Prognostic value of discharge heart rate in acute heart failure patients: More relevant in atrial fibrillation?

Aims: The prognostic impact of heart rate (HR) in acute heart failure (AHF) patients is not well known especially in atrial fibrillation (AF) patients. The aim of the study was to evaluate the impact of admission HR, discharge HR, HR difference (admission-discharge) in AHF patients with sinus rhythm (SR) or AF on long- term outcomes. Methods: We included 1398 patients consecutively admitted with AHF between October 2013 and December 2014 from a national multicentre, prospective registry. Logistic regression models were used to estimate the association between admission HR, discharge HR and HR difference and one- year all-cause mortality and HF readmission. Results: The mean age of the study population was 72+/-12years. Of these, 594 (42.4%) were female, 655 (77.8%) were hypertensive and 655 (46.8%) had diabetes. Among all included patients, 745 (53.2%) had sinus rhythm and 653 (46.7%) had atrial fibrillation. Only discharge HR was associated with one year all-cause mortality (Relative risk (RR)=1.182, confidence interval (CI) 95% 1.024-1.366, p=0.022) in SR. In AF patients discharge HR was associated with one year all cause mortality (RR=1.276, CI 95% 1.115-1.459, p</=0.001). We did not observe a prognostic effect of admission HR or HRD on long-term outcomes in both groups. This relationship is not dependent on left ventricular ejection fraction. Conclusions: In AHF patients lower discharge HR, neither the admission nor the difference, is associated with better long-term outcomes especially in AF patients

Prognostic value of discharge heart rate in acute heart failure patients: more relevant in atrial fibrillation?

[Abstract] Aims. The prognostic impact of heart rate (HR) in acute heart failure (AHF) patients is not well known especially in atrial fibrillation (AF) patients. The aim of the study was to evaluate the impact of admission HR, discharge HR, HR difference (admission-discharge) in AHF patients with sinus rhythm (SR) or AF on long- term outcomes. Methods. We included 1398 patients consecutively admitted with AHF between October 2013 and December 2014 from a national multicentre, prospective registry. Logistic regression models were used to estimate the association between admission HR, discharge HR and HR difference and one- year all-cause mortality and HF readmission. Results. The mean age of the study population was 72 ± 12 years. Of these, 594 (42.4%) were female, 655 (77.8%) were hypertensive and 655 (46.8%) had diabetes. Among all included patients, 745 (53.2%) had sinus rhythm and 653 (46.7%) had atrial fibrillation. Only discharge HR was associated with one year all-cause mortality (Relative risk (RR) = 1.182, confidence interval (CI) 95% 1.024–1.366, p = 0.022) in SR. In AF patients discharge HR was associated with one year all cause mortality (RR = 1.276, CI 95% 1.115–1.459, p ≤ 0.001). We did not observe a prognostic effect of admission HR or HRD on long-term outcomes in both groups. This relationship is not dependent on left ventricular ejection fraction. Conclusions. In AHF patients lower discharge HR, neither the admission nor the difference, is associated with better long-term outcomes especially in AF patients

Cystatin C, a measure of renal function, as prognostic risk marker in acute heart failure : Studies on the cardiorenal syndrome

Acute heart failure (AHF) is a complex syndrome associated with exceptionally high mortality. Still, characteristics and prognostic factors of contemporary AHF patients have been inadequately studied. Kidney function has emerged as a very powerful prognostic risk factor in cardiovascular disease. This is believed to be the consequence of an interaction between the heart and kidneys, also termed the cardiorenal syndrome, the mechanisms of which are not fully understood. Renal insufficiency is common in heart failure and of particular interest for predicting outcome in AHF. Cystatin C (CysC) is a marker of glomerular filtration rate with properties making it a prospective alternative to the currently used measure creatinine for assessment of renal function. The aim of this thesis is to characterize a representative cohort of patients hospitalized for AHF and to identify risk factors for poor outcome in AHF. In particular, the role of CysC as a marker of renal function is evaluated, including examination of the value of CysC as a predictor of mortality in AHF. The FINN-AKVA (Finnish Acute Heart Failure) study is a national prospective multicenter study conducted to investigate the clinical presentation, aetiology and treatment of, as well as concomitant diseases and outcome in, AHF. Patients hospitalized for AHF were enrolled in the FINN-AKVA study, and mortality was followed for 12 months. The mean age of patients with AHF is 75 years and they frequently have both cardiovascular and non-cardiovascular co-morbidities. The mortality after hospitalization for AHF is high, rising to 27% by 12 months. The present study shows that renal dysfunction is very common in AHF. CysC detects impaired renal function in forty percent of patients. Renal function, measured by CysC, is one of the strongest predictors of mortality independently of other prognostic risk markers, such as age, gender, co-morbidities and systolic blood pressure on admission. Moreover, in patients with normal creatinine values, elevated CysC is associated with a marked increase in mortality. Acute kidney injury, defined as an increase in CysC within 48 hours of hospital admission, occurs in a significant proportion of patients and is associated with increased short- and mid-term mortality. The results suggest that CysC can be used for risk stratification in AHF. Markers of inflammation are elevated both in heart failure and in chronic kidney disease, and inflammation is one of the mechanisms thought to mediate heart-kidney interactions in the cardiorenal syndrome. Inflammatory cytokines such as interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) correlate very differently to markers of cardiac stress and renal function. In particular, TNF-α showed a robust correlation to CysC, but was not associated with levels of NT-proBNP, a marker of hemodynamic cardiac stress. Compared to CysC, the inflammatory markers were not strongly related to mortality in AHF. In conclusion, patients with AHF are elderly with multiple co-morbidities, and renal dysfunction is very common. CysC demonstrates good diagnostic properties both in identifying impaired renal function and acute kidney injury in patients with AHF. CysC, as a measure of renal function, is also a powerful prognostic marker in AHF. CysC shows promise as a marker for assessment of kidney function and risk stratification in patients hospitalized for AHF.Sammandrag på svenska Akut hjärtsvikt är ett mångfasetterat tillstånd med exceptionellt hög dödlighet. Forskningen har dock inte i tillräckligt stor utsträckning undersökt kliniska karaktärsdrag och prognostiska faktorer hos patienter med akut hjärtsvikt. Njurfunktionen har visat sig spela en nyckelroll för prognosen hos patienter med hjärt-kärlsjukdomar. Mekanismerna bakom detta samband mellan hjärta och njurar, ofta kallat det kardiorenala syndromet, är otillräckligt klarlagda. Nedsatt njurfunktion är vanlig vid hjärtsvikt och därmed av speciellt intresse för bedömning av prognosen vid akut hjärtsvikt. Cystatin C (CysC) är en markör för den glomerulära filtrationen med egenskaper som gör den till ett intressant alternativ till kreatininet, som för närvarande används för att bedöma njurfunktionen. Syftet med avhandlingen är att karaktärisera en representativ grupp patienter med akut hjärtsvikt och att identifiera riskfaktorer för dålig prognos vid akut hjärtsvikt. Särskild vikt läggs vid att utvärdera vilken roll CysC spelar som markör för njurfunktionen, samt vid att bedöma dess värde som prediktor av mortaliteten vid akut hjärtsvikt. FINN-AKVA är en finländsk prospektiv multicenter-studie som utförs för att undersöka akut hjärtsvikt: klinisk bild, etiologi, komorbiditet, behandling och mortalitet. Patienter med akut hjärtsvikt som intagits på sjukhus rekryterades till FINN-AKVA-studien och följdes under 12 månader med avseende på mortaliteten. Medelåldern för personerna som ingår i studien är 75 år. De har ett flertal grundsjukdomar, både kardiovaskulära och icke-kardiovaskulära. Mortaliteten efter akut hjärtsvikt är hög, 27 % på 12 månader. Resultaten i avhandlingen visar att försämrad njurfunktion är mycket vanligt vid akut hjärtsvikt. CysC upptäcker en nedsatt njurfunktion hos 40 % av patienterna och är dessutom en av de faktorer som är starkast relaterad till mortaliteten, även om man beaktar andra vanliga riskmarkörer så som ålder, kön, grundsjukdomar och systoliskt blodtryck. Studien påvisar att höga nivåer av CysC har samband med en ökad mortalitet även hos patienter med normala kreatininvärden. Akut njursvikt, i studien definierad som en ökning av CysC-nivåerna med 0.3mg/l under de första två dygnen av sjukhusvistelsen, konstateras hos en betydande andel av patienterna och medför också en ökad mortalitet, både omedelbar och på längre sikt under uppföljningstiden. Resultaten antyder att CysC är användbar för riskbedömning vid akut hjärtsvikt. Förhöjda nivåer av olika inflammatoriska cytokiner, såsom interleukin-6 (IL-6) och tumörnekros faktor alfa (TNF-α) har påvisats både vid hjärtsvikt och vid kronisk njursjukdom. Inflammationen antas vara en av mekanismerna vid växelverkan mellan hjärta och njurar i det kardiorenala syndromet. IL-6 och TNF-α uppvisar rätt olika korrelation med markörer för njurfunktion och hjärtsvikt (NT-proBNP). Speciellt stark var korrelationen mellan CysC och TNF-α, som i sin tur inte korrelerade med NT-proBNP. CysC var dock en bättre riskmarkör för mortaliteten än de inflammatoriska markörerna. Sammanfattningsvis kan konstateras att patienter med akut hjärtsvikt är äldre personer, har många grundsjukdomar, och att nedsatt njurfunktion är mycket vanlig. CysC visar sig ha goda diagnostiska egenskaper både för att upptäcka försämrad njurfunktion och akut njursvikt hos patienter med akut hjärtsvikt. CysC är också en stark prognostisk markör vid akut hjärtsvikt. CysC bör betraktas som en lovande markör för bedömningen av njurfunktionen och riskbedömningen hos patienter med akut hjärtsvikt.Tiivistelmä suomeksi Akuutti sydämen vajaatoiminta on monimuotoinen oireyhtymä johon liittyy poikkeuksellisen suuri kuolleisuus. Siitä huolimatta näiden potilaiden kliinisiä piirteitä ja ennustetekijöitä on puutteellisesti tutkittu. Munuaistoiminta on noussut vahvaksi ennustetekijäksi sydän- ja verisuonisairauksissa. Tätä sydämen ja munuaisten välistä yhteyttä kuvataan nimellä kardiorenaalinen syndrooma, mutta sen mekanismit ovat huonosti tunnettuja. Munuaisten vajaatoiminta on tavallinen sydämen vajaatoimintapotilailla, ja siksi erityisen mielenkiinnon kohteena kuolleisuuden ennustajana akuutissa sydämen vajaatoiminnassa. Kystatiini C (CysC) on glomerulusfiltraation mittari jonka ominaisuudet tekevät siitä mielenkiintoisen vaihtoehdon nykyisin käytössä olevalle kreatiniinille munuaistoiminnan merkkiaineena. Väitöskirjan tavoitteena on kuvata edustava aineisto akuuttia sydämen vajaatoimintaa sairastavia potilaita ja tunnistaa akuutin sydämen vajaatoiminnan huonon ennusteen tekijöitä. Erityisenä tavoitteena on tutkia CysC:tä munuaistoiminnan merkkiaineena akuutissa sydämen vajaatoiminnassa ja selvittää sen merkitystä kuolleisuuden ennustetekijänä. FINN-AKVA on suomalainen prospektiivinen monikeskustutkimus akuutin sydämen vajaatoiminnan kliinisestä ilmentymästä, etiologiasta, liitännäissairauksista, sekä hoidosta ja kuolleisuudesta. Tutkimukseen otettiin akuutin sydämen vajaatoiminnan takia sairaalahoitoon joutuneita potilaita, ja kuolleisuutta seurattiin 12 kuukauden ajan. Potilaiden keski-ikä oli 75 vuotta, ja heillä esiintyi paljon sydän- ja verisuonisairauksia sekä useita muita liitännäissairauksia. Kuolleisuus sairaalahoitojakson jälkeisen vuoden aikana oli korkea (27 %). Tutkimuksessa CysC:llä todetaan alentunutta munuaistoimintaa 40 %:lla akuutin sydämen vajaatoimintapotilaiden joukosta. Munuaistoiminta, CysC:llä mitattuna, on yksi vahvimmista itsenäisistä kuolleisuuden ennustajista senkin jälkeen, kun muut tavanomaiset riskitekijät on otettu huomioon. Niilläkin potilailla joilla kreatiniini on normaali, koholla olevaan CysC-arvoon liittyy huomattavasti korkeampi kuolleisuus. Akuutti munuaisvaurio, määritelmänä CysC-arvon nousu 0.3 mg/l kahden vuorokauden sisällä sairaalaan tulosta, havaitaan merkittävällä osalla potilaista, ja siihen liittyy lisääntynyt kuolleisuus sekä lyhyellä että keskipitkällä aikavälillä. Tulosten perusteella vaikuttaa siltä, että CysC on käyttökelpoinen merkkiaine riskinarvioon akuutissa sydämen vajaatoiminnassa. Kohonneita pitoisuuksia tulehduksellisia sytokiineja, kuten interleukiini-6 (IL-6) ja tuumorinekroositekijä alfa (TNF-α), on todettu sekä sydämen että munuaisten vajaatoiminnassa. Tulehduksen ajatellaan olevan mukana välittäjänä sydämen ja munuaisten välisessä vuorovaikutuksessa, kardiorenaalisessa syndroomassa. IL-6 ja TNF-α korreloivat eri tavalla munuaistoimintaa ja sydämen kuormitusta (NT-proBNP) kuvaaviin merkkiaineisiin. Etenkin TNF-α:lla on vankka korrelaatio CysC:n kanssa, mutta ei taas assosioidu NT-proBNP-tasoihin. CysC:n verrattuna tulehdusmerkkiaineiden vaikutus ennusteeseen on heikompi. Yhteenvetona voi todeta, että akuuttia sydämen vajaatoimintaa sairastavat potilaat ovat iäkkäitä, varsin monisairaita, ja etenkin munuaisten vajaatoiminta on tavallinen löydös. CysC osoittaa hyviä diagnostisia ominaisuuksia, sekä alentuneen munuaistoiminnan että akuutin munuaisvaurion havaitsemiseen akuuttia sydämen vajaatoimintaa sairastavilla potilailla. Munuaistoiminnan merkkiaineena CysC on myös vahva ennustetekijä. CysC vaikuttaa lupaavalta merkkiaineelta munuaistoiminnan arviointiin ja akuutin sydämen vajaatoimintapotilaiden riskinarvioon

A pragmatic approach to the use of inotropes for the management of acute and advanced heart failure. an expert panel consensus

Inotropes aim at increasing cardiac output by enhancing cardiac contractility. They constitute the third pharmacological pillar in the treatment of patients with decompensated heart failure, the other two being diuretics and vasodilators. Three classes of parenterally administered inotropes are currently indicated for decompensated heart failure, (i) the beta adrenergic agonists, including dopamine and dobutamine and also the catecholamines epinephrine and norepinephrine, (ii) the phosphodiesterase III inhibitor milrinone and (iii) the calcium sensitizer levosimendan. These three families of drugs share some pharmacologic traits, but differ profoundly in many of their pleiotropic effects. Identifying the patients in need of inotropic support and selecting the proper inotrope in each case remain challenging. The present consensus, derived by a panel meeting of experts from 21 countries, aims at addressing this very issue in the setting of both acute and advanced heart failure

A pragmatic approach to the use of inotropes for the management of acute and advanced heart failure: An expert panel consensus

Inotropes aim at increasing cardiac output by enhancing cardiac contractility. They constitute the third pharmacological pillar in the treatment of patients with decompensated heart failure, the other two being diuretics and vasodilators. Three classes of parenterally administered inotropes are currently indicated for decompensated heart failure, (i) the beta adrenergic agonists, including dopamine and dobutamine and also the catecholamines epinephrine and norepinephrine, (ii) the phosphodiesterase III inhibitor milrinone and (iii) the calcium sensitizer levosimendan. These three families of drugs share some pharmacologic traits, but differ profoundly in many of their pleiotropic effects. Identifying the patients in need of inotropic support and selecting the proper inotrope in each case remain challenging. The present consensus, derived by a panel meeting of experts from 21 countries, aims at addressing this very issue in the setting of both acute and advanced heart failure. (C) 2019 The Authors. Published by Elsevier B.V.Peer reviewe

Effects of Widespread Inotrope Use in Acute Heart Failure Patients

Current guidelines recommend that inotropes should not be used in patients with normal systolic blood pressure (SBP). However, this is not supported with concrete evidence. We aimed to evaluate the effect of inotropes in acute heart failure (HF) patients from a nationwide HF registry. A total of 5625 patients from the Korean Acute Heart Failure (KorAHF) registry were analyzed. The primary outcomes were in-hospital adverse events and 1-month mortality. Among the total population, 1703 (31.1%) received inotropes during admission. Inotrope users had a higher event rate than non-users (in-hospital adverse events: 13.3% vs. 1.4%, p < 0.001; 1-month mortality: 5.5% vs. 2.5%, p < 0.001), while inotrope use was an independent predictor for clinical outcomes (in-hospital adverse events: ORadjusted 5.459, 95% CI 3.622⁻8.227, p < 0.001; 1-month mortality: HRadjusted 1.839, 95% CI 1.227⁻2.757, p = 0.003). Subgroup analysis showed that inotrope use was an independent predictor for detrimental outcomes only in patients with normal initial SBP (≥90 mmHg) (in-hospital adverse events: ORadjusted 5.931, 95% CI 3.864⁻9.104, p < 0.001; 1-month mortality: HRadjusted 3.584, 95% CI 1.280⁻10.037, p = 0.015), and a propensity score-matched population showed consistent results. Clinicians should be cautious with the usage of inotropes in acute heart failure patients, especially in those with a normal SBP.ope

Clinical Characteristics and Predictors of In-Hospital Mortality among Older Patients with Acute Heart Failure

Acute Heart Failure (AHF)-related hospitalizations and mortality are still high in western countries, especially among older patients. This study aimed to describe the clinical characteristics and predictors of in-hospital mortality of older patients hospitalized with AHF. We conducted a retrospective study including all consecutive patients ≥65 years who were admitted for AHF at a single academic medical center between 1 January 2008 and 31 December 2018. The primary outcome was all-cause, in-hospital mortality. We also analyzed deaths due to cardiovascular (CV) and non-CV causes and compared early in-hospital events. The study included 6930 patients, mean age 81 years, 51% females. The overall mortality rate was 13%. Patients ≥85 years had higher mortality and early death rate than younger patients. Infections were the most common condition precipitating AHF in our cohort, and pneumonia was the most frequent of these. About half of all hospital deaths were due to non-CV causes. After adjusting for confounding factors other than NYHA class at admission, infections were associated with an almost two-fold increased risk of mortality, HR 1.74, 95% CI 1.10–2.71 in patients 65–74 years (p = 0.014); HR 1.83, 95% CI 1.34–2.49 in patients 75–84 years (p = 0.001); HR 1.74, 95% CI 1.24–2.19 in patients ≥85 years (p = 0.001). In conclusion, among older patients with AHF, in-hospital mortality rates increased with increasing age, and infections were associated with an increased risk of in-hospital mortality. In contemporary patients with AHF, along with the treatment of the CV conditions, management should be focused on timely diagnosis and appropriate treatment of non-CV factors, especially pulmonary infections

The overlooked immune state in candidemia: A risk factor for mortality

Producción CientíficaLymphopenia has been related to increased mortality in septic patients. Nonetheless, the impact of lymphocyte count on candidemia mortality and prognosis has not been addressed. We conducted a retrospective study, including all admitted patients with candidemia from 2007 to 2016. We examined lymphocyte counts during the first 5 days following the diagnosis of candidemia. Multivariable logistic regression analysis was performed to determine the relationship between lymphocyte count and mortality. Classification and Regression Tree analysis was used to identify the best cut-off of lymphocyte count for mortality associated with candidemia. From 296 cases of candidemia, 115 died, (39.8% 30-day mortality). Low lymphocyte count was related to mortality and poor outcome (p < 0.001). Lymphocyte counts <0.703 × 109 cells/L at diagnosis (area under the curve (AUC)-ROC, 0.783 ± 0.042; 95% confidence interval (CI), 0.700–0.867, p < 0.001), and lymphocyte count <1.272 × 109 cells/L five days later (AUC-ROC, 0.791 ± 0.038; 95%CI, 0.716–0.866, p < 0.001) increased the odds of mortality five-fold (odds ratio (OR), 5.01; 95%CI, 2.39–10.93) at time of diagnosis, and three-fold (OR, 3.27; 95%CI, 1.24–8.62) by day 5, respectively. Low lymphocyte count is an independent predictor of mortality in patients with candidemia and might serve as a biomarker for predicting candidemia-associated mortality and poor outcome.Junta de Castilla y León (grant VA161G18