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The short-term mortality and rehospitalization rates after admission for acute heart failure (AHF) remain high, despite the high level of adherence to contemporary practice guidelines. Observational data from non-randomized studies in AHF strongly support the in-hospital administration of oral evidence-based modifying chronic heart failure (HF) medications (i.e., b-blockers, ACE inhibitors, mineralocorticoid receptor antagonists) to reduce morbidity and mortality. Interestingly, a well-designed prospective randomized multicenter study (PIONEER-HF) showed an improved clinical outcome and stress/injury biomarker profile after in-hospital administration of sacubitril/valsartan (sac/val) as compared to enalapril, in hemodynamically stable patients with AHF. However, sac/val implementation during hospitalization remains suboptimal due to the lack of an integrated individualized plan or well-defined appropriateness criteria for transition to oral therapies, an absence of specific guidelines regarding dose selection and the up-titration process, and uncertainty regarding patient eligibility. In the present expert consensus position paper, clinical practical recommendations are proposed, together with an action plan algorithm, to encourage and facilitate sac/val administration during hospitalization after an AHF episode with the aim of improving efficiencies of care and resource utilization.

Sacubitril/valsartan (S/V) has been shown to reduce the risk of cardiovascular death or heart failure hospitalization and improve symptoms in chronic heart failure with reduced ejection fraction compared with enalapril. After 7 years since the publication of the results of PARADIGM-HF, further insight has been gained with potential new indications. Two prospective randomized multicentre studies (PIONEER-HF and TRANSITION) in patients hospitalized for acute heart failure (AHF) have shown an improved clinical outcome and biomarker profile as compared with enalapril, and good tolerability, safety, and feasibility of initiating in-hospital administration of S/V. Furthermore, some studies have highlighted the favourable effects of S/V in attenuating adverse myocardial remodelling, supporting an early benefit after treatment. Observational data from non-randomized studies in AHF report that in-hospital and pre-discharge prescription of evidence-based drugs associated with better survival still remain suboptimal. Additionally, the COVID-19 pandemic has also negatively impacted on outpatient activities. Therefore, hospitalization, a real crossroad in the history of heart failure, must become a management and therapeutic opportunity for our patients. The objective of this ANMCO position paper is to encourage and facilitate early S/V administration in stabilized patients during hospitalization after an AHF episode, with the aim of improving care efficiency and clinical outcome.

Heart failure is a global public health challenge frequently presenting to the emergency department. After initial stabilization and management, one of the most important decisions is to determine which patients can be safely discharged and which require hospitalization. This is a complex decision that depends on numerous subjective factors, including both the severity of the patient's underlying condition and an estimate of the acuity of the presentation. An emergency department observation period may help select the correct option. Ideally, during an observation period, risk stratification should be carried out using parameters specifically designed for use in the emergency department. Unfortunately, there is little objective literature to guide this disposition decision. An objective and reliable definition of low-risk characteristics to identify early discharge candidates is needed. Benchmarking outcomes in patients discharged from the emergency department without hospitalization could aid this process. Biomarker determinations, although undoubtedly useful in establishing diagnosis and predicting longer-term prognosis, require prospective validation for emergency department disposition guidance. The challenge of identifying emergency department acute heart failure discharge candidates will only be overcome by future multidisciplinary research defining the current knowledge gaps and identifying potential solutions.

Acute heart failure (AHF) continues to have unacceptably high rates of mortality and morbidity. This position paper highlights the need for more intense interdisciplinary cooperation as one key element to overcome the challenges associated with fragmentation in the care of AHF patients. Additional aspects discussed include the importance of early diagnosis and treatment, options for initial treatment, referral bias as a potential cause for treatment preferences among experts, considerable uncertainty regarding patient disposition, the diagnosis of accompanying acute myocardial infarction, the need for antibiotic therapy, as well as assessment of intravascular volume status.

WOS: 000356799600005, PubMed ID: 25999021, Acute heart failure is a fatal syndrome. Emergency physicians, cardiologists, intensivists, nurses and other health care providers have to cooperate to provide optimal benefit. However, many treatment decisions are opinion-based and few are evidenced-based. This consensus paper provides guidance to practicing physicians and nurses to manage acute heart failure in the pre-hospital and hospital setting. Criteria of hospitalization and of discharge are described. Gaps in knowledge and perspectives in the management of acute heart failure are also detailed. This consensus paper on acute heart failure might help enable contiguous practice., Bayer; Cardiorentis; Medicine Company; Critical Diagnostics; Novartis; Steering Committee member of Cardiorentis; TUBITAK; Medicines Company; Cornerstone Therapeutics; Otsuka; Janssen; Apex Innovations; Inte-Section Medical; Trevena; Vifor Pharma Ltd; Amgen; Servier; Abbott Vascular; Coridea; Respicardia; Swiss National Science Foundation; Swiss Heart Foundation; Cardiovascular Research Foundation Basel; 8sense; Abbott; ALERE; Brahms; Nanosphere; Roche; Siemens; University Hospital Basel; Astra Zeneca; BG medicine; Biomerieux; Lilly; Orion; Resmed; Roche Diagnostics; Ratiopharm; BMS; Boehringer-Ingelheim; Pfizer; Daiichi Sankyo; Boehinger Ingelheim; AstraZeneca; European Union, A.M. received speaker's honoraria from Alere, Bayer, Edwards Life Sciences, The Medicines Company, Novartis, Orion, Servier, Thermofisher, Vifor Pharma and also received fee as member of advisory board and/or Steering Committee from Bayer, Cardiorentis, The Medicine Company, Critical Diagnostics.; M.B.Y. received speaker's honoraria and research fee from Novartis and received fee as Steering Committee member of Cardiorentis, and is supported by TUBITAK.; P.L. received speaker's honoraria from Beckman Coulter and Novartis and also received fees as a member of advisory board and/or Steering Committee from Bayer, Cardiorentis, The Medicines Company, Cornerstone Therapeutics, Novartis, Otsuka, Janssen, Apex Innovations, Inte-Section Medical, and Trevena.; P.P. received speaker's honoraria from Bayer, Novartis, Servier, Vifor Pharma, Amgen, Pfizer, Cardiorentis, Merck-Serono, Abbott Vascular and Respicardia and also received fee as member of advisory board and/or Steering Committee from Bayer, Cardiorentis, Novartis, Vifor Pharma Ltd, Amgen, Servier, Abbott Vascular, Coridea and Respicardia.; E.L. received consultancy fee from Novartis.; J.M. received honoraria for speaker or advisor from Abbott, Novartis, Orion, Otsuka, and Sanofi and fee as a member of Steering Committee from Corthera, Novartis, and Cardiorentis.; C.M. received research grants from the Swiss National Science Foundation and the Swiss Heart Foundation, the Cardiovascular Research Foundation Basel, 8sense, Abbott, ALERE, Brahms, Critical Diagnostics, Nanosphere, Roche, Siemens, and the University Hospital Basel, as well as speaker/consulting honoraria from Astra Zeneca, Abbott, ALERE, BG medicine, Biomerieux, Brahms, Cardiorentis, Lilly, Novartis, Pfizer, Roche, and Siemens.; V.P.H. received speaker's fee: Bayer, Orion, Resmed, Roche Diagnostics, Ratiopharm; consultation fees: Bayer, BMS, Boehringer-Ingelheim, Novartis, Pfizer, Roche Diagnostics, Servier. H.A.T. received speaker's honoraria from Daiichi Sankyo, Lilly, Medicines Company, AstraZeneca, Boehinger Ingelheim. Advisory board for Maquet Cardiovascular. Institutional research support by Maquet Cardiovascular, Teleflex, Terumo, Lilly, The Medicine Company.; G.F. has received research grants and/or has served as Committee member or Cochair of studies sponsored by Bayer, Novartis, Cardiorentis, Vifor Pharma, and the European Union.

Для большинства эпизодов острой сердечной недостаточности характерно усиление симптомов и признаков застойных явлений с объемной перенагрузкой. Цель терапии у таких пациентов заключается в облегчении застойных явлений путем достижения нормоволемии, главным образом с помощью терапии диуретиками. Однако должное применение диуретиков остается сложным, особенно при ухудшении функции почек, резистентности к диуретикам и нарушениях баланса электролитов. В этом официальном заявлении рассматривается применение диуретиков при застойной сердечной недостаточности. В работе рассматриваются распространенные проблемы, такие как: 1) оценка застойных явлений и клинической нормоволемии; 2) оценка ответа на диуретики/резистентности к диуретикам при лечении острой сердечной недостаточности; 3) подход к поэтапным фармакологическим стратегиям применения диуретиков на основе ответа на диуретики; 4) лечение распространенных нарушений баланса электролитов. Рекомендации приведены в соответствии с доступними руководствами, свидетельствами и экспертными выводами., Для більшості епізодів гострої серцевої недостатності характерне посилення симптомів та ознак застійних явищ з об’ємним перенавантаженням. Мета терапії в таких пацієнтів полягає в полегшенні застійних явищ шляхом досягнення нормоволемії, головним чином за допомогою терапії діуретиками. Проте належне застосування діуретиків залишається складним, особливо при погіршенні функції нирок, резистентності до діуретиків та порушеннях балансу електролітів. У цій офіційній заяві розглядається застосування діуретиків при застійній серцевій недостатності. У роботі розглядаються поширені проблеми, такі як: 1) оцінка застійних явищ та клінічної нормоволемії; 2) оцінка відповіді на діуретики/резистентності до діуретиків при лікуванні гострої серцевої недостатності; 3) підхід до поетапних фармакологічних стратегій застосування діуретиків на основі відповіді на діуретики; 4) лікування поширених порушень балансу електролітів. Рекомендації наведені відповідно до доступних настанов, свідчень та експертних висновків., The vast majority of acute heart failure episodes are characterized by increasing symptoms and signs of congestion with volume overload. The goal of therapy in those patients is the relief of congestion through achieving a state of euvolaemia, mainly through the use of diuretic therapy. The appropriate use of diuretics however remains challenging, especially when worsening renal function, diuretic resistance and electrolyte disturbances occur. This position paper focuses on the use of diuretics in heart failure with congestion. The manuscript addresses frequently encountered challenges, such as (i) evaluation of congestion and clinical euvolaemia, (ii) assessment of diuretic response/resistance in the treatment of acute heart failure, (iii) an approach towards stepped pharmacologic diuretic strategies, based upon diuretic response, and (iv) management of common electrolyte disturbances. Recommendations are made in line with available guidelines, evidence and expert opinion.

Introduction Left ventricular endomyocardial biopsy (LV-EMB) is the only procedure that allows a direct assessment of the left ventricular myocardium, thus enabling the diagnosis of myocarditis or other myocardial diseases. Aim To describe the characteristics of a population that underwent LV-EMB, as well as to address the periprocedural and technical aspects of the LV-EMB. Material and methods Since its initiation in our center in 2016, a total of 43 patients have undergone LV-EMB. In the manuscript, the indications for LV-EMB and the detailed technical aspects of its safe performance, including the equipment used, are described. A large part of the text is also devoted to the possible complications of LV-EMB. Results The results of the initial population that underwent LV-EMB in our center are presented. The patients who were qualified for LV-EMB were predominantly male (85.7%), with a mean age of 38.8 years. Of those, 38 (88.3%) had acute heart failure. The mean left ventricular ejection fraction was 19.6%. The primary indications for LV-EMB were unexplained heart failure with a left ventricular ejection fraction < 35% and (1) hemodynamic abnormalities or electrical instability of the heart and/or (2) recent worsening of heart failure (NYHA class II, III, or IV) with no response to standard therapy for 2 weeks. The mean fluoroscopy time was 5.4 min, and the mean radiation dose was 87 mGy. No periprocedural complications were found. Conclusions The results of the analysis indicate that LV-EMB can be performed safely by skilled physicians in an experienced center.

This study aimed to evaluate the impact of serial changes in nutritional status on 1-year events including all-cause mortality or rehospitalization owing to heart failure (HF) among hospitalized patients with acute decompensated HF (ADHF). The study subjects comprised 253 hospitalized patients with ADHF. The controlling nutritional status (CONUT) score was assessed both at hospital admission and discharge. The subjects were divided into three groups according to nutritional status using CONUT score: normal (0 and 1), mild risk (2–4), and moderate to severe risk defined as malnutrition (5–12). We observed nutritional status was improved or not. The incidence of malnutrition was 30.4% at hospital admission and 23.7% at discharge, respectively. Malnutrition was independently associated with 1-year events among hospitalized patients with ADHF. Presence or absence of improvement in nutritional status was significantly associated with 1-year events (P < 0.05), that was independent of percentage change in plasma volume in multivariate Cox regression analyses. We determined a reference model, including gender and estimated glomerular filtration rate, using multivariate logistic regression analysis (P < 0.05). Adding the absence of improvement in nutritional status during hospitalization to the reference model significantly improved both NRI and IDI (0.563, P < 0.001 and 0.039, P = 0.001). Furthermore, malnutrition at hospital discharge significantly improved NRI (0.256, P = 0.036) In conclusion, serial changes in the nutritional status evaluated on the basis of multiple measurements may provide more useful information to predict 1-year events than single measurement at hospital admission or discharge in hospitalized patients with ADHF.

Aims The effect of early administration of intravenous (IV) furosemide in the emergency department (ED) on short-term outcomes of acute heart failure (AHF) patients remains controversial, with one recent Japanese study reporting a decrease of in-hospital mortality and one Korean study reporting a lack of clinical benefit. Both studies excluded patients receiving prehospital IV furosemide and only included patients requiring hospitalization. To assess the impact on short-term outcomes of early IV furosemide administration by emergency medical services (EMS) before patient arrival to the ED. Methods and results In a secondary analysis of the Epidemiology of Acute Heart Failure in Emergency Departments (EAHFE) registry of consecutive AHF patients admitted to Spanish EDs, patients treated with IV furosemide at the ED were classified according to whether they received IV furosemide from the EMS (FAST-FURO group) or not (CONTROL group). In-hospital all-cause mortality, 30-day all-cause mortality, and prolonged hospitalization (>10 days) were assessed. We included 12 595 patients (FAST-FURO = 683; CONTROL = 11 912): 968 died during index hospitalization [7.7%; FAST-FURO = 10.3% vs. CONTROL = 7.5%; odds ratio (OR) = 1.403, 95% confidence interval (95% CI) = 1.085–1.813; P = 0.009], 1269 died during the first 30 days (10.2%; FAST-FURO = 13.4% vs. CONTROL = 9.9%; OR = 1.403, 95% CI = 1.146–1.764; P = 0.004), and 2844 had prolonged hospitalization (22.8%; FAST-FURO = 25.8% vs. CONTROL = 22.6%; OR = 1.189, 95% CI = 0.995–1.419; P = 0.056). FAST-FURO group patients had more diabetes mellitus, ischaemic cardiomyopathy, peripheral artery disease, left ventricular systolic dysfunction, and severe decompensations, and had a better New York Heart Association class and had less atrial fibrillation. After adjusting for these significant differences, early IV furosemide resulted in no impact on short-term outcomes: OR = 1.080 (95% CI = 0.817–1.427) for in-hospital mortality, OR = 1.086 (95% CI = 0.845–1.396) for 30-day mortality, and OR = 1.095 (95% CI = 0.915–1.312) for prolonged hospitalization. Several sensitivity analyses, including analysis of 599 pairs of patients matched by propensity score, showed consistent findings. Conclusion Early IV furosemide during the prehospital phase was administered to the sickest patients, was not associated with changes in short-term mortality or length of hospitalization after adjustment for several confounders.

Background Intrarenal venous flow (IRVF) measured by Doppler ultrasound has gained interest as a potential surrogate marker of renal congestion and adverse outcomes in heart failure. In this work, we aimed to determine if antigen carbohydrate 125 (CA125) and plasma amino-terminal pro-B-type natriuretic peptide (NT-proBNP) are associated with congestive IRVF patterns (i.e., biphasic and monophasic) in acute heart failure (AHF). Methods and results We prospectively enrolled a consecutive cohort of 70 patients hospitalized for AHF. Renal Doppler ultrasound was assessed within the first 24-h of hospital admission. The mean age of the sample was 73.5 ± 12.3 years; 47.1% were female, and 42.9% exhibited heart failure with preserved ejection fraction. The median (interquartile range) for NT-proBNP and CA125 were 6149 (3604–12 330) pg/mL and 64 (37–122) U/mL, respectively. The diagnostic performance of both exposures for identifying congestive IRVF patterns was tested using the receiving operating curve (ROC). The cut-off for CA125 of 63.5 U/mL showed a sensibility and specificity of 67% and 74% and an area under the ROC curve of 0.71. After multivariate adjustment, CA125 remained non-linearly and positively associated with congestive IRVF (P-value = 0.008) and emerged as the most important covariate explaining the variability of the model (R2: 47.5%). Under the same multivariate setting, NT-proBNP did not show to be associated with congestive IRVF patterns (P-value = 0.847). Conclusions CA125 and not NT-proBNP is a useful marker for identifying patients with AHF and congestive IRVF patterns.

Background Patients admitted to hospital with heart failure will have had a chest X-ray (CXR), but little is known about their prognostic significance. We aimed to report the prevalence and prognostic value of the initial chest radiograph findings in patients admitted to hospital with heart failure (acute heart failure, AHF). Methods The erect CXRs of all patients admitted with AHF between October 2012 and November 2016 were reviewed for pulmonary venous congestion, Kerley B lines, pleural effusions and alveolar oedema. Film projection (whether anterior–posterior [AP] or posterior–anterior [PA]) and cardiothoracic ratio (CTR) were also recorded. Trial registration: ISRCTN96643197 Results Of 1145 patients enrolled, 975 [median (interquartile range) age 77 (68–83) years, 61% with moderate, or worse, left ventricular systolic dysfunction, and median NT-proBNP 5047 (2337–10,945) ng/l] had an adequate initial radiograph, of which 691 (71%) were AP. The median CTR was 0.57 (IQR 0.53–0.61) in PA films and 0.60 (0.55–0.64) in AP films. Pulmonary venous congestion was present in 756 (78%) of films, Kerley B lines in 688 (71%), pleural effusions in 649 (67%) and alveolar oedema in 622 (64%). A CXR score was constructed using the above features. Increasing score was associated with increasing age, urea, NT-proBNP, and decreasing systolic blood pressure, haemoglobin and albumin; and with all-cause mortality on multivariable analysis (hazard ratio 1.10, 95% confidence intervals 1.07–1.13, p Conclusions Radiographic evidence of congestion on a CXR is very common in patients with AHF and is associated with other clinical measures of worse prognosis. Graphic abstract

Background: Our purpose was to describe the care pathway of patients hospitalized for acute heart failure (AHF) and investigate whether a management involving a cardiology department had an impact on in-hospital mortality. Methods: Between June 2014 and October 2018, we included patients hospitalized for AHF in 24 French hospitals. Characteristics of the episode, patient’s care pathway and outcomes were recorded on a specific assessment tool. The primary outcome was the association between patient care pathway and in-hospital mortality. The independent association between admission to a cardiology ward and in-hospital mortality was assessed through a multivariate regression model and propensity score matching. Results: A total of 3677 patients, mean age of 78, were included. The in-hospital mortality rate was 8% (n = 287) and was associated on multivariate regression with advanced age, presence of sepsis, of cardiogenic shock, high New York Heart Association (NYHA) score and increased plasma creatinine level on admission. High blood pressure and admission to a cardiology department appeared as protective factors. After propensity score matching, hospitalization in a cardiology department remained a protective factor of in-hospital mortality (OR = 0.61 [0.44–0.84], p = 0.002). Conclusion: A hospital course of care involving a cardiology department was associated with an increase in hospital survival in AHF patients. These finding may highlight the importance of collaboration between cardiologists and other in-hospitals specialties, such as emergency physicians, in order to find the best in-hospital pathway for patients with AHF.Clinical Trial NCT03903198. Keywords: Acute heart failure, Acute cardiac care, Outcome

Takotsubo syndrome (TTS) is a poorly recognized heart disease that was initially regarded as a benign condition. Recently, it has been shown that TTS may be associated with severe clinical complications including death and that its prevalence is probably underestimated. Since current guidelines on TTS are lacking, it appears timely and important to provide an expert consensus statement on TTS. The clinical expert consensus document part I summarizes the current state of knowledge on clinical presentation and characteristics of TTS and agrees on controversies surrounding TTS such as nomenclature, different TTS types, role of coronary artery disease, and etiology. This consensus also proposes new diagnostic criteria based on current knowledge to improve diagnostic accuracy. ispartof: EUROPEAN HEART JOURNAL vol:39 issue:22 pages:2032-2046 ispartof: location:England status: published

Background: The assessment of acute heart failure (AHF) in patients with acute coronary syndrome (ACS) is challenging. This study tested whether measuring plasma adrenomedullin in patients admitted for ACS provides valuable information regarding the presence of AHF at admission or its occurrence during hospitalization. Methods and results: The study population consisted of 927 prospectively enrolled patients with ACS. Blood samples for the measurement of plasma bio-adrenomedullin (bio-ADM) were collected at admission. Patients with alveolar pulmonary edema and interstitial pulmonary edema on chest radiography at admission had stepwise higher plasma concentrations of bio-ADM compared to patients with no or mild pulmonary congestion: 54.3 ± 10.6 vs. 27.6 ± 2.1 vs. 22.5 ± 0.7 ng/L, overall P

Background Poor response to diuretics is associated with worse prognosis in patients with acute heart failure (AHF). We hypothesized that treatment with tolvaptan improves diuretic response in patients with AHF. Methods We performed a secondary analysis of the AQUAMARINE open-label randomized study in which a total of 217 AHF patients with renal impairment (eGFR

Aims: Mortality in cardiogenic shock patients remains high. Short-term mechanical circulatory support with Impella can be used to support the circulation in these patients, but data from randomised controlled studies and ‘real-world’ data are sparse. The aim is to describe real-life data on outcomes and complications of our 12 years of clinical experience with Impella in patients with cardiogenic shock after acute myocardial infarction and to identify predictors of 6-month mortality. Methods: We describe a single-centre registry from October 2004 to December 2016 including all patients treated with Impella for cardiogenic shock after acute myocardial infarction. We report outcomes and complications and identify predictors of 6-month mortality. Results: Our overall clinical experience consists of 250 patients treated with Impella 2.5, Impella CP or Impella 5.0. A total of 172 patients received Impella therapy for cardiogenic shock, of which 112 patients had cardiogenic shock after acute myocardial infarction. The mean age was 60.1±10.6 years, mean arterial pressure was 67 (56–77) mmHg, lactate was 6.2 (3.6–9.7) mmol/L, 87.5% were mechanically ventilated and 59.6% had a cardiac arrest before Impella placement. Overall 30-day mortality was 56.2% and 6-month mortality was 60.7%. Complications consisted of device-related vascular complications (17.0%), non-device-related bleeding (12.5%), haemolysis (7.1%) and stroke (3.6%). In a multivariate analysis, pH before Impella placement is a predictor of 6-month mortality. Conclusions: Our registry shows that Impella treatment in cardiogenic shock after acute myocardial infarction is feasible, although mortality rates remain high and complications occur.

Background:\ud Heart failure is heterogeneous in aetiology, pathophysiology and presentation. Despite this diversity, clinical trials of patients hospitalized for HF deal with this problem as a single entity, which may be one reason for repeated failures. \ud \ud Methods: \ud First EuroHeart Failure Survey screened consecutive deaths and discharges of patients with suspected heart failure during 2000-2001. Patients were sorted into seven mutually exclusive hierarchical presentations: 1) with cardiac arrest/ ventricular arrhythmia; 2): with acute coronary syndrome; 3) with rapid atrial fibrillation; 4) with acute breathlessness; 5) with other symptoms/signs such as peripheral oedema ; 6) with stable symptoms and 7) others in whom the contribution of HF to admission was not clear. \ud \ud Results:\ud The 10,701 patients enrolled were classified into the above seven presentations as follows:- 260 (2%), 560 (5%), 799 (8%), 2,479 (24%), 1,040 (10%), 703 (7%), and 4,691 (45%) for which index-admission mortality was 26%, 20%, 10%, 8%, 6%, 6% and 4% respectively. Compared to those in group 7, the hazard ratios for death during the index admission were 4.9 (p=

Background Atrial fibrillation (AF) is the most common sustained arrhythmia in patients with acute heart failure (AHF). The presence of AF is associated with adverse prognosis in patients with chronic heart failure (CHF) but little is known about its impact in AHF. Methods Data were collected between April 2007 and March 2013 across 185 (> 95%) hospitals in England and Wales from patients with a primary death or a discharge diagnosis of AHF. We investigated the association between the presence of AF and all-cause mortality during the index hospital admission, at 30 days and 1 year post-discharge. Results Of 96,593 patients admitted with AHF, 44,642 (46%) were in sinus rhythm (SR) and 51,951 (54%) in AF. Patients with AF were older (mean age 79.8 (79.7–80) versus 74.7 (74.5–74.7) years; p

Acute heart failure is still characterized by poor prognosis with high mortality. Diagnosis is based on clinical symptoms and hemodynamic measurements. Early coronary revascularization in cardiogenic shock complicating myocardial infarction improves outcome. The further contemporary therapeutic options in the management of acute heart failure are limited to a merely symptomatic effect with relief of dyspnea, reduction of volume overload and improvement of hemodynamic parameters by vasodilators (in hypertension) or inotropic and vasopressor agents (in hypotension). However, so far no medical therapy has been shown to positively affect clinical outcomes of patients with acute heart failure. Early identification of impending circulatory collapse coupled with rapid implementation of mechanical circulatory support may contribute to mortality reduction as a combined concept of the management of acute heart failure.

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. Keywords: Heart rate, Acute heart failure, Sinus rhythm, Atrial fibrillation, Mortality

Introduction: Frailty is a complex condition that results from the loss of physiological reserve across multiple systems. Its presence should be considered in the aging heart failure population, since it is an important predictor of death and institutionalization in the elderly. Methods and results: In a prospective, observational and analytical single-center study of 100 elderly patients hospitalized for acute heart failure, we assessed the characteristics associated with an increased hospital and 1-year mortality. Frailty was evaluated with the Clinical Frailty Scale, and there was a significant association between its presence and 1-year mortality (RR = 2.03; 95% CI = 1.18–3.48; p = 0.014), although not with in-hospital mortality. After adjusting for probable confounders, it remained independently associated with 1-year mortality. Conclusion: Frailty can be assessed with a simple bed-side scale and provides significant prognostic information in acute heart failure patients. Keywords: Frailty, Heart failure, Acute heart failure, 1-year mortality, Elderly, CFS

To investigate the association between both neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) and 30-day mortality in patients hospitalized for an episode of acute decompensated heart failure (ADHF).439 patients admitted to emergency department (ED) for an episode of ADHF. Clinical history, demographic, clinical and laboratory data recorded at ED admission and then correlated with 30-day mortality.45/439 (10.3%) patients died within 30 days from ED admission. The median values of NLR (4.1 vs 11.7) and PLR (159.1 vs 285.9) were significantly lower in survivors than in patients who died. The area under the ROC curve of NLR was significantly higher than that of the neutrophil count (0.76 vs 0.59; p0.001), whilst the AUC of PLR was significantly better than that of the platelet count (0.71 vs 0.51; p0.001). In univariate analysis, both NLR and PLR were significantly associated with 30-day. In the fully-adjusted multivariate model, NLR (odds ratio, 3.63) and PLR (odds ratio, 3.22) remained independently associated with 30-day mortality after ED admission.Routine assessment of NLR and PLR at ED admission may be a valuable aid to complement other conventional measures for assessing the medium-short risk of ADHF patients.Svrha rada je bila da se ispitaju odnosi povezanosti između neutrofila prema limfocitima (NLR) i trombocita prema limfocitima (PLR) i 30-dnevna smrtnost kod pacijenata koji su hospitalizovani zbog akutnog dekompenzovanog srčanog oštećenja (ADHF).U odeljenje hitne medicine (ED) primljeno je 439 pacijenata sa ADHF. Istorija bolesti, demografski i laboratorijski podaci su praćeni prilikom prijema u ED i upoređivani su sa 30-dnevnom smrtnošću.U toku 30 dana od prijema u ED umrlo je 45/439 (10,33%) pacijenata. Srednje vrednosti NLR (4,11 vs, 11,7) i PLR (159,1 vs 285,9) bile su značajno niže kod preživelih u odnosu na preminule pacijente. Površina ispod ROC krive u NLR bila je značajno viša nego kod iste u broju neutrofila (0,76 vs 0,59; p0,001), dok je AUC u slučaju PLR bio značajno bolji nego u odnosu na broj trombocita (0,71 vs 0,51; p0,001). Univarijantne analize u slučaju oba NLR iPLR bile su značajno povezane za 30-danom. U potpuno podešenom multivarijantnom modelu, NLR (Odds odnos, 2,63) i PLR (Odds odnos, 3,22) bili su nezavisno povezani sa 30-dnevnom smrtnošću posle prijema u ED.Rutinsko praćenje NLR i PLR pri ED prijemu može da bude veoma značajna pomoć uz druga konvencionalna merenja i praćenja radi umanjenja rizika kod ADHF pacijenata.

The clinical expert consensus statement on takotsubo syndrome (TTS) part II focuses on the diagnostic workup, outcome, and management. The recommendations are based on interpretation of the limited clinical trial data currently available and experience of international TTS experts. It summarizes the diagnostic approach, which may facilitate correct and timely diagnosis. Furthermore, the document covers areas where controversies still exist in risk stratification and management of TTS. Based on available data the document provides recommendations on optimal care of such patients for practising physicians. ispartof: EUROPEAN HEART JOURNAL vol:39 issue:22 pages:2047-2062 ispartof: location:England status: published

In this study, we examined the possible immune-mediated mechanisms in cardiorenal syndrome (CRS) type 1 pathogenesis. We enrolled 40 patients with acute heart failure (AHF), 11 patients with CRS type 1 and 15 controls. Plasma from the different groups was incubated with monocytes; subsequently, cell apoptosis was evaluated by DNA fragmentation, caspase activity and cytofluorometric assay. Cytokine quantification in plasma and supernatant was performed by ELISA. Monocytes treated with CRS type 1 plasma showed significantly higher apoptosis compared with those treated with AHF and the controls (p < 0.05). Caspase-3 (CRS type 1: 2.20 ng/ml, IQR 2.06-2.33; AHF: 1.48 ng/ml, IQR 1.31-1.56; controls: 0.71 ng/ml, IQR 0.67-0.81) and caspase-8 levels (CRS type 1: 1.49 ng/ml, IQR 1.42-1.57; AHF: 0.94 ng/ml, IQR 0.84-0.98; controls: 0.56 ng/ml, IQR 0.51-0.58) in cells incubated with plasma from these patients demonstrated a significantly higher concentration. We observed a strong upregulation of plasma IL-6 and IL-18 in CRS type 1 compared with AHF and the controls (p < 0.05). Interestingly, we observed a similar concentration of TNF-α in CRS type 1 and AHF. In CRS type 1 patients, IL-6 (52.13 ng/ml, IQR 47.29-66.83) and IL-18 levels (197.75 ng/ml, IQR 120.80-265.49) in supernatant were significantly higher than in AHF patients (IL-6: 28.79 ng/ml, IQR 19.90-36.10; IL-18: 21.98 ng/ml, IQR 15.98-29.85) and controls (IL-6: 5.02 ng/ml, IQR 4.56-6.44; IL-18: 7.91 ng/ml, IQR 5.57-10.62). These findings suggest the presence of a defective regulation of monocyte apoptosis in CRS type 1 patients and the involvement of an immune-mediated mechanism in the pathophysiology of this syndrome.

Background Atrial fibrillation (AFib) is a common comorbidity in HF and affects patients’ outcome. We sought to assess the effects of serelaxin in patients with and without AFib. Methods In a post hoc analysis of the RELAX-AHF trial, we compared the effects of serelaxin on efficacy end points, safety end points and biomarkers in 1161 patients with and without AFib on admission electrocardiogram. Results AFib was present in 41.3% of patients. Serelaxin had a similar effect in patients with and without AFib, including dyspnea relief by visual analog scale through day 5 [mean change in area under the curve, 541.11 (33.79, 1048.44), p = 0.0366 in AFib versus 361.80 (−63.30, 786.90), p = 0.0953 in non-AFib, interaction p = 0.5954] and all-cause death through day 180 [HR = 0.42 (0.23, 0.77), p = 0.0051 in AFib versus 0.90 (0.53, 1.52), p = 0.6888 in non-AFib, interaction p = 0.0643]. Serelaxin was similarly safe in the two groups and induced similar reductions in biomarkers of cardiac, renal and hepatic damage. Stroke occurred more frequently in AFib patients (2.8 vs. 0.8%, p = 0.0116) and there was a trend for lower stroke incidence in the serelaxin arm in AFib patients (odds ratios, 0.31, p = 0.0759 versus 3.88, p = 0.2255 in non-AFib, interaction p = 0.0518). Conclusions Serelaxin was similarly safe and efficacious in improving short- and long-term outcomes and inducing organ protection in acute HF patients with and without AFib.

Objective To define the short-and mid-term outcomes of patients discharged after an episode of acute-decompensated heart failure (ADHF) and evaluate the differences between patients discharged directly from the emergency department (ED) and those discharged after hospitalization. Methods We performed a prospective, multicenter, cohort-designed study, including consecutive patients diagnosed with ADHF in 27 Spanish EDs. Thirty-four variables on epidemiology, comorbidity, baseline status, vital signs, signs of congestion, laboratory tests, and treatment were collected in every patient. The primary outcome was a combined endpoint of ED revisit (without hospitalization) or hospitalization due to ADHF, or all-cause death. Secondary outcomes were each of these three events individually. Outcomes were obtained by survival analysis at different timepoints in the entire cohort, and crude and adjusted comparisons were carried out between patients discharged directly from the ED and after hospitalization. Results Of the 3233 patients diagnosed with ADHF during a 2-month period, we analyzed 2986 patients discharged alive: 787 (26.4%) discharged from the ED and 2199 (73.6%) after hospitalization. The cumulative percentages of events for the whole cohort (at 7/30/180 days) for the combined endpoint were 7.8/24.7/57.8; for ED revisit 2.5/9.4/25.5; for hospitalization 4.6/15.3/40.7; and for death 0.9/4.3/16.8. After adjustment for patient profile and center, significant increases were found in the hazard ratios for ED-compared to hospital-discharged patients in the combined endpoint, ED revisit and hospitalization, being higher at short-term [at 7 days, 2.373 (1.678-3.355), 2.069 (1.188-3.602), and 3.071 (1.915-4.922), respectively] than at mid-term [at 180 days, 1.368 (1.160-1.614), 1.642 (1.265-2.132), and 1.302 (1.044-1.623), respectively]. No significant differences were found in death. Conclusions Patients with ADHF discharged from the ED have worse outcomes, especially at short term, than those discharged after hospitalization. The definition and implementation of effective strategies to improve patient selection for direct ED discharge are needed.

BackgroundSerelaxin showed beneficial effects on clinical outcome and trajectories of renal markers in patients with acute heart failure. We aimed to study the interaction between renal function and the treatment effect of serelaxin.MethodsIn the current post hoc analysis of the RELAX-AHF trial, we included all patients with available estimated glomerular filtration rate (eGFR) at baseline (n=1132). Renal impairment was defined as an eGFR

Anticancer treatment with the human epidermal growth factor receptor (HER) 2 inhibitors can lead to significant myocardial dysfunction. The primary aim of the study was to estimate the possible association between gene expression in the ErbB signaling pathway and selected clinical event data in patients with acute heart failure. Twenty-four patients (19 males), aged 68.6 ± 12.3 years, were diagnosed and treated due to acute heart failure. The globaltest method was used for the correlation between blood nuclear cells’ gene expression in the ErbB pathway (KEGG pathway id 04012) and important clinical data. Decreased expression of ErbB2/HER2 was found to be associated with the release of troponin and the need for inotropic support, whereas decreased neuregulin 1 (NRG1) expression was found to be associated with a decrease of ejection fraction below 40 % (globaltest p-value < 0.05). In summary, the ErbB signaling pathway and, especially, HER2/ErbB2 receptor expression are significantly associated with some of the recognized, clinically significant parameters of patients with acute heart failure. Evaluation of the molecular function of the HER2 receptor may be essential for the prognosis and targeted therapy of heart diseases.

BackgroundThere’s scarce evidence about cardiovascular events (CV) in patients with hospitalization for acute heart failure (HF) and no indication for immediate device implant. ObjectiveThe CARdiac RhYthm monitorING after acute decompensatiON for Heart Failure study was designed to assess the incidence of prespecified clinical and arrhythmic events in this patient population. MethodsIn this pilot study, 18 patients (12 (67%) male; age 72±10; 16 (89%) NYHA II-III), who were hospitalized for HF with low left ventricular ejection fraction (LVEF) (

Introduction: Inflammatory markers have been identified as potential indicators of future adverse outcome after acute cardiac events. Aim: This study aimed to analyze baseline inflammatory cytokines levels in patients with acute heart failure (AHF) and/or acute coronary syndrome (ACS) according to survival. The main objective was to identify risk factors for mortality after an episode of AHF and/or ACS. Methods: In this prospective longitudinal study 75 patients with the diagnosis of AHF and/or ACS were enrolled. Baseline laboratory and clinical data were retrieved. Serum and urine interleukin-6 (IL-6) and interleukin-18 (IL-18) levels, plasma B-type natriuretic peptide (BNP) and serum cystatin C values were determined. The primary outcome was in-hospital mortality while secondary outcome was six-month mortality. Results: Median serum and urine IL-6 levels, serum and urine IL-18 levels, as well as median concentrations of plasma BNP and serum cystatin C, were significantly increased in deceased in comparison to surviving AHF and/or ACS patients. Univariate Cox regression analysis identified serum IL-6, serum IL-18, urine IL-6, urine IL-18 as well as serum cystatin C and Acute Physiology and Chronic Health Evaluation (APACHE) II score as risk factors for mortality after an episode of AHF and/or ACS. Multivariate Cox regression analysis revealed that only serum IL-6 is the independent risk factor for mortality after acute cardiac events (HR 61.7, 95% CI 2.1-1851.0; p=0.018). Conclusion: Present study demonstrated the strong prognostic value of serum IL-6 in predicting mortality of patients with AHF and/or ACS.