Outcomes In Acute Heart Failure Research Articles

Association of gut-related metabolites with outcome in acute heart failure

Trimethylamine N-oxide (TMAO), a gut-related metabolite, is associated with heart failure (HF) outcomes. However, TMAO is the final product of a complex metabolic pathway (ie, choline/carnitine) that has never been entirely investigated in HF. The present study investigates a panel of metabolites involved in the TMAO-choline/carnitine metabolic pathway for their associations with outcome in acute HF patients. In total, 806 plasma samples from acute HF patients were analyzed for TMAO, trimethyllysine, L-carnitine, acetyl-L-carnitine, γ-butyrobetaine, crotonobetaine, trimethylamine, betaine aldehyde, choline, and betaine using a developed liquid chromatography-tandem mass spectrometry method. Associations with outcome of all-cause mortality (death) and a composite of all-cause mortality and/or rehospitalization caused by HF (death/HF) at 30 days and 1 year were investigated. TMAO, trimethyllysine, L-carnitine, acetyl-L-carnitine, and γ-butyrobetaine were associated with death and death/HF at 30 days (short term; hazard ratio 1.30-1.49, P≤ .021) and at 1 year (long term; hazard ratio 1.15-1.25, P≤ .026) when adjusted for cardiac risk factors. L-carnitine and acetyl-L-carnitine were superior for short-term outcomes whereas TMAO was the superior metabolite for association with long-term outcomes. Furthermore, acetyl-L-carnitine and L-carnitine were superior for in-hospital mortality and improved risk stratification when combined with current clinical risk scores (ie, Acute Decompensated HEart Failure National REgistry, Organized Program To Initiate Lifesaving Treatment In Hospitalized Patients With Heart Failure, and Get With The Guidelines-Heart Failure; odds ratio (OR) ≥ 1.52, P≤ .020). Carnitine-related metabolites show associations with adverse outcomes in acute HF, in particular L-carnitine and acetyl-L-carnitine for short-term outcomes, and TMAO for long-term outcomes. Further studies are warranted to investigate the role and implications of carnitine metabolites including intervention in the pathogenesis of HF.

Right ventricular ejection fraction as predictor of outcome in acute heart failure using RV ellipsoid model: A retrospective analysis of a prospective cross-sectional study.

ObjectivesThe right ventricular (RV) function is an important prognostic factor in acute and chronic heart failure (HF). Echocardiography is an essential imaging modality with established parameters for RV function which are useful and easy to perform. However, these fail to reflect global RV volumes due to reliability on one acoustic window. It is therefore attractive to calculate RV volumes and ejection fraction (RVEF/E) using an ellipsoid geometric model which has been validated against MRI in healthy adults but not in the HF patients.DesignThis is a retrospective analysis of a prospective cross-sectional study enrolling 418 consecutive patients with symptoms of HF according to a predefined study protocol. All patients underwent echocardiographic assessment of RV function using Tricuspid Annular Plane Systolic Excursion (TAPSE) and RV fractional area change (RVFAC) and RVEF/E.SettingSingle centre study with multiple locations for acute in-patients including high dependency units.ParticipantsPatients with acute or exacerbation of chronic HF older than 18 y.o.Main outcome measuresAbility of RVEF/E to predict patient outcomes compared with two established parameters of RV function over two-year follow-up period. Primary outcome measure was all-cause mortality.ResultsRVEF/E is equal to TAPSE & RVFAC in predicting outcome (p ≤ 0.01 vs p ≤ 0.01) and provides additional benefit of RV volume estimation based on standard 2D echo measurements.ConclusionsIn this study we have shown that RVEF/E derived from ellipsoid model is not inferior to well established measures of RV function as a prognostic indicator of outcome in the acute HF.

Vasopressin antagonism in heart failure: a review of the hemodynamic studies and major clinical trials.

For decades, plasma arginine vasopressin (AVP) levels have been known to be elevated in patients with congestive heart failure (HF). Excessive AVP signaling at either or both the V1a and V2 receptors could contribute to the pathophysiology of HF by several mechanisms. V1a activation could cause vasoconstriction and/or direct myocardial hypertrophy as intracellular signaling pathways are closely related to those for angiotensin II. V2 activation could cause fluid retention and hyponatremia. A hemodynamic study with the pure V2 antagonist tolvaptan (TV) showed minimal hemodynamic effects. Compared with furosemide in another study, the renal and neurohormonal effects of TV were favorable. Several clinical trials with TV as adjunctive therapy in acute HF have shown beneficial effects on fluid balance and dyspnea, with no worsening of renal function or neurohormonal stimulation. Two smaller studies, one in acute and one in chronic HF, have shown comparable clinical and more favorable renal and neurohormonal effects of TV compared with loop diuretics. However, long-term treatment with TV did not alter outcomes in acute HF. No data are available other than single-dose studies of an intravenous pure V1a antagonist, which showed a vasodilating effect if plasma AVP levels were elevated. One hemodynamic study and one short-duration clinical trial with the balanced intravenous V1a/V2 antagonist conivaptan (CV) showed hemodynamic and clinical effects largely similar to those with TV in similar studies. A new orally effective balanced V1/V2 antagonist (pecavaptan) is currently undergoing phase II study as both adjunctive and alternative therapy during and after hospitalization for acute HF. The purpose of this review is to summarize what we have learned from the clinical experience with TV and CV, and to suggest implications of these findings for future work with newer agents.

Validation of Saiful Anwar Clinical Congestion Score in Comparison with NT-proBNP for Prediction of Short-term Outcome in Acute Heart Failure with Reduced Ejection Fraction

Background : Risk stratification of acute heart failure (AHF) patient during hospital admission utilizing clinical scores emerges as an alternative to standart natriuretic peptide measurement. Development of Saiful Anwar clinical congestion score (SACS) as multivariable predictive model for prediction of short-term outcome in AHF with reduced ejection fraction (AHF-rEF) requires validation in comparison to NT-proBNP. Objective : To validate prognostic value of SACS compare with NT-proBNP in AHF-rEF Method : This single-center, prospective cohort study was held in dr. Saiful Anwar General Hospital during January 2019 to June 2020. From total 89 AHF-rEF patients who admitted to emergency department, were assigned to SACS prospective questionnaire fulfillment and NT-proBNP measurement during first 12-hours since admission. Patients were divided into two groups based on SACS score and NT-proBNP value during admission. 90-days follow up was performed after index hospitalization with outcome of interest i.e all-cause mortality (ACM) and HF-related rehospitalization (HFR). Results : ACM and HFR rate in this study were 16.8% and 22.5%, respectively. SACS ≥6 demonstrated higher ACM and HFR rate during 90-days follow-up compared to SACS <6 (p=0.000; p=0.000, respectively). Performance of SACS ≥6 on admission showed good discriminative power for predicting 90-days ACM and HFR (AUC 0.841, p=0.000; AUC 0.788, p=0.000, respectively) compared to NT-proBNP ≥5000pg/mL (AUC 0.812, p=0.000; AUC 0.819, p=0.000, respectively). Additive value of NT-proBNP ≥5000pg/mL on top of SACS ≥6 increases discriminative power for predicting 90-days ACM and HFR after index hospitalization (AUC 0.836, p=0.000; AUC 0.90, p=0.000, respectively). Conclusion : SACS has demonstrated prognostic value compared to NT-proBNP for prediction of 90-days ACM and HFR after index hospitalization in AHF-rEF patients.

Time-weighted lactate as a predictor of adverse outcome in acute heart failure.

AimsThe role of dynamic changes in lactate concentrations on prognosis in acute heart failure has been poorly investigated. The aim of this study was to explore the predictive value of 24 h time‐weighted lactate (LACTW) in patients with acute heart failure.Methods and resultsNinety‐six consecutive acute heart failure patients presenting to the Emergency Department of San Paolo Hospital, Naples, Italy, were prospectively enrolled. Arterial blood lactate was measured at admission and during the following 24 h at random time intervals. LACTW was obtained by the sum of the average lactate values among consecutive time points multiplied by the intervals between consecutive time points and dividing the sum by the total time (24 h). The outcome was a composite of need of admission to the intensive care unit, hospitalization duration >7 days, or intra‐hospital death. Admission lactate, maximum measured lactate, and LACTW were collected. Univariate and multivariate Cox regression analysis was applied to determine the hazard ratio (HR) of developing the outcome. Forty‐three patients experienced the pre‐specified outcome. In sex‐adjusted and age‐adjusted multivariable analysis, LACTW predicted the outcome occurrence (HR: 1.51, 95% confidence interval: 1.24, 1.84, P < 0.001). Risk stratification analysis based on LACTW tertiles demonstrated a gradual increase in risk of developing the outcome (HR: 17.32, 95% confidence interval: 2.30, 130.23, P = 0.006) for the highest LACTW tertile.ConclusionsIn acute heart failure patients, 24 h LACTW had a significant independent predictive value for adverse intra‐hospital outcome. LACTW could be a useful index at identifying high‐risk patients who may require a more aggressive treatment during hospitalization.

The association between acute-to-chronic glycemic ratio and outcome in acute heart failure

Abstract Introduction Elevated blood glucose level on admission worsen outcome in acute heart failure (AHF). The admission blood glucose (ABG)/ the estimated average glucose (eAG) ratio which combines both acute and chronic glucose levels is attracting attention as a newly introduced glycemic index. It may be accepted as indicating the true acute glycemic rise in critically in all patients. Purpose The aim of this study was to assess the association between acute-to-chronic glycemic ratio and outcome in AHF. Methods This study assessed consecutive patients with AHF. The ABG/ eAG ratio was determined as ABG divided by eAG. We examined the relationship between ABG/ eAG ratio and all-cause mortality and readmission for heart failure within 30 days. Results A total of 249 patients with AHF (mean age; 81 years, 50% male and 37% DM) were studied. 31 (12.4%) patients had events within 30 days [18 (7.2%) died and 13 (5.2%) readmitted for HF]. We divided into three tertiles [T1 (&amp;lt;0.93), T2 (0.93–1.21) and T3 (&amp;gt;1.21)] based on the ABG/ eAG ratio. There was a stepwise worsening of the 30 days outcome [1 patient (0.4%) vs 7 patients (2.8%) vs 23 patients (9.2%), p&amp;lt;0.0001]. In multiple variable analysis, ABG/ eAG ratio was an independent predictor of the events (p=0.002). A cut-off value of the ABG/ eAG ratio &amp;lt;1.11 had a sensitivity of 94% and specificity of 67% for the increase of events within 30 days. In full model, the ABG/ eAG ratio was independent predictor of 30 days outcome in AHF (odds ratio: 11.7; 95% confidence interval: 3.65–37.5; p&amp;lt;0.0001). Conclusion ABG/ eAG ratio was one of the strong predictors 30 days outcome in AHF. Elevated blood glucose in the acute phase evaluated using the ABG/ eAG ratiocan enhance affect outcome and it could be a potential therapeutic target in patients of AHF. Funding Acknowledgement Type of funding source: None

Elevated plasma endothelin-1 is related to low natriuresis, clinical signs of congestion, and poor outcome in acute heart failure.

AimsEndothelin‐1 (ET‐1) is a potent vasoconstrictor, which regulates renal and vascular function. We aimed to relate plasma levels of ET‐1 with the clinical picture and outcomes in acute heart failure (AHF).Methods and resultsWe studied 113 patients with AHF [mean age 65 ± 13 (years), median (upper and lower quartiles) N‐terminal pro‐B‐type natriuretic peptide, 5422 (2689; 8582) (pg/mL)], in whom plasma levels of ET‐1 were serially measured at admission (10.8 ± 5.2), Day 1 (9.5 ± 3.4), and Day 2 (8.9 ± 3.8) (pg/mL). The population was divided into tertiles across baseline ET‐1 levels. Patients in the highest ET‐1 tertile had predominant clinical signs of peripheral congestion; however, no difference was observed in pulmonary congestion and severity of dyspnoea. They also presented lower spot urine sodium at admission (75 ± 35 vs. 99 ± 43 vs. 108 ± 30), 6 h (84 ± 34 vs. 106 ± 43 vs. 106 ± 35), and Day 1 (75 ± 38 vs. 96 ± 36 vs. 100 ± 35) (mmol/L), when compared with the second and first tertile, respectively (all P < 0.05); furthermore, they received higher doses of intravenous furosemide from Day 2 and had longer intravenous diuretics, as median switch to oral furosemide was 4 (3; 4) vs. 3 (2; 4) vs. 2 (2; 3) (days), respectively, P < 0.05. There was no difference in serum creatinine, urea, and renal injury biomarkers (kidney injury molecule‐1, serum cystatin C, and urine neutrophil gelatinase‐associated lipocalin) between the ET‐1 tertiles. Higher values of ET‐1 measured at each time point were related with a higher risk of 1 year mortality.ConclusionsElevation of ET‐1 is related to clinical signs of peripheral congestion, low urine sodium excretion, and poor outcome in AHF.

246 Sonographic Right Ventricular Dysfunction Predicts Acute Heart Failure Outcomes Independent of Current Emergency Department Risk Measures

Right ventricular dysfunction (RVD) on ultrasound is one of the strongest predictors of acute heart failure (AHF) risk in inpatient and outpatient studies but has not been studied in the ED. We sought to evaluate the performance of RVD-assessment on emergency physician (EP)-performed point of care ultrasound (POCUS) to predict AHF risk when compared to currently utilized measures of AHF risk stratification. Right Ventricular Evaluation in ED AHF (REED-AHF) is an ongoing prospective observational study at two urban-academic hospitals, supported by a grant from the Blue Cross Blue Shield of Michigan Foundation. EP POCUS has been performed in 66 (of planned 123) patients with suspected AHF ≤60 minutes after initiation of IV diuresis, vasodilator, or non-invasive positive pressure ventilation. Ten met exclusion criteria (failure to obtain consent within 24 hours of the POCUS, or ED physician indicated that AHF was not suspected by time of disposition), resulting in a 56-person sample thus far. Patients were followed (phone) at 30 days for the primary composite outcome of AHF-readmission, mortality, new onset dialysis, intubation, acute coronary intervention and/or ICU admission. Using logistic regression, tricuspid annular plane systolic excursion (TAPSE) and free-wall RV strain (fwRVLS) were evaluated in separate models as POCUS markers of RVD for prediction of the primary outcome, adjusted for ED measures of AHF risk specified a priori: troponin, age, estimated glomerular filtration rate, ejection fraction, and chronic obstructive pulmonary disease history. TAPSE and fwRVLS were normally distributed with mean and standard deviation of 20 +/- 6mm and -17 +/- 6 strain units, respectively. Mean age was 62 +/- 13 years, while mean ejection fraction was 31 +/- 13%. The composite outcome occurred in 20 patients (36%). TAPSE was independently associated with the composite outcome (odds ratio [OR]=0.42 per 6 mm increase; 95% confidence interval [CI]:0.20-0.90), while fwRVLS showed a trend towards significance (OR=0.37 per 6 unit improvement; 95% CI: 0.27-1.02). Area under the receiver operating curve (AUROC) for the models of TAPSE and fwRVLS were 0.72 (95% CI:0.58-0.86) and 0.75 (0.61-0.89), respectively. No other risk markers reached statistical significance after adjustment for TAPSE. Further analyses including time to POCUS image acquisition, comparison of TAPSE and fwRVLS cutoffs, and sensitivity analysis for other potential confounders are pending completion of the study enrollment. TAPSE obtained by EPs on POCUS independently predicted 30-day adverse outcomes. Conversely, pending completion of study enrollment, clinical risk-markers currently used for AHF risk-stratification to predict 30-day outcomes were non-significant after adjustment for TAPSE. Further studies are warranted to externally validate our results, and to assess the most effective and feasible clinical implementation of RV POCUS into a broader strategy of AHF risk-stratification by EPs.

Lymphocytopenia During Hospitalization for Acute Heart Failure and Its Relationship with Portal Congestion and Right Ventricular Function

Lymphocytopenia During Hospitalization for Acute Heart Failure and Its Relationship with Portal Congestion and Right Ventricular Function

Beta-Blockers and Cardiovascular Outcomes in Acute Heart Failure with a History of Coronary Artery Disease and an Ejection Fraction ≥ 40.

The prognostic impact of beta-blockers (BB) in coronary artery disease (CAD) is controversial, especially in the post-reperfusion era. We studied in-hospital cardiovascular events in patients hospitalized for acute HF, a previous history of CAD and a left ventricular ejection fraction (LVEF) ≥40%, in relation to BB on admission; and 1-year outcome in relation to BB on discharge, in the GULF aCute heArt failuRe (GULF-CARE) registry. From a total of 5005 patients included in the GULF-CARE registry, 303 patients with a previous history of CAD and a LVEF ≥40% on BB were propensity-matched to 303 patients without BB on admission. In-hospital mortality (OR= 0.82; 95% CI [0.35-1.94]), stroke and cardiogenic shock were not reduced by BB. On discharge, 306 patients on BB, including the ones newly diagnosed with myocardial infarction as a precipitating cause of HF, were propensity-scored matched with 306 patients without BB. Mortality (OR= 0.86; 95%CI [0.51-1.45], hospitalization for HF or PCI/CABG at 1 year were also not reduced by BB at discharge. In summary, our data show that BB have a neutral effect on in-hospital and 1-year outcomes in acute heart failure patients with a previous history of CAD and a LVEF ≥40%.

Trayectoria precoz del sodio urinario y riesgo de eventos adversos en insuficiencia cardiaca aguda y disfunción renal

Introduction and objectivesUrinary sodium (UNa+) has emerged as a useful biomarker of poor clinical outcomes in acute heart failure (AHF). Here, we sought to evaluate: a) the usefulness of a single early determination of UNa+ for predicting adverse outcomes in patients with AHF and renal dysfunction, and b) whether the change in UNa+ at 24hours (ΔUNa24h) adds any additional prognostic information over baseline values. MethodsThis is a post-hoc analysis of a multicenter, open-label, randomized clinical trial (IMPROVE-HF) (ClinicalTrials.gov NCT02643147) that randomized 160 patients with AHF and renal dysfunction on admission to a) the standard diuretic strategy, or b) a carbohydrate antigen 125-guided diuretic strategy. The primary end point was all-cause mortality and total all-cause readmissions. ResultsThe mean age was 78±8 years, and the mean glomerular filtration rate was 34.0±8.5mL/min/1.73 m2. The median UNa+ was 90 (65-111) mmol/L. At a median follow-up of 1.73 years [interquartile range, 0.48-2.35], 83 deaths (51.9%) were registered, as well as 263 all-cause readmissions in 110 patients. UNa+ was independently associated with mortality (HR, 0.75; 95%CI, 0.65-0.87; P <.001) and all-cause readmissions (HR, 0.92; 95%CI, 0.88-0.96; P <.001). The prognostic usefulness of the ΔUNa24h varied according to UNa+ at admission (P for interaction <.05). The ΔUNa24h was inversely associated with both end points only in the group with UNa+ ≤ 50 mmol/L. Conversely, no effect was found in the group with UNa+> 50 mmol/L. ConclusionsIn patients with AHF and renal dysfunction, a single early determination of UNa+ ≤ 50 mmol/L identifies patients with a higher risk of all-cause mortality and readmission. The ΔUNa24h adds prognostic information over baseline values only when UNa+ at admission is ≤ 50 mmol/L.

Association of Heart Rate Trajectory Patterns with the Risk of Adverse Outcomes for Acute Heart Failure in a Heart Failure Cohort in Taiwan.

Heart rate trajectory with multiple heart rate measurements is considered to be a more sensitive predictor of outcomes than single heart rate measurements. The association of heart rate trajectory patterns with acute heart failure outcomes has not been well studied. We examined the association of heart rate trajectory patterns with post-discharge outcomes. This prospective cohort study was based on an acute heart failure registry in Taiwan. A total of 1509 patients were enrolled in the Taiwan Society of Cardiology - Heart Failure with Reduced Ejection Fraction Registry from May 2013 to October 2015. The outcomes were post-discharge all-cause mortality and heart failure re-admission. Two heart trajectory patterns were identified in group-based trajectory analysis. One started with a higher heart rate and had an increasing trend over 6 months then a subsequent decline (high-increasing-decreasing group; n = 352; 23.9%). The other started with a lower heart rate and had a relatively stable pattern (low-stable group; n = 1121; 76.1%). Compared with those in the low-stable group, patients in the high-increasing-decreasing group had a higher risk of events (all-cause mortality: hazard ratio 3.10 and 95% confidence interval 1.24-7.77; heart failure re-admission: hazard ratio 1.13 and 95% confidence interval 0.55-2.32). Patients with a high-increasing-decreasing heart rate trajectory pattern had a higher risk of all-cause mortality than those with a low-stable pattern.

Factors associated with plasma antigen carbohydrate 125 and amino-terminal pro-B-type natriuretic peptide concentrations in acute heart failure.

Plasma amino-terminal pro-B-type natriuretic peptide and antigen carbohydrate 125 levels are positively associated with a higher risk of adverse clinical outcomes in acute heart failure. As a proxy of congestion, antigen carbohydrate 125 has also been proposed as a right-sided heart failure marker. Thus, we aimed to determine in this population the main factors - including echocardiographic right-sided heart failure parameters - associated with antigen carbohydrate 125 and amino-terminal pro-B-type natriuretic peptide. We prospectively included 2949 patients admitted with acute heart failure. Amino-terminal pro-B-type natriuretic peptide and antigen carbohydrate 125 were used as dependent variables in a multivariable linear regression analysis. The mean age of the sample was 73.9±11.1 years; 48.9% were female, 35.8% showed ischaemic aetiology, and 51.6% exhibited heart failure with preserved ejection fraction. The median (interquartile range) for amino-terminal pro-B-type natriuretic peptide and antigen carbohydrate 125 were 4840 (2111-9204) pg/ml and 58 (26-129) U/ml, respectively. In a multivariable setting, and ranked in order of importance (R2), estimated glomerular filtration rate (43.7%), left ventricle ejection fraction (15.1%), age (12.4%) and high-sensitivity troponin T (10.9%) emerged as the most important factors associated with amino-terminal pro-B-type natriuretic peptide. The five main factors associated with antigen carbohydrate 125 were, in order of importance: the presence of pleural effusion (36.8%), tricuspid regurgitation severity (25.1%), age (11.9%), amino-terminal pro-B-type natriuretic peptide (6.5%) and peripheral oedema (4.3%). In patients with acute heart failure the main factors associated with amino-terminal pro-B-type natriuretic peptide were renal dysfunction, left ventricle ejection fraction and age. For antigen carbohydrate 125, clinical parameters of congestion and the severity of tricuspid regurgitation were the most important predictors. These results endorse the value of antigen carbohydrate 125 as a useful marker of right-sided heart failure.

Galectin-3 and acute heart failure: genetic polymorphisms, plasma level, myocardial fibrosis and 1-year outcomes.

Aim: This study sought to investigate the relationship between galectin-3 (Gal-3), myocardial fibrosis (MF) and outcomes in acute heart failure. Materials & methods: The single-nucleotide polymorphisms (SNPs) of LGALS3 at rs4644 and rs4652, plasma Gal-3 level, MF and major adverse events (MAEs) were obtained. Results: There was no significant difference in MAEs when categorizing patients by the LGALS3 SNPs at rs4644 and rs4652. The circulating Gal-3 was related to the degree of MF (p < 0.001). Plasma Gal-3 level and MF can predict an increased risk of MAEs (p < 0.001, p = 0.023, respectively). Conclusion: Not the SNPs of LGALS3 but Gal-3 and MF can predict MAEs in acute heart failure at 1 year of follow-up.

Lymphocytopenia During Hospitalization for Acute Heart Failure and Its Relationship With Portal Congestion and Right Ventricular Function

BackgroundLymphocytopenia is associated with mortality in acute heart failure (AHF), and portal congestion has been suggested to play a role in leukocyte distribution. The associations between lymphocytopenia and ultrasound surrogates for portal congestion have never been studied. We aimed to characterize the determinants of lymphocytopenia, explore the associations between lymphocytopenia and portal congestion, and explore the relationships between lymphocytopenia and outcomes in AHF. Methods and ResultsPatients were compared according to tertiles of lymphocyte count (very low, <0.87 × 109/L; low, 0.87–1.2 × 109/L; or normal, >1.2 × 109/L). One hundred three patients with AHF were prospectively assessed at baseline and discharge. At baseline, 69% of patients had a lymphocyte count below the normal range. Patients with baseline very low lymphocyte count were older, had more advanced disease and higher portal vein pulsatility index when compared with those in the higher tertiles. Very low lymphocyte count at baseline was associated with age (odds ratio (OR) 1.098), portal vein pulsatility index (OR, 1.026), and tricuspid annular plane systolic excursion (OR, 0.865, all P < .05). The portal vein pulsatility index was the most powerful determinant of lymphocytopenia at discharge (OR 1.033, P < .05). In a Cox model, lymphocytopenia at discharge was associated with mortality (hazard ratio 4.796, P < .05). ConclusionsIn AHF, lymphocytopenia is associated with ultrasound surrogates for portal congestion and right ventricular dysfunction. Whether these associations depict a potent pathophysiologic pathway or whether they only reflect a more advanced disease remains uncertain.

Early urinary sodium trajectory and risk of adverse outcomes in acute heart failure and renal dysfunction

Introduction and objectivesUrinary sodium (UNa+) has emerged as a useful biomarker of poor clinical outcomes in acute heart failure (AHF). Here, we sought to evaluate: a) the usefulness of a single early determination of UNa+ for predicting adverse outcomes in patients with AHF and renal dysfunction, and b) whether the change in UNa+ at 24hours (ΔUNa24h) adds any additional prognostic information over baseline values. MethodsThis is a post-hoc analysis of a multicenter, open-label, randomized clinical trial (IMPROVE-HF) (ClinicalTrials.gov NCT02643147) that randomized 160 patients with AHF and renal dysfunction on admission to a) the standard diuretic strategy, or b) a carbohydrate antigen 125-guided diuretic strategy. The primary end point was all-cause mortality and total all-cause readmissions. ResultsThe mean age was 78±8 years, and the mean glomerular filtration rate was 34.0±8.5mL/min/1.73 m2. The median UNa+ was 90 (65-111) mmol/L. At a median follow-up of 1.73 years [interquartile range, 0.48-2.35], 83 deaths (51.9%) were registered, as well as 263 all-cause readmissions in 110 patients. UNa+ was independently associated with mortality (HR, 0.75; 95%CI, 0.65-0.87; P <.001) and all-cause readmissions (HR, 0.92; 95%CI, 0.88-0.96; P <.001). The prognostic usefulness of the ΔUNa24h varied according to UNa+ at admission (P for interaction <.05). The ΔUNa24h was inversely associated with both end points only in the group with UNa+ ≤ 50 mmol/L. Conversely, no effect was found in the group with UNa+> 50 mmol/L. ConclusionsIn patients with AHF and renal dysfunction, a single early determination of UNa+ ≤ 50 mmol/L identifies patients with a higher risk of all-cause mortality and readmission. The ΔUNa24h adds prognostic information over baseline values only when UNa+ at admission is ≤ 50 mmol/L.

THE PREDICTIVE VALUE OF DIURETIC RESISTANCE AT THE TIME OF DISCHARGE FOR ACUTE HEART FAILURE

Diuretic resistance has been found to be associated with poor outcomes in acute heart failure (AHF). However, the prognostic implication of furosemide dosage for diuretic-resistant patients at discharge is not well explored. AHF patients at a single tertiary center from July 2017 to March 2018 were

Readmission-free period and in-hospital mortality at the time of first readmission in acute heart failure patients—NRD-based analysis of 40,000 heart failure readmissions

The 30-day readmission rates, predictors, and outcomes for acute heart failure (AHF) patients are well published, but data beyond 30days and the association between readmission-free period (RFP) and in-hospital readmission-related mortality remain unknown. We queried the National Readmission Database to analyze comparative outcomes of AHF. Patients were divided into three groups based on their RFP: group 1 (1-30days), group 2 (31-90days), and group 3 (91-275days). AHF cases and clinical variables were identified using ICD-9 codes. The primary outcome was in-hospital mortality at the time of readmission. A total of 39,237 unplanned readmissions occurred within 275days; 15,181 within group 1, 11,925 within group 2, and 12,131 within group 3. In-hospital mortality in groups 1, 2, and 3 were 7.4%, 5.1%, and 4.1% (p < 0.001). Group 1 had higher percentages of patients with cardiogenic shock (1.3% vs. 0.9% vs. 0.9%; p < 0.001), acute kidney injury (30.2% vs. 25.9% vs. 24.0%; p < 0.001), dialysis use (8.6% vs. 7.5% vs. 6.9%; p < 0.001), and non-ST elevation myocardial infarction (4.4% vs. 3.8% vs. 3.6%; p < 0.001), but there was no statistical difference among the three groups for ST-elevation myocardial infarction, percutaneous coronary intervention (PCI), or ventricular assist device use at the time of index admission. However, group 3 had higher PCI (1.7%) compared with groups 1 and 2 (p < 0.001). In multivariable logistic regression, groups 2 and 3 had odd ratio of 0.70 and 0.55, respectively, for in-hospital mortality compared with group 1. Longer RFP is associated with decreased risk of in-hospital mortality at the time of first readmission.

Beta-blocker Therapy at Discharge in Patients with Acute Heart Failure and Atrial Fibrillation.

Backgroundβ-blockers (BBs) are considered primary therapy in stable heart failure (HF) with reduced ejection fraction (HFrEF) without atrial fibrillation (AF); evidence-based benefits of BB on outcome have been documented. However, BBs have not been shown to improve mortality or reduce hospital admissions in HF patients with AF. This study assessed the relationship between BBs at discharge and relevant clinical outcomes in acute heart failure (AHF) patients with AF.MethodsFrom the Korean Acute Heart Failure Registry, 936 HFrEF and 639 HF patients with preserved ejection fraction (HFpEF) and AF were selected. Propensity score (PS) matching accounted for BB selection bias when assessing associations.ResultsBB-untreated patients in the overall cohort of HFrEF and HFpEF had greater deteriorated clinical and laboratory characteristics. In the 670 PS-matched cohort of HFrEF patients, incidences of all clinical events at 60 days and 1 year were not different according to use of BBs. In the 470 PS-matched cohort of HFpEF, rehospitalization and composite outcome at 6 months and 1 year more frequently occurred in non-users of BBs. After adjusting for covariates in the multivariable Cox model of matched cohorts, BB was not associated with clinical outcomes at 60 days and 1 year in HFrEF with AF patients. In HFpEF patients with AF, BB use was associated with reduced 6-month (hazard ratio [HR], 0.38; 95% confidence interval [CI], 0.20–0.74) and 1-year rehospitalization (HR, 0.53; 95% CI, 0.34–0.82).ConclusionIn the HFrEF with AF PS-matched cohort, the use of BBs at discharge was not associated with clinical outcome. However, in HFpEF with AF, the use of BB was associated with reduced rehospitalization during the 6-month and 1-year follow up.

Short-term prognostic implications of serum and urine neutrophil gelatinase-associated lipocalin in acute heart failure: findings from the AKINESIS study.

Kidney impairment has been associated with worse outcomes in acute heart failure (AHF), although recent studies challenge this association. Neutrophil gelatinase-associated lipocalin (NGAL) is a novel biomarker of kidney tubular injury. Its prognostic role in AHF has not been evaluated in large cohorts. The present study aimed to determine if serum NGAL (sNGAL) or urine NGAL (uNGAL) is superior to creatinine for predicting short-term outcomes in AHF. The study was conducted in an international, multicentre, prospective cohort consisting of 927 patients with AHF. Admission and peak values of sNGAL, uNGAL and uNGAL/urine creatinine (uCr) ratio were compared to admission and peak serum creatinine (sCr). The composite endpoints were death, initiation of renal replacement therapy, heart failure (HF) readmission and any emergent HF-related outpatient visit within 30 and 60 days, respectively. The mean age of the cohort was 69 years and 62% were male. The median length of stay was 6 days. The composite endpoint occurred in 106 patients and 154 patients within 30 and 60 days, respectively. Serum NGAL was more predictive than uNGAL and the uNGAL/uCr ratio but was not superior to sCr [area under the curve: admission sNGAL 0.61, 95% confidence interval (CI) 0.55-0.67, and 0.59, 95% CI 0.54-0.65; peak sNGAL: 0.60, 95% CI 0.54-0.66, and 0.57, 95% CI 0.52-0.63; admission sCr: 0.60, 95% CI 0.54-0.64, and 0.59, 95% CI 0.53-0.64; peak sCr: 0.61, 95% CI 0.55-0.67, and 0.59, 95% CI 0.54-0.64, at 30 and 60 days, respectively]. NGAL was not predictive of the composite endpoint in multivariate analysis. Serum NGAL outperformed uNGAL but neither was superior to admission or peak sCr for predicting adverse events.