Background: Comorbidities are associated with poor clinical outcome in patients with chronic heart failure, and cardiac MIBG imaging also provides prognostic information in patients with heart failure.However, there is no information available on the impact of comorbidities on the prognostic value of cardiac MIBG imaging in patients admitted for acute decompensated heart failure (ADHF).Methods: We studied 354 consecutive ADHF patients with survival discharge.Comorbidity was measured with the Age-adjusted Charlson comorbidity index (ACCI) which is commonly used for the evaluation of the comorbid condition which is weighted and scored, with additional points added for age.Cardiac MIBG imaging were performed just before discharge and the cardiac MIBG heart-tomediastinum ratio (late HMR) were measured on the delayed image.The endpoint was cardiac event defined as a composite of cardiac death and unplanned hospitalization for worsening heart failure.Results: During a follow-up period of 2.1±1.4 years, 133 patients had cardiac event.At multivariate Cox analysis, ACCI (p=0.0003) and late HMR (p=0.0001) were significantly and independently associated with cardiac event.Patients with high ACCI (≥6: median value) had a significantly greater risk of cardiac event (47% vs 26%, p=0.0001,).In the subgroup of high ACCI≥6, patients with low late HMR (<1.55 determined by ROC analysis) had a significantly greater risk of cardiac event (68% vs 37% p<0.0001,).Furthermore, in the subgroup of low ACCI<6, patients with low late HMR (<1.48 determined by ROC analysis) also had a significantly greater risk of the cardiac event (54% vs 26%, p=0.0001, adjusted HR 3.62 [1.94-6.77]). Conclusions:The prognostic value of cardiac MIBG imaging is not affected by comorbidities and cardiac MIBG imaging provide prognostic information even in patients admitted for ADHF, irrespective of comorbidity burden.
Background: Comorbidities are associated with poor clinical outcome in heart failure patients. AHEAD (A: atrial fibrillation; H: hemoglobin; E: elderly; A: abnormal renal parameters; D: diabetes mellitus) score has been related to clinical outcomes in patients with acute decompensated heart failure (ADHF). On the other hand, systemic inflammation plays a critical role in the outcomes of heart failure. Malnutrition is also associated with poor outcome in heart failure patients. It has been recently reported that advanced lung cancer inflammation index (ALI), which is calculated as body mass index х serum albumin / neutrophil to lymphocyte ratio, is an independent prognostic marker in several types of cancer. We sought to investigate the prognostic value of the combination of AHEAD score and ALI in ADHF patients. Methods and Results: We studied 263 patients admitted for ADHF and discharged with survival. At the discharge, we obtained ALI and AHEAD score (range 0-5, atrial fibrillation, hemoglobin <13 mg/dL for men and 12 mg/dL for women, age >70 years, creatinine >130 μmol/L, and diabetes mellitus). During a follow-up period of 5.0±4.2 yrs, 67 patients had cardiovascular death (CVD). At multivariate Cox analysis, AHEAD score and ALI were significantly independently associated with CVD, independently of prior heart failure hospitalization, systolic blood pressure and serum sodium level. The patients with both greater AHEAD score (≥median value=3) and lower ALI (≤median value=42.3) had a significantly increased risk of CVD than those with either and none of them (45% vs 24% vs 13%, p<0.0001, respectively). Conclusion: ALI would provide the additional long-term prognostic information to AHEAD score in patients with ADHF.
Backgrounds: Increased heart rate (HR) and low systolic blood pressure (SBP) are associated with adverse clinical outcomes in patients (pts) admitted for acute decompensated heart failure (ADHF). It has been reported that simple risk index (SRI) based on easily assessed clinical characteristics (age, HR, and SBP) is useful for the prediction of short-term mortality in pts with acute myocardial infarction. However, there is no information available on the prognostic significance of pre-discharge SRI in pts admitted for ADHF relating to reduce or preserved left ventricular ejection fraction (HFrEF or HFpEF). Methods and Results: We studied 303 consecutive ADHF pts discharged with survival (HFrEF(LVEF<50%);n=163, HFpEF(LVEF≥50%);n=140), and obtained clinical characteristics, conventional hemodynamic parameters and laboratory data. SRI was calculated as (HRх[age/10] 2 )/SBP. During a follow up period of 4.2±3.3 yrs, 96 pts had all-cause death. In HFrEF group, at multivariate Cox analysis, SRI at the discharge (adjusted hazard ratio:1.055[95%CI 1.029 to 1.081], p<0.0001) was significantly associated with total mortality, independently of prior heart failure hospitalization, and serum sodium and albumin levels after adjustment for anemia and renal function. The mortality risk significantly increased by SRI tertiles (lowest tertile [<26.3]: 19%, middle tertile [26.3-36.3]: 38% and highest tertile [>36.3]: 54%, p=0.0001). In HFpEF group, SRI at the discharge (adjusted hazard ratio:1.065[95%CI 1.022 to 1.109], p=0.0026) was also significantly associated with total mortality, independently of anemia and serum sodium level after adjustment for renal function. Pts with highest and middle SRI tertile had a increased risk of total mortality than those with lowest tertile (30% vs 28% vs 13%, p=0.002, respectively). Conclusion: SRI at the discharge would provide the long-term prognostic information in ADHF pts, regardless of HFrEF or HFpEF.
Abstract Background Elevated serum uric acid (UA) level has been shown to be associated with reduced survival among patients (pts) with heart failure. Sodium glucose cotransporter 2 (SGLT2) inhibitors have been reported to lower serum uric acid level in pts with type 2 diabetes mellitus (T2D). Empagliflozin, one of the SGLT2 inhibitors, has been shown to reduce the risk of cardiovascular mortality in T2D pts with cardiovascular disease, and involvement of UA lowering effect by empagliflozin in the reduction of cardiovascular mortality has been suggested. However, little is known about the effect of empagliflozin as add-on therapy on serum UA level in T2D pts with acute decompensated heart failure (ADHF). Purpose We sought to elucidate the effect of empagliflozin as add-on therapy on serum UA level in T2D pts with ADHF. Methods We enrolled 38 consecutive T2D pts admitted for ADHF. On admission, enrolled pts were randomly assigned in a 1:1 ratio to either empagliflozin add-on therapy (EMPA(+)) or conventional glucose-lowering therapy (EMPA(−)). All pts in EMPA(+) group received empagliflozin (10 mg/day) throughout the study period. Left ventricular ejection fraction (LVEF) was measured at baseline using echocardiography. Body weight and vital signs, such as blood pressure and heart rate, were measured, and blood and urine samples were collected at baseline and 1, 2, 3 and 7 days after randomization. Renal handling of UA was evaluated by fractional excretion of UA (FEUA). Results Twenty pts were assigned to the EMPA(+) group, and 18 pts were assigned to the EMPA(−) group. There were no significant baseline differences in LVEF, plasma brain natriuretic peptide level, body mass index, or serum creatinine level between the EMPA(+) and EMPA(−) groups. In addition, prevalence rate of hyperuricemia, serum UA level, and FEUA did not significantly differ between the two groups at baseline. However, there was significant difference in the change in serum UA level from baseline at 2, 3 and 7 days after randomization between the two groups (Figure A). As a result, serum UA level was significantly lower in the EMPA(+) group than in the EMPA(−) group at 7 days after randomization (6.2±1.8 mg/dL vs 7.8±1.8 mg/dL, p=0.0127). Moreover, FEUN of the EMPA(+) group was significantly higher at 1, 2 and 7 days after randomization (Figure B), which suggested that serum UA level was lowered in the EMPA(+) group by increased urinary excretion of UA. Figure 1 Conclusions This study demonstrated that empagliflozin as add-on therapy can lower serum UA level in T2D pts with ADHF through the effect on the urinary excretion rate of UA.
Abstract Background A four-parameter risk model including cardiac iodine-123 metaiodobenzylguanidine (MIBG) imaging and readily available clinical parameters has been recently developed for the prediction of 2-year cardiac mortality risk in patients with chronic heart failure (CHF) using a Japanese CHF database consisting of 1322 patients. On the other hand, the Acute Decompensated Heart Failure National Registry (ADHERE) and Get With The Guidelines-Heart Failure (GWTG-HF) risk scores, simple tools to predict risk of in-hospital mortality, have been reported to be predictive of post-discharge outcome in patients with acute decompensated heart failure (ADHF). However, there is no information available on the usefulness of 2-year MIBG-based cardiac mortality risk score for the prediction of post-discharge prognosis in ADHF patients and its comparison with the ADHERE and GWTG-HF risk scores. Purpose We sought to validate the predictability of the 2-year MIBG-based cardiac mortality risk score for post-discharge clinical outcome in ADHF patients, and to compare its prognostic value with those of ADHERE and GWTG-HF risk scores. Methods We studied 297 consecutive patients who were admitted for ADHF, survived to discharge, and had definitive 2-year outcomes. Venous blood sampling was performed on admission, and echocardiography and cardiac MIBG imaging were performed just before discharge. In cardiac MIBG imaging, the cardiac MIBG heart-to-mediastinum ratio (HMR) was measured from the chest anterior view images obtained at 20 and 200 min after isotope injection. The 2-year cardiac mortality risk score was calculated using four parameters, including age, left ventricular ejection fraction, NYHA functional class, and HMR on delayed image. The patients were stratified into three groups based on the 2-year cardiac mortality risk score: low- (<4%), intermediate- (4–12%), and high-risk (>12%) groups. The ADHERE and GWTG-HF risk scores were also calculated from admission data as previously reported. The predictive ability of the scores was compared using receiver operating characteristic curve analysis. The endpoint was a composite of all-cause mortality and unplanned hospitalization for worsening heart failure. Results During a follow-up period, 110 patients reached the primary endpoint. There was significant difference in the rate of primary endpoint among the three groups stratified by 2-year cardiac mortality risk score (low-risk group: 18%, intermediate-risk group: 36%, high-risk group: 64%, Figure 1A). The 2-year cardiac mortality risk score demonstrated a greater area under the curve for the primary endpoint compared to the ADHERE and the GWTG-HF risk scores (Figure 1B). Figure 1 Conclusions The 2-year MIBG-based cardiac mortality risk score is also useful for the prediction of post-discharge clinical outcome in ADHF patients, and its prognostic value is superior to those of the ADHERE and the GWTG-HF risk scores.
Backgrounds: Acute kidney injury (AKI) during heart failure treatment is associated with poor outcome in patients admitted for acute decompensated heart failure (ADHF). Clinical scenario (CS) is used in the early clinical management of ADHF. However, there is no information available on the long-term prognostic significance of AKI, relating to CS classification in ADHF patients. Methods and Results: We studied 303 ADHF patients discharged with survival. According to systolic blood pressure (SBP) at admission, these patients were classified into CS1 (SBP>140mmHg, n=162), CS2 (SBP:100-140 mmHg, n=114), and CS3(SBP 2- to 3-fold increase in Cr, stage 3: >3-fold increase in Cr or Cr≥4.0mg/dl with an acute rise of ≥0.5mg/dl). During a follow-up period of 4.1±3.2 yrs, 81 patients had cardiovascular-renal poor outcome (CVR), defined as cardiovascular death and the development of end-stage renal disease requiring renal replacement therapy. At multivariate Cox analysis, SBP (p=0.0078) and AKI (p=0.0029) were significantly associated with CVR, independently of serum sodium level and renal function. In group with CS1, patients with stage 2 or 3 AKI (adjusted HR: 4.2[1.4-25.8]) had a significant increased risk of CVR, compared to patients with no AKI, while there was no significant difference in the risk between patients with stage 1 AKI and no AKI. On the other hand, in groups with CS2 or CS3, AKI stages were not significantly associated with CVR. Conclusion: Moderate to severe AKI during heart failure treatment would provide the long-term prognostic information in ADHF patients presenting CS1, but not CS2 and CS3. These results suggested that AKI which occurred in the setting without lower SBP would have the long-term prognostic value in ADHF patients.
