Outcomes In Acute Heart Failure Research Articles

The Outcome Of Acute Heart Failure In Patients With A History Of Pulmonary Embolism, A Nationwide Analysis

The Outcome Of Acute Heart Failure In Patients With A History Of Pulmonary Embolism, A Nationwide Analysis

The Outcome Of Acute Heart Failure In Patients With Pulmonary Embolism, A Nationwide Analysis

The Outcome Of Acute Heart Failure In Patients With Pulmonary Embolism, A Nationwide Analysis

Circulating dipeptidyl peptidase 3 predicts hemodynamic impairment and premature death in acute coronary syndromes: insights from the prospective multicenter SPUM-ACS study

Abstract Background Dipeptidyl peptidase 3 (DPP3) is mechanistically involved in the degradation of angiotensin II and in the depression of systolic left ventricular function thereby disturbing peripheral blood pressure regulation. Small pilot studies suggested that circulating DPP3 (cDPP3) portends poor outcomes in acute heart failure and may refine risk assessment in patients with acute coronary syndromes (ACS). Purpose We aimed to assess the predictive value of cDPP3 in contemporary patients with ACS. Methods Circulating DPP3 was studied in 4311 patients with ACS in the prospective multicentre SPUM-ACS study. DPP3 levels were centrally measured in EDTA plasma by blinded study personnel using an established sandwich-type luminometric immunoassay. Kaplan-Meier survival curves and multivariable-adjusted regression models adjusted for sex, age, heart rate, systolic blood pressure, history of diabetes, levels of creatinine, centrally measured high-sensitivity troponin T, N-terminal pro-B-type natriuretic peptide, and high-sensitivity C-reactive protein, and the Global Registry of Acute Coronary Events (GRACE) risk score. Results At baseline, median cDPP3 levels were 19.0 ng/ml (interquartile range [IQR] 15.0-26.0) with higher levels observed in patients with ST-segment elevation myocardial infarction than in those with non-ST-segment elevation ACS (20.1 [15.9-28.2] vs. 18.0 [14.1-23.9], respectively, P<0.001). High cDPP3 was linked to longer hospitalization and higher risk to require vasopressor use or mechanical circulatory support (per log2 increase: odds ratio [OR] 1.91, 95% confidence interval [CI] 1.62-2.24, P<0.001; adjusted OR 1.35 95% CI 1.08-1.69, P=0.008). In line, high cDPP was strongly associated with increased mortality at 30 days (per log2 increase: hazard ratio [HR] 1.96, 95% CI 1.48-2.59, P<0.001) and at 1 year (HR 1.51, 95% CI 1.24-1.83, P<0.001). When accounting for established risk factors, cDPP3 remained an independent predictor of premature death with doubling in cDPP3 levels translating into an 58% and 40% increase in 30-day and 1-year mortality risk, respectively (adjusted HR 1.58, 95% CI 1.06-2.34, P<0.023, adjusted HR 1.40, 95% CI 1.10-1.77, P=0.006, respectively). Conclusion We identified cDPP3 as a novel marker of cardiogenic shock and increased mortality in patients with ACS. Circulating DPP3 provides prognostic information beyond established risk factors and improves early risk assessment.DPP3 is linked to hemodynamic impairmentDPP3 independently predicts mortality

Organ perfusion pressure at admission and clinical outcomes in patients hospitalized for acute heart failure

Abstract Background Hypoperfusion portends adverse outcomes in acute heart failure (AHF). The gradient between end-organ inflow and outflow pressures may more closely reflect hypoperfusion than mean arterial pressure (MAP) alone. Purpose To investigate organ perfusion pressure (OPP), calculated as MAP minus central venous pressure (CVP), as a prognostic marker in AHF. Methods The SNIP-AHF study was a multicenter retrospective cohort study of 200 consecutive patients hospitalized for AHF treated with sodium nitroprusside. Only patients with both MAP and invasive CVP data available from the SNIP-AHF cohort were included. The primary endpoint was to assess OPP as a predictor of worsening heart failure (WHF) at 48 hours. Results 146 patients were included (mean age: 61.1±13.5 years, 32 [21.9%] females; mean left ventricular ejection fraction: 23.8%±11.4%, mean MAP: 80.2±13.2 mmHg, mean CVP: 14.0±6.1 mmHg). WHF occurred in 14 (9.6%) patients. At multivariable models including hemodynamic variables (OPP, shock index, MAP and CVP), OPP at admission was the best predictor of WHF at 48 hours (OR 0.91 [95%CI 0.86-0.96], p-value = 0.001) with an optimal cut-off value of 67.5 mmHg (specificity 47.3%, sensitivity 100%, AUC 0.784±0.054 [p-value<0.001]). In a multivariable model including univariable significant parameters available at first beside assessment, namely New York Heart Association functional class, OPP, shock index, MAP and left ventricular end-diastolic diameter, OPP significantly predicted WHF at 48 hours (OR 0.82 [95%CI 0.68-0.98], p-value=0.027). Conclusion In this retrospective analysis on patients hospitalized for AHF treated with sodium nitroprusside, on-admission OPP significantly predicted WHF at 48 hours with high sensitivity.OPP in acute heart failureMultivariable analysis on WHF

Left ventricular stroke volume index outperforms ejection fraction in predicting 1-year mortality in patients with acute heart failure - data from the SwissHeart Failure Network (SHFN)

Abstract Background Left ventricular ejection fraction (LVEF) has prevailed as the gold standard for quantifying LV function in acute heart failure (AHF) for both clinical trials and routine clinical practice. Most landmark studies in AHF stratify patients according to LVEF-based cut-offs. AHF is a clinical syndrome resulting from insufficient cardiac output, defined as LV stroke volume (LVSV) x heart rate. Thus, LVSV and its derived value LVSV index (LVSVI = LVSV/body surface area) may be better suited than LVEF for assessing LV function and heart failure severity, as well as predicting outcome in AHF. Purpose This study compared the predictive power for 1-year all-cause mortality of readily available echocardiographic parameters related to LV function (LVEF, LVSV and LVSVI) in patients with AHF. Methods Automatic data extraction was performed in 966 patients fulfilling criteria for AHF, retrospectively included between 2015-19 in 4 tertiary centres in Switzerland constituting the SwissHeart Failure Network (SHFN). Patients were selected if they had a standardised TTE study performed upon diagnosis of AHF, wherein all necessary values were reported. Cut-off values were chosen in consideration of the cohort’s median values. Patient follow-up was censored at 365d. Values are displayed as medians and interquartile ranges. Hazard ratios (HR) for 1-year all-cause mortality were computed with univariate Cox Proportional Hazards models. Kaplan-Meier curves were derived along with log-rank p-values. Results Median values for the evaluated parameter were as follows: LVEF (%): 38 (28–54); LVSV (mL): 45 (35–58); LVSVI (ml/m2): 24 (19–31). 1-year all-cause mortality was 33.7% (326/966 patients). The highest predictive capacity for 1-year all-cause mortality was observed for LVSVI<25ml/m2 (HR = 1.57 [1.26–1.97], p<0.001), followed by LVSV<45ml (HR = 1.57 [1.26–1.96], p<0.001). The lowest predictive capacity was seen for LVEF<40% (HR = 1.35 [1.08–1.68], p = 0.007, Figure 1). Applying the rounded medians as cut-off values, Kaplan-Meier curves showed greater divergence for higher vs. lower LVSVI (log-rank p<0.001) than for higher vs. lower LVEF (log-rank p = 0.007, Figures 2A and 2B). For patients with higher LVSVI, mortality rates did not change irrespective of higher or lower LVEF (Figure 2C, blue vs. green curves: log-rank p = 0.885). Patients with lower LVEF showed significantly higher mortality when they also had lower LVSVI (green vs. orange curves: log-rank p= 0.001). Conclusions In patients with AHF, LVSV and its derived value LVSVI are superior in predicting 1-year all-cause mortality compared to LVEF. Requiring the same echocardiographic measurements and thus being as readily available as the currently prevailing LVEF, the assessment of LVSV and LVSVI deserves intensified attention, both for future studies and clinical routine.Figure 1:Hazard RatiosFigure 2:Kaplan-Meier Analyses

Abstract 14909: Door-to-Diuretic Time and Mortality in Patients With Acute Heart Failure: A Meta-Analysis

Background: Recent studies have highlighted potential benefit with time-to-therapy of intravenous (IV) diuretics in patients with acute heart failure (AHF), although the data is conflicting. We sought to evaluate the impact of door-to-IV diuretic time on mortality in patients with AHF presenting to hospital. Methods: Electronic databases were searched for prospectively registered (PROSPERO CRD42023394255) studies published up to February 2023 that evaluated the effect of door-to-IV diuretic time on clinical outcomes in AHF. The primary outcome was in-hospital mortality and the secondary outcome 30-day all-cause mortality. Three reviewers independently appraised the data, with summary odds ratios (OR) and 95% confidence intervals (CIs) pooled using a random-effects model. Results: Seven observational studies comprising 29,102 patients were included. Three studies were prospective in design. Diuretics of choice were furosemide or bumetanide. Early IV diuretic administration was defined as a reference range from 30 to 105 minutes. Early IV diuresis was not associated with any difference in in-hospital mortality (OR 0.84, 95% CI 0.57-1.24) with high heterogeneity (I 2 =74%). However, pooled data from 4 studies evaluating 30-day outcomes demonstrated reduced 30-day mortality (OR 0.77, 95% CI 0.64-0.93). Conclusion: Door-to-IV diuretic time was not associated with reduced in-hospital death but was associated with significantly improved 30-day mortality. Prospective trials are warranted to evaluate the effect of early IV diuresis across heart failure phenotypes and disease severities.

Organ perfusion pressure at admission and clinical outcomes in patients hospitalized for acute heart failure.

Hypoperfusion portends adverse outcomes in acute heart failure (AHF). The gradient between end-organ inflow and outflow pressures may more closely reflect hypoperfusion than mean arterial pressure (MAP) alone. The aim of this study was to investigate organ perfusion pressure (OPP), calculated as MAP minus central venous pressure (CVP), as a prognostic marker in AHF. The Sodium NItroPrusside Treatment in Acute Heart Failure (SNIP)-AHF study was a multicentre retrospective cohort study of 200 consecutive patients hospitalized for AHF treated with sodium nitroprusside. Only patients with both MAP and invasive CVP data available from the SNIP-AHF cohort were included in this analysis. The primary endpoint was to assess OPP as a predictor of worsening heart failure (WHF), defined as the worsening of signs and symptoms of heart failure leading to intensification of therapy at 48 h. One hundred and forty-six patients fulfilling the inclusion criteria were included [mean age: 61.1 ± 13.5 years, 32 (21.9%) females; mean body mass index: 26.2 ± 11.7 kg/m2; mean left ventricular ejection fraction: 23.8%±11.4%, mean MAP: 80.2 ± 13.2 mmHg, and mean CVP: 14.0 ± 6.1 mmHg]. WHF occurred in 14 (9.6%) patients. At multivariable models including hemodynamic variables (OPP, shock index, and CVP), OPP at admission was the best predictor of WHF at 48 h [OR 0.91 (95% confidence interval 0.86-0.96), P-value = 0.001] with an optimal cut-off value of 67.5 mmHg (specificity 47.3%, sensitivity 100%, and AUC 0.784 ± 0.054). In multivariable models, including univariable significant parameters available at first bedside assessment, namely New York Heart Association functional class, OPP, shock index, CVP, and left ventricular end-diastolic diameter, OPP consistently and significantly predicted WHF at 48 h. In this retrospective analysis on patients hospitalized for AHF treated with sodium nitroprusside, on-admission OPP significantly predicted WHF at 48 h with high sensitivity.

Prognostic impact of red blood cell distribution width in chronic heart failure patients with left ventricular dysfunction.

Red blood cell (RBC) distribution width (RDW) measures RBC variations in size. Higher RDW values have been associated with poor outcome in acute heart failure (HF). We aimed to assess the prognostic impact of the RDW in chronic HF. We retrospectively analysed a cohort of chronic HF patients with left ventricular systolic dysfunction followed in our HF clinic between January 2012 and May 2018. Patients with missing data concerning RDW were excluded. Patients were categorized according to RDW tertiles: ≤13.5%; between 13.5 and 14.7%; and >14.7%. Patients were followed until January 2021; all-cause mortality was the end point analysed. The association of RDW with all-cause mortality was assessed with a Cox-regression analysis. Two multivariate models were built. We studied 860 chronic HF patients, 66.4% males, mean age 70 (standard deviation, SD 13) years. Patients were followed for a median of 49 (29-82) months. During this period, 423 (49.2%) patients died. Mortality increased with increasing RDW tertiles. Patients with RDW >14.7% had a HR of mortality of 1.95 (1.47-2.58), p < 0.001 (model 1) and of 1.81 (1.35-2.41), p < 0.001 (model 2) when compared with those with RDW ≤13.5. Patients in the second RDW tertile had an all-cause death HR of 1.47 (1.12-1.93) and of 1.44 (1.09-1.90) in models 1 and 2, respectively. Chronic HF patients with RDW values >14.7% presented an almost 2-fold higher risk of dying in the long term than those with RDW <13.5%. RDW is a widely available and easily measured parameter that can help clinicians in the risk stratification of chronic HF patients.

Global Variations According to Sex in Patients Hospitalized for Heart Failure in the REPORT-HF Registry

BackgroundPrevious reports suggest that risk factors, management, and outcomes of acute heart failure (AHF) may differ by sex, but they rarely extended analysis to low- and middle-income countries. ObjectivesIn this study, the authors sought to analyze sex differences in treatment and outcomes in patients hospitalized for AHF in 44 countries. MethodsThe authors investigated differences between men and women in treatment and outcomes in 18,553 patients hospitalized for AHF in 44 countries in the REPORT-HF (Registry to Assess Medical Practice With Longitudinal Observation for the Treatment of Heart Failure) registry stratified by country income level, income disparity, and world region. The primary outcome was 1-year all-cause mortality. ResultsWomen (n = 7,181) were older than men (n = 11,372), were more likely to have heart failure with preserved left ventricular ejection fraction, had more comorbid conditions except for coronary artery disease, and had more severe signs and symptoms at admission. Coronary angiography, cardiac stress tests, and coronary revascularization were less frequently performed in women than in men. Women with AHF and reduced left ventricular ejection fraction were less likely to receive an implanted device, regardless of region or country income level. Women were more likely to receive treatments that could worsen HF than men (18% vs 13%; P < 0.0001). In countries with low-income disparity, women had better 1-year survival than men. This advantage was lost in countries with greater income disparity (Pinteraction < 0.001). ConclusionsWomen were less likely to have diagnostic testing or receive guideline-directed care than men. A survival advantage for women was observed only in countries with low income disparity, suggesting that equity of HF care between sexes remains an unmet goal worldwide.

Clinical Features, Socioeconomic Status, Management, and Outcomes of Acute Heart Failure: PEACE MENA Registry Phase I Results.

PEACE MENA (Program for the Evaluation and Management of Cardiac Events in the Middle East and North Africa) is a prospective registry in Arab countries for in-patients with acute myocardial infarction (AMI) or acute heart failure (AHF). Here, we report the baseline characteristics and outcomes of in-patients with AHF who were enrolled during the first 14 months of the recruitment phase. A prospective, multi-centre, multi-country study including patients hospitalized with AHF was conducted. Clinical characteristics, echocardiogram, BNP (B-type natriuretic peptide), socioeconomic status, management, 1-month, and 1-year outcomes are reported. Between April 2019 and June 2020, a total of 1258 adults with AHF from 16 Arab countries were recruited. Their mean age was 63.3 (±15) years, 56.8% were men, 65% had monthly income ≤US$ 500, and 56% had limited education. Furthermore, 55% had diabetes mellitus, 67% had hypertension; 55% had HFrEF (heart failure with reduced ejection fraction), and 19% had HFpEF (heart failure with preserved ejection fraction). At 1 year, 3.6% had a heart failure-related device (0-22%) and 7.3% used an angiotensin receptor neprilysin inhibitor (0-43%). Mortality was 4.4% per 1 month and 11.77% per 1-year post-discharge. Compared with higher-income patients, lower-income patients had a higher 1-year total heart failure hospitalization rate (45.6 vs 29.9%, p=0.001), and the 1-year mortality difference was not statistically significant (13.2 vs 8.8%, p=0.059). Most of the patients with AHF in Arab countries had a high burden of cardiac risk factors, low income, and low education status with great heterogeneity in key performance indicators of AHF management among Arab countries.

Association of Carbohydrate Antigen 125 on the Response to Dapagliflozin in Patients With Heart Failure

BackgroundElevated circulating carbohydrate antigen 125 (CA125) is a marker of congestion and a predictor of outcomes in acute heart failure (HF). Less is known about CA125 in chronic ambulatory HF with reduced ejection fraction. ObjectivesThis study examined the association between baseline CA125 (and changes in CA125) and outcomes in patients with HF with reduced ejection fraction in the DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure; NCT03036124) trial and its relationship with the effect of dapagliflozin. MethodsThe primary outcome was a composite of a first episode of worsening HF or cardiovascular death. CA125 was measured at baseline and 12 months following randomization. ResultsMedian baseline CA125 was 13.04 U/mL (IQR: 8.78-21.13 U/mL) in 3,123 of 4,774 patients with available data. Compared with CA125 ≤35 U/mL (upper limit of normal), patients with CA125 >35 U/mL were at a higher risk of the primary outcome (adjusted HR: 1.59; 95% CI: 1.29-1.96). The adjusted risks of the primary outcome relative to quartile 1 (Q1) (≤8.78 U/mL) were as follow: Q2, 8.79-13.04 U/mL (HR: 0.94; 95% CI: 0.71-1.24); Q3, 13.05-21.13 U/mL (HR: 1.22; 95% CI: 0.94-1.59); Q4, ≥21.14 U/mL (HR: 1.63; 95% CI: 1.28-2.09). The beneficial effect of dapagliflozin compared with placebo on the primary outcome was consistent whether CA125 was analyzed in quartiles (interaction P = 0.13) or as a continuous variable (interaction P = 0.75). The placebo-corrected relative change in CA125 at 12 months was −5.2% (95% CI: −10.6% to 0.5%; P = 0.07). ConclusionsIn DAPA-HF, elevated CA125 levels were an independent predictor of the risk of worsening HF or cardiovascular death. Dapagliflozin reduced the risk of worsening HF or cardiovascular death regardless of baseline CA125.

Association of Tricuspid Regurgitation With Outcome in Acute Heart Failure.

Tricuspid regurgitation (TR) is common in chronic heart failure (HF) and is associated with negative prognosis. However, evidence on prognostic implications of TR in acute HF is lacking. We sought to investigate the association between TR and mortality and the interaction with pulmonary hypertension (PH) in patients admitted for acute HF. We enrolled 1176 consecutive patients with a primary diagnosis of acute HF and with available noninvasive estimation of TR and pulmonary arterial systolic pressure. Moderate-severe TR was present in 352 patients (29.9%) and was associated with older age and more comorbidities. The prevalence of PH (ie, pulmonary arterial systolic pressure >40 mm Hg), right ventricular dysfunction, and mitral regurgitation was higher in moderate-severe TR. At 1 year, 184 (15.6%) patients died. Moderate-severe TR was associated with higher 1-year mortality risk after adjustment for other echocardiographic parameters (pulmonary arterial systolic pressure, left ventricle ejection fraction, right ventricular dysfunction, mitral regurgitation, left and right atrial indexed volumes; hazard ratio, 1.718; P=0.009), and the association with outcome was maintained when clinical variables (eg, natriuretic peptides, serum creatinine and urea, systolic blood pressure, atrial fibrillation) were added to the multivariable model (hazard ratio, 1.761; P=0.024). The association between moderate-severe TR and outcome was consistent in patients with versus without PH, with versus without right ventricular dysfunction, and with versus without left ventricle ejection fraction <50%. Patients with coexistent moderate-severe TR and PH had 3-fold higher 1-year mortality risk compared with patients with no TR or PH (hazard ratio, 3.024; P<0.001). In patients hospitalized for acute HF, the severity of TR is associated with 1-year survival, regardless of the presence of PH. The coexistence of moderate-severe TR and estimated PH was associated with a further increase in mortality risk. Our data must be interpreted in the context of potential underestimation of pulmonary arterial systolic pressure in patients with severe TR.

Comprehensive characterization of non-cardiac comorbidities in acute heart failure: an analysis of ESC-HFA EURObservational Research Programme Heart Failure Long-Term Registry.

To evaluate the prevalence and associations of non-cardiac comorbidities (NCCs) with in-hospital and post-discharge outcomes in acute heart failure (AHF) across the ejection fraction (EF) spectrum. The 9326 AHF patients from European Society of Cardiology (ESC)-Heart Failure Association (HFA)-EURObservational Research Programme Heart Failure Long-Term Registry had complete information for the following 12 NCCs: anaemia, chronic obstructive pulmonary disease (COPD), diabetes, depression, hepatic dysfunction, renal dysfunction, malignancy, Parkinson's disease, peripheral vascular disease (PVD), rheumatoid arthritis, sleep apnoea, and stroke/transient ischaemic attack (TIA). Patients were classified by number of NCCs (0, 1, 2, 3, and ≥4). Of the AHF patients, 20.5% had no NCC, 28.5% had 1 NCC, 23.1% had 2 NCC, 15.4% had 3 NCC, and 12.5% had ≥4 NCC. In-hospital and post-discharge mortality increased with number of NCCs from 3.0% and 18.5% for 1 NCC to 12.5% and 36% for ≥4 NCCs.Anaemia, COPD, PVD, sleep apnoea, rheumatoid arthritis, stroke/TIA, Parkinson, and depression were more prevalent in HF with preserved EF (HFpEF). The hazard ratio (95% confidence interval) for post-discharge death for each NCC was for anaemia 1.6 (1.4-1.8), diabetes 1.2 (1.1-1.4), kidney dysfunction 1.7 (1.5-1.9), COPD 1.4 (1.2-1.5), PVD 1.2 (1.1-1.4), stroke/TIA 1.3 (1.1-1.5), depression 1.2 (1.0-1.5), hepatic dysfunction 2.1 (1.8-2.5), malignancy 1.5 (1.2-1.8), sleep apnoea 1.2 (0.9-1.7), rheumatoid arthritis 1.5 (1.1-2.1), and Parkinson 1.4 (0.9-2.1). Anaemia, kidney dysfunction, COPD, and diabetes were associated with post-discharge mortality in all EF categories, PVD, stroke/TIA, and depression only in HF with reduced EF, and sleep apnoea and malignancy only in HFpEF. Multiple NCCs conferred poor in-hospital and post-discharge outcomes. Ejection fraction categories had different prevalence and risk profile associated with individual NCCs.

Relationship of Vascular Endothelial Growth Factor C, a Lymphangiogenesis Modulator, With Edema Formation, Congestion and Outcomes in Acute Heart Failure

Although vascular endothelial growth factor C (VEGF-C) is a known lymphangiogenesis modulator, its relationship with congestion formation and outcomes in acute heart failure (AHF) is unknown. Serum VEGF-C levels were measured in 237 patients hospitalized for AHF. The population was stratified by VEGF-C levels and linked with clinical signs of congestion and outcomes. The study's population was divided in VEGF-C tertiles: low (median [Q25-Q75]: 33 [15-175]), medium (606 [468-741]) and high (1141 [968-1442] pg/mL). The group with low VEGF-C on admission presented with the highest prevalence of severe lower-extremity edema (low VEGF-C vs medium VEGF-C vs high VEGF-C): 30% vs 13% vs 20%; P = 0.02); the highest percentage of patients with ascites: 22% vs 9% vs 6%; P = 0.006; and the lowest proportion of patients with pulmonary congestion: 22% vs 30% vs 46%; P = 0.004. The 1-year mortality rate was the highest in the low VEGF-C tertile: 35% vs 28% vs 18%, respectively; P = 0.049. The same pattern was observed for the composite endpoint (death and AHF rehospitalization): 45% vs 43% vs 26%; P = 0.029. The risks of death at 1-year follow-up and composite endpoint were significantly lower in the high VEGF-C group. Low VEGF-C was associated with more severe signs of congestion (signs of fluid accumulation) and adverse clinical outcomes.

Effects of obesity on short-term mortality in patients with acute heart failure under different nutritional status

BackgroundIncreased body mass index (BMI) is associated with better survival in patients with acute heart failure (AHF), which is a paradoxical phenomenon. However, it is unclear whether different nutritional status affects this association.Methods1325 patients with AHF from the Medical Information Mart for Intensive Care III database were retrospectively included. Nutritional status was assessed by serum albumin (SA) and prognostic nutritional index (PNI). Patients were divided into High-SA (≥ 3.5 g/dL) and Low-SA groups (< 3.5 g/dL), and they also were divided into High-PNI (≥ 38) and Low-PNI groups (< 38). Propensity-score matching (PSM) was used to control for the effect of baseline confounding factors, multifactor regression model was adopted to assess the association of nutritional status, BMI, and outcomes in AHF patients.ResultsOf the 1325 patients (mean age 72.4 ± 13.1 years), 52.1% (n = 690) were male, 13.1% (n = 173) died in hospital and 23.5% (n = 311) died within 90 days. Before PSM, after adjusting for potential confounders, in the High-SA population, compared with the under/normal BMI group, overweight and obesity were negatively correlated with 90-day mortality, with adjusted hazard ratios (HR) of 0.47, 95% confidence interval (CI) (0.30–0.74), P = 0.001; HR 0.45, 95%CI (0.28–0.72), P = 0.001, respectively. However, this correlation was much attenuated in the Low-SA group (overweight BMI: HR 1.06, 95%CI 0.75–1.50, P = 0.744; obese BMI: HR 0.86, 95%CI 0.59–1.24, P = 0.413). After PSM, those who were overweight or obese in the High-SA group had a 50–58% reduction in 90-day risk of death, while the protective effect disappeared in the Low-SA group (HR 1.09, 95% CI 0.70–1.71; HR 1.02, 95%CI 0.66 − 0.59). Similarly, results were similar in analyses using PNI as a nutritional assessment criterion.ConclusionOverweight or Obesity was associated with lower short-term mortality in well-nourished AHF patients, whereas this association was significantly attenuated or even disappeared in malnourished patients. Therefore, further research is needed for weight loss recommendations for malnourished obese patients with AHF.

QT interval and short-term outcome in acute heart failure

ObjectiveTo investigate the association of corrected QT (QTc) interval duration and short-term outcomes in patients with acute heart failure (AHF).MethodsWe analyzed AHF patients enrolled in 11 Spanish emergency departments (ED) for whom an ECG with QTc measurement was available. Patients with pace-maker rhythm were excluded. Primary outcome was 30-day all-cause mortality and secondary outcomes were need of hospitalization, in-hospital mortality and prolonged hospitalization (> 7 days). Association between QTc and outcomes was explored by restricted cubic spline (RCS) curves. Results were expressed as odds ratios (OR) and 95%CI adjusted by patients baseline and decompensation characteristics, using a QTc = 450 ms as reference.ResultsOf 1800 patients meeting entry criteria (median age 84 years (IQR = 77–89), 56% female), their median QTc was 453 ms (IQR = 422–483). The 30-day mortality was 9.7%, while need of hospitalization, in-hospital mortality and prolonged hospitalization were 77.8%, 9.0% and 50.0%, respectively. RCS curves found longer QTc was associated with 30-day mortality if > 561 ms, OR = 1.86 (1.00–3.45), and increased up to OR = 10.5 (2.25–49.1), for QTc = 674 ms. A similar pattern was observed for in-hospital mortality; OR = 2.64 (1.04–6.69), for QTc = 588 ms, and increasing up to OR = 8.02 (1.30–49.3), for QTc = 674 ms. Conversely, the need of hospitalization had a U-shaped relationship: being increased in patients with shorter QTc [OR = 1.45 (1.00–2.09) for QTc = 381 ms, OR = 5.88 (1.25–27.6) for the shortest QTc of 200 ms], and also increasing for prolonged QTc [OR = 1.06 (1.00–1.13), for QTc = 459 ms, and reaching OR = 2.15 (1.00–4.62) for QTc = 588 ms]. QTc was not associated with prolonged hospitalization.ConclusionIn ED AHF patients, initial QTc provides independent short-term prognostic information, with increasing QTc associated with increasing mortality, while both, shortened and prolonged QTc are associated with need of hospitalization.Graphical abstract

Clinical presentation and outcomes of acute heart failure in the critically ill patient: A prospective, observational, multicentre study

To assess the clinical profile and factors associated with 30-day mortality in patients with acute heart failure (AHF) admitted to the intensive care unit (ICU). Prospective, multicentre cohort study . Thirty-two Spanish ICUs. Adult patients admitted to the ICU between April and June 2017. Patients were classified into three groups according to AHF status: without AHF (no AHF); AHF as the primary reason for ICU admission (primary AHF); and AHF developed during the ICU stay (secondary AHF). Incidence of AHF and 30-day mortality. A total of 4330 patients were included. Of these, 627 patients (14.5%) had primary ( n = 319; 7.4%) or secondary ( n = 308; 7.1%) AHF. Among the main precipitating factors , fluid overload was more common in the secondary AHF group than in the primary group (12.9% vs 23.4%, p < 0.001). Patients with AHF had a higher risk of 30-day mortality than those without AHF (OR 2.45; 95% CI: 1.93–3.11). APACHE II, cardiogenic shock , left ventricular ejection fraction , early inotropic therapy, and diagnostic delay were independently associated with 30-day mortality in AHF patients. Diagnostic delay was associated with a significant increase in 30-day mortality in the secondary group (OR 6.82; 95% CI 3.31–14.04). The incidence of primary and secondary AHF was similar in this cohort of ICU patients. The risk of developing AHF in ICU patients can be reduced by avoiding modifiable precipitating factors, particularly fluid overload. Diagnostic delay was associated with significantly higher mortality rates in patients with secondary AHF. Evaluar el perfil clínico y los factores asociados con la mortalidad a 30 días en pacientes con insuficiencia cardíaca aguda (ICA) ingresados en Unidades de Cuidados Intensivos (UCI). Prospectivo, multicéntrico. 32 UCI españolas. Pacientes adultos ingresados en UCI entre abril y junio de 2017. Los pacientes se clasificaron en tres grupos según el estado de la ICA: sin ICA (no ICA), ICA como motivo principal de ingreso en UCI (ICA-primaria), e ICA desarrollada durante la estancia en UCI (ICA-secundaria). Incidencia de ICA y mortalidad a los 30 días. Se incluyeron 4.330 pacientes, de estos, 627 (14,5%) tenían ICA-primaria (n = 319; 7,4%) o secundaria (n = 308; 7,1%). Entre los principales factores precipitantes, la sobrecarga hídrica fue más común en el grupo ICA-secundaria que el ICA-primaria (12,9 vs. 23,4%, p < 0,001). Los pacientes con ICA tuvieron un mayor riesgo de mortalidad que los que no tenían ICA (OR 2,45; IC 95%: 1,93-3,11). APACHE II, choque cardiogénico, fracción de eyección del ventrículo izquierdo, tratamiento precoz con inotrópicos y el retraso diagnóstico se asociaron de forma independiente con la mortalidad en los pacientes con ICA. El retraso diagnóstico se asoció con un aumento significativo de mortalidad en el grupo secundario (OR 6,82; IC 95%: 3,31-14,04). La incidencia de ICA primaria y secundaria fue similar. El riesgo de desarrollar ICA en pacientes críticos puede reducirse evitando factores precipitantes modificables, en particular la sobrecarga de líquidos. El retraso diagnóstico se asoció con mayor mortalidad en pacientes con ICA-secundaria.

Sodium-glucose cotransporter-2 inhibitors and cardiovascular clinical outcomes in acute heart failure: A narrative review.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. This review describes the evidence from randomized controlled trials (RCTs) regarding the effects of sodium-glucose cotransporter 2 (SGLT2) inhibitors on cardiovascular (CV) clinical outcomes when therapy is initiated during acute heart failure (HF). SGLT2 inhibitors have become a cornerstone of guideline-directed medical therapy (GDMT) for type 2 diabetes mellitus, chronic kidney disease, and HF. Because of their ability to promote natriuresis and diuresis as well as other potentially beneficial CV effects, use of SGLT2 inhibitors has been investigated when therapy is initiated during hospitalization for acute HF. We identified 5 placebo-controlled RCTs that reported CV clinical outcomes incorporating one or more components of all-cause mortality, CV mortality, CV hospitalization, HF worsening, and hospitalization for HF in patients treated with empagliflozin (n = 3 trials), dapagliflozin (n = 1 trial), and sotagliflozin (n = 1 trial). Nearly all CV outcomes in these trials showed benefit with SGLT2 inhibitor use during acute HF. Incidence of hypotension, hypokalemia, and acute renal failure was generally similar to that with placebo. These findings are limited by heterogeneous outcome definitions, variation in time to SGLT2 inhibitor initiation, and small sample sizes. SGLT2 inhibitors may have a role in inpatient management of acute HF, provided there is close monitoring for fluctuations in hemodynamic, fluid, and electrolyte status. Initiation of SGLT2 inhibitors at the time of acute HF may promote optimized GDMT, continued medication adherence, and reduced risk of CV outcomes.

Association between changes in loop diuretic dose and outcomes in acute heart failure.

Little is known about the association between the starting of or dose changes in loop diuretics during acute heart failure (AHF) hospitalization and post-discharge outcomes. We investigated the clinical impact of starting loop diuretics and changing the loop diuretics dose during hospitalization on post-discharge outcomes. From the Kyoto Congestive Heart Failure registry, 3665 consecutive patients hospitalized for HF and discharged alive were included in this study. We analysed 1906 patients without loop diuretics on admission and were discharged alive and 1759 patients who received loop diuretics on admission and were discharged alive. The primary outcome measure was all-cause death. Of the 1906 patients without loop diuretics on admission, 1366 (71.7%) patients started loop diuretics during the index AHF hospitalization. Starting loop diuretics was not associated with lower post-discharge mortality [adjusted hazard ratio (HR) 0.92, 95% confidence interval (CI) 0.68-1.25]. Of the 1759 patients who received loop diuretics on admission, loop diuretic dose was decreased in 23.8%, unchanged in 44.6%, and increased in 31.6% of the patients. Changes in the dose at discharge compared with no change in dose were not associated with lower risk of post-discharge mortality (decrease relative to no change: adjusted HR 0.98, 95% CI 0.76-1.28; increase relative to no change: adjusted HR 1.00, 95% CI 0.78-1.27). Compared with no loop diuretics at discharge, a loop diuretics dose of ≥80mg at discharge was associated with higher post-discharge mortality risk. In patients with AHF, we found no association between the starting of loop diuretics and post-discharge outcomes and between dose changes and post-discharge outcomes.

The role of comorbidities in acute heart failure outcomes

The role of comorbidities in acute heart failure outcomes