Epidemiology of acute heart failure syndromes

Acute Heart Failure is a heterogeneous set of syndromes associated with significant morbidity and mortality. There are several classifications of acute heart failure syndromes (AHFS) based on pathophysiology or clinical presentation. In the USA and in Europe, AHFS are the first cause of hospitalization of the elderly, and the leading health care cost. Despite this clinical and social importance, AHFS have received little attention from clinicians and researchers. Recently published epidemiological studies described clinical presentation, characteristics and treatment of over 100,000 patients hospitalized with AHFS. These studies also underlined the poor, short, and medium term prognosis, especially for the most severe patients admitted to an intensive care unit, with in-hospital mortality of 28%. Further epidemiological and clinical research is needed to improve our understanding of AHFS, thereby enhancing patient care.     

Algorithm for therapeutic management of acute heart failure syndromes

As for other critically ill diseases, two key factors may markedly improved morbidity and mortality of acute heart failure syndromes (AHFS): early initiation of treatment and tailored therapy. Early initiation aims to stop the negative cascade of heart dysfunction. Tailored therapy should be based on the level of systolic blood pressure at admission and fluid retention. Indeed, EFICA and OPTIMIZE-HF showed that patients with high systolic blood pressure have a left ventricular systolic function that is likely preserved and those with low systolic blood pressure have a lower left ventricular ejection fraction and frequent signs of organ’s hypoperfusion. Among the proposed treatments, non-invasive ventilation is the only treatment that was consistently proven to be beneficial on morbidity and mortality in almost all types of AHFS. Concerning pharmacological agents, actions should be taken to increase the use of vasodilators and reduce the use of diuretics.     

Early pharmacological treatment of acute heart failure syndromes: A systematic review of clinical trials

Context: Acute Heart Failure Syndromes (AHFS) is a common admission diagnosis associated with high mortality and hospital readmissions. Given the mixed results of recent clinical trials, the early management of AHFS remains controversial. Objective: To review the recent evidence regarding current and investigational therapies for the early management of AHFS. Data Sources: A systematic search of peer‐reviewed publications was performed on MEDLINE and EMBASE from January 1990 to August 2006. The results of unpublished or ongoing trials were obtained from presentations at national and international meetings and pharmaceutical industry releases. Bibliographies from these references were also reviewed, as were additional articles identified by content experts. Study Selection and Data Extraction: Criteria used for study selection were controlled study design, relevance to clinicians and validity based on venue of publication and power analysis. Data Synthesis: Although all current intravenous therapies for the early management of AHFS appear to improve hemodynamics, this may not always translate into short‐term clinical benefit. Conclusion: The results of the trials conducted to date in AHFS have generally been disappointing. There is, therefore, an unmet need for new therapeutic approaches for the early management of AHFS that may improve the short‐term and long‐term outcomes.     

Diuretics for the treatment of acute decompensated heart failure

Diuretics have been a mainstay for the treatment of acute decompensated heart failure (ADHF) for the past four decades, though their short-term gains have been questioned recently given their potential long-term deleterious systemic effects. The methods of diuretic administration as well as the optimal dosing regimen of these agents are both areas that have been increasingly coming under scrutiny. The lack of rigorous clinical trials examining diuretic use in ADHF, however, has led to a general adoption of non-evidence based treatment algorithms for this patient population. Though the use of intravenous vasodilators for the treatment of decompensated heart failure has grown tremendously over the last few years, the fact remains that diuretics are still indispensable for alleviating congestive symptoms. Given this reality and until further information is available about the most ideal utilization of these medications, diuretics will continue to represent a double-edged sword for physicians treating this disease process.     

Lessons learned in acute heart failure

Acute heart failure (HF) is a global pandemic with more than one million admissions to hospital annually in the US and millions more worldwide. Post‐discharge mortality and readmission rates remain unchanged and unacceptably high. Although recent drug development programmes have failed to deliver novel therapies capable of reducing cardiovascular morbidity and mortality in patients hospitalized for worsening chronic HF, hospitalized HF registries and clinical trial databases have generated a wealth of information improving our collective understanding of the HF syndrome. This review will summarize key insights from clinical trials in acute HF and hospitalized HF registries over the last several decades, focusing on improving the management of patients with HF and reduced ejection fraction.     

急性心力衰竭综合病因评分预计死亡率研究

目的 探讨急性心力衰竭病因评分在急性心力衰竭疾病中的应用价值.方法 采用APACHEⅡ评分、心力衰竭基础病因及诱因综合评分,在此评分基础上对42 例急性心力衰竭患者预计死亡率进行评估并建立预计死亡率模型,分层计算群体预计死亡率.结果 根据急性心力衰竭病因评分分值进行分组,随着分值逐渐升高,实际病死率和预计死亡率也逐渐升高,死亡组评分均值显著高于生存组(P＜0.05).结论 急性心力衰竭病因评分系统简易实用,可用于院前急救及急诊急性心力衰竭患者初步评估.     

奈西立肽治疗急性心力衰竭的研究进展

严重心力衰竭时,可能存在内源性脑钠肽相对不足和/或脑钠肽抵抗。奈西立肽是重组人脑钠肽。国内外多项前瞻性临床研究均证实,奈西立肽能迅速改善急性心力衰竭患者的血流动力学状况和临床症状,其有效性和安全性明显优于常规静脉制剂。但是汇总分析发现奈西立肽有引起肾脏损害和死亡率增加的风险。因此临床医师在使用此药时应严格掌握临床适应证,同时需要进一步的临床研究明确奈西立肽在急性心力衰竭中的治疗地位。     

Decongestion in acute heart failure

Congestion is a major reason for hospitalization in acute heart failure (HF). Therapeutic strategies to manage congestion include diuretics, vasodilators, ultrafiltration, vasopressin antagonists, mineralocorticoid receptor antagonists, and potentially also novel therapies such as gut sequesterants and serelaxin. Uncertainty exists with respect to the appropriate decongestion strategy for an individual patient. In this review, we summarize the benefit and risk profiles for these decongestion strategies and provide guidance on selecting an appropriate approach for different patients. An evidence‐based initial approach to congestion management involves high‐dose i.v. diuretics with addition of vasodilators for dyspnoea relief if blood pressure allows. To enhance diuresis or overcome diuretic resistance, options include dual nephron blockade with thiazide diuretics or natriuretic doses of mineralocorticoid receptor antagonists. Vasopressin antagonists may improve aquaresis and relieve dyspnoea. If diuretic strategies are unsuccessful, then ultrafiltration may be considered. Ultrafiltration should be used with caution in the setting of worsening renal function. This review is based on discussions among scientists, clinical trialists, and regulatory representatives at the 9th Global Cardio Vascular Clinical Trialists Forum in Paris, France, from 30 November to 1 December 2012.     

Acute heart failure syndromes: clinical scenarios and pathophysiologic targets for therapy

Acute heart failure syndromes (AHFS) represent the most common discharge diagnosis in patients over age 65 years, with an exceptionally high mortality and readmission rates at 60–90 days. Recent surveys and registries have generated important information concerning the clinical characteristics of patients with AHFS and their prognosis. Most patients with AHFS present either with normal systolic blood pressure or elevated blood pressure. Patients who present with elevated systolic blood pressure usually have pulmonary congestion, a relatively preserved left ventricular ejection fraction (LVEF), are often elderly women, and their symptoms develop typically and abruptly. Patients with normal systolic blood pressure present with systemic congestion, reduced LVEF, are usually younger with a history of chronic HF, and have symptoms that develop gradually over days or weeks. In addition to the abnormal hemodynamics (increase in pulmonary capillary wedge pressure and/or decrease in cardiac output) that characterize patients with AHFS, myocardial injury, which may be related to a decrease in coronary perfusion and/or further activation of neurohormones and renal dysfunction, probably contributes to short-term and post-discharge cardiac events. Patients with AHFS also have significant cardiac and noncardiac underlying conditions that contribute to the pathogenesis of AHFS, including coronary artery disease (ischemia, hibernating myocardium, and endothelial dysfunction), hypertension, atrial fibrillation, and type 2 diabetes mellitus. Therefore, the targets of therapy for AHFS should be not only to improve symptoms and hemodynamics but also to preserve or improve renal function, prevent myocardial damage, modulate neurohumoral and inflammatory activation, and to manage other comorbidities that may cause and/or contribute to the progression of this syndrome.     

急性ST段抬高型心肌梗死患者血浆微小核糖核酸-208a水平对并发急性心力衰竭的预测价值

目的:探讨血清微小核糖核酸-208a(miR-208a)表达水平对急性ST段抬高型心肌梗死(STEMI)患者并发急性心力衰竭的预测关系。方法:连续性收集2018年1月至2019年6月,就诊于我科的152例急性STEMI患者纳入病例组,并随机选择同期在我院行健康体检的志愿者60例为对照组。根据发病48 h内是否发生急性心力衰竭(AHF)将病例组分为AHF亚组和非AHF亚组。采用实时荧光定量PCR(RT-qPCR)法检测血浆miR-208a的相对表达水平。结果:病例组血浆miR-208a相对表达水平显著高于对照组(Z=10.919,P=0.000)。AHF亚组血浆miR-208a相对表达水平显著高于非AHF亚组(Z=9.573,P=0.000)。Pearson相关性分析结果显示,病例组患者血浆miR-208a相对表达水平与BNP、hsCRP和cTnI均呈正相关关系(r=0.612,P=0.000;r=0.447,P=0.000;r=0.378,P=0.000)。二分类Logistic回归分析结果显示血浆miR-208a相对表达水平是急性STEMI患者并发AHF的危险因素(OR=2.118,95%CI 1.127~3.982,P=0.007)。血浆miR-208a预测AHF的AUC为0.896(0.844,0.948),cut-off值为32.00,对应的敏感性和特异性分别为88.4%和83.3%。结论:急性STEMI患者血浆miR-208a表达水平显著升高,且可能是并发AHF的危险因素。     

New and emerging pharmacologic strategies in the management of chronic heart failure

Chronic heart failure (CHF) is a complex syndrome involving activation of multiple cellular, metabolic, and neurohumoral pathways following the initial myocardial insult. Recently, there have been considerable advances in the pharmacologic management of CHF. The current approach to treatment recognizes the need to target neurohormonal activation, and the use of angiotensin-converting enzyme (ACE) inhibitors and beta blockers should now be regarded as part of standard therapy in many patients with CHF. However, because of the complexity of the disease, blockade of additional pathways is likely to be required to maximize the therapeutic benefit of intervention. To this end, there are several agents under active late-phase clinical evaluation. The most advanced of these new strategies (beyond renin-angiotensin-aldosterone blockade) is inhibition of the endothelin system. There is a substantial body of evidence that this system is intimately involved in CHF disease progression. Early-phase clinical data are very encouraging and support the potential utility of long-term endothelin inhibition. Other novel approaches involve the use of cytokine antagonists (e.g., agents that block tumor necrosis factor-alpha activity) and the augmentation of natriuretic peptides. If all these potential agents prove to be of benefit in CHF, the question of which agent or combination of agents to use in which patients will arise. There is therefore a need to develop scientific approaches in order to be able to identify more accurately patients who will obtain benefit from specific classes or combinations of drugs.     

急性左心衰竭的抢救及护理体会

目的探究急性左心衰竭的抢救及护理体会。方法对2012年3月~2013年3月期间我院收治的42例急性左心衰患者抢救及护理的临床资料进行回顾性分析。结果 42例急性左心衰患者经抢救及相关护理支持,5例患者死亡,死亡率11.9%,其他患者的临床症状及体征均在30~60min内得以明显改善。结论护理人员与医生积极配合,加强病情监护,及时准确给药,是抢救成功的重要保障。     

In‐hospital worsening heart failure

Acute worsening heart failure (WHF) is seen in a sizable portion of patients hospitalized for heart failure, and is increasingly being recognized as an entity that is associated with an adverse in‐hospital course. WHF is generally defined as worsening heart failure symptoms and signs requiring an intensification of therapy, and is reported to be seen in anywhere from 5% to 42% of heart failure admissions. It is difficult to ascertain the exact epidemiology of WHF due to varying definitions used in the literature. Studies indicate that WHF cannot be precisely predicted on the basis of baseline variables assessed at the time of admission. Recent data suggest that some experimental therapies may reduce the risk of development of WHF among hospitalized heart failure patients, and this is associated with a reduction in risk of subsequent post‐discharge cardiovascular mortality. In this respect, WHF holds promise as a endpoint for acute heart failure clinical trials to better elucidate the benefit of targeted novel therapies. Better understanding of the pathophysiology and a consensus on the definition of WHF will further improve our epidemiological and clinical understanding of this entity.     

Newer mechanical devices in the management of acute heart failure

Heart Failure is the only cardiovascular disease diagnosis increasing in prevalence in the United States. Currently there are more than 5 million people diagnosed with heart failure in the United States and that population is increasing exponentially. Clinical trials in advanced pharmacological therapies have shown a significant value in reducing the morbidity and mortality of the disease process. Nevertheless, many patients who are optimally treated with drug therapy continue to progress from asymptomatic left ventricular dysfunction to symptomatic and then end-stage heart failure. Beyond drug therapy, devices have begun to make a significant impact on symptoms and clinical outcomes in patients, particularly those with more advanced forms of heart failure. New technologies being investigated include destination and bridge LV assist devices. Due to the invasive nature of these devices a new generation of “less invasive” percutaneous devices are now being studied. These new generation devices offer the promise of improved LV function and an enhanced neurohormonal profile for the failing ventricle, thus improving the quality of life in the ever-burgeoning heart failure population.