Diagnosis Of Acute Decompensated Heart Failure Research Articles

Sex and Age Differences in Atypical Chief Complaints for Acute Decompensated Heart Failure in Emergency Department Visits.

Around one million United States emergency department (ED) visits annually are due to acute decompensated heart failure (ADHF) symptoms. Characterizing ED symptom presentation of ADHF patients may improve clinical care, yet sex and age differences in ED chief complaints have not been thoroughly investigated. This paper aims to describe differences in chief complaints and comorbid conditions for ED patients with a ADHF diagnosis, stratified by sex and age. Retrospective analysis of adults presenting to North Carolina EDs in NC DETECT, a statewide syndromic surveillance system, between 2010 and 2016 with a diagnosis of ADHF. Frequencies of chief complaint categories for ED visits and comorbid conditions, stratified by sex and age, were evaluated and standardized differences computed. Top chief complaints were dyspnea (19.1%), chest pain (13.5%), and other respiratory complaints (13.4%). In the 18-44 age group, females when compared to males reported more nausea/vomiting (6.7% versus 4.1%) and headache (4.2% versus 2.0%). In those 45-64 and 65+ years old, complaints were similar by sex. When stratified by age group alone, the 18-44 and 45-64 age groups had more complaints of chest pain, whereas balance issues, weakness, and confusion were more common in the 65+ age group. Sex and age differences in atypical ADHF symptoms were seen in in ED patients with ADHF. Characterizing variation of ADHF symptoms in ED patients can inform the identification of ED patients with ADHF and the management of ADHF-related symptoms.

#2999 Renal venous congestion as a predictor of poor prognosis in patients with acute decompensated heart failure

Abstract Background and Aims Systemic venous congestion in acute decompensated heart failure (ADHF) is associated with a risk of end-organ damage and high in-hospital mortality. We aimed to assess the prevalence and severity of renal venous congestion using venous excess ultrasound (VExUS) protocol in intensive care unit (ICU) patients with ADHF, and to evaluate the association between type of intra-renal venous blood flow, incidence of acute kidney injury (AKI), and in-hospital death. Method A prospective single-center study included 99 patients who were admitted to the ICU with ADHF (mean age 71.1 ± 12.54 years, 56 (56.6%) males). Inclusion criteria: age ≥18 years, ADHF II–IV, signed informed consent. Exclusion criteria: acute coronary syndrome, severe concomitant diseases, refusal to participate in the study. Upon admission, routine clinical, laboratory and instrumental examinations, lung ultrasound using the BLUE protocol, and assessment of venous congestion using the pulse-wave dopplerography were performed. The presence of continuous blood flow was regarded as the absence of renal venous congestion, while intermittent (biphasic and monophasic blood flow) indicated venous congestion. The diagnosis of ADHF and AKI was established based on generally accepted criteria in accordance with modern international recommendations. All patients received optimal drug therapy. The end point was defined as death from cardiovascular causes during hospitalization. Statistical analysis was performed using SPSS Statistics, version 26.0. Results Upon admission, continuous renal venous blood flow was detected in 17 (17.2%) patients, intermittent in 82 (82.8%): biphasic in 47 (47.5%) and monophasic in 35 (35.3%). The patient groups were comparable in gender, age, frequency of coronary heart disease, diabetes mellitus, anemia. Atrial fibrillation was more common in case of monophasic (p < 0.006), and arterial hypertension in patients with continuous venous blood flow (p < 0.001). Patients with renal venous congestion, compared with patients without signs of congestion, had more severe heart failure: swollen neck veins: 5 (29.4%) vs 21 (45%) vs 28 (60%), p < 0.001; hepatomegaly 12 (72.6%) vs 40 (85.1%) vs 31 (88.6%), p < 0.001; edema 8 (47.3%) vs 40 (85.1%) vs 24 (68.6%), p < 0.001; NYHA functional class IV 8 (47.1%) vs 32 (68.1%) vs 26 (74.6%), p < 0.001; more B-lines on lung ultrasound, M+SD 28.82 ± 8.91 vs 34.38 ± 9.64 vs 35.37 ± 8.72, p < 0.001, higher NTproBNP levels, pg/l, Ме(IQR) 2100 (1800;4560) vs 3418 (2300;8434) vs 4100 (2500;9282), p < 0.001, and albuminuria levels mg/g, Ме(IQR) 85 (29;145) vs 127 (49;248) vs 139 (64;245), p < 0.001. The incidence of AKI (4 (23.5%) vs 23 (49%) vs 31 (88.6%), p < 0.001), and in-hospital death (0 (0) vs 11 (23.4%) vs 12 (34.3%), p < 0.003) was also higher in the group of patients with monophasic renal blood flow. The presence of renal venous congestion on admission was associated with an increased risk of death due to heart failure during hospitalization with RR 1.32 (95% CI: 1.16-2.64), p < 0.001, and RR 1.64 (95% CI: 1.48-2.83), p < 0.001 in patients with biphasic and monophasic renal venous blood flow respectively, and with development of AKI RR 3.29 (95% CI: 1.50-7.24), p < 0.003 in patients with monophasic renal venous blood flow. Conclusion In ICU patients with ADHF, the presence of renal venous congestion, assessed on admission with Doppler ultrasound of the intrarenal veins using the VEXUS protocol, is associated with a high risk of developing AKI and in-hospital death.

Differential Mortality Among Heart Failure Patients Across Different COVID-19 Surges in New York City.

Learning from the healthcare system's response to the COVID-19 pandemic is essential to better prepare for potential future crises. We sought to assess mortality rates for patients admitted for acute decompensated heart failure (HF) and to analyze which factors demonstrated a statistically significant correlation with this primary endpoint. We performed a retrospective analysis of patients hospitalized with a primary diagnosis of acute decompensated HF within the New York City Health and Hospitals 11-hospital system across the different COVID surge periods. Mortality information was collected in 4,405 participants (mean [SD] age 70.54 [14.44] years, 1885 [42.87%] female).The highest mortality existed in the first surge (9.02%), then improved to near prepandemic levels (3.65%) in the second (3.91%) and third surges (5.94%, p < 0.0001). In-hospital mortality inversely correlated with receipt of a COVID-19 vaccination, but had no correlation with left ventricular ejection fraction or the number of vaccination doses. Mortality for acute decompensated HF patients improved after the first surge, suggesting that hospitals adequately adapted to provide quality care. As future infectious outbreaks may occur, emergency preparedness must ensure that adequate focus and resources remain for other clinical entities, such as HF, to ensure optimal care is delivered across all areas of illness.

Association of Hypoalbuminemia within Hospital Mortality in Patients with Acute Decompensated Heart Failure

Background: Acute decompensated heart failure (ADHF) remains a leading cause of hospitalization with significant morbidity and mortality. Hypoalbuminemia has been identified as a potential prognostic factor in various medical conditions, including heart failure. Understanding its association with in-hospital mortality in ADHF patients could enhance risk assessment and management strategies. Objective: This study aimed to investigate the association of hypoalbuminemia with in-hospital mortality in patients admitted with ADHF. Methods: This was a retrospective observational study conducted at a tertiary cardiac care center in Rawalpindi between July and November 2023. A total of 480 patients with a confirmed diagnosis of ADHF were included. Inclusion criteria were age ≥ 18 years, confirmed ADHF diagnosis, and available serum albumin levels upon admission. Exclusion criteria included incomplete medical records, end-stage renal disease, active malignancies, acute liver disease, and acute infectious diseases. Data on demographics, clinical characteristics, and serum albumin levels were collected. Logistic regression analysis was used to assess the association between hypoalbuminemia (defined as serum albumin &lt;3.0 g/dL) and in-hospital mortality, adjusting for confounders like age, sex, and comorbidities. Results: The cohort comprised 60% males and 40% females, with a mean age of 68 years. Hypertension (78%), diabetes (42%), and chronic kidney disease (36%) were the most prevalent comorbidities. The mean serum albumin level was 3.2 g/dL (SD = 0.4). Hypoalbuminemia was observed in 42% of patients. In-hospital mortality was 15%. Patients with hypoalbuminemia had a 2.5-fold increased risk of in-hospital mortality (unadjusted HR = 2.5, p &lt; 0.001). The adjusted HR was 2.0 (p &lt; 0.01), indicating hypoalbuminemia as an independent predictor of in-hospital mortality. Conclusion: Hypoalbuminemia is significantly associated with increased in-hospital mortality in patients with ADHF, serving as an independent prognostic indicator. This finding highlights the importance of serum albumin in the risk assessment and management of ADHF patients.

Combined Prognostic Impact of Two Quick Frailty Assessments in Acute Heart Failure

Introduction: We aimed to investigate the prognostic impact of frailty (defined by the Study of Osteoporotic Fracture [SOF] index and the Clinical Frailty Scale [CFS]) in hospitalized patients with acute decompensated heart failure (HF). Methods: A total of 1,053 patients over 75 years of age, who were primarily admitted to hospital with a diagnosis of acute decompensated HF, were enrolled. The prognostic value of frailty by the two tools for predicting all-cause mortality was analyzed using multivariate Cox regression models. Results: The incidence of frailty was 57.1% when using the SOF index, 37.6% when using the CFS, and 23.3% when using both tools. Frailty, via the SOF index or CFS, was an independent predictor of all-cause mortality in model 1, after adjustment for significantly associated factors by univariate analysis (hazard ratio [HR] 1.38, 95% confidence interval [CI] 1.04–1.84, p = 0.027; HR 1.53, 95% CI 1.15–2.05, p = 0.003, respectively), and in model 2, after adjustment for previously reported prognostic factors (HR 1.42, 95% CI 1.07–1.89, p = 0.015; HR 1.56, 95% CI 1.17–2.07, p = 0.002, respectively). Compared to non-frail patients, frail patients via both tools had a significantly higher incidence of all-cause mortality in models 1 (adjusted HR 2.16, 95% CI 1.42−3.29, p < 0.001) and 2 (adjusted HR 2.30, 95% CI 1.51−3.50, p < 0.001). Conclusions: Combined frailty screening using the SOF index and CFS contributed to stratify the risk of mortality in patients with acute decompensated HF.

Abstract 17404: Heart Failure Hospitalization Readmissions and Mortality on Cardiology versus Non-Cardiology Services in a U.S. Hospital System

Introduction: With the number of patients diagnosed with heart failure (HF) in the U.S. exceeding the number of cardiologists specialized to care for them, there is increasing reliance on non-cardiologists for treatment of acute decompensated heart failure (ADHF). Based on prior studies, there is concern that outcomes may be inferior under this circumstance. Hypothesis: Patients admitted with ADHF have lower 30-day readmissions when admitted to cardiology versus non-cardiology services. Methods: This was an observational, retrospective cohort study of 6885 patients with a primary diagnosis of ADHF based on ICD diagnosis-codes from 2015 to 2020. Data were retrieved from an EPIC-based registry with patients admitted to any of five network hospitals in a single health system. The registries were constructed through Clarity. Logistic regression adjusted for age, race, and gender was employed to distinguish differences in 30-day readmissions in those admitted with ADHF to cardiology vs. non-cardiology services. Results: Of the 6885 patients, 14% were admitted to cardiology, and 86% under non-cardiology services. The total cohort’s mean age was 69 (±15). The majority were White (71%) and male (54%). There was a statistically significant difference in mean age between cardiology services (68 [±14]) and non-cardiology services (69 [±15]) (p= 0.013). Black patients represented 15% of patients on cardiology services and 28% on non-cardiology services (p &lt;0.0001). There were more male patients on the cardiology services (64%) than the non-cardiology services (52%) (p &lt;0.0001). Unadjusted 30-day readmissions were lower for those admitted to cardiology vs. non-cardiology services (odds ratio 0.82 [95%CI: 0.67, 0.99, p=0.041]). Adjusted 30-day readmissions for those admitted to cardiology vs non-cardiology services were also lower (odds ratio 0.79 [95%CI: 0.65, 0.97, p=0.022). Conclusion: In this institutional electronic health record-based study, 30-day HF readmissions were found to be significantly lower in those admitted to cardiology vs. non-cardiology services. A future study to explore the variables contributing to these outcomes and to validate this data in a larger population is required.

Abstract 15569: The Effect of Cardiac Pulmonary Nerve Stimulation on Cardiac Inotropy and Quality of Life in Patients With Acute Decompensated Heart Failure

Background: Acute decompensated heart failure (ADHF) results in over 1 million hospitalizations annually and involves neurohormonal disruption as well as autonomic dysfunction. Neuromodulation of the cardiac plexus using cardiopulmonary nerve stimulation (CPNS), currently being evaluated in clinical trials, is a novel strategy to treat ADHF. Methods: An interim analysis of 12 patients from ongoing trials was conducted. Patients were admitted with a principal diagnosis of ADHF (elevated NT-proBNP and LVEF≤50%) and underwent implant of a 16-electrode catheter (Figure 1A) in the right pulmonary artery, allowing cardiac plexus stimulation for 48 hrs. Stimulation was performed at 20 Hz frequency, 2.0 ms pulse width, and stimulation amplitude/vector (2.5-10 mA) to optimize cardiac function. LV pressure, arterial pressure, and ECG were concurrently recorded. An additional 12 patients not implanted were followed as a parallel standard of care (SOC) cohort. Results: There were no device-related serious adverse events (SAEs) during the index hospitalization or at 30 days post-discharge. Two SAEs unrelated to device occurred in 2 patients (clonic seizure and post-discharge pneumonia resulting in death). In response to stimulation, there was a statistical increase in maximum LV dP/dt (from 799 to 824 mmHg/sec, p&lt;0.01) and a statistical decrease in pressure time index (from 27.9 to 27.5 mmHg*sec, p&lt;0.05). Patients that received CPNS reported a significantly greater improvement in symptoms, function, and quality of life at 30 days (KCCQ-12; from 14.1 to 74.7, p&lt;0.0001) compared to patients in the SOC cohort (Figure 1B; 60.6 vs. 8.4, p&lt;0.05). Conclusion: In-hospital CPNS therapy is feasible and well-tolerated in ADHF patients. Stimulation increased cardiac inotropy, decreased energy consumption, and improved symptoms, function, and quality of life. Further investigation is required to determine if CPNS therapy leads to sustained improvement in clinical outcomes.

Prevalence and clinical significance of iron deficiency in patients with acute decompensated heart failure

Aim. To study the prevalence of iron deficiency (ID) and anemia, as well as their impact on the clinical performance and quality of life in patients with acute decompensated heart failure (ADHF).Material and methods. The work was performed as part of cross-sectional multicenter screening study of ID in patients with heart failure (HF), managed by the Russian Society of Heart Failure. We examined 80 patients hospitalized in the cardiology department due to ADHF, who signed an informed consent. The diagnosis of ADHF was based on clinical signs of decompensated heart failure requiring intravenous therapy with diuretics, vasodilators, or inotropic agents.Results. The prevalence of ID was 80,0%, anemia — 35,0%, combination of anemia and ID — 31,2%. The mean age of patients with ID was 69,4±10,9 years. Patients with ID had higher HF class (40,6% vs 6,3% without ID, p&lt;0,001), a higher incidence of hydrothorax (65,6% vs 31,3%, p=0,012), higher N-terminal pro-brain natriuretic peptide (5155,5 [3267,3;9786,3] pg/mL vs 2055,5 [708,8;2839,0] pg/mL, p&lt;0,001), lower 6-minute walk test distance (155,9±84,0 m vs 239,6±82,7 m in patients without ID, p=0,01), lower quality of life according to the visual analogue scale (36,4±16,3 vs 46,3±20,7, p=0,036). ID was more often recorded in patients with frailty (95,7% vs 73,7% in patients without frailty, p=0,003), requiring a higher starting dose of intravenous diuretics (50,9±18,9 mg vs 38,6±12,3 mg without ID, p=0,021).Conclusion. In patients hospitalized due to ADHF, the prevalence of ID is 80,0%, anemia — 35,0%, combination of ID and anemia — 31,2%. Patients with ID have a higher N-terminal pro-brain natriuretic peptide level, more severe signs of decompensation, which requires higher starting dose of loop diuretics. Patients with ID are more likely to have frailty, lower exercise tolerance and quality of life.

Pulmonary Congestion on Lung Ultrasound Predicts Increased Risk of 30-Day Readmission in Heart Failure Patients.

Heart failure exacerbations are a common cause of hospitalizations with a high readmission rate. There are few validated predictors of readmission after treatment for acute decompensated heart failure (ADHF). Lung ultrasound (LUS) is sensitive and specific in the assessment of pulmonary congestion; however, it is not frequently utilized to assess for congestion before discharge. This study assessed the association between number of B-lines, on LUS, at patient discharge and risk of 30-day readmission in patients hospitalized for acute decompensated heart failure (ADHF). This was a single-center prospective study of adults admitted to a quaternary care center with a diagnosis of ADHF. At the time of discharge, the patient received an 8-zone LUS exam to evaluate for the presence of B-lines. A zone was considered positive if ≥3 B-lines was present. We assessed the risk of 30-day readmission associated with the number of lung zones positive for B-lines using a log-binomial regression model. Based on data from 200 patients, the risk of 30-day readmission in patients with 2-3 positive lung zones was 1.25 times higher (95% CI: 1.08-1.45), and in patients with 4-8 positive lung zones was 1.50 times higher (95% CI: 1.23-1.82, compared with patients with 0-1 positive zones, after adjusting for discharge blood urea nitrogen, creatinine, and hemoglobin. Among patients admitted with ADHF, the presence of B-lines at discharge was associated with a significantly increased risk of 30-day readmission, with greater number of lung zones positive for B-lines corresponding to higher risk.

Urine osmolality predicts worsening renal function and poor prognosis in acute decompensated heart failure

Abstract Background/Purpose Worsening renal function (WRF) can sometimes occur in the patients with acute decompensated heart failure (ADHF) and increase the risk of morbidity and mortality (1). In a previous study, it was reported that fractional excretion of sodium (FENa) reflects net sodium reabsorption from nephron segments and predicts WRF during treating ADHF (2). On the other hand, recently the new drugs which approach urine concentration mechanism and affect urine osmolality (U-OSM), such as tolvaptan and sodium-glucose cotransporter-2 inhibitor, have begun to be widely used as treatment of heart failure. Thus, we focused on U-OSM, which reflects not only sodium handling but also water excretion controlled by the collecting duct, and evaluated the association between WRF and U-OSM. Moreover, previous studies have demonstrated that FENa, fractional excretion of urea nitrogen and transtubular potassium concentration gradient are markers for long-term prognosis in patients with ADHF (3–5). Therefore, we also studied whether U-OSM can predict prognosis in ADHF. Methods A total of 157 patients admitted to our hospital because of a primary diagnosis of ADHF from February 2020 through July 2021 were retrospectively reviewed. U-OSM in the spot urinary samples were examined within 72 hours after admission. U-OSM was calculated based on the following validated formula (6): U-OSM = 1.07 × {2 × [urine sodium (mEq/L)] + [urine urea nitrogen (mg/dL)]/2.8 + [urine creatinine (mg/dl)] × 2/3} + 16.2. The primary outcome was the occurrence of WRF during hospitalization. WRF was defined as increased serum creatinine ≥0.3 mg/dL from baseline (7). The secondary outcome was the occurrence of ADHF readmission and all-cause death within 180 days after discharge. Results Primary Outcome. WRF developed in 46% of all patients. In the patients that developed WRF during hospitalization, U-OSM was significantly lower than in the patients without WRF (366±106 mOsm/L versus 430±128 mOsm/L; P&amp;lt;0.001). Receiver operating characteristic curve analysis revealed the optimal cutoff values of U-OSM was 403 mOsm/L (AUC 0.64; 95% CI: 0.56–0.72; P&amp;lt;0.001) to predict the WRF (Figure 1). On multivariable logistic regression analysis, U-OSM (OR, 1.99, 95% CI: 1.27–3.12; p=0.003) and serum creatinine (OR, 1.00, 95% CI: 0.99–1.00; P=0.009) were independent predictors of WRF. Secondary Outcome. There were 34 patients (22%) readmitted and 9 patients (6%) died within 180 days after discharge. ROC curve analysis revealed the optimal cutoff values of U-OSM as 349 mOsm/L (C-statistic 0.74; 95% CI: 0.65–0.83; P&amp;lt;0.001) to predict ADHF readmission and all-cause death within 180 days (Figure 2A). On Kaplan-Meier analysis, the secondary outcome was significantly higher in patients with U-OSM&amp;lt;349 mOsm/L (u-OSM≥349, 57%, U-OSM&amp;lt;349, 43%; HR, 0.99; 95% CI: 0.99–1.00, P&amp;lt;0.001) (Figure 2B). Conclusion U-OSM on admission may be a predictor of WRF and a prognostic marker in ADHF patients. Funding Acknowledgement Type of funding sources: None.

Meta-Analysis of Point-of-Care Lung Ultrasonography Versus Chest Radiography in Adults With Symptoms of Acute Decompensated Heart Failure

Acute decompensated heart failure (ADHF) is a primary cause of older adults presenting to the emergency department with acute dyspnea. Point-of-care lung ultrasound (LUS) has shown comparable or superior diagnostic accuracy in comparison with a chest x-ray (CXR) in patients presenting with symptoms of ADHF. The systematic review and meta-analysis aimed to elucidate the sensitivity and specificity of LUS in comparison with CXR for diagnosing ADHF and summarize the rapidly growing body of evidence in this domain. A total of 5 databases were searched through February 18, 2021, to identify observational studies that reported on the use of LUS compared with CXR in diagnosing ADHF in patients presenting with shortness of breath. Meta-analysis was conducted on the sensitivities and specificities of each diagnostic method. A total of 8 studies reporting on 2,787 patients were included in this meta-analysis. For patients presenting with signs and symptoms of ADHF, LUS was found to be more sensitive than CXR (91.8% vs 76.5%) and more specific than CXR (92.3% vs 87.0%) for the detection of cardiogenic pulmonary edema. In conclusion, LUS is more sensitive and specific than CXR in detecting pulmonary edema. This highlights the importance of sonographic B-lines, along with the accurate interpretation of clinical data, in the diagnosis of ADHF. In addition to its convenience, reduced costs, and reduced radiation exposure, LUS should be considered an effective alternative to CXR for evaluating patients with dyspnea in the setting of ADHF.

Inferior Vena Cava Diameter Independently Predicts Acute Decompensated Heart Failure Rehospitalizations

<h3>Objectives</h3> The aim of this study was to assess the relationship between inferior vena cava (IVC) diameter, clinical variables, and acute decompensated heart failure (ADHF) rehospitalizations. Background: The vast majority of ADHF hospitalizations are due to symptomatic volume overload rather than low cardiac output. Serial volume status assessment is crucial in ADHF yet routinely used measures are inexact. IVC diameter may be a surrogate for volume status in ADHF. The utility of IVC diameter measurement is under studied. <h3>Methods</h3> Retrospective chart review was conducted for 200 patients admitted from 2018-2019 for primary diagnosis of ADHF who had a transthoracic echocardiogram during the index hospitalization. Charts were assessed for ADHF rehospitalization within one year. Correlates of IVC diameter were determined using Pearson correlation coefficients. Unpaired t-test and chi-squared test were used to compare variables between groups. Univariable and multivariable cox proportional hazards regression analysis with forwards and backwards procedures were used to determine independent predictors of ADHF rehospitalization. Receiver operating curve was plotted for IVC diameter as a continuous variable in predicting rehospitalization. Optimal IVC diameter cut off was calculated by Youden index. Kaplan-Meier curve with log-rank statistic was used to assess rehospitalization within one year. <h3>Results</h3> The median age was 64, 30.5% were female, and average left ventricular ejection fraction was 41% ± 20%. IVC diameter correlated to pulmonary arterial (PA) pressure (R=0.347, P<0.0001) and body surface area (BSA) (R=0.424 P<0.0001). IVC diameter corrected for BSA correlated to PA pressure (R=0.287, P<0.0001) and log NT-proBNP (R=0.247, P=0.001). Patients rehospitalized within one year had significantly greater mean IVC diameter compared to those not rehospitalized (P<0.0001) while there was no difference in mean net weight lost during index hospitalization or mean log NT-proBNP. Patients with IVC diameter greater than 2.07 cm had significantly increased ADHF rehospitalization (85.6% vs 49.3%, log rank P<0.0001) with hazard ratio 2.44 (95% CI 1.85-3.23, P<0.0001). In multivariable cox regression only IVC diameter (P<0.0001), presence of tricuspid regurgitation (P=0.022), and NYHA class III/IV (P<0.0001) independently predicted ADHF rehospitalization within one year. <h3>Conclusions</h3> IVC diameter is predictive of rehospitalization in patients with ADHF and may identify patients in need of greater monitoring and diuresis. We are conducting a prospective study to further test this hypothesis.

Early Palliative Care Consultation Reduces Length Of Stay And Cost In Patients Hospitalized With Acute Decompensated Heart Failure

Early Palliative Care Consultation Reduces Length Of Stay And Cost In Patients Hospitalized With Acute Decompensated Heart Failure

Use and diagnostic value of liver enzyme tests in the emergency department and subsequent heart failure diagnosis: a retrospective cohort study.

ObjectivesTo determine (1) if liver function tests (LFTs) are ordered in the emergency department (ED) in patients with suspected acute decompensated heart failure (ADHF) and (2) if the pattern of LFT abnormalities are meaningfully associated with a discharge diagnosis of ADHF among patients for whom these tests were ordered.SettingWe conducted a single-centre retrospective cohort study of patients with suspected ADHF who were seen in an academic tertiary ED using electronic medical records.ParticipantsAll ED patients admitted with suspected ADHF from January 2017 to May 2018, defined as any patient who had a brain natriuretic peptide (BNP) ordered.Primary outcomeThe primary outcome was ADHF diagnosis at discharge.ResultsIn 5323 ED patients with suspected ADHF, 60% (n=3184) had LFTs ordered; 34.6% were abnormal. Men comprised 56% of patients with abnormal LFTs and the average age was 67 years. The odds of a final diagnosis of ADHF in the univariate analysis was 59% higher in patients with abnormal LFTs (OR=1.59, (95% CI 1.35 to 1.87) p<0.001) and remained significant though attenuated after adjusting for BNP, race and ethnicity and age (ORadj=1.31 (95% CI 1.09 to 1.57), p=0.004). Likelihood ratios for abnormal and normal LFTs were 1.2 (95% CI 1.21 to 1.28) and 0.76 (95% CI 0.68 to 0.84), respectively.ConclusionsA significant proportion (40%) of patients with suspected ADHF was missing LFTs in their ED workup. Among patients with LFTs, abnormal LFTs are associated with discharge diagnosis of ADHF after accounting for potential confounders, but their diagnostic value was relatively low. Future prospective studies are warranted to explore the role of LFTs in the workup of ADHF.

568 Echocardiography and impedance cardiography as determinants of successful slow Levosimendan infusion in patients with acute advanced heart failure

Abstract Aims Despite new therapeutic options, patients with heart failure (HF) still progress to advanced stage. Among new therapeutic options, Levosimendan was recently approved in order to treat patients hospitalized for acute decompensated heart failure (ADHF) with severe systolic dysfunction. The pharmacological effects of Levosimendan consist of inotropy, vasodilatation, and cardioprotection through the increase of calcium sensitivity. These effects should be monitored with echocardiography and in particular with speckle tracking and tri-dimensional echocardiography which appear to be useful in LV systolic function detection and monitoring. In this study we aim to evaluate the effect of slow infusion of Levosimendan on the non-invasive measurement of cardiac output, the speckle tracking parameters and the tri-dimensional echocardiography measurements in advanced ADHF patients. Methods and results This is a prospective observational study evaluating Levosimendan efficacy through advanced echocardiography. We enrolled 11 patients with diagnosis of ADHF who respect the recent ESC criteria of ‘advanced heart failure’. Patients underwent to blood sample examination to measure electrolytes, creatinine, and NTproBNP. Patients underwent to advanced echocardiography examination (performed for each patient pre- and post-Levosimendan infusion) with tri-dimensional echocardiography and global longitudinal strain assessment. Furthermore patients underwent to non-invasive cardiac output and cardiac index collection through impedance cardiography pre- and post-Levosimendan infusion. All patients were followed for 30 days after discharge for all cause of mortality and HF re-hospitalization. A total of 11 patients affected by advanced ADHF were included in this study. Mean age was 73.8 ± 4.7 years. 72.7% (n 8) patients were men. 81.9% (n 9) of patients recognize ischaemic heart disease as HF etiology. At admission mean systolic arterial pressure was 100 ± 17 mmHg, mean NTproBNP was 24 445 ± 12 194 pg/ml and mean serum creatinine was 1.55 ± 0.84 mg/dl. At tri-dimensional echocardiography mean LV ejection fraction (LVEF) was 19.7 ± 5.7% and at bi-dimensional echocardiography mean tricuspid anular plane systolic excursion (TAPSE) and pulmonary arterial systolic pressure (PASP) were, respectively, 12.5 ± 2.7 mm and 48 ± 16 mmHg. Mean LV global longitudinal strain (GLS) was −3.0 ± 1.8. Mean furosemide in-hospital infusion was 306 ± 102 mg/die and mean urine output 1436 ± 496 ml. None developed significant ventricular or supraventricular arrhythmias. All patients were treated with betablockers during infusion. At 30 days of follow-up two patients died and 1 patient was re-hospitalized. Evaluating the differences among our variables pre- and post-Levosimendan infusion, we found that NTproBNP was significantly reduced post-Levosimendan infusion (P = 0.01). Among ICG non-invasive measurement, we found significant differences in stroke volume (SV) and cardiac output (CO) in terms of significant improvement (P = 0.001 for both). Analysing tri-dimensional echocardiography variables, we observed a significant improvement of LVEF (P = 0.003), SV (P = 0.03) and 3-D LV GLS (P = 0.002). Furthermore, we observed a significant reduction in end-systolic volume (ESV) post-Levosimendan infusion (P = 0.02). Among bi-dimensional echocardiography measurements, there was a significant reduction in end-diastolic diameter of right ventricle (EDDRV) and in B-lines count (respectively, P = 0.02 and P = 0.002). Moreover, we observed a significant improvement in TAPSE (P = 0.003) and in LV GLS (P = 0.004). Conclusions Our study showed that slow Levosimendan infusion (12.5 mg at velocity of 0.05–1 mcg/kg/min) without bolus could be considered in advanced ADHF patients to improve cardiac performance without severe adverse events. ICG and echocardiography in-hospital evaluation seemed to be necessary to understand treatment success and patients status improvement as well as cardiac function benefit.

The prognostic value of heart rate at discharge in acute decompensation of heart failure with reduced ejection fraction.

AimsThe effect of elevated heart rate (HR) on morbidity and mortality is evident in chronic stable heart failure; data in this regard in acute decompensated heart failure (ADHF) setting are scarce. In this single‐centre study, we sought to address the prognostic value of HR and beta‐blocker dosage at discharge on all‐cause mortality among patients with heart failure and reduced ejection fraction and ADHF.Methods and resultsIn this retrospective observational study, 2945 patients were admitted for the first time with the primary diagnosis of ADHF between January 2008 and February 2018. Patients were divided by resting HR at discharge into three groups (HR < 70 b.p.m., HR 70–90 b.p.m., and HR > 90 b.p.m.). Evidence‐based beta‐blockers were defined as metoprolol, bisoprolol, and carvedilol. The doses of prescribed beta‐blockers were calculated into a percentage target dose of each beta‐blocker and divided to four quartiles: 0 < Dose ≤ 25%, 25% < Dose ≤ 50%, 50% < Dose ≤ 75%, and >75% of the target dose. Cox regression was used to calculate the hazard ratio for various HR categories and adjusting for clinical and laboratory variables. At discharge, 1226 patients had an HR < 70 b.p.m., 1347 patients had an HR at range 70–90 b.p.m., and 372 patients with an HR > 90 b.p.m. The 30 day mortality rate was 2.2%, 3.7%, and 12.1% (P < 0.001), respectively. Concordantly, 1 year mortality rate was 14.6%, 16.7%, and 30.4% (P < 0.001) among patients with HR < 70 b.p.m., HR 70–90 b.p.m., and HR > 90 b.p.m., respectively. The adjusted hazard ratio was significantly increased only in HR above 90 b.p.m. category (hazard ratio, 2.318; 95% confidence interval, 1.794–2.996).ConclusionsPatients with ADHF and an HR of <90 b.p.m. at discharge had significantly a lower 1 year mortality independent of the dosage of beta‐blocker at discharge. It is conceivable to discharge these patients with lower HR.

Does high sensitivity troponin add prognostic value to validated risk scores to predict in-hospital mortality in patients with acute heart failure?

Troponin elevation correlates with an increased short and long-term mortality in patients with acute decompensated heart failure (AHF). However, it has not been included in the development of multiple validated predictive models of mortality. We aim to determine whether the addition of high-sensitivity troponin T (hs-TnT) to clinical risk scores improves the prediction of in-hospital mortality in patients with AHF. A retrospective analysis of a prospective and consecutive cohort was performed. Adult patients hospitalized between 2015 and 2019 with a primary diagnosis of AHF were included. Hs-TnT was measured on admission. OPTIMIZE-HF, GWTG-HF, and ADHERE risks score were calculated for each patient. The primary endpoint was all-cause in-hospital mortality. Discrimination of isolated hs-TnT and the risk scores with and without the addition of hs-TnT were evaluated using the area under the ROC curve (AUC-ROC). A subanalysis was performed according to left ventricular ejection fraction (LVEF). Of 712 patients, 562 (79%) had hs-TnT measurement upon admission, and was elevated in 91%. In-hospital mortality was 8.7% (n = 49). The AUC-ROC was 0.70 (95% CI 0.63-0.77) for isolated hs-TnT, and 0.80 (0.74-0.87), 0.79 (0.72 -0.86) and 0.79 (0.71-0.86) for the OPTIMIZE-HF, GWTG-HF and ADHERE scores, respectively. The addition of hs-TnT to the models did not increase the AUC: 0.72 (0.66-0.79) for the OPTIMIZE-HF + hs-TnT score (difference between AUC - 0.08 p = 0.04), 0.74 (0.68-0.80) for GWTG-HF (difference between AUC-0.04, p = 0.2) and 0.7 (0.63-0.77) for ADHERE (difference between AUC - 0.085 p = 0.07). The models presented good calibration (p > 0.05). In the sub-analysis, no differences were found between risk scores with the addition of hs-TnT in the population with LVEF < 40% and ≥ 40%. Elevated hs-TnT on admission was frequent and its incorporation into the validated risk scores did not prove an incremental prognostic benefit in patients hospitalized for AHF, regardless of LVEF. Isolated hs-TnT had a modest ability to predict hospital mortality. Additional prospective studies are needed to validate these findings.

The predictive value of precise-dapt score for mortality in patients with acute decompansed heart failure

Introduction: Acute decompensated heart failure (ADHF) is an emergency clinical syndrome defined as a sudden worsening of heart failure. PREdicting bleeding Complications In patients undergoing Stent implantation and subsEquent Dual Anti-Platelet Therapy (PRECISE-DAPT) score is a new scoring used in the management of duration of dual-antiplatelet therapy after coronary intervention. We presented the hypothesis that this scoring can be used as a predictor of mortality in heart failure. Objective: In this study, the correlation between mortality and PRECISE-DAPT score will be analyzed in patients diagnosed with ADHF. Materials and Methods: A total of 114 patients hospitalized with a diagnosis of ADHF were included in this study. The patients were divided into two groups: PRECISE-DAPT score ≥25 and PRECISE-DAPT score 6 months) and overall mortality. Results: According to univariate analysis, it was found that PRECISE-DAPT score was significantly related with early (P < 0.001), late (P < 0.001), and overall (P < 0.001) mortality. Multivariate Cox regression analysis showed that PRECISE-DAPT was independently associated with late (hazard ratio: 6.6; 95% confidence interval [CI] 1.6–27.3; P = 0.009) and overall (hazard ratio: 11.3; 95% CI 3.2–40.9; P < 0.001) mortality. According to Kaplan–Meier curve, those with a score of ≥25 were shown to have significantly higher mortality. The predictive ability for the PRECISE-DAPT score threshold value of 25 was investigated in 3 mortality subgroups. Conclusion: The PRECISE-DAPT score may be a significant independent predictor of mortality in patients with ADHF. Limitations: This study is subject to the limitations inherent to a retrospective study and the sample size in our study is relatively small.

Erythroferrone can Diagnose Acute Decompensated Heart Failure in Patients Presenting With Breathlessness

Comorbidities are a major concern for heart failure (HF) patients as they lead to adverse outcomes and increased mortality rates. Circulating levels of N-terminal pro-hormone B-type natriuretic peptide (NT-proBNP) are clinically mandated in the diagnosis of HF, but levels can be altered by co-morbidities such as atrial fibrillation (AF) and obesity. Thus, complementary biomarkers not influenced by these comorbidities are needed. Here we provide the first report on the performance of a novel biomarker, erythroferrone, in the diagnosis of acute decompensated HF (ADHF). The diagnostic potential of erythroferrone was determined in patients (n=479) presenting to the Christchurch emergency department with dyspnoea. Erythroferrone (ELISA, Intrinsic Lifesciences) and NT-proBNP (Roche Cobas e411) were measured in EDTA plasma by immunoassay. Ability to diagnose ADHF was assessed using areas under (AUC) receiver operator curves and binary logistic models with adjustment for conventional clinical risk factors. Plasma erythroferrone levels were significantly elevated in ADHF compared to all other diagnoses (4.9 vs 1.4 ng/mL, n=171, p<0.001). Logistic regression revealed erythroferrone to be a significant independent predictor of ADHF (p=0.001), although it was outperformed by NT-proBNP (p<0.001). Erythroferrone (ERFE) appeared to be slightly better at diagnosing ADHF than NT-proBNP in obese patients (BMI ≥30 kg/m2, AUC 0.91 vs 0.90, respectively, n=53) and those with AF (AUC 0.80 vs 0.77, n=64), although sample numbers preclude formal comparisons. Diagnosis of ADHF in patients with comorbidities could be enhanced using erythroferrone, either on its own or in combination with NT-proBNP. These preliminary Results warrant further investigation in larger cohorts.

Impact of COVID-19 Pandemic Lockdown in Decompensated Heart Failure Hospitalizations

Background and ObjectivesCoronavirus disease 2019 (COVID-19) pandemic lockdown may have collaterally affected the care of patients with acute decompensated heart failure (ADHF). We aimed to evaluate the impact of lockdown pandemic on hospitalizations for ADHF.MethodsWe conducted a single-center study, performing a retrospective analysis of prospectively collected data. We included consecutive adult patients with a primary diagnosis of ADHF admitted to a cardiovascular disease specialized hospital. We compared those patients admitted between March–June of 2019 (before COVID-19 [BC]) and 2020 (after COVID-19 [AC]), during mandatory lockdown.ResultsA total 79 corresponding to BC period and 60 to AC period were included, representing a decrease of 25% (interquartile range [IQR], 11–33). During the BC period, 31.6% of patients were referred from other centers compared to 15% during the pandemic (p=0.02). In the AC period patients were older (median age, 81[IQR, 73–87] years vs. 77 [IQR, 64–84] years, p=0.014). The etiology of HF, cause of decompensation, left ventricular function, and laboratory parameters were similar in both periods. The use of mechanical ventilation (13.9% vs. 3.3%, p=0.03) and circulatory support (7.6% vs. 0%, p=0.02) was higher in the BC period. During the BC period, 5 emergency heart transplants were performed, and none in AC, (p=0.004). In-hospital mortality was similar in both periods (3.8% vs. 3.3%; p=0.80).ConclusionsWe observed a reduction in the number of hospitalizations and referral of patients for ADHF during COVID-19 pandemic.