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Kolupoti A, Fudim M, Pandey A, Kucharska-Newton A, Hall ME, Vaduganathan M, Mentz RJ, Caughey MC. Temporal Trends and Prognosis of Physical Examination Findings in Patients With Acute Decompensated Heart Failure: The ARIC Study Community Surveillance. Circ Heart Fail 2021; 14:e008403. [PMID: 34702047 PMCID: PMC8692393 DOI: 10.1161/circheartfailure.121.008403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 08/30/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Bedside evaluation of congestion is a mainstay of heart failure (HF) management. Whether detected physical examination signs have changed over time as obesity prevalence has increased in HF populations, or if the associated prognosis differs for HF with reduced or preserved ejection fraction (HFrEF or HFpEF) is uncertain. METHODS From 2005 to 2014, the ARIC study (Atherosclerosis Risk in Communities) conducted adjudicated hospital surveillance of acute decompensated HF. We analyzed trends in physical examination findings, imaging signs, and symptoms related to congestion, both over time and by obesity class, and associated 28-day mortality risks. RESULTS Of 24 937 weighted hospitalizations for acute decompensated HF (mean age 75 years, 53% women, 32% Black), 47% had HFpEF. The prevalence of obesity increased from 2005 to 2014 for both HF types. With increasing obesity category, detected edema increased, while jugular venous distension decreased, and rales remained stable. Detected edema also increased over time, for both HF types. Associations between 28-day mortality and individual signs and symptoms of congestion were similar for HFpEF and HFrEF; however, the adjusted mortality risk with all 3 (edema, rales, and jugular venous distension) versus <3 physical examination findings was higher for patients with HFpEF (odds ratio, 2.41 [95% CI, 1.53-3.79]) than HFrEF (odds ratio, 1.30 [95% CI, 0.87-1.93]); P for interaction by HF type =0.02. CONCLUSIONS In patients hospitalized with acute decompensated HF, detected physical examination findings differ both temporally and by obesity. Combined findings from the physical examination are more prognostic of 28-day mortality for patients with HFpEF than HFrEF.
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Affiliation(s)
| | - Marat Fudim
- Division of Cardiology, Duke University School of Medicine; Durham, NC
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern; Dallas, TX
| | - Anna Kucharska-Newton
- Department of Epidemiology, University of North Carolina at Chapel Hill; Chapel Hill, NC
- Department of Epidemiology, University of Kentucky College of Public Health; Lexington, KY
| | - Michael E. Hall
- Department of Medicine, University of Mississippi Medical Center; Jackson, MS
| | | | - Robert J. Mentz
- Division of Cardiology, Duke University School of Medicine; Durham, NC
| | - Melissa C. Caughey
- Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University; Chapel Hill, NC
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2
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Zheng J, Zu D, Cheng K, Xia Y, Dong Y, Gao Z. Decreased estimated glomerular filtration rate predicts long-term recurrence after catheter ablation of atrial fibrillation in mild to moderate renal insufficiency. BMC Cardiovasc Disord 2021; 21:508. [PMID: 34674646 PMCID: PMC8529753 DOI: 10.1186/s12872-021-02320-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/06/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Catheter ablation is an established therapy for atrial fibrillation (AF), but recurrence after ablation remains a great challenge. Additionally, little is known about the effect of renal function on the efficiency of AF ablation. This study aimed to evaluate the predictors of the prognosis of catheter ablation for AF, especially the effect of renal function. METHODS A total of 306 drug-refractory symptomatic patients with AF who underwent first-time catheter ablation were enrolled in the present study. Individuals underwent circumferential pulmonary vein isolation for paroxysmal AF and stepwise ablation for persistent AF. RESULTS The follow-up time was 27.2 ± 19.5 months, 202 patients (66.01%) were free of atrial tachyarrhythmia (non-recurrence group), and the other 104 patients experienced recurrence (recurrence group). The recurrence group had a larger left atrial diameter (LAD) and left atrial volume (LAV), a higher LAV index (LAVI) (both, p < 0.01), and a lower estimated glomerular filtration rate (eGFR) (53.5 ± 14.4 vs. 65.5 ± 13.3 ml/min/1.732, p < 0.001) and creatinine clearance rate (CCr) (85.2 ± 26.1 vs. 101.5 ± 29.4 ml/min, p < 0.05). Multivariate logistic regression indicated both eGFR (p = 0.002) and LAVI (p < 0.001) as independent associated factors for long-term recurrence after single catheter ablation; multivariate Cox proportional hazard regression with backward feature selection identified both eGFR (HR: 0.93, 95% CI: 0.91-0.95, p < 0.001) and LAVI (HR: 1.32, 95% CI: 1.25-1.40, p < 0.001) as independent prognostic factors for recurrence when adjusting other clinical variables. CONCLUSIONS Decreased eGFR and elevated LAVI may facilitate the long-term recurrence of atrial tachyarrhythmia after catheter ablation for AF.
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Affiliation(s)
- Jing Zheng
- Department of Cardiology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, 324000, Zhejiang, China
| | - Deling Zu
- Department of Cardiology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, 324000, Zhejiang, China
| | - Keyun Cheng
- Department of Cardiology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, 324000, Zhejiang, China
| | - Yunlong Xia
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning, China
| | - Yingxue Dong
- Department of Cardiology, The First Affiliated Hospital of Dalian Medical University, Dalian, 116000, Liaoning, China.
| | - Zhenyan Gao
- Department of Cardiology, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, 324000, Zhejiang, China.
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3
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Thibodeau JT, Pham DD, Kelly SA, Ayers CR, Garg S, Grodin JL, Drazner MH. Subclinical Myocardial Injury and the Phenotype of Clinical Congestion in Patients With Heart Failure and Reduced Left Ventricular Ejection Fraction. J Card Fail 2021; 28:422-430. [PMID: 34534666 DOI: 10.1016/j.cardfail.2021.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Clinical congestion is associated with adverse outcomes in patients with heart failure. The pathophysiological mediators of this association remain uncertain. METHODS AND RESULTS We prospectively enrolled a cohort of patients with heart failure and reduced left ventricular ejection fraction and performed a detailed clinical examination followed on the same day by an invasive right heart catheterization and blood sampling for biomarkers. High-sensitivity troponin T and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels were measured. A clinical congestion score was calculated based on jugular venous pressure (cm H20 <10 = 0, 10-14 = 1, >14 = 2 points), bendopnea (0 vs 1), a third heart sound (0 vs 1), or peripheral edema (0-2). Congestion was categorized into tiers as absent (0 points), mild (1 point), or moderate to severe (≥ 2 points). We tested for associations of high-sensitivity troponin T, NT-proBNP, and elevated ventricular filling pressures with clinical congestion in both univariate and multivariable analyses. Of 153 participants, 65 (42%) had absent, 35 mild (23%), and 53 (35%) had moderate to severe clinical congestion. Congestion tier was associated with higher NT-proBNP and hs-troponin levels, and the right atrial pressure and pulmonary capillary wedge pressure (P < .001 for each). Increased congestion tier was also associated with the coexistent presence of elevated troponin T (≥52 ng/L), NT-proBNP (≥1000 pg/mL), and pulmonary capillary wedge pressure (≥22 mm Hg). Specifically, 78% of those with absent clinical congestion had 0 to 1 of these findings, whereas 75% of those with moderate-severe congestion had 2 or all 3 of these abnormalities (P < .001). An elevated hs-troponin was associated with mild or greater clinical congestion (odds ratio 3, 95% confidence interval 1.2-7.5, P = .02) in multivariable analysis adjusting for potential confounders including the right atrial pressure, pulmonary capillary wedge pressure, and NT-proBNP levels. CONCLUSIONS Clinical congestion is a phenotype in which there is a high coexistent presence of elevated ventricular filling pressures, elevated natriuretic peptide levels, and subclinical myocardial injury. An elevated troponin was associated with clinical congestion in multivariable models that adjusted for ventricular filling pressures and natriuretic peptide levels. These data strengthen the evidence base for an association of elevated troponin with clinical congestion, suggesting that subclinical myocardial injury may be an important contributor to the pathophysiology of the congested state.
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Affiliation(s)
- Jennifer T Thibodeau
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - David D Pham
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Samuel A Kelly
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Colby R Ayers
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sonia Garg
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mark H Drazner
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
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4
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Chaudhary R, Sukhi A, Simon MA, Villanueva FS, Pacella JJ. Role of Internal Jugular Venous Ultrasound in suspected or confirmed Heart Failure: A Systematic Review. J Card Fail 2021; 28:639-649. [PMID: 34419599 DOI: 10.1016/j.cardfail.2021.08.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Few data are available on the use of internal jugular vein (IJV) ultrasound parameters to assess central venous pressure and clinical outcomes among patients with suspected or confirmed heart failure (HF). METHODS We performed electronic searches on PubMed, The Cochrane Library, EMBASE, EBSCO, Web of Science, and CINAHL databases from the inception through January 9, 2021, to identify studies evaluating the accuracy and reliability of the IJV ultrasound parameters and exploring its correlation with central venous pressure and clinical outcomes in adult patients with suspected or confirmed acutely decompensated HF. The studies' report quality was assessed by Quality Assessment of Diagnostic Accuracy Studies-2 scale. RESULTS A total of 11 studies were eligible for final analysis (n = 1481 patients with HF). The studies were segregated into 3 groups: (1) the evaluation of patients presenting to the emergency department with dyspnea, (2) the evaluation of patients presenting to the HF clinic for follow-up, and (3) the evaluation of hospitalized patients with acutely decompensated HF or undergoing right heart catheterization. US parameters included IJV height, IJV diameter, IJV diameter ratio, IJV cross-sectional area, respiratory compressibility index, and compression compressibility index. CONCLUSIONS The findings of this systematic review suggest a significant role for ultrasound interrogation of the IJV in evaluation of patients in the emergency department presenting with dyspnea, in the outpatient clinic for poor clinical outcomes in HF, and in determining the timing of discharge for patients admitted with acutely decompensated HF. Further studies are warranted for testing the reliability of the reported ultrasound indices.
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Affiliation(s)
- Rahul Chaudhary
- UPMC Heart and Vascular Institute, Pittsburgh, Pennsylvania.
| | - Ajaypaul Sukhi
- Department of Cardiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Marc A Simon
- Department of Medicine, Division of Cardiology, University of California San Francisco, San Francisco, California
| | - Flordeliza S Villanueva
- UPMC Heart and Vascular Institute, Pittsburgh, Pennsylvania; Center for Molecular Imaging & Image-Guided Therapeutics, Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John J Pacella
- UPMC Heart and Vascular Institute, Pittsburgh, Pennsylvania; Pittsburgh Heart, Lung, Blood and Vascular Medicine Institute, Pittsburgh, Pennsylvania; Department of Bioengineering, Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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5
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Effect of Acoustic Cardiography-guided Management on 1-year Outcomes in Patients With Acute Heart Failure. J Card Fail 2020; 26:142-150. [DOI: 10.1016/j.cardfail.2019.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 09/17/2019] [Accepted: 09/25/2019] [Indexed: 12/20/2022]
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6
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Ambulatory Monitoring of Heart Sounds via an Implanted Device Is Superior to Auscultation for Prediction of Heart Failure Events. J Card Fail 2020; 26:151-159. [DOI: 10.1016/j.cardfail.2019.10.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 09/30/2019] [Accepted: 10/15/2019] [Indexed: 11/19/2022]
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7
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Selvaraj S, Claggett B, Pozzi A, McMurray JJ, Jhund PS, Packer M, Desai AS, Lewis EF, Vaduganathan M, Lefkowitz MP, Rouleau JL, Shi VC, Zile MR, Swedberg K, Solomon SD. Prognostic Implications of Congestion on Physical Examination Among Contemporary Patients With Heart Failure and Reduced Ejection Fraction. Circulation 2019; 140:1369-1379. [DOI: 10.1161/circulationaha.119.039920] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The contemporary prognostic value of the physical examination— beyond traditional risk factors including natriuretic peptides, risk scores, and symptoms—in heart failure (HF) with reduced ejection fraction is unknown. We aimed to determine the association between physical signs of congestion at baseline and during study follow-up with quality of life and clinical outcomes and to assess the treatment effects of sacubitril/valsartan on congestion.
Methods:
We analyzed participants from PARADIGM-HF (Prospective Comparison of Angiotensin Receptor-Neprilysin Inhibitor With Angiotensin Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in HF) with an available physical examination at baseline. We examined the association of the number of signs of congestion (jugular venous distention, edema, rales, and third heart sound) with the primary outcome (cardiovascular death or HF hospitalization), its individual components, and all-cause mortality using time-updated, multivariable-adjusted Cox regression. We further evaluated whether sacubitril/valsartan reduced congestion during follow-up and whether improvement in congestion is related to changes in clinical outcomes and quality of life, assessed by Kansas City Cardiomyopathy Questionnaire overall summary scores.
Results:
Among 8380 participants, 0, 1, 2, and 3+ signs of congestion were present in 70%, 21%, 7%, and 2% of patients, respectively. Patients with baseline congestion were older, more often female, had higher MAGGIC risk scores (Meta-Analysis Global Group in Chronic Heart Failure) and lower Kansas City Cardiomyopathy Questionnaire overall summary scores (
P
<0.05). After adjusting for baseline natriuretic peptides, time-updated Meta-Analysis Global Group in Chronic Heart Failure score, and time-updated New York Heart Association class, increasing time-updated congestion was associated with all outcomes (
P
<0.001). Sacubitril/valsartan reduced the risk of the primary outcome irrespective of clinical signs of congestion at baseline (
P
=0.16 for interaction), and treatment with the drug improved congestion to a greater extent than did enalapril (
P
=0.011). Each 1-sign reduction was independently associated with a 5.1 (95% CI, 4.7–5.5) point improvement in Kansas City Cardiomyopathy Questionnaire overall summary scores. Change in congestion strongly predicted outcomes even after adjusting for baseline congestion (
P
<0.001).
Conclusions:
In HF with reduced ejection fraction, the physical exam continues to provide significant independent prognostic value even beyond symptoms, natriuretic peptides, and Meta-Analysis Global Group in Chronic Heart Failure risk score. Sacubitril/valsartan improved congestion to a greater extent than did enalapril. Reducing congestion in the outpatient setting is independently associated with improved quality of life and reduced cardiovascular events, including mortality.
Clinical Trial Registration:
https://www.clinicaltrials.gov
. Unique identifier: NCT01035255.
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Affiliation(s)
- Senthil Selvaraj
- Division of Cardiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia (S.S.)
| | - Brian Claggett
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., E.F.L, M.V., S.D.S.)
| | - Andrea Pozzi
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (A.P., J.J.V.M., P.S.J.)
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (A.P., J.J.V.M., P.S.J.)
| | - Pardeep S. Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (A.P., J.J.V.M., P.S.J.)
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
- Imperial College, London, United Kingdom (M.P.)
| | - Akshay S. Desai
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., E.F.L, M.V., S.D.S.)
| | - Eldrin F. Lewis
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., E.F.L, M.V., S.D.S.)
| | - Muthiah Vaduganathan
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., E.F.L, M.V., S.D.S.)
| | | | - Jean L. Rouleau
- Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.)
| | | | - Michael R. Zile
- Medical University of South Carolina and Ralph H. Johnson Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden (K.S.)
- National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.)
| | - Scott D. Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., E.F.L, M.V., S.D.S.)
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8
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Shono A, Mori S, Yatomi A, Kamio T, Sakai J, Soga F, Tanaka H, Hirata KI. Ultimate Third Heart Sound. Intern Med 2019; 58:2535-2538. [PMID: 31118397 PMCID: PMC6761354 DOI: 10.2169/internalmedicine.2731-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 79-year-old man with dilated cardiomyopathy and severe functional mitral regurgitation presented with general fatigue and dyspnea. Auscultation revealed a systolic regurgitant murmur with a minimized second heart sound due to a low output. On the other hand, the third heart sound was ultimately enhanced, being visible and palpable as a pulsatile knock of the precordium. Phonocardiography and echocardiography successfully confirmed early-diastolic rapid distension of the left ventricle along with rapid ventricular filling and abrupt deceleration of the atrioventricular blood flow to be the precise etiology of the ultimate third heart sound, indicating critically deteriorated hemodynamics due to massive mitral regurgitation combined with a low output.
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Affiliation(s)
- Ayu Shono
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Shumpei Mori
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Atsusuke Yatomi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Tsubasa Kamio
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Jun Sakai
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Fumitaka Soga
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
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9
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Selvaraj S, Claggett B, Shah SJ, Anand IS, Rouleau JL, Desai AS, Lewis EF, Vaduganathan M, Wang SY, Pitt B, Sweitzer NK, Pfeffer MA, Solomon SD. Utility of the Cardiovascular Physical Examination and Impact of Spironolactone in Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2019; 12:e006125. [PMID: 31220936 DOI: 10.1161/circheartfailure.119.006125] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The prognostic value of physical examination, its relation to quality of life, and influence of therapy in heart failure with preserved ejection fraction is not well known. METHODS AND RESULTS We studied participants from the Americas with available physical examination (jugular venous distention, rales, and edema) at baseline in the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist). The association of the number of signs of congestion with the primary outcome (cardiovascular death or heart failure hospitalization), its individual components, and all-cause mortality was assessed using time-updated, multivariable-adjusted Cox regression analyses. We evaluated whether spironolactone improved congestion at 4 months and whether improvement in congestion was related to quality of life as assessed by Kansas City Cardiomyopathy Questionnaire overall summary scores and to outcomes. Among 1644 participants, 22%, 54%, 20%, and 4% had 0, 1, 2, and 3 signs of congestion, respectively, at baseline. After multivariable adjustment, each additional increase in sign of congestion was associated with a 30% to 60% increased risk of each outcome ( P<0.001). Spironolactone reduced the total number of signs of congestion by -0.10 ( P=0.005) signs, jugular venous distention (odds ratio, 0.60; P=0.01), and edema (odds ratio, 0.74; P=0.006) at 4 months compared with placebo. Each reduction in sign of congestion was independently associated with a 4.0 (95% CI, 2.4-5.6) point improvement in Kansas City Cardiomyopathy Questionnaire overall summary score. When assessed simultaneously, time-updated, but not baseline congestion, predicted outcomes. CONCLUSIONS In heart failure with preserved ejection fraction, the physical exam provides independent prognostic value for adverse outcomes. Spironolactone improved congestion compared with placebo. Reducing congestion was independently associated with improved quality of life and outcomes and is a modifiable risk factor. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT00094302.
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Affiliation(s)
- Senthil Selvaraj
- Division of Cardiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia (S.S.)
| | - Brian Claggett
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (B.C., A.S.D., E.F.L., M.V., S.Y.W., M.A.P., S.D.S.)
| | - Sanjiv J Shah
- The Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
| | - Inder S Anand
- VA Medical Center, University of Minnesota, Minneapolis (I.S.A)
| | - Jean L Rouleau
- Department of Medicine, Montreal Heart Institute, University of Montreal, QC, Canada (J.L.R.)
| | - Akshay S Desai
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (B.C., A.S.D., E.F.L., M.V., S.Y.W., M.A.P., S.D.S.)
| | - Eldrin F Lewis
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (B.C., A.S.D., E.F.L., M.V., S.Y.W., M.A.P., S.D.S.)
| | - Muthiah Vaduganathan
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (B.C., A.S.D., E.F.L., M.V., S.Y.W., M.A.P., S.D.S.)
| | - Stephen Y Wang
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (B.C., A.S.D., E.F.L., M.V., S.Y.W., M.A.P., S.D.S.)
| | - Bertram Pitt
- Division of Cardiology, Department of Medicine, University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Nancy K Sweitzer
- The Sarver Heart Center, University of Arizona College of Medicine, Tucson (N.K.S.)
| | - Marc A Pfeffer
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (B.C., A.S.D., E.F.L., M.V., S.Y.W., M.A.P., S.D.S.)
| | - Scott D Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (B.C., A.S.D., E.F.L., M.V., S.Y.W., M.A.P., S.D.S.)
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10
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He J, Yang Y, Zhang G, Lu XH. Clinical risk factors for new-onset atrial fibrillation in acute myocardial infarction: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e15960. [PMID: 31261502 PMCID: PMC6616519 DOI: 10.1097/md.0000000000015960] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
New-onset atrial fibrillation (NOAF) remains common arrhythmia in acute myocardial infarction (AMI), and is closely associated with increased subsequent cardiovascular mortality. Our meta-analysis aims to summarize more clinical risk factors for NOAF.Comprehensive systematic search of MEDLINE, EMBASE, and the Cochrane Library were carried out to find relevant studies inception to December 2017. Pooled mean difference (MD) and 95% confidence interval (CI) were calculated to evaluate the value of clinical risk factors in the prediction of NOAF after AMI.Eleven studies containing 9570 patients were included in the meta-analysis. Overall, older age and increased heart rate (HR) levels had a significant positive association with NOAF in patients with AMI. The MD in age between the patients with, and those without NOAF, was 8.22 units (95% confidence interval [CI]: 7.44-9.01), test for overall effect z score = 20.51 (P < .00001, I = 0%). Moreover, the MD in a subgroup analysis for HR levels between the patients with, and those without NOAF was 4.34 units (95% Cl: 2.56-6.11), test for overall effect z score = 4.78 (P < .00001, I = 31%).In patient with AMI, our meta-analysis demonstrated that older age and increased HR levels on admission are related to greater risk of NOAF.
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Affiliation(s)
- Jing He
- Guangdong Sanjiu Brain Hospital
| | - Yi Yang
- Guangdong Provincial Corps Hospital of Chinese People's Armed Police Forces, Guangzhou Medical University, Guangzhou, China
| | - Gui Zhang
- Guangdong Provincial Corps Hospital of Chinese People's Armed Police Forces, Guangzhou Medical University, Guangzhou, China
| | - Xiu-Hong Lu
- Guangdong Provincial Corps Hospital of Chinese People's Armed Police Forces, Guangzhou Medical University, Guangzhou, China
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11
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Mullens W, Damman K, Harjola VP, Mebazaa A, Brunner-La Rocca HP, Martens P, Testani JM, Tang WHW, Orso F, Rossignol P, Metra M, Filippatos G, Seferovic PM, Ruschitzka F, Coats AJ. The use of diuretics in heart failure with congestion - a position statement from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2019; 21:137-155. [PMID: 30600580 DOI: 10.1002/ejhf.1369] [Citation(s) in RCA: 563] [Impact Index Per Article: 112.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/14/2018] [Accepted: 10/27/2018] [Indexed: 12/11/2022] Open
Abstract
The vast majority of acute heart failure episodes are characterized by increasing symptoms and signs of congestion with volume overload. The goal of therapy in those patients is the relief of congestion through achieving a state of euvolaemia, mainly through the use of diuretic therapy. The appropriate use of diuretics however remains challenging, especially when worsening renal function, diuretic resistance and electrolyte disturbances occur. This position paper focuses on the use of diuretics in heart failure with congestion. The manuscript addresses frequently encountered challenges, such as (i) evaluation of congestion and clinical euvolaemia, (ii) assessment of diuretic response/resistance in the treatment of acute heart failure, (iii) an approach towards stepped pharmacologic diuretic strategies, based upon diuretic response, and (iv) management of common electrolyte disturbances. Recommendations are made in line with available guidelines, evidence and expert opinion.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University of Hasselt, Hasselt, Belgium
| | - Kevin Damman
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Veli-Pekka Harjola
- Emergency Medicine, University of Helsinki, Helsinki University Hospital, Helsinki, Finland
| | - Alexandre Mebazaa
- University of Paris Diderot, Hôpitaux Universitaires Saint Louis Lariboisière, APHP, U 942 Inserm, F-CRIN INI-CRCT, Paris, France
| | | | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University of Hasselt, Hasselt, Belgium
| | | | | | | | - Patrick Rossignol
- Université de Lorraine, Inserm, Centre d'Investigations Clinique 1433 and Inserm U1116; CHRU Nancy; F-CRIN INI-CRCT, Nancy, France
| | | | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, Athens, Greece.,University of Cyprus, Nicosia, Cyprus
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12
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Garcia-Gutierrez S, Quintana JM, Antón-Ladislao A, Gallardo MS, Pulido E, Rilo I, Zubillaga E, Morillas M, Onaindia JJ, Murga N, Palenzuela R, Ruiz JG. Creation and validation of the acute heart failure risk score: AHFRS. Intern Emerg Med 2017; 12:1197-1206. [PMID: 27730492 DOI: 10.1007/s11739-016-1541-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 09/15/2016] [Indexed: 01/12/2023]
Abstract
Our aims were to create and validate a clinical decision rule to assess severity in acute heart failure. We conducted a prospective cohort study of patients with symptoms of acute heart failure who attended the emergency departments (EDs) of three hospitals between April 2011 and April 2013. The following data were collected on arrival to or during the stay in the ED: baseline severity of symptoms; presence of decompensated comorbidities; number of hospital admissions/visits to EDs for acute heart failure during the previous 24 months; triggers of the exacerbation; clinical signs and symptoms; results of ancillary tests requested in the ED; treatments prescribed; and response to the initial treatment in the ED. The main outcome was poor course during the acute phase, in-hospital for admitted patients and during the first week following the ED visit for discharged patients, this being a composite endpoint that included death, admission to an intensive care unit, need for invasive mechanical ventilation, cardiac arrest and use of non-invasive mechanical ventilation. Multivariate logistic regression models were developed. Predictors of poor course in acute heart failure were oedema on chest radiography, visits to the ED and/or admissions in the previous two years, and levels of glycemia and blood urea nitrogen (areas under the curve of 0.83 in the derivation sample, and 0.82 in the validation sample). Four clinical predictors available in the ED can be used to create a simple score to predict poor course in acute heart failure.Clinical Trials.gov ID: NCT02437058.
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Affiliation(s)
- Susana Garcia-Gutierrez
- Unidad de Investigación, Hospital Galdakao-Usansolo [Osakidetza], Red de Investigación en Servicios de Salud en Enfermedades Crónicas [REDISSEC], Barrio Labeaga s/n, 48960, Galdakao, Vizcaya, Spain.
| | - José Maria Quintana
- Unidad de Investigación, Hospital Galdakao-Usansolo [Osakidetza], Red de Investigación en Servicios de Salud en Enfermedades Crónicas [REDISSEC], Barrio Labeaga s/n, 48960, Galdakao, Vizcaya, Spain
| | - Ane Antón-Ladislao
- Unidad de Investigación, Hospital Galdakao-Usansolo [Osakidetza], Red de Investigación en Servicios de Salud en Enfermedades Crónicas [REDISSEC], Barrio Labeaga s/n, 48960, Galdakao, Vizcaya, Spain
| | | | - Esther Pulido
- Servicio de Urgencias, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain
| | - Irene Rilo
- Servicio de Cardiología, Hospital Donostia, Donostia, Spain
| | - Elena Zubillaga
- Servicio de Medicina Interna, Hospital Donostia, Donostia, Spain
| | - Miren Morillas
- Servicio de Cardiología, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain
| | - José Juan Onaindia
- Servicio de Cardiología, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain
| | - Nekane Murga
- Servicio de Cardiología, Hospital de Basurto, Bilbao, Spain
| | | | - José González Ruiz
- Servicio de Cardiología, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain
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13
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Li S, Barywani S, Fu M. Impact of heart rate in atrial fibrillation versus sinus rhythm on mortality in octogenarian patients with acute coronary syndrome. Pan Afr Med J 2017; 28:89. [PMID: 29255559 PMCID: PMC5724948 DOI: 10.11604/pamj.2017.28.89.11170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 08/29/2017] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Association of heart rate (HR) with mortality in patients with acute coronary syndrome (ACS) and aged ≥ 80 years are underrepresented in clinical trials. We therefore aimed to investigate the association of HR in atrial fibrillation (AF) versus sinus rhythm (SR) with all-cause mortality in octogenarian patients with ACS. METHODS A total of 336 patients with ACS patients and aged ≥ 80 years were enrolled into the current study. The end point of interest was death from any cause. Association of HR in AF versus SR with mortality was analyzed by Kaplan-Meier curve following log-rank test and multivariable Cox regression analysis. RESULTS In total, 63 (87.5%) of patients with AF were dead and 147 (59.8%) of patients with SR were dead during the follow-up period. The best cut-off was 80 bpm, with a sensitivity of 62% and specificity of 66%. HR ≤ 80 bpm in SR but not in AF was associated with better outcome as compared with HR > 80 bpm (Chi-Square = 26.55, Log rank P < 0.001). In SR subgroup, the hazard ratios of HR ≤ 80 bpm were 0.51(95% CI 0.37-0.70, P < 0.001) adjusted for age, 0.46 (95%CI 0.33-0.63, P < 0.001) adjusted for gender, 0.62 (95%CI 0.42- 0.93, P = 0.020) adjusted for multivariables respectively. In AF subgroup, the hazard ratios of HR ≤ 80 bpm were 0.83(95% CI 0.49-1.38, P = 0.464) adjusted for age, 0.96 (95%CI 0.59-1.58, P = 0.882) adjusted for gender, 0.72(95% CI 0.41-1.26, P = 0.249) adjusted for multivariables respectively. CONCLUSION The current study demonstrates that heart rate is an independent prognostic predictor for all-cause mortality, and HR ≤ 80 bpm is associated with improved outcome in SR but not in AF in octogenarian patients with ACS.
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Affiliation(s)
- Shijun Li
- Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China
- Section of Cardiology, Department of Medicine, Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden
| | - Salim Barywani
- Section of Cardiology, Department of Medicine, Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden
| | - Michael Fu
- Section of Cardiology, Department of Medicine, Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden
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14
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Bloom MW, Greenberg B, Jaarsma T, Januzzi JL, Lam CSP, Maggioni AP, Trochu JN, Butler J. Heart failure with reduced ejection fraction. Nat Rev Dis Primers 2017; 3:17058. [PMID: 28836616 DOI: 10.1038/nrdp.2017.58] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Heart failure is a global public health problem that affects more than 26 million people worldwide. The global burden of heart failure is growing and is expected to increase substantially with the ageing of the population. Heart failure with reduced ejection fraction accounts for approximately 50% of all cases of heart failure in the United States and is associated with substantial morbidity and reduced quality of life. Several diseases, such as myocardial infarction, certain infectious diseases and endocrine disorders, can initiate a primary pathophysiological process that can lead to reduced ventricular function and to heart failure. Initially, ventricular impairment is compensated for by the activation of the sympathetic nervous system and the renin-angiotensin-aldosterone system, but chronic activation of these pathways leads to worsening cardiac function. The symptoms of heart failure can be associated with other conditions and include dyspnoea, fatigue, limitations in exercise tolerance and fluid accumulation, which can make diagnosis difficult. Management strategies include the use of pharmacological therapies and implantable devices to regulate cardiac function. Despite these available treatments, heart failure remains incurable, and patients have a poor prognosis and high mortality rate. Consequently, the development of new therapies is imperative and requires further research.
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Affiliation(s)
- Michelle W Bloom
- Division of Cardiology, Stony Brook University Medical Center, 101 Nicolls Road, HSC, T-16, Rm 080, Stony Brook, New York 11794-8167, USA
| | - Barry Greenberg
- Division of Cardiovascular Medicine, University of California, San Diego, La Jolla, California, USA
| | - Tiny Jaarsma
- Faculty of Medicine and Health Sciences, Linkoping University, Linkoping, Sweden.,Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital Harvard Medical School, Harvard University, Boston, Massachusetts, USA
| | - Carolyn S P Lam
- Department of Cardiology, National Heart Centre Singapore, Singapore.,Programme in Cardiovascular and Metabolic Disorders, Duke-National University of Singapore Medical School, Singapore
| | - Aldo P Maggioni
- Italian Association of Hospital Cardiologists (ANMCO) Research Center, Florence, Italy
| | - Jean-Noël Trochu
- l'institut du thorax, Centre Hospital-Universitaire de Nantes, Nantes, France.,Medical School, University of Nantes, Nantes, France.,INSERM UMR1087 and CIC 1413, Nantes, France
| | - Javed Butler
- Division of Cardiology, Stony Brook University Medical Center, 101 Nicolls Road, HSC, T-16, Rm 080, Stony Brook, New York 11794-8167, USA
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15
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Baydemir C, Ural D, Karaüzüm K, Balcı S, Argan O, Karaüzüm I, Kozdağ G, Ağır AA. Predictors of Long-Term Mortality and Frequent Re-Hospitalization in Patients with Acute Decompensated Heart Failure and Kidney Dysfunction Treated with Renin-Angiotensin System Blockers. Med Sci Monit 2017; 23:3335-3344. [PMID: 28690311 PMCID: PMC5515119 DOI: 10.12659/msm.902786] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 01/02/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Assessment of risk for all-cause mortality and re-hospitalization is an important task during discharge of acute heart failure (AHF) patients, as they warrant different management strategies. Treatment with optimal medical therapy may change predictors for these 2 end-points in AHF patients with renal dysfunction. The aim of this study was to evaluate the predictors for long-term outcome in AHF patients with kidney dysfunction who were discharged on optimal medical therapy. MATERIAL AND METHODS The study was conducted retrospectively. The study group consisted of 225 AHF patients with moderate-to-severe kidney dysfunction, who were hospitalized at Kocaeli University Hospital Cardiology Clinic and who were prescribed beta-blockers and ACE-inhibitors or angiotensin II receptor blockers at discharge. Clinical, echocardiographic, and biochemical predictors of the composite of total mortality and frequent re-hospitalization (≥3 hospitalizations during the follow-up) were assessed using Cox regression and the predictors for each end-point were assessed by competing risk regression analysis. RESULTS Incidence of all-cause mortality was 45.3% and frequent readmissions were 49.8% in a median follow-up of 54 months. The associates of the composite end-point were age, NYHA class, respiration rate on admission, eGFR, hypoalbuminemia, mitral valve E/E' ratio, and ejection fraction. In competing risk regression analysis, right-sided HF, hypoalbuminemia, age, and uric acid appeared as independent associates of all-cause mortality, whereas NYHA class, NT-proBNP, mitral valve E/E' ratio, and uric acid were predictors for re-hospitalization. CONCLUSIONS Predictors for all-cause mortality in AHF with kidney dysfunction treated with optimal therapy are mainly related to advanced HF with right-sided dysfunction, whereas frequent re-hospitalization is associated with volume overload manifested by increased mitral E/E' ratio and NT-proBNP levels.
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Affiliation(s)
- Canan Baydemir
- Department of Biostatistics and Medical Informatics, Kocaeli University, School of Medicine, Kocaeli, Turkey
| | - Dilek Ural
- Department of Cardiology, Koç University, School of Medicine, Istanbul, Turkey
| | - Kurtuluş Karaüzüm
- Department of Cardiology, Derince Education and Research Hospital, Kocaeli, Turkey
| | - Sibel Balcı
- Department of Biostatistics and Medical Informatics, Kocaeli University, School of Medicine, Kocaeli, Turkey
| | - Onur Argan
- Department of Cardiology, Kocaeli State Hospital, Kocaeli, Turkey
| | - Irem Karaüzüm
- Department of Cardiology, Izmit Seka State Hospital, Kocaeli, Turkey
| | - Güliz Kozdağ
- Department of Cardiology, Kocaeli University, School of Medicine, Kocaeli, Turkey
| | - Ayşen A. Ağır
- Department of Cardiology, Kocaeli University, School of Medicine, Kocaeli, Turkey
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16
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Kimura BJ. Point-of-care cardiac ultrasound techniques in the physical examination: better at the bedside. Heart 2017; 103:987-994. [PMID: 28259843 DOI: 10.1136/heartjnl-2016-309915] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 02/02/2017] [Indexed: 12/19/2022] Open
Abstract
The development of hand-carried, battery-powered ultrasound devices has created a new practice in ultrasound diagnostic imaging, called 'point-of-care' ultrasound (POCUS). Capitalising on device portability, POCUS is marked by brief and limited ultrasound imaging performed by the physician at the bedside to increase diagnostic accuracy and expediency. The natural evolution of POCUS techniques in general medicine, particularly with pocket-sized devices, may be in the development of a basic ultrasound examination similar to the use of the binaural stethoscope. This paper will specifically review how POCUS improves the limited sensitivity of the current practice of traditional cardiac physical examination by both cardiologists and non-cardiologists. Signs of left ventricular systolic dysfunction, left atrial enlargement, lung congestion and elevated central venous pressures are often missed by physical techniques but can be easily detected by POCUS and have prognostic and treatment implications. Creating a general set of repetitive imaging skills for these entities for application on all patients during routine examination will standardise and reduce heterogeneity in cardiac bedside ultrasound applications, simplify teaching curricula, enhance learning and recollection, and unify competency thresholds and practice. The addition of POCUS to standard physical examination techniques in cardiovascular medicine will result in an ultrasound-augmented cardiac physical examination that reaffirms the value of bedside diagnosis.
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Affiliation(s)
- Bruce J Kimura
- Department of Cardiology, Scripps Mercy Hospital, San Diego, California, USA.,Department of Graduate Medical Education, Scripps Mercy Hospital, San Diego, California, USA
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17
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Sani MU, Cotter G, Davison BA, Mayosi BM, Damasceno A, Edwards C, Ogah OS, Mondo C, Dzudie A, Ojji DB, Kouam Kouam C, Suliman A, Yonga G, Abdou Ba S, Maru F, Alemayehu B, Sliwa K. Symptoms and Signs of Heart Failure at Admission and Discharge and Outcomes in the Sub-Saharan Acute Heart Failure (THESUS-HF) Registry. J Card Fail 2016; 23:739-742. [PMID: 27664511 DOI: 10.1016/j.cardfail.2016.09.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 09/02/2016] [Accepted: 09/13/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Symptoms and signs of heart failure (HF) are the most common reasons for admission to hospital for acute HF (AHF) and are used routinely throughout admission to assess the severity of disease and response to therapy. METHODS AND RESULTS The data were collected in The Sub-Saharan Africa Survey on Heart Failure (THESUS-HF) study, a prospective, multicenter, observational survey of AHF from 9 countries in sub-Saharan Africa. A total of 1006 patients, ≥12 years of age, hospitalized for AHF were recruited. Symptoms and signs of HF and changes in dyspnea and well-being, relative to admission, were assessed at entry and on days 1, 2, and 7 (or on discharge if earlier) and included oxygen saturation, degree of edema and rales, body weight, and level of orthopnea. The patient determined dyspnea and general well-being, whereas the physician determined symptoms and signs of HF, as well as improvements in vital sign measurement, throughout the admission. After multivariable adjustment, baseline rales and changes to day 7 or discharge in general well-being predicted death or HF hospitalization through day 60, and baseline orthopnea, edema, rales, oxygen saturation, and changes to day 7 or on discharge in respiratory rate and general well-being were predictive of death through day 180. CONCLUSIONS In AHF patients in sub-Saharan Africa, symptoms and signs of HF improve throughout admission, and simple assessments, including edema, rales, oxygen saturation, respiratory rate, and asking the patient about general well-being, are valuable tools in patients' clinical assessment.
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Affiliation(s)
- Mahmoud U Sani
- Department of Medicine, Bayero University Kano/Aminu Kano Teaching Hospital, Kano, Nigeria.
| | - Gad Cotter
- Momentum Research, Durham, North Carolina, United States
| | - Beth A Davison
- Momentum Research, Durham, North Carolina, United States
| | - Bongani M Mayosi
- Department of Medicine, GF Jooste and Groote Schuur Hospitals, University of Cape Town, Cape Town, South Africa
| | | | | | - Okechukwu S Ogah
- Department of Medicine, University College Hospital, Ibadan, Nigeria
| | | | - Anastase Dzudie
- Department of Internal Medicine, Douala General Hospital and Buea Faculty of Health Sciences, Douala, Cameroon
| | - Dike B Ojji
- Department of Medicine, University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Charles Kouam Kouam
- Department of Internal Medicine, Douala General Hospital and Buea Faculty of Health Sciences, Douala, Cameroon
| | - Ahmed Suliman
- Faculty of Medicine, University of Khartoum, Khartoum, Sudan
| | - Gerald Yonga
- Department of Medicine, Aga Khan University, Nairobi, Kenya
| | - Sergine Abdou Ba
- Service de Cardiologie, Faculté de Médecine de Dakar, Dakar, Senegal
| | - Fikru Maru
- Addis Cardiac Hospital, Addis Ababa, Ethiopia
| | | | - Karen Sliwa
- Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
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18
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Chen LJ, Hung CL, Yeh HI, Jeng MJ, Su CH, Wu TY, Shih SC, Tsai CH. The utilization and prognostic impact of B-type Natriuretic Peptide in hospitalized acute decompensated heart failure in an Asian population. BMC Cardiovasc Disord 2016; 16:178. [PMID: 27613439 PMCID: PMC5017059 DOI: 10.1186/s12872-016-0342-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 07/30/2016] [Indexed: 12/03/2022] Open
Abstract
Background B-type natriuretic peptide (BNP) levels during admission have been shown to have prognostic value in the diagnosis of heart failure and further predict the in-hospital mortality of acute decompensated heart failure (ADHF). This study describes the characteristics of BNP among hospitalized ADHF and elucidates its prognostic value of in-hospital mortality in an Asian population. Methods We consecutively studied patients aged 20+ who were discharged with a diagnosis of ADHF from March 2013 to March 2014 in a tertiary hospital of northern Taiwan by reviewing medical records. Prognostic predictors of mortality were assessed using Cox proportional hazard regression models. BNP > 100 pg/ml was used as the cut-off for defining abnormally high BNP based on current clinical practice criteria. Results After implementation of our exclusion criteria, a total of 1,807 patients hospitalized with ADHF were studied. Compared to those subjects with BNP ≤100 pg/ml, individuals with higher BNP tended to have more advanced age, more clusters of the typical signs of heart failure (HF) (e.g., peripheral edema or lung rales) at presentation, lower ejection fraction, lower hemoglobin levels, more disturbed biochemical data, worsened renal function, and twice the risk for in-hospital mortality (15.2 vs 6.2 %, all p < 0.05). In a multivariate analysis, more advanced age, the presence of rales, a worse New York Heart Association functional class, wider QRS duration, and abnormal BNP levels (>100 pg/ml) were all associated with in-hospital mortality among admitted HF patients after accounting for clinical co-variates and global ventricular ejection fraction (HR: 2.17, 95 % CI: 1.15–6.64, p = 0.024). Conclusion Abnormally high BNP levels in ADHF patients during admission were tightly linked to clinical features of worse physical, functional, and clinical presentations, and further provided prognostic value for determining in-hospital mortality among patients with ADHF in an Asian population.
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Affiliation(s)
- Li Juen Chen
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei, 112, Taiwan.,UW Medicine Valley Medical Center, 400 S 43rd Street, Renton, WA, 98055, USA
| | - Chung-Lieh Hung
- Department of Medicine, Mackay Medical College, No.46, Sec. 3, Zhongzheng Rd., Sanzhi Dist., New Taipei City, 252, Taiwan. .,Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei Branch, No. 92, Sec. 2, Zhongshan N. Rd., Taipei City, 10449, Taiwan.
| | - Hung-I Yeh
- Department of Medicine, Mackay Medical College, No.46, Sec. 3, Zhongzheng Rd., Sanzhi Dist., New Taipei City, 252, Taiwan
| | - Mei-Jy Jeng
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei, 112, Taiwan.,Department of Pediatrics, School of Medicine, National Yang-Ming University, No.155, Sec.2, Linong Street, Taipei, 112, Taiwan.,Department of Pediatrics, Taipei Veterans General Hospital, No. 201, Section 2, Shipai Rd, Beitou District, Taipei City, 112, Taiwan
| | - Cheng-Huang Su
- Department of Medicine, Mackay Medical College, No.46, Sec. 3, Zhongzheng Rd., Sanzhi Dist., New Taipei City, 252, Taiwan.,Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei Branch, No. 92, Sec. 2, Zhongshan N. Rd., Taipei City, 10449, Taiwan
| | - Te-Yu Wu
- Department of Medicine, Mackay Medical College, No.46, Sec. 3, Zhongzheng Rd., Sanzhi Dist., New Taipei City, 252, Taiwan.,Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei Branch, No. 92, Sec. 2, Zhongshan N. Rd., Taipei City, 10449, Taiwan
| | - Shou-Chuan Shih
- Division of Gastroenterology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei Branch, No. 92, Sec. 2, Zhongshan N. Rd, Taipei City, 10449, Taiwan
| | - Cheng-Ho Tsai
- Department of Medicine, Mackay Medical College, No.46, Sec. 3, Zhongzheng Rd., Sanzhi Dist., New Taipei City, 252, Taiwan. .,Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei Branch, No. 92, Sec. 2, Zhongshan N. Rd., Taipei City, 10449, Taiwan.
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19
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Dillon P, Ghanbari H. Diagnostic Evaluation and Follow-Up of Patients with Atrial Fibrillation. Heart Fail Clin 2016; 12:179-91. [PMID: 26968664 DOI: 10.1016/j.hfc.2015.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In this article, a review of the diagnostic evaluation and outpatient follow-up of patients with atrial fibrillation is presented. After exploring details of symptoms, past medical history, quality of life, and physical exam findings, diagnostic tools are then discussed. Furthermore, important considerations after the initial diagnosis and treatment of patients with atrial fibrillation are discussed.
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Affiliation(s)
- Patrick Dillon
- Division of Cardiovascular Medicine, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Hamid Ghanbari
- Division of Cardiovascular Medicine, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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20
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Li SJ, Sartipy U, Lund LH, Dahlström U, Adiels M, Petzold M, Fu M. Prognostic Significance of Resting Heart Rate and Use of β-Blockers in Atrial Fibrillation and Sinus Rhythm in Patients With Heart Failure and Reduced Ejection Fraction. Circ Heart Fail 2015; 8:871-9. [DOI: 10.1161/circheartfailure.115.002285] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 07/29/2015] [Indexed: 01/06/2023]
Abstract
Background—
In heart failure and reduced ejection fraction, the prognostic role of heart rate (HR) in atrial fibrillation (AF) is unknown and the effectiveness of β-blockers has recently been questioned in AF.
Methods and Results—
A total of 18 858 patients with heart failure and reduced ejection fraction registered with Swedish Heart Failure Registry were included in this study: patients with sinus rhythm (SR; n=11 466) and patients with AF (n=7392). The outcome measure was all-cause mortality. Compared with HR ≤60 beats per minute, the adjusted hazard ratios for mortality in SR were 1.26 for HR=61 to 70 beats per minute, 1.37 for HR=71 to 80 beats per minute, 1.52 for HR=81 to 90 beats per minute, 1.63 for HR=91 to 100 beats per minute, and 2.69 for HR >100 beats per minute. However, in AF, the hazard ratio increased only for HR >100 beats per minute (1.30;
P
=0.001). β-blocker use was associated with reduced mortality in SR (hazard ratio, 0.77;
P
=0.011) and in AF (hazard ratio, 0·71;
P
<0.001). For β-blocker use in SR, the hazard ratio gradually increased with HR increment, whereas in AF, the hazard ratio significantly increased only for HR >100 beats per minute (1.29;
P
=0.003) compared with HR ≤60 beats per minute.
Conclusions—
In patients with heart failure and reduced ejection fraction, a higher HR was associated with increased mortality in SR, but in AF, this is true only for HR >100 beats per minute. β-blocker use was associated with reduced mortality both in SR and in AF.
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Affiliation(s)
- Shi-Jun Li
- From the Department of Medicine, Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden (S.-J.L., M.F.); Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China (S.-J.L.); Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden (U.S.); Department of Molecular Medicine and Surgery (U.S.), Unit of Cardiology, Department of Medicine (L.H.L.), Karolinska Institute, Stockholm, Sweden; Department of Cardiology and
| | - Ulrik Sartipy
- From the Department of Medicine, Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden (S.-J.L., M.F.); Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China (S.-J.L.); Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden (U.S.); Department of Molecular Medicine and Surgery (U.S.), Unit of Cardiology, Department of Medicine (L.H.L.), Karolinska Institute, Stockholm, Sweden; Department of Cardiology and
| | - Lars H. Lund
- From the Department of Medicine, Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden (S.-J.L., M.F.); Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China (S.-J.L.); Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden (U.S.); Department of Molecular Medicine and Surgery (U.S.), Unit of Cardiology, Department of Medicine (L.H.L.), Karolinska Institute, Stockholm, Sweden; Department of Cardiology and
| | - Ulf Dahlström
- From the Department of Medicine, Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden (S.-J.L., M.F.); Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China (S.-J.L.); Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden (U.S.); Department of Molecular Medicine and Surgery (U.S.), Unit of Cardiology, Department of Medicine (L.H.L.), Karolinska Institute, Stockholm, Sweden; Department of Cardiology and
| | - Martin Adiels
- From the Department of Medicine, Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden (S.-J.L., M.F.); Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China (S.-J.L.); Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden (U.S.); Department of Molecular Medicine and Surgery (U.S.), Unit of Cardiology, Department of Medicine (L.H.L.), Karolinska Institute, Stockholm, Sweden; Department of Cardiology and
| | - Max Petzold
- From the Department of Medicine, Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden (S.-J.L., M.F.); Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China (S.-J.L.); Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden (U.S.); Department of Molecular Medicine and Surgery (U.S.), Unit of Cardiology, Department of Medicine (L.H.L.), Karolinska Institute, Stockholm, Sweden; Department of Cardiology and
| | - Michael Fu
- From the Department of Medicine, Sahlgrenska University Hospital/Östra Hospital, Gothenburg, Sweden (S.-J.L., M.F.); Department of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, China (S.-J.L.); Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden (U.S.); Department of Molecular Medicine and Surgery (U.S.), Unit of Cardiology, Department of Medicine (L.H.L.), Karolinska Institute, Stockholm, Sweden; Department of Cardiology and
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Cardiovascular and Pulmonary Research. Cardiopulm Phys Ther J 2015. [DOI: 10.1097/cpt.0000000000000008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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Abstract
In this article, a review of the diagnostic evaluation and outpatient follow-up of patients with atrial fibrillation is presented. After exploring details of symptoms, past medical history, quality of life, and physical exam findings, diagnostic tools are then discussed. Furthermore, important considerations after the initial diagnosis and treatment of patients with atrial fibrillation are discussed.
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Affiliation(s)
- Patrick Dillon
- Division of Cardiovascular Medicine, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Hamid Ghanbari
- Division of Cardiovascular Medicine, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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