Purpose
To date, treatment with intravenous (IV) agents such as vasodilators, diuretics, and inotropes has shown marginal or mixed benefits in acute heart failure (AHF) trials. The aim of this study ...was to identify the risks and benefits of IV drugs in patients hospitalized with acute decompensated heart failure.
Methods
The AHF global survey of standard treatment (ALARM-HF) reviewed in-hospital treatments in eight countries. The present study was a post hoc analysis of ALARM-HF data in which propensity scoring was used to identify groups of patients who differed by treatment but had the same multivariate distribution of covariates. Such propensity matching allowed estimations of the effect of specific treatments on the outcome of in-hospital mortality.
Results
Unadjusted analysis showed a lower in-hospital mortality rate in AHF patients receiving “diuretics + vasodilators” (
n
= 1,805) compared to those receiving “diuretics alone” (
n
= 2,362) (7.6 vs. 14.2%,
p
< 0.0001). Propensity-based matching (
n
= 1,007 matched pairs) confirmed the lower mortality of AHF patients receiving diuretics + vasodilators: 7.8 versus 11.0% (
p
= 0.016). Unadjusted analysis showed a much greater in-hospital mortality rate in patients receiving IV inotropes (25.9%) compared to those who did not (5.2%) (
p
< 0.0001). Propensity-based matching (
n
= 954 pairs) confirmed that IV catecholamine use was associated with 1.5-fold increase for dopamine or dobutamine use and a >2.5-fold increase for norepinephrine or epinephrine use.
Conclusions
In terms of in-hospital survival, a vasodilator in combination with a diuretic fared better than treatment with only a diuretic. Catecholamine inotropes should be used cautiously as it has been seen that they actually increase the risk for in-hospital mortality.
Abstract Background Anemia in heart failure patients and has been associated with increased morbi–mortality. Previous studies have treated anemia in heart failure patients with either erythropoietin ...alone or combination of erythropoietin and intravenous (IV) iron. However, the effect of IV or oral (PO) iron supplementation alone in heart failure patients with anemia was virtually unknown. Aim To compare, in a double-blind design, the effects of IV iron versus PO iron in anemic heart failure patients. Methods IRON-HF study was a multicenter, investigator initiated, randomized, double-blind, placebo controlled trial that enrolled anemic heart failure patients with preserved renal function, low transferrin saturation (TSat) and low-to-moderately elevated ferritin levels. Interventions were Iron Sucrose IV 200 mg, once a week, for 5 weeks, ferrous sulfate 200 mg PO TID, for 8 weeks, or placebo. Primary endpoint was variation of peak oxygen consumption (peak VO2 ) assessed by ergospirometry over 3 month follow-up. Results Eighteen patients had full follow-up data. There was an increment of 3.5 ml/kg/min in peak VO2 in the IV iron group. There was no increment in peak VO2 in the PO iron group. Patients' ferritin and TSat increased significantly in both treated groups. Hemoglobin increased similarly in all groups. Conclusion IV iron seems to be superior in improving functional capacity of heart failure patients. However, correction of anemia seems to be at least similar between PO iron and IV iron supplementation.
Cardiovascular diseases are the major cause of death in the world. Current treatments have not been able to reverse this scenario, creating the need for the development of new therapies. Cell ...therapies have emerged as an alternative for cardiac diseases of distinct causes in experimental animal studies and more recently in clinical trials.
We have designed clinical trials to test for the efficacy of autologous bone marrow derived mononuclear cell therapies in four different cardiopathies: acute and chronic ischemic heart disease, and Chagasic and dilated cardiomyopathy. All trials are multicenter, randomized, double-blind and placebo controlled. In each trial 300 patients will be enrolled and receive optimized therapy for their specific condition. Additionally, half of the patients will receive the autologous bone marrow cells while the other half will receive placebo (saline with 5% autologous serum). For each trial there are specific inclusion and exclusion criteria and the method for cell delivery is intramyocardial for the chronic ischemic heart disease and intracoronary for all others. Primary endpoint for all studies will be the difference in ejection fraction (determined by Simpson's rule) six and twelve months after intervention in relation to the basal ejection fraction. The main hypothesis of this study is that the patients who receive the autologous bone-marrow stem cell implant will have after a 6 month follow-up a mean increase of 5% in absolute left ventricular ejection fraction in comparison with the control group.
Many phase I clinical trials using cell therapy for cardiac diseases have already been performed. The few randomized studies have yielded conflicting results, rendering necessary larger well controlled trials to test for efficacy of cell therapies in cardiopathies. The trials registration numbers at the NIH registry are the following: Chagasic cardiomyopathy (NCT00349271), dilated cardiomyopathy (NCT00333827), acute myocardial infarction (NCT00350766) and Chronic Ischemic Heart Disease (NCT00362388).
Much has been achieved in one century after Carlos Chagas' discovery. However, there is surely much to be done in the next decades. At present, we are witnessing many remarkable efforts to monitor ...the epidemiology of the disease, to better understand the biology of the T. cruzi and its interaction with human beings as well as the pathogenesis and pathophysiology of the complications in the chronic phase, and deal more appropriately and effectively with late cardiac and digestive manifestations. Although the vector and transfusion-derived transmission of the disease has been controlled in many countries, there remains a pressing need for sustained surveillance of the measures that led to this achievement. It is also necessary to adopt initiatives that enable appropriate management of social and medical conditions resulting from the migration of infected individuals to countries where the disease formerly did not exist. It's also necessary to standardize the most reliable methods of detection of infection with T. cruzi, not only for diagnosis purposes, but more crucially, as a cure criterion. The etiological treatment of millions of patients in the chronic stage of the disease is also to be unraveled. A renewed interest in this area is observed, including prospects of studies focusing on the association of drugs with benznidazole. We also wait for full evidence of the actual effectiveness of the etiological treatment to impact favorably on the natural history of the disease in its chronic phase. Eventually, cardiologists are primarily responsible for improving the clinical management of their patients with Chagas' disease, judiciously prescribing drugs and interventions that respect, as much as possible, the peculiar pathophysiology of the disease, wasting no plausible therapeutic opportunities.
Aims
Acute pulmonary oedema (APE) is the second, after acutely decompensated chronic heart failure (ADHF), most frequent form of acute heart failure (AHF). This subanalysis examines the clinical ...profile, prognostic factors, and management of APE patients (n = 1820, 36.7%) included in the Acute Heart Failure Global Survey of Standard Treatment (ALARM‐HF).
Methods and results
ALARM‐HF included a total of 4953 patients hospitalized for AHF in Europe, Latin America, and Australia. The final diagnosis was made at discharge, and patients were classified according to European Society of Cardiology guidelines. Patients with APE had higher in‐hospital mortality (7.4 vs. 6.0%, P = 0.057) compared with ADHF patients (n = 1911, 38.5%), and APE patients exhibited higher systolic blood pressures (P < 0.001) at admission and higher left ventricular ejection fraction (LVEF, P < 0.01) than those with ADHF. These patients also had a higher prevalence of diabetes (P < 0.01), arterial hypertension (P < 0.001), peripheral vascular disease (P < 0.001), and chronic renal disease (P < 0.05). They were also more likely to receive intravenous (i.v.) diuretics (P < 0.001), i.v. nitrates (P < 0.01), dopamine (P < 0.05), and non‐invasive ventilation (P < 0.001). Low systolic blood pressure (P < 0.001), low LVEF (<0.05), serum creatinine ≥1.4 mg/dL (P < 0.001), history of cardiomyopathy (P < 0.05), and previous cardiovascular event (P < 0.001) were independently associated with increased in‐hospital mortality in the APE population.
Conclusion
APE differs in clinical profile, in‐hospital management, and mortality compared with ADHF. Admission characteristics (systolic blood pressure and LVEF), renal function, and history may identify high‐risk APE patients.
Acute heart failure (AHF) with preserved left ventricular ejection fraction (PLVEF) represents a significant part of AHF syndromes featuring particular characteristics. We sought to determine the ...clinical profile and predictors of in-hospital mortality in patients with AHF and PLVEF in the Acute Heart Failure Global Survey of Standard Treatment (ALARM-HF). This survey is an international observational study of 4,953 patients admitted for AHF in 9 countries (6 European countries, Mexico, and Australia) from October 2006 to March 2007. Patients with PLVEF were defined by an LVEF ≥45%. Of the total cohort, 25% of patients had PLVEF. In-hospital mortality was significantly lower in this subgroup (7% vs 11% in patients with decreased LVEF, p = 0.013). Candidate variables included demographics, baseline clinical findings, and treatment. Multivariate logistic regression analysis showed that the variables independently associated with in-hospital mortality included systolic blood pressure at admission (p <0.001), serum sodium (p = 0.041), positive troponin result (p = 0.023), serum creatinine >2 mg/dl (p = 0.042), history of peripheral vascular disease and anemia (p = 0.004 and p = 0.015, respectively), secondary (hospitalization for other reason) versus primary AHF diagnosis (p = 0.043), and previous treatment with diuretics (p = 0.023) and angiotensin-converting enzyme inhibitors (p = 0.021). In conclusion, patients with AHF and PLVEF have lower in-hospital mortality than those with decreased LVEF. Low systolic blood pressure, low serum sodium, renal dysfunction, positive markers of myocardial injury, presence of co-morbidities such as peripheral vascular disease and anemia, secondary versus primary AHF diagnosis, and absence of treatment with diuretics and angiotensin-converting enzyme inhibitors at admission may identify high-risk patients with AHF and PLVEF.
Heart failure due to Chagas cardiomyopathy (HFCC) differs from failure with other etiologies because of the occurrence of intense inflammatory infiltrate and right ventricle compromise. This article ...investigates correlations of B‐type natriuretic peptide (BNP) levels with parameters of severity in HFCC. Twenty‐eight patients and 8 normal controls underwent heart catheterization and clinical and laboratory analyses. BNP levels were higher in patients with HFCC (P<.0001) and correlated with New York Heart Association (NYHA) class; right atrial pressure; wedge pressure; cardiac output; levels of serum sodium, hemoglobin, urea, and tumor necrosis factor‐α; and ejection fraction. Interferon‐γ and transforming growth factor‐β did not correlate with BNP level. The authors conclude that BNP levels are elevated in patients experiencing HFCC, irrespective of NYHA class, and that the occurrence of HFCC correlates with severity of disease.
Abstract Background Anemia is a common finding in heart failure (HF) patients and has been associated with increased morbidity and mortality. It is generally denominated as anemia of chronic disease ...(ACD), but the association with true ferropenic anemia is common. Many studies have investigated the effects of treating anemia in HF patients with either erythropoietin alone or combination of erythropoietin and intravenous iron. However, the effect of iron supplementation alone in HF patients with ACD, ferropenic anemia, or both is unknown. Methods and Results IRON-HF study is a multicenter, investigator initiated, randomized, double-blind, placebo controlled trial that will enroll anemic HF patients with relatively preserved renal function, low transferrin saturation, low iron levels, and low to moderately elevated ferritin levels. Interventions are iron sucrose intravenously 200 mg once per week for 5 weeks, ferrous sulfate 200 mg by mouth 3 times per day for 8 weeks, or placebo. The primary objective is to assess the impact of iron supplementation (intravenously or by mouth) compared with placebo in HF patients with anemia from deficient iron availability. The primary end point is variation of peak oxygen consumption assessed by ergospirometry over 3-month follow-up. Secondary end points include functional class, brain natriuretic peptide levels, quality of life scores, left ventricular ejection fraction, adverse events, HF hospitalization, and death. Conclusions The results of IRON-HF should help to clarify the potential clinical impact of mild to moderate anemia correction in HF patients.
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