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Hodroge SS, Glenn M, Breyre A, Lee B, Aldridge NR, Sporer KA, Koenig KL, Gausche-Hill M, Salvucci AA, Rudnick EM, Brown JF, Gilbert GH. Adult Patients with Respiratory Distress: Current Evidence-based Recommendations for Prehospital Care. West J Emerg Med 2020; 21:849-857. [PMID: 32726255 PMCID: PMC7390576 DOI: 10.5811/westjem.2020.2.43896] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 02/21/2020] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION We developed evidence-based recommendations for prehospital evaluation and treatment of adult patients with respiratory distress. These recommendations are compared with current protocols used by the 33 local emergency medical services agencies (LEMSA) in California. METHODS We performed a review of the evidence in the prehospital treatment of adult patients with respiratory distress. The quality of evidence was rated and used to form guidelines. We then compared the respiratory distress protocols of each of the 33 LEMSAs for consistency with these recommendations. RESULTS PICO (population/problem, intervention, control group, outcome) questions investigated were treatment with oxygen, albuterol, ipratropium, steroids, nitroglycerin, furosemide, and non-invasive ventilation. Literature review revealed that oxygen titration to no more than 94-96% for most acutely ill medical patients and to 88-92% in patients with acute chronic obstructive pulmonary disease (COPD) exacerbation is associated with decreased mortality. In patients with bronchospastic disease, the data shows improved symptoms and peak flow rates after the administration of albuterol. There is limited data regarding prehospital use of ipratropium, and the benefit is less clear. The literature supports the use of systemic steroids in those with asthma and COPD to improve symptoms and decrease hospital admissions. There is weak evidence to support the use of nitrates in critically ill, hypertensive patients with acute pulmonary edema (APE) and moderate evidence that furosemide may be harmful if administered prehospital to patients with suspected APE. Non-invasive positive pressure ventilation (NIPPV) is shown in the literature to be safe and effective in the treatment of respiratory distress due to acute pulmonary edema, bronchospasm, and other conditions. It decreases both mortality and the need for intubation. Albuterol, nitroglycerin, and NIPPV were found in the protocols of every LEMSA. Ipratropium, furosemide, and oxygen titration were found in a proportion of the protocols, and steroids were not prescribed in any LEMSA protocol. CONCLUSION Prehospital treatment of adult patients with respiratory distress varies widely across California. We present evidence-based recommendations for the prehospital treatment of undifferentiated adult patients with respiratory distress that will assist with standardizing management and may be useful for EMS medical directors when creating and revising protocols.
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Affiliation(s)
- Sammy S Hodroge
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Melody Glenn
- University of Arizona, Department of Emergency Medicine, Tucson, Arizona
| | - Amelia Breyre
- Alameda Health System, Highland Hospital, Department of Emergency Medicine, Oakland, California
| | - Bennett Lee
- Hawaii Emergency Physicians Associated, Kailua, Hawaii
| | - Nick R Aldridge
- Kaiser Permanente San Diego, Department of Emergency Medicine, San Diego, California
| | - Karl A Sporer
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Kristi L Koenig
- County of San Diego Health & Human Services Agency, EMS, University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Marianne Gausche-Hill
- Harbor-UCLA Medical Center, Department of Emergency Medicine, Los Angeles County EMS Agency, Santa Fe Springs, California
| | | | | | - John F Brown
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Gregory H Gilbert
- Stanford University, Department of Emergency Medicine, Palo Alto, California
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Freund Y, Gorlicki J. High-dose intravenous nitrates in acute heart failure: Level of evidence and adherence. Am J Emerg Med 2020; 38:1272-1273. [DOI: 10.1016/j.ajem.2020.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/07/2020] [Accepted: 03/10/2020] [Indexed: 10/24/2022] Open
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Congestion in heart failure: a contemporary look at physiology, diagnosis and treatment. Nat Rev Cardiol 2020; 17:641-655. [DOI: 10.1038/s41569-020-0379-7] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2020] [Indexed: 12/14/2022]
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Harjola V, Parissis J, Bauersachs J, Brunner‐La Rocca H, Bueno H, Čelutkienė J, Chioncel O, Coats AJ, Collins SP, Boer RA, Filippatos G, Gayat E, Hill L, Laine M, Lassus J, Lommi J, Masip J, Mebazaa A, Metra M, Miró Ò, Mortara A, Mueller C, Mullens W, Peacock WF, Pentikäinen M, Piepoli MF, Polyzogopoulou E, Rudiger A, Ruschitzka F, Seferovic P, Sionis A, Teerlink JR, Thum T, Varpula M, Weinstein JM, Yilmaz MB. Acute coronary syndromes and acute heart failure: a diagnostic dilemma and high‐risk combination. A statement from the Acute Heart Failure Committee of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2020; 22:1298-1314. [DOI: 10.1002/ejhf.1831] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 04/04/2020] [Accepted: 04/06/2020] [Indexed: 12/17/2022] Open
Affiliation(s)
- Veli‐Pekka Harjola
- Emergency Medicine University of Helsinki, Department of Emergency Medicine and Services, Helsinki University Hospital Helsinki Finland
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology Medical School Hannover Hannover Germany
| | | | - Hector Bueno
- Centro Nacional de Investigaciones Cardiovasculares Madrid Spain
- Cardiology Department Hospital Universitario 12 de Octubre Madrid Spain
- Universidad Complutense de Madrid Madrid Spain
| | - Jelena Čelutkienė
- Institute of Clinical Medicine, Clinic of Cardiac and Vascular Diseases, Faculty of Medicine Vilnius University Vilnius Lithuania
| | - Ovidiu Chioncel
- University of Medicine Carol Davila/Institute of Emergency for Cardiovascular Disease Bucharest Romania
| | | | - Sean P. Collins
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN USA
| | - Rudolf A. Boer
- Department of Cardiology University of Groningen, University Medical Center Groningen Groningen The Netherlands
| | | | - Etienne Gayat
- Département d'Anesthésie – Réanimation – SMUR Hôpitaux Universitaires Saint Louis – Lariboisière, INSERM – UMR 942, Assistance Publique – Hôpitaux de Paris, Université Paris Diderot Paris France
| | - Loreena Hill
- School of Nursing and Midwifery Queen's University Belfast UK
| | - Mika Laine
- Cardiology, Heart and Lung Center University of Helsinki, Helsinki University Hospital Helsinki Finland
| | - Johan Lassus
- Cardiology, Heart and Lung Center University of Helsinki, Helsinki University Hospital Helsinki Finland
| | - Jyri Lommi
- Cardiology, Heart and Lung Center University of Helsinki, Helsinki University Hospital Helsinki Finland
| | - Josep Masip
- Consorci Sanitari Integral University of Barcelona Barcelona Spain
- Hospital Sanitas CIMA Barcelona Spain
| | - Alexandre Mebazaa
- Département d'Anesthésie – Réanimation – SMUR Hôpitaux Universitaires Saint Louis – Lariboisière, INSERM – UMR 942, Assistance Publique – Hôpitaux de Paris, Université Paris Diderot Paris France
- U942 Inserm, AP‐HP Paris France
- Investigation Network Initiative Cardiovascular and Renal Clinical Trialists (INI‐CRCT) Nancy France
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health University of Brescia Brescia Italy
| | - Òscar Miró
- Emergency Department Hospital Clínic, University of Barcelona Catalonia Spain
| | - Andrea Mortara
- Department of Cardiology Policlinico di Monza Monza Italy
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology University of Basel, University Hospital Basel Basel Switzerland
| | - Wilfried Mullens
- Department of Cardiology Ziekenhuis Oost Limburg, Genk – Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University Diepenbeek Belgium
| | - W. Frank Peacock
- Henry JN Taub Department of Emergency Medicine Baylor College of Medicine Houston TX USA
| | - Markku Pentikäinen
- Cardiology, Heart and Lung Center University of Helsinki, Helsinki University Hospital Helsinki Finland
| | | | | | - Alain Rudiger
- Cardio‐Surgical Intensive Care Unit University and University Hospital Zurich Zurich Switzerland
| | - Frank Ruschitzka
- University Heart Center University Hospital Zurich Zurich Switzerland
| | - Petar Seferovic
- Department of Internal Medicine Belgrade University School of Medicine and Heart Failure Center, Belgrade University Medical Center Belgrade Serbia
| | - Alessandro Sionis
- Cardiology Department Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona Barcelona Spain
| | - John R. Teerlink
- Section of Cardiology San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco CA USA
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS) Hannover Medical School Hannover Germany
| | - Marjut Varpula
- Cardiology, Heart and Lung Center University of Helsinki, Helsinki University Hospital Helsinki Finland
| | - Jean Marc Weinstein
- Cardiology Division Soroka University Medical Centre Beer‐Sheva Israel
- Faculty of Health Sciences Ben Gurion University of the Negev Beer‐Sheva Israel
| | - Mehmet B. Yilmaz
- Department of Cardiology Cumhuriyet University Faculty of Medicine Sivas Turkey
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Fukata M. Acute Decompensated Heart Failure in Patients with Heart Failure with Reduced Ejection Fraction. Heart Fail Clin 2020; 16:187-200. [PMID: 32143763 DOI: 10.1016/j.hfc.2019.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Acute decompensated heart failure (ADHF) requires immediate treatments because it impairs perfusion to systemic organs and their function. Half of all patients with ADHF are diagnosed with heart failure with reduced left ventricular ejection fraction (HFrEF). The initial goal of management for ADHF is to stabilize hemodynamic status. Pulmonary edema is treated with vasodilators or diuretics. Inhibitors of the renin-angiotensin-aldosterone system and β-blockers should be started and/or increased to meet the maximum dose, ideally the target dose, that the patient can tolerate as a treatment of HFrEF. Patients with severe circulatory failure need inotropic drugs or mechanical circulatory support.
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Affiliation(s)
- Mitsuhiro Fukata
- Department of Hematology, Oncology and Cardiovascular Medicine, Heart Center, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan.
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Patrick C, Ward B, Anderson J, Rogers Keene K, Adams E, Cash RE, Panchal AR, Dickson R. Feasibility, Effectiveness and Safety of Prehospital Intravenous Bolus Dose Nitroglycerin in Patients with Acute Pulmonary Edema. PREHOSP EMERG CARE 2020; 24:844-850. [DOI: 10.1080/10903127.2020.1711834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Management of Acute Heart Failure during an Early Phase. INTERNATIONAL JOURNAL OF HEART FAILURE 2020; 2:91-110. [PMID: 36263292 PMCID: PMC9536658 DOI: 10.36628/ijhf.2019.0014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 12/20/2022]
Abstract
Acute heart failure (AHF), a global pandemic with high morbidity and mortality, exerts a considerable economic burden. AHF includes a broad spectrum of clinical presentations ranging from new-onset heart failure to cardiogenic shock. Key elements of the management rely on the clinical diagnosis confirmed on, both, increased natriuretic peptides and echocardiography, and on the prompt initiation of oxygen therapy, including non-invasive positive pressure ventilation, vasodilators, and diuretics. A care pathway is essential, specifically when an acute coronary syndrome is suspected or in the case of cardiogenic shock. Association or increasing doses of vasopressors despite an adequate volume status are markers of progression toward a refractory cardiogenic shock state. For the latter, mechanical circulatory support should be initiated early, optimally before the onset of renal or liver failure. Thus, a tertiary care center is recommended for the management of patients with AHF who require percutaneous coronary intervention or mechanical circulatory support. This narrative review provides multidisciplinary guidance for the management of AHF and cardiogenic shock from pre-hospital to intensive care unit/cardiac care unit, based on contemporary evidence and expert opinion.
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Wang K, Samai K. Role of high-dose intravenous nitrates in hypertensive acute heart failure. Am J Emerg Med 2020; 38:132-137. [DOI: 10.1016/j.ajem.2019.06.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/19/2019] [Accepted: 06/24/2019] [Indexed: 12/20/2022] Open
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Kozhuharov N, Goudev A, Flores D, Maeder MT, Walter J, Shrestha S, Gualandro DM, de Oliveira Junior MT, Sabti Z, Müller B, Noveanu M, Socrates T, Ziller R, Bayés-Genís A, Sionis A, Simon P, Michou E, Gujer S, Gori T, Wenzel P, Pfister O, Conen D, Kapos I, Kobza R, Rickli H, Breidthardt T, Münzel T, Erne P, Mueller C. Effect of a Strategy of Comprehensive Vasodilation vs Usual Care on Mortality and Heart Failure Rehospitalization Among Patients With Acute Heart Failure: The GALACTIC Randomized Clinical Trial. JAMA 2019; 322:2292-2302. [PMID: 31846016 PMCID: PMC6990838 DOI: 10.1001/jama.2019.18598] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Short-term infusions of single vasodilators, usually given in a fixed dose, have not improved outcomes in patients with acute heart failure (AHF). OBJECTIVE To evaluate the effect of a strategy that emphasized early intensive and sustained vasodilation using individualized up-titrated doses of established vasodilators in patients with AHF. DESIGN, SETTING, AND PARTICIPANTS Randomized, open-label blinded-end-point trial enrolling 788 patients hospitalized for AHF with dyspnea, increased plasma concentrations of natriuretic peptides, systolic blood pressure of at least 100 mm Hg, and plan for treatment in a general ward in 10 tertiary and secondary hospitals in Switzerland, Bulgaria, Germany, Brazil, and Spain. Enrollment began in December 2007 and follow-up was completed in February 2019. INTERVENTIONS Patients were randomized 1:1 to a strategy of early intensive and sustained vasodilation throughout the hospitalization (n = 386) or usual care (n = 402). Early intensive and sustained vasodilation was a comprehensive pragmatic approach of maximal and sustained vasodilation combining individualized doses of sublingual and transdermal nitrates, low-dose oral hydralazine for 48 hours, and rapid up-titration of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or sacubitril-valsartan. MAIN OUTCOMES AND MEASURES The primary end point was a composite of all-cause mortality or rehospitalization for AHF at 180 days. RESULTS Among 788 patients randomized, 781 (99.1%; median age, 78 years; 36.9% women) completed the trial and were eligible for primary end point analysis. Follow-up at 180 days was completed for 779 patients (99.7%). The primary end point, a composite of all-cause mortality or rehospitalization for AHF at 180 days, occurred in 117 patients (30.6%) in the intervention group (including 55 deaths [14.4%]) and in 111 patients (27.8%) in the usual care group (including 61 deaths [15.3%]) (absolute difference for the primary end point, 2.8% [95% CI, -3.7% to 9.3%]; adjusted hazard ratio, 1.07 [95% CI, 0.83-1.39]; P = .59). The most common clinically significant adverse events with early intensive and sustained vasodilation vs usual care were hypokalemia (23% vs 25%), worsening renal function (21% vs 20%), headache (26% vs 10%), dizziness (15% vs 10%), and hypotension (8% vs 2%). CONCLUSIONS AND RELEVANCE Among patients with AHF, a strategy of early intensive and sustained vasodilation, compared with usual care, did not significantly improve a composite outcome of all-cause mortality and AHF rehospitalization at 180 days. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00512759.
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Affiliation(s)
- Nikola Kozhuharov
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Assen Goudev
- Queen Ioanna University Hospital Sofia, Department of Cardiology, Medical University of Sofia, Sofia, Bulgaria
| | - Dayana Flores
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Micha T. Maeder
- Department of Cardiology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Joan Walter
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Samyut Shrestha
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Danielle Menosi Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Heart Institute (INCOR), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | | | - Zaid Sabti
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Beat Müller
- Department of General Internal and Emergency Medicine, Medical University Clinic of the University of Basel, Kantonsspital Aarau, Aarau, Switzerland
| | - Markus Noveanu
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Thenral Socrates
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Medical Outpatient Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ronny Ziller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Antoni Bayés-Genís
- Heart Institute, Hospital Universitari Germans Trias i Pujol, CIBERCV, Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB-Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Patrick Simon
- Clinical Trial Unit, University Hospital Basel, Basel, Switzerland
| | - Eleni Michou
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Samuel Gujer
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Internal Medicine, Kantonsspital Obwalden, Sarnen, Switzerland
| | - Tommaso Gori
- University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Philip Wenzel
- University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Otmar Pfister
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - David Conen
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Ioannis Kapos
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Richard Kobza
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Hans Rickli
- Department of Cardiology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Tobias Breidthardt
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thomas Münzel
- University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Paul Erne
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
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Lamboley L, Debax P, Courtiol G, Ricard C, Morvan C, Debaty G, Dubie E, Oberlin J, Savary D, Ageron FX, Belle L. Quality of acute heart failure treatment in France: Data from REseau Nord-Alpin des Urgences (RENAU). Ann Cardiol Angeiol (Paris) 2019; 68:285-292. [PMID: 31570158 DOI: 10.1016/j.ancard.2019.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 08/28/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Although mortality due to acute heart failure has decreased, its prevalence in France is still high. The aim of this study was to examine the quality of acute heart failure treatment in French emergency departments (EDs) with reference to subsequently published European Society of Cardiology (ESC) recommendations. METHODS The medical records of patients with acute pulmonary oedema (as a marker for acute heart failure) admitted to the EDs of 11 French hospitals in 2013 were reviewed retrospectively. RESULTS A total of 834 patients were included (median [interquartile range] age 84 [78-89] years; 48.6% male). Rates of compliance of initial management in 2013 to subsequently published 2015 recommendations were as follows: (1) thoracic ultrasound was performed in 17.3%; (2) loop diuretics were given in 75.9%; at a correct dose (among those for whom this was calculable) in 40.0% (3); intravenous nitrates were given in 21.7% of patients with systolic blood pressure>110mmHg; (4) non-invasive ventilation was initiated in 22.0% of patients with respiratory distress. Discharge summaries most often lacked a scheduled cardiologist follow-up (89.4%) and discharge patient weight (78.9%). CONCLUSIONS The early management of patients with acute pulmonary oedema (as a marker of acute heart failure) in France in 2013 was quite different to recommendations published in 2015. A programme to implement the new recommendations is in place, and a repeat evaluation will be conducted in 2017.
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Affiliation(s)
- L Lamboley
- Emergency department, hospital, Annecy, France
| | - P Debax
- Emergency department, university hospital of Grenoble-Alps, Grenoble, France
| | - G Courtiol
- Emergency department, hospital, Annecy, France
| | - C Ricard
- Reseau Nord-Alpin des urgences, hospital, Annecy, France
| | - C Morvan
- Reseau Nord-Alpin des urgences, hospital, Annecy, France
| | - G Debaty
- Emergency department, university hospital of Grenoble-Alps, Grenoble, France
| | - E Dubie
- Emergency department, hospital, Chambery, France
| | - J Oberlin
- Emergency department, university hospital of Grenoble-Alps, Grenoble, France
| | - D Savary
- Emergency department, hospital, Annecy, France
| | - F-X Ageron
- Emergency department, hospital, Annecy, France
| | - L Belle
- Reseau Nord-Alpin des urgences, hospital, Annecy, France; Cardiology department, hospital, Annecy, France.
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Liu P, McMenamin ÚC, Spence AD, Johnston BT, Coleman HG, Cardwell CR. Furosemide use and survival in patients with esophageal or gastric cancer: a population-based cohort study. BMC Cancer 2019; 19:1017. [PMID: 31664951 PMCID: PMC6819347 DOI: 10.1186/s12885-019-6242-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 10/03/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Pre-clinical studies have shown that furosemide slows cancer cell growth by acting on the Na-K-2Cl transporter, particularly for gastric cancer cells. However, epidemiological studies have not investigated furosemide use and mortality in gastroesophageal cancer patients. Consequently, we conducted a population-based study to investigate whether furosemide use is associated with reduced cancer-specific mortality in esophageal/gastric cancer patients. METHODS A cohort of patients newly diagnosed with esophageal or gastric cancer between 1998 and 2013 were identified from English cancer registries and linked to the Clinical Practice Research Datalink to provide prescription records and the Office of National Statistics to provide death data up to September 2015. Time-dependant Cox-regression models were used to calculate hazard ratios (HRs) comparing cancer-specific mortality in furosemide users with non-users. Analyses were repeated restricting to patients with common furosemide indications (heart failure, myocardial infarction, edema or hypertension) to reduce potential confounding. RESULTS The cohort contained 2708 esophageal cancer patients and 2377 gastric cancer patients, amongst whom 1844 and 1467 cancer-specific deaths occurred, respectively. Furosemide use was not associated with reduced cancer-specific mortality overall (adjusted HR in esophageal cancer = 1.28, 95% CI 1.10, 1.50 and in gastric cancer = 1.27, 95% CI 1.08, 1.50) or when restricted to patients with furosemide indications before cancer diagnosis (adjusted HR in esophageal cancer = 1.07, 95% CI 0.88, 1.30 and in gastric cancer = 1.18, 95% CI 0.96, 1.46). CONCLUSIONS In this large population-based cohort study, furosemide was not associated with reduced cancer-specific mortality in patients with esophageal or gastric cancer.
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Affiliation(s)
- Peipei Liu
- Centre for Public Health, Queen’s University Belfast, Institute for Clinical Science, Royal Victoria Hospital, Grosvenor Road, Belfast, Belfast, Northern Ireland BT12 6BJ UK
| | - Úna C. McMenamin
- Centre for Public Health, Queen’s University Belfast, Institute for Clinical Science, Royal Victoria Hospital, Grosvenor Road, Belfast, Belfast, Northern Ireland BT12 6BJ UK
| | - Andrew D. Spence
- Centre for Public Health, Queen’s University Belfast, Institute for Clinical Science, Royal Victoria Hospital, Grosvenor Road, Belfast, Belfast, Northern Ireland BT12 6BJ UK
- Belfast Health and Social Care Trust, Belfast, Northern Ireland UK
| | | | - Helen G. Coleman
- Centre for Public Health, Queen’s University Belfast, Institute for Clinical Science, Royal Victoria Hospital, Grosvenor Road, Belfast, Belfast, Northern Ireland BT12 6BJ UK
- Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, Northern Ireland UK
| | - Chris R. Cardwell
- Centre for Public Health, Queen’s University Belfast, Institute for Clinical Science, Royal Victoria Hospital, Grosvenor Road, Belfast, Belfast, Northern Ireland BT12 6BJ UK
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Tsutsui H, Isobe M, Ito H, Ito H, Okumura K, Ono M, Kitakaze M, Kinugawa K, Kihara Y, Goto Y, Komuro I, Saiki Y, Saito Y, Sakata Y, Sato N, Sawa Y, Shiose A, Shimizu W, Shimokawa H, Seino Y, Node K, Higo T, Hirayama A, Makaya M, Masuyama T, Murohara T, Momomura SI, Yano M, Yamazaki K, Yamamoto K, Yoshikawa T, Yoshimura M, Akiyama M, Anzai T, Ishihara S, Inomata T, Imamura T, Iwasaki YK, Ohtani T, Onishi K, Kasai T, Kato M, Kawai M, Kinugasa Y, Kinugawa S, Kuratani T, Kobayashi S, Sakata Y, Tanaka A, Toda K, Noda T, Nochioka K, Hatano M, Hidaka T, Fujino T, Makita S, Yamaguchi O, Ikeda U, Kimura T, Kohsaka S, Kosuge M, Yamagishi M, Yamashina A. JCS 2017/JHFS 2017 Guideline on Diagnosis and Treatment of Acute and Chronic Heart Failure ― Digest Version ―. Circ J 2019; 83:2084-2184. [DOI: 10.1253/circj.cj-19-0342] [Citation(s) in RCA: 276] [Impact Index Per Article: 55.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | | | - Hiroshi Ito
- Department of Cardiovascular and Respiratory Medicine, Akita University Graduate School of Medicine
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Division of Biophysiological Sciences, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
| | - Masafumi Kitakaze
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center
| | | | - Yasuki Kihara
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University
| | | | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Yoshikatsu Saiki
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Naoki Sato
- Department of Cardiovascular Medicine, Kawaguchi Cardiovascular and Respiratory Hospital
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Graduate School of Medical Sciences
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
| | - Taiki Higo
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Atsushi Hirayama
- The Division of Cardiology, Department of Medicine, Nihon University Graduate School of Medicine
| | | | - Tohru Masuyama
- Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | | | - Masafumi Yano
- Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Kenji Yamazaki
- Department of Cardiology Surgery, Tokyo Women’s Medical University
| | - Kazuhiro Yamamoto
- Department of Molecular Medicine and Therapeutics, Faculty of Medicine, Tottori University
| | | | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
| | - Masatoshi Akiyama
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Shiro Ishihara
- Department of Cardiology, Nippon Medical School Musashi-Kosugi Hospital
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital
| | | | - Yu-ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | | | - Takatoshi Kasai
- Cardiovascular Respiratory Sleep Medicine, Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Mahoto Kato
- Department of Cardiovascular Medicine, Nihon University Graduate School of Medicine
| | - Makoto Kawai
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine
| | | | - Shintaro Kinugawa
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Toru Kuratani
- Department of Minimally Invasive Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Shigeki Kobayashi
- Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Yasuhiko Sakata
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | | | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kotaro Nochioka
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Masaru Hatano
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | | | - Takeo Fujino
- Department of Advanced Cardiopulmonary Failure, Kyushu University Graduate School of Medical Sciences
| | - Shigeru Makita
- Department of Cardiac Rehabilitation, Saitama Medical University International Medical Center
| | - Osamu Yamaguchi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Masami Kosuge
- Division of Cardiology, Yokohama City University Medical Center
| | - Masakazu Yamagishi
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine
| | - Akira Yamashina
- Medical Education Promotion Center, Tokyo Medical University
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Uehara K, Yamamoto Y, Hatsuse S, Isotani Y, Fukuyama M, Yanagisawa K, Yamamoto K, Takizawa M, Uozumi H, Ikenouchi H. Systolic blood pressure on admission as a marker of fluid re-distribution in acute heart failure. J Cardiol 2019; 74:245-250. [DOI: 10.1016/j.jjcc.2019.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 02/14/2019] [Accepted: 03/06/2019] [Indexed: 11/28/2022]
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65
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Arao Y, Sawamura A, Nakatochi M, Okumura T, Kato H, Oishi H, Yamaguchi S, Haga T, Kuwayama T, Yokoi T, Hiraiwa H, Kondo T, Morimoto R, Murohara T. Early Blood Pressure Reduction by Intravenous Vasodilators Is Associated With Acute Kidney Injury in Patients With Hypertensive Acute Decompensated Heart. Circ J 2019; 83:1883-1890. [DOI: 10.1253/circj.cj-19-0333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yoshihito Arao
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Akinori Sawamura
- Department of Cardiology, Nagoya University Graduate School of Medicine
- Department of Cardiology, Ichinomiya Municipal Hospital
| | - Masahiro Nakatochi
- Data Science Division, Data Coordinating Center, Department of Advanced Medicine, Nagoya University Hospital
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Hiroo Kato
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Hideo Oishi
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Shogo Yamaguchi
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Tomoaki Haga
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Tasuku Kuwayama
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Tsuyoshi Yokoi
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Ryota Morimoto
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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66
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Rossello X, Gil V, Escoda R, Jacob J, Aguirre A, Martín-Sánchez FJ, Llorens P, Herrero Puente P, Rizzi M, Raposeiras-Roubín S, Wussler D, Müller CE, Gayat E, Mebazaa A, Miró Ò. Editor's Choice- Impact of identifying precipitating factors on 30-day mortality in acute heart failure patients. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2019; 8:667-680. [PMID: 31436133 DOI: 10.1177/2048872619869328] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The aim of this study was to describe the prevalence and prognostic value of the most common triggering factors in acute heart failure. METHODS Patients with acute heart failure from 41 Spanish emergency departments were recruited consecutively in three time periods between 2011 and 2016. Precipitating factors were classified as: (a) unrecognized; (b) infection; (c) atrial fibrillation; (d) anaemia; (e) hypertension; (f) acute coronary syndrome; (g) non-adherence; and (h) two or more precipitant factors. Unadjusted and adjusted logistic regression models were used to assess the association between 30-day mortality and each precipitant factor. The risk of dying was further evaluated by week intervals over the 30-day follow-up to assess the period of higher vulnerability for each precipitant factor. RESULTS Approximately 69% of our 9999 patients presented with a triggering factor and 1002 died within the first 30 days (10.0%). The most prevalent factors were infection and atrial fibrillation. After adjusting for 11 known predictors, acute coronary syndrome was associated with higher 30-day mortality (odds ratio (OR) 1.87; 95% confidence interval (CI) 1.02-3.42), whereas atrial fibrillation (OR 0.75; 95% CI 0.56-0.94) and hypertension (OR 0.34; 95% CI 0.21-0.55) were significantly associated with better outcomes when compared to patients without precipitant. Patients with infection, anaemia and non-compliance were not at higher risk of dying within 30 days. These findings were consistent across gender and age groups. The 30-day mortality time pattern varied between and within precipitant factors. CONCLUSIONS Precipitant factors in acute heart failure patients are prevalent and have a prognostic value regardless of the patient's gender and age. They can be managed with specific treatments and can sometimes be prevented.
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Affiliation(s)
- Xavier Rossello
- Translational Laboratory for Cardiovascular Imaging and Therapy, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain.,Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Víctor Gil
- Emergency Department, Hospital Clínic Barcelona, Spain
| | - Rosa Escoda
- Emergency Department, Hospital Clínic Barcelona, Spain
| | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, Spain
| | | | - Francisco J Martín-Sánchez
- Translational Laboratory for Cardiovascular Imaging and Therapy, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain.,Emergency Department, Hospital Clínico San Carlos, Spain
| | - Pere Llorens
- Emergency Department, Hospital General de Alicante, Spain
| | | | - Miguel Rizzi
- Emergency Department, Hospital de la Santa Creu i Sant Pau, Spain
| | | | - Desiree Wussler
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland
| | - Christian E Müller
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, Switzerland.,The GREAT (Global REsearch in Acute cardiovascular conditions Team) network
| | - Etienne Gayat
- Department of Anesthesiology and Critical Care Medicine, Saint Louis Lariboisière University Hospital, France
| | - Alexandre Mebazaa
- The GREAT (Global REsearch in Acute cardiovascular conditions Team) network.,Department of Anesthesiology and Critical Care Medicine, Saint Louis Lariboisière University Hospital, France
| | - Òscar Miró
- Emergency Department, Hospital Clínic Barcelona, Spain.,The GREAT (Global REsearch in Acute cardiovascular conditions Team) network
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67
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Cai H, Thombal RS, Li X, Lee YR. Rhodium(III)‐Catalyzed Regioselective C−H Activation/Annulation for the Diverse Pyrazole‐Core Substituted Furans. Adv Synth Catal 2019. [DOI: 10.1002/adsc.201900498] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Hongyun Cai
- School of Chemical Engineering Yeungnam University Gyeongsan 38541 Republic of Korea
| | - Raju S. Thombal
- School of Chemical Engineering Yeungnam University Gyeongsan 38541 Republic of Korea
| | - Xin Li
- College of Biotechnology and Pharmaceutical Engineering Nanjing Tech University 30 Puzhu Rd S. Nanjing 211816 China
| | - Yong Rok Lee
- School of Chemical Engineering Yeungnam University Gyeongsan 38541 Republic of Korea
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68
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Davis WT, Montrief T, Koyfman A, Long B. Dysrhythmias and heart failure complicating acute myocardial infarction: An emergency medicine review. Am J Emerg Med 2019; 37:1554-1561. [PMID: 31060863 DOI: 10.1016/j.ajem.2019.04.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 04/24/2019] [Accepted: 04/26/2019] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Patients with acute myocardial infarction (AMI) may suffer several complications after the acute event, including dysrhythmias and heart failure (HF). These complications place patients at risk for morbidity and mortality. OBJECTIVE This narrative review evaluates literature and guideline recommendations relevant to the acute emergency department (ED) management of AMI complicated by dysrhythmia or HF, with a focus on evidence-based considerations for ED interventions. DISCUSSION Limited evidence exists for ED management of dysrhythmias in AMI due to relatively low prevalence and frequent exclusion of patients with active cardiac ischemia from clinical studies. Management decisions for bradycardia in the setting of AMI are determined by location of infarction, timing of the dysrhythmia, rhythm assessment, and hemodynamic status of the patient. Atrial fibrillation is common in the setting of AMI, and caution is warranted in acute rate control for rapid ventricular rate given the possibility of compensation for decreased ventricular function. Regular wide complex tachycardia in the setting of AMI should be managed as ventricular tachycardia with electrocardioversion in the majority of cases. Management directed towards HF from left ventricular dysfunction in AMI consists of noninvasive positive pressure ventilation, nitroglycerin therapy, and early cardiac catheterization. Norepinephrine is the first line vasopressor for patients with cardiogenic shock and hypoperfusion on clinical examination. Early involvement of a multi-disciplinary team is recommended when caring for patients in cardiogenic shock. CONCLUSIONS This review discusses considerations of ED management of dysrhythmias and HF associated with AMI.
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Affiliation(s)
- William T Davis
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States
| | - Tim Montrief
- University of Miami, Jackson Memorial Hospital/Miller School of Medicine, Department of Emergency Medicine, 1611 N.W. 12th Avenue, Miami, FL 33136, United States
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
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69
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Abstract
PURPOSE OF REVIEW We provide a concise review of recent studies focusing on the management of patients with acute heart failure (AHF). RECENT FINDINGS In well designed randomized trials, no mortality benefit has been observed with the use of diuretics, ultrafiltration, inotropes and vasodilators in AHF. Recent trials examining the role of novel inotropes and vasodilators as well as the role of mineralocorticoid receptor antagonists in the AHF population, is reviewed. SUMMARY The focus of therapy in AHF should be directed towards symptom management. No mortality benefit has been observed despite good quality studies.
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70
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Komuro J, Nagatomo Y, Mahara K, Isobe M, Goda A, Sujino Y, Mizuno A, Shiraishi Y, Kohno T, Kohsaka S, Yoshikawa T. Clinical Scenario Classification for Characterization and Outcome Prediction of Acute Decompensated Heart Failure Under Contemporary Phenotyping. Circ Rep 2019; 1:162-170. [PMID: 33693133 PMCID: PMC7889455 DOI: 10.1253/circrep.cr-18-0013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background: The concept of Clinical Scenario (CS) classification has been widely utilized to aid in choosing appropriate management strategies for acute decompensated heart failure (ADHF). Methods and Results: The West Tokyo-Heart Failure (WET-HF) Registry is a multicenter, prospective cohort registry enrolling consecutive hospitalized ADHF patients. Based on systolic blood pressure (SBP) at admission, 4,000 patients enrolled between 2006 and 2017 were classified into 3 groups: CS1, SBP ≥140 mmHg; CS2, 100≤SBP<140 mmHg; and CS3, SBP <100 mmHg. The CS1 group had a high rate of fluid retention such as leg edema, and the largest reduction in body weight at discharge. In-hospital diuretics use was the most frequent in CS1. Although the primary endpoint of long-term all-cause death and/or ADHF re-hospitalization was more common in more advanced CS, there was no significant difference between the 3 CS groups in patients with HF with preserved ejection fraction (HFpEF; P=0.10). Although more advanced CS was associated with larger left ventricular (LV) chamber size in HF with reduced EF (HFrEF), it was associated with smaller LV size in HFpEF. Conclusions: The long-term prognostic value of CS classification was limited in HFpEF. Whereas CS was closely associated with degree of LV remodeling in HFrEF, a smaller LV chamber might be associated with a lower cardiovascular functional reserve in HFpEF.
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Affiliation(s)
- Jin Komuro
- Department of Cardiology, Sakakibara Heart Institute Fuchu Japan.,Department of Cardiology, Keio University School of Medicine Tokyo Japan
| | - Yuji Nagatomo
- Department of Cardiology, Sakakibara Heart Institute Fuchu Japan.,Department of Cardiology, National Defense Medical College Tokorozawa Japan
| | - Keitaro Mahara
- Department of Cardiology, Sakakibara Heart Institute Fuchu Japan
| | - Mitsuaki Isobe
- Department of Cardiology, Sakakibara Heart Institute Fuchu Japan
| | - Ayumi Goda
- Division of Cardiology, Kyorin University School of Medicine Tokyo Japan
| | - Yasumori Sujino
- Department of Cardiology, Saitama Medical University, International Medical Center Hidaka Japan
| | - Atsushi Mizuno
- Department of Cardiology, St. Luke's International Hospital Tokyo Japan
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine Tokyo Japan
| | - Takashi Kohno
- Department of Cardiology, Keio University School of Medicine Tokyo Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine Tokyo Japan
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Chioncel O, Collins SP, Ambrosy AP, Pang PS, Antohi EL, Iliescu VA, Maggioni AP, Butler J, Mebazaa A. Improving Postdischarge Outcomes in Acute Heart Failure. Am J Ther 2019; 25:e475-e486. [PMID: 29985826 PMCID: PMC6114135 DOI: 10.1097/mjt.0000000000000791] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Ovidiu Chioncel
- University of Medicine Carol Davila, Bucharest; Emergency Institute
for Cardiovascular Diseases-“Prof. C.C. Iliescu”, Bucharest,
Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University, Nashville,
TN, USA
| | - Andrew P Ambrosy
- Division of Cardiology, Duke University Medical Center, Durham, NC,
USA Duke Clinical Research Institute, Durham, NC, USA
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of
Medicine, Indiana USA
| | - Elena-Laura Antohi
- University of Medicine Carol Davila, Bucharest; Emergency Institute
for Cardiovascular Diseases-“Prof. C.C. Iliescu”, Bucharest,
Romania
| | - Vlad Anton Iliescu
- University of Medicine Carol Davila, Bucharest; Emergency Institute
for Cardiovascular Diseases-“Prof. C.C. Iliescu”, Bucharest,
Romania
| | - Aldo P Maggioni
- ANMCO Research Center, Florence, Italy; EORP-European Society of
Cardiology, Sophia Antipolis, France
| | - Javed Butler
- Department of Medicine, University of Mississippi School of
Medicine, Jackson, MI, USA
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care, APHP – Saint
Louis Lariboisière University Hospitals, University Paris Diderot and INSERM
UMR-S 942, Paris, France
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Early Treatment in Emergency Department Patients with Acute Heart Failure: Does Time Matter? Curr Heart Fail Rep 2019; 16:12-20. [PMID: 30828762 DOI: 10.1007/s11897-019-0419-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE OF REVIEW Acute heart failure accounts for over one million hospital discharges annually. Current guidelines suggest treatments for AHF should begin "without delay" but this time interval has not been clearly defined. RECENT FINDINGS Data suggest that certain treatments such as earlier treatment with diuretics and vasodilators may improve patient symptom relief, morbidity, and mortality. Secondary analyses of clinical trials of novel treatments under development have not shown similar results. The data are equivocal regarding the impact of early treatment in AHF on in-hospital and long-term morbidity and mortality. Improved clinical trial designs will help answer when and if "early" treatment should begin and whether it impacts short- and long-term outcomes in AHF.
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74
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Freund Y, Gorlicki J, Cachanado M, Salhi S, Lemaître V, Simon T, Mebazaa A. Early and comprehensive care bundle in the elderly for acute heart failure in the emergency department: study protocol of the ELISABETH stepped-wedge cluster randomized trial. Trials 2019; 20:95. [PMID: 30704508 PMCID: PMC6357377 DOI: 10.1186/s13063-019-3188-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 01/09/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Acute heart failure (AHF) is one of the most common diagnoses for elderly patients in the emergency department (ED), with an admission rate above 80% and 1-month mortality around 10%. The European guidelines for the management of AHF are based on moderate levels of evidence, due to the lack of randomized controlled trials and the scarce evidence of any clinical added value of a specific treatment to improve outcomes. Recent reports suggest that the very early administration of full recommended therapy may decrease mortality. However, several studies have highlighted that elderly patients often received suboptimal treatment. Our hypothesis is that an early care bundle that comprises early and comprehensive management of symptoms, along with prompt detection and treatment of precipitating factors should improve AHF outcome in elderly patients. METHODS/DESIGN ELISABETH is a stepped-wedge, cluster randomized controlled, clinical trial in 15 emergency departments in France recruiting all patients aged 75 years and older with a diagnosis of AHF. The tested intervention is a care bundle with a checklist that mandates detection and early treatment of AHF precipitating factors, early and intensive treatment of congestion with intravenously administered nitrate boluses, and application of other recommended treatment (low-dose diuretics, non-invasive ventilation when indicated, and preventive low-molecular-weight heparin). Each center is randomized to the order in which they will switch from a "control period" to an "intervention period." All centers begin the trials with the control period for 2 weeks, then after each 2-week step a new center will enter the intervention period. At the end of the trial, all clusters will receive the intervention regimen. The primary outcome is the number of days alive and out of the hospital at 30 days. DISCUSSION If our hypothesis is confirmed, this trial will strengthen the level of evidence of AHF guidelines and stress the importance of the associated early and comprehensive treatment of precipitating factors. This trial could be the first to report a reduction in short-term morbidity and mortality in elderly AHF patients. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT03683212. Prospectively registered on 25 September 2018.
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Affiliation(s)
- Yonathan Freund
- Sorbonne Université, Paris, France
- Emergency Department, Hôpital Pitié-Salpêtrière, Paris, France
- Service d’accueil des urgences, Hôpital Pitié-Salpêtrière, 83 boulevard de l’hôpital, 75013 Paris, France
| | - Judith Gorlicki
- Emergency Department, Hôpital Avicenne, Université Paris 13, Sorbonne Paris Cité, Bobigny, France
| | - Marine Cachanado
- Clinical Research Platform, Hôpital Saint-Antoine, Paris, France
| | - Sarah Salhi
- Clinical Research Platform, Hôpital Saint-Antoine, Paris, France
| | - Vanessa Lemaître
- Clinical Research Platform, Hôpital Saint-Antoine, Paris, France
| | - Tabassome Simon
- Sorbonne Université, Paris, France
- Clinical Research Platform, Hôpital Saint-Antoine, Paris, France
| | - Alexandre Mebazaa
- Department of Anaesthesiology and Critical Care Medicine, Saint Louis and Lariboisière University Hospitals and INSERM UMR-S 942, Paris, France
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López-Rivera F, Cintrón Martínez HR, Castillo LaTorre C, Rivera González A, Rodríguez Vélez JG, Fonseca Ferrer V, Méndez Meléndez OF, Vázquez Vargas EJ, González Monroig HA. Treatment of Hypertensive Cardiogenic Edema with Intravenous High-Dose Nitroglycerin in a Patient Presenting with Signs of Respiratory Failure: A Case Report and Review of the Literature. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:83-90. [PMID: 30662059 PMCID: PMC6350673 DOI: 10.12659/ajcr.913250] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Pulmonary edema is the accumulation of fluid in the lung secondary to increased hydrostatic pressure. Hypertensive cardiogenic pulmonary edema presents with a sudden onset of severe dyspnea, tachycardia, and tachypnea, and can occur when the systolic blood pressure exceeds 160 mmHg in association with acute decompensated congestive cardiac failure (CCF). A case is presented of hypertensive cardiogenic pulmonary edema treated with high-dose nitroglycerin and includes a review of the literature. CASE REPORT A 63-year-old Hispanic male with a medical history of hypertension, coronary artery disease, heart failure with a reduced ejection fraction of 35%, chronic kidney disease (CKD) and diabetes mellitus, presented as an emergency with acute, severe dyspnea. The patient was initially managed with 100% oxygen supplementation and intravenous (IV) high-dose nitroglycerin (30 mcg/min), which was titrated every 3 minutes, increasing by 15 mcg/min until a dose of 120 mcg/min was reached. After 18 minutes of aggressive therapy, the patient's condition improved and he no longer required mechanical ventilation. CONCLUSIONS Hypertensive cardiogenic pulmonary edema is a challenging clinical condition that should be diagnosed and managed as early as possible, and distinguished from respiratory failure due to other causes. Although hypertensive cardiogenic pulmonary edema is usually managed acutely with high-dose diuretics, this case has highlighted the benefit of high-dose IV nitroglycerin, and review of the literature supports this treatment approach.
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Affiliation(s)
- Fermín López-Rivera
- Department of Internal Medicine, San Juan City Hospital, San Juan, Puerto Rico
| | | | | | | | | | | | - Omar F Méndez Meléndez
- Department of Pneumology and Critical Care Medicine, San Juan City Hospital, San Juan, Puerto Rico
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Lee JH, Kim MS, Yoo BS, Park SJ, Park JJ, Shin MS, Youn JC, Lee SE, Jang SY, Choi S, Cho HJ, Kang SM, Choi DJ. KSHF Guidelines for the Management of Acute Heart Failure: Part II. Treatment of Acute Heart Failure. Korean Circ J 2019; 49:22-45. [PMID: 30637994 PMCID: PMC6331324 DOI: 10.4070/kcj.2018.0349] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 10/14/2018] [Accepted: 12/18/2018] [Indexed: 12/11/2022] Open
Abstract
The prevalence of heart failure (HF) is on the rise due to the aging of society. Furthermore, the continuous progress and widespread adoption of screening and diagnostic strategies have led to an increase in the detection rate of HF, effectively increasing the number of patients requiring monitoring and treatment. Because HF is associated with substantial rates of mortality and morbidity, as well as high socioeconomic burden, there is an increasing need for developing specific guidelines for HF management. The Korean guidelines for the diagnosis and management of chronic HF were introduced in March 2016. However, chronic and acute HF represent distinct disease entities. Here, we introduce the Korean guidelines for the management of acute HF with reduced or preserved ejection fraction. Part II of this guideline covers the treatment of acute HF.
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Affiliation(s)
- Ju Hee Lee
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Min Seok Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung Su Yoo
- Division of Cardiology, Department of Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea.
| | - Sung Ji Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Joo Park
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Mi Seung Shin
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jong Chan Youn
- Division of Cardiology, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Sang Eun Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Se Yong Jang
- Division of Cardiology, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Seonghoon Choi
- Division of Cardiology, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hyun Jai Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seok Min Kang
- Division of Cardiology, Department of Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ju Choi
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
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Kim MS, Lee JH, Cho HJ, Cho JY, Choi JO, Hwang KK, Yoo BS, Kang SM, Choi DJ. KSHF Guidelines for the Management of Acute Heart Failure: Part III. Specific Management of Acute Heart Failure According to the Etiology and Co-morbidity. Korean Circ J 2019; 49:46-68. [PMID: 30637995 PMCID: PMC6331326 DOI: 10.4070/kcj.2018.0351] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 12/31/2022] Open
Abstract
The prevalence of heart failure (HF) is on the rise due to the aging of society. Furthermore, the continuous progress and widespread adoption of screening and diagnostic strategies have led to an increase in the detection rate of HF, effectively increasing the number of patients requiring monitoring and treatment. Because HF is associated with substantial rates of mortality and morbidity, as well as high socioeconomic burden, there is an increasing need for developing specific guidelines for HF management. The Korean guidelines for the diagnosis and management of chronic heart failure (CHF) were introduced in March 2016. However, CHF and acute heart failure (AHF) represent distinct disease entities. Here, we introduce the Korean guidelines for the management of AHF with reduced or preserved ejection fraction. Part III of this guideline covers management strategies optimized according to the etiology of AHF and the presence of co-morbidities.
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Affiliation(s)
- Min Seok Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ju Hee Lee
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Hyun Jai Cho
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.
| | - Jae Yeong Cho
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Jin Oh Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Kuk Hwang
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Byung Su Yoo
- Division of Cardiology, Department of Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seok Min Kang
- Division of Cardiology, Department of Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ju Choi
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
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78
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Long B, Koyfman A, Gottlieb M. Management of Heart Failure in the Emergency Department Setting: An Evidence-Based Review of the Literature. J Emerg Med 2018; 55:635-646. [DOI: 10.1016/j.jemermed.2018.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/09/2018] [Accepted: 08/03/2018] [Indexed: 12/21/2022]
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79
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National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart Lung Circ 2018; 27:1123-1208. [DOI: 10.1016/j.hlc.2018.06.1042] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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80
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Verbrugge FH. Editor's Choice-Diuretic resistance in acute heart failure. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 7:379-389. [PMID: 29897275 DOI: 10.1177/2048872618768488] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diuretic resistance is a powerful predictor of adverse outcome in acute heart failure (AHF), irrespectively of underlying glomerular filtration rate. Metrics of diuretic efficacy such as natriuresis, urine output, weight loss, net fluid balance, or fractional sodium excretion, differ in their risk for measurement error, convenience, and biological plausibility, which should be taken into account when interpreting their results. Loop diuretic resistance in AHF has multiple causes including altered drug pharmacokinetics, impaired renal perfusion and effective circulatory volume, neurohumoral activation, post-diuretic sodium retention, the braking phenomenon and functional as well as structural adaptations in the nephron. Ideally, these mechanisms should guide specific treatment decisions with the goal of achieving complete decongestion. Therefore, volume overload needs to be identified correctly to avoid poor diuretic response due to electrolyte depletion or dehydration. Next, renal perfusion should be optimised if possible and loop diuretics should be prescribed above their threshold dose. Addition of thiazide-type diuretics should be considered when a progressive decrease in loop diuretic efficacy is observed with prolonged use (i.e., the braking phenomenon). Furthermore, thiazide-type diuretics are a useful addition in patients with low glomerular filtration rate. However, they limit free water excretion and are relatively contraindicated in cases of hypotonic hyponatremia, where acetazolamide is the better option. Finally, ultrafiltration should be considered in patients with refractory diuretic resistance as persistent volume overload after decongestive treatment is associated with worse outcomes. Whether more upfront use of any of these individually tailored decongestion strategies is superior to monotherapy with loop diuretics remains to be shown by adequately powered randomised clinical trials.
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82
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Singh A, Laribi S, Teerlink JR, Mebazaa A. Agents with vasodilator properties in acute heart failure. Eur Heart J 2018; 38:317-325. [PMID: 28201723 DOI: 10.1093/eurheartj/ehv755] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 12/14/2015] [Accepted: 12/22/2015] [Indexed: 01/05/2023] Open
Abstract
Millions of patients worldwide are admitted for acute heart failure (AHF) each year and physicians caring for these patients are confronted with the short-term challenges of reducing symptoms while preventing end organ dysfunction without causing additional harm, and the intermediate-term challenges of improving clinical outcomes such as hospital readmission and survival. There are limited data demonstrating the efficacy of any currently available therapies for AHF to meet these goals. After diuretics, vasodilators are the most common intravenous therapy for AHF, but neither nitrates, nitroprusside, nor nesiritide have robust evidence supporting their ability to provide meaningful effects on clinical outcomes, except perhaps early symptom improvement. Recently, a number of novel agents with vasodilating properties have been developed for the treatment of AHF. These agents include serelaxin, natriuretic peptides (ularitide, cenderitide), β-arrestin-biased angiotensin II type 1 receptor ligands (TRV120027), nitroxyl donors (CXL-1020, CXL-1427), soluble guanylate cyclase modulators (cinaciguat, vericiguat), short-acting calcium channel blockers (clevidipine), and potassium channel activators (nicorandil). These development programmes range from the stage of early dose-finding studies (e.g. TRV120027, CXL-1427) to large, multicentre mortality trials (e.g. serelaxin, ularitide). There is an urgent need for agents with vasodilating properties that will improve both in-hospital and post-discharge clinical outcomes, and these novel approaches may provide opportunities to address this need.
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Affiliation(s)
- Abhishek Singh
- Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.,School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Saïd Laribi
- INSERM, UMRS 942, Biomarkers and cardiac diseases, Paris, France.,Emergency Department, APHP, Saint Louis-Lariboisière Hospitals, Paris, France
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.,School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Alexandre Mebazaa
- INSERM, UMRS 942, Biomarkers and cardiac diseases, Paris, France.,University Paris Diderot, Sorbonne Paris Cité, Paris, France.,Department of Anesthesiology and Critical Care, APHP, Saint Louis-Lariboisière Hospitals, Paris, France
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83
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Tanaka TD, Sawano M, Ramani R, Friedman M, Kohsaka S. Acute heart failure management in the USA and Japan: overview of practice patterns and review of evidence. ESC Heart Fail 2018; 5:931-947. [PMID: 29932314 PMCID: PMC6165950 DOI: 10.1002/ehf2.12305] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 04/17/2018] [Indexed: 01/23/2023] Open
Abstract
Globally, acute heart failure (AHF) remains an ongoing public health issue with its prevalence and mortality increasing in the east and the west. Effective treatment strategies to stabilize AHF are important to alleviate clinical symptoms and to improve clinical outcomes. However, despite the progress in the management of stable and chronic heart failure, no single agent has been proven to play a definitive role in the management of AHF. As a consequence, contemporary treatment strategies for patients with AHF vary greatly by region. This manuscript reviews the medical treatment options for AHF, with an emphasis on the differences between the treatment strategies in the USA and Japan. This information would provide a framework for clinicians to evaluate and manage patients with AHF and highlight the remaining questions to improve clinical outcomes.
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Affiliation(s)
- Toshikazu D Tanaka
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Ravi Ramani
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Mark Friedman
- Section of Cardiology, Sarver Heart Center, Banner University Medical Center, Tucson, AZ, USA
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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84
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Elucidation of the Strongest Predictors of Cardiovascular Events in Patients with Heart Failure. EBioMedicine 2018; 33:185-195. [PMID: 29936136 PMCID: PMC6085496 DOI: 10.1016/j.ebiom.2018.06.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/15/2018] [Accepted: 06/04/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND In previous retrospective studies, we identified the 50 most influential clinical predictors of cardiovascular outcomes in patients with heart failure (HF). The present study aimed to use the novel limitless-arity multiple-testing procedure to filter these 50 clinical factors and thus yield combinations of no more than four factors that could potentially predict the onset of cardiovascular events. A Kaplan-Meier analysis was used to investigate the importance of the combinations. METHODS In a multi-centre observational trial, we prospectively enrolled 213 patients with HF who were hospitalized because of exacerbation, discharged according to HF treatment guidelines and observed to monitor cardiovascular events. After the observation period, we stratified patients according to whether they experienced cardiovascular events (rehospitalisation or cardiovascular death). FINDINGS Among 77,562 combinations of fewer than five clinical parameters, we identified 151 combinations that could potentially explain the occurrence of cardiovascular events. Of these, 145 combinations included the use of inotropic agents, whereas the remaining 6 included the use of diuretics without bradycardia or tachycardia, suggesting that the high probability of cardiovascular events is exclusively determined by these two clinical factors. Importantly, Kaplan-Meier curves demonstrated that the use of inotropes or of diuretics without bradycardia or tachycardia were independent predictors of a markedly worse cardiovascular prognosis. INTERPRETATION Patients treated with either inotropic agents or diuretics without bradycardia or tachycardia were at a higher risk of cardiovascular events. The uses of these drugs, regardless of heart rate, are the strongest clinical predictors of cardiovascular events in patients with HF.
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85
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Peschanski N, Ray P, Depil-Duval A, Renard A, Avondo A, Chouihed T. L'insuffisance cardiaque aiguë aux urgences : présentations cliniques, diagnostic et prise en charge thérapeutique. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L’insuffisance cardiaque (IC) est une maladie fréquente dont l'incidence croît dans tous les pays développés et dont la morbimortalité est effroyable. Devant une dyspnée aiguë, maître symptôme de la décompensation, le diagnostic d’insuffisance cardiaque aiguë (ICA) reste difficile aux urgences. En effet, les connaissances ayant permis de comprendre les mécanismes physiopathologiques, le concept nosologique d’une seule entité clinique a évolué vers la notion de syndromes d’ICA (SICA) intégrant plusieurs cadres nosographiques de la décompensation d’une IC chronique au tableau de détresse respiratoire aiguë dans l’œdème aigu du poumon cardiogénique, voire au choc cardiogénique. Afin de poser le diagnostic devant ces différentes formes de décompensations aiguës, l'urgentiste a recours à des examens complémentaires qui permettent de déterminer l'étiologie de l'épisode d'IC. Si la réalisation de l'électrocardiogramme et celle de la radiographie thoracique restent indispensables, l’utilisation de biomarqueurs cardiaques, au premier rang desquels les peptides natriurétiques se sont imposés, fait aujourd'hui partie intégrante des outils nécessaires à l'élaboration de la démarche diagnostique. Par ailleurs, la généralisation progressive de l'échographie clinique au sein des services d'urgences permet aujourd'hui d'améliorer la démarche diagnostique et de proposer une approche thérapeutique plus rapide. Ainsi, le concept moderne de « Time-to-therapy » prend-il tout son sens aux urgences où l'utilisation optimisée des différents traitements médicamenteux doit s'associer aux supports d'oxygénothérapie souvent nécessaires à la prise en charge de la dyspnée aiguë. Cet article se propose de faire une revue de la littérature et des recommandations actuelles afin d'assurer une prise en charge optimale des SICA aux urgences et en extrahospitalier.
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86
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Long B, Koyfman A, Chin EJ. Misconceptions in acute heart failure diagnosis and Management in the Emergency Department. Am J Emerg Med 2018; 36:1666-1673. [PMID: 29887195 DOI: 10.1016/j.ajem.2018.05.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/24/2018] [Accepted: 05/31/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Acute heart failure (AHF) accounts for a significant number of emergency department (ED) visits, and the disease may present along a spectrum with a variety of syndromes. OBJECTIVE This review evaluates several misconceptions concerning heart failure evaluation and management in the ED, followed by several pearls. DISCUSSION AHF is a heterogeneous syndrome with a variety of presentations. Physicians often rely on natriuretic peptides, but the evidence behind their use is controversial, and these should not be used in isolation. Chest radiograph is often considered the most reliable imaging test, but bedside ultrasound (US) provides a more sensitive and specific evaluation for AHF. Diuretics are a foundation of AHF management, but in pulmonary edema, these medications should only be provided after vasodilator administration, such as nitroglycerin. Nitroglycerin administered in high doses for pulmonary edema is safe and effective in reducing the need for intensive care unit admission. Though classically dopamine is the first vasopressor utilized in patients with hypotensive cardiogenic shock, norepinephrine is associated with improved outcomes and lower mortality. Disposition is complex in patients with AHF, and risk stratification tools in conjunction with other assessments allow physicians to discharge patients safely with follow up. CONCLUSION A variety of misconceptions surround the evaluation and management of heart failure including clinical assessment, natriuretic peptide use, chest radiograph and US use, nitroglycerin and diuretics, vasopressor choice, and disposition. This review evaluates these misconceptions while providing physicians with updates in evaluation and management of AHF.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, 78234, TX, United States.
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas 75390, TX, United States
| | - Eric J Chin
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, 78234, TX, United States.
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87
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Čerlinskaitė K, Javanainen T, Cinotti R, Mebazaa A. Acute Heart Failure Management. Korean Circ J 2018; 48:463-480. [PMID: 29856141 PMCID: PMC5986746 DOI: 10.4070/kcj.2018.0125] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/02/2018] [Indexed: 01/06/2023] Open
Abstract
Acute heart failure (AHF) is a life-threatening medical condition, where urgent diagnostic and treatment methods are of key importance. However, there are few evidence-based treatment methods. Interestingly, despite relatively similar ways of management of AHF throughout the globe, mid-term outcome in East Asia, including South Korea is more favorable than in Europe. Yet, most of the treatment methods are symptomatic. The cornerstone of AHF management is identifying precipitating factors and specific phenotype. Multidisciplinary approach is important in AHF, which can be caused or aggravated by both cardiac and non-cardiac causes. The main pathophysiological mechanism in AHF is congestion, both systemic and inside the organs (lung, kidney, or liver). Cardiac output is often preserved in AHF except in a few cases of advanced heart failure. This paper provides guidance on AHF management in a time-based approach. Treatment strategies, criteria for triage, admission to hospital and discharge are described.
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Affiliation(s)
- Kamilė Čerlinskaitė
- Department of Anesthesiology and Reanimation, Hôpital Lariboisière, Paris, France
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisiere, Assistance Publique des Hopitaux de Paris, Paris, France
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Tuija Javanainen
- Department of Anesthesiology and Reanimation, Hôpital Lariboisière, Paris, France
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisiere, Assistance Publique des Hopitaux de Paris, Paris, France
- Department of Cardiology, University of Helsinki, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Raphaël Cinotti
- Department of Anesthesiology and Reanimation, Hôpital Lariboisière, Paris, France
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisiere, Assistance Publique des Hopitaux de Paris, Paris, France
- Department of Anesthesia and Critical Care, University Hospital of Nantes, Nantes Cedex, France
| | - Alexandre Mebazaa
- Department of Anesthesiology and Reanimation, Hôpital Lariboisière, Paris, France
- Department of Anesthesiology and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisiere, Assistance Publique des Hopitaux de Paris, Paris, France
- University Paris Diderot, Paris, France.
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88
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Travessa AM, Menezes Falcão L. Vasodilators in acute heart failure - evidence based on new studies. Eur J Intern Med 2018; 51:1-10. [PMID: 29482882 DOI: 10.1016/j.ejim.2018.02.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 02/04/2018] [Accepted: 02/21/2018] [Indexed: 12/28/2022]
Abstract
Acute heart failure (AHF) contributes largely to the worldwide burden of heart failure (HF) and is associated with high mortality, poor prognosis and high rehospitalization rate. The pharmacologic therapy of AHF includes diuretics and vasodilators, which are a keystone when fluid overload and congestion are present. However, vasodilators are mainly focused on controlling symptoms, and drugs that also improve long-term mortality and morbidity seem to be in high demand. In this review, we summarize the existing evidence on mortality benefits of IV vasodilators in AHF. There is lack of evidence on the mortality benefits of IV vasodilators in AHF, as well as well-designed and large-scale trials for some of them. The existing trials on nitrates have conflicting results and are insufficient to establish definitive conclusions. Other vasodilators, such as enalaprilat, clevidipine, carperitide, and ularitide, have been evaluated only in a few trials assessing mortality. Levosimendan, nesititide and carperitide are approved by some regulatory agencies; however, data regarding mortality are also conflicting and large-scale post-marketing studies would be important. Serelaxin is a recent therapy with a novel mechanism of action and seemed to be promising; although serelaxin was safe and well tolerated in earlier trials, the results of a larger phase III trial failed to meet the primary endpoints of reduction in cardiovascular death at day 180 and reduction of worsening heart failure at day 5. The absence of definitive mortality benefits and high-quality and large-scale data not allow firm conclusions to be drawn about the role of IV vasodilators in AHF. Well-designed studies are needed to clarify the role of these drugs in the long-term outcome of AHF, as well as new therapies entering the clinical investigation.
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Affiliation(s)
- André M Travessa
- Centro Hospitalar Lisboa Norte, Lisbon, Portugal; Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - L Menezes Falcão
- Centro Hospitalar Lisboa Norte, Lisbon, Portugal; Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.
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Intubations in elderly patients have decreased from 1999 through 2014-Results of a multi-center cohort study. Am J Emerg Med 2018; 36:1964-1966. [PMID: 29506891 DOI: 10.1016/j.ajem.2018.02.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 02/17/2018] [Accepted: 02/24/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Advances in pharmacologic therapy, non-invasive positive pressure ventilation (NIPPV) and advanced directives may have decreased the intubations of dyspneic elderly (≥65years old) patients in the emergency department (ED). OBJECTIVE To determine if the percentage of elderly ED patients intubated has decreased in recent years. METHODS Design: Retrospective multihospital cohort. SETTING Consecutive ED patients in nine NJ hospitals (1/1/1999 to 9/30/2014). PROTOCOL We identified patients intubated in the ED by CPT codes. DATA ANALYSIS We calculated the annual percentage of patients ≥65 intubated and the percentage intubated by diagnosis along with 95% confidence intervals (CIs). RESULTS Of the 5,693,380 total patients in the database there were 1,065,371 visits for patients≥65. Their average age was 80±8years; 54% were female. Of these, 6297 were intubated (0.59%). From 1999 to 2014 the percent intubated decreased from 0.73% to 0.52%, a relative decrease of 29% (95% CI: 17%, 38%). The specific diagnoses with >500 intubations were congestive heart failure (CHF), pneumonia and cardiac arrest, accounting for 37% of the total. Of these three, CHF was the only diagnosis with a statistically significant change from 1999 to 2014: a relative decrease of 70% (95% CI: 53%, 81%). If all diagnoses without CHF are analyzed the overall relative decrease is 14% (95% CI: 3%, 24%). CONCLUSION Intubation rates for patients≥65 decreased from 1999 through 2014, particularly in CHF patients. We speculate that these findings reflect wider implementation of NIPPV, other therapeutic modalities and advanced directives.
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Abstract
PURPOSE OF REVIEW In spite of advances in our understanding of acute heart failure (AHF) and its different phenotypic expressions, AHF management is still centered on volume removal with intravenous diuretics. This narrative review describes the pathophysiology underlying hypertensive AHF and appraises therapies targeting these mechanisms. RECENT FINDINGS Vascular redistribution rather than volume overload may be the primary determinant of elevated cardiac filling pressures and subsequent pulmonary congestion in patients with hypertensive AHF; in these patients, vasodilators should be the predominant treatment. Additional therapy with diuretics in hypertensive AHF should be relegated to the treatment of overt volume overload or persistent congestion in spite of optimized hemodynamics. Intravenous nitroglycerin at high doses can rapidly achieve pulmonary decongestion and reduce downstream critical care needs in these patients. The therapeutic role for synthetic peptides with vasodilator properties has yet to be defined. Evidence supporting both old and new vasodilator therapies is limited by a paucity of well-designed studies and failure to demonstrate improvement in long-term outcomes. Targeted study of this phenotype of AHF is needed before vasodilator therapies become incorporated into treatment guidelines.
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Abstract
Acute heart failure (AHF) is a life-threatening condition requiring immediate treatment. The initial therapy should take into account the clinical presentation, pathophysiology at play, precipitating factors and underlying cardiac pathology. Particular attention should be given to polymorbidity and the avoidance of potential iatrogenic harm. Patient preferences and ethical issues should be integrated into the treatment plan at an early stage. The average survival of AHF patients is 2 years and the most vulnerable period is the 3-month time window directly after discharge. Reducing both persistent subclinical congestion and underutilisation of disease-modifying heart failure therapies as well as ensuring optimal transitions of care after hospital discharge are essential in improving outcomes for AHF patients.
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Affiliation(s)
- Mattia Arrigo
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Petra Nijst
- Department of Cardiology, Ziekenhuis Oost Limburg Genk, Genk, Belgium
| | - Alain Rudiger
- Cardiosurgical Intensive Care Unit, University Hospital Zurich, Zurich, Switzerland
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Shah P, Pellicori P, Cuthbert J, Clark AL. Pharmacological and Non-pharmacological Treatment for Decompensated Heart Failure: What Is New? Curr Heart Fail Rep 2017; 14:147-157. [PMID: 28421408 PMCID: PMC5423987 DOI: 10.1007/s11897-017-0328-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF THE REVIEW Acute heart failure (AHF) is a life-threatening clinical condition that requires prompt medical attention. The aim of the current review is to summarise the results of recent clinical trials conducted in patients with AHF. RECENT FINDINGS Several novel compounds have apparently beneficial acute effects on cardiovascular haemodynamics and patients' symptoms, but their administration has not yet translated into improved survival and has been deleterious in some cases. The management of patients with AHF is challenging and reflects the heterogeneity of patient's presentation, the complexity and severity of a multi-organ syndrome, and the limited therapeutic options, usually restricted to a combination of diuretics and vasodilators. Ongoing trials of novel treatments may provide evidence of an effect on outcomes.
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Affiliation(s)
- Parin Shah
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK.
| | - Pierpaolo Pellicori
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK
| | - Joseph Cuthbert
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK
| | - Andrew L Clark
- Department of Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK
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93
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Kwok TYT, Mak PSK, Rainer TH, Graham CA. Treatment and Outcome of Acute Cardiogenic Pulmonary Oedema Presenting to an Emergency Department in Hong Kong: Retrospective Cohort Study. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790601300304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives To explore the epidemiology, treatment and outcome of acute cardiogenic pulmonary oedema (ACPO) in a Hong Kong emergency department (ED). Methods This was a retrospective cohort study in a university hospital ED. Cases were identified from ED records and resuscitation room logbooks. The study extended from 1 September 2004 to 30 April 2005. Parametric tests and logistic regression were used to identify predictors of survival. Results A total of 140 patients were identified, with a mean age of 75 years and male:female ratio of 1:1.4. Mean values (range) on presentation were as follows: pulse rate 103 beats/minute (36–108); blood pressure (BP) 169/88 mmHg (77-274/20-162) and respiratory rate 31 breaths/minute (12–88). Past medical history included previous ACPO (12.1%), diabetes (45.7%), chronic obstructive pulmonary disease (9.3%), ischaemic heart disease (45.0%), hypertension (72.1%) and congestive heart failure (40.7%). On admission, 47.1% had pH<7.35 and 40.7% had PaCO2>5.5kPa. ED treatments included: sublingual nitrates (n=2), intravenous (IV) nitrates (n=89, median 10 mg/hr), IV frusemide (n=85, median 40 mg), IV morphine (n=25, median 3 mg). There were 21 patients on non-invasive ventilation; 27 intubations and 41 patients were admitted to the intensive care unit. Survival to discharge was 95.7%; and median length of hospital stay was 8 days. The 90-day all-cause hospital readmission rate was 30.0%. The 30-day mortality was 12.9% (n=18) and 90-day mortality was 29.3% (n=41). Logistic regression showed that past history of hypertension (p=0.0061), higher systolic BP on ED discharge (p=0.0102) and lower creatinine following treatment (p=0.035) were predictors of improved survival at 90 days. Conclusion ACPO commonly presents to the ED in Hong Kong and has a high 90-day mortality. Previous hypertension, higher systolic blood pressure on leaving the ED and lower creatinine following treatment predict improved survival at 90 days.
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Affiliation(s)
| | | | - TH Rainer
- University of Birmingham, Faculty of Medicine, United Kingdom
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95
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Ezekowitz JA, O'Meara E, McDonald MA, Abrams H, Chan M, Ducharme A, Giannetti N, Grzeslo A, Hamilton PG, Heckman GA, Howlett JG, Koshman SL, Lepage S, McKelvie RS, Moe GW, Rajda M, Swiggum E, Virani SA, Zieroth S, Al-Hesayen A, Cohen-Solal A, D'Astous M, De S, Estrella-Holder E, Fremes S, Green L, Haddad H, Harkness K, Hernandez AF, Kouz S, LeBlanc MH, Masoudi FA, Ross HJ, Roussin A, Sussex B. 2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure. Can J Cardiol 2017; 33:1342-1433. [PMID: 29111106 DOI: 10.1016/j.cjca.2017.08.022] [Citation(s) in RCA: 433] [Impact Index Per Article: 61.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 08/28/2017] [Accepted: 08/28/2017] [Indexed: 02/06/2023] Open
Abstract
Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.
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Affiliation(s)
| | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | - Michael Chan
- Edmonton Cardiology Consultants, Edmonton, Alberta, Canada
| | - Anique Ducharme
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Adam Grzeslo
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Serge Lepage
- Université de Sherbrooke, Sherbrooke, Québec, Canada
| | | | | | - Miroslaw Rajda
- QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | | | - Sean A Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | - Sabe De
- London Health Sciences, Western University, London, Ontario, Canada
| | | | - Stephen Fremes
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lee Green
- University of Alberta, Edmonton, Alberta, Canada
| | - Haissam Haddad
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Karen Harkness
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Simon Kouz
- Centre Hospitalier Régional de Lanaudière, Joliette, Québec, Canada
| | | | | | | | - Andre Roussin
- Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Bruce Sussex
- Memorial University, St John's, Newfoundland, Canada
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96
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Falls R, Seman M, Braat S, Sortino J, Allen JD, Neil CJ. Inorganic nitrate as a treatment for acute heart failure: a protocol for a single center, randomized, double-blind, placebo-controlled pilot and feasibility study. J Transl Med 2017; 15:172. [PMID: 28789663 PMCID: PMC5549289 DOI: 10.1186/s12967-017-1271-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 07/24/2017] [Indexed: 01/07/2023] Open
Abstract
Background Acute heart failure (AHF) is a frequent reason for hospitalization worldwide and effective treatment options are limited. It is known that AHF is a condition characterized by impaired vasorelaxation, together with reduced nitric oxide (NO) bioavailability, an endogenous vasodilatory compound. Supplementation of inorganic sodium nitrate (NaNO3) is an indirect dietary source of NO, through bioconversion. It is proposed that oral sodium nitrate will favorably affect levels of circulating NO precursors (nitrate and nitrite) in AHF patients, resulting in reduced systemic vascular resistance, without significant hypotension. Methods and outcomes We propose a single center, randomized, double-blind, placebo-controlled pilot trial, evaluating the feasibility of sodium nitrate as a treatment for AHF. The primary hypothesis that sodium nitrate treatment will result in increased systemic levels of nitric oxide pre-cursors (nitrate and nitrite) in plasma, in parallel with improved vasorelaxation, as assessed by non-invasively derived systemic vascular resistance index. Additional surrogate measures relevant to the known pathophysiology of AHF will be obtained in order to assess clinical effect on dyspnea and renal function. Discussion The results of this study will provide evidence of the feasibility of this novel approach and will be of interest to the heart failure community. This trial may inform a larger study.
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Affiliation(s)
- Roman Falls
- Western Centre for Health Research and Education, Western Health, Melbourne, Australia.,Department of Medicine-Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Michael Seman
- Western Centre for Health Research and Education, Western Health, Melbourne, Australia.,Department of Medicine-Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Sabine Braat
- Department of Medicine-Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Australia.,Melbourne School of Population and Global Health and Melbourne Clinical and Translational Sciences Platform (MCATS), Parkville, Australia
| | - Joshua Sortino
- Western Centre for Health Research and Education, Western Health, Melbourne, Australia
| | - Jason D Allen
- Western Centre for Health Research and Education, Western Health, Melbourne, Australia.,Clinical Exercise Science Research Program, Institute of Sport Exercise and Active Living (ISEAL), Melbourne, Australia
| | - Christopher J Neil
- Western Centre for Health Research and Education, Western Health, Melbourne, Australia. .,Department of Medicine-Western Health, Melbourne Medical School, The University of Melbourne, Melbourne, Australia. .,Clinical Exercise Science Research Program, Institute of Sport Exercise and Active Living (ISEAL), Melbourne, Australia. .,Western Health Cardiology, Footscray Hospital, Gordon St, Locked Bag 2, Footscray, VIC, 3011, Australia.
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Cardiovascular Conditions in the Observation Unit: Beyond Chest Pain. Emerg Med Clin North Am 2017; 35:549-569. [PMID: 28711124 DOI: 10.1016/j.emc.2017.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The first emergency department observation units (EDOUs) focused on chest pain and potential acute coronary syndromes. However, most EDOUs now cover multiple other conditions that lend themselves to protocolized, aggressive diagnostic and therapeutic regimens. In this article, the authors discuss the management of 4 cardiovascular conditions that have been successfully deployed in EDOUs around the country.
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98
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Zhang F, Wang Q, Wang L, Bai Y. Implementing plant-derived isosorbide and isomannide as comonomers for polyester synthesis: Effects of crystallization properties on optical properties. J Appl Polym Sci 2017. [DOI: 10.1002/app.45444] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Fuchen Zhang
- School of Chemical Engineering and Technology; Harbin Institute of Technology; Harbin 150001 People's Republic of China
| | - Qiuxia Wang
- School of Chemical Engineering and Technology; Harbin Institute of Technology; Harbin 150001 People's Republic of China
| | - Lipeng Wang
- School of Chemical Engineering and Technology; Harbin Institute of Technology; Harbin 150001 People's Republic of China
| | - Yongping Bai
- School of Chemical Engineering and Technology; Harbin Institute of Technology; Harbin 150001 People's Republic of China
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99
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The Use of Nitrates in the Management of Acute Heart Failure in the Emergency Department: a Review. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2017. [DOI: 10.1007/s40138-017-0132-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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100
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Abstract
Clinicians make frequent treatment decisions regarding acute blood pressure reduction for the critically ill. Key to the decision making process is a balance between reducing arterial wall stress and maintaining perfusion to vital organs. In this article, we review the physiological considerations underlying acute blood pressure management, including the concept of cerebral autoregulation and its adaptations to chronic hypertension. We then discuss available pharmacological interventions suited for reducing blood pressure acutely. We also discuss specific blood pressure targets in common critical illnesses and consider future directions in this therapeutic area.
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