Marat Fudim

Aetiology, timing and clinical predictors of early vs. late readmission following index hospitalization for acute heart failure: insights from ASCEND‐HF

Patients hospitalized for heart failure (HF) are at high risk for 30‐day readmission. This study sought to examine the timings and causes of readmission within 30u2009days of an HF hospitalization.

Splanchnic Nerve Block for Acute Heart Failure

The abdominal vascular compartment is the main storage of intravascular blood volume, and decreased abdominal vascular capacitance has been proposed as a major contributor to the complex pathophysiology of heart failure (HF) in animals and humans.1, 2 In HF, as a result of neurohormonal imbalance, the vascular capacitance (storage-space) is decreased and acute sympathetic nerve activation can result in acute volume redistribution3 from the abdominal compartment to the thoracic compartment (heart and lungs), which increases intra-cardiac pressures and precipitates HF symptoms (Figure 1A). The sympathetic nervous system controls the splanchnic compartment via branches from the sympathetic thoracic ganglia (T6 through T11).4 We have identified the splanchnic nerves as a potential target for treating HF.

Hyperkalemia in Heart Failure: Probably Not O“K”

Hyperkalemia is routinely defined as a serum potassium level >5xa0mmol/L and is a common occurrence in patients with acute and chronic heart failure (HF). For example, prior work has demonstrated that hyperkalemia is present in ≈9% of patients admitted for acute HF,[1][1] and the total annual

Mechanical dyssynchrony according to validated cut-off values using gated SPECT myocardial perfusion imaging

In an attempt to grade the severity of mechanical dyssynchrony, Aguade’-Bruix et al. classified 408 patients prospectively into 4 groups based on the presence or the absence of any software-generated myocardial perfusion gated SPECT dyssynchrony parameters such as standard deviation, bandwidth, skewness, and kurtosis. The authors found that an increase in the degree of agreement between those measurements elevated the chance for future cardiac resynchronization therapy (CRT). Several limitations are worth mentioning:

Early versus late readmission during the vulnerable phase following hospitalization for heart failure: reply: Early versus late readmission during the vulnerable phase following hospitalization for heart failure: reply

We thank Kimura and colleagues for extending the discussion of our findings with complementary registry data from Japan exploring the post-discharge period following heart failure (HF) hospitalization. Our analysis of the ASCEND-HF trial found that approximately 10% of patients were readmitted within 30 days following discharge from an index hospitalization with worsening HF.1 One third of readmissions occurred within 7 days and two thirds within 15 days, indicating a skewed relationship in timing of readmission. The readmission rate was higher in North America than in Asia or Europe. Interestingly, timing of readmission within the first 30 days (early vs. later) was not associated with a differential relationship with clinical outcomes. An equally important finding was the high proportion of non-HF-related (54%) or even noncardiovascular (36%) causes of readmission. We are in agreement with Kimura and colleagues regarding the importance of the ‘vulnerable phase’ for recurrent events, which patients with HF enter as they transition into the outpatient setting following acute stabilization. HF patients are at an increased risk for readmission and death as has been shown in several analyses.2,3 The time window associated with a particularly high risk clearly extends beyond the first 30 days. As the Japanese data suggest, approximately the same percentage of patients are admitted in the time from day 0–30 as from day 31–180. A holistic management strategy may not unnecessarily focus on the 30-day metric when individual patients may benefit to a greater extent from longer term, sustained interventions. As many are well aware, the use of 30 days as cut-off is based on the health care metric set forward by the Centers for Medicaid and Medicare Services (CMS). While this is an arbitrary cut-off that does not follow a particular pathophysiologic rationale, countries around the world commonly use the same policy-driven 30-day benchmark.4 A recent review of the impact of the Hospital Readmission Reduction Program in the US has yielded some alarming results. Despite a US wide reduction in 30-day readmissions, there is evidence of simultaneously increased 30-day and 1-year mortality.5–7 While these findings have been contested,8 it does raise the question whether HF readmission to hospital during the vulnerable phase is an adverse event that is detrimental to the patient’s clinical course. It is well possible that over-aggressive attempts to prevent hospital readmissions do more harm than good. Thus, a critical review of the US but also worldwide readmission reduction programmes is urgently needed. Conflict of interest: M.F.: AxonTherapies, Coridea, Cibiem. GE Healthcare, supported by AHA grant 17MCPRP33460225 and the NHLBI T32 postdoctoral training grant 5T32HL007101-42. R.J.M.: Amgen, AstraZeneca, Bristol Myers Squibb, Gilead, GlaxoSmithKline, Novartis, Otsuka, ResMed, Thoratec.

Splanchnic nerve block for decompensated chronic heart failure: splanchnic-HF

Division of Cardiology, Department of Medicine, Duke Clinical Research Institute, 2400 Pratt St, Durham, NC 27705, USA; Division of Pain Medicine, Department of Anesthesiology, Duke University School of Medicine, 2301 Erwin Road, Durham, NC 27710, USA; and Department of Biostatistics and Bioinformatics and Duke Clinical Research Institute, Duke University School of Medicine, 2424 Erwin Road, Durham, NC 27710, USA

Relation of Volume Overload to Clinical Outcomes in Acute Heart Failure (From ASCEND-HF)

We aimed to study whether jugular venous distension (JVD) and peripheral edema were associated with worse outcomes in patients with acute heart failure in the Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure trial. Of 7,141 patients in Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure, 7,135 had complete data on baseline JVD and peripheral edema status. Patients were grouped according to baseline examination findings: (1) no JVD or peripheral edema; (2) JVD only; (3) peripheral edema only; (4) JVD and peripheral edema. We used unadjusted and adjusted logistic or Cox regression analyses to assess associations between groups and the outcomes of index length of stay (LOS), in-hospital mortality, 30- and 180-day all-cause mortality. Patients with peripheral edema (Groups 3 and 4) had higher body mass index, NT-proBNP and BNP values, and more co-morbid disease, and reduced left ventricular ejection fraction compared with patients in Groups 1-2. The median (25th-75th) LOS for Groups 1-4 was 6 (4-9), 5 (4-8), 7 (4-11), and 6 days (4-10), respectively. For the 30-day and 180-day outcomes, adjusted analyses found no significant difference in risk for patients presenting with JVD only or peripheral edema only as compared with patients without evidence of JVD or peripheral edema (p >0.05 for all). The presence of both JVD and peripheral edema was associated with an adjusted 24% increase in risk for all-cause mortality at 30 days, but no risk difference at 180 days. In conclusion, in patients with heart failure presenting to the hospital with dyspnea, the presence of peripheral edema is associated with a longer hospital LOS, but no difference in short- and long-term clinical outcomes when compared with patients wihout peripheral edema. The combination of peripheral edema and JVD identifies the highest risk cohort for poor clinical outcomes.

HEMOCONCENTRATION DURING MANAGEMENT OF PATIENTS WITH ACUTE HEART FAILURE AND CARDIORENAL SYNDROME: INSIGHTS FROM CARRESS-HF

Background: Hemoconcentration correlates with superior decongestion and improved outcomes among acute heart failure (AHF) patients, but data are limited to those with preserved renal function receiving intravenous diuretics. The role of hemoconcentration in AHF complicated by cardiorenal syndrome (