Management Of Acute Heart Failure Research Articles

Continuous infusion of furosemide versus intermittent boluses in acute decompensated heart failure: Effect on thoracic fluid content.

IntroductionThe administration of loop diuretics in the management of acute decompensated heart failure (ADHF) whether IV boluses or continuous infusion is still controversial. We intended to evaluate differences between the two administration routes on the thoracic fluid content (TFC) and the renal functions.MethodsSixty patients with ADHF admitted to the critical care medicine department (Cairo University, Egypt) were initially enrolled in the study. Twenty patients were excluded due to EF > 40%, myocardial infarction within 30 days, and baseline serum creatinine level > 4.0 mg/dL. Furosemide (120 mg/day) was given to the remaining 40 pts who continued the study after 1:1 randomization to either continuous infusion (group-I, 20 pts) or three equal intermittent daily doses (group-II, 20 pts). Subsequent dose titration was allowed after 24 h, but not earlier, according to patient’s response. No other diuretic medications were allowed. All patients were daily evaluated for NYHA class, urine output, TFC, body weight, serum K+, and renal chemistry.ResultsThe median age (Q1–Q3) was 54.5 (43.8–63.8) years old with 24 (60%) males. Apart from TFC which was significantly higher in group-I, the admission demographic, clinical, laboratory and co-morbid conditions were similar in both groups. There was statistically insignificant tendency for increased urine output during the 1st and 2nd days in group-I compared to group-II (p = .08). The body weight was decreased during the 1st day by 2 (1.5–2.5) kg in group-I compared to 1.5 (1–2) kg in group-II, (p = .03). These changes became insignificant during the 2nd day (p = .4). The decrease of TFC was significantly higher in group-I than in group-II [10 (6.3–14.5) vs 7 (3.3–9.8) kΩ−1 during the first day and 8 (6–11) vs 6 (3.3–8.5) kΩ−1 during the second day in groups-I&II respectively, P = .02 for both]. There was similar NYHA class improvement in both groups (p = .7). The serum creatinine was increased by 0.2 (0.1–0.5) vs 0 (−0.1 to 0.2) mg% and the CrCl was decreased by 7.4 (4.5–12.3) vs 3.1 (0.2–8.8) ml/min in groups-I&II respectively (p = .009 and .02 respectively).ConclusionsWe concluded that continuous furosemide infusion in ADHF might cause greater weight loss and more decrease in TFC with no symptomatic improvement and possibly with more nephrotoxic effect.

A systematic review of in-hospital worsening heart failure as an endpoint in clinical investigations of therapy for acute heart failure.

In-hospital worsening heart failure (WHF) occurs frequently in patients hospitalized for acute heart failure (AHF) and has strongly negative prognostic associations. It may be a useful endpoint in studies of AHF management but important questions remain regarding optimization of its definition and variability in its incidence. Our objective was to survey the full extent of clinical interest in WHF and assess the impact of baseline variables and trial design on outcomes. PubMed, Embase, and BIOSIS were searched systematically for clinical studies that had in-hospital WHF as an endpoint. Differences in definitions of in-hospital WHF were reviewed for their potential impact on observed incidence of WHF and its associations with post-discharge outcomes. The search identified 35 publications representing 13 interventional trials, 3 observational studies, several different classes of therapeutic agent, and 78,752 patients overall. Incidence of in-hospital WHF varied greatly-from 4.2% to 37%. Concerning the impact of differences in the way in which WHF was defined, two important factors were physician determination of worsening and whether intensification of diuretic therapy alone was defined as a WHF event. Patients having in-hospital WHF were at substantially greater risk for death and longer length of stay during index hospitalizations, all-cause and heart-failure rehospitalization, cardiovascular complications, renal failure, all-cause death, cardiovascular death, and higher healthcare costs post-discharge. There is diverse interest in selecting in-hospital WHF as an endpoint in clinical trials. Differences in reported incidence are complexly related to differences in the way in which WHF is defined.

Inotropes for the management of acute heart failure and their renal repercussions: Are they all the same?

Inotropes for the management of acute heart failure and their renal repercussions: Are they all the same?

Characteristics, Management, and Outcomes of Acute Heart Failure in the Emergency Department: A Multicenter Registry Study with 1-year Follow-up in a Chinese Cohort in Beijing.

Background:The emergency department (ED) has a pivotal influence on the management of acute heart failure (AHF), but data concerning current ED management are scarce. This Beijing AHF Registry Study investigated the characteristics, ED management, and short- and long-term clinical outcomes of AHF.Methods:This prospective, multicenter, observational study consecutively enrolled 3335 AHF patients who visited 14 EDs in Beijing from January 1, 2011, to September 23, 2012. Baseline data on characteristics and management were collected in the EDs. Follow-up data on death and readmissions were collected until November 31, 2013, with a response rate of 92.80%. The data were reported as median (interquartile range) for the continuous variables, or as number (percentage) for the categorical variables.Results:The median age of the enrolled patients was 71 (58–79) years, and 46.84% were women. In patients with AHF, coronary heart disease (43.27%) was the most common etiology, and myocardium ischemia (30.22%) was the main precipitant. Most of the patients in the ED received intravenous treatments, including diuretics (79.28%) and vasodilators (74.90%). Fewer patients in the ED received neurohormonal antagonists, and 25.94%, 31.12%, and 33.73% of patients received angiotensin converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and spironolactone, respectively. The proportions of patients who were admitted, discharged, left against medical advice, and died were 55.53%, 33.58%, 7.08%, and 3.81%, respectively. All-cause mortalities at 30 days and 1 year were 15.30% and 32.27%, respectively.Conclusions:Substantial details on characteristics and ED management of AHF were investigated. The clinical outcomes of AHF patients were dismal. Thus, further investigations of ED-based therapeutic approaches for AHF are needed.

Clinically Relevant Biomarkers in Acute Heart Failure: An Update.

Acute Heart Failure (AHF), owing to the difficulties in diagnosis, prognostic stratification and patient-related management, is still associated with unusually high morbidity and mortality. The advent of novel biomarkers apart from natriuretic peptides involved in myocardial injury, neuro-hormonal activation, and ventricular remodeling augurs immense hope in redefining the biomarker-based approach towards AHF. A thorough review of the available literature including latest review articles from distinguished experts, textbook references and guidelines from leading cardiological societies worldwide as well as the latest trials, encompassing various biomarkers known in AHF was conducted. The most relevant ones were chosen as references for the current review article. Biomarkers such as midregional proatrial natriuretic peptide, soluble ST2, highly-sensitive troponin, and midregional proadrenomedullin are some such examples that have passed various stages of substantiation while there is an array of potential biomarkers innascent stages like osteopontin, CTGF, GDF-15 and TGF beta-1 awaiting further reiteration. Not only the diagnosis of AHF itself but the evaluation of co-morbidities using markers like PCT, hematologic markers or acute kidney injury markers like NGAL present a new perspective to the management of AHF. This review article outlines the current status of the most relevant cardiac biomarkers related to AHF.

311 - An Evidence-Based Study: Evaluating the Management of Acute Heart Failure in the Gaza-Strip Hospitals

Introduction: Acute heart failure (AHF) is a life-threatening medical condition requiring urgent evaluation and treatment. This is the first clinical audit to evaluate the adherence of clinicians to international guidelines for management of AHF. Hypothesis: Development of local guidelines and adherence to them by clinicians will improve quality of care and ensure patient safety. Methods: This was a retrospective clinical audit conducted from January to December 2016. Two-hundred files of patients admitted to Nasser Hospital (n = 74) and Al-Shifaa Hospital (n = 126) were reviewed and compared to the European Society of Cardiology (ESC) Guidelines 2016. Results: The mean age of our sample was 66 ± 13 years. Fifty percent of patients were females and 96% had co-morbidities including hypertension, DM and heart disease. Shockingly vital signs were poorly documented (51% temperature, 59% pulse rate, 71.5% respiratory rate and 13% blood pressure) and SpO2 in only 69.5%. From the available data, at time of presentation, 40% had a high blood pressure, 37.7% had an SpO2 < 90%, 50.5% were anemic and 33% had leukocytosis. ECG, chest x-ray and echocardiography were done in 94.5%, 48.5% and 45%, respectively. Creatinine and urea levels were obtained in 93.5% and 89% with elevated values observed in 45.5% and 96.6%, respectively. Electrolytes (Na+ and K+) were measured in 63% of cases, glucose level in 88% but only 10% had arterial blood gases measured and 2.5% TSH level. It was found that 21.4% had hyperkalemia and 77.3% had hyperglycemia. Cardiac troponins were only done in 5.5% while 66.5% of patients had CKMB measured and BNP level wasn't utilized at all. Although 37.7% of patients had an SpO2 < 90%, it was surprising that only 12.5% received oxygen therapy. Intravenous furosemide was used in 69% and opiates were only administered to 30%. Vasodilators were given to 46.5% where systolic blood pressure was > 90 mmHg in 89.1% of them. Beta blockers (BB) were used in 57% (70.2% bisoprolol, 29.8% carvedilol). It was noted that BB were given to 2 hypotensive patients, which is not consistent with ESC guidelines. Digoxin 0.25 mg was given in 28.5% of which 53.4% had atrial fibrillation. Venous thromboembolism prophylaxis was administered to 70%. Conclusions: The results of this audit reflect the fact that the management of AHF does not comply with the ESC guidelines. This could be attributed to the lack of local guidelines and unawareness of international guidelines. Furthermore, the poor medical record and registry systems cause loss of data and physician orders which in turn causes more deviation from the recommended guidelines. Therefore, there is an urgent need for the development of local guidelines as well as promotion of knowledge of evidence-based practice among clinicians. In addition, the current documentation system should be improved as soon as possible to facilitate the process of evaluating the clinical practice in future.

Heart failure – what’s new and what’s changed?

Physicians responsible for the care of patients with heart failure due to left ventricular systolic dysfunction have access to a broad range of evidence-based treatments that prolong life and reduce symptoms. In spite of the significant progress made over the last four decades, there is an ongoing need for novel therapies to treat a condition that is associated with stubbornly high morbidity and mortality. In this article, we discuss the findings of SERVE-HF, a randomised controlled trial of adaptive servo-ventilation in patients with left ventricular systolic dysfunction, as well as EMPA-REG, a study of the effects of a novel diabetic agent that may be of greater interest to heart failure specialists than diabetologists. We also examine further analyses of the groundbreaking PARADIGM-HF trial, which attempt to answer some of the unresolved questions from the original study of the first combined angiotensin-receptor blocker and neprilysin inhibitor, sacubitril valsartan. The recently published National Institute for Health and Care Excellence guidelines for the management of acute heart failure and plans to introduce best practice tariffs bring into focus the need for well-organised, multidisciplinary care. We discuss the challenges involved in developing and delivering a specialist service that meets the needs of a growing population of patients living with heart failure.

P1490Age-related differences in characteristics and management of acute decompensated heart failure in Japan: insights from the kyoto congestive heart failure registry

P1490Age-related differences in characteristics and management of acute decompensated heart failure in Japan: insights from the kyoto congestive heart failure registry

The Challenges of Diagnostic and Management of Acute Heart Failure From Hemodynamic Subset to Appropriate Treatment

Acute heart failure (AHF) is a common and growing medical problem associated with major morbidity and mortality. Despite the high prevalence of this condition and its associated major morbidity and mortality, diagnosis can be difficult, and optimal treatment remains poorly defined. Identification of the acute triggers for the decompensation as well as characterization of cardiac filling pressures and output is central to management. Evaluation of patients with Heart Failure (HF) is critical for the appropriate selection and monitoring of therapy as well as for the prevention of recurrent hospitalizations.Diagnostic and management AHF is a challenge because of the heterogeneity of the patient population, the existence of a universal definition of understanding, not understanding the pathophysiology, and the lack of bases guideline Evidence-based medicine

The Modern Aspects of Acute Heart Failure Management

Acute heart failure (AHF) is one the most common causes of morbidity and mortality. The prognosis of patients admitted with AHF remains dismal, with over 20% experiencing recurrent HF admission and over 20% dying during the first year after initial admission.The purpose of this study was to provide contemporary perspective for hospital management of AHF within the context of the most recent data and to provide guidance, based on expert opinions, to practicing physicians and other healthcare professionals. Material and methods: In this paper we reviewed of current updated European Cardiology Society (ESC) HF guideline (2016) and modern trials for AHF from Medscape database. Results: Diuretics are the main medications in the treatment of patients with AHF and signs of fluid overload and congestion. Intravenous vasodilators are the second most used agent in AHF. Their use was shown to be associated with lower mortality, and a delay in administration was associated with a higher mortality.Use of an inotropic medications (such as dopamine, dobutamine, milrinone, levosimendan, epinephrine, norepenephrine) should be reserved for patients with a severe reduction in cardiac output resulting in compromised vital organ perfusion, which occurs most often in hypotensive AHF. Conclusion: Acute heart failure is a life-threatening medical condition, which needs emergency management for death prevention.

The Use of Nitrates in the Management of Acute Heart Failure in the Emergency Department: a Review

Purpose of Review Nitrates represent a frequently used group of medications in the management of hypertensive patients in acute heart failure. Despite its longevity, usage of this medication seems to be guided chiefly by expert opinion, with relatively few trials involving interventions in the emergency department. This review seeks to define more precisely the role of nitrates in the emergency department by discussing some of the more compelling research that exists on the topic in addition to their biochemistry and current guidelines.

The effect of intravenous isosorbide dinitrate in acute decompensated heart failure in hospital.

Background According to new recommendations for the management of acute decompensated heart failure (ADHF) in 2015, intravenous vasodilator therapy might be given as an early therapy when systolic blood pressure is normal to high (≥110mmHg). Only 29% of patients with ADHF are treated with vasodilators without medical contraindication. Objective To evaluate the effect of the systematic use of ISDN on ADHF without contraindication especially on rehospitalization rate. Settings The 600-bed hospital (Centre Hospitalier de l'Ouest Vosgien, Neufchâteau, France). Methods This is a retrospective study with data analysed from medical records. Patients with ADHF episodes and hospitalization in the cardiology department or intensive care unit (ICU) between November 2013 and December 2015 were included resulting in 199 hospitalizations in the analysis (37 were treated by ISDN, and 162 were not). Main outcome measure Effects of ISDN on 180-day hospital readmission for ADHF or acute myocardial infarction (AMI), in-hospital mortality, length of stay, number of ICU admissions, and ICU length of stay. Results Patients who received ISDN required more ICU admissions than the other patients (54.1 vs 33.3%, p=0.02). Nevertheless 180-day hospital readmission was lower for patients who were receiving ISDN (8.1 vs 22.8%, p=0.04). ISDN did not influence other clinical outcomes tested. Conclusion ISDN may minimize or prevent the consequences of altered haemodynamics. Lower rehospitalization rate with ISDN was seen in this study.

Aetiology, diagnosis and management of heart failure in infants and children

Heart failure is due to failure of ventricular filling with failure of ejection of blood from the ventricles. It may present as volume overload with ventricular dysfunction, volume overload with preserved ventricular function, and pressure overload. Causes of heart failure in the paediatric age group include both congenital and acquired heart diseases. Dilated cardiomyopathy remains the most common cause of heart failure in the paediatric population. In this article, epidemiology; pathophysiology; aetiology; clinical presentation; investigations including radiological and laboratory investigations; medical and non-medical management of acute, chronic and end-stage heart failure and prognosis will be reviewed.

Differences between determinants of in-hospital mortality and hospitalisation costs for patients with acute heart failure: a nationwide observational study from Japan

ObjectivesAlthough current case-mix classifications in prospective payment systems were developed to estimate patient resource usage, whether these classifications reflect clinical outcomes remains unknown. The efficient management of acute heart failure...

A review of the current management of acute and chronic heart failure in the context of ischemic heart disease

AbstractHeart failure secondary to left ventricular systolic dysfunction is a prevalent condition across Europe with ischemic heart disease the most common etiology. Acute heart failure is a medical emergency and management comprises diuretics and vasodilators. Several alternative intravenous treatments have been trialed in recent years but no mortality benefit has been found with these agents. For chronic heart failure there are several well‐characterized disease‐modifying treatments available which include beta blockers, ACE inhibitors, mineralocorticoid antagonists, and device therapy. Sacubitril/valsartan is a novel therapy that has recently been demonstrated to have additional prognostic benefit.Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/5222693/Activity.aspx

Noninvasive Bioelectrical Impedance for Predicting Clinical Outcomes in Outpatients With Heart Failure

Noninvasive bioelectrical impedance analysis (BIA) has shown promise in acute heart failure (HF) management. To our knowledge, its use in predicting outcomes in outpatients with chronic HF patients has not been well described. BIA assessment of edema index was performed in 359 outpatients with HF using the InBody 520 scale. Edema index was calculated by dividing extracellular by total body water. Patients were stratified into those with low (≤0.39) and high (>0.39) edema indices. The outcome of interest was death, urgent transplant, or ventricular assist device over 2-year follow up. Patients with a high edema index were older, had higher B-type natriuretic peptide values and New York Heart Association Class. Patients with a high edema index had poorer outcomes (unadjusted hazard ratio 1.90, 95% confidence intervals 1.05-3.56). However, in multivariate analyses, a high edema index was not an independent predictor of outcomes (adjusted hazard ratio 1.21, 95% confidence interval 0.51-2.90). A high edema index using a bioimpedance scale in a HF clinic correlated with patient outcomes in unadjusted analyses, but was not a predictor of outcomes once other measures of HF severity are accounted for. As a noninvasive measure of volume status, use of BIA in a HF clinic may be beneficial in determining patient prognosis and treatment when other outcome predictors are not immediately available.

Design and Rationale of a Randomized Trial of a Care Transition Strategy in Patients With Acute Heart Failure Discharged From the Emergency Department: GUIDED-HF (Get With the Guidelines in Emergency Department Patients With Heart Failure).

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02519283.

Heart failure – what’s new and what’s changed?

Physicians responsible for the care of patients with heart failure due to left ventricular systolic dysfunction have access to a broad range of evidence-based treatments that prolong life and reduce symptoms. In spite of the significant progress made over the last four decades, there is an ongoing need for novel therapies to treat a condition that is associated with stubbornly high morbidity and mortality. In this article, we discuss the findings of SERVE-HF, a randomised controlled trial of adaptive servo-ventilation in patients with left ventricular systolic dysfunction, as well as EMPA-REG, a study of the effects of a novel diabetic agent that may be of greater interest to heart failure specialists than diabetologists. We also examine further analyses of the groundbreaking PARADIGM-HF trial, which attempt to answer some of the unresolved questions from the original study of the first combined angiotensin-receptor blocker and neprilysin inhibitor, sacubitril valsartan. The recently published National Institute for Health and Care Excellence guidelines for the management of acute heart failure and plans to introduce best practice tariffs bring into focus the need for well-organised, multidisciplinary care. We discuss the challenges involved in developing and delivering a specialist service that meets the needs of a growing population of patients living with heart failure.

Intravenous enalaprilat for treatment of acute hypertensive heart failure in the emergency department.

BackgroundAfterload reduction with bolus enalaprilat is used by some for management of acute hypertensive heart failure (HF) but existing data on the safety and effectiveness of this practice are limited. The purpose of this study was to evaluate the clinical effects of bolus enalaprilat when administered to patients with acute hypertensive heart failure.FindingsWe performed an IRB-approved retrospective cohort study of patients who presented to the emergency department of a large urban academic hospital. Patients were identified by pharmacy record and included if they received enalaprilat intravenous (IV) bolus in the setting of acute hypertensive HF. A total of 103 patients were included. Patients were hypertensive on presentation (systolic blood pressure [SBP] = 195.2 [SD ± 32.3] mmHg) with significantly elevated mean NT-proBNP levels (3797.8 [SD ± 6523.2] pg/ml). The mean dose of enalaprilat was 1.3 [SD ± 0.7] mg, with most patients (76.7%) receiving a single 1.25 mg bolus. By 3 h post­enalaprilat, SBP had decreased substantially (−30.5 mmHg) with only 2 patients (1.9%) developing hypotension. Renal function was unaffected, with no significant change in serum creatinine by 72 h. In the 30 days post-admission, patients spent an average of 23 [SD ± 7.5] days alive and out of hospital.ConclusionsIn this retrospective cohort of acute hypertensive HF patients, bolus IV enalaprilat resulted in a substantial reduction in systolic BP without adverse effect.

Evolving therapies for the management of chronic and acute decompensated heart failure.

The pharmacology, clinical efficacy, and safety profiles of evolving therapies for the management of chronic heart failure (HF) and acute decompensated heart failure (ADHF) are described. HF confers a significant financial burden despite the widespread use of traditional guideline-directed medical therapies such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, and aldosterone receptor antagonists, and the rates of HF-related mortality and hospitalization have remained unacceptably high. In response to a demand for novel pharmacologic agents, several therapeutic compounds have recently gained approval or are currently under review by the Food and Drug Administration. Sacubitril-valsartan has demonstrated benefit in reducing cardiovascular mortality and HF-related hospitalizations in clinical trials, while ivabradine and ferric carboxymaltose have proven efficacious in reducing HF-related hospitalizations. Lastly, the role of serelaxin in ADHF is currently under investigation in an ongoing Phase III study. While large, outcome-driven clinical trials are fundamental in informing the clinical application of these therapeutic agents, careful patient selection is imperative to ensuring similar outcomes postmarketing. In addition, optimization of current guideline-directed medical therapy remains essential as new therapies emerge and are incorporated into guideline recommendations. Additional therapeutic agents currently undergoing investigation include bucindolol hydrochloride, cimaglermin alfa, nitroxyl, omecamtiv mecarbil, TRV027, and ularitide. Clinical practitioners should remain abreast of emerging literature so that new therapeutic entities are optimally applied and positive patient outcomes are achieved. Recently introduced agents for the treatment of patients with HF include sacubitril-valsartan, ivabradine, and ferric carboxymaltose. Additional agents worthy of attention include serelaxin and other therapies currently under investigation.