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Prognostic value of pulmonary congestion assessed by lung ultrasound imaging during heart failure hospitalisation: A two-centre cohort study. Sci Rep 2016; 6:39426. [PMID: 27995971 PMCID: PMC5171824 DOI: 10.1038/srep39426] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 11/22/2016] [Indexed: 12/11/2022] Open
Abstract
Pulmonary congestion assessed at discharge by lung ultrasonography predicts poor prognosis in heart failure (HF) patients. We investigated the association of B-lines with indices of hemodynamic congestion [BNP, E/e', pulmonary systolic arterial pressure (PAPs)] in HF patients, and their prognostic value overall and according to concomitant atrial fibrillation (AF), reduced (≤40%) ejection fraction (EF), and timing of quantification during hospitalisation for heart failure (HHF). In 110 HHF patients, B-lines were highly discriminative of BNP >400 pg/ml (AUC ≥ 0.80 for all), and moderately discriminative of PAPs >50 mmHg (AUC = 0.68, 0.56 to 0.80); conversely, B-lines poorly discriminated average E/e' ≥ 15, except at discharge. B-line count significantly predicted mid-term recurrent HHF or death (overall and in subgroups), regardless of AF status, EF, and timing of quantification during HHF (all p for interaction >0.10). regardless, B-lines ≥30 at discharge were most predictive of outcome (HR = 7.11, 2.06-24.48; p = 0.002) while B-lines ≥45 early during HHF were most predictive of outcome (HR = 9.20, 1.82-46.61; p = 0.007). Lung ultrasound was able to identify patients with high BNP levels, but not with increased E/e', also showing a prognostic role regardless of AF status, EF or timing of quantification; best B-line cut-off appears to vary according to the timing of quantification during hospitalization.
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Rubio Gracia J, Sánchez Marteles M, Pérez Calvo JI. Involvement of systemic venous congestion in heart failure. Rev Clin Esp 2016; 217:161-169. [PMID: 27979306 DOI: 10.1016/j.rce.2016.10.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 10/05/2016] [Accepted: 10/31/2016] [Indexed: 12/17/2022]
Abstract
Systemic venous congestion has gained significant importance in the interpretation of the pathophysiology of acute heart failure, especially in the development of renal function impairment during exacerbations. In this study, we review the concept, clinical characterisation and identification of venous congestion. We update current knowledge on its importance in the pathophysiology of acute heart failure and its involvement in the prognosis. We pay special attention to the relationship between abdominal congestion, the pulmonary interstitium as filtering membrane, inflammatory phenomena and renal function impairment in acute heart failure. Lastly, we review decongestion as a new therapeutic objective and the measures available for its assessment.
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Affiliation(s)
- J Rubio Gracia
- Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España; Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, España.
| | - M Sánchez Marteles
- Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España; Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, España
| | - J I Pérez Calvo
- Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España; Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Zaragoza, España; Facultad de Medicina, Universidad de Zaragoza, Zaragoza, España
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103
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Simoni F, Vitturi N, Dugo M. Usefulness of ultrasound imaging in overhydrated nephropathic patients. J Ultrasound 2016; 19:299-300. [DOI: 10.1007/s40477-016-0213-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 05/03/2016] [Indexed: 10/21/2022] Open
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Cubo-Romano P, Torres-Macho J, Soni NJ, Reyes LF, Rodríguez-Almodóvar A, Fernández-Alonso JM, González-Davia R, Casas-Rojo JM, Restrepo MI, de Casasola GG. Admission inferior vena cava measurements are associated with mortality after hospitalization for acute decompensated heart failure. J Hosp Med 2016; 11:778-784. [PMID: 27264844 DOI: 10.1002/jhm.2620] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 04/30/2016] [Accepted: 05/08/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND Prognostication of patients hospitalized with acute decompensated heart failure (ADHF) is important to patients, providers, and healthcare systems. Few bedside tools exist to prognosticate patients hospitalized with ADHF. OBJECTIVE The objective of this study was to assess the relationship between inferior vena cava (IVC) diameter and postdischarge mortality in patients hospitalized with ADHF. DESIGN Prospective observational study. SETTING A 247-bed urban teaching hospital in Spain PATIENTS: Ninety-seven patients hospitalized with ADHF. INTERVENTION None. MEASUREMENTS The IVC diameter and collapsibility were measured by a hospitalist at the time of admission and discharge. Primary outcome was 90-day all-cause mortality. Secondary outcomes were readmission rates at 90 and 180 days, and 180-day all-cause mortality. Patients were followed for 180 days. RESULTS Data from 80 patients were analyzed. From admission to discharge, a significant improvement in IVC maximum (IVCmax ) diameter (2.12 vs 1.87 cm; P < 0.001) and IVC collapsibility (25.7% vs 33.1%; P < 0.001) was seen in the total study cohort. During the 90-day follow-up period, 11 patients (13.7%) died. An admission IVCmax diameter ≥1.9 cm was associated with a higher mortality rate at 90 days (25.4% vs 3.4%; P = 0.009) and 180 days (29.3% vs 3.4%; P = .003). In a multivariate Cox proportional hazards regression analysis, admission IVCmax diameter was an independent predictor of 90-day mortality (hazard ratio [HR]: 5.88; 95% confidence interval [CI]: 1.21-28.10; P = 0.025) and 90-day readmission (HR: 3.20; 95% CI: 1.24-8.21; P = 0.016). CONCLUSION In patients hospitalized with acute decompensated heart failure, a dilated IVC by bedside ultrasound at the time of admission is associated with a higher 90-day mortality after hospitalization. Journal of Hospital Medicine 2016;11:778-784. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Pilar Cubo-Romano
- Department of Internal Medicine and Emergency Medicine, Infanta Cristina University Hospital, Madrid, Spain
- Department of Medicine, Complutense University, Madrid, Spain
| | - Juan Torres-Macho
- Department of Internal Medicine and Emergency Medicine, Infanta Cristina University Hospital, Madrid, Spain
- Department of Medicine, Complutense University, Madrid, Spain
| | - Nilam J Soni
- Section of Pulmonary and Critical Care Medicine, South Texas Veterans Health Care System and University of Texas Health Science Center, San Antonio, Texas.
- Division of Hospital Medicine, University of Texas School of Medicine in San Antonio, Texas.
| | - Luis F Reyes
- Section of Pulmonary and Critical Care Medicine, South Texas Veterans Health Care System and University of Texas Health Science Center, San Antonio, Texas
| | - Ana Rodríguez-Almodóvar
- Department of Medicine, Complutense University, Madrid, Spain
- Department of Cardiology, Infanta Cristina University Hospital, Madrid, Spain
| | | | - Rosa González-Davia
- Department of Medicine, Complutense University, Madrid, Spain
- Department of Cardiology, Infanta Cristina University Hospital, Madrid, Spain
| | - José Manuel Casas-Rojo
- Department of Internal Medicine and Emergency Medicine, Infanta Cristina University Hospital, Madrid, Spain
- Department of Medicine, Complutense University, Madrid, Spain
| | - Marcos I Restrepo
- Section of Pulmonary and Critical Care Medicine, South Texas Veterans Health Care System and University of Texas Health Science Center, San Antonio, Texas
| | - Gonzalo García de Casasola
- Department of Internal Medicine and Emergency Medicine, Infanta Cristina University Hospital, Madrid, Spain
- Department of Medicine, Complutense University, Madrid, Spain
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105
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Tang WW, Kitai T. Intrarenal Venous Flow. JACC-HEART FAILURE 2016; 4:683-6. [DOI: 10.1016/j.jchf.2016.05.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 05/18/2016] [Indexed: 12/24/2022]
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Gil Martínez P, Mesado Martínez D, Curbelo García J, Cadiñanos Loidi J. Amino-terminal pro-B-type natriuretic peptide, inferior vena cava ultrasound, and biolectrical impedance analysis for the diagnosis of acute decompensated CHF. Am J Emerg Med 2016; 34:1817-22. [PMID: 27396536 DOI: 10.1016/j.ajem.2016.06.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 06/07/2016] [Accepted: 06/09/2016] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Both Framingham criteria and natriuretic peptides (NPs) may worsen their diagnostic validity for acute decompensated heart failure (ADHF) in elderly patients with comorbidities, mainly renal failure. Ultrasound of inferior vena cava (IVCu) and bioelectrical impedance analysis (BIA) are useful tools for detecting ADHF, although their utility compared with NP is not fully established. METHODS AND RESULTS We conducted a prospective study with 96 patients who presented at the emergency department with dyspnea and were classified as ADHF and non-ADHF groups. Inferior vena cava ultrasonography measured maximum and minimum inferior vena cava diameters and collapsibility index (CIx), whereas BIA calculated resistance (Rz) and reactance (Xc). The primary goal was to compare amino-terminal pro-B-type NP (NT-proBNP), IVCu, and BIA for identifying ADHF. The ADHF group showed significantly (P<.001) higher NT-proBNP values (5801 vs 599 pg/mL), higher maximum IVC diameter (2.26 vs 1.58 cm), higher minimum IVC diameter (1.67 vs 0,7 cm), and lower CIx (27% vs 59%), as well as lower Rz (458.8 vs 627.1 Ohm) and lower Xc (23.5 vs 38.4 Ohm) compared with the non-ADHF group. The estimated area under the curve for ADHF diagnosis was 0.84 for NT-proBNP, 0.90 for maximum IVC diameter, 0.93 for minimum IVC diameter, and 0.90 for CIx, as well as 0.83 and 0.80 for Rz and Xc respectively, without finding significant difference. Cutoff values for diagnosis of ADHF with IVCu and BIA are proposed. Amino-terminal pro-B-type NP values significantly varied in patients with renal impairment, independently of ADHF status, whereas neither IVCu nor BIA did. CONCLUSIONS Inferior vena cava ultrasonography and BIA analysis are as useful as NT-proBNP to ADHF diagnosis, validated in an elderly population with kidney disease.
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Affiliation(s)
- Paloma Gil Martínez
- Emergency and Internal Medicine Department, Universitary Hospital La Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Heart Failure Division, Internal Medicine Department, Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Madrid, Spain.
| | - Daniel Mesado Martínez
- Emergency and Internal Medicine Department, Universitary Hospital La Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Internal Medicine Department, Hospital General de Villalba, Madrid, Spain.
| | - Jose Curbelo García
- Emergency and Internal Medicine Department, Universitary Hospital La Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Heart Failure Division, Internal Medicine Department, Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Madrid, Spain.
| | - Julen Cadiñanos Loidi
- Emergency and Internal Medicine Department, Universitary Hospital La Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Internal Medicine Department, Hospital General de Villalba, Madrid, Spain.
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Ferrari R, Malagù M, Biscaglia S, Fucili A, Rizzo P. Remodelling after an Infarct: Crosstalk between Life and Death. Cardiology 2016; 135:68-76. [DOI: 10.1159/000445882] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 03/29/2016] [Indexed: 11/19/2022]
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108
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New ways to visualize and combat congestion in heart failure. Rev Clin Esp 2016; 216:202-4. [PMID: 27129360 DOI: 10.1016/j.rce.2016.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 03/31/2016] [Indexed: 11/20/2022]
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109
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Pellicori P, Goode KM, Nicholls R, Ahmed D, Clark AL, Cleland JG. Regional circulatory distribution of novel cardiac bio-markers and their relationships with haemodynamic measurements. Int J Cardiol 2016; 210:149-55. [DOI: 10.1016/j.ijcard.2016.02.081] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/30/2015] [Accepted: 02/02/2016] [Indexed: 01/19/2023]
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110
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111
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Frea S, Pidello S, Bovolo V, Iacovino C, Franco E, Pinneri F, Galluzzo A, Volpe A, Visconti M, Peirone A, Morello M, Bergerone S, Gaita F. Prognostic incremental role of right ventricular function in acute decompensation of advanced chronic heart failure. Eur J Heart Fail 2016; 18:564-72. [DOI: 10.1002/ejhf.504] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 12/17/2015] [Accepted: 12/25/2015] [Indexed: 11/08/2022] Open
Affiliation(s)
- Simone Frea
- Division of Cardiology; Città della Salute e della Scienza University Hospital of Torino; Italy
| | - Stefano Pidello
- Division of Cardiology; Città della Salute e della Scienza University Hospital of Torino; Italy
| | - Virginia Bovolo
- Division of Cardiology; Città della Salute e della Scienza University Hospital of Torino; Italy
| | - Cristina Iacovino
- Division of Cardiology; Città della Salute e della Scienza University Hospital of Torino; Italy
| | - Erica Franco
- Division of Cardiology; Ospedale Civico of Chivasso; Torino Italy
| | | | - Alessandro Galluzzo
- Division of Cardiology; Città della Salute e della Scienza University Hospital of Torino; Italy
| | - Alessandra Volpe
- Division of Cardiology; Città della Salute e della Scienza University Hospital of Torino; Italy
| | - Massimiliano Visconti
- Division of Cardiology; Città della Salute e della Scienza University Hospital of Torino; Italy
| | - Andrea Peirone
- Division of Cardiology; Città della Salute e della Scienza University Hospital of Torino; Italy
| | - Mara Morello
- Division of Cardiology; Città della Salute e della Scienza University Hospital of Torino; Italy
| | - Serena Bergerone
- Division of Cardiology; Città della Salute e della Scienza University Hospital of Torino; Italy
| | - Fiorenzo Gaita
- Division of Cardiology; Città della Salute e della Scienza University Hospital of Torino; Italy
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112
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Torres D, Cuttitta F, Paterna S, Garofano A, Conti G, Pinto A, Parrinello G. Bed-side inferior vena cava diameter and mean arterial pressure predict long-term mortality in hospitalized patients with heart failure: 36 months of follow-up. Eur J Intern Med 2016; 28:80-4. [PMID: 26751720 DOI: 10.1016/j.ejim.2015.11.029] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 10/16/2015] [Accepted: 11/30/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND In discharged patients with heart failure (HF), diverse conditions can intervene to worsen outcome. We would investigate whether such factors present on hospital admission can affect long-term mortality in subjects hospitalized for acute HF. METHODS One hundred twenty-three consecutive patients hospitalized for acute HF (mean age 74.8 years; 57% female) were recruited and followed for 36 months after hospitalization. RESULTS At multivariate Cox model, only inferior vena cava (IVC) diameter and mean arterial pressure (MAP) registered bed-side on admission, resulted, after correction for all confounders factors, the sole factors significantly associated with a higher risk of all-cause mortality in long-term (HR 1.06, p=0.0057; HR 0.97, p=0.0218; respectively). Study population was subdivided according to median values of IVC diameter (23 mm) and MAP (93.3 mm Hg). The Kaplan–Meier curve showed that HF patients with both IVC ≥ 23 mm and MAP b93.3 mm Hg on admission had reduced probability of survival free from all-cause death (log rank p = 0.0070 and log rank p = 0.0028, respectively). CONCLUSIONS In patients hospitalized for acute HF, IVC diameter, measured by hand-carried ultrasound (HCU), and MAP detected on admission are strong predictors of long-term all-cause mortality. The data suggest the need for a careful clinical-therapeutic surveillance on these patients during the post-discharge period. IVC diameter and MAP can be utilized as parameters to stratify prognosis on admission and to be supervised during follow-up.
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Affiliation(s)
- Daniele Torres
- Dipartimento Biomedico di Medicina Interna e Specialistica, Azienda Ospedaliera Universitaria Policlinico (A.O.U.P.) "Paolo Giaccone", Università degli Studi di Palermo, Palermo, Italia
| | - Francesco Cuttitta
- Dipartimento Biomedico di Medicina Interna e Specialistica, Azienda Ospedaliera Universitaria Policlinico (A.O.U.P.) "Paolo Giaccone", Università degli Studi di Palermo, Palermo, Italia.
| | - Salvatore Paterna
- Dipartimento Biomedico di Medicina Interna e Specialistica, Azienda Ospedaliera Universitaria Policlinico (A.O.U.P.) "Paolo Giaccone", Università degli Studi di Palermo, Palermo, Italia
| | - Alessandro Garofano
- Dipartimento Biomedico di Medicina Interna e Specialistica, Azienda Ospedaliera Universitaria Policlinico (A.O.U.P.) "Paolo Giaccone", Università degli Studi di Palermo, Palermo, Italia
| | - Giosafat Conti
- Dipartimento Biomedico di Medicina Interna e Specialistica, Azienda Ospedaliera Universitaria Policlinico (A.O.U.P.) "Paolo Giaccone", Università degli Studi di Palermo, Palermo, Italia
| | - Antonio Pinto
- Dipartimento Biomedico di Medicina Interna e Specialistica, Azienda Ospedaliera Universitaria Policlinico (A.O.U.P.) "Paolo Giaccone", Università degli Studi di Palermo, Palermo, Italia
| | - Gaspare Parrinello
- Dipartimento Biomedico di Medicina Interna e Specialistica, Azienda Ospedaliera Universitaria Policlinico (A.O.U.P.) "Paolo Giaccone", Università degli Studi di Palermo, Palermo, Italia
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Afsar B, Ortiz A, Covic A, Solak Y, Goldsmith D, Kanbay M. Focus on renal congestion in heart failure. Clin Kidney J 2015; 9:39-47. [PMID: 26798459 PMCID: PMC4720202 DOI: 10.1093/ckj/sfv124] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 10/27/2015] [Indexed: 12/11/2022] Open
Abstract
Hospitalizations due to heart failure are increasing steadily despite advances in medicine. Patients hospitalized for worsening heart failure have high mortality in hospital and within the months following discharge. Kidney dysfunction is associated with adverse outcomes in heart failure patients. Recent evidence suggests that both deterioration in kidney function and renal congestion are important prognostic factors in heart failure. Kidney congestion in heart failure results from low cardiac output (forward failure), tubuloglomerular feedback, increased intra-abdominal pressure or increased venous pressure. Regardless of the cause, renal congestion is associated with increased morbidity and mortality in heart failure. The impact on outcomes of renal decongestion strategies that do not compromise renal function should be explored in heart failure. These studies require novel diagnostic markers that identify early renal damage and renal congestion and allow monitoring of treatment responses in order to avoid severe worsening of renal function. In addition, there is an unmet need regarding evidence-based therapeutic management of renal congestion and worsening renal function. In the present review, we summarize the mechanisms, diagnosis, outcomes, prognostic markers and treatment options of renal congestion in heart failure.
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Affiliation(s)
- Baris Afsar
- Department of Medicine, Division of Nephrology , Konya Numune State Hospital , Konya , Turkey
| | - Alberto Ortiz
- Nephrology and Hypertension Department , IIS-Fundacion Jimenez Diaz and School of Medicine , Madrid , Spain
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center , 'C.I. PARHON' University Hospital, and 'Grigore T. Popa' University of Medicine , Iasi , Romania
| | - Yalcin Solak
- Department of Nephrology , Sakarya Training and Research Hospital , Sakarya , Turkey
| | - David Goldsmith
- Renal and Transplantation Department , Guy's and St Thomas' Hospitals , London , UK
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology , Koc University School of Medicine , Istanbul , Turkey
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114
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Barbosa MM, Nunes MCP. The potential of point-of-care ultrasound by non-experts to improve diagnosis and patient care. Heart 2015; 102:3-4. [PMID: 26552757 DOI: 10.1136/heartjnl-2015-308802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Marcia Melo Barbosa
- Hospital Socor, Belo Horizonte, Minas Gerais, Brazil Hospital das Clinicas of the Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Maria Carmo P Nunes
- Hospital das Clinicas of the Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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115
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Saha NM, Barbat JJ, Fedson S, Anderson A, Rich JD, Spencer KT. Outpatient Use of Focused Cardiac Ultrasound to Assess the Inferior Vena Cava in Patients With Heart Failure. Am J Cardiol 2015; 116:1224-8. [PMID: 26279108 DOI: 10.1016/j.amjcard.2015.07.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 07/12/2015] [Accepted: 07/12/2015] [Indexed: 10/23/2022]
Abstract
Accurate assessment of volume status is critical in the management of patients with heart failure (HF). We studied the utility of a pocket-sized ultrasound device in an outpatient cardiology clinic as a tool to guide volume assessment. Inferior vena cava (IVC) size and collapsibility were assessed in 95 patients by residents briefly trained in focused cardiac ultrasound (FCU). Cardiologist assessment of volume status and changes in diuretic medication were also recorded. Patients were followed for occurrence of 30-day events. There was a 94% success rate of obtaining IVC size and collapsibility, and agreement between visual and calculated IVC parameters was excellent. Most patients were euvolemic by both FCU IVC and clinical bedside assessment (51%) and had no change in diuretic dose. Thirty-two percent had discrepant FCU IVC and clinical volume assessments. In clinically hypervolemic patients, the FCU evaluation of the IVC suggested that the wrong diuretic management plan might have been made 46% of the time. At 30 days, 14 events occurred. The incidence of events increased significantly with FCU IVC imaging categorization, from 11% to 23% to 36% in patients with normal, intermediate, and plethoric IVCs. By comparison, when grouped in a binary manner, there was no significant difference in event rates for patients who were deemed to be clinically volume overloaded. Assessment of volume status in an outpatient cardiology clinic using FCU imaging of the IVC is feasible in a high percentage of patients. A group of patients were identified with volume status discordant between FCU IVC and routine clinic assessment, suggesting that IVC parameters may provide a valuable supplement to the in-office physical examination.
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116
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Gundersen GH, Norekval TM, Haug HH, Skjetne K, Kleinau JO, Graven T, Dalen H. Adding point of care ultrasound to assess volume status in heart failure patients in a nurse-led outpatient clinic. A randomised study. Heart 2015; 102:29-34. [PMID: 26438785 PMCID: PMC4717409 DOI: 10.1136/heartjnl-2015-307798] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 09/13/2015] [Indexed: 01/18/2023] Open
Abstract
Objectives Medical history, physical examination and laboratory testing are not optimal for the assessment of volume status in heart failure (HF) patients. We aimed to study the clinical influence of focused ultrasound of the pleural cavities and inferior vena cava (IVC) performed by specialised nurses to assess volume status in HF patients at an outpatient clinic. Methods HF outpatients were prospectively included and underwent laboratory testing, history recording and clinical examination by two nurses with and without an ultrasound examination of the pleural cavities and IVC using a pocket-size imaging device, in random order. Each nurse worked in a team with a cardiologist. The influence of the different diagnostic tests on diuretic dosing was assessed descriptively and in linear regression analyses. Results Sixty-two patients were included and 119 examinations were performed. Mean±SD age was 74±12 years, EF was 34±14%, and N-terminal pro-brain natriuretic peptide (NT-proBNP) value was 3761±3072 ng/L. Dosing of diuretics differed between the teams in 31 out of 119 consultations. Weight change and volume status assessed clinically with and without ultrasound predicted dose adjustment of diuretics at follow-up (p<0.05). Change of oedema, NT-proBNP, creatinine, and symptoms did not (p≥0.10). In adjusted analyses, only volume status based on ultrasound predicted dose adjustments of diuretics at first visit and follow-up (all ultrasound p≤0.01, all other p≥0.2). Conclusions Ultrasound examinations of the pleural cavities and IVC by nurses may improve diagnostics and patient care in HF patients at an outpatient clinic, but more studies are needed to determine whether these examinations have an impact on clinical outcomes. Trial registration number NCT01794715.
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Affiliation(s)
- Guri Holmen Gundersen
- Department of Medicine, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway
| | - Tone M Norekval
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Hilde Haugberg Haug
- Department of Medicine, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway
| | - Kyrre Skjetne
- Department of Medicine, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway
| | - Jens Olaf Kleinau
- Department of Medicine, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway
| | - Torbjorn Graven
- Department of Medicine, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway
| | - Havard Dalen
- Department of Medicine, Levanger Hospital, Nord-Trøndelag Health Trust, Levanger, Norway MI Lab, Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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Pellicori P, Kaur K, Clark AL. Fluid Management in Patients with Chronic Heart Failure. Card Fail Rev 2015; 1:90-95. [PMID: 28785439 PMCID: PMC5490880 DOI: 10.15420/cfr.2015.1.2.90] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 07/23/2015] [Indexed: 02/06/2023] Open
Abstract
Congestion, or fluid overload, is a classic clinical feature of patients presenting with heart failure patients, and its presence is associated with adverse outcome. However, congestion is not always clinically evident, and more objective measures of congestion than simple clinical examination may be helpful. Although diuretics are the mainstay of treatment for congestion, no randomised trials have shown the effects of diuretics on mortality in chronic heart failure patients. Furthermore, appropriate titration of diuretics in this population is unclear. Research is required to determine whether a robust method of detecting - and then treating - subclinical congestion improves outcomes.
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Affiliation(s)
- Pierpaolo Pellicori
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK
| | - Kuldeep Kaur
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK
| | - Andrew L Clark
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK
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118
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Coiro S, Rossignol P, Ambrosio G, Carluccio E, Alunni G, Murrone A, Tritto I, Zannad F, Girerd N. Prognostic value of residual pulmonary congestion at discharge assessed by lung ultrasound imaging in heart failure. Eur J Heart Fail 2015; 17:1172-81. [PMID: 26417699 DOI: 10.1002/ejhf.344] [Citation(s) in RCA: 183] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 07/22/2015] [Accepted: 07/23/2015] [Indexed: 11/07/2022] Open
Abstract
AIMS Residual pulmonary congestion at discharge is associated with poor prognosis in heart failure (HF), but its quantification through physical examination is challenging. Ultrasound imaging of lung comets (B-lines) could improve congestion evaluation. The aim of this study was to assess the short-term prognostic value of B-lines after discharge from HF hospitalisation compared with other indices of haemodynamic congestion (BNP, E/e', and inferior vena cava diameter) or clinical status (NYHA class). METHODS AND RESULTS Sixty consecutive HF inpatients underwent clinical examination, echocardiography, and lung ultrasound at discharge, independently of, and in addition to routine management by the attending physicians. The median B-line count was 8.5 (5-34). Three-month event-free survival for the primary endpoint (all-cause death or HF hospitalisation) was 27 ± 10% in patients with ≥30 B-lines and 88 ± 5% in those with <30 B-lines (P < 0.0001). In a multivariable model, ≥30 B-lines significantly predicted the combined endpoint (hazard ratio 5.66, 95% confidence interval 1.74-18.39, P = 0.04), along with NYHA ≥III and inferior vena cava diameter, while other indirect measures of congestion (BNP and E/e' ≥15) were not retained in the model; furthermore ≥30 B-lines independently also predicted the secondary outcomes (HF hospitalisation and death). Importantly, B-line addition to NYHA class and BNP was associated with improved risk classification (integrated discrimination improvement 15%, P = 0.02; continuous net reclassification improvement 65%, P = 0.03). CONCLUSION Residual pulmonary congestion at discharge, as assessed by a B-line count ≥30, is a strong predictor of outcome. Lung ultrasonography may represent a useful tool to identify and monitor congestion and optimize therapy during and/or after hospitalisation for HF, which should be further validated in multicentre studies.
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Affiliation(s)
- Stefano Coiro
- Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy.,INSERM, Centre d'Investigations Cliniques 9501, Université de Lorraine, CHU de Nancy, Institut Lorrain du Cœur et des Vaisseaux, France.,INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN network, Nancy, France
| | - Patrick Rossignol
- INSERM, Centre d'Investigations Cliniques 9501, Université de Lorraine, CHU de Nancy, Institut Lorrain du Cœur et des Vaisseaux, France.,INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN network, Nancy, France
| | - Giuseppe Ambrosio
- Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - Erberto Carluccio
- Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - Gianfranco Alunni
- Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - Adriano Murrone
- Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - Isabella Tritto
- Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques 9501, Université de Lorraine, CHU de Nancy, Institut Lorrain du Cœur et des Vaisseaux, France.,INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN network, Nancy, France
| | - Nicolas Girerd
- INSERM, Centre d'Investigations Cliniques 9501, Université de Lorraine, CHU de Nancy, Institut Lorrain du Cœur et des Vaisseaux, France.,INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN network, Nancy, France
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119
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De Vecchis R, Baldi C. Inferior Vena Cava and Hemodynamic Congestion. Res Cardiovasc Med 2015; 4:e28913. [PMID: 26436075 PMCID: PMC4588705 DOI: 10.5812/cardiovascmed.28913v2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 05/06/2015] [Accepted: 05/07/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Among the indices able to replace invasive central venous pressure (CVP) measurement for patients with acute decompensated heart failure (ADHF) the diameters of the inferior vena cava (IVC) and their respiratory fluctuations, so-called IVC collapsibility index (IVCCI), measured by echocardiography, have recently gained ground as a quite reliable proxy of CVP. OBJECTIVES The aims of our study were to compare three different ways of evaluating cardiac overload by using the IVC diameters and/or respiratory fluctuations and by calculating the inter-method agreement. PATIENTS AND METHODS Medical records of patients hospitalized for right or bi-ventricular acute decompensated heart failure from January to December 2013 were retrospectively evaluated. The predictive significance of the IVC expiratory diameter and IVC collapsibility index (IVCCI) was analyzed using three different methods, namely a) the criteria for the indirect estimate of right atrial pressure by Rudski et al. (J Am Soc Echocardiogr. 2010); b) the categorization into three IVCCI classes by Stawicki et al. (J Am Coll Surg. 2009); and c) the subdivision based on the value of the maximum IVC diameter by Pellicori et al. (JACC Cardiovasc Imaging. 2013). RESULTS Among forty-seven enrolled patients, those classified as affected by persistent congestion were 22 (46.8%) using Rudski's criteria, or 16 (34%) using Stawicki's criteria, or 13 (27.6%) using Pellicori's criteria. The inter-rater agreement was rather poor by comparing Rudski's criteria with those of Stawicki (Cohen's kappa = 0.369; 95% CI 0.197 to 0.54), as well as by comparing Rudski's criteria with those of Pellicori (Cohen's kappa = 0.299; 95% CI 0.135 to 0.462). Further, a substantially unsatisfactory concordance was also found for Stawicki's criteria compared to those of Pellicori (Cohen's kappa= 0.468; 95% CI 0.187 to 0.75). CONCLUSIONS The abovementioned IVC ultrasonographic criteria for hemodynamic congestion appear clearly inconsistent. Alternatively, a sequential or simultaneous combination of clinical scores of congestion, IVC ultrasonographic indices, and circulating levels of natriuretic peptides could be warranted.
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Affiliation(s)
- Renato De Vecchis
- Cardiology Unit, Presidio Sanitario Intermedio “Elena d’Aosta”, Naples, Italy
- Corresponding author: Renato De Vecchis, MD, Cardiology Unit, Presidio Sanitario Intermedio “Elena d’Aosta”, ASL Napoli 1 Centro, Naples, Italy. Tel: +393483313530; Fax: +390812543144; E-mail:
| | - Cesare Baldi
- Heart Department, Interventional Cardiology, A.O.U. “San Giovanni di Dio e Ruggi D’Aragona”, Salerno, Italy
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120
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Pellicori P, Kallvikbacka-Bennett A, Dierckx R, Zhang J, Putzu P, Cuthbert J, Boyalla V, Shoaib A, Clark AL, Cleland JGF. Prognostic significance of ultrasound-assessed jugular vein distensibility in heart failure. Heart 2015; 101:1149-58. [PMID: 26006717 DOI: 10.1136/heartjnl-2015-307558] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Accepted: 04/29/2015] [Indexed: 11/03/2022] Open
Abstract
AIMS Jugular venous distension is a classical sign of heart failure (HF) but it can be difficult to assess clinically. METHODS AND RESULTS Outpatients with HF and control subjects were assessed. Internal jugular vein diameter (JVD) was measured using a linear high-frequency ultrasound probe (10 MHz) at rest, after a Valsalva manoeuvre and during deep inspiration. JVD ratio was calculated as the maximum diameter during Valsalva to that measured at rest. 311 patients (mean age 71 years, mean left ventricular EF 42%, median (IQR) amino-terminal pro-brain natriuretic peptide 979 (441-2007) ng/L) and 66 controls were included. JVD (median and IQR range) at rest was smaller in controls (0.16 (0.14-0.20) cm) than in patients with HF (0.23 (0.17-0.33) cm; p<0.001) but similar during Valsalva (1.03 (0.90-1.16) cm vs 1.08 (0.90-1.25) cm; p=0.28). Consequently, JVD ratio was greater in controls (6.3 (4.9-7.6)) than in patients (4.5 (2.9-6.1); p<0.001). During a median follow-up of 516 (IQR 335-622) days, 48 patients (15%) with HF died or were hospitalised for HF. In multivariable models, among clinical, echocardiographic or biochemical variables, only increasing NT-proBNP and ultrasound assessment of internal jugular vein were independently associated with prognosis. Comparing top and bottom tertiles of JVD ratio (2.3 (IQR 1.7-2.9) versus 6.8 (6.1-7.7)), the tertile with lower values had a 10-fold greater risk of an adverse event (HR 10.05, 95% CI 3.07 to 32.93). CONCLUSIONS Ultrasound assessment of the internal jugular vein identifies outpatients with HF who have a higher risk of an adverse outcome. CLINICAL TRIAL REGISTRATION NCT01872299.
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Affiliation(s)
- Pierpaolo Pellicori
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - Anna Kallvikbacka-Bennett
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - Riet Dierckx
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - Jufen Zhang
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - Paola Putzu
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - Joe Cuthbert
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - Vennela Boyalla
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - Ahmed Shoaib
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - Andrew L Clark
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK
| | - John G F Cleland
- Department of Cardiology, Hull York Medical School (University of Hull), Castle Hill Hospital, Kingston upon Hull, UK National Heart & Lung Institute and National Institute of Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield Hospitals, Imperial College, London, UK
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121
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Besli F, Kecebas M. Usefulness of inferior vena cava in management of heart failure. Am J Emerg Med 2015; 33:728-9. [DOI: 10.1016/j.ajem.2015.02.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 02/18/2015] [Indexed: 10/24/2022] Open
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122
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The utility of inferior vena cava diameter and the degree of inspiratory collapse in patients with systolic heart failure. Am J Emerg Med 2015; 33:653-7. [DOI: 10.1016/j.ajem.2015.02.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 01/22/2015] [Accepted: 02/02/2015] [Indexed: 01/22/2023] Open
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123
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Abstract
Urea is generated by the urea cycle enzymes, which are mainly in the liver but are also ubiquitously expressed at low levels in other tissues. The metabolic process is altered in several conditions such as by diets, hormones, and diseases. Urea is then eliminated through fluids, especially urine. Blood urea nitrogen (BUN) has been utilized to evaluate renal function for decades. New roles for urea in the urinary system, circulation system, respiratory system, digestive system, nervous system, etc., were reported lately, which suggests clinical significance of urea.
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Pellicori P, Joseph AC, Zhang J, Lukaschuk E, Sherwi N, Bourantas CV, Loh H, Clark AL, Cleland JGF. The relationship of QRS morphology with cardiac structure and function in patients with heart failure. Clin Res Cardiol 2015; 104:935-45. [DOI: 10.1007/s00392-015-0861-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 04/15/2015] [Indexed: 10/23/2022]
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125
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Cleland JGF, Pellicori P, Dierckx R. Clinical trials in patients with heart failure and preserved left ventricular ejection fraction. Heart Fail Clin 2015; 10:511-23. [PMID: 24975913 DOI: 10.1016/j.hfc.2014.04.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
There is no robust evidence that any treatment can modify the natural history of patients with heart failure and preserved left ventricular ejection fraction (HFpEF), although most agree that diuretics can control congestion and improve symptoms. HFpEF is often complicated by systemic and pulmonary hypertension, atrial fibrillation, obesity, chronic lung and kidney disease, lack of physical fitness, and old age that can complicate both diagnosis and management. Further trials should phenotype patients precisely and create better definitions of HFpEF based on biomarkers.
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Affiliation(s)
- John G F Cleland
- National Heart & Lung Institute, NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield Hospitals NHS Trust, Imperial College, London, UK.
| | - Pierpaolo Pellicori
- Department of Cardiology, Castle Hill Hospital, Hull and York Medical School, University of Hull, Kingston-upon-Hull, UK
| | - Riet Dierckx
- Department of Cardiology, Castle Hill Hospital, Hull and York Medical School, University of Hull, Kingston-upon-Hull, UK
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126
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Tchernodrinski S, Lucas BP, Athavale A, Candotti C, Margeta B, Katz A, Kumapley R. Inferior vena cava diameter change after intravenous furosemide in patients diagnosed with acute decompensated heart failure. JOURNAL OF CLINICAL ULTRASOUND : JCU 2015; 43:187-193. [PMID: 24897939 DOI: 10.1002/jcu.22173] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 03/03/2014] [Accepted: 05/06/2014] [Indexed: 06/03/2023]
Abstract
PURPOSE Measurement of the inferior vena cava (IVC) diameters may improve decision-making for patients hospitalized with acute decompensated heart failure. Nevertheless, little is known about how the IVC is affected by loop diuretics. We sought to determine if bolus infusions of intravenous furosemide affect IVC diameters measured by hand-carried ultrasonography. METHODS We conducted a prospective cohort study at a public teaching hospital from September 2009 through June 2010. Physician investigators performed IVC ultrasonography on a convenience sample of 70 hospitalized adults who were prescribed intravenous furosemide for the diagnosis of acute decompensated heart failure. RESULTS Participants' median baseline IVC diameter was 2.38 cm (interquartile range, 1.91-2.55 cm). At 1-2 hours after furosemide, IVC diameters decreased an average of 0.21 cm (95% CI, 0.13-0.29 cm) and remained significantly below baseline at 2-3 hours after furosemide by an average of 0.15 cm (95% CI, 0.07-0.22 cm). CONCLUSIONS IVC diameters of adults diagnosed with acute decompensated heart failure become measurably smaller after single doses of intravenous furosemide. Whether this represents a true change in volume status has not been studied.
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Yamanoğlu A, Çelebi Yamanoğlu NG, Parlak İ, Pınar P, Tosun A, Erkuran B, Akgür A, Satılmış Siliv N. The role of inferior vena cava diameter in the differential diagnosis of dyspneic patients; best sonographic measurement method? Am J Emerg Med 2015; 33:396-401. [DOI: 10.1016/j.ajem.2014.12.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 12/19/2014] [Accepted: 12/21/2014] [Indexed: 12/31/2022] Open
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129
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Does speckle tracking really improve diagnosis and risk stratification in patients with HF with normal EF? J Am Coll Cardiol 2015; 64:1535. [PMID: 25277623 DOI: 10.1016/j.jacc.2014.02.616] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 02/18/2014] [Accepted: 02/20/2014] [Indexed: 11/23/2022]
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Abstract
Many patients with heart failure (HF) have a normal left ventricular ejection fraction, and are labelled as having HF with preserved left ventricular ejection fraction (HFPEF). Hypertension, atrial fibrillation and age are important contributors to the development of HFPEF and, therefore, its prevalence is likely to increase in the next few decades. The pathophysiology of HFPEF is heterogeneous but with a final common pathway leading to congestion. HF remains a clinical diagnosis but the plasma concentration of B-type natriuretic peptide (eg BNP/N-terminal prohormone BNP (NT-proBNP)), a marker of congestion, is an essential component. Imaging, usually by echocardiography, is required to determine the cardiac phenotype (ie valve disease, left ventricular ejection fraction) underlying HF. A superficially normal echocardiogram does not exclude a diagnosis of HF. No treatment has been shown conclusively to alter the prognosis of HFPEF. However, treatments directed at congestion and hypertension, such as diuretics, mineralocorticoid receptor antagonists (MRAs) and angiotensin converting-enzyme inhibitors, may improve symptoms and probably do improve outcomes. No treatment has yet been shown to reverse the underlying myocardial pathology of HFPEF, although there is some hope that MRAs might.
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Affiliation(s)
| | - John G F Cleland
- Cardiovascular Biomedical Research Unit Royal Brompton and Harefield Hospitals, Imperial College, London, UK
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131
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Pleister A, Kahwash R, Haas G, Ghio S, Cittadini A, Baliga RR. Echocardiography and Heart Failure: A Glimpse of the Right Heart. Echocardiography 2014; 32 Suppl 1:S95-107. [DOI: 10.1111/echo.12678] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Adam Pleister
- Division of Cardiovascular Medicine; The Ohio State University Wexner Medical Center; Columbus Ohio
| | - Rami Kahwash
- Division of Cardiovascular Medicine; The Ohio State University Wexner Medical Center; Columbus Ohio
| | - Garrie Haas
- Division of Cardiovascular Medicine; The Ohio State University Wexner Medical Center; Columbus Ohio
| | - Stefano Ghio
- Thoracic and Vascular Department; Fondazione IRCCS Policlinico San Matteo; Pavia Italy
| | - Antonio Cittadini
- Department of Translational Medical Sciences; Universityà Federico II; Napoli Italy
| | - Ragavendra R Baliga
- Division of Cardiovascular Medicine; The Ohio State University Wexner Medical Center; Columbus Ohio
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Sherwi N, Pellicori P, Joseph AC, Buga L. Old and newer biomarkers in heart failure: from pathophysiology to clinical significance. J Cardiovasc Med (Hagerstown) 2014; 14:690-7. [PMID: 23846675 DOI: 10.2459/jcm.0b013e328361d1ef] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Heart failure is a complex disease in which a careful clinical examination and the measurement of cardiac function may not always be sufficient for making a correct diagnosis. Measuring plasma levels of natriuretic peptides may assist in this process, also offering a good tool for accurate risk stratification. Other alternative biomarkers may give insight into the different pathways of heart failure genesis and pathophysiology, and may help to identify those patients with overt heart failure and a more adverse outcome, or distinguish between those at risk of developing heart failure. Despite a high number of potentially useful biomarkers, only a few will likely be introduced routinely into clinical practice. However, a multi-marker approach might increase the diagnostic accuracy and it might identify different phenotypes of heart failure patients who might benefit from individualized therapy in the future.
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Affiliation(s)
- Nasser Sherwi
- Department of Academic Cardiology, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Cottingham, Kingston upon Hull, UK
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Hutchinson K, Pellicori P, Dierckx R, Cleland JGF, Clark AL. Remote telemonitoring for patients with heart failure: might monitoring pulmonary artery pressure become routine? Expert Rev Cardiovasc Ther 2014; 12:1025-33. [DOI: 10.1586/14779072.2014.935340] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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134
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Gianstefani A, Savelli F, Gramenzi A, Zucconi E, Di Battista N, Francesconi R, Cavazza M. Redefinition of diagnostic role of inferior vena cava ultrasonography in the identification of acute heart failure. Am J Emerg Med 2014; 32:799-800. [DOI: 10.1016/j.ajem.2014.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 04/07/2014] [Indexed: 10/25/2022] Open
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Lee HF, Hsu LA, Chang CJ, Chan YH, Wang CL, Ho WJ, Chu PH. Prognostic significance of dilated inferior vena cava in advanced decompensated heart failure. Int J Cardiovasc Imaging 2014; 30:1289-95. [DOI: 10.1007/s10554-014-0468-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 06/09/2014] [Indexed: 01/31/2023]
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136
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Carbone F, Montecucco F. Reply to "precipitants of heart failure must be fully considered when predicting readmission". Eur J Clin Invest 2014; 44:614-5. [PMID: 24739065 DOI: 10.1111/eci.12271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 04/11/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Federico Carbone
- Department of Internal Medicine, University of Genoa School of Medicine, IRCCS Azienda Ospedaliera Universitaria San Martino-IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy; Division of Cardiology, Foundation for Medical Researches, Department of Medical Specialties, University of Geneva, Geneva, Switzerland
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Carbone F, Bovio M, Rosa GM, Ferrando F, Scarrone A, Murialdo G, Quercioli A, Vuilleumier N, Mach F, Viazzi F, Montecucco F. Inferior vena cava parameters predict re-admission in ischaemic heart failure. Eur J Clin Invest 2014; 44:341-9. [PMID: 24397419 DOI: 10.1111/eci.12238] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 01/05/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND The clinical history of heart failure (HF) is usually characterized by frequent hospitalizations for decompensation. Therefore, several markers of subclinical hemodynamic congestion are under investigation for predicting early rehospitalization. In this field, the potential of ultrasound inferior vena cava (IVC) assessment has been recently investigated in HF but not yet assessed in the different aetiological categories. MATERIAL AND METHODS Forty-eight patients admitted for decompensated HF (n = 25 with ischaemic heart disease [IHD] and n = 23 non-IHD) underwent biochemical examination (including NT-proBNP), echocardiography and IVC assessment by hand-carried ultrasound (HCU). During 60-day follow-up after discharge, the re-hospitalization rate for HF was recorded to investigate the predictive power of NT-proBNP and IVC assessment among the two study groups. RESULTS IHD and non-IHD patients with HF were similar except for gender distribution. During follow-up, 16·7% of patients were rehospitalized for decompensated HF, with higher prevalence in IHD group (28% vs. 4·3% P = 0·031). IVC assessment at discharge significantly predicted re-admission in the overall population and in IHD group, whereas NT-proBNP failed to predict rehospitalization in IHD group. In adjusted hazard ratio, only IVC min and the changes of IVC from admission significantly predicted re-admission. ROC analysis confirmed the change in IVC min as the best predictor of rehospitalization in patients with IHD. CONCLUSION This pilot study showed a higher early re-admission rate in patients with HF due to IHD. In addition, the change in IVC min diameter from admission to discharge was the best predictor of re-admission in patients with IHD.
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Affiliation(s)
- Federico Carbone
- Department of Internal Medicine, University of Genoa School of Medicine, IRCCS Azienda Ospedaliera Universitaria San Martino-IST Istituto Nazionale per la Ricerca sul Cancro, Genoa, Italy; Division of Cardiology, Foundation for Medical Researches, Department of Medical Specialties, University of Geneva, Geneva, Switzerland
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Mentz RJ, Kjeldsen K, Rossi GP, Voors AA, Cleland JGF, Anker SD, Gheorghiade M, Fiuzat M, Rossignol P, Zannad F, Pitt B, O'Connor C, Felker GM. Decongestion in acute heart failure. Eur J Heart Fail 2014; 16:471-82. [PMID: 24599738 DOI: 10.1002/ejhf.74] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Revised: 01/24/2014] [Accepted: 01/31/2014] [Indexed: 12/20/2022] Open
Abstract
Congestion is a major reason for hospitalization in acute heart failure (HF). Therapeutic strategies to manage congestion include diuretics, vasodilators, ultrafiltration, vasopressin antagonists, mineralocorticoid receptor antagonists, and potentially also novel therapies such as gut sequesterants and serelaxin. Uncertainty exists with respect to the appropriate decongestion strategy for an individual patient. In this review, we summarize the benefit and risk profiles for these decongestion strategies and provide guidance on selecting an appropriate approach for different patients. An evidence-based initial approach to congestion management involves high-dose i.v. diuretics with addition of vasodilators for dyspnoea relief if blood pressure allows. To enhance diuresis or overcome diuretic resistance, options include dual nephron blockade with thiazide diuretics or natriuretic doses of mineralocorticoid receptor antagonists. Vasopressin antagonists may improve aquaresis and relieve dyspnoea. If diuretic strategies are unsuccessful, then ultrafiltration may be considered. Ultrafiltration should be used with caution in the setting of worsening renal function. This review is based on discussions among scientists, clinical trialists, and regulatory representatives at the 9th Global Cardio Vascular Clinical Trialists Forum in Paris, France, from 30 November to 1 December 2012.
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Kutty S, Li L, Hasan R, Peng Q, Rangamani S, Danford DA. Systemic Venous Diameters, Collapsibility Indices, and Right Atrial Measurements in Normal Pediatric Subjects. J Am Soc Echocardiogr 2014; 27:155-62. [DOI: 10.1016/j.echo.2013.09.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Indexed: 10/26/2022]
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Pellicori P, Kallvikbacka-Bennett A, Zhang J, Khaleva O, Warden J, Clark AL, Cleland JGF. Revisiting a classical clinical sign: jugular venous ultrasound. Int J Cardiol 2013; 170:364-70. [PMID: 24315339 DOI: 10.1016/j.ijcard.2013.11.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Revised: 09/17/2013] [Accepted: 11/02/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Increased jugular venous pressure, reflecting the increased right atrial pressure, is a classical sign of heart failure (HF) but clinical assessment may be difficult. METHODS In ambulatory patients with HF and control subjects, jugular vein diameter (JVD) was measured using a linear high-frequency ultrasound probe (10 MHz) at rest, during a Valsalva manoeuvre and during deep inspiration. JVD ratio was calculated as diameter during Valsalva to that at rest. RESULTS 211 patients (mean age 70 years; mean left ventricular ejection fraction 43%) and 20 controls were included. JVD (median and inter-quartile [IQR] range) at rest was 0.17 (0.15-0.20) cm in controls and 0.23 (0.17-0.33) cm in patients with HF (p=0.012), JVD ratio was 6.3 (4.3-6.8) in controls and 4.4 (2.7-5.8) in patients with HF (p=0.001).With increasing quartiles of plasma NT-proBNP, JVD at rest rose (0.20 (0.15-0.23) cm, 0.21 (0.16-0.29) cm, 0.25 (0.18-0.35) cm and 0.34 (0.20-0.53) cm (P=<0.001), whilst JVD ratio decreased (5.4 (4.2-6.4), 4.4 (3.5-6.3), 3.9 (2.4-5.4) and 2.8 (1.7-4.7); p=<0.001). JVD ratio correlated with log (NT-proBNP) (r=-0.39, p=<0.001), LV filling pressures (E/E', r=-0.33, p=<0.001) and left atrial volume (r=-0.21, p=0.002). In a multivariable regression model, only trans-tricuspid gradient and TAPSE were independently associated with JVD ratio (R(2)=0.27). CONCLUSIONS Distension of the JV at rest relative to the maximum diameter during a Valsalva manoeuvre (JVD ratio) identifies patients with heart failure who have higher plasma NT-proBNP levels, right ventricular dysfunction and raised pulmonary artery pressure.
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Affiliation(s)
- Pierpaolo Pellicori
- Department of Academic Cardiology, Hull and East Yorkshire Medical Research and Teaching Centre, MRTDS (Daisy) Building, Entrance 2, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK.
| | - Anna Kallvikbacka-Bennett
- Department of Academic Cardiology, Hull and East Yorkshire Medical Research and Teaching Centre, MRTDS (Daisy) Building, Entrance 2, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK
| | - Jufen Zhang
- Department of Academic Cardiology, Hull and East Yorkshire Medical Research and Teaching Centre, MRTDS (Daisy) Building, Entrance 2, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK
| | - Olga Khaleva
- Department of Academic Cardiology, Hull and East Yorkshire Medical Research and Teaching Centre, MRTDS (Daisy) Building, Entrance 2, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK
| | - John Warden
- Department of Academic Cardiology, Hull and East Yorkshire Medical Research and Teaching Centre, MRTDS (Daisy) Building, Entrance 2, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK
| | - Andrew L Clark
- Department of Academic Cardiology, Hull and East Yorkshire Medical Research and Teaching Centre, MRTDS (Daisy) Building, Entrance 2, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK
| | - John G F Cleland
- Department of Academic Cardiology, Hull and East Yorkshire Medical Research and Teaching Centre, MRTDS (Daisy) Building, Entrance 2, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK
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Global longitudinal strain in patients with suspected heart failure and a normal ejection fraction: does it improve diagnosis and risk stratification? Int J Cardiovasc Imaging 2013; 30:69-79. [DOI: 10.1007/s10554-013-0310-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 10/09/2013] [Indexed: 10/26/2022]
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Pellicori P, Torromeo C, Calicchia A, Ruffa A, Di Iorio M, Cleland JGF, Merli M. Does cirrhotic cardiomyopathy exist? 50 years of uncertainty. Clin Res Cardiol 2013; 102:859-64. [PMID: 23995321 DOI: 10.1007/s00392-013-0610-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 08/14/2013] [Indexed: 02/08/2023]
Abstract
Subtle abnormalities of cardiac structure or function are often identified in patients with liver cirrhosis and have been termed cirrhotic cardiomyopathy. However, in the absence of a precise definition, its diagnosis remains a challenge. Cardiac dysfunction in patients with cirrhosis can often be attributed to concomitant diseases such as hypertension, ischaemic heart disease or excess alcohol consumption in many patients. Further research is required to identify the existence, origin and importance of abnormal cardiac function due specifically to liver disease. Cardiac dysfunction may be masked by treatments given to cirrhotic patients, such as mineral-corticoid receptor antagonists, or by co-existing conditions, such as anaemia. New imaging tests or plasma biomarkers might be able to detect abnormal cardiac function at an early stage of its development.
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Affiliation(s)
- Pierpaolo Pellicori
- Department of Academic Cardiology, Hull and East Yorkshire Medical Research and Teaching Centre MRTDS (Daisy) Building, Entrance 2 Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, UK,
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Practice Guidelines for the Diagnosis and Management of Systolic Heart
Failure in Low- and Middle-Income Countries. Glob Heart 2013; 8:141-70. [DOI: 10.1016/j.gheart.2013.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Drazner MH. Is the Inferior Vena Cava Really Superior? JACC Cardiovasc Imaging 2013; 6:29-31. [DOI: 10.1016/j.jcmg.2012.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 11/08/2012] [Indexed: 12/01/2022]
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