Clinical, respiratory, haemodynamic, and metabolic determinants of lactate in heart failure

Background: Lactate is an end-product of anaerobic cell metabolism. Although it is believed to have prognostic significance in heart failure (HF), data on the pathomechanisms that lead to lactate accumulation are scarce. Aims: We aimed to determine the clinical, respiratory, biochemical, and haemodynamic correlates of lactate in HF. Methods: Patients diagnosed with HF hospitalised in a single cardiac centre, who underwent haemodynamic monitoring, were included in this retrospective analysis. Results: The population consisted of 93 patients (44 acute HF [AHF] and 49 chronic HF [CHF] cases). The mean age, left ventricular ejection fraction, and lactate level were 60 ± 13 years, 33% ± 17%, 1.4 ± 0.9 mmol/L, respectively. The mean cardiac index (CI), right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP) were 2.2 ± 0.5 L/min/m2, 8.7 ± 6 mmHg, and 18 ± 6 mmHg, respectively. AHF patients had significantly higher RAP, heart rate (HR), and levels of N-terminal pro–B-type natriuretic peptide and creatinine, compared to the CHF group. Both HR and natriuretic peptide level were correlated with lactate. Among haemodynamic indices, lactate correlated with CI (r = –0.25, p = 0.01). We found no correlation between lactate and RAP (p > 0.05) or PCWP (p > 0.05). There was no relationship between lactate and peripheral blood gases. Lactate was strongly correlated with mixed venous oxygen saturation (svO2) (r = –0.61, p < 0.05). HR, svO2, and systemic vascular resistance (SVR) were found to be independent determinants of lactate. Conclusions: Lactate accumulation in HF is not a result of respiratory disturbances or hypoxaemia. Among haemodynamic indices, CI is correlated with lactate. The strongest determinants of lactate included svO2, SVR, and HR

Elevated lactate in acute heart failure patients with intracellular iron deficiency as identifier of poor outcome

Background: We believe that there is a physiological link between intracellular iron status (assessed by soluble transferrin receptor [sTfR]) and efficiency of energy production/consumption (assessed by lactate, a product of anaerobic cell metabolism), which may further impact the outcome of patients with acute heart failure (AHF).  Aims: To examine if elevated levels of lactate ( > 2 mmol/L) accompanied by unmet cellular iron requirements (defined as sTfR > 1.59 mg/L) identify AHF patients with an unfavourable outcome.  Methods: The study is a single-centre, retrospective analysis of AHF patients in whom lactate and iron status were assessed on admission. The endpoint of the study was one-year mortality.  Results: The study population consisted of 89 patients at a mean age of 65 ± 13 years. Mean systolic blood pressure and creatinine level were 135 ± 36 mmHg and 1.3 ± 0.6 mg/dL, respectively, and median [25th–75th quartiles] lactate level on admission was 2.0 [1.6–2.6] mmol/L. In 17 (19%) patients, both lactate and sTfR were below the cut-off values (group 1). In 38 (43%) individuals one of the markers was elevated (group 2) and in the remaining 34 (38%) patients both markers were above the predefined cut-off values (group 3). There was no difference in clinical and laboratory characteristics between the groups. During one-year follow-up 23 (26%) patients died. Mortality risk in group 3 was higher compared to the rest of the population (hazard ratio 5.6, 95% confidence interval 2.2–14, p = 0.0003), even after adjustments for well-defined prognostic factors.  Conclusions: Patients with unmet iron cell requirements and hyperlactataemia on admission have significantly higher mortality risk compared to individuals without those pathologies.

Zastosowanie lewosimendanu u chorych z ostrą niewydolnością serca z objawami małego rzutu minutowego serca: opis serii przypadków

The report presents single centre experience in application of levosimendan in patients with acute heart failure with low cardiacoutput. All patients underwent haemodynamic measurement before and after administration of the drug. Levosimendanimproved haemodynamics and was useful in this subpopulation of patients

Persistent hyperlactataemia is related to high rates of in-hospital adverse events and poor outcome in acute heart failure

Background: Although lactate is a well-established marker in intensive care, our understanding of its utility in acute heart  failure (AHF) is modest and based on studies with a single measurement of this marker.  Aims: We aimed to investigate whether persistent elevation of lactate during hospitalisation is related to a higher risk of ad- verse events.  Methods: We conducted a prospective study to assess AHF patients hospitalised in one cardiac centre. The diagnosis of persistent hyperlactataemia was based on two measurements of the marker (on admission and at 24 h of hospitalisation) and it was defined as lactate elevation (≥ 2 mmol/L) at both time points.  Results: The population consisted of 222 patients at a mean age of 70 ± 13 years. Mean ejection fraction and creatinine level on admission were 37% ± 16% and 1.36 ± 0.51 mg/dL, respectively. The percentage of patients with elevated lactates on admission, at 24 h of hospitalisation, and persistent hyperlactataemia were 47%, 35%, and 24%, respectively. The group with persistent hyperlactataemia did not differ in most clinical and laboratory variables from the rest of the population. Patients with persistent hyperlactataemia had higher rate of adverse events during hospitalisation: worsening of heart failure (22.6% vs. 6.5%, p < 0.05), inotrope use (22.6% vs. 5.3%, p < 0.05), and increase of N-terminal pro–B-type natriuretic peptide at 48 h of hospitalisation (30% vs. 18%, p < 0.05). Persistent hyperlactataemia was an independent predictor of one-year mortality (hazard ratio 2.5, 95% confidence interval 1.5–4.3, p < 0.001).  Conclusions: Persistent hyperlactataemia within the first 24 h of hospitalisation is a predictor of a worse outcome in AHF and is related to higher rates of in-hospital adverse events and one-year mortality.

The patient perspective: Quality of life in advanced heart failure with frequent hospitalisations.

End of life is an unfortunate but inevitable phase of the heart failure patients' journey. It is often preceded by a stage in the progression of heart failure defined as advanced heart failure, and characterised by poor quality of life and frequent hospitalisations. In clinical practice, the efficacy of treatments for advanced heart failure is often assessed by parameters such as clinical status, haemodynamics, neurohormonal status, and echo/MRI indices. From the patients' perspective, however, quality-of-life-related parameters, such as functional capacity, exercise performance, psychological status, and frequency of re-hospitalisations, are more significant. The effects of therapies and interventions on these parameters are, however, underrepresented in clinical trials targeted to assess advanced heart failure treatment efficacy, and data are overall scarce. This is possibly due to a non-universal definition of the quality-of-life-related endpoints, and to the difficult standardisation of the data collection. These uncertainties also lead to difficulties in handling trade-off decisions between quality of life and survival by patients, families and healthcare providers. A panel of 34 experts in the field of cardiology and intensive cardiac care from 21 countries around the world convened for reviewing the existing data on quality-of-life in patients with advanced heart failure, discussing and reaching a consensus on the validity and significance of quality-of-life assessment methods. Gaps in routine care and research, which should be addressed, were identified. Finally, published data on the effects of current i.v. vasoactive therapies such as inotropes, inodilators, and vasodilators on quality-of-life in advanced heart failure patients were analysed.This project did not receive any financial support, apart for covering the logistic expenses related to the organisation of the consensus meeting in Munich on January 23, 2015, which was achieved by collecting unrestricted educational grants from Orion Pharma (Finland), AbbVie (U.S.A.), Medis d.o.o. (Slovenia) and Biomed JR Ltd. (Israel). The attendees did not receive any honoraria. PP and MK are employees of Orion Pharma

Renal Assessment in Acute Cardiorenal Syndrome

Cardiorenal syndrome (CRS) is a complex, heterogeneous spectrum of symptoms that has kept cardiologists awake for decades. The heart failure (HF) population being burdened with multimorbidity poses diagnostic and therapeutic challenges even for experienced clinicians. Adding deteriorated renal function to the equation, which is one of the strongest predictors of adverse outcome, we measure ourselves against possibly the biggest problem in modern cardiology. With the rapid development of new renal assessment methods, we can treat CRS more effectively than ever. The presented review focuses on explaining the pathophysiology, recent advances and current practices of monitoring renal function in patients with acute CRS. Understanding the dynamic interaction between the heart and the kidney may improve patient care and support the selection of an effective and nephroprotective treatment strategy