Mateusz Sokolski

Iron deficiency defined as depleted iron stores accompanied by unmet cellular iron requirements identifies patients at the highest risk of death after an episode of acute heart failure

AIM Acute heart failure (AHF) critically deranges haemodynamic and metabolic homoeostasis. Iron is a key micronutrient for homoeostasis maintenance. We hypothesized that iron deficiency (ID) defined as depleted iron stores accompanied by unmet cellular iron requirements would in this setting predict the poor outcome. METHODS AND RESULTS Among 165 AHF patients (age 65 ± 12 years, 81% men, 31% de novo HF), for ID diagnosis we prospectively applied: low serum hepcidin reflecting depleted iron stores (<14.5 ng/mL, the 5th percentile in healthy peers), and high-serum soluble transferrin receptor (sTfR) reflecting unmet cellular iron requirements (≥1.59 mg/L, the 95th percentile in healthy peers). Concomitance of low hepcidin and high sTfR (the most profound ID) was found in 37%, isolated either high sTfR or low hepcidin was found in 29 and 9% of patients, and 25% of subjects demonstrated preserved iron status. Patients with low hepcidin and high sTfR had peripheral oedema, high NT-proBNP, high uric acid, low haemoglobin (P < 0.05), and 5% in-hospital mortality (0% in remaining patients). During the 12-month follow-up, 33 (20%) patients died. Those with low hepcidin and high sTfR had the highest 12-month mortality [(41% (95% CI: 29-53%)] when compared with those with isolated high sTfR [15% (5-25%)], isolated low hepcidin [7% (0-19%)] and preserved iron status (0%) (P < 0.001). Analogous mortality patterns were seen separately in anaemics and non-anaemics. CONCLUSION Iron deficiency defined as depleted body iron stores and unmet cellular iron requirements is common in AHF, and identifies those with the poor outcome. Its correction may be an attractive therapeutic approach.

Comparison of invasive and non-invasive measurements of haemodynamic parameters in patients with advanced heart failure.

Aim Measurement of haemodynamic parameters using a Swan–Ganz catheter is of clinical importance in patients with advanced heart failure; however, its applicability is limited due to its invasiveness. The aim of the study was to estimate the concordance between invasive and non-invasive measurements of haemodynamic parameters in patients with advanced heart failure. Methods and results We examined 25 patients with advanced heart failure (20 men, age: 64 ± 11 years, New York Heart Association class III/IV: 88/12%, left ventricular ejection fraction: 37 ± 20%), 13 (52%) demonstrated decompensated heart failure. Resting haemodynamic parameters were measured simultaneously using two methods: an invasive Swan–Ganz catheterization and a thermodilution technique; and a non-invasive recording using a device for finger arterial pressure waveform analysis. The following parameters were analysed: stroke volume (SV, ml), cardiac output (CO, l/min) and systemic vascular resistance (SVR, dyne × s/cm5). The concordance between these two methods was assessed using the variability coefficient calculated according to a Bland–Altman method. Comparing the invasive and non-invasive measures, variability coefficients were: 13, 18 and 11% for SV, SVR and CO, respectively. Similar variability coefficients were obtained when invasive and non-invasive measurements were compared in prespecified subgroups of patients, distinguished based on the presence of decompensation, atrial fibrillation and values of SBP. Conclusions Evaluation of haemodynamic parameters using a non-invasive method based on a pressure pulse contour model reveals an adequate concordance with the measures obtained using an invasive approach. Our results suggest that a non-invasive method for haemodynamic monitoring could be applied in clinical practice in patients with advanced heart failure.

Impaired hepato-renal function defined by the MELD XI score as prognosticator in acute heart failure.

Multi‐organ dysfunction often complicates the natural course of acute heart failure (AHF) and identifies patients with poor prognosis. The MELD score (Model of End‐Stage Liver Dysfunction) combines data reflecting liver and kidney function, which makes it a potentially useful tool for the assessment of patients with AHF. The aim of this study was to assess the prognostic utility of the MELD score in patients with AHF.

Urinary levels of novel kidney biomarkers and risk of true worsening renal function and mortality in patients with acute heart failure

Recent studies indicate the need to redefine worsening renal function (WRF) in acute heart failure (AHF), linking a rise in creatinine with clinical status to identify patients who develop ‘true WRF’. We evaluated the usefulness of serial assessment of urinary levels of neutrophil gelatinase‐associated lipocalin (uNGAL), kidney injury molecule‐1 (uKIM‐1), and cystatin C (uCysC) for prediction of ‘true WRF’.

Increased blood lactate is prevalent and identifies poor prognosis in patients with acute heart failure without overt peripheral hypoperfusion.

Lactate is produced by anaerobic metabolism and may reflect inadequate tissue perfusion in conditions such as acute heart failure (AHF). We evaluated the prevalence and clinical significance of elevated blood lactate on admission in patients with AHF.

Validation of transurethral intra‑abdominal pressure measurement in acute heart failure

Patients and methods The study population in‐ volved 8 prospectively enrolled patients with pri‐ mary diagnosis of acute HF, who were hospitalized between 2010 and 2015 in the Centre for Heart Diseases at the 4th Military Hospital in Wrocław, Poland, and who underwent paracentesis due to ascites. All patients had Foley catheters inserted for clinical indications. Informed consent to par‐ ticipate in the study was obtained from all partici‐ pants. The study protocol was approved by the lo‐ cal ethics committee, and the study was conduct‐ ed in accordance with the Helsinki Declaration. The IAP was measured using 2 simultane‐ ous methods: direct and indirect (transure‐ thral). The first technique involved intraperito‐ neal pressure measurement through the para‐ centesis. A needle was inserted into the abdom‐ inal cavity to evacuate the ascites (as a standard of care). The tip of the pressure tube line was placed in the peritoneal fluid through a paracen‐ tesis needle to prevent air from entering the line and the needle, and thus damping of the read‐ ing. The second method estimated the pressure in the urinary bladder using a Foley catheter after filling the bladder with saline, according to previ‐ ous recommendations.2,3 The tip of the pressure tube was connected to the catheter to prevent air from entering the line and catheter, in order to avoid damping of the recording. All measure‐ ments were performed before the evacuation of ascites. Both pressure measurements were per‐ formed using the TruWave (3cc)/150 cm transduc‐ er sets (Edwards Lifesciences, Irvine, California, Introduction Intra ‐abdominal pressure (IAP) is the pressure within the abdominal cavity; its el‐ evated values have been considered to be an im‐ portant underlying mechanism of organ function deterioration in selected populations (described mainly in critical care patients). Interestingly, in‐ creased IAP was identified as one of the factors responsible for deteriorated renal function in pa‐ tients with heart failure (HF) due to fluid over‐ load.1,2 Venous congestion significantly decreases intra ‐abdominal venous and arterial blood flow, leading to multiorgan failure. In some cases, ex‐ travascular fluid (in the body cavities) require treatment modification, including evacuation to prevent further organ dysfunction.3-5 However, we should be aware that not only patients with evident signs of ascites present with abnormal‐ ly increased IAP. Although fluid accumulation in this compartment is not evident in many cases, it may play an important role in organ perfusion, especially in HF with kidney deterioration or di‐ uretic resistance. Moreover, a reduction of IAP through adequate treatment (optimal pharmaco‐ therapy, ultrafiltration/dialysis, or, in some cas‐ es, paracentesis) could significantly improve or‐ gan function.1-3 Therefore, this parameter could be useful in accurate patient profiling and pro‐ viding adequate treatment strategies. The direct IAP assessment is difficult because it involves an invasive penetration into the peri‐ toneum. Therefore, many different (less invasive) methods have been proposed, with the transure‐ thral approach being an interesting option. This technique assumes that pressure measured using a Foleys bladder catheter reflects the adequate IAP.3-7 However, there have been only limited re‐ ports showing the applicability of transurethral IAP measurement in selected populations (gen‐ erally limited to critically ill patients under an‐ esthesia or mechanically ventilated, individuals undergoing surgery, or patients with trauma). RESEARCH LETTER

InterAtrial Shunt Device (IASD®) implantation — a novel treatment method for heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is a condition with complex pathophysiology and clinical profile. No treatment has been proven to reduce mortality or reduce morbidity in a meaningful way. In the era of percutaneous cardiac interventions, a novel method of reducing left atrial pressure by creating an iatrogenic interatrial shunt has been introduced. We present a report of implantation of InterAtrial Shunt Device (IASD®) in three consecutive patients.

Acute heart failure in patients admitted to the emergency department with acute myocardial infarction

BACKGROUND Acute heart failure (AHF), occurring as a complication of ongoing acute myocardial infarction (AMI), is a common predictor of worse clinical outcome. Much less is known about the unique subpopulation of patients who present these two life-threatening conditions in the emergency department (ED). AIM The aim of the study was to establish the prevalence of coexistence of AHF with AMI in the ED, to identify clinical factors associated with the higher prevalence of AHF at very early onset of AMI, and to assess the prognostic impact of the presence of AHF with AMI. METHODS A prospective study of 289 consecutive patients (mean age: 68 ± 11 years, 61% men) admitted to our institution (via the ED) with the diagnosis of AMI between May and October 2012 and followed-up for 2.5 years. RESULTS Acute heart failure was diagnosed in 13% of patients in the ED. In multivariable analysis, female sex, chronic obstruc-tive pulmonary disease, and chronic kidney disease significantly increased the risk of developing AHF together with AMI (all p < 0.05). Patients with AHF were hospitalised for longer (9.2 ± 6.1 vs. 6.3 ± 4.5 days, p < 0.001), had higher in-hospital cardiovascular mortality (8% vs. 0%, p < 0.001), and all-cause (34% vs. 15%, p = 0.004) and cardiovascular mortality (26% vs. 9%, p = 0.002) during long-term follow-up. CONCLUSIONS Despite good logistic- and evidence-based treatment, AHF is present in one in eight patients with AMI at the time of admission to the ED. Particularly poor outcomes characterise critically ill patients; therefore, great effort should be undertaken to improve their care.