Severe Acute Decompensated Heart Failure Research Articles

Risk of Developing Acute Kidney Injury on the VA ECLS Circuit in Patients with Acute Decompensated Heart Failure

Abstract Aims Venoarterial extracorporeal life support (VA ECLS) is a life-saving treatment with a high risk of mortality. Appropriate patient selection is critical for optimal patient outcomes. Acute kidney injury (AKI) is a common risk among VA ECLS patients, and more information is needed to understand how AKI affects the mortality risk of these patients. To do this, we examined acute decompensated heart failure (ADHF) patients supported by VA ECLS and compared their risk of developing AKI to a background population. VA ECLS has become an increasingly important tool to bridge or recover patients with severe ADHF as the primary indication of VA ECLS. Methods and Results All VA ECLS patients from a single center were included. ADHF patients supported by VA ECLS were compared with the remaining VA ECLS cohort. CATEGORICAL comparisons were made between groups using chi-squared and Fisher's exact tests. A survival analysis was conducted to determine freedom from AKI between the two groups. Predictor variables were tested by multiple logistic regression. Of the 255 patients included in this study, 110 had ADHF as their primary indication for VA ECLS and 145 patients had other VA ECLS indications. The survival analysis showed that patients with ADHF had a decreased risk of developing AKI on the VA ECLS circuit. Multiple logistic regression revealed no predictors in AKI development between groups and no difference in 30-day mortality was observed. Conclusion Patients supported by VA ECLS are at high risk of mortality and complications. This research demonstrated that medically complex ADHF patients had less chance of developing AKI when compared with other patients supported by VA ECLS. Future research is needed to investigate potential protective mechanisms of VA ECLS support.

Percutaneous Mitral Valve Repair in Patients with Severe Mitral Regurgitation and Acute Decompensated Heart Failure.

The role of percutaneous mitral valve repair (PMVr) in management of high-risk patients with severe mitral regurgitation (MR) and acute decompensated heart failure (ADHF) is undetermined. We screened all patients who underwent PMVr between October 2015 and March 2020. We evaluated immediate, 30-day, and 1-year outcomes in patients who underwent PMVr during hospitalization due to ADHF as compared to elective patients. From a cohort of 237 patients, we identified 46 patients (19.4%) with severe MR of either functional or degenerative etiology who underwent PMVr during index hospitalization due to ADHF, including 17 (37%) critically ill patients. Patients’ mean age was 75.2 ± 9.8 years, 56% were males. There were no differences in background history between ADHF and elective patients. Patients with ADHF were at higher risk for surgery, reflected in higher mean EuroSCORE II, compared with elective patients. After PMVr, we observed higher 30-day mortality rate in ADHF patients as compared to the elective group (10.9% vs. 3.1%, respectively, p = 0.042). One-year mortality rate was similar between the groups (21.7% vs. 17.9%, p = 0.493). Clinical and echocardiographic follow-up showed improvement of NYHA functional class and sPAP reduction in both groups ((54 ± 15 mmHg to 50 ±15 in the elective group (p = 0.02), 58 ± 13 mmHg to 52 ± 12 in the ADHF group (p = 0.02)). PMVr could be an alternative option for treatment of patients with severe MR and ADHF.

Metolazone Add-On Therapy in Heart Failure: A Cohort Study from Persian Registry of Cardiovascular Disease/Heart Failure (PROVE/HF).

Background One of the strategies for overcoming diuretic resistance among heart failure (HF) patients is adding thiazide-type diuretics. The main aim of this article is to compare the adverse clinical outcomes, including death and re-hospitalization, among individuals suffering from severe acute decompensated HF (ADHF) that consumed furosemide or furosemide plus metolazone. Methods This retrospective cohort study was done in the context of the Persian registry of cardiovascular disease (PROVE) from September 2017 to September 2018. One thousand and four hundred thirty-eight individuals (furosemide: 972 and furosemide plus metolazone: 466) with the final diagnosis of severe ADHF (left ventricular ejection fraction < 30%) were selected and followed for 10.3 ± 7.8 months. The association between two groups, as mentioned above, with the incidence of death and re-admission, was evaluated with different models. Results The mean age of the study population was 68.19 ± 12.98 years. There was no significant relation in terms of death or re-hospitalization between patients with different diuretic regimens. After adjustment of potential confounders, we found that adding metolazone as an adjuvant HF therapy was not independently associated with death or re-hospitalization (hazard ratio (HR): 0.78,95% confidence interval (CI) = 0.59–1.03, P = 0.085, and odds ratio (OR): 0.80, 95% CI: 0.60–1.07, P = 0.135, respectively). Conclusion Our findings revealed that adding metolazone in patients with furosemide resistance is not associated with higher morbidity and mortality. Therefore, usage of these two therapeutic agents could be a helpful strategy for severe HF patients.

Inotropic therapies in heart failure and cardiogenic shock: an educational review.

Reduced systolic function is central to the pathophysiology and clinical sequelae of acute decompensated heart failure (ADHF) with reduced ejection fraction and cardiogenic shock. These clinical entities are the final common pathway for marked deterioration of right or left ventricular function and can occur in multiple clinical presentations including severe ADHF, myocardial infarction, post-cardiac surgery, severe pulmonary hypertension, and advanced or end-stage chronic heart failure. Inotropic therapies improve ventricular systolic function and may be divided into three classes on the basis of their mechanism of action (calcitropes, mitotropes, and myotropes). Most currently available therapies for cardiogenic shock are calcitropes which can provide critical haemodynamic support, but also may increase myocardial oxygen demand, ischaemia, arrhythmia, and mortality. Emerging therapies to improve cardiac function such as mitotropes (e.g. perhexiline, SGLT2i) or myotropes (e.g. omecamtiv mecarbil) may provide useful alternatives in the future.

Cocaine induced heart failure: report and literature review

ABSTRACT Heart failure is a complex clinical syndrome associated with high mortality and morbidity, creating a major public healthcare problem. It has a variety of etiologies, including substance abuse. Cocaine-induced cardiotoxicity is caused by direct effects of inhibition of sodium channels and indirect effects by inhibiting catecholamine uptake leading to increased sympathetic activity. Management is through the cessation of cocaine use and implantation of guideline-directed medical therapy for heart failure with the exception of beta-blockers as their safe usage is still controversial due to the risk of the unopposed alpha-adrenergic activity. Dexmedetomidine (Precedex) and Benzodiazepines (i.e., midazolam) are options for patients that demonstrate signs and symptoms of acute cocaine intoxication. If the actions of benzodiazepines fail to achieve hemodynamic stability, nitroglycerin may be used (especially in patients with cocaine-associated chest pain and hypertension). Cardiac transplantation is recommended for those who have demonstrated severe cardiovascular disease from cocaine. We present a 43-year-old male with a long-standing history of cocaine use who developed cardiomyopathy and severe acute decompensated heart failure found to have an ejection fraction of <20% admitted to the intensive care unit. He required inotropic support with milrinone and mechanical ventilation. He was later extubated and then discharged with an outpatient evaluation for a cardiac transplant.

Inferior Vena Cava Collapsibility Index in Severe Acute Decompensated Heart Failure as Predictor of In-Hospital Mortality

Inferior Vena Cava Collapsibility Index in Severe Acute Decompensated Heart Failure as Predictor of In-Hospital Mortality

Застосування левосимендану порівняно з добутаміном за необхідності інотропної підтримки в пацієнтів з гострою декомпенсованою хронічною серцевою недостатністю тяжкого ступеня

The aim – to conduct clinical effectiveness, meta-analysis of 30 and 120-days mortality data, pharmacoeconomic evaluation of levosimendan treatment compared with dobutamine in patients with severe acute decompensated chronic heart failure (ADCHF) who require inotropic support.Materials and methods. The PubMed and Cochrane databases were searched for direct randomized clinical trials of levosimendan treatment compared with dobutamine in patients with ADCHF. The clinical efficacy of levosimendan and dobutamine was analyzed. Pharmacoeconomic analysis was carried out using the cost-effectiveness method with an assessment of the incremental cost-effectiveness ratio. A decision tree model of levosimendan or dobutamine treatments was constructed. The efficacy endpoints and impact on the budget were analyzed in terms of long-term effectiveness of levosimendan and dobutamine use. Discounted was conducted with rate of 3 %. Sensitivity analysis was carried out in terms of price changing of drugs, the cost of drugs in mg, the likelihood of re-hospitalization of the patient in a 3-year horizon and survival in the long term.Results and discussion. Analysis of clinical data and meta-analysis of randomized clinical trials found that mortality rates with levosimendan and dobutamine in the 30-day period were 9.6 % and 13.8 %, RR 0.71 (95 % CI 0.53–0.95) and in the 120-day period – 13.5 % and 25.2 %, RR 0.54 (95 % CI 0.32–0.92), respectively. The total cost of the course of treatment, taking into account the price of the drug, medical devices, staff services, diagnostic procedures and treatment of adverse reactions when using levosimendan, was 34 003.02 UAH per patient and 18 787.28 UAH when treated with dobutamine. The weighted average hospital stay was 6.4 days in case of levosimendan treatment and 7.5 days of dobutamine treatment. Extrapolation of the data from clinical trials to the 3-year survival rate of patients allowed us to determine an additional indicator of efficacy – the number of life years saved with levosimendan – 2.64 and 2.37 with dobutamine treatment. A cost-effectiveness analysis found that levosimendan is more efficient but more expensive technology compare to dobutamine. The incremental cost-effectiveness ratio for the additional life year saved of a patient with severe CHF is 43,473.55 UAH, which is 6 times less than the likely threshold of willingness to pay in Ukraine.Conclusions. The multivariate sensitivity analysis detected the model sustainability to the most crucial parameters of the model – drug price; the cost of drugs associated with their actual use in mg, the possibility of re-hospitalization of the patient in a 3-year horizon, and long-term survival, which is associated with the time horizon of the model. The total cost of a cohort of patients with ADCHF in Ukraine when using scenario 1 (100 % distribution of costs for dobutamine treatment) over 5 years is 268 188 351.94 UAH, when using scenario 2 (100 % distribution for treatment with levosimendan) total budget costs will be in amount of 485 393 073.09 UAH, if scenario 3 is applied (gradual 5 % transition in the treatment of patients with ADCHF with dobutamine for treatment with levosimendan within 5 years), the total budget costs will amount to 289 916 431.92 UAH.

Appraisal of urgent transcatheter aortic valve replacement

Urgent transcatheter aortic valve replacement (TAVR) is needed in unstable patients with severe aortic stenosis and acute decompensated heart failure who are refractory to initial medical management. The outcome of urgent TAVR is worse and heavily influenced by the severity of the clinical status prior to intervention. Careful patient evaluation, procedural planning, and postoperative management should be optimized to improve the clinical results.

Early continuous ultrafiltration in Chinese patients with congestive heart failure (EUC-CHF): study protocol for an open-label registry-based prospective clinical trial

BackgroundConventional pharmacologic therapies aim to reduce fluid overload in advanced heart failure (HF) represented by intravenous (IV) loop diuretics (LDs) have sometimes not so efficacious and been reported to have side effects such as unpredictable removal of water and sodium and electrolyte disturbance. It is not certain whether early ultrafiltration (UF) is effective than LDs in relieving edema. Given the weakness of evidence for early UF in patients with fluid overload, recommendations of UF in guidelines is considered as second-line therapy only for patients with refractory congestion, who failed to respond to LD-based strategies.MethodsThe early continuous ultrafiltration in Chinese patients with congestive heart failure (EUC-CHF) trial is an open-label, registry-based, prospective study, recruiting patients with severe acute decompensated HF who are hospitalized for HF worsening due to overt fluid overload 24 h from hospital admission. Forty patients will be enrolled to two treatment groups (n = 20 for each group). The primary outcomes are the changes of weight loss and dyspnea severity score after treatment, as well as the occurrence of clinically overt major bleeding.DiscussionEUC-CHF trial was primarily designed to evaluate the efficacy and safety of early UF in patients with acute decompensated HF to reduce volume overload and improve clinical outcome. The trial aims to determine if early UF in acute HF is superior to IV LDs in clinical parameter improvement without adverse events and prevents rehospitalization up to 30 days. Also the trial is expected to establish a scoring system based on Chinese population to guide early UF treatment in appropriate patients. EUC-CHF is one of the first controlled trials tailored to determine the benefit of UF with 24 h from hospital admission.Trial registrationwww.chictr.org.cn, ChiCTR1800019556. Registered on 18 November 2018.

Outcomes After Predischarge Initiation of β-Blocker in Patients Hospitalized for Severe Decompensated Heart Failure Requiring Inotropic Therapy

BackgroundThe optimal time for initiating β-blocker (BB) treatment in patients with severe acute decompensated heart failure requiring inotropic therapy has not been well defined. We evaluated the effect of predischarge initiation of BB treatment on clinical outcomes. MethodsAmong the 5625 patients enrolled in the Korean Acute Heart Failure (KorAHF) registry, 672 BB-naive patients suffering from heart failure with reduced ejection fraction (median, 67.0 years; 62.5% male; median left ventricular ejection fraction, 24.1%) who received inotropic support during hospitalization were evaluated. We compared the risk of post-discharge mortality and rehospitalization between groups with (n = 282) and without (n = 390) pre-discharge BB treatment. ResultsDuring a median follow-up of 2.6 years, all-cause mortality occurred in 252 patients (37.5%). Those who received pre-discharge BB treatment showed lower 2-year mortality rates compared with those who did not (21.3% vs 39.3%; P < 0.001). In a Cox proportional hazards model, all-cause mortality was consistently lower in pre-discharge BB groups after multivariable adjustment (hazard ratio, 0.69; 95% confidence interval, 0.50-0.95; P = 0.025) and adjustment for propensity score methods using the inverse probability of treatment weighting (hazard ratio, 0.70; 95% confidence interval, 0.52-0.93; P = 0.016). The same trend was observed for secondary outcomes of rehospitalization for any cause and rehospitalization for heart failure. Pre-discharge BB was associated with higher rates of BB prescription after 6 (90.1% vs 23.9%; P < 0.001) and 12 (88.9% vs 25.0%; P < 0.001) months. ConclusionsPre-discharge BB initiation is associated with better clinical outcomes after severe acute decompensated heart failure episodes requiring inotropic therapy.

Ratio of pro-B-type natriuretic peptide (BNP) to total BNP is decreased in mild, but not severe, acute decompensated heart failure patients: A novel compensatory mechanism for acute heart failure

BackgroundA recent study showed that both glycosylation of pro-B-type natriuretic peptide (BNP) and the proBNP/total BNP ratio are decreased in acute decompensated heart failure (ADHF). However, the following points regarding the proBNP/total BNP ratio have not been determined in patients with ADHF: 1) the relationship with the severity of ADHF, 2) the changes in the ratio during treatment, and 3) the relationship with cyclic guanosine monophosphate (cGMP)-generating activity. MethodsPlasma proBNP and total BNP (proBNP+mature BNP) were measured in patients with ADHF (n=154). Measurement was performed on admission, 3 and 7days after admission, and before discharge using recently developed sandwich chemiluminescence enzyme immunoassays. The percent proBNP was calculated as: (proBNP/total BNP)×100. ResultsOn admission, %proBNP was higher in patients with severe ADHF than in patients with mild ADHF (median: 61.7% vs. 56.2%, respectively; p<0.01), while the plasma cGMP/total BNP ratio, an index of the biological activity of BNP, was lower (p<0.001). In patients with severe ADHF, the higher %proBNP and lower cGMP/total BNP ratio were unchanged during hospitalization, whereas %proBNP increased gradually in patients with mild ADHF and the cGMP/total BNP ratio also increased at 3days after admission. ConclusionThese findings suggest that in patients with mild ADHF, compensation for heart failure occurs via increased proBNP processing, leading to increase of mature BNP and activation of the BNP/cGMP cascade. In contrast, this compensatory mechanism may be impaired in patients with severe ADHF and a vicious cycle can potentially occur.

Pheochromocytoma, “the Great Masquerader,” Presenting as Severe Acute Decompensated Heart Failure in a Young Patient

A 22-year-old man presented to the hospital with progressive shortness of breath, chest discomfort, sinus tachycardia, and emesis. The echocardiogram demonstrated global hypokinesis with a left ventricle ejection fraction of 15–20%. The patient was treated for acute systolic heart failure decompensation with diuresis and afterload reduction. Unexpectedly, an abdominal computed tomography showed a left adrenal mass and subsequent serum/urine metanephrine tests suggested pheochromocytoma. Once the patient had stabilized, he underwent an uneventful adrenalectomy with histology results confirming the diagnosis of pheochromocytoma. After six months follow-up, he is currently doing well with close outpatient follow-up by cardiology.

Comparative evaluation of copeptin and NT-proBNP in patients with severe acute decompensated heart failure, and prediction of adverse events in a 90-day follow-up period: A prospective clinical observation trial.

The present study compared the prognostic value of a marker, the C-terminal section of the arginine vasopressin prohormone (copeptin), with N-terminal B-type natriuretic peptide (NT-proBNP) in patients with severe acute decompensated heart failure. A prospective, observational cohort study was conducted in a tertiary care hospital and enrolled 129 patients with severe acute decompensated heart failure. Clinicians were blinded to investigational markers except NT-proBNP, and the study participants were followed up for 90 days. The end-point was a composite of cardiovascular death or re-hospitalization due to decompensated heart failure. Of the 129 patients enrolled, 47 reached the end-point and 82 were in a stable condition during follow-up. Receiver operating characteristic curve analysis revealed that the areas under curve for the prediction of adverse events within 90 days were similar for copeptin [0.602±0.052; 95% confidence interval (CI), 0.499-0.705], NT-proBNP (0.659±0.048; 95% CI, 0.565-0.753) and their combination (0.670±0.050; 95% CI, 0.573-0.767). Kaplan-Meier survival analysis showed that the predictive value of NT-proBNP regarding the probability of survival was superior compared with that of copeptin (log-rank test for trend, P=0.001 vs. 0.040). Furthermore, multivariate Cox proportional-hazards regression analysis revealed that increased NT-proBNP and copeptin plasma concentrations were significant independent predictors of adverse events. The present study provided evidence that copeptin has similar predictive properties compared with NT-proBNP regarding adverse events within 90-days in patients with severe acute decompensated heart failure, but that copeptin may not provide superior 90-day prediction compared to NT-proBNP.

Clinical Impact of Enteral Nutrition for Severe Acute Decompensated Heart Failure Patients Who Required Mechanical Ventilation

Introduction: While enteral nutrition is standard nutritional support for acutely ill patients, it is uncertain whether artificial nutritional support is necessary for acute decompensated heart failure (ADHF) patients who required mechanical ventilation. The purpose of this study is to observe nutritional support techniques in consecutive cardiac care unit (CCU) patients with ADHF who required mechanical ventilation. Methods and Results: We reviewed 96 consecutive patients who admitted in our CCU and were required noninvasive or invasive ventilation from January 2013 to December 2014. Of those, 5 patients in the noninvasive-ventilation group (NV-group, n = 81, average ventilation duration: 4.0 ± 0.5 days, enteral nutrition for 1 and parenteral nutrition for 4), and 13 patients in the invasive-ventilation group (IV-group, n = 13, average ventilation duration: 20.7 ± 6.3 days, enteral nutrition for 5 and parenteral nutrition for 6) were reviewed. Premature nutrition discontinuation (PND) occurred in 3 patients because of treated infectious complication (n = 2 in parenteral nutrition) and cholecystitis (n = 1 in parenteral nutrition) in NV-group, whereas PND occurred in 2 patients because of treated infectious complication (n = 1 in parenteral nutrition) and paralytic ileus (n = 1 in parenteral nutrition) in IV-group. No PND occurred in enteral feeding patients in either group. Conclusion: Considering the patient selection bias could not be fully avoided, the enteral nutrition as the default strategy for severe ADHF patients who required mechanical ventilation might be warranted.

Longitudinal Trends, Hemodynamic Profiles, and Prognostic Value of Abnormal Liver Function Tests in Patients With Acute Decompensated Heart Failure: An Analysis of the ESCAPE Trial

BackgroundThis study analyzed liver function abnormalities in heart failure patients admitted with severe acute decompensated heart failure (ADHF). Methods and ResultsA post hoc analysis was conducted with the use of data from the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE). Liver function tests (LFTs) were measured at 7 time points from baseline, at discharge, and up to 6 months follow-up. Survival analyses were used to assess the association between admission Model of End-Stage Liver Disease Excluding International Normalized Ratio (MELD-XI) scores and patient outcome.There was a high prevalence of abnormal baseline (admission) LFTs (albumin 23.8%, aspartate transaminase 23.5%, alanine transaminase 23.8%, and total bilirubin 36.1%). The percentage of patients with abnormal LFTs decreased significantly from baseline to 6-months' follow-up. When mean hemodynamic profiles were compared in patients with abnormal versus normal LFTs, elevated total bilirubin was associated with a significantly lower cardiac index (1.80 vs 2.1; P < .001) and higher central venous pressure (14.2 vs 12.0; P = .03). Multivariable analyses revealed that patients with elevated MELD-XI scores (≥16.8) had a 2-fold (hazard ratio 2.06, 95% confidence interval 1.05–4.03) increased risk of death, rehospitalization, or transplantation after adjusting for baseline LFTs, age, sex, race, body mass index, diabetes, and systolic blood pressure. ConclusionsAbnormal LFTs are common in the ADHF population and are a dynamic marker of an impaired hemodynamic state. Elevated MELD-XI scores are associated with poor outcomes among patients admitted with ADHF.

GW24-e3071 Comparative evaluation of copeptin and NT-proBNP in Patients with severe Acute Decompensated Heart Failure

ObjectivesThis study compared the prognostic value of a marker, C-terminal part of the arginine vasopressin prohormone (Copeptin), with N-terminal B-type natriuretic peptide (NT-proBNP) in patients with severe acute decompensated heart...

GW24-e1414 Comparative evaluation of copeptin and NT-proBNP in Patients with severe Acute Decompensated Heart Failure Prediction of adverse events in 90-day

ObjectivesThis study compared the prognostic value of a marker, C-terminal part of the arginine vasopressin prohormone (Copeptin), with N-terminal B-type natriuretic peptide (NT-proBNP) in patients with severe acute decompensated heart...

Reduction of Systemic Vascular Resistance Predicts a More Favorable Outcome in Patients with Severe Acute Decompensated Heart Failure: Insights from the MOMENTUM Trial

Background: Systemic vascular resistance (SVR) is typically increased in pts hospitalized with acute decompensated heart failure (ADHF). This study assessed whether reduction of SVR may benefit those pts hospitalized with ADHF who are not adequately responsive to intravenous inotrope and vasodilator therapy. Methods: Hemodynamic data from 168 pts enrolled in the MOMENTUM trial, a randomized trial testing continuous aortic flow augmentation (CAFA) using the Orqis Medical Cancion System in pts with severe ADHF, were reviewed.

Current treatment options for early management in acute decompensated heart failure

Acute decompensated heart failure (ADHF) is a common syndrome that precedes over 100,000 hospitalizations in Canada per year (with length of stay in excess of six to eight days), making this the most costly disorder for patients older than 65 years of age. Over 85% of ADHF patients present with shortness of breath and exhibit evidence of volume overload. These findings may be variable in elderly patients, which complicates diagnosis. In fact, even in experienced centres, diagnostic accuracy is less than 80%. Despite advances in the treatment of chronic heart failure, meaningful improvements in outcomes associated with ADHF are very few. The basic assessment and treatments have not changed (early parenteral diuretics, electrocardiographic and oxygen saturation monitoring, supplemental oxygen administration). The introduction of measurement of natriuretic peptides in those in whom the diagnosis is uncertain may reduced the error rate by over 50%. The use of vasodilator therapy in the absence of cardiogenic shock can lead to earlier amelioration of symptoms, especially in those who do not respond to initial diuretics. Repeated monitoring of vital signs, body weight, electrolytes and creatinine levels is essential to minimize the risk of side effects of treatments. Noninvasive ventilation may reduce the need for endotracheal intubation in patients with severe ADHF and hypoxia at rest. Once the initial phase of heart failure treatment is completed, then the clinician should begin to focus on maximization of chronic heart failure therapy and discharge planning.

Severe Acute Decompensated Heart Failure: Epidemiology, Therapy and Hospitalization Costs

Severe Acute Decompensated Heart Failure: Epidemiology, Therapy and Hospitalization Costs