Heart Failure Exacerbation In Patients Research Articles

1-Minute Pearls/Pitfalls for the Clinician

This article describes some pearls/pitfalls pertinent to the management of heart failure exacerbation in patients with asymptomatic hypotension along with treatment strategies for patients with new atrial fibrillation.

Artificial Intelligence Predicts Hospitalization for Acute Heart Failure Exacerbation in Patients Undergoing Myocardial Perfusion Imaging.

Heart failure (HF) is a leading cause of morbidity and mortality in the United States and worldwide, with a high associated economic burden. This study aimed to assess whether artificial intelligence models incorporating clinical, stress test, and imaging parameters could predict hospitalization for acute HF exacerbation in patients undergoing SPECT/CT myocardial perfusion imaging. Methods: The HF risk prediction model was developed using data from 4,766 patients who underwent SPECT/CT at a single center (internal cohort). The algorithm used clinical risk factors, stress variables, SPECT imaging parameters, and fully automated deep learning-generated calcium scores from attenuation CT scans. The model was trained and validated using repeated hold-out (10-fold cross-validation). External validation was conducted on a separate cohort of 2,912 patients. During a median follow-up of 1.9 y, 297 patients (6%) in the internal cohort were admitted for HF exacerbation. Results: The final model demonstrated a higher area under the receiver-operating-characteristic curve (0.87 ± 0.03) for predicting HF admissions than did stress left ventricular ejection fraction (0.73 ± 0.05, P < 0.0001) or a model developed using only clinical parameters (0.81 ± 0.04, P < 0.0001). These findings were confirmed in the external validation cohort (area under the receiver-operating-characteristic curve: 0.80 ± 0.04 for final model, 0.70 ± 0.06 for stress left ventricular ejection fraction, 0.72 ± 0.05 for clinical model; P < 0.001 for all). Conclusion: Integrating SPECT myocardial perfusion imaging into an artificial intelligence-based risk assessment algorithm improves the prediction of HF hospitalization. The proposed method could enable early interventions to prevent HF hospitalizations, leading to improved patient care and better outcomes.

Pre-emptive treatment of heart failure exacerbations in patients managed with the HeartLogic™ algorithm.

Heart failure (HF) is a chronic disease affecting 64 million people worldwide and places a severe burden on society because of its mortality, numerous re-hospitalizations and associated costs. HeartLogic™ is an algorithm programmed into implanted devices incorporating several biometric parameters which aims to predict HF episodes. It provides an index which can be monitored remotely, allowing pre-emptive treatment of congestion to prevent acute decompensation. We aim to assess the impact and security of pre-emptive HF management, guided by the HeartLogic™ index. The HeartLogic™ France Cohort Study is an investigator-initiated, prospective, multi-centre, non-randomized study. Three hundred ten patients with a history of HF (left ventricular ejection fraction ≤40%; or at least one episode of clinical HF with elevated NT-proBNP ≥450ng/L) and implanted with a cardioverter defibrillator enabling HeartLogic™ index calculation will be included across 10 French centres. The HeartLogic™ index will be monitored remotely for 12months and in the event of a HeartLogic™ index ≥16, the local investigator will contact the patient for assessment and adjust HF treatment as necessary. The primary endpoint is unscheduled hospitalization for HF. Secondary endpoints are all-cause mortality, cardiovascular death, HF-related death, unscheduled hospitalizations for ventricular or atrial arrhythmia and HeartLogic™ index evolution over time. Blood samples will be collected for biobanking, and quality of life will be assessed. Finally, the safety of a HeartLogic™-triggered strategy for initiating or increasing diuretic therapy will be assessed. A blind and independent committee will adjudicate the events. The HeartLogic™ France Cohort Study will provide robust real-world data in a cohort of HF patients managed with the HeartLogic™ algorithm allowing pre-emptive treatment of heart failure exacerbations.

Pregabalin Does Not Increase Risk of Heart Failure Exacerbation in Patients With Pre-existing Heart Failure.

Through actions of calcium channel trafficking inhibition and sodium/water retention, pregabalin may increase the risk of acute heart failure (AHF). The objective of this study was to determine the prevalence of heart failure (HF) acute exacerbations, measured by a composite of emergency department (ED) visits, per-patient per-year (PPPY) hospitalizations, time-to first ED admission, and time-to hospitalizations in pre-existing HF patients taking pregabalin compared with those who were pregabalin-naive. A retrospective cohort study of pregabalin users with HF were propensity score-matched to pregabalin-naïve patients with HF to evaluate the composite of ED admissions or PPPY hospitalizations, time-to first ED admission, and time-to hospitalizations during the 365 days post-index. Doubly robust generalized linear regression and Cox-proportional hazard regression modeling were undertaken for analysis of differences between groups. The matched cohort of 385 pregabalin users and 3460 pregabalin nonusers were principally middle-aged, equally gender distributed, and primary Caucasian. Most patients were on guideline-directed HF medical therapy. The estimated cumulative incidence of the primary outcome was a hazard ratio of 1.099 (95% CI: 0.789-1.530; P = 0.58). This large, single-center, cohort study shows pregabalin is not associated with an increased risk of AHF events in patients with pre-existing HF.

Alogliptin and Heart Failure Outcomes in Patients With Type 2 Diabetes

Background: In 2016, the FDA issued a warning for saxagliptin and alogliptin regarding an increased risk of heart failure (HF), potentially limiting the use of effective medications in type 2 diabetes. Current data and guideline recommendations regarding HF risk are conflicting, especially with alogliptin. In March 2019, the Memphis Veterans Affairs Medical Center made a formulary change from saxagliptin to alogliptin, creating an opportunity to evaluate a large number of patients receiving alogliptin. Objective: To evaluate the risk of HF with alogliptin use in type 2 diabetes patients. Methods: A retrospective chart review of patients prescribed alogliptin was performed. The primary outcome was the composite number of HF hospital admissions and ED visits. Secondary outcomes included exacerbation rates among established HF patients, incidence of new-onset HF, incidence of alogliptin discontinuation due to HF, comparison of HF exacerbations between saxagliptin and alogliptin in patients with prior saxagliptin use, and evaluation of concomitant cardiotoxic medications. Results: 455 patients were included. A composite of 28 hospital admissions and ED visits occurred for a HF exacerbation. Fourteen patients (26.4%) of 53 patients with established HF had an exacerbation, whereas 5 patients (1.2%) of 402 patients with no history of HF had an exacerbation. Eight patients (2%) developed new-onset HF. Alogliptin was discontinued in 4 patients (0.9%) due to HF. No statistically significant difference in HF exacerbations was found between patients on alogliptin who previously received saxagliptin (4.8% vs 4.2%, P = 0.726). Conclusions: Alogliptin may increase the risk of HF exacerbation in patients with established HF.

Restrictive versus Liberal Blood Transfusion Strategy in Patients With Acute Myocardial Infarction: A Meta-Analysis of Randomized Clinical Trials.

BackgroundA meta-analysis of observational studies comparing differences in outcomes between restrictive blood transfusion (RBT) and liberal blood transfusion (LBT) in patients with acute myocardial infarction (AMI) reported that LBT is associated with higher all-cause mortality. Few randomized clinical trials (RCTs) have compared RBT to LBT in patients with AMI and anemia, but no meta-analysis of RCTs was performed to date.AimTo assess the clinical effect of RBT compared to LBT in patients with AMI and anemia regarding was all-cause mortality, recurrent MI, revascularization, and heart failure exacerbation.MethodsThe electronic databases Ovid MEDLINE, EMBASE, Cochrane Central, Scopus, and Google Scholar, were systematically searched to identify eligible studies published before June 19th, 2021. RCTs that assessed the effect of RBT compared to LBT were included. The primary endpoint was all-cause mortality. Secondary endpoints included recurrent MI, revascularization, and heart failure exacerbation.ResultsThree RCTs with 821 patients were included (421 received RBT, and 400 received LBT). The mean age was 75.9 ± 6.1 years, and 56% were male. Our meta-analysis showed that RBT was not associated with reduced all-cause mortality (RR = 1.61; 95% CI = 0.38–6.96, p = 0.52), recurrent MI (RR = 0.98; 95% CI = 0.48–1.96, p = 0.94), revascularization (RR = 1.18; 95% CI = 0.26–5.44, p = 0.83) and heart failure exacerbation (RR = 0.86; 95% CI = 0.23–3.22, p = 0.82) when compared to LBT.ConclusionRBT was not associated with reduced all-cause mortality, recurrence of MI, need for revascularization, or heart failure exacerbation in patients with AMI and anemia compared to LBT. A larger RCT is required to confirm the above findings.

Multisensor Remote Monitoring for Heart Failure Exacerbations in Patients with Left Ventricular Assist Devices

Background Continuous flow left ventricular assist devices (cfLVADs) have improved outcomes for advanced Heart Failure (HF) patients. Recurrent HF continues to be a complication and clinical examination is limited by the nature of the LVAD therapy requiring better diagnostics to improve patient outcomes. Methods We describe a multisensory diagnostic in two LVAD patients. Results Two patients with end-stage HF supported with a HeartMate II and HeartMate III containing a multisensor diagnostic for HF (HeartLogic) presented to clinic with exercise intolerance. In both, exam revealed no elevation of venous pressure, lungs were clear and no heart sounds were appreciated above the normal LVAD hum. On right heart catheterization of patient A, RA pressure was 14 mmHg, PCWP 18 mmHg and CI 1.9 L/min/m2. LVAD speed was increased from 10,000 to 10,400 rpm. Similarly, elevated filling pressures were seen with patient B, who had LVAD speed increased as well. In both cases, S3 magnitude decreased following LVAD speed increase. Both patients later had outpatient alerts detected and diuretics were doubled until alert resolution. In each instance, the clinical events were associated with a HeartLogic alert, and remarkably, the S3 changed in manner consistent with the interventions that occurred although clinicians could not appreciate an S3. Conclusion These cases demonstrate that a multisensory HF diagnostic changes and alerts during clinically meaningful events that is useful in the management of LVAD patients.

Outcomes of Acute Heart Failure in Patients with Amyloid or Sarcoid Cardiomyopathy: A 10 Year Nationwide Analysis

Background Ischemic Cardiomyopathy is the leading cause of heart failure in the United States. Restrictive cardiomyopathy etiologies like sarcoid and amyloid are less common causes of heart failure and in hospital outcome descriptions are scant across the literature. Purpose describe the outcomes of acute heart failure exacerbations in patients with sarcoid or amyloid cardiomiopathy Methods A retrospective analysis using the 2005-2014 United States Nationwide Inpatient Sample was performed. Patients above 18 years with primary diagnosis of acute heart failure (AHF), systolic heart failure (SHF) and diastolic heart failure (DHF) were included. Secondary diagnosis of Sarcoid Cardiomyopathy (SCM) or Amyloid Cardiomyopathy (ACM) was generated. End stage renal disease patients were excluded. Primary outcome was in-hospital mortality. Secondary outcomes included length of stay, cost of stay, shock, utilization of mechanical ventilation, acute kidney injury requiring dialysis (AKID), use of non-invasive ventilation (NIV), cardiac arrest, and short term mechanical circulatory support. Diagnoses were identified using ICD-9- CM codes . Multivariate logistic regression analysis adjusting for age, race, gender, hospital location was done using STATA 15. Results 2,821,201 patients with primary diagnosis of AHF were identified. In AHF cohort 2,893 patients had a history of ACM, corresponding to 42% patients with SHF and 58% patients with DHF. The SCM cohort was composed of 1,905 with AHF of which 83% had SHF and 17% had DHF. Mean age in ACM with AHF was 73 years. 63% were males. In the SCM, 52 % males with mean age of 53 years. ACM patients had increased mortality in the AHF(OR 2.5 p Conclusions In patients with AHF, mortality is increased in those with ACM compared to those without. SCM is associated with increased mechanical support use and development of shock

De novo mitral regurgitation as a cause of heart failure exacerbation in patients with hypertrophic cardiomyopathy

AimsTo determine the prevalence and mechanisms of de novo severe MR due to mitral valve structural abnormalities causing clinical deterioration in patients with HCM. Methods and resultsThis is an observational study based on HCM registry comprising consecutive HCM patients (n=397) who have been evaluated and followed in the Cardiomyopathy Clinic of Sheba Medical Center.Sixteen patients (4.0%), 8 males, mean age 65±14 years, developed acute clinical deterioration due to development of severe mitral regurgitation unrelated to mitral valve systolic anterior motion. Compared to the remaining HCM population, those patients were older at their initial diagnosis (51±20 vs. 38±18 years) and more often females. Most frequently (in 10 patients, 63%) mitral regurgitation resulted from a flail posterior leaflet, while 4 patients had severe prolapse and 2 had isolated mitral annular/leaflet calcifications. Fourteen underwent surgery; myxomatous changes were found in all excised valves (n=9). On age-adjusted univariate analysis, 3 clinical parameters remained significantly associated with the development of de novo MR, female gender, LVOT obstruction and significant MR at baseline. On multivariable analysis, only LVOT obstruction (HR=3.8) and MR at baseline evaluation (HR=8.2) predicted development of severe MR. ConclusionsDe novo severe MR leading to acute heart failure was repeatedly observed in our HCM series. This etiology needs to be considered as a cause of acute clinical deterioration in these patients.

Catheter ablation of repetitive ventricular tachycardia in patients with ischemic heart disease – our experience

Ventricular tachycardia (VT) poses a significant risk for sudden death and heart failure exacerbation in patients with ischemic heart disease. Catheter-based radiofrequency ablation is the last treatment option for patients with frequent VT recurrences despite antiarrhythmic drugs. The aim was to present our retrospective catheter ablation data in this group of patients.The majority of 34 patients, who underwent percutaneous endocardial radiofrequency catheter ablation, were male, median age 67.5 years, who presented with electrical storm, had underlying cardiomyopathy after remote inferior wall myocardial infarction and preceding myocardial revascularization procedure, and had been implanted with cardioverter-defibrillator (ICD). Two ablation methods were used: linear ablation and/or scar homogenization. Acute ablation success (non-inducibility of any VT) was achieved in 59 % of procedures. VT could not be interrupted in 2 (6 %) patients. Pericardial tamponade that needed surgical intervention occurred in one procedure (2 %), and was related to inadvertent perforation of the right ventricular apex with a diagnostic catheter. Seven (20 %) patients died and additional 3 were lost from the median of 31 (6–151, rank) months of follow-up. No late VT recurrences were demonstrated in 20 (59 %) patients, and rare in 4 (12 %). Overall, the ablation procedure was successful in 71 % of patients.Catheter ablation gave very good long-term clinical result in about two-thirds of our patients with ischaemic cardiomyopathy and frequent VT recurrences. Catheter ablation, preferably with scar homogenization approach, should be considered early to reduce the number of VT episodes and ICD discharges.

122 - Prediction of Heart Failure Readmission Using Echocardiographic Variables in Patients with Heart Failure with Preserved Ejection Fraction in an Urban Inner City Teaching Hospital

Objective: The purpose of this study was to determine the relationship between echocardiographic variables and hospital readmission rates in patients with Heart Failure with preserved EF (HFpEF) admitted for acute decompensated heart failure (HF). Background: Acute HF exacerbation in patients with HFpEF is caused by congestion which may be not clinically evident. Congestion is due to elevated LV filling pressure which is often reflected by high levels of natriuretic peptides. Using the echocardiogram to determine specific parameters such as LVEDP, E/e' ratio, left atrial volume index can help to identify patients with elevated filling pressures that are congested but may not be reflected clinically and may be increased risk for HF readmission. Methods: One hundred sixteen patients with HFpEF who were admitted for acute HF exacerbation with an echocardiogram done during initial presentation were included. Patients were divided based on readmission in 60 days. Continuous variables were analyzed using Wilcoxon rank sum test and categorical variables(atrial fibrillation, coronary artery disease, diabetes mellitus, hypertension, hyperlipidemia, gender, race) were analyzed using Fisher's exact test. The best subset selection method was performed to assess the best predictive model of readmission. Results: There were no significant relationship between readmission and any of the categorical variables. A significant relationship was noted between readmission and both NT pro-BNP and left atrial (LA) Volume index (ml/m2). The best fit model predicting readmission was applied to E/e' ratio and LA volume index (ml/m2). For every unit increase in E/e' ratio, the odds of readmission decreased. For every unit increase in LA Volume index, the odds of readmission increased. Conclusion: Our results reveal that LA volume index predicted HF readmission in HFpEF patients, while E/e' ratio did not. This could be due to the dynamic nature of E/e' being volume related and unclear timing of the echocardiogram in relation to diuresis. Increased LA volume index correlating with readmission appropriately reflects the pathophysiology of HFpEF and LA remodeling in these patients. The analysis showed significant correlation with HF readmission rates in patients with higher NT proBNP levels. LA volume index can be considered as an additional prognostic marker for HF readmission. Further studies are warranted to evaluate echocardiographic variables at the time of admission for acute decompensated HF in HFpEF patients.

Pulmonary Pressure Monitoring for Patients With Heart Failure.

Heart failure (HF) affects over 5.8 million patients in the United States, and can be very costly due to the number of hospitalizations and rehospitalizations during the final years of life. Due to the large number of hospitalizations for HF exacerbations, effective methods for preventing these occurrences are necessary. Improvements in the outpatient treatment of HF, aided by noninvasive and invasive home monitoring methods, can reduce the number of hospitalizations. Pulmonary pressure monitoring through the CardioMEMS system provides one method of hemodynamic assessment of patients. The efficacy of the CardioMEMS system in reducing the number of HF exacerbations has been explored in the CHAMPION trial (CardioMEMS Heart Sensor Allows Monitoring of Pressures to Improve Outcomes in NYHA Functional Class III Heart Failure Patients), which demonstrated a reduction in hospitalizations for HF exacerbations in patients whose medical management was guided by adjusting medications based on pulmonary pressures compared with clinical signs and symptoms. Retrospective analyses suggest that HF patients of certain subgroups, including those with left heart dysfunction and those with preserved left ventricular ejection fraction, could benefit from pulmonary pressure monitoring in controlling their HF. Larger studies are needed to determine whether mortality can be reduced with pulmonary pressure monitoring.

Heart acceleration and deceleration capacities associated with dilated cardiomyopathy.

Heart rate deceleration capacity and acceleration capacity are novel autonomic nervous system indicators of cardiac neural regulation. Dilated cardiomyopathy (DCM) changes cardiac electrophysiology; however, how deceleration capacity and acceleration capacity associated with DCM remain unclear. To evaluate the association between heart rate acceleration capacity, deceleration capacity and DCM, 66 DCM patients with DCM and 209 controls were enrolled in the study. Demographic data, echocardiographic data, heart rate variability, deceleration capacity and acceleration capacity were collected. The association pattern between DCM and these indexes were studied by multiple logistic regression analysis. Deceleration capacity and acceleration capacity were independent risk factors for DCM with an odds ratio (OR) and 95% confidence interval (CI), determined by multiple logistic regression analysis, of 7·97 (3·87-16·42) and 0·09 (0·05-0·19), respectively. Univariate ordinal logistic regression analysis showed that acceleration capacity, fastest heart rate, standard deviation of normal-to-normal RR intervals (SDNN) and left ventricular ejection fraction (LEVF) associated with heart failure grade. The OR for each covariate was further adjusted for the effects of other significant covariates in multivariate ordinal logistic regression analysis. Acceleration capacity, fastest heart rate and LVEF were still independent risk factors in the final equation with ORs of 1·32 (1·03-1·79), 1·04 (0·01-1·07) and 0·46 (0·23-0·93), respectively. Heart rate acceleration capacity and deceleration capacity are independent risk factors for DCM, and acceleration capacity is a predictive factor for heart failure exacerbation in patients with DCM.

Non-steroidal anti-inflammatory drugs and risk of heart failure exacerbation: A systematic review and meta-analysis

BackgroundThe association between exacerbation of heart failure (HF) and use of non-steroidal anti-inflammatory drugs (NSAIDs) has long been recognized but the data on this adverse effect are limited. MethodsTo further characterize this possible association, we conducted a systematic review and meta-analysis of observation studies that reported odds ratio, relative risk, hazard ratio or standardized incidence ratio comparing risk of exacerbation of HF in patients with pre-existing HF who took NSAIDs versus non-users. Pooled risk ratios (RR) and 95% confidence intervals for conventional NSAIDs, celecoxib and rofecoxib were calculated using random-effect, generic inverse variance method. ResultsSix studies were identified and included in our data analysis. Use of conventional NSAIDs was associated with a significantly higher risk of development of exacerbation of HF with the pooled RR of 1.39 (95% CI 1.20–1.62). Elevated risk was also observed among celecoxib and rofecoxib users (RR 1.34, 95% CI 0.98–1.85 and RR 2.04, 95% CI 1.68–2.48). The pooled RR of rofecoxib was significantly higher than conventional NSAIDs (p=0.02). ConclusionUse of NSAIDs is associated with an increased risk of HF exacerbation among patients with pre-existing HF. The excess risk was approximately 40% for conventional NSAIDs and celecoxib. The highest risk was observed among rofecoxib users.

Addition of Angiotensin-Converting Enzyme Inhibitors to Beta-Blockers Has a Distinct Effect on Hispanics Compared With African Americans and Whites With Heart Failure and Reduced Ejection Fraction: A Propensity Score–Matching Study

BackgroundThere are currently no data on the efficacy of angiotensin-converting enzyme inhibitors (ACEis) in Hispanic patients with heart failure (HF) and reduced ejection fraction (HFrEF). We aimed to investigate the effect of adding ACEis to beta-blockers on mortality and hospitalization for HF exacerbation in patients with HFrEF stratified by race/ethnicity. Methods and ResultsFrom Montefiore Medical Center’s 3 large hospitals, 618 consecutive patients with HFrEF (left ventricular ejection fraction [LVEF] <35%) who were on a beta-blocker were retrospectively identified. Patients were divided into 2 groups based on whether or not they were on an ACEi for 24 consecutive months. Propensity score matching including all baseline characteristics was performed and patients were then categorized into 3 groups: African Americans, Hispanics, and Whites/Caucasians. We evaluated 2-year all-cause mortality and 2-year hospitalization for HF exacerbation. Of 618 patients, 66% were categorized as ACEi and 34% as no-ACEi. Four hundred twenty-seven patients were matched 2:1 between the ACEi and no-ACEi groups. After matching, overall 2-year mortality and hospitalization rates were similar between ACEi and no-ACEi (12.4% vs 17.8%, hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.38–1.16; P = .14; and 8.1% vs 9.5%, HR 0.84, 95% CI 0.44–1.60; P = .6; respectively). After stratifying patients based on race/ethnicity, ACEi demonstrated a lower 2-year mortality compared with no-ACEi in Hispanics (9.8% vs 28.4%, HR 0.33, 95% CI 0.13–0.87; P = .018) but not in African Americans (17.0% vs 11.8%, HR 0.94, 95% CI 0.34–2.65; P = .91) or Whites (9.2% vs 10.3%, HR 0.89, 95% CI 0.29–2.74; P = .83). Two-year hospitalization was not different between ACEi and no-ACEi in Hispanics, African Americans, or Whites (all P = NS). In multivariate analysis, ACEi therapy was an independent predictor of lower 2-year mortality (HR 0.33, 95% CI 0.12–0.89; P = .028) in Hispanics only. ConclusionsIn this retrospective propensity-matched study of patients with HFrEF who were on a beta-blocker, ACEi therapy was associated with greater mortality reduction in Hispanic patients compared with African Americans and Whites. These findings need to be confirmed in large national studies that include a significant fraction of Hispanic patients.

Shoshin beriberi induced by long-term administration of diuretics: a case report.

Previous studies have suggested that diuretic therapy for heart failure may lead to thiamine deficiency due to the increased urinary thiamine excretion. Herein, we present the case of a 61-year-old man with shoshin beriberi, a fulminant form of wet beriberi, induced by long-term diuretic therapy. The patient had a history of heart failure with preserved ejection fraction and was receiving furosemide and trichlormethiazide therapy. He presented with worsening exertional dyspnea and was admitted for heart failure exacerbation. His condition failed to improve even after intensive treatment. A hemodynamic evaluation with the Swan-Ganz catheter revealed high-output heart failure with low peripheral vascular resistance. Thiamine was administered for suspected shoshin beriberi; his hemodynamic status improved dramatically within the next six hours. The serum thiamine level was below the normal range; the patient was therefore diagnosed with shoshin beriberi. The common causes of thiamine deficiency were not identified. Long-term diuretic therapy with furosemide and thiazide was thought to have played a major role in the development of thiamine deficiency. This case illustrates the importance of considering wet beriberi as a possible cause of heart failure exacerbation in patients taking diuretics, even when the common thiamine deficiency causes are not identified with history-taking.

Anemia and Associated Clinical Outcomes in Patients With Heart Failure Due to Reduced Left Ventricular Systolic Function

Anemia is associated with decreased functional capacity, reduced quality of life, and worsened outcomes among patients with heart failure (HF) due to reduced left ventricular ejection fraction (HFREF). We sought to evaluate the independent effect of anemia on clinical outcomes among those with HFREF. Anemia is associated with cardiovascular events in patients with heart failure. The HF-ACTION trial was a prospective, randomized trial of exercise therapy vs usual care in 2331 patients with HFREF. Patients with New York Heart Association class II to IV HF and left ventricular ejection fractions of ≤ 35% were recruited. Hemoglobin (Hb) was measured up to 1 year prior to entry and was stratified by quintile. Anemia was defined as baseline Hb <13 g/dL and <12 g/dL in men and women, respectively. Hemoglobin was assessed in 2 models: a global prediction model that had been previously developed, and a modified model including variables associated with anemia and the studied outcomes. Hemoglobin was available at baseline in 1763 subjects (76% of total study population); their median age was 59.0 years, 73% were male, and 62% were Caucasian. The prevalence of anemia was 515/1763 (29%). Older age, female sex, African American race, diabetes, hypertension, and lower estimated glomerular filtration rates were all more frequent in lower Hb quintiles. Over a median follow-up of 30 months, the primary outcome of all-cause mortality or all-cause hospitalization occurred in 78% of those with anemia and 64% in those without (P < 0.001). The secondary outcomes of all-cause mortality alone,cardiovascular (CV) mortality or CV hospitalization, and CV mortality or HF hospitalization occurred in 23% vs 15%, 67% vs 54%, and 44 vs 29%, respectively (P < 0.001). Heart failure hospitalizations occurred in 36% vs 22%, and urgent outpatient visits for HF exacerbations occurred in 67% and 55%, respectively (P < 0.001). For the global model, there was an association observed for anemia and all-cause mortality or hospitalization (adjusted hazard ratio [HR]: 1.15, 95% confidence interval [CI]: 1.01-1.32, P = 0.04), but other outcomes were not significant at P < 0.05. In the modified model, the adjusted HR for anemia and the primary outcome of all-cause mortality or all-cause hospitalization was 1.25 (95% CI: 1.10-1.42, P < 0.001). There were independent associations between anemia and all-cause death (HR: 1.11, 95% CI: 0.87-1.42, P = 0.38), CV death or CV hospitalization (HR: 1.16, 95% CI: 1.01-1.33, P = 0.035), and CV death and HF hospitalization (HR: 1.27, 95% CI: 1.06-1.51, P = 0.008). Anemia modestly is associated with increased rates of death, hospitalization, and HF exacerbation in patients with chronic HFREF. After adjusting for other important covariates, anemia is independently associated with an excess hazard for all-cause mortality and all-cause hospitalization. Anemia is also associated with combinations of CV death and CV/HF hospitalizations as composite endpoints.

Depressive symptoms increase risk of rehospitalisation in heart failure patients with preserved systolic function

To examine the impact of depressive symptoms on rehospitalisation for heart failure exacerbation in patients with preserved systolic function. Depressive symptoms associated with higher risk of rehospitalisation have been primarily demonstrated in heart failure patients with systolic dysfunction (ejection fraction <40%) and the factors influencing rehospitalisation of patients with preserved systolic function (ejection fraction > or =40%) remain unclear. A prospective, descriptive study design was used. The following baseline data were collected from 165 patients with preserved systolic function during an index hospitalisation for heart failure in South Korea: age, gender, body mass index, New York Heart Association functional class, the ratio of mitral velocity to early diastolic velocity of the mitral annulus, comorbidities, history of prior admission and depressive symptoms. Patients were followed monthly for six months after discharge to collect date on all rehospitalisation for heart failure exacerbation. Hierarchical Cox proportional hazards regression was used to identify independent predictors of rehospitalisation. Kaplan-Meier survival curves with log-rank test were used to determine differences in time to rehospitalisation according to severity of depressive symptoms. Almost half of the patients (48%) had moderate to severe depressive symptoms. The ratio of mitral velocity to early diastolic velocity of the mitral annulus (hazard ratio = 1.06, 95% confidence interval = 1.02-1.10) and depressive symptoms (hazard ratio = 1.05, 95% confidence interval = 1.02-1.08) independently predicted rehospitalisation after controlling for other risk factors. Moderate and severe depressive symptoms were associated with both a higher rate and shorter time to rehospitalisation. Moderate to severe depressive symptoms predict early rehospitalisation for heart failure exacerbations in patients with preserved systolic function. Nurses should assess for depressive symptoms in patients with heart failure and refer those with depressive symptoms for treatment to improve outcomes.

Possible heart failure exacerbation associated with pregabalin: case discussion and literature review

Pregabalin is an analog of the neurotransmitter gamma-aminobutyric acid that exhibits analgesic, anticonvulsant, and anxiolytic properties. Owing to its pharmacologic properties, the drug has been used worldwide in the management of diabetic peripheral neuropathy, postherpetic neuralgia, generalized anxiety disorder, and social anxiety disorder. Although central nervous system disturbances account for the majority of pregabalin's side effects, dose-dependent peripheral edema and weight gain have also been reported. Recently, three case reports have been published documenting a possible association between pregabalin administration and chronic heart failure decompensation. We present three additional cases of possible heart failure exacerbation in patients with clinically stable heart failure who received pregabalin for neuropathic pain. Additionally, we review the literature addressing the nature and possible etiology for this adverse effect.

Correlation and Prognostic Utility of B-Type Natriuretic Peptide and Its Amino-Terminal Fragment in Patients With Chronic Kidney Disease

This study compared the correlation and prognostic utility of B-type natriuretic peptide (BNP) and the N-terminal fragment of proBNP (NT-proBNP) in 171 outpatients with renal dysfunction. The NT-proBNP correlated well with BNP in all cases (r = 0.911; P ≤ .01), regardless of degree of renal impairment or type of left ventricular dysfunction. BNP and NT-proBNP concentrations (P < .005) and their ratios (P ≤ .01) increased as the glomerular filtration rate (GFR) declined, indicating a greater effect of GFR on NT-proBNP levels. Both natriuretic peptide levels were higher in patients with systolic dysfunction (P < .05) compared with patients with normal echocardiograms. In contrast, BNP and NT-proBNP levels were below the diagnostic cutoffs for congestive heart failure exacerbations in patients with normal heart function or diastolic dysfunction, with no statistical difference between these groups (P = .99). Both peptides are useful prognostic tools for predicting mortality and cardiac hospitalization in renal patients.