It is not clear to date whether a first admission in heart failure (HF) marks a worse evolution in patients not previously diagnosed with HF (“de novo HF”) than those already diagnosed as outpatients ...(“acutely decompensated HF”). The aim of the study was to analyze whether survival in patients admitted for de novo HF differs from the survival in those admitted for a first episode of decompensation but with a previous diagnosis of HF. This study includes an analysis of 1,728 patients admitted for decompensated HF during 9 years. Readmissions and patients with left ventricular ejection fraction ≥50% were excluded (finally, 524 patients analyzed). We compared de novo HF (n = 186) in patients not diagnosed with HF, although their structural heart disease was defined, versus acutely decompensated HF (n = 338). The clinical profiles in both groups were similar. The de novo HF group more frequently presented with normal right ventricular function, with less presence of severe tricuspid regurgitation. The probability of survival was low in both groups. Thus, the median life in the de novo HF group was 2.1 years and in the acutely decompensated HF group, 3.5 years. There was a lower probability of long-term survival in the de novo HF group (p = 0.035). The variables associated with mortality were age (p <0.0001), ischemic heart disease (p <0.0001), hypertension (p = 0.009), obesity (p = 0.025), diabetes (p = 0.001), and N-terminal pro-brain natriuretic peptide at admission (p <0.0001). A higher glomerular filtration rate was associated with better survival (p = 0.033). De novo HF was associated with a higher mortality than chronic HF with acute decompensation (hazard ratio 1.53, 95% confidence interval 1.03 to 2.27, p = 0.036). In conclusion, the first admission for HF decompensation in patients with no previous diagnosis of HF identifies a subgroup of patients with higher long-term mortality.
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Quadruple therapy (renin angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists and sodium/glucose cotransporter type 2 inhibitors SGLT2i) has become the current ...prognostic modifying treatment for heart failure (HF) with reduced ejection fraction (HFrEF). This study aimed to analyse the prescription´s evolution of this combination therapy, the analysis of each pharmacological group and the differences according to HF subgroups.
Retrospective analysis of consecutive patients admitted for cardiac decompensation. Inclusion period: from 1-1-2020 to 12-31-2022. Patients with left ventricular ejection fraction > 40% and deceased during admission were excluded. Finally, 602 patients were included. These were divided into: (a) de novo HF without previous heart disease (n:108), (b) de novo with previous heart disease (n:107), and (c) non-de novo (n:387).
Over the study time, all pharmacological groups experienced an increase in drugs prescription (p < 0.001). The group with the largest prescription rate increase was SGLT2i (2020:20%, 2021:42.9%, 2022:70.4%; mean increase 47.2%). The discharge rate prescription of quadruple therapy increased progressively (2020:7.4%, 2021:21.1%, 2022:32.5%; mean increase 21.9%). The subgroup with the highest combined prescription in 2022 was de novo with previous heart disease (43.9%).
The pharmacological group with the largest prescription´s rate increase was SGLT2i. The percentage of patients discharged on quadruple therapy has progressed significantly in recent years, although it remains low. The most optimised subgroup at discharge was that of de novo HF with previous heart disease.
The treatment of congestion in heart failure (HF) is a challenge despite the therapeutic arsenal available. The aim of this study was to analyze different combinations of diuretics used to resolve ...congestion in patients admitted for decompensated HF and to define clinical profiles according to these treatments.
Single-center study of 1,559 patients admitted for decompensated HF was done between 2016 and 2020. Patients were grouped according to the diuretic combination that led to clinical stabilization and discharge from the hospital: (1) Loop diuretic. (2) Loop diuretic + distal tubule (antialdosterone ± thiazides). (3) Loop diuretic + distal + proximal tubule (acetazolamide ± SGLT2 inhibitor). (4) Loop diuretic + distal tubule + collecting duct (tolvaptan). (5) Loop diuretic + distal + proximal + collecting duct. Based on these diuretic combinations, profiles with clinical, analytical, and echocardiographic differences were established.
There were more previous hospitalizations in groups 4 and 5 (p = 0.001) with a predominance of pulmonary congestion in profiles 1 and 2 and systemic congestion in 3, 4, and 5. Creatinine and CA125 were higher in profiles 4 and 5 (p = 0.01 and p = 0.0001), with no differences in NT-proBNP. Profiles 4 and 5 had a higher proportion of dilatation and depression of right ventricular (p = 0.0001) and left ventricular (p = 0.003) function. Diuretic therapy-defined groups showed difference in clinical characteristics.
The diuretic treatment used identifies five clinical profiles according to the degree of congestion, renal function, CA125, and right ventricular functionality. These profiles would guide the best diuretic treatment on admission.
Congestion profiles. Footnote: Profile 1: Pulmonary congestion. Profile 2: pulmonary congestion with moderate CA 125 elevation. Profile 3: systemic congestion with RV dysfunction. Profile 4: systemic congestion with RV and renal dysfunction. Profile 5: systemic congestion with renal dysfunction, RV dilatation, RV dysfunction, and severe elevation of CA 125. The last row represents the combination of treatments used to resolve each of the congestion pictures. Display omitted
Background In heart failure (HF), not all episodes of decompensation are alike. The study aimed to characterize the clinical groups of decompensation and perform a survival analysis. Methods A ...retrospective study was conducted on patients consecutively admitted for HF from 2018 to 2023. Patients who died during admission were excluded (final number 1,668). Four clinical types of HF were defined: low cardiac output ( n :83), pulmonary congestion ( n :1,044), mixed congestion ( n :353), and systemic congestion ( n :188). Results The low output group showed a higher prevalence of reduced left ventricular ejection fraction (93%) and increased biventricular diameters ( p < 0.01). The systemic congestion group exhibited a greater presence of tricuspid regurgitation with dilatation and right ventricular dysfunction ( p :0.0001), worse renal function, and higher uric acid and CA125 levels ( p :0.0001). Diuretics were more commonly used in the mixed and, especially, systemic congestion groups ( p :0.0001). The probability of overall survival at 5 years was 49%, with higher survival in pulmonary congestion and lower in systemic congestion ( p :0.002). Differences were also found in survival at 1 month and 1 year ( p :0.0001). Conclusions Mortality in acute HF is high. Four phenotypic profiles of decompensation differ clinically, with distinct characteristics and varying prognosis in the short, medium, and long term.
Worsening heart failure (HF) is a vulnerable period in which the patient has a markedly high risk of death or HF hospitalization (up to 10% and 30%, respectively, within the first weeks after ...episode). The prognosis of HF patients can be improved through a comprehensive approach that considers the different neurohormonal systems, with the early introduction and optimization of the quadruple therapy with sacubitril–valsartan, beta‐blockers, mineralocorticoid receptor antagonists, and inhibitors. Despite that, there is a residual risk that is not targeted with these therapies. Currently, it is recognized that the cyclic guanosine monophosphate deficiency has a negative direct impact on the pathogenesis of HF, and vericiguat, an oral stimulator of soluble guanylate cyclase, can restore this pathway. The effect of vericiguat has been explored in the VICTORIA study, the largest chronic HF clinical trial that has mainly focused on patients with recent worsening HF, evidencing a significant 10% risk reduction of the primary composite endpoint of cardiovascular death or HF hospitalization (number needed to treat 24), after adding vericiguat to standard therapy. This benefit was independent of background HF therapy. Therefore, optimization of treatment should be performed as earlier as possible, particularly within vulnerable periods, considering also the use of vericiguat.
This study aims to analyse whether in acute heart failure (AHF) with iron deficiency (ID), the administration of ferric carboxymaltose (FCM) produces a greater benefit in renal dysfunction.
A total ...of 812 consecutive patients admitted for AHF and ID were studied. Untreated (n:272) and treated (n:540) patients were compared. The six-month prevalence of a combined event (readmission for HF, all-cause death, and emergency department visit for decompensation) was analysed. Three grades of renal dysfunction (KDIGO) were compared, Group 1 (grades 1 and 2), Group 2 (grades 3a and 3b), and Group 3 (grades 4 and 5).
There were differences in sex distribution (untreated group: males 39.7% vs. treated group: males 51.9%;
< 0.001). Sex-adjusted combined event analysis showed a greater benefit in Group 1 (OR: 0.31, 95% CI:0.19-0.5;
< 0.001) and Group 2 (OR: 0.23, 95% CI:0.14-0.38;
< 0.001), but not in Group 3 (OR: 0.51, 95% CI:0.17-0.55;
: 0.237).
The administration of FCM in patients with AHF and ID reduces the combined event analysed. The benefit is greater when renal dysfunction is present, except in very advanced degrees where no significant benefit is obtained.
Aims
Patients with heart failure (HF) admitted for decompensation often require high doses of intravenous diuretics. This study aims to analyse whether the use of peripheral ultrafiltration (UF) in ...patients hospitalized for acute HF with systemic‐predominant congestion results in better hydric control, renal protection, and reduction of hospital stay compared with conventional treatment.
Methods and results
This study was a retrospective, comparative, single‐centre study of 56 patients admitted for HF with systemic congestion with a poor diuretic response after diuretic escalation. One group underwent peripheral UF (35 patients) and others were maintained on intense diuretic treatment (control group, 21 patients). The diuretic response and days of hospital stay were compared between and within groups. The baseline characteristics of both groups were similar: males with right ventricular failure and renal dysfunction. The inter‐group analysis showed that patients who received UF had better glomerular filtration rate (GFR; UF: 39.2 ± 18.2 vs. control: 28.7 ± 13.4 mL/min; P = 0.031) and higher diuresis (UF: 2184 ± 735 vs. control: 1335 ± 297 mL; P = 0.0001) at hospital discharge despite less need for diuretic drugs. Days of hospital stay were shorter in the UF group (UF: 11.7 ± 10.1 vs. control: 19.1 ± 14.4 days; P = 0.027). Intra‐group analysis showed that patients receiving UF improved GFR, increased diuresis, and reduced weight at discharge (P < 0.001), whereas patients on conventional treatment only experienced improved weight but worsening renal function at discharge.
Conclusions
In patients with acute HF with systemic congestion and diuretic resistance, UF compared with conventional treatment produces greater decongestion and renal protection, reduces the total diuretic load, and shortens the length of hospital stay.
Imaging is important in the diagnosis and follow-up of patients with heart failure (HF). Several thoracic radiological features have been described in these patients. The nodules with halo sign are ...very rarely reported in HF patients. This sign can appear in several diseases and a clinical context is essential for a final diagnosis.
We present two immunocompetent patients with advanced HF waiting for cardiac transplantation showing multiple transient lung nodules with halo sign on preoperative chest CT.
Our patients showed mild interstitial pulmonary edema and more interestingly multiple transient pulmonary nodules with halo sign. These nodules didn't coalesce, they even appear and disappear rapidly during worsening of pulmonary edema and showed thick halos. Nodules with halo sign are rarely reported in heart failure and considered focal pulmonary edema.
Nodules with halo sign in patients with advanced heart failure are a not usual finding that could not be the result of focal pulmonary edema, but of hemorrhage.
•The nodules with halo pattern is a very rare manifestation of HF and therefore rarely reported.•In immunocompetent patients most cases are due to pulmonary adenocarcinoma, whereas in immunocompromised patients angioinvasive aspergillosis remains the main cause of the nodule with halo sign.•In advanced heart failure patients, is mandatory to exclude malignancy, because this patients usually need heart transplant.•We report two immunocompetent patients with advanced HF waiting for cardiac transplantation showing multiple transient lung nodules with halo sign on preoperative chest CT.
Aims
Hyperkalaemia (HK) is common in heart failure (HF) patients, related to renal dysfunction and medical treatment. It limits medical therapy optimization, which impacts prognosis. New potassium ...(K) binders help control HK, allowing better medical management of HF.
Methods and results
A retrospective multicentre register included all outpatients with HF and HK (K ≥ 5.1 mEq/L) treated with patiromer according to current recommendations. We evaluated analytic and clinical parameters before starting the treatment and at 7, 30 and 90 days, as well as adverse events related to patiromer and treatment optimization. We included 74 patients (71.6% male) with a mean age of 70.8 years (SD 9.2). Sixty‐seven patients (90.5%) presented HK in the previous year. Forty patients (54.1%) underwent down‐titration of a renin–angiotensin–aldosterone inhibitor (RAASi) or a mineralocorticoid receptor antagonist (MRA), and 27 (36.5%) stopped any of them due to HK. Initial K was 5.5 mEq/L (SD 0.6), with a significantly reduction at 7 days (4.9 mEq/L (SD 0.8); P < 0.001), maintained at 90 days (4.9 mEq/L (SD 0.8); P < 0.001). There were no other electrolyte disturbances, with a slight improvement in renal function glomerular filtration rate 39.6 mL/min (SD 20.4) to 42.7 mL/min (SD 23.2); P = 0.005. Adverse events were reported in 33.9% of patients, the most common being hypomagnesaemia (16.3%), gastrointestinal disturbances (14.9%) and HK (2.8%). Withdrawal of patiromer was uncommon (12.2%) due to gastrointestinal disturbances in 66.7% of cases.
Nine patients (12.2%) started on a RAASi, and 15 patients (20.3%) on an MRA during the follow‐up. Forty‐five patients (60.8%) increased the dose of RAASi or MRA, increasing to target doses in 5.4 and 10.8% of patients, respectively. At 90 days, NTproBNP values were reduced from 2509.5 pg/mL IQR 1311–4,249 to 1396.0 pg/mL IQR 804–4263; P = 0.003, but the reduction was only observed in those who optimized HF medical treatment NTproBNP from 1950.5 pg/mL (IQR 1208–3403) to 1349.0 pg/mL (IQR 804–2609); P < 0.01. NYHA functional class only improved in 7.5% of patients, corresponding with those who optimized HF medical treatment. Compared with the previous 3 months before patiromer treatment, the rate of hospitalization was reduced from 28.4 to 10.9% (P < 0.01), and the emergency room visits from 18.9 to 5.4% (P < 0.01).
Conclusions
In a real‐life cohort of patients with HF, patiromer reduced and maintained K levels during 3 months of follow‐up. The most common adverse events were hypomagnesaemia and gastrointestinal disturbances. Patiromer helps optimize medical treatment, increasing the percentage of patients treated with RAASi and MRA at target doses. At the end of follow‐up, natriuretic peptides values and hospital visits were reduced, suggesting the benefit of optimizing HF medical treatment.
Background
In Spain, listing for high‐urgent heart transplantation is allowed for critically ill candidates not weanable from temporary mechanical circulatory support (T‐MCS). We sought to analyse ...the clinical outcomes of this strategy.
Methods and results
We conducted a case‐by‐case, retrospective review of clinical records of 291 adult patients listed for high‐urgent heart transplantation under temporary devices from 2010 to 2015 in 16 Spanish institutions. Survival after listing and adverse clinical events were studied. At the time of listing, 169 (58%) patients were supported on veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO), 70 (24%) on temporary left ventricular assist devices (T‐LVAD) and 52 (18%) on temporary biventricular assist devices (T‐BiVAD). Seven patients transitioned from VA‐ECMO to temporary ventricular assist devices while on the waiting list. Mean time on T‐MCS was 13.1 ± 12.6 days. Mean time from listing to transplantation was 7.6 ± 8.5 days. Overall, 230 (79%) patients were transplanted and 54 (18.6%) died during MCS. In‐hospital postoperative mortality after transplantation was 33.3%, 11.9% and 26.2% for patients bridged on VA‐ECMO, T‐LVAD and T‐BiVAD, respectively (P = 0.008). Overall survival from listing to hospital discharge was 54.4%, 78.6% and 55.8%, respectively (P = 0.002). T‐LVAD support was independently associated with a lower risk of death over the first year after listing (hazard ratio 0.52, 95% confidence interval 0.30–0.92). Patients treated with VA‐ECMO showed the highest incidence rate of adverse clinical events associated with T‐MCS.
Conclusion
Temporary devices may be used to bridge critically ill candidates directly to heart transplantation in a setting of short waiting list times, as is the case of Spain. In our series, bridging with T‐LVAD was associated with more favourable outcomes than bridging with T‐BiVAD or VA‐ECMO.
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