Levosimendan Improves Renal Function in Patients with Acute Decompensated Heart Failure: Comparison with Dobutamine

Background Levosimendan is a relatively new cardiac inotropic agent with calcium sensitizing activity. This study was conducted to investigate the effects of levosimendan (L) and dobutamine (D) on renal function in patients hospitalized with decompensated heart failure (HF). Method The present study included 88 consecutive patients hospitalized with acutely decompensated HF (New York Heart Association (NYHA) Class 3–4) requiring inotropic therapy. Patients were randomized 2:1 to either L or D for intravenous inotropic support. Diuretic therapy was kept constant during infusions. Renal function values, including serum creatinine (CR), blood urea nitrogen, 24-h urinary output levels and calculated glomerular filtration rate (GFR) were measured just prior to and 24 h after the infusions in all patients, and 48 and 72 h after the infusions in every second patient in both groups. The pre and post-infusion values of renal function and left ventricular ejection fraction (LVEF) were evaluated. Results LVEF increased significantly in both groups. Those in L showed a significant improvement in calculated GFR after 24 h, whereas those in D showed no significant change (median in change in L:+15.3%, median change in D: −1.33%). Furthermore, in the L group a significant improvement was observed in calculated GFR after 72 h compared to baseline levels, whereas in D no significant change (median change in L:+45.45%, median change in D: +0.09%) was seen. Both agents improved 24-h urinary output. Conclusion Levosimendan seems to provide beneficial effects in terms of improvement in renal function compared to dobutamine in patients with heart failure who require inotropic therapy.     

Discordance Between Clinical Assessment and Invasive Hemodynamics in Patients With Advanced Heart Failure

BackgroundHistorically, invasive hemodynamic guidance was not superior compared to clinical assessment in patients admitted with acute decompensated heart failure (ADHF). This study assessed the accuracy of clinical assessment vs invasive hemodynamics in patients with ADHF.Methods and ResultsWe conducted a prospective cohort study of patients admitted with ADHF. Prior to right-heart catheterization (RHC), physicians categorically predicted right atrial pressure, pulmonary capillary wedge pressure, cardiac index and hemodynamic profile (wet/dry, warm/cold) based on physical examination and clinical data evaluation (warm = cardiac index > 2.2 L/min/m²; wet = pulmonary capillary wedge pressure > 18 mmHg). We collected 218 surveys (of 83 cardiology fellows, 55 attending cardiologists, 45 residents, 35 interns) evaluating 97 patients. Of those patients, 46% were receiving inotropes prior to RHC. The positive and negative predictive values of clinical assessment compared to RHC for the cold and wet subgroups were 74.7% and 50.4%. The accuracy of categorical prediction was 43.6% for right atrial pressure, 34.4% for pulmonary capillary wedge pressure and 49.1% for cardiac index, and accuracy did not differ by clinician (P > 0.05 for all). Interprovider agreement was 44.4%. Therapeutic changes following RHC occurred in 71.1% overall (P < 0.001).ConclusionsClinical assessment of patients with advanced heart failure presenting with ADHF has low accuracy across all training levels, with exaggerated rates of misrecognition of the most high-risk patients.     

Effects of Levosimendan on Quality of Life and Emotional Stress in Advanced Heart Failure Patients

AIM: Levosimendan improves central hemodynamics and symptoms in acutely decompensated chronic heart failure (CHF) patients. However, its effects on quality of life, emotional stress and functional capacity of patients with advanced CHF have not been properly investigated. METHODS AND RESULTS: Sixty-three advanced CHF patients (NYHA III-IV, LVEF<30%) were randomized (2:1) to receive either a 24-h levosimendan infusion of 0.1 mug/kg/min or placebo. Questionnaires addressing quality of life [Kansas City Cardiomyopathy Questionnaire (KCCQ), functional and overall, Duke's Activity Status Index (DASI)] and emotional stress [Zung self-rating depression scale (SDS), Beck Depression Inventory (BDI)], as well as plasma BNP and 6-min walking distance (6MWT as a marker of exercise capacity) were assessed before treatment and at hospital discharge. A significant improvement in NYHA class (2.1 +/- 0.7 from 3.3 +/- 0.7, p < 0.01), 6 MWT (305 +/- 152 from 215 +/- 142 m, p < 0.01) and plasma BNP (598 +/- 398 from 1,078 +/- 756 pg/ml, p < 0.01) was observed post-treatment only in levosimendan-treated group. KCCQ functional (45 +/- 19 from 35 +/- 17%, p < 0.05) and overall (34 +/- 13 from 28 +/- 11%, p < 0.05), DASI (26 +/- 13 from 22 +/- 12, p < 0.05), Zung SDS (38 +/- 12 from 42 +/- 13, p < 0.01) and BDI (11 +/- 6 from 14 +/- 8, p < 0.05) scores also improved in levosimendan-treated patients, while remained unchanged in the placebo group. The hospital length stay was shorter in levosimendan group compared to placebo (3.2 +/- 1.7 versus 5.8 +/- 2.1 days, p < 0.01). Levosimendan-induced BNP reduction was significantly correlated with concomitant increase in 6MWT (r = 0.643, p < 0.001) as well as with the decrease of BDI (r = 0.30, p < 0.05) and Zung SDS (r = 0.25, p = 0.05). CONCLUSION: Levosimendan seems to have a beneficial effect on quality of life, physical activity and emotional stress in advanced CHF patients, reducing concurrently hospitalization length.     

左西孟旦对心力衰竭危重患者死亡率影响的Meta分析

目的:研究左西孟旦对心力衰竭(心衰)危重患者死亡率的影响。方法:在Pub Med、EMBASE、Cochrane心血管组数据库中收集左西孟旦与其他干预措施的随机对照研究,文献检索时间从各数据库建库时间至2014-07。根据Jadad量表评价纳入文献的质量并提取资料。对符合质量标准的对照研究(无剂量及给药方式的限制)采用Rev Man 5.2进行Meta分析。根据纳入标准最终入选37篇文献,共入选病例4 470例。结果:左西孟旦与对照组相比能降低心脏相关疾病所致心衰危重患者的死亡率[危险比(RR):0.85;95%可信区间(CI):0.75~0.97;P=0.02],并能降低心脏手术所致心衰危重患者的死亡率(RR:0.49;95%CI:0.28~0.85;P=0.01)。与多巴酚丁胺进一步比较,左西孟旦能降低心衰危重患者的死亡率(RR:0.84;95%CI:0.73~0.98;P=0.02),并能降低缺血性心脏病所致心衰危重患者的死亡率(RR:0.85;95%CI:0.73~0.99;P=0.04)。结论:左西孟旦能降低心脏相关疾病、心脏手术及缺血性心脏病所致心衰危重患者的死亡率。     

间断重复使用左西孟旦在不同肾小球滤过率的进展期心力衰竭中的作用比较

目的探讨不同肾小球滤过率的进展期心力衰竭间断重复使用左西孟旦的疗效差异。方法纳入住院的进展期射血分数降低性心力衰竭患者,分为常规治疗组和左西孟旦组,随访观察6个月,按照肾小球滤过率估算值(e GFR)分为e GFR≥60 m L/(min·1. 73 m²)组和<60 m L/(min·1. 73 m²)组,分别评估治疗前后e GFR、脑钠肽(BNP)、左室射血分数(LVEF)的变化,非计划再入院率和住院时间。结果共有177例射血分数降低性心力衰竭患者,常规治疗组118例,左西孟旦组59例;两组性别、年龄、肌酐、e GFR、BNP、LVEF和NYHA心功能分级等无差异(P> 0. 05)。左西孟旦组基线时收缩压偏低[(111. 86±22. 59) mm Hg vs(124. 36±22. 59) mm Hg,P <0. 001]。两组无论基线e GFR水平,治疗后e GFR增加30%的比例无差异(23. 96%vs 23. 92%,P=0. 691);左西孟旦组的非计划再入院率低于常规治疗组(80. 56%vs 100%,...     

左西孟旦治疗失代偿性心力衰竭的临床效果及不良反应研究

目的探讨左西孟旦治疗失代偿性心力衰竭的临床效果及不良反应。方法选取2012年3月—2013年3月我院收治的失代偿性心力衰竭患者72例,将其随机分为试验组38例和对照组34例,对照组在常规治疗的基础上予以多巴酚丁胺治疗,试验组在常规治疗的基础上予以左西孟旦注射液治疗,比较两组的临床疗效,并观察两组不良反应发生率和治疗前后心功能指标改善情况,包括B型脑利钠肽(BNP)、每搏输出量(SV)和左室射血分数(LVEF)。结果对照组总有效率为73.5%(25/34),低于试验组的97.4%(37/38)(P0.05)。治疗前两组BNP、SV及LVEF比较,差异无统计学意义(P0.05);治疗后试验组BNP低于对照组,SV和LVEF高于对照组(P0.05)。对照组不良反应发生率为44.1%(15/34),高于试验组的10.5%(4/38)(P0.05)。结论左西孟旦治疗失代偿性心力衰竭能明显改善患者BNP、SV和LVEF,疗效显著,且不良反应少,值得临床进一步推广。     

左西孟旦治疗心力衰竭的研究进展

钙离子增敏剂是近年来新的正性肌力药物,其代表药品为左西孟旦,具有独特的双重作用模式,增强心肌收缩力、扩张血管,能有效的改善心力衰竭患者血流动力学障碍,且不增加心肌耗氧,不影响心肌舒张功能,也不增加恶性心律失常的风险,同时具有抑制心室重塑的作用,因此在理论上可用于心力衰竭患者的治疗.现有的临床研究均证实左西孟旦可明显改善失代偿性心力衰竭患者的临床症状,但对于心力衰竭患者的远期预后却得出了不同的结果.     

Nutraceuticals in Patients With Heart Failure: A Systematic Review

BackgroundNutraceuticals are pharmacologically active substances extracted from vegetable or animal food and administered to produce health benefits. We recently reviewed the current evidence for nutraceuticals in patients diagnosed with heart failure as part of the writing of the Australian Guidelines for the prevention, diagnosis, and management of heart failure.MethodsA systematic search for studies that compared nutraceuticals to standard care in adult patients with heart failure was performed. Studies were included if >50 patients were enrolled, with ≥6 months follow-up. If no studies met criteria then studies <50 patients and <6 months follow-up were included. The primary outcomes included mortality/survival, hospitalization, quality of life, and/or exercise tolerance. Iron was not included in this review as its role in heart failure is already well established.ResultsForty studies met the inclusion criteria. The strongest evidence came from studies of polyunsaturated fatty acids, which modestly decreased mortality and cardiovascular hospitalizations in patients with mostly New York Heart Association class II and III heart failure across a range of left ventricular ejection fraction. Coenzyme Q10 may decrease mortality and hospitalization, but definite conclusions cannot be drawn. Studies that examined nitrate-rich beetroot juice, micronutrient supplementation, hawthorn extract, magnesium, thiamine, vitamin E, vitamin D, L-arginine, L-carnosine, and L-carnitine were too small or underpowered to properly appraise clinical outcomes.ConclusionOnly one nutraceutical, omega-3 polyunsaturated fatty acid, received a positive recommendation in the Australian heart failure guidelines. Although occasionally showing some promise, all other nutraceuticals are inadequately studied to allow any conclusion on efficacy. Clinicians should favor other treatments that have been clearly shown to decrease mortality.     

Dietary Habits are Related to Outcomes in Patients With Advanced Heart Failure Awaiting Heart Transplantation

BackgroundEmpirical evidence supporting the benefits of dietary recommendations for patients with advanced heart failure is scarce. We prospectively evaluated the relation of dietary habits to pre-transplant clinical outcomes in the multisite observational Waiting for a New Heart Study.Methods and ResultsA total of 318 heart transplant candidates (82% male, age 53 ± 11 years) completed a Food Frequency Questionnaire (foods high in salt, saturated fats, poly-/monounsaturated fats [PUFA+MUFA], fruit/vegetables/legumes, and fluid intake) at time of waitlisting. Cox proportional hazard models controlling for heart failure severity (eg, Heart Failure Survival Score, creatinine) estimated cause-specific hazard ratios (HRs) associated with each dietary habit individually, and with all dietary habits entered simultaneously. During follow-up (median 338 days, range 13–1,394), 54 patients died, 151 received transplants (110 in high-urgency status, 41 electively), and 45 became delisted (15 deteriorated, 30 improved). Two robust findings emerged: Frequent intake of salty foods, which correlated positively with saturated fat and fluid intake, was associated with transplantation in high-urgency status (HR 2.90, 95% confidence interval [CI] 1.55–5.42); and frequent intake of foods rich in PUFA+MUFA reduced the risk for death/deterioration (HR 0.49, 95% CI 0.26–0.92).ConclusionsThese results support the importance of dietary habits for the prognosis of patients listed for heart transplantation, independently from heart failure severity.     

Complex Care Options for Patients With Advanced Heart Failure Approaching End of Life

Care for patients with advanced cardiac disease continues to evolve in a complex milieu of therapeutic options, advanced technological interventions, and efforts at improving patient-centered care and shared decision-making. Despite improvements in quality of life and survival with these interventions, optimal supportive care across the advanced illness trajectory remains diverse and heterogeneous. Herein, we outline challenges in prognostication, communication, and caregiving in advanced heart failure and review the unique needs of patients who experience frequent hospitalizations, require chronic home inotropic support, and who have implantable cardioverter-defibrillators and mechanical circulatory support in situ, to name a few.     

Clinical Course of Patients With Worsening Heart Failure With Reduced Ejection Fraction

Background

Epidemiology of patients with worsening heart failure and reduced ejection fraction (HFrEF) in the real-world setting is not well described.

Patterns of Care During the Terminal Hospital Admission for Patients With Advanced Heart Failure: A Retrospective Cohort Study

Costs of end of life care for patients who have advanced heart failure (HF) are increasing. There is a perception that many of these patients receive aggressive treatments near the end of life. However, actual patterns of care are unclear. In this article we describe the use of life-sustaining treatments and the timing of goals of care discussions during patients’ terminal admission for HF. We conducted a single-centre retrospective cohort study of patients aged 18 years or older with a most responsible discharge diagnosis of HF who died between April 2012 and December 2013. We identified 133 eligible decedents of whom 67 (50%) received some form of life-sustaining treatment, although only 14 (11%) received cardiopulmonary resuscitation (CPR). The first documented orders for scope of treatment were: CPR for 39 (29%), active medical treatment with no CPR for 81 (61%), and comfort care with no CPR for 11 (8%) patients. The last documented orders were for comfort care in 85 (64%) patients. There were 28 (21%) patients who received palliative care consultation. Median time between palliative care consultation and death was 6 days and between orders for comfort care and death was 24 hours. In contrast to the high mortality risk of our study cohort, palliative care consultation was often absent or in the final days of life, with orders for comfort-oriented care being written only 24 hours before death, suggesting there remain opportunities for earlier integration of palliative and goal-directed approaches to therapy for patients who have advanced HF.     

慢性充血性心力衰竭患者心率变异性与病情的相关性分析

目的：为探讨心力衰竭（心衰）患者心率变异性与病情的关系。方法：本文采用时域及频域２种分析方法，对９２例心衰患者和５１例对照组健康人进行了心率变异性对比分析，并对部分患者（ｎ＝１０）及对照组健康人（ｎ＝２０）进行血浆儿茶酚胺（去甲肾上腺素、肾上腺素）浓度测定及心率变异性随访。结果：心衰患者的心率变异性显著低于对照组健康人；并且与病情及心功能明显相关（Ｐ＜０．０５～０．００１）；心衰患者中近期死亡者心率变异性进一步降低（Ｐ＜０．０５～０．００１）；心衰患者血浆去甲肾上腺素及肾上腺素浓度明显高于健康组（Ｐ＜０．０２～０．０１）。结论：心衰患者心率变异性降低提示，心衰患者心率变异性的数量变化，反应患者病情变化。高的血浆儿茶酚胺浓度间接说明了心衰患者心脏自主神经功能受损是神经激素系统持续激活的结果