High-sensitivity cardiac troponin T and N-terminal pro-B-type natriuretic peptide in acute heart failure: Data from the ACE 2 study

BackgroundTo assess if cardiac troponins can improve diagnostics of acute heart failure (AHF) and provide prognostic information in patients with acute dyspnea.MethodsWe measured cardiac troponin T with a high-sensitivity assay (hs-cTnT) in 314 patients hospitalized with acute dyspnea. The index diagnosis was adjudicated and AHF patients were stratified into AHF with reduced or preserved ejection fraction (HFrEF/HFpEF). The prognostic and diagnostic merit of hs-cTnT was compared to the merit of N-terminal pro-B-type natriuretic peptide (NT-proBNP).ResultsIn the total population, median age was 73 (quartile [Q] 1–3 63–81) years and 48% were women. One-hundred-forty-three patients were categorized as AHF (46%) and these patients had higher hs-cTnT concentrations than patients with non-AHF-related dyspnea: median 38 (Q1-3 22–75) vs. 13 (4–25) ng/L; p < 0.001. hs-cTnT concentrations were similar between patients with HFrEF and HFpEF (p = 0.80), in contrast to NT-proBNP, which was higher in HFrEF (p < 0.001). C-statistics for discriminating HFpEF from non-AHF-related dyspnea was 0.80 (95% CI 0.73–0.86) for hs-cTnT, 0.79 (0.73–0.86) for NT–proBNP, and 0.83 (0.76–0.89) for hs-cTnT and NT-proBNP in combination. Elevated hs-cTnT remained associated with HFpEF in logistic regression analysis after adjusting for demographics, comorbidities and renal function. During median 27 months of follow-up, 114 (36%) patients died in the total population. Higher hs-cTnT concentrations were associated with increased risk of all-cause mortality after adjustment for clinical variables and NT-proBNP: hazard ratio 1.30 (95% CI 1.07–1.58), p = 0.009.Conclusionhs-cTnT measurements improve diagnostic accuracy for HFpEF and provide independent prognostic information in unselected patients with acute dyspnea.     

HFpEF,a Disease of the Vasculature: A Closer Look at the Other Half

Patients with heart failure are commonly divided into those with reduced ejection fraction (EF<40%) and those with preserved ejection fraction (HFpEF; EF>50%). For heart failure with reduced EF, a number of therapies have been found to improve patient morbidity and mortality, and treatment is guideline based. However for patients with HFpEF, no treatment has been found to have clinical benefit. To objectively assess treatments for HFpEF, a comprehensive PubMed literature search was performed using the terms HFpEF, heart failure, smooth muscle, myosin, myosin phosphatase, and PKG (up to December 31, 2017), with an unbiased focus on pathophysiology, cell signaling, and therapy. This review provides evidence that could explain the lack of clinical benefit in treating patients with HFpEF with sildenafil and long-acting nitrates. Furthermore, the review highlights the vascular abnormalities present in patients with HFpEF, and these abnormalities of the vasculature could potentially contribute to the pathophysiology of HFpEF. Thus, focusing on HFpEF as a vascular disease could result in the development of novel and effective treatment paradigms.     

Left Atrial Structure and Function,and Left Ventricular Diastolic Dysfunction: JACC State-of-the-Art Review

Defining left atrial (LA) function has recently emerged as a powerful parameter, particularly in evaluation of left ventricular (LV) diastolic dysfunction (LVDD) and heart failure with preserved ejection fraction. Echocardiographic assessment of LVDD by echocardiography remains a challenging task; recent recommendations provide a simpler approach than previous. However, the shortcomings of the proposed approach (including transmitral flow, tissue velocity, maximum left atrial volume [LAV], and estimated pulmonary artery systolic pressure), lead to the presence and severity of LVDD remaining undetermined in a significant proportion of patients. Maximum LAV is a surrogate measure of the chronicity and severity of LVDD, but LAV alone is an insensitive biomarker of early phases of LVDD, because the LA may take time to remodel. Because the primary function of the LA is to modulate LV filling, it is not surprising that functional LA changes become evident at the earliest stages of LVDD. Moreover, LA function may provide additive value, not only in diagnosing LVDD, but also in grading its severity and in monitoring the effects of treatment. The current review provides a critical appraisal on the existing evidence for the role of LA metrics in evaluation of LVDD and consequent heart failure with preserved ejection fraction.     

Ultrasonography in Heart Failure: A Story that Matters

Heart failure (HF) is a clinical syndrome caused by structural and/or functional cardiac abnormalities, resulting in a reduced cardiac output and/or elevated intracardiac pressures at rest or during stress. It is the leading cause of hospitalization in Internal Medicine departments. This article aims at reviewing evidence of the importance of ultrasound in HF both for hospitalized patients and in the follow-up. Ultrasound may be used as a recovery monitoring instrument at the bedside and also as a global cardiovascular assessment tool for these patients. HF represents an exciting opportunity to create an integrative ultrasound approach in Internal Medicine and/or Geriatric departments. The authors plan a five-step ultrasound examination to evaluate and monitor HF patients during hospitalization and follow-up. They call this examination: the “ABCDE” score. It includes the evaluations of A, the ankle-brachial index, B, the B-lines, C, the carotid intima media thickness, D, the diameter of the abdominal aorta and of the inferior cava vein and E, the echocardiographic assessment of the ejection fraction. This score may represent an integrative ultrasound approach in Internal Medicine and/or Geriatric departments.     

Pulmonary Vascular Resistance Is Associated With Brachial-Ankle Pulse-Wave Velocity and Adverse Clinical Outcomes in Patients With Heart Failure With Preserved Ejection Fraction

BackgroundThe precise mechanisms underlying the high prevalence of pulmonary hypertension (PH) with increased pulmonary vascular resistance (PVR) in heart failure with preserved ejection fraction (HFpEF) remain largely unknown. Measurements of brachial-ankle pulse wave velocity (baPWV) have been shown to be useful for risk assessment in HF patients. Thus, this study sought to define the association of PVR with baPWV and clinical outcomes in HFpEF.Methods and ResultsPatients with HFpEF (n = 198) had measurements of baPWV and PVR by right heart catheterization, and were prospectively followed-up for <96 months or until the occurrence of a composite of all-cause death, hospitalization with worsening HF, and nonfatal acute coronary syndrome.ResultsMultivariate logistic analysis showed that baPWV was independently associated with PH with increased PVR (P < .001). During the follow-up period, 46 clinical events occurred. Multivariate Cox proportional hazards analysis showed that PH with increased PVR was a significant predictor of adverse outcomes after adjustment for conventional risk factors (HR 1.96, 95% CI 1.03–3.76, P = .04).ConclusionsPH with increased PVR was associated with increased baPWV and adverse clinical outcomes in HFpEF. Thus, increased arterial stiffness may contribute to increased risk predictability of PVR for patients with HFpEF.     

红细胞分布宽度对不同射血分数的老年急性心力衰竭的预测价值

目的 探讨红细胞分布宽度（RDW）对不同射血分数的老年急性心力衰竭患者分类的诊断价值。方法选取293例老年急性心力衰竭患者,根据左室射血分数（LVEF）不同,分为射血分数减低性心力衰竭（LVEF＜40%）38例（HFrEF组）、射血分数中间性心力衰竭（40%≤LVEF＜50%）74例（HFmrEF组）、射血分数保留性心力衰竭（LVEF≥50%）131例（HFpEF组）,同时选取年龄、性别相匹配的无心力衰竭老年人51例作为对照组,收集患者的临床资料,分别检测血常规、生化指标、氨基末端B型钠尿肽原（NT-proBNP）及超声心动图。分析RDW与不同射血分数的老年急性心力衰竭的相关性及诊断意义。结果HFrEF组、HFmrEF组、HFpEF组中RDW值（1442±217)％、(1330±200)％、(1339±247)％,与对照组RDW值(1210±057)％差异有统计学意义（P<005)。RDW与LVEF呈显著负相关(r=-014,P<005)。RDW与NT-proBNP呈显著正相关 (r=013,P<005)。RDW鉴别HFpEF、HFmrEF的受试者工作特征（ROC）曲线下面积（AUC）为059,RDW取值1405%作为界值的敏感度为338%,特异度为829%;RDW鉴别HFrEF、HFmrEF的AUC为062,RDW取值1445%作为界值的敏感度为50%,特异度为76%。结论RDW在老年急性心力衰竭患者中显著升高,并且在HFpEF组、HFmrEF组、HFrEF组中表达各不相同。RDW＜1405%时,诊断HFpEF可能性大;1405%≤RDW≤1445%时,诊断HFmrEF可能性大;RDW＞1445%时,诊断HFrEF可能性大。RDW结合NT-proBNP可作为快速区分不同射血分数类型老年急性心力衰竭的有效指标。     

ABCs of Heart Failure (HFpEF) Management: Guide for Nurse Practitioners

Heart failure with preserved ejection fraction (HFpEF) management can be challenging for nurse practitioners due to a lack of conclusive evidence toward improving clinical outcomes and the limitations of pharmacologic options. Current pharmacotherapy in HFpEF is directed toward managing its underlying comorbidities and counteracting the impact of compensatory mechanisms. In this report we provide a 7-letter alphabetical mnemonic strategy similar to the approach used in part 1 of this 2-part series, to focus on the pharmacologic management of patients with HFpEF.