Protocolized Natriuresis-Guided Decongestion Improves Diuretic Response: The Multicenter ENACT-HF Study.

BACKGROUND: The use of urinary sodium to guide diuretics in acute heart failure is recommended by experts and the most recent European Society of Cardiology guidelines. However, there are limited data to support this recommendation. The ENACT-HF study (Efficacy of a Standardized Diuretic Protocol in Acute Heart Failure) investigated the feasibility and efficacy of a standardized natriuresis-guided diuretic protocol in patients with acute heart failure and signs of volume overload. METHODS: ENACT-HF was an international, multicenter, open-label, pragmatic, 2-phase study, comparing the current standard of care of each center with a standardized diuretic protocol, including urinary sodium to guide therapy. The primary end point was natriuresis after 1 day. Secondary end points included cumulative natriuresis and diuresis after 2 days of treatment, length of stay, and in-hospital mortality. All end points were adjusted for baseline differences between both treatment arms. RESULTS: Four hundred one patients from 29 centers in 18 countries worldwide were included in the study. The natriuresis after 1 day was significantly higher in the protocol arm compared with the standard of care arm (282 versus 174 mmol; adjusted mean ratio, 1.64; P<0.001). After 2 days, the natriuresis remained higher in the protocol arm (538 versus 365 mmol; adjusted mean ratio, 1.52; P<0.001), with a significantly higher diuresis (5776 versus 4381 mL; adjusted mean ratio, 1.33; P<0.001). The protocol arm had a shorter length of stay (5.8 versus 7.0 days; adjusted mean ratio, 0.87; P=0.036). In-hospital mortality was low and did not significantly differ between the 2 arms (1.4% versus 2.0%; P=0.852). CONCLUSIONS: A standardized natriuresis-guided diuretic protocol to guide decongestion in acute heart failure was feasible, safe, and resulted in higher natriuresis and diuresis, as well as a shorter length of stay.

Characteristics of patients admitted with heart failure: Insights from the first Malaysian Heart Failure Registry.

AIMS: Heart failure (HF) is a growing health problem, yet there are limited data on patients with HF in Malaysia. The Malaysian Heart Failure (MY-HF) Registry aims to gain insights into the epidemiology, aetiology, management, and outcome of Malaysian patients with HF and identify areas for improvement within the national HF services. METHODS AND RESULTS: The MY-HF Registry is a 3-year prospective, observational study comprising 2717 Malaysian patients admitted for acute HF. We report the description of baseline data at admission and outcomes of index hospitalization of these patients. The mean age was 60.2 ± 13.6 years, 66.8% were male, and 34.3% had de novo HF. Collectively, 55.7% of patients presented with New York Heart Association (NYHA) Class III or IV; ischaemic heart disease was the most frequent aetiology (63.2%). Most admissions (87.3%) occurred via the emergency department, with 13.7% of patients requiring intensive care, and of these, 21.8% needed intubation. The proportion of patients receiving guideline-directed medical therapy increased at discharge (84.2% vs. 93.6%). The median length of stay (LOS) was 5 days, and in-hospital mortality was 2.9%. Predictors of LOS and/or in-hospital mortality were age, NYHA class, estimated glomerular filtration rate, and comorbid anaemia. LOS and in-hospital mortality were similar regardless of ejection fraction. CONCLUSIONS: The MY-HF Registry showed that the HF population in Malaysia is younger, predominantly male, and ischaemic-driven and has good prospects with hospitalization for optimization of treatment. These findings suggest a need to reassess current clinical practice and guide resource allocation to improve patient outcomes.

From Primary to Tertiary Care: Expert Position Statements to Guide Heart Failure with Preserved Ejection Fraction Diagnosis.

Globally, heart failure with preserved ejection fraction (HFpEF) is quickly becoming the dominant form of heart failure (HF) in ageing populations. However, there are still multiple gaps and challenges in making a firm diagnosis of HFpEF in many low-to-middle income Asian countries. In response to this unmet need, the Malaysian HFpEF Working Group (MY-HPWG) gathered and reviewed evidence surrounding the use of different diagnostic modalities indicated for patients with HFpEF to identify diagnostic tools that could be conveniently accessed across different healthcare settings. As a result, five recommendation statements were proposed and an accompanying algorithm was developed, with the aim of improving the diagnostic rate of HFpEF. The MY-HPWG recommends using more easily accessible and non-invasive tools, such as natriuretic peptide (NP) biomarkers and basic echocardiogram (ECHO), to ensure timely HFpEF diagnosis in the primary and secondary care settings, and prompt referral to a tertiary care centre for more comprehensive assessments in uncertain cases.

Novel treatment of atrial functional tricuspid regurgitation using transcatheter bicaval valve implantation (TricValve).

Background: Transcatheter tricuspid valve intervention has recently emerged as a viable alternative to surgery for patients with symptomatic severe tricuspid regurgitation (TR). Though usually performed on the basis of compassionate grounds, we are now exploring the extension of its usage as an elective option in a patient with severe atrial functional tricuspid regurgitation. Aims: The aim of this study was to select a suitable patient and proceed with the implantation of the TricValve in order to provide symptomatic relief as well as to improve morbidity and mortality. Methods: A 67-year-old woman had underlying atrial fibrillation and severe tricuspid regurgitation. Despite optimised medical therapy, she remained symptomatic with elevated NT-proBNP levels. As the patient refused surgery on multiple occasions, we chose a percutaneous procedure guided by transoesophageal echocardiography and fluoroscopy. Results: The procedure was uneventful and the patient was discharged. At 3-month follow-up, there was marked improvement clinically and biochemically. Conclusions: Bicaval valve implantation with the TricValve is a viable alternative to surgery in patients with symptomatic severe tricuspid regurgitation. This intervention is crucial as we are now able to intervene before irreversible right ventricular dysfunction sets in.

Patient profiles on outcomes in patients hospitalized for heart failure: a 10-year history of the Malaysian population.

AIMS: Heart failure (HF) affects an estimated 38 million people worldwide and is the leading cause of hospitalization among adults and the elderly. Evidence suggests that there may be regional and ethnic differences in the prevalence, outcomes and management of HF. The aim of this study was to understand the disease burden and treatment patterns of patients hospitalized for HF in multi-ethnic Malaysia. METHODS AND RESULTS: A retrospective, non-interventional study was conducted utilizing 10 years of medical records from the National Heart Institute Malaysia (IJN) from 1 January 2009 to 31 December 2018. Of the 4739 patients in the IJN database, 3923 were eligible and were included in this analysis. The study recorded a high male prevalence (72.3%) with a mean age of 62.0 (±13.26) years. The 30-day and 1-year rehospitalization rate was 6.8% and 24.7%, respectively. In-hospital mortality was 7.2% with 27.0% due to cardiovascular causes and 14.2% non-cardiovascular causes. The 30-day and 1-year rehospitalization rates were significantly higher in patients with lower systolic blood pressure (SBP, P < 0.001 and P = 0.002), diastolic blood pressure (DBP, P < 0.001 and P = 0.017), sodium (P < 0.001 and P = 0.029) and estimated glomerular filtration rate (eGFR, P < 0.001 and P = 0.002) and higher urea (P < 0.001 for both), serum creatinine (P < 0.001 and P = 0.003), and uric acid (P < 0.001 for both), respectively. Risk of hospitalization within 1 year varied significantly by ethnicity and was relatively higher in Indian (28.3%), followed by Malay (24.4%) and Chinese (21.9%; P = 0.008). In-hospital mortality within 1-year post-index date was higher in patients with lower weight (P = 0.002), body mass index (P = 0.009), SBP (P < 0.001), DBP (P < 0.001), sodium (P < 0.001), eGFR (P < 0.001) and higher heart rate (P = 0.039), urea (P < 0.001), serum potassium (P = 0.038), serum creatinine (P < 0.001), and uric acid (P < 0.001). In-hospital mortality within 1-year post-index date was also higher in patients with severe or end-stage chronic kidney disease (CKD) compared with mild/moderate CKD (P < 0.001) and in patients with HF with reduced ejection fraction (HFrEF) compared with those with mid-range or preserved ejection fraction (P < 0.001). The most commonly prescribed HF medications at discharge were loop diuretics (89.2%), ß-blockers (68.5%), mineralocorticoid receptor antagonists (56.2%), angiotensin-converting enzyme inhibitors (31.5%), and angiotensin receptor blockers (20.8%). CONCLUSIONS: This study provides a greater understanding of the characteristics, treatment patterns, and outcome of hospitalized HF patients in a leading referral centre in Malaysia and will aid the implementation of meaningful interventions to improve patient outcome for HF patients.

The Great Asian Mismatch: Training Versus Care in Heart Failure.

The prevalence of heart failure (HF) in South-East Asia is relatively higher than in Western countries, and yet there is a lack of established fellowship programs within the region to help cultivate HF specialists. Part of this may be due to a misunderstanding that HF training and curricula require the incorporation of advanced therapies, such as ventricular assist device implantation and heart transplantation, which are rarely performed in this region. Developing a structured curriculum tailored to the needs of HF care in South-East Asia may help to provide for this subspecialty the much-needed and long-overdue recognition it deserves. Collaboration between local societies and their international counterparts is an important starting point. Customization of local and regional curricula, depending on local needs and capabilities, allows for the gap in this Great Asian Mismatch to be bridged and to ensure that equitable training is delivered for all.

Rationale and Design of the Efficacy of a Standardized Diuretic Protocol in Acute Heart Failure Study.

AIMS: Although acute heart failure (AHF) with volume overload is treated with loop diuretics, their dosing and type of administration are mainly based upon expert opinion. A recent position paper from the Heart Failure Association (HFA) proposed a step-wise pharmacologic diuretic strategy to increase the diuretic response and to achieve rapid decongestion. However, no study has evaluated this protocol prospectively. METHODS AND RESULTS: The Efficacy of a Standardized Diuretic Protocol in Acute Heart Failure (ENACT-HF) study is an international, multicentre, non-randomized, open-label, pragmatic study in AHF patients on chronic loop diuretic therapy, admitted to the hospital for intravenous loop diuretic therapy, aiming to enrol 500 patients. Inclusion criteria are as follows: at least one sign of volume overload (oedema, ascites, or pleural effusion), use ≥ 40 mg of furosemide or equivalent for >1 month, and a BNP > 250 ng/L or an N-terminal pro-B-type natriuretic peptide > 1000 pg/L. The study is designed in two sequential phases. During Phase 1, all centres will treat consecutive patients according to the local standard of care. In the Phase 2 of the study, all centres will implement a standardized diuretic protocol in the next cohort of consecutive patients. The protocol is based upon the recently published HFA algorithm on diuretic use and starts with intravenous administration of two times the oral home dose. It includes early assessment of diuretic response with a spot urinary sodium measurement after 2 h and urine output after 6 h. Diuretics will be tailored further based upon these measurements. The study is powered for its primary endpoint of natriuresis after 1 day and will be able to detect a 15% difference with 80% power. Secondary endpoints are natriuresis and diuresis after 2 days, change in congestion score, change in weight, in-hospital mortality, and length of hospitalization. CONCLUSIONS: The ENACT-HF study will investigate whether a step-wise diuretic approach, based upon early assessment of urinary sodium and urine output as proposed by the HFA, is feasible and able to improve decongestion in AHF with volume overload.

Intramyocardial dissecting haematoma mimicking left ventricular clot, a rare complication of myocardial infarction: a case report.

BACKGROUND: Intramyocardial dissecting haematoma is a rare complication of myocardial infarction (MI) associated with high mortality rates. Studies and research of this occurrence are limited largely to isolated case reports or case series. CASE SUMMARY: We report a case of late presenting MI, where on initial echocardiogram had what was thought to be an intraventricular clot. However, upon further evaluation, the patient actually had an intramyocardial haematoma, with the supporting echocardiographic features to distinguish it from typical left ventricular (LV) clot. While this prevented the patient from receiving otherwise unnecessary anticoagulation, this diagnosis also put him at a much higher risk of mortality. Despite exhaustive medical and supportive management, death as consequence of pump failure occurred after 2 weeks. DISCUSSION: This report highlights the features seen on echocardiography which support the diagnosis of an intramyocardial haematoma rather than an LV clot, notably the various acoustic densities, a well visualized myocardial dissecting tear leading into a neocavity filled with blood, and an independent endocardial layer seen above the haematoma. Based on this report, we wish to highlight the importance of differentiating intramyocardial haematomas from intraventricular clots in patients with recent MI.

Oxidative status and reduced glutathione levels in premature coronary artery disease and coronary artery disease.

Identifying patients at risk of developing premature coronary artery disease (PCAD) which occurs at age below 45 years old and constitutes approximately 7-10% of coronary artery disease (CAD) worldwide remains a problem. Oxidative stress has been proposed as a crucial step in the early development of PCAD. This study was conducted to determine the oxidative status of PCAD in comparison to CAD patients. PCAD (<45 years old) and CAD (>60 years old) patients were recruited with age-matched controls (n = 30, each group). DNA damage score, plasma malondialdehyde (MDA) and protein carbonyl content were measured for oxidative damage markers. Antioxidants such as erythrocyte glutathione (GSH), oxidised glutathione (GSSG), and glutathione peroxidase activity (GPx), superoxide dismutase (SOD) and catalase (CAT) were also determined. DNA damage score and protein carbonyl content were significantly higher in both PCAD and CAD when compared to age-matched controls while MDA level was increased only in PCAD (p<.05). In contrast, GSH, GSH/GSSG ratio, α-tocotrienol isomer, and GPx activity were significantly decreased, but only in PCAD when compared to age-matched controls. The decrease in GSH was associated with PCAD (OR = 0.569 95%CI [0.375 - 0.864], p = .008) and cut-off values of 6.69 µM with areas under the ROC curves (AUROC) 95%CI: 0.88 [0.80-0.96] (sensitivity of 83.3%; specificity of 80%). However, there were no significant differences in SOD and CAT activities in all groups. A higher level of oxidative stress indicated by elevated MDA levels and low levels of GSH, α-tocotrienol and GPx activity in patients below 45 years old may play a role in the development of PCAD and has potential as biomarkers for PCAD.

Heart failure across Asia: Same healthcare burden but differences in organization of care.

A gap in the knowledge on the status of heart failure (HF) in Asia versus other regions led to the creation of a working group of Asian experts from 9 countries or regions (Hong Kong, Indonesia, Malaysia, Philippines, Singapore, South Korea, Taiwan, Thailand, and Vietnam). Each expert sought the best available data from local publications, registries, or clinical practice. The prevalence of HF in Asia was generally similar to global values (1% to 3%), but with some outliers. There were substantial variations in healthcare spending, and the average cost of HF hospitalization varied from 813 US$ in Indonesia to nearly 9000 US$ in South Korea. Comorbidities were frequent, particularly hypertension, diabetes mellitus, and dyslipidemia. Modifiable risk factors such as smoking were alarmingly common in some countries. Asian HF patients spent between 5 and 12.5days in hospital, and 3% to 15% were readmitted for HF by 30days. The pharmacological treatment of Asian patients generally followed international guidelines, including renin-angiotensin-aldosterone system inhibitors (61% to 90%), diuretics (76% to 99%), beta-blockers (32% to 78%), and digoxin (19% to 53%), with some room for improvement in terms of life-saving therapies. Our review supports implementation of a more comprehensive and organized approach to HF care in Asia.

Heart transplantation for advanced heart failure due to cardiac sarcoidosis.

BACKGROUND: Selected patients with cardiac sarcoidosis undergo heart transplantation, but outcomes may be adversely affected by recurrent cardiac sarcoidosis or progressive extra-cardiac sarcoidosis. OBJECTIVES: We present our single-center experience of patients with cardiac sarcoidosis who underwent heart transplantation. METHODS: Consecutive patients that underwent heart transplantation between 1990 and 2012 were assessed. Cardiac sarcoidosis was defined by the presence of multiple non-caseating epithelioid cell granulomata in the explanted heart. Baseline characteristics and clinical outcomes were compared with a control group without cardiac sarcoidosis that underwent heart transplantation during this period. RESULTS: 901 patients underwent heart transplantation during the study period, of whom 4 patients had a pre-transplant diagnosis of cardiac sarcoidosis and 8 patients had sarcoidosis identified in the explanted heart. Patients with cardiac sarcoidosis had excellent post-transplant outcomes with survival of 92% at one year and 83% at five years. Survival was similar to patients that underwent heart transplantation for an alternate diagnosis. We did not encounter recurrent cardiac sarcoidosis or progressive extra-cardiac sarcoidosis during 1001 months of follow-up. CONCLUSIONS: Carefully selected patients with advanced heart failure due to cardiac sarcoidosis have an acceptable outcome after transplantation. Cardiologists should be aware that reported experience of transplantation for cardiac sarcoidosis mostly represents isolated cardiac sarcoidosis that was only diagnosed at pathological examination of the explanted heart.

The journey of Malaysian NCVD-PCI (National Cardiovascular Disease Database-Percutaneous Coronary Intervention) Registry: a summary of three years report.

INTRODUCTION: The Malaysian National Cardiovascular Disease Database (NCVD) team presents Percutaneous Coronary Intervention (PCI) Registry report for the year 2007 to 2009. It provides comprehensive information regarding practice and outcome of PCI in Malaysia. METHODOLOGY: It was a voluntary, multi-centered, observational, cohort study and included patients of 18 years or above who underwent PCI at eleven participating centers in Malaysia from the year 2007 to 2009. RESULT: Ten thousand six hundred and two patients underwent 11,498 PCI procedures with 18,116 stents for 15,538 lesions. Mean age of the patients was 57 years and more than 98% of patients had at least one cardiovascular risk factor. A significant number of our patients were diabetic (50%) and had renal impairment (44.7% had ≤ stage 3 chronic kidney disease) at the time of procedure. Fifty eight percent of the lesions were type B2 or type C lesion. Twenty eight percent of the lesions had high risk characteristics. Procedural success rate was about 97% and post-procedural complications were low. Overall in-hospital, all cause mortality was 1%, of which 85% were cardiac related deaths. The poor prognostic factors for in-hospital mortality were acute coronary syndrome cases, higher Killip class and increasing age. CONCLUSION: Compared to other registries, Malaysian patients undergoing PCI were much younger with high prevalence of risk factors. In spite of complex and high risk lesions, procedural success was high, with overall low mortality rate. NCVD-PCI Registry aims to improve over-all cardiac services in Malaysia through its ongoing journey.