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Research Article | Open Access2024|Volume 5|Issue 2| https://doi.org/10.37191/Mapsci-JCCR-5(2)-095

Early Diagnostic and Management of Acute Heart Failure: Can Cardiogenic Shock be Prevented?

Antonio Felipe Leite Simao1,5*, Gdayllon Cavalcante Meneses2, Lia Cavalcante Cezar3, Heraldo Guedis Lobo Filho1,3 and Fátima Rosane de Almeida Oliveira1,4

1Carlos Alberto Studart Gomes Hospital, Fortaleza, Brazil

2Medical Sciences Post-graduate Program, Department of Physiology and Pharmacology, Faculty of Medicine, Federal University of Ceara, Fortaleza, Brazil

3Department of Surgery, School of Medicine, Federal University of Ceara, Fortaleza, Brazil

4Walter Cantidio University Hospital, Federal University of Ceara, Fortaleza, Brazil

5Xiamen Cardiovascular Hospital Xiamen University, Xiamen, China

*Corresponding Author: Antonio Felipe Leite Simao, MD, MSc, PhD, Carlos Alberto Studart Gomes Hospital, Fortaleza Brazil, Xiamen Cardiovascular Hospital Xiamen University, Xiamen, China.

ReceivedMay 1, 2024RevisedMay 10, 2024AcceptedMay 22, 2024PublishedJun 5, 2024
Abstract

Background: Heart failure is a growing health concern, affecting about 2% of the adult population. It emphasizes the importance of recognizing and addressing a specific subgroup of patients suffering from acute heart failure (AHF). AHF is described as a critical clinical condition often overlooked in diagnosis, leading to catastrophic outcomes if not promptly identified. Given its potential severity, understanding the unique characteristics of AHF, along with appropriate therapeutic interventions, is crucial for improving patient outcomes and reducing mortality rates.

Methods: The study included 20 patients with heart failure and reduced ejection fraction who presented with decompensated clinical conditions characteristic of acute heart failure. Data were collected preoperatively, perioperatively, and postoperatively up to a 30-day follow-up period.

Results: The primary outcome was the 30-day mortality, which was found to be 20%. Among the patients with AHF, 60% had congestive heart failure with an average ejection fraction of 29.8%, indicating severe ventricular dysfunction. Additionally, 45% of patients presented with chronic kidney injury, characterized by a low mean glomerular filtration rate and elevated urea and creatinine levels. The presence of acute congestive and retention syndrome was evident in these patients, exacerbating the underlying disease. Notably, 10% of patients required left ventricular assistance devices, and associated procedures were performed as part of the surgical management of heart failure.

Conclusion: The failure to recognize the diagnosis of this serious acute condition can quickly lead to patient’s death. Although, AHF showed 30-days high mortality rate, early diagnose, decongestive therapy and myocardial revascularization had avoided worst outcomes in cardiogenic shock.

Keywords

Acute heart failure; Ischemic cardiomyopathy; Myocardial infarction; Congestive heart failure; Kidney failure; Myocardial revascularization; Cardiogenic shock.

Abbreviations

AAD: Ascending Aorta Diameter; CABG: Coronary Artery Bypass Grafting; CAD: Coronary Artery Disease; HF: Heart Failure; LA: Left Atrium; LVEDD: Left Ventricular End-diastolic Diameter; LVEF: Left Ventricular Ejection Fraction; LVESD: Left Ventricular End-systolic Diameter; PET scan: Positron Emission Tomography Scan; STICH: Surgical Treatment for Ischemic Heart; SHOCK: SHould we Emergently Revascularize Occluded Coronaries for Cardiogenic; VAD: Vasoactive Drugs.

Introduction

Heart Failure (HF) has emerged as a significant public health concern, affecting approximately 2% of the adult population. Hospital admissions related to HF have tripled since the 1990’s [1].

HF is characterized as a chronic and progressive clinical syndrome resulting from structural or functional abnormalities in the heart, with manifestations of either decreased (HFrEF) or maintained (HFpEF) left ventricular ejection fraction (LVEF) [2]. The burden of HF is substantial, with an estimated 5.8 million patients in the United States and 15 million in Europe affected [3]. Hypertension was a consistent contributor to HF globally (17%) [4].

Despite the extensive spectrum of HF, the authors wish to highlight a specific subset of patients often overlooked yet facing critical circumstances. These patients suffer from Acute Heart Failure (AHF), with ischemic heart disease being the major underlying contributor to AHF admissions in over 50% of patients in high-income regions, as well as eastern and central European regions [4].

AHF is characterized by the emergence or worsening of symptoms and signs of heart failure and is the leading cause of unexpected hospitalization in individuals over the age of 65 [5]. Despite significant advancements in drug therapies for HF, AHF remains an underdiagnosed medical condition [6]. AHF often serves as a precursor to the most severe form of heart failure, known as cardiogenic shock (CS), with the risk of CS increasing tenfold without appropriate treatment [7]. Faced with this underrecognized diagnosis, the authors designed this study to evaluate patients with HFrEF secondary to coronary artery disease (CAD), who find themselves in a clinical limbo between daily clinical urgency and cardiogenic shock, often presenting with a general decompensating status requiring hospitalization due to the underlying disease. This study aims to assess specific features of AHF, intervention treatments, surgical approaches, and 30-day mortality in patients who not only present with severe illness but also with an acute clinical profile. It is crucial for the healthcare community to increasingly recognize and address the needs of these patients to improve outcomes and reduce mortality rates.

Methods

The study complied with the declaration of Helsinki and was approved by the Research Ethics Committee of Dr. Carlos Alberto Studart Gomes Hospital (CASGH) which is linked to the Brazilian national research system called Plataforma Brazil, under number 2666803 was obtained from the subjects or their legally authorized representatives.

This was a retrospective longitudinal study with patients with ischemic cardiomyopathy who underwent a coronary artery bypass grafting surgery (CABG) in Fortaleza, Brazil, from November 2021 to February 2023. The trial population consisted of CAD patients undergoing CABG admitted to CASGH Hospital, which comprised a total of 304 patients in the above-mentioned period.

Inclusion and exclusion criteria

Inclusion criteria

1. Already admitted to hospital due to the need for clinical stabilization.

2. Women who are not of childbearing potential and men.

3. Age ≥ 18 years.

4. LVEF ≤ 0.35 measured by ECHO, CMR ventriculogram or gated SPECT ventriculogram.

5. CAD suitable for revascularization.

Exclusion Criteria

1. Cardiogenic shock (within 72 hours of randomization), as defined by the need for intraaortic balloon support or the requirement for intravenous inotropic support preoperatively.

2. Failure to provide informed consent.

3. Aortic valvular heart disease clearly indicating the need for aortic valve repair or replacement.

4. History of more than 1 prior coronary bypass operation.

5. Noncardiac illness with a life expectancy of less than 3 years.

6. Noncardiac illness imposing substantial operative mortality.

7. Previous heart, kidney, liver, or lung transplantation.

Sample and collected variables

After applying inclusion and exclusion criteria, 20 (twenty) patients were assigned. Preoperative, perioperative, and postoperative data were collected until 30 days post-operative.

Data collected

• Preoperative data: age, body mass index, gender, systemic arterial hypertension, diabetes mellitus, dyslipidemia, previous acute MI, unstable angina, stable angina, chronic arterial fibrillation, use of definitive pacemaker, Chagas disease, congestive heart failure, previous stroke, peripheral occlusive arterial disease, valvular heart disease (mitral stenosis; mitral regurgitation; tricuspid regurgitation), kidney failure, and current smoking; laboratory data: hematocrit, hemoglobin, leukocytes, platelets, prothrombin activity time, troponin, urea, creatinine, glomerular filtration rate, glycemia; risk scores (European System for Cardiac Operative Risk Evaluation-EuroSCORE II and Society of Thoracic Surgeons score-STS score), and echocardiographic data concerning left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), left atrium (LA), ascending aorta diameter (AAD) and left ventricular mean ejection fraction (LVEF).

• Perioperative variables: intra-aortic balloon pump (IABP) therapy, Extracorporeal membrane oxygenation (ECMO); cardiopulmonary bypass (CPB), nitric oxide, need for temporary pacemaker, cardiac arrest in anesthetic induction, right ventricular dysfunction, atrial fibrillation, bleeding coagulopathy and surgical accident; coronary vessels approached, implantation of biological or mechanical mitral prosthesis, mitral repair, tricuspid repair, left ventricular aneurysm repair.

• Postoperative variables: deaths within 30 days of surgery.

For the analysis of mortality, the authors presented overall and age-specific mortality rate (≤ 75 years and >75 years).

Study procedures

Coronary artery bypass grafting surgeries were performed at CASG Hospital operating theater. Previously and onset of case, it was discussed and decided about the use of cardiopulmonary bypass (CPB). Cardiac surgery was performed by hospital staff surgeons experienced in CABG procedure with low operative mortality rates even in complex cases. They were to be performed within around 7 days after admission, depends on each patient’s need for clinical stabilization. All patients underwent follow-up evaluations until 30 days.

Study outcomes

The primary outcome was the rate of death from any cause. Secondary outcomes were age-specific mortality rate; findings related to patient’s profile with high complexity approach and mortality in AHF.

Statistical analysis

To verify the normality of data in the groups, the Shapiro-wilk test was used. Continuous data with Gaussian distribution were expressed as mean ± standard deviation; data without Gaussian distribution, median and percentiles and categorical were expressed in absolute value and percentage. The tests used were unpaired Student’s T-test, Mann-whitney or Fisher’s exact test, when appropriate. P-value was calculated with two-tailed tests and was considered significant with P <0.05. The program used was SPSS 20.0 for Windows.

Results

Preoperative and study population

Out of 304 patients were evaluated within the strictness of the selection criteria (inclusion and exclusion), during 16 months from November 2021 until February 2023, a total of 20 patients were enrolled, assigned and followed within the proposed criteria. Clinical characteristics, Lab and preoperative Echo well-distributed data. Risk Assessment Systems Scores were calculated, and both were plenty of high (EuroSCORE II 13,4 STS-Score:8,4), reflecting the severity profile of the patients (Table 1-3).

Study intervention treatment and surgical approach

One fifth of patients, 4(20%) had to use a temporary pacemaker, 2(10%) patients required ventricular assist devices ECMO or IABP therapy (intra-aortic balloon and extracorporeal membrane oxygenation) and CIVD syndrome was presented in 1(5%) patient, these data mirror high risk patients present in this group.

Among the revascularized vessels, left anterior descending artery (LAD) was grafted in 18(90%) surgeries. Grafts were quantitatively evaluated; the median was 3 grafts per patient. Mitral valve repair or replacement were associated procedure to CABG in 3(15%) patients as well as ventricular aneurysm repair in 3(15%). CPB was used in more than half of the patients, 11(55%).

There were no significant data regarding the age difference. There was also no difference regarding the use of CPB, although there was a trend toward a greater use in younger group. Pinteraction=0.06.

Effects and outcomes

The primary outcome was the rate of death from any cause which happened in 4 patients (20%) (Table 6). A total of 15 patients (75%) were younger than 75 years and 5 (25%) were the other patients who underwent myocardial revascularization (Table 6).

Age-categorized mortality rate did not reported difference between the groups studied. Indeed, presented same rate: 1 patient (20%) over 75 years and 3 patients (20%) under this (P>0.999) (Table 6). The sick who was dead (4) used cardiopulmonary bypass (CPB) as part of the surgical treatment of the respective illnesses.

The results with respect to findings related patient’s profile to the high complexity approach and mortality have shown 12 patients (60%) in congestive heart failure, whose average ejection fraction was 29.8%, characterizing severe ventricular dysfunction and 9(45%) in kidney chronic injury with mean glomerular filtration rate in 41ml/min and high level of urea and creatinine (Table 1 and 2).

In addition to the high mortality rate (Table 3), these patients required left ventricular assistance devices in 2(10%) cases and underwent associated procedures that are part of the surgical management of heart failure. Specifically, 5(25%) patients required valve approaches and 3(15%) and LV aneurysm repair (Table 5).

Total group (n=20)

Age, years

68 ± 9

Body mass index, kg/m2

25 ± 2

Gender, male

10 (50)

Systemic arterial hypertension

14 (70)

Diabetes mellitus

10 (50)

Dyslipidemia

11 (55)

Previous acute myocardial infarction

11 (55)

Unstable angina

5 (25)

Stable angina

2 (10)

Chronic arterial fibrillation

1 (5)

Use of definitive pacemaker

1 (5)

Chagas disease

1 (5)

Congestive heart failure

12 (60)

Previous stroke

1 (5)

Peripheral occlusive artery disease

2 (10)

Valve diseases

7 (35)

Mitral stenosis

1 (5)

Mitral regurgitation

4 (20)

Tricuspid regurgitation

2 (10)

Kidney failure

9 (45)

Current smoking

3 (27)

Table 1: Clinical characteristics. *Data expressed as mean ± standard deviation and as absolute count and percentage.

Total group (n=20)

Lab

Hematocrit

36.3 ± 5.1

Hemoglobin

12.2 ± 1.7

Leukocytes

9544.3 ± 2430

Platelets (mm3)

242.800 ± 134.2

Protrombine activity time (s)

1.1 ± 0.1

Troponin

1 ± 1.9

Urea (mg/dl)

60.5 ± 26.9

Creatinine (mg/dl)

1.6 ± 1.1

Glomerular filtration rate (ml/min)

41.8 ± 13.5

Blood glucose

142.8 ± 67.1

Echocardiography

Left ventricular end-diastolic diameter

58.2 ± 11.5

Left ventricular end-systolic diameter

53.6 ± 13.3

Left atrium

43.3 ± 10.1

Ascending aorta diameter

32.8 ± 3.2

Left ventricular ejection fraction Average

29.8 ± 4.9

Table 2: Laboratory data and Preoperative echocardiogram data. *Data expressed as mean ± standard deviation and as absolute count and percentage.

Total group (n=20)

Euroscore II

13.4

STS risk score

8.4

Table 3: Risk Assessment Systems Score. *Data expressed as mean ± standard deviation and as absolute count and percentage.

Total group (n=20)

Intra-aortic balloon pump therapy (IABP)

1 (5)

Extracorporeal oxygenation membrane (ECMO)

1 (5)

Use of nitric oxide

0 (0)

Use of temporary pacemaker

4 (20)

Cardiac arrest

0 (0)

Right ventricular dysfunction

1 (5)

Atrial fibrillation

2 (10)

Coagulopathy (CIVD) with increased bleeding

1 (5)

Surgical accident

0 (0)

Table 4: Clinical and Surgical features of surgical intervention. *Data expressed as absolute count and percentage in parentheses.

Total group

n=20 (%)

Number of grafts used

3 (2-3)

Left anterior descending artery (LAD)

18 (90)

Left circumflex artery (LCx)

6 (30)

Diagonal coronary artery

7 (35)

Right coronary artery (RCA)

5 (25)

Posterior descending artery(PDA)

4 (20)

Posterior ventricular artery(PVA)

1 (5)

Bioprosthetic mitral valve implantation

1 (5)

Mechanical mitral valve prosthesis implantation

1 (5)

Mitral valve repair

1 (5)

Tricuspid valve repair

2 (10)

Left ventricular aneurysm repair

3 (15)

Surgery with cardiopulmonary bypass (CPB)

11 (55)

Table 5: Grafted vessels and associated procedures. *Data expressed as absolute count and percentage.

Groups

>75 years

n=5(%)

<75 years

n=15(%)

P

Anterior descending artery revascularization

5 (100)

13 (81)

0.389

1st circumflex artery revascularization

1 (20)

5 (31)

0.573

1st circumflex artery revascularization

0 (0)

4 (25)

0.197

Diagonal coronary artery revascularization

0 (0)

7 (44)

0.058

Diagonal artery branch revascularization

0 (0)

1 (6)

0.554

Right coronary artery revascularization

3 (60)

2 (12)

0.037

Posterior descending artery revascularization

0 (0)

4 (25)

0.197

Posterior ventricular artery revascularization

0 (0)

1 (6)

0.554

Surgeries with cardiopulmonary bypass (CPB)

1 (20)

10 (68)

0.069

Number of grafts used

2 (1-2.5)

3 (2-3)

0.22

30-day overall mortality

1 (20%)

3 (20%)

>0.999

Mortality with CPB

1 (100%)

3 (30%)

0.364

Table 6: Technical aspects of myocardial revascularization surgery-revascularized vessels and associated procedures stratified by age of 75 years. *Data expressed as absolute count, mean and percentage.

Discussion

The patients were selected for inclusion in the study based on predefined inclusion and exclusion criteria, focusing on those presenting with clinical symptoms consistent with acute heart failure (AHF), a condition that often progresses rapidly and can lead to cardiogenic shock, with a mortality rate exceeding 50%. The 30-day overall mortality rate in this study was 20%, which, although high, is not comparable to the mortality rate of cardiogenic shock (CS), which is at least two-fold higher, ranging from 40% to 50%. CS remains a leading cause of death in acute myocardial infarction (AMI) [8,9]. Although predicted 30-day mortality in studies is less than 5% [10], excluded patients with acute conditions that could be characterized as AHF or cardiogenic shock. This selection detail significantly impacted patient follow-up and final outcomes [10].

Moreover, in contrast to the substantial improvements in the treatment of chronic heart failure with reduced ejection fraction (HFrEF), AHF is still associated with poor outcomes. Specifically, 90-day readmission rates and 1-year mortality reach 10-30% [11,12]. A puzzling detail is all the patients, who died, had put under CBP. There is a known inflammatory response of cardiopulmonary bypass, when faced with a patient with an acute inflammatory state such as AH, the authors can suggest the devastating synergistic effect of exacerbating the pro-inflammatory state of these patients and contributing to the death. Current studies are strongly advocating off-pump surgery to avoid adding complicating factors to an ACH syndrome even though in 30-days survival [13]. Patients of this study present very high complexity, not only due the underlying condition, but also the metabolic “environment” at that time. The clinical presentation of acute heart failure (AHF) is characterized by symptoms and signs related to systemic congestion [14]. This is initiated by increased biventricular cardiac filling pressures, which result, at the end, in extracellular fluid accumulation [15]. It was noted that not only the majority of patients were in congestive heart failure (CHF) (60%), but also in AKI demonstrated by the increase in the mean increase of acute and chronic renal biomarkers with striking altered kidney function meeting that typical congestive characteristic of AHF status. An underlying structural or functional cardiac condition is a prerequisite for decompensated AHF and includes a multitude of different acute (for example, myocardial infarction) or chronic (for example, dilated cardiomyopathy and ischaemic heart disease) cardiac pathologies [16]. The average EF (29%) placed all the population of study in severe HFrEF. Recognizing patients with HFrEF in this acute phase has dramatically improved the follow-up and prognosis of these patients. Missing diagnostic leads to cardiogenic shock, greatly increasing the chances of death for these patients. Immediate and energetic therapeutic measures must be taken at this stage, both for the acute condition, using decongestive therapy until euvolemia be achieved, also for the treatment of the chronic condition [17]. The etiology of which is mostly ischemic disease and the treatment of which is myocardial revascularization [16].

Due to acute ischemic decompensation in AHF, left ventricular relaxation is impaired since it is dependent on the Ca2+ ATPase. This phenomenon leads to overload filling pressures retrogradely and contributes to increase in LV wall stiffness. This worsens the already low ventricular function in this patient cluster, maintaining a cycle of progressive worsening up to circulatory shock, if the ischemia is not treated in this case, as well as in other etiologies. More than CABG, in some cases, patients had been summited a valve approach (5-25%), LV aneurysm correction (3-15%). Some of the patients had implanted devices to assist LV (ECMO and an IABP) (2-10%). These associated treatments are part of the spectrum of surgical treatment for heart failure, whether acute or chronic, just have mirrored how severe they are and could evolve [18].

This study had several limitations. The authors had small sample size; it may make difficult to determine if outcomes are true findings or type II error might occur. The population was 304 CABG-patients who the sample were very restricted in very low EF, and it was further partitioned into age groups, so everyone would have to get a very big universe to avoid this restriction. Additionally, the short-term follow-up avoided the doctors from demonstrating the real benefit of CABG if medium and long-term outcomes were assessed. Even with high mortality (20%) over a 30-day period in patients with decompensated ischemic cardiomyopathy, the worst-case non-diagnosis scenario would culminate in a higher mortality rate in CS. This essay drew attention to an under-seeming diagnosis and the purpose of identifying and raising awareness of the urgent need to correctly diagnose the acute condition of these patients has been achieved and the authors hope that this message will be taken on board and applied by everyone.

Conclusion

In summary, failure to recognize this serious acute condition can quickly lead to the patient's death. Timely and accurate diagnosis of acute heart failure, coupled with immediate implementation of essential measures like decongestive therapy and myocardial revascularization, can prevent the onset of cardiogenic shock, which has a mortality rate of up to 80%.

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