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Acute and Advanced Heart Failure Blog

Professor Gerhard Pölzl is Chief of the Heart Failure and Heart Transplant Program at the Medical University Innsbruck. His research is focused on clinical studies in advanced and chronic heart failure and on translational studies in cardiomyopathies.

He has been Principal Investigator of the LevoRep clinical trial that tested the efficacy and safety of pulsed infusions of levosimendan in outpatients with advanced heart failure. He is now P.I. of the clinical trial LEODOR, on repetitive use of levosimendan in advanced heart failure.

This blog is focused on the therapeutic options for Acute and Advanced Heart Failure: new data, new studies, new opinions, new trends.


Latest posts

3 June 2019

June 2019 post

Back from the HEART FAILURE congress in Athens with pleasant memories, new acquaintances, and a big bag with information and ideas.

LEODOR study on “repetitive use of levosimendan in advanced heart failure patients” has been discussed in the main program (see presentation in MyESC) and an investigator meeting has been held to discuss about the progress in initiation of the centers and enrollment of the patients.

As it regards the inodilator levosimendan, many posters were presented and a series of tutorials on i.v. vasoactive drugs in the treatment of acute and advanced heart failure was held by 12 speakers from Austria, Cyprus, Finland, Germany, Greece, Hungary, Italy, Spain, Sweden, and Switzerland. The lectures were recorded and the videos are available on the landing page www.acutehf.com/hf for educational purposes.

The speakers agreed that, despite the use of i.v. vasoactive drugs, diuretics, vasodilators and inotropes, for correcting hemodynamic dysfunction in patients with congestive heart failure has been described over many decades, insufficient data has been collected on their effects on Quality of life (QoL) and long term survival. Of particular note is that for inotropes belonging to the cardiac glycoside, catecholamine, and phosphodiesterase inhibitor families, data on the impact of these agents on QoL and survival are not positive and in several cases indicate an increase in mortality risk.

In acute heart failure, selecting the proper agent according to patients’ clinical profile and limiting usage to the shortest time at the lowest effective dose are important considerations to optimize inotrope use. In these settings, levosimendan bears an advantage also due to its beneficial renal effects. Levosimendan’s overall hemodynamic profile and clinical tolerability, combined with its extended duration of effect, has encouraged its intermittent use also in patients with advanced heart failure, to promote functional independence and quality of life and avert the need for unplanned hospitalizations resulting from episodes of decompensation. Further clinical research is in progress to refine the drug’s use for this purpose.

 

 

 

14 May 2019

May 2019 post

The HEART FAILURE meeting in Athens is approaching. On the web pages of the ESC it is already possible to have a glance over the final program of the congress.

Organised by the Heart Failure Association of the European Society of Cardiology, the Heart Failure Congress is a unique forum where cardiologists, interventional heart failure  specialists, cardiac surgeons, internists, practicing general physicians, basic scientists,  epidemiologists, cardiac nurses, industry affiliates and others have the opportunity to meet and exchange ideas and information.

The HFA congress is an international event open to healthcare professionals interested in any aspect of heart failure from epidemiology, through basic and translational science to prevention (reviewing the treatment of hypertension and post-infarction care), diagnosis (including novel imaging modalities and biomarkers), monitoring (together with remote monitoring), prognostication (risk stratification as well as use of biomarkers), medical and nursing management (including drugs, devices, tele-care and surgery).

I will be there presenting a rapid fire abstract on “repetitive levosimendan infusion” on Monday at 09:40 on the AGORA 2 stage: see you there!

Included in the program, some tutorials on how to use medications and devices are also accessible to the participants. As an example Orion Pharma will organize a series of 12 lectures on the use of inotropes for correcting hemodynamic dysfunction in patients with congestive heart failure. Over many decades, negative or insufficient data has been collected on the effects of cardiac glycosides, cathecolamines, and phosphodiesthrase inhibitors on quality of life and survival. More recently, the calcium sensitizer and potassium channel opener levosimendan have been proposed as a safer inodilator. The tutorials lectures in Athens will focus on how to use safely and effectively levosimendan in acute and advanced heart failure.

2 April 2019

April 2019 post

Among the recent literature on Advanced Heart Failure which I found on PubMed, I particularly enjoyed reading the opinion paper by Burnside et al on the American Journal of Hospital Palliative Care (2019, ePub Mar 28, doi: 10.1177/1049909119838250).

The authors state that "Advanced heart failure therapies such as ventricular assist devices and home inotrope use are becoming more common. Technology advances as well as increased indications for use of such therapies is leading to a higher percentage of patients with end-stage heart failure receiving these therapies at end of life.".

In the manuscript, the authors present a case of a young man with dilated cardiomyopathy who undergoes advanced cardiac care in the setting of progressively declining cardiac function, which outlines the importance of acute care, palliative care, and hospice services being coordinated prior to and during acute-care services to provide goal-concordant and expeditious care. With advancing medical therapies for heart disease, increased coordination and collaboration of services are needed, particularly between hospice and acute-care services.

I would like also to mention the work by Shoaib et al (Int J Cardiol. 2019. ePub on Mar 15, doi: 10.1016/j.ijcard.2019.03.020) which describe the “Characteristics and outcome of acute heart failure patients according to the severity of peripheral oedema”.

The authors state that "Most trials of patients hospitalized for heart failure focus on breathlessness, but worsening peripheral oedema is also an important presentation." They investigate the relationship between the severity of peripheral oedema on admission and outcome amongst patients with a primary discharge death or diagnosis of heart failure. Of 121,214 patients taken into consideration in their research, peripheral oedema on admission was absent in 24%, mild in 24%, moderate in 33% and severe in 18%. Median length of stay was, respectively, 6, 7, 9 and 12 days (P- < 0.001), index admission mortality was 7%, 8%, 10% and 16% (P- < 0.001) and mortality at a median follow-up of 344 (IQR 94-766) days was 39%, 46%, 52% and 59%. In an adjusted multi-variable Cox model, length of hospital stay and mortality during index admission and after discharge increased progressively with increasing severity of peripheral oedema at admission.

Finally, I considered it worth of reading the small retrospective study of six patients by De Lazzari et al (Comput Methods Programs Biomed. 2019;172:117-126) who focused on how LVAD support influence ventricular energetics parameters in advanced heart failure. The analysis of ventricular energetics parameters based on external work and pressure volume area confirmed LVAD support as a beneficial therapeutic option for the patients considered eligible for this type of treatment. The authors conclude that a quantitative approach with the ability to predict outcome during patient's assessment may well be an aid and not a substitute for clinical decision-making.