amp;plusmn; 15 years and 61 &amp;plusmn; 17 years between Ivabradine and Non-ivabradine groups. EF upon discharge was 37.48% &amp;plusmn; 5.34% vs 40.01% &amp;plusmn; 8. 12%, with &lt;em&gt;p&lt;/em&gt;-value of 0.036. At discharge, higher HR was noted in patients with Ivabradine 84 &amp;plusmn; 13 bpm compared to 77.84 &amp;plusmn; 12. 13 bpm in patients without Ivabradine (&lt;em&gt;p&lt;/em&gt;-value = 0.006). After a year, HR in Ivabradine group was low compared to non-Ivabradine group, but was not statistically significant, 66.15 &amp;plusmn; 8 vs. 69.29 &amp;plusmn; 11.3 bpm, respectively. In the Ivabradine group 27.4% of patients visited emergency room (ER) more than once compared to 60.2 % without Ivabradine (&lt;em&gt;p&lt;/em&gt;-value = 0.0001). 9.7% of patients in Ivabradine group required one readmission compared to 55.9% without Ivabradine (&lt;em&gt;p&lt;/em&gt;-value = 0.0001). &lt;strong&gt;Conclusions: &lt;/strong&gt;In ADCHF patients there was significant reduction in ER room visit and re-admission rate in patients discharged with Ivabradine. Hence Ivabradine therapy may be considered in patients with ADCHF with EF &amp;lt; 50% and HR &amp;gt; 70 bpm to prevent re-hospitalization and save hospitalization costs.&lt;/span&gt;&lt;span lang="EN-GB" style="font-size: 10.0pt; line-height: 115%; font-family: 'Times New Roman',serif; mso-fareast-font-family: 'Times New Roman'; mso-ansi-language: EN-IN; mso-fareast-language: ZH-CN; mso-bidi-language: AR-SA;"&gt; &lt;/span&gt;&lt;/p&gt;

Postnatally overfed mice display cardiac function alteration following myocardial infarction

BackgroundCardiovascular (CV) pathologies remain a leading cause of death worldwide, often associated with common comorbidities such as overweight, obesity, type 2 diabetes or hypertension. An innovative mouse model of metabolic syndrome induced by postnatal overfeeding (PNOF) through litter size reduction after birth was developed experimentally. This study aimed to evaluate the impact of PNOF on cardiac remodelling and the development of heart failure following myocardial infarction. MethodsC57BL/6 male mice were raised in litter adjusted to 9 or 3 pups for normally-fed (NF) control and PNOF group respectively. After weaning, all mice had free access to standard diet and water. At 4 months, mice were subjected to myocardial infarction (MI). Echocardiographic follows-up were performed up to 6-months post-surgery and biomolecular analyses were carried-out after heart collection. FindingsAt 4 months, PNOF mice exhibited a significant increase in body weight, along with a basal reduction in left ventricular ejection fraction (LVEF) and an increase in left ventricular end-systolic area (LVESA), compared to NF mice. Following MI, PNOF mice demonstrated a significant decrease in stroke volume and an increased heart rate compared to their respective initial values, as well as a notable reduction in cardiac output 4-months after MI. After 6-months, left ventricle and lung masses, fibrosis staining, and mRNA expression were all similar in the NF-MI and PNOF-MI groups. InterpretationAfter MI, PNOF mice display signs of cardiac function worsening as evidenced by a decrease in cardiac output, which could indicate an early sign of heart failure decompensation.

Extensive Dysregulation of Phenylalanine Metabolism Is Associated With Stress Hyperphenylalaninemia and 30-Day Death in Critically Ill Patients With Acute Decompensated Heart Failure.

Stress hyperphenylalaninemia predicts elevated mortality rates in patients with acute decompensated heart failure (ADHF). This study investigated the metabolic pathways underlying this association and identified a unique metabolic phenotype underlying the association between stress hyperphenylalaninemia and adverse outcomes in ADHF. This was a retrospective cohort study. We enrolled 120 patients with ADHF in an intensive care unit (60 with a phenylalanine level ≥112 μM, 60 with a phenylalanine level <112 μM), and 30 controls. Plasma phenylalanine-derived metabolites were measured, and participants were evaluated for 30-day death. Patients with ADHF had extensive activations of the alternative pathways for metabolizing phenylalanine, leading to the levels of phenylalanine-derived downstream metabolites 1.5 to 6.1 times higher in patients with ADHF than in the controls (all P<0.001). Extensive dysregulation of these alternative pathways significantly increased phenylalanine levels and contributed to a distinct metabolic phenotype, characterized by increased phenylalanine, tyrosine, homogentisic acid, and succinylacetone levels but decreased benzoic acid and 3,4-dihydroxyphenylalanine levels. Throughout the 30-day follow-up period, 47 (39.2%) patients died. This distinct metabolic phenotype was associated with an increased mortality rate (odds ratio, 1.59 [95% CI, 1.27-1.99]; P<0.001). A multivariable analysis confirmed the independent association of this metabolic phenotype, in addition to phenylalanine and tyrosine levels, with 30-day death. In patients with ADHF, extensive dysregulation of the alternative pathways for metabolizing phenylalanine was correlated with stress hyperphenylalaninemia and a distinct metabolic phenotype on the phenylalanine-tyrosine-homogentisic acid-succinylacetone axis. Both stress hyperphenylalaninemia and metabolic dysregulation on this axis were associated with poor outcomes.

The Impact of Beta-Blocker Maintenance on Decompensated Heart Failure: A Systematic Review and Meta-Analysis.

Acute Heart Failure (HF) is related to a significant hospital mortality rate and functional impairment in many patients. However, there is still a lack of studies that support the use of Beta-blockers (BB) in the management of decompensated HF. This study aimed to evaluate the impact on mortality of maintaining BB in patients with decompensated HF. A systematic review and meta-analysis was performed, using the databases PubMed, Cochrane Library, SCIELO and BVS, selecting only cohort studies and Randomized Clinical Trials (RCTs) from the last 10 years, which have been selected based on inclusion and exclusion criteria. An 86% reduction in the risk of in-hospital death was found (RR=0.14, 95% CI: 0.10- 0.18) in patients with HF who maintained the use of BB during hospitalization. A second analysis found a 44% (RR=0.56, 95% CI: 0.47-0.66) lower chance of in-hospital death in the group that previously used BB. Regarding the analysis of mortality after hospital discharge, only studies that have evaluated the use of BB in HF with reduced ejection fraction pointed to a reduction in mortality. Furthermore, some articles have found a relationship between the reduction in readmissions and the use of post-discharge BB. There is still no consensus regarding the use of BB in patients hospitalized with decompensated HF. In view of the limitations of the data found in the present study, the need for more RCTs that address this topic is emphasized in order to resolve this uncertainty in the management of cardiovascular patients.

Intravenous Levosimendan versus Inhalational Milrinone in the Management of Pulmonary Hypertension during Adult Cardiac Surgery: A Randomized Clinical Trial.

Introduction: The perioperative management of patients with pulmonary hypertension (PH) undergoing cardiac surgery is challenging, mainly due to the potential risk of right ventricular failure (RVF). Levosimendan is a calcium-sensitizing agent that has primarily been used in the treatment of decompensated heart failure. However, recently levosimendan has been shown to be an effective and safe therapeutic strategy for patients with pulmonary arterial hypertension and PH associated with left heart disease. The aim of this study was to investigate the potential utility of the preemptive administration of levosimendan in cardiac surgical patients with preexisting PH and to compare its effectiveness with milrinone, which represents an already established therapeutic option in the management of PH during cardiac surgery. Materials and Methods: In this study, 40 adult cardiac surgical patients with PH were randomly assigned to receive either levosimendan intravenously or milrinone via inhalation in a double-blind fashion prior to a cardiopulmonary bypass (CPB). Hemodynamic and echocardiographic parameters were recorded and evaluated before and after the administration of the drugs. Results and Conclusions: The results of this study demonstrated that both levosimendan and milrinone administered before CPB in cardiac surgical patients with PH may offer protective benefits, reducing pulmonary artery pressure and preventing the exacerbation of PH and RVF. Pulmonary vasodilation attributed to levosimendan is of longer duration and greater magnitude compared to pulmonary vasodilation afforded by milrinone.

In-hospital evolution of secondary mitral regurgitation in acutely decompensated heart failure.

Secondary mitral regurgitation (MR) negatively affects prognosis in acutely decompensated heart failure (ADHF), but can be rapidly sensitive to changes in volume status and medical interventions. We sought to assess the evolution of secondary MR in patients hospitalized for ADHF and its prognostic implications. We retrospectively enrolled 782 patients admitted for ADHF with at least two in-hospital echocardiographic evaluations of MR. We classified MR severity as none-mild or moderate-severe. Based on MR evolution, patients were divided into 'persistent moderate-severe MR', 'improved MR' (from moderate-severe to none-mild) and 'persistent none-mild MR'. Four hundred and forty patients (56%) had moderate-severe MR at first evaluation, of whom 144 (33% of patients with baseline moderate-severe MR) had 'improved MR', while 296 (67%) had 'persistent moderate-severe MR'. Patients with improved MR had better clinical, laboratory and echocardiographic parameters of decongestion at discharge compared with those with persistent moderate-severe MR and showed a higher up-titration of recommended therapies. Left ventricular volume, ejection fraction and serum urea were the predictors of improved MR at multivariable analysis. After adjustment, no differences in 5-years survival (primary outcome) were observed according to baseline MR severity. When patients were stratified according to the in-hospital changes in MR severity, improved MR was associated with lower risk of 5-years mortality, compared with both persistent none-mild MR [hazard ratio (HR) = 0.505, P = 0.032] and persistent moderate-severe MR (HR = 0.556, P = 0.040). The severity of MR frequently improved during hospitalization for ADHF; the extent and the changes in MR severity during the in-hospital stay identified distinct patient phenotypes, and seemed to portend different long-term outcomes, with higher 5-years survival associated with improvement in MR.

Portal Vein Pulsatility: A Valuable Approach for Monitoring Venous Congestion and Prognostic Evaluation in Acute Decompensated Heart Failure.

The severity of systemic congestion is associated with increased portal vein flow pulsatility (PVP). To determine the usefulness of PVP as a marker of decongestion and prognosis in acute decompensated heart failure (ADHF) patients. 105 patients, 60% of whom were men, were hospitalized with ADHF, and their PVP index (PVPI) was calculated (maximum velocity-minimum velocity/maximum velocity) × 100 on admission and before discharge, along with their EVEREST score, inferior vena cava diameter (IVC), NT-proBNP, serum sodium, and glomerular filtration rate. A PVPI ≥ 50% was defined as a marker of systemic congestion. After treatment with loop diuretics, a decrease in PVPI of >50% before discharge was considered a marker of decongestion The patients were classified into two groups (G): G1-PVPI decrease ≥ 50% (54 patients) and G2-PVPI decrease < 50% (51 patients). At discharge, compared to G2, G1 patients had lower mean PVPI (14.2 vs. 38.9; p < 0.001), higher serum Na (138 vs. 132 mmol/L, p = 0.03), and a higher number of patients with a significant (>30%) NT-proBNP decrease (42 vs. 27, p = 0.007). PVPI correlated with IVC (r = 0.55, p < 0.001), NT-proBNP (r = 0.21, p = 0.04), and serum Na (r = -0.202, p = 0.04). A total of 55% of patients had worsening renal failure (G1 63% vs. G2 48%, p = 0.17). After 90 days, G2 patients had higher mortality (27.45% vs. 3.7 p = 0.001) and rehospitalization (49.01% vs. 33.33%, p < 0.001). In multivariate regression analysis, PVPI was an independent predictor of rehospitalization (OR 1.05, 95% CI 1.00-1.10, p = 0.048). Portal vein flow pulsatility, a meaningful marker of persistent subclinical congestion, is related to short-term prognosis in ADHF patients.