High-dose spironolactone changes renin and aldosterone levels in acutely decompensated heart failure

BackgroundIn acutely decompensated heart failure (ADHF) patient's higher aldosterone levels correlate with worse postdischarge outcomes, suggesting that further modulation of the mineralocorticoid system during or immediately after hospitalization might favorably improve outcomes.Methods and resultsThis was an observational, retrospective secondary analysis of a study including 100 patients with ADHF. In that study 50 patients were submitted to spironolactone treatment (50–100 mg/day). A higher proportion of patients with renin levels above 16.5 pg/mL and aldosterone levels above 100 ng/dL were observed in subjects submitted to spironolactone treatment (44.7% vs. 66.7% and 56% vs. 64.7%, respectively, both p < 0.05). In the group of patients submitted to spironolactone treatment the proportion of patients with renin and aldosterone levels above the cutoff had a significant increase from baseline to day 3 (24–32% and 16–44%, respectively, both p < 0.05). Log renin and aldosterone were higher in patients with renin and aldosterone levels above the cutoff point (both p < 0.05).ConclusionsHigh-dose spironolactone added to standard ADHF therapy induces an additional increase in renin and aldosterone levels. Whether higher levels of renin and aldosterone due to the reactive response to full MRA still have prognostic value requires further investigation.     

Sleep-disordered breathing in patients with decompensated heart failure

Sleep-disordered breathing (SDB) has a higher prevalence in patients with heart failure than in the general middle-aged population. Obstructive sleep apnea (OSA), one of the forms of SBD, promotes poorly controlled hypertension, coronary events, and atrial fibrillation events that can lead to acutely decompensated heart failure (ADHF), and evidence suggests that untreated OSA increases mortality in patients with heart failure. Cheyne–Stokes respiration and central sleep apnea (CSA) have long been associated with heart failure and, in many patients, can coexist with OSA. In this article, we propose a systematic approach to diagnose and treat OSA in patients with ADHF based on current evidence.     

Lung ultrasound in the management of acute decompensated heart failure

Once thought impracticable, lung ultrasound is now used in patients with a variety of pulmonary processes. This review seeks to describe the utility of lung ultrasound in the management of patients with acute decompensated heart failure (ADHF). A literature search was carried out on PubMed/Medline using search terms related to the topic. Over three thousand results were narrowed down via title and/or abstract review. Related articles were downloaded for full review. Case reports, letters, reviews and editorials were excluded. Lung ultrasonographic multiple B-lines are a good indicator of alveolar interstitial syndrome but are not specific for ADHF. The absence of multiple B-lines can be used to rule out ADHF as a causative etiology. In clinical scenarios where the assessment of acute dyspnea boils down to single or dichotomous pathologies, lung ultrasound can help rule in ADHF. For patients being treated for ADHF, lung ultrasound can also be used to monitor response to therapy. Lung ultrasound is an important adjunct in the management of patients with acute dyspnea or ADHF.     

Endogenous B-type natriuretic peptide: a limb of the regulatory response to acutely decompensated heart failure

Acutely decompensated heart failure (ADHF) represents an episodic failure of cardiorenal homeostasis that may resolve with upregulation of natriuretic peptides, bradykinin, and certain prostacyclins. B-type natriuretic peptide (BNP) has multiple favorable effects, including vasodilation, diuresis, natriuresis, and inhibition of vascular endothelial proliferation and cardiac fibrosis. By antagonizing the effects of activation of the renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system in volume overload, the endogenous BNP response may help rescue patients from episodic ADHF. Although knowledge of BNP physiology is expanding, we still have limited understanding of the heterogeneity of proBNP-derived molecules, including active 32 amino acid BNP and less active junk BNP forms. Emerging evidence suggests that in ADHF, the endogenous BNP response is overwhelmed by neurohormonal activation. This relative BNP deficiency may also be accompanied by physiologic resistance to BNP. Additionally, abnormalities of BNP production may result in a lower proportion of active BNP relative to less active forms that may also be detected by point-of-care tests. Improved detection of the various BNP species may clarify these concepts and facilitate improved clinical management of ADHF. Copyright (c) 2008 Wiley Periodicals, Inc.     

Prognostic implications of arterial blood gases in acute decompensated heart failure

Background

The prognostic value of arterial blood gases (ABG) in patients with acute decompensated heart failure (ADHF) is not well-established. We therefore conducted the present study to determine the relationship between ABG on admission and long-term mortality in patients with ADHF.

Methods

We studied 588 patients consecutively admitted to our department with ADHF. ABG and classical prognostic variables were determined at patients' arrival to the emergency department. The independent association among the main variables of ABG (pO2, pCO2 and pH) and mortality was assessed with Cox regression analysis.

Results

At a median follow-up of 23 months, 221 deaths (37.6%) were registered. 308 (52.4%), 54 (9.2%) and 50 (8.5%) patients showed hypoxemia (pO2 < 60 mm Hg), hypercapnia (pCO2 > 50 mm Hg) and acidosis (pH < 7.35), respectively. Patients with hypoxemia, hypercapnia and acidosis did not show higher mortality rates (38% vs. 37.1%, 42.6% vs. 37.1%, and 48% vs. 36.6%, respectively; p-value = ns for all comparisons). In multivariate analysis, after adjusting for well-known prognostic covariates, pO2, pCO2 and pH did not show a significant association with mortality. Hazard ratios (HR) for these variables were: pO2, per increase in 10 mm Hg: 0.99 (95% CI: 0.90–1.09), p = 0.861; pCO2, per increase in 10 mm Hg: 1.12 (95% CI: 0.91–1.39), p = 0.262; pH per increase in 0.1: 1.01 (95% CI: 0.99–1.04), p = 0.309. When dichotomizing these variables according to established cut-points, the HR were: hypoxemia (pO2 < 60 mm Hg):1.07 (95% CI: 0.81–1.40), p = 0.637; hypercapnia (pCO2 > 50 mm Hg): 0.98 (95% CI: 0.62–1.57), p = 0.952; acidosis (pH < 7.35): 1.38 (95% CI: 0.87–2.19), p = 0.173.

Conclusion

In patients admitted with ADHF, admission arterial pO2, pCO2 and pH were not associated with all-cause long-term mortality.     

体外超滤治疗急性失代偿性心力衰竭的疗效与安全性

目的：对血液超滤装置在心力衰竭患者应用安全性和有效性进行评价。方法：选择在我院CCU进行治疗的心力衰竭伴钠水潴留患者34例,其中扩张型心肌病伴心衰患者20例,缺血性心肌病伴心衰14例,采用血液超滤装置治疗,分析治疗前后呼吸困难评分、血氧饱和度、体重、血流动力学指标(心排量、心脏指数、胸液体容积、左心射血分数)、N-端脑钠肽前体(NT-proBNP)等指标,评价血液超滤的临床疗效,同时分析超滤前后的心率、血压、肝功能、肾功能、电解质、血常规等指标,进行安全性评价。结果：经治疗后,扩张型心肌病伴心衰患者及缺血性心肌病伴心衰患者的呼吸困难评分、血氧饱和度、体重、血流动力学指标(心排量、心脏指数、胸液体容积、左心射血分数)、NT-proBNP等指标均有改善,与治疗前相比有统计学意义(P<0．05)。治疗过程对患者血压、心率、血常规、肝功能、肾功能、电解质等无负面影响,且肾功能还有改善的趋势。结论：血液超滤装置治疗扩张型心肌病及缺血性心肌病伴心衰患者疗效明显,且安全可靠。     

Interleukin-6 levels are inversely correlated with heart rate variability in patients with decompensated heart failure

INTRODUCTION: Increased local and systemic elaboration of cytokines have an important role in the pathogenesis of congestive heart failure (CHF) through diverse mechanisms. Because cytokines are known to act at the neuronal level in both the peripheral and central nervous system, we sought to determine whether increased cytokine levels are associated with the autonomic dysfunction that characterizes CHF. METHODS AND RESULTS: We studied 64 patients admitted for decompensated CHF (mean age 59+/-12 years). Autonomic function was assessed using time- and frequency-domain heart rate variability (HRV) measures, obtained from 24-hour Holter recordings. In addition, norepinephrine, tumor necrosis factor-alpha (TNF-alpha), and interleukin-6 (IL-6) were measured in all patients. TNF-alpha levels did not correlate with any of the HRV measures. IL-6 inversely correlated with the time-domain parameters of standard deviation of RR intervals (SDNN) (r = -0.36, P = 0.004) and standard deviation of all 5-minute mean RR intervals (SDANN) (r = -0.39, P = 0.001), and with the frequency-domain parameters of total power (TP) (r = -0.37, P = 0.003) and ultralow-frequency (ULF) power (r = -0.43, P = 0.001). No correlation was found between IL-6 and indices of parasympathetic modulation. Using multiple linear regression models, adjusting for clinical variables and drug therapies, the strong inverse relationship between IL-6 and SDNN (P = 0.006), SDANN (P = 0.001), TP (P = 0.04), and ULF power (P = 0.0007) persisted. CONCLUSION: Reduction of long-term HRV indices is associated with increased levels of IL-6 in patients with decompensated heart failure. The ability of long-term HRV parameters to better reflect activation of diverse hormonal systems may explain their greater prognostic power for risk stratification in patients with CHF.     

Utility of the neutrophil to lymphocyte ratio for predicting in-hospital mortality after levosimendan infusion in patients with acute decompensated heart failure

BackgroundThe aim of this study was to investigate the effect of a levosimendan infusion on hematological variables in patients with acute decompensated heart failure (ADHF). The predictive value of these variables for in-hospital mortality was also evaluated.MethodsA total of 553 patients (368 males; mean age, 63.4 ± 14.9 years) with acute exacerbations of advanced heart failure (ejection fraction ≤35%) and treated with either dobutamine or levosimendan were included in this retrospective analysis. The patients that received levosimendan therapy were divided into two groups according to in-hospital mortality: group 1 (21%) included patients who died during hospitalization (n = 45), while group 2 (79%) included patients with a favorable outcome (n = 174) after levosimendan infusion. Changes in several hematological variables between admission and the third day after levosimendan infusion were evaluated.ResultsThe demographic characteristics and risk factors of the two groups were similar. A comparison of changes in laboratory variables after the infusion of levosimendan revealed significant improvement only in those patients who had not died (group 2) during hospitalization. The neutrophil to lymphocyte (N/L) ratio after levosimendan infusion was an independent predictor of in-hospital mortality (odds ratio: 1.310, 95% CI: 1.158–1.483, p < 0.001). In a receiver-operating characteristic curve analysis, a value of 5.542 for the N/L ratio after levosimendan administration was identified as an effective cut-off point for predicting in-hospital mortality (area under the curve = 0.737; 95% confidence interval = 1100–1301; p < 0.001).ConclusionsLevosimendan treatment was associated with significant changes in hematological variables in patients with ADHF. A sustained higher N/L ratio after levosimendan infusion is associated with an increased risk of in-hospital mortality in patients with ADHF.     

奈西立肽对高龄急性失代偿性心力衰竭患者心、肾相关指标的影响

目的 评价奈西立肽对高龄急性失代偿性心力衰竭患者心肾相关指标的影响.方法 入选80例高龄急性失代偿性心力衰竭患者,随机分为常规治疗组(n=40)和常规治疗+奈西立肽组(奈西立肽组,n=40).两组均接受抗心力衰竭常规治疗,奈西立肽组在常规治疗的基础上增加奈西立肽0.5～1.0 mg/d持续泵入,速度0.0075～0.0...     

IL-6, TNF-alpha and atherosclerosis risk indicators in a healthy family population: the STANISLAS cohort

There are no satisfactory data on circulating concentrations of inflammatory cytokines and their potential relationship with traditional and nontraditional atherosclerosis risk factors in a large healthy young population. The present study was conducted to examine, in 179 healthy families selected from the STANISLAS cohort, the association between interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), C-reactive protein (CRP), orosomucoid, haptoglobin, cell-adhesion molecules (ICAM-1, E-, L- and P-selectin) and lipid parameter concentrations. Age, BMI, white blood cells and tobacco consumption contributed to the variation of IL-6 concentrations. Age and tobacco contributed also to TNF-alpha variation. Taking into account potential covariates, we showed strong positive correlation between IL-6 and both inflammatory markers TNF-alpha and CRP in parents and in offspring (P<0.001). In parents, IL-6 was associated with ICAM-1 and L-selectin (P<0.01), while IL-6 and TNF-alpha predicted E-selectin in offspring only (0.001相似文献   

Ultrafiltration for acute decompensated heart failure: A systematic review and meta-analysis of randomized controlled trials

Background

Current clinical guidelines recommend ultrafiltration (UF) for patients with acute decompensated heart failure (ADHF) who are unresponsive or resistant to diuretics. We systematically reviewed the latest randomized evidence on the efficacy and safety of UF in ADHF.

Methods

MEDLINE, EMBASE and the Cochrane database were searched in January 2013 for eligible randomized controlled trials (RCTs) evaluating UF in patients with ADHF. A Mantel–Haenszel random-effects model was used to calculate mean differences (MDs) and odds ratios (ORs) for continuous and dichotomous data, respectively, with 95% confidence intervals (CIs).

Results

Data of 12 studies (n = 659) were meta-analyzed; follow-up duration ranged from 36 h to 12 months. Compared to control, treatment of UF was associated with significant fluid removal (MD 1.28, 95% CI 0.43 to 2.12, P = 0.003) and weight loss (MD 1.23, 95% CI 0.03 to 2.44, P = 0.04), with no significant effects on all-cause mortality (OR 1.08, 95% CI 0.63 to 1.86, P = 0.77) or all-cause rehospitalization (OR 0.89, 95% CI 0.39 to 2.00, P = 0.77). No significant differences were observed in the analyses of change in serum creatinine or unscheduled medical care; analysis of adverse effects was inconclusive since only one study provided usable data.

Conclusions

For patients with ADHF, UF is effective in reducing fluid retention and body weight, with no significant benefits in mortality or rehospitalization. The current limited randomized evidence highlights the need for further well-conducted randomized studies of adequate power to establish the role of UF in ADHF patients for whom conventional HF treatment is unsuccessful or contraindicated.