The Analysis of Arterial Stiffness in Heart Failure Patients: The Prognostic Role of Pulse Wave Velocity, Augmentation Index and Stiffness Index.

Background: The role of arterial stiffness in the pathogenesis and clinical outcome of heart failure (HF) patients has to be clarified. The aim of this study was to evaluate the prognostic role of arterial stiffness in HF patients discharged after acute episode of decompensation by evaluating cut-off values for clinical assessment. Methods: Patients admitted for decompensated heart failure (ADHF) underwent pre-discharge evaluation. Arterial stiffness was measured by aortic pulse wave velocity (aPWV), augmentation index (AIx75) and stiffness index (ß0). Patients were also evaluated after discharge for a variable follow-up time. Results: We observed 199 patients (male 61.3%, age 76.2 ± 10.7 years) after discharge for a median of 437 days (IQR 247-903), 69 (34.7%) patients suffered HF with preserved ejection fraction (HFpEF), 45 (22.6%) patients experienced HF with mid-range ejection fraction (HFmEF) and 85 (42.7%) reported an HF with reduced ejection fraction (HFrEF). After the adjustment for principal confounders, aPWV, AIx75 and ß0 were inversely correlated with free-event survival (p = 0.006, p < 0.001, p = 0.001): only ß0 was inversely correlated with overall survival (p = 0.03). Analysing the threshold, overall survival was inversely correlated with ß0 ≥3 (HR 2.1, p = 0.04) and free-event survival was inversely correlated with aPWV ≥10 m/s (HR 1.7, p = 0.03), AIx75 ≥ 25 (HR 2.4, p < 0.001), and ß0 ≥ 3 (HR 2.0, p = 0.009). Dividing HF patients for LV ejection fraction, ß0 and AIx75 appeared to be accurate prognostic predictors among the three different classes according to free-event survival. Conclusions: The non-invasive measurements of arterial stiffness proved to be strong prognostic parameters in HF patients discharged after an acute HF decompensation.

Correction: Feola, M., et al. Six-Month Predictive Value of Diuretic Resistance Formulas in Discharged Heart Failure Patients after an Acute Decompensation. J. Clin. Med. 2020, 9, 2932.

There was an error in the original article [...].

Six-Month Predictive Value of Diuretic Resistance Formulas in Discharged Heart Failure Patients after an Acute Decompensation.

BACKGROUND: The diuretic response has been shown to be a robust independent marker of cardiovascular outcomes in acute heart failure patients. The objectives of this clinical research are to analyze two different formulas (diuretic response (DR) or response to diuretic (R-to-D)) in predicting 6-month clinical outcomes. METHODS: Consecutive patients discharged alive after an acute decompensated heart failure (ADHF) were enrolled. All patients underwent N-terminal-pro hormone BNP (NT-proBNP) and an echocardiogram together with DR and R-to-D calculation during diuretic administration. Death by any cause, cardiac transplantation and worsening heart failure (HF) requiring readmission to hospital were considered cardiovascular events. RESULTS: 263 patients (62% male, age 78 years) were analyzed at 6-month follow-up. During the follow-up 58 (22.05%) events were scheduled. Patients who experienced CV-event had a worse renal function (p = 0.001), a higher NT-proBNP (p = 0.001), a lower left ventricular ejection fraction (p = 0.01), DR (p = 0.02) and R-to-D (p = 0.03). Spearman rho's correlation coefficient showed a strong direct correlation between DR and R to D in all patients (r = 0.93; p < 0.001) and both in heart failure with reduced ejection fraction (HFrEF) (r = 0.94; p < 0.001) and HF preserved ejection fraction (HFpEF) (r = 0.91; p < 0.001). At multivariate analysis, a value of R-to-D <1.69 kg/40 mg, but only <0.67 kg/40 mg for DR were significantly related to poor 6-month outcome (p = 0.04 and p = 0.05, respectively). Receiver operating characteristic (ROC) curve analyses demonstrated that DR and R-to-D are equivalent in predicting prognosis (area under curve (AUC): 0.39 and 0.40, respectively). Only R-to-D was inversely related to in-hospital stay (r = -0.23; p = 0.01). CONCLUSION: Adding diuresis to DR seemed to provide a better risk assessment in alive HF patients discharged after an acute decompensation.

The Analysis of Arterial Stiffness in Heart Failure Patients in Comparison with Healthy Subjects and Patients with Cardiovascular Risk Factors.

The arterial stiffness in the pathogenesis and clinical outcome in heart failure (HF) patients still needs to be clarified. An increased pulse wave velocity (PWV) in HF patients in comparison with healthy subjects and cardiovascular risk factors (CVRF) patients has been demonstrated. The aim of this study was to evaluate the arterial stiffness in HF patients in comparison to control populations. METHODS: Consecutive patients admitted for decompensated heart failure underwent echocardiogram and evaluation of arterial stiffness by measuring the PWV and the augmentation index (AIx75). The arterial stiffness was also calculated in a control group formed by healthy volunteers and in CVRF subjects. RESULTS: Fifty-nine HF patients (62% males; age 75 years) with mean left ventricular ejection fraction (LVEF) 38% and N-terminal pro B-type natriuretic peptide (NT-proBNP) (8111 pg/mL) entered the study. The HF population were compared with 22 healthy controls (age 58 years) and 20 CVRF patients (age 72 years). The analysis of PWV demonstrated a velocity of 10.6 m/s (9-12.1 m/s), 11.7 m/second (10.4-12.8 m/s), and 10.1 m/second (8.6-10.8m/s) in controls, CVRF, and HF patients (p = 0.01). AIx75 was seen to be higher in the CVRF group vs. HF patients (34% vs. 22%, p = 0.001). In HF patients PWV was inversely correlated with the glomerular filtration rate (r = -0.40; p = 0.002) and directly with central systolic pressure (SP) (r = 0.29; p = 0.02), brachial SP (r = 0.33; p = 0.01) as well as AIx75 correlated with GFR (r = -033; p = 0.01). CONCLUSION: PWV proved to be different in HF patients in comparison with CVRF/healthy population. The strongest correlation was revealed between the values of PWV/AIx75 and renal function.

The Predictive Value of Plasma Brain Natriuretic Peptide and Galectin-3 in Elderly Patients Admitted for Heart Failure.

Galectin-3 is demonstrated to be a robust independent marker of cardiovascular mid-term (18-month) outcomes in heart failure (HF) patients. The aim of this study was to analyze the value of a pre-discharged determination of galectin-3 alone and with brain natriuretic peptide (BNP) in predicting mid-term outcomes in elderly patients (>70 years old) discharged after an acute decompensated HF (ADHF) episode. METHODS: all elderly (≥70 years old) HF subjects discharged alive after an ADHF were enrolled. All patients underwent a determination of BNP and galectin-3, a 6-min walking test (6MWT), and an echocardiogram within 48 h of hospital discharge. Cardiac death, cardiac transplantation, and worsening heart failure requiring readmission to hospital were considered cardiovascular events. RESULTS: 84 patients (63 males (75%), age 77.5 ± 5.9 years old) were analyzed (mean follow-up: 16.2 ± 12.3 months). During the follow-up, 45 events (53.6%) were scheduled (18 cardiac deaths, 27 re-hospitalizations for ADHF). HF patients who suffered an event demonstrated more impaired ventricular function (p = 0.04), higher value of BNP (p = 0.02), and Gal-3 at a pre-discharge evaluation (p = 0.05). By choosing adequate cut-off points (BNP ≥ 500 pg/mL and Gal-3 ≥ 17.6 ng/mL), the Kaplan⁻Meier curves depicted a powerful stratification using Galectin-3 > 17.6 ng/mL alone (log-rank 13.22; p = 0.0003), and by adding BNP + Gal-3, an even better result was obtained (log-rank 17.96; p < 0.00001). CONCLUSION: in an elderly population, by adding Gal-3 to BNP, a single pre-discharge strategy testing seemed to obtain a satisfactorily predictive value in alive HF patients discharged after an ADHF episode.

Role of Response-to-Diuretic in Predicting Prognosis in Discharged Heart Failure Patients After an Acute Decompensation.

BACKGROUND: The diuretic response has been shown to be a robust independent marker of cardiovascular outcomes in acute heart failure (ADHF) patients. The objectives of this clinical research, will aim are to: a) include diuresis in the formula for diuretic response (R-to-D); b) add to R-to-D the value of a pre-discharged determination of galectin-3 and BNP in predicting mid-term clinical outcome. METHODS: Consecutive patients discharged alive after an ADHF were enrolled. All patients underwent BNP and galectin-3, a 6 min walk test and an echocardiogram together with diuresis and body weight during diuretic administration. Death by any cause, cardiac transplantation and worsening HF requiring readmission to the hospital were considered cardiovascular events. RESULTS: 141 patients (98 males, age 73.8) were analysed (follow-up 17 months). During the follow-up 45 (31.9%) events were scheduled (19 cardiac deaths, 26 re-hospitalisation for HF). Patients who experienced CV-event had a worst renal function (p = 0.003), an higher BNP (p = 0.006) and galectin-3 (p = 0.008). At multivariate analysis, only R-to-D, galectin-3 and BNP showed a significant correlation with worst clinical prognosis (respectively p = 0.043; OR 6.01; p = 0.01; OR 8.9; p = 0.02 OR 10.38), independently of age and renal function. Kaplan-Meier curves depicted a powerful stratification using an R-to-D <1.2 kg/40 mg furosemide (log rank 10.96; p = 0.0009). Adding R-to-D<1.2 mg/40 mg furosemide to galectin-3>17.6 pg/mL and BNP>500 pg/mL the predictive value improved (log rank 23.59; p = 0.0001). CONCLUSION: Adding R-to-D to Gal-3 and BNP, a single pre-discharge strategy testing seemed to obtain a satisfactorily predictive value in alive HF patients discharged after an ADHF episode.

Usefulness of a Telemedicine Program in Refractory Older Congestive Heart Failure Patients.

BACKGROUND: Home telemonitoring is a modern and effective disease management model that is able to improve medical care, quality of life, and prognosis of chronically ill patients, and to reduce expenditure. The objective of this study was to evaluate the efficacy, costs, and patients' and caregivers' acceptance of our model of telemedicine in a high-risk chronic heart failure (CHF) older population. METHODS: Patients with high risk/refractory CHF were included. In the case of alarm parameters' modifications, a cardiologist decided to inform the emergency department (ED), the patient's General Practioner, or to programme a clinical ambulatory control. RESULTS: Forty-eight CHF patients (28 males; 58.3%), with a mean age of 80.4 ± 7.7 years, entered this clinical experience. During the 20-months follow-up, four patients dropped out from counselling (8.3%), ambulatory clinical control within-24 h was planned in 18% of patients, 11% of patients were admitted to an ED, and 18% were hospitalized. Thirteen patients (29.5%) died a cardiac death; hospital admissions for heart failure decreased during the year after the enrolment when compared to the year before (from 35 to 12 acute HF hospitalizations/year; p = 0.0001). Moreover, in these HF patients followed, accesses to an ED for an acute episode of HF decompensation reduced from 21/year to five/year (p = 0.0001). The economic expenditure, calculated for the year before and after the enrolment, reduced from 116.856 Euros to 40.065 Euros/year. CONCLUSIONS: A telemedicine surveillance in high-risk older CHF patients determines a continuous and active contact between patients/caregivers, the Heart Failure Clinic, and family physicians, permitting an early evaluation of signs and symptoms of acute decompensation.

Prognostic Value of Different Allelic Polymorphism of Aldosterone Synthase Receptor in a Congestive Heart Failure European Continental Ancestry Population.

Aldosterone synthase (CYP11B2) is as an 9-exon gene on chromosome 8q22 and exists as a common single nucleotide polymorphism C-T transition for position -344. The aim of this study was to assess the -344T/C polymorphism of the aldosterone synthase promoter in a European continental ancestry congestive heart failure (CHF) population. METHODS: Patients discharged after an acute decompensation were enrolled and underwent echocardiography, determination of BNP, evaluation of non-invasive cardiac outputs and determination of -344 T/C SNP in the aldosterone synthase gene. RESULTS: 175 patients (137 male; age 69.9 ± 10.2 years) were enrolled. The genotype distribution of -344 T/C SNP demonstrated a TT genotype in 61 patients (34.9%), CT in 80 (45.7%) and finally CC in 34 (19.4%) CHF patients. According to presence of C allele, CHF patients were divided into C group (-CT/CC genotype, 114 subjects) and T Group (-TT genotype, 61 subjects). The two groups did not differ in term of age, non-invasive cardiac output at rest, creatinine level or end-systolic or diastolic left ventricle diameter, LVEF and BNP. In group C patients in comparison than in group T a higher degree of disability (Barthel Index p = 0.004), NYHA class (p = 0.02) and a lower cardiac index (p = 0.01) emerged. Moreover, the two groups showed a similar clinical outcome (death for any cause/hospital readmission for CHF) at 48 month follow-up (p = 0.16; log-rank 1.99). CONCLUSIONS: In European continental ancestry patients the C allele (CC or CT) at -344T/C SNP in the aldosterone synthase gene does not significantly influence clinical prognosis of CHF.

Role of galectin-3 and plasma B type-natriuretic peptide in predicting prognosis in discharged chronic heart failure patients.

Galectin-3 demonstrated to be a robust independent marker of cardiovascular mid-term (18-month) outcome in heart failure (HF) patients. The objective of this study was to analyze the value of a predischarged determination of plasma galectin-3 alone and with plasma brain natriuretic peptide (BNP) in predicting mid-term outcome in frequent-flyers (FF) HF (≥2 hospitalization for HF/year)/dead patients discharged after an acute decompensated HF (ADHF) episode.All FF chronic HF subjects discharged alive after an ADHF were enrolled. All patients underwent a determination of BNP and galectin-3, a 6-minute walk test, and an echocardiogram within 48 hours upon hospital discharge. Death by any cause, cardiac transplantation, and worsening HF requiring readmission to hospital were considered cardiovascular events.Eighty-three patients (67 males, age 73.2 ±â€Š8.6 years old) were analyzed (mean follow-up 11.6 ±â€Š5.2 months; range 4-22 months). During the follow-up 38 events (45.7%) were scheduled: (13 cardiac deaths, 35 rehospitalizations for ADHF). According to medical history, in 33 patients (39.8%) a definition of FF HF patients was performed (range 2-4 hospitalization/year). HF patients who suffered an event (FF or death) demonstrated more impaired ventricular function (P = 0.037), higher plasma BNP (P = 0.005), and Gal-3 at predischarge evaluation (P = 0.027). Choosing adequate cut-off points (BNP ≥ 500 pg/mL and Gal-3 ≥ 17.6 ng/mL), the Kaplan-Meier curves depicted the powerful stratification using BNP + Gal-3 in predicting clinical course at mid-term follow-up (log rank 5.65; P = 0.017).Adding Gal-3 to BNP, a single predischarge strategy testing seemed to obtain a satisfactorily predictive value in alive HF patients discharged after an ADHF episode.

The predictive value of plasma biomarkers in discharged heart failure patients: role of plasma NT-proBNP.

BACKGROUND: Natriuretic peptides (NPs) have demonstrated their value to support clinical diagnosis of heart failure (HF); furthermore they are also studied for their prognostic role using them to guide appropriate management strategies. The present review gathers available evidence on prognostic role of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients hospitalized for acute decompensated heart failure (ADHF). METHODS: We searched Medline for English-language studies with the sequent key-words: "acute heart failure/acute decompensated heart failure", "NT-proBNP/N-terminal pro-B type natriuretic peptide" and "prognosis/mortality/readmission". RESULTS: Almost 30 studies were included. NT-proBNP plasma levels at admission are strongly associated with all-cause short-term mortality (2-3 months), mid-term (6-11 months) or long- term mortality (more than one year) of follow-up. Regarding the prognostic power on cardiac death fewer data are available with uncertain results. NT-proBNP at discharge demonstrated its prognostic role for all-cause mortality at mid and long-term follow-up. The relation between NT-proBNP at discharge and cardiovascular mortality or composite end-point is under investigation. A decrease in NT-proBNP values during hospitalization provided prognostic prospects mainly for cardiovascular mortality and HF readmission. A 30% variation in NT-proBNP levels during in-hospital stay seemed to be an optimal cut-off for prognostic role. CONCLUSION: SNT-proBNP plasma levels proved to have a strong correlation with all-cause mortality, cardiovascular mortality, morbidity and composite outcomes in patients discharged after an ADHF. A better definition of the correct time of serial measurements and the cut-off values might be the challenge for the future investigations.

Role of (123)I-Iobenguane Myocardial Scintigraphy in Predicting Short-term Left Ventricular Functional Recovery: An Interesting Image.

(123)I-iobenguane myocardial scintigraphy (MIBG) has been shown to be a predictor of sudden cardiac mortality in patients with heart failure. One patient with recent anterior myocardial infarction (MI) treated with coronary angioplasty and having left ventricular ejection fraction (LVEF) of 30% underwent early MIBG myocardial scintigraphy/tetrofosmin single-photon emission computed tomography (SPECT) in order to help evaluate his eligibility for implantable cardioverter defibrillator (ICD). The late heart/mediastinum (H/M) ratio was calculated to be 1.32% and the washout rate was 1%. At 40-day follow-up after angioplasty, LVEF proved to be 32%, New York Heart Association (NYHA) class was still II-III, and an ICD was placed in order to reduce mortality from ventricular arrhythmias. MIBG myocardial scintigraphy might be a promising method for evaluating left ventricular recovery in post-MI patients.

Correlation between B-Type Natriuretic Peptide and Functional/Cognitive Parameters in Discharged Congestive Heart Failure Patients.

The determination of B-type natriuretic peptides (BNP) may have a role in the diagnosis of heart failure (HF) or guiding HF therapy. This study investigated the role of BNP determination in a cohort of elderly patients admitted to hospital with acute decompensated HF and its correlation with main demographic, clinical, and instrumental data and evaluated possible association with major outcome such as mortality or readmission after a 6-month period of follow-up. Methods. From October 2011 to May 2014 consecutive patients admitted to our unit with symptoms of acute HF or worsening of chronic HF entered the study collecting functional, echocardiographic, and hydration parameters. Correlation between BNP and main parameters was analysed, as well as the mortality/6-month readmission rate. Results. In 951 patients (mean age 71 ys; 37% females) a positive correlation was obtained between BNP and age, creatinine levels, NYHA class at admission and discharge, and levels of hydration; an inverse, negative correlation between BNP and sodium levels, LVEF, distance performed at 6MWT at admission and at discharge, and scores at MMSE at admission and discharge emerged. BNP levels at admission and at discharge were furthermore clearly associated with mortality at 6 months (Chi-square 704.38, p = 0.03) and hospital readmission (Chi-square 741.57, p < 0.01). Conclusion. In an elderly HF population, BNP is related not only with clinical, laboratory, and instrumental data but also with multidimensional scales evaluating global status; higher BNP levels are linked with a worse prognosis in terms of mortality and 6-month readmission.

Usefulness of myocardial positron emission tomography/nuclear imaging in Takotsubo cardiomyopathy.

AIM: To analyse and summarize all the articles related to positron emission tomography and Takotsubo cardiomyopathy (TTC). METHODS: We performed a systematic review of the existing literature on positron emission tomography/nuclear imaging and Takotsubo cardiomyopathy using PUBMED database. We combined search terms such as "takotsubo", "takotsubo syndrome", "myocardial positron emission tomography", "positron emission tomography". All case reports were excluded. The list included only four articles which were reviewed by two independent investigators. It was not possible to undertake a formal meta-analysis because of the heterogeneity of the studies; therefore, we made a narrative synthesis of the collected data. RESULTS: Nuclear medicine techniques can be useful employed in the differential diagnosis of TTC from an acute coronary syndrome (ACS). In fact, transient left ventricular (LV) apical ballooning is a syndrome frequently misdiagnosed as an ACS and can mimic symptoms of myocardial infarction with ST-T segments changes on electrocardiography (ECG), a limited release of myocardial enzyme, mainly reported after sudden emotional or physical stress, and an akinesis or dyskinesis of the left ventricle apex which are completely reversible in a few weeks. In the studies included in this review, nuclear medicine techniques have demonstrated a discrepancy between normal perfusion and a reduced glucose utilization in TTC, commonly known as "inverse flow metabolism mismatch". This suggests that apical ballooning represents a transient metabolic disorder on the cellular level, rather than a structural contractile disease of the myocardium, due to a transient decrease of glucose metabolism that might be related to a coronary microcirculation impairment followed by prolonged myocardial stunning. CONCLUSION: Nuclear medicine techniques can be usefully used for the diagnosis of TTC and can increase our knowledge of the pathophysiological mechanisms of TTC.

Relationship between Cognitive Function, Depression/Anxiety and Functional Parameters in Patients Admitted for Congestive Heart Failure.

UNLABELLED: Cognitive impairment, anxiety and depression have been described in patients with congestive heart failure (CHF). We analyzed in-hospital CHF patients before discharge with neuropsychological tests attempting to correlate with prognostic parameters. METHODS: All subjects underwent a mini mental state examination (MMSE), geriatric depression scale (GDS), anxiety and depression scale test (HADS). We evaluated NYHA class, brain natriuretic peptide (BNP), left ventricular ejection fraction (LVEF) and non-invasive cardiac output (CO). RESULTS: Three-hundred and three CHF patients (age 71.6 ys) were analysed. The mean NYHA class was 2.9±0.8, LVEF was 43.4±15.8%; BNP plasma level and CO were calculated as 579.8±688.4 pg/ml and 3.9±1.1 l/min, respectively. In 9.6% a pathological MMSE score emerged; a depression of mood in 18.2% and anxiety in 23.4% of patients were observed. A significant correlation between MMSE and age (r=0.11 p=0.001), BNP (r=0.64 p=0.03) but not between MMSE and NYHA class and LVEF was observed. GDS and HADS were inversely correlated with NYHA class (r=0.38 p=0.04) and six-minute walking test (r=0.18 p=0.01) without an association with objective parameters in CHF (BNP, LVEF and cardiac output). At multivariate analysis only MMSE and BNP are inversely correlated significantly (p=0.019 OR=-0.64, CI=-042-0.86). CONCLUSIONS: in-hospital CHF patients may manifest a reduction of MMSE and important anxiety/depression disorders. The results of the study suggest that the presence of cognitive impairment in older CHF patients with higher BNP plasma level should be considered. In admitted CHF patients anxiety and depression of mood are commonly reported and influenced the perception of the severity of illness.