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Machado GP, Telo GH, de Araujo GN, da Rosa Barbato JP, Amon A, Martins A, Nassif M, Azevedo W, da Silveira AD, Scolari FL, Pagnoncelli A, Goncalves SC, Truesdell AG, Wainstein R, Wainstein M. A combination of left ventricular outflow tract velocity time integral and lung ultrasound to predict mortality in ST elevation myocardial infarction. Intern Emerg Med 2024:10.1007/s11739-024-03719-z. [PMID: 39044051 DOI: 10.1007/s11739-024-03719-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Accepted: 07/15/2024] [Indexed: 07/25/2024]
Abstract
Development of ventricular failure and pulmonary edema is associated with a worse prognosis in ST-elevation myocardial infarction (STEMI). We aimed to evaluate the prognostic ability of a novel classification combining lung ultrasound (LUS) and left ventricular outflow tract (LVOT) velocity time integral (VTI) in patients with STEMI. LUS and LVOT-VTI were performed within 24 h of admission in STEMI patients. A LUS combined with LVOT-VTI (LUV) classification was developed based on LUS with < or ≥ 3 positive zone scans, combined with LVOT-VTI > or ≤ 14. Patients were classified as A (< 3zones/ > 14 cm VTI), B (≥ 3zones/ > 14 cm VTI), C (< 3zones/ ≤ 14 cm VTI) and D (≥ 3zones/ ≤ 14 cm VTI). Primary outcome was occurrence of in-hospital mortality. Development of cardiogenic shock (CS) within 24 h was also assessed. A total of 308 patients were included. Overall in-hospital mortality was 8.8%, while mortality for LUV A, B, C, and D was 0%, 3%, 12%, and 45%, respectively. The area under the curve (AUC) for predicting in-hospital mortality was 0.915. Moreover, after exclusion of patients admitted in Killip IV, at each increasing degree of LUV, a higher proportion of patients developed CS within 24 h: LUV A = 0.0%, LUV B 5%, LUV C = 12.5% and LUV D = 30.8% (p < 0.0001). The AUC for predicting CS was 0.908 (p < 0.001). In a cohort of STEMI patients, LUV provided to be an excellent method for prediction of in-hospital mortality and development of CS. LUV classification is a fast, non-invasive and very user-friendly ultrasonographic evaluation method to stratify the risk of mortality and CS.
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Affiliation(s)
- Guilherme Pinheiro Machado
- Cardiology Department, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2350, Porto Alegre, RS, 90035-003, Brazil.
| | - Guilherme Heiden Telo
- Cardiology Department, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2350, Porto Alegre, RS, 90035-003, Brazil
| | | | - Joao Pedro da Rosa Barbato
- Cardiology Department, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2350, Porto Alegre, RS, 90035-003, Brazil
| | - Andre Amon
- Cardiology Department, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2350, Porto Alegre, RS, 90035-003, Brazil
| | - Antônia Martins
- Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Marina Nassif
- Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Wagner Azevedo
- Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Anderson Donelli da Silveira
- Cardiology Department, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2350, Porto Alegre, RS, 90035-003, Brazil
| | - Fernando Luis Scolari
- Cardiology Department, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2350, Porto Alegre, RS, 90035-003, Brazil
| | - Alan Pagnoncelli
- Cardiology Department, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2350, Porto Alegre, RS, 90035-003, Brazil
| | - Sandro Cadaval Goncalves
- Cardiology Department, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2350, Porto Alegre, RS, 90035-003, Brazil
| | | | - Rodrigo Wainstein
- Cardiology Department, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2350, Porto Alegre, RS, 90035-003, Brazil
| | - Marco Wainstein
- Cardiology Department, Hospital de Clínicas de Porto Alegre, Ramiro Barcelos 2350, Porto Alegre, RS, 90035-003, Brazil
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2
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Mandoli GE, Cameli M, Pastore MC, Loiacono F, Righini FM, D'Ascenzi F, Focardi M, Cavigli L, Lisi M, Bisleri G, Dokollari A, Bernazzali S, Maccherini M, Valente S, Henein MY. Left ventricular fibrosis as a main determinant of filling pressures and left atrial function in advanced heart failure. Eur Heart J Cardiovasc Imaging 2024; 25:446-453. [PMID: 38109280 DOI: 10.1093/ehjci/jead340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/26/2023] [Accepted: 12/04/2023] [Indexed: 12/20/2023] Open
Abstract
AIMS Advanced heart failure (AdHF) is characterized by variable degrees of left ventricular (LV) dysfunction, myocardial fibrosis, and raised filling pressures which lead to left atrial (LA) dilatation and cavity dysfunction. This study investigated the relationship between LA peak atrial longitudinal strain (PALS), assessed by speckle-tracking echocardiography (STE), and invasive measures of LV filling pressures and fibrosis in a group of AdHF patients undergoing heart transplantation (HTX). METHODS AND RESULTS We consecutively enrolled patients with AdHF who underwent HTX at our Department. Demographic and basic echocardiographic data were registered, then invasive intracardiac pressures were obtained from right heart catheterization, and STE was also performed. After HTX, biopsy specimens from explanted hearts were collected to quantify the degree of LV myocardial fibrosis. Sixty-four patients were included in the study (mean age 62.5 ± 11 years, 42% female). The mean LV ejection fraction (LVEF) was 26.7 ± 6.1%, global PALS was 9.65 ± 4.5%, and mean pulmonary capillary wedge pressure (PCWP) was 18.8 ± 4.8 mmHg. Seventy-three % of patients proved to have severe LV fibrosis. Global PALS was inversely correlated with PCWP (R = -0.83; P < 0.0001) and with LV fibrosis severity (R = -0.78; P < 0.0001) but did not correlate with LVEF (R = 0.15; P = 0.2). Among echocardiographic indices of LV filling pressures, global PALS proved the strongest [area under the curve 0.955 (95% confidence interval 0.87-0.99)] predictor of raised (>18 mmHg) PCWP. CONCLUSION In patients with AdHF, reduced global PALS strongly correlated with the invasively assessed LV filling pressure and degree of LV fibrosis. Such relationship could be used as non-invasive indicator for optimum patient stratification for therapeutic strategies.
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Affiliation(s)
- Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale Mario Bracci, 1, 53100 Siena, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale Mario Bracci, 1, 53100 Siena, Italy
| | - Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale Mario Bracci, 1, 53100 Siena, Italy
| | - Ferdinando Loiacono
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale Mario Bracci, 1, 53100 Siena, Italy
| | - Francesca Maria Righini
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale Mario Bracci, 1, 53100 Siena, Italy
| | - Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale Mario Bracci, 1, 53100 Siena, Italy
| | - Marta Focardi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale Mario Bracci, 1, 53100 Siena, Italy
| | - Luna Cavigli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale Mario Bracci, 1, 53100 Siena, Italy
| | - Matteo Lisi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale Mario Bracci, 1, 53100 Siena, Italy
- Division of Cardiology, Department of Cardiovascular Diseases-AUSL Romagna, 'Santa Maria delle Croci' Hospital, Ravenna, Italy
| | | | | | - Sonia Bernazzali
- Department of Cardiac Surgery, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Massimo Maccherini
- Department of Cardiac Surgery, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Serafina Valente
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Viale Mario Bracci, 1, 53100 Siena, Italy
| | - Michael Y Henein
- Institute of Public Health and Clinical Medicine, Umea University, Umea, Sweden
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3
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Drazner MH. Risk Stratification of Patients With Decompensated Heart Failure by Echocardiographic Assessment of Hemodynamics. Am J Cardiol 2023; 207:280-282. [PMID: 37769571 DOI: 10.1016/j.amjcard.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 09/05/2023] [Indexed: 10/03/2023]
Affiliation(s)
- Mark H Drazner
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
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Takahashi T, Iwano H, Shibayama K, Kitai T, Tanaka H, Yamada H, Sata M, Kusunose K. The Clinical Utility of Noninvasive Forrester Classification in Acute Heart Failure from PREDICT Study. Am J Cardiol 2023; 207:75-81. [PMID: 37734303 DOI: 10.1016/j.amjcard.2023.08.119] [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] [Received: 05/15/2023] [Revised: 08/14/2023] [Accepted: 08/20/2023] [Indexed: 09/23/2023]
Abstract
The Forrester classification plays a crucial role in comprehending the underlying pathophysiology of heart failure (HF) and is employed to categorize the severity and predict the outcomes of patients with acute HF. Our objective was to assess the predictive value of the Forrester classification, based on noninvasive hemodynamic measurements obtained through Doppler echocardiography at admission, in forecasting the short-term prognosis posthospitalization of patients with acute HF. Patients were recruited for the Prospect trial to elucidate the utility of EchocarDIography-based Cardiac ouTput in acute heart failure (PREDICT) study, a multicenter, prospective study conducted in Japan. Participants were stratified into 4 profiles using cardiac index (CI) and early mitral filling velocity (E)/early-diastolic mitral annular velocity (e') ratio obtained from Doppler echocardiography upon admission (profile I: CI >2.2, E/e' ≤15, profile II: CI >2.2, E/e' >15, profile III: CI ≤2.2, E/e' ≤15, profile IV: CI ≤2.2, E/e' >15). The primary composite outcome of the study was all-cause mortality or worsening HF during the 14 days of hospitalization. Cox proportional hazards model analysis was employed to identify prognostic factors during the observation period. A total of 270 subjects, with a mean age of 74 ± 14 years and a male proportion of 60%, were enrolled in the study. During the 14-day period of hospitalization, 58 participants (22%) had a composite outcome. Patients with low CI (i.e., profiles III and IV) demonstrated an elevated risk of composite outcome after adjusting for confounding variables, as evidenced by the adjusted hazard ratios of 5.85 (95% confidence interval 1.17 to 29.09, p <0.01, vs profile III) and 6.50 (95% confidence interval 1.53 to 27.68, p <0.01, vs profile IV) in comparison with profile I, respectively. In conclusion, the Forrester classification, derived from noninvasive Doppler echocardiography at admission, may predict early deterioration in patients hospitalized with acute HF.
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Affiliation(s)
- Tomonori Takahashi
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Hiroyuki Iwano
- Division of Cardiology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Kentaro Shibayama
- Department of Cardiology, Tokyo Cardiovascular and Internal Medicine Clinic, Tokyo, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hirotsugu Yamada
- Department of Community Medicine for Cardiology, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Kenya Kusunose
- Department of Cardiovascular Medicine, Tokushima University Hospital, Tokushima, Japan; Department of Cardiovascular Medicine, Nephrology, and Neurology, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan.
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5
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Fortuni F, Zilio F, Iannopollo G, Ciliberti G, Trambaiolo P, Ceriello L, Musella F, Scicchitano P, Albani S, Di Fusco SA, Gulizia MM, Gabrielli D, Oliva F, Colivicchi F. Management of temporary mechanical circulatory support devices in cath-lab and cardiac intensive care unit. EUROPEAN HEART JOURNAL. IMAGING METHODS AND PRACTICE 2023; 1:qyad011. [PMID: 39044800 PMCID: PMC11195697 DOI: 10.1093/ehjimp/qyad011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/10/2023] [Indexed: 07/25/2024]
Abstract
Different temporary mechanical circulatory support (tMCS) devices are available and can be used to maintain end-organ perfusion while reducing cardiac work and myocardial oxygen demand. tMCS can provide support to the right ventricle, left ventricle, or both, and its use can be considered in emergency situations such as cardiogenic shock or in elective procedures such as high-risk percutaneous coronary intervention to prevent haemodynamic deterioration. Invasive and, most importantly, non-invasive haemodynamic parameters should be taken into account when choosing the type of tMCS device and its initiation and weaning timing, determining the need for a device upgrade, and screening for complications. In this context, ultrasound tools, specifically echocardiography, can provide important data. This review aims to provide a description of the different tMCS devices, the invasive and non-invasive tools and parameters to guide their management, and their advantages and drawbacks.
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Affiliation(s)
- Federico Fortuni
- Department of Cardiology, San Giovanni Battista Hospital, via Massimo Arcamone, CAP 06034, Foligno (PG), Italy
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2330RC Leiden, The Netherlands
| | - Filippo Zilio
- Department of Cardiology, Santa Chiara Hospital, Trento, Italy
| | - Gianmarco Iannopollo
- Department of Cardiology, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Giuseppe Ciliberti
- Cardiology and Arrhythmology Clinic, Marche University Hospital, Ancona, Italy
| | | | - Laura Ceriello
- Cardiology Department, Ospedale Civile G. Mazzini, Teramo, Italy
| | - Francesca Musella
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Cardiology Department, Santa Maria delle Grazie Hospital, Naples, Italy
| | | | - Stefano Albani
- Division of Cardiology, U. Parini Hospital, Aosta, Italy
- Department of Cardiology, Cardiovascular Institute Paris Sud, Massy, France
| | | | | | - Domenico Gabrielli
- Cardio-Toraco-Vascular Department, San Camillo-Forlanini Hospital, Rome, Italy
- Heart Care Foundation, Florence, Italy
| | - Fabrizio Oliva
- Cardiologia 1, A. De Gasperis Cardicocenter, ASST Niguarda, Milan, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Unit, San Filippo Neri Hospital, Rome, Italy
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6
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Raghu A, Schlesinger D, Pomerantsev E, Devireddy S, Shah P, Garasic J, Guttag J, Stultz CM. ECG-guided non-invasive estimation of pulmonary congestion in patients with heart failure. Sci Rep 2023; 13:3923. [PMID: 36894601 PMCID: PMC9998622 DOI: 10.1038/s41598-023-30900-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/03/2023] [Indexed: 03/11/2023] Open
Abstract
Quantifying hemodynamic severity in patients with heart failure (HF) is an integral part of clinical care. A key indicator of hemodynamic severity is the mean Pulmonary Capillary Wedge Pressure (mPCWP), which is ideally measured invasively. Accurate non-invasive estimates of the mPCWP in patients with heart failure would help identify individuals at the greatest risk of a HF exacerbation. We developed a deep learning model, HFNet, that uses the 12-lead electrocardiogram (ECG) together with age and sex to identify when the mPCWP > 18 mmHg in patients who have a prior diagnosis of HF. The model was developed using retrospective data from the Massachusetts General Hospital and evaluated on both an internal test set and an independent external validation set, from another institution. We developed an uncertainty score that identifies when model performance is likely to be poor, thereby helping clinicians gauge when to trust a given model prediction. HFNet AUROC for the task of estimating mPCWP > 18 mmHg was 0.8 [Formula: see text] 0.01 and 0.[Formula: see text] 0.01 on the internal and external datasets, respectively. The AUROC on predictions with the highest uncertainty are 0.50 [Formula: see text] 0.02 (internal) and 0.[Formula: see text] 0.04 (external), while the AUROC on predictions with the lowest uncertainty were 0.86 ± 0.01 (internal) and 0.82 ± 0.01 (external). Using estimates of the prevalence of mPCWP > 18 mmHg in patients with reduced ventricular function, and a decision threshold corresponding to an 80% sensitivity, the calculated positive predictive value (PPV) is 0.[Formula: see text] 0.01when the corresponding chest x-ray (CXR) is consistent with interstitial edema HF. When the CXR is not consistent with interstitial edema, the estimated PPV is 0.[Formula: see text] 0.02, again at an 80% sensitivity threshold. HFNet can accurately predict elevated mPCWP in patients with HF using the 12-lead ECG and age/sex. The method also identifies cohorts in which the model is more/less likely to produce accurate outputs.
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Affiliation(s)
- Aniruddh Raghu
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Building 36-796, 77 Massachusetts Ave., Cambridge, MA, 02139, USA.,Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, 32 Vassar St., Cambridge, MA, 02139, USA.,Research Laboratory of Electronics, Massachusetts Institute of Technology, 77 Massachusetts Ave., Cambridge, MA, 02139, USA
| | - Daphne Schlesinger
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Building 36-796, 77 Massachusetts Ave., Cambridge, MA, 02139, USA.,Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, 32 Vassar St., Cambridge, MA, 02139, USA.,Research Laboratory of Electronics, Massachusetts Institute of Technology, 77 Massachusetts Ave., Cambridge, MA, 02139, USA.,Institute of Medical Engineering and Science, Massachusetts Institute of Technology, 77 Massachusetts Ave., Cambridge, MA, 02139, USA
| | - Eugene Pomerantsev
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.,Division of Cardiology, Massachusetts General Hospital, 55 Fruit St., Boston, MA, 02114, USA
| | - Srikanth Devireddy
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - Pinak Shah
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.,Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA
| | - Joseph Garasic
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.,Division of Cardiology, Massachusetts General Hospital, 55 Fruit St., Boston, MA, 02114, USA
| | - John Guttag
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Building 36-796, 77 Massachusetts Ave., Cambridge, MA, 02139, USA.,Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, 32 Vassar St., Cambridge, MA, 02139, USA
| | - Collin M Stultz
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Building 36-796, 77 Massachusetts Ave., Cambridge, MA, 02139, USA. .,Computer Science and Artificial Intelligence Laboratory, Massachusetts Institute of Technology, 32 Vassar St., Cambridge, MA, 02139, USA. .,Research Laboratory of Electronics, Massachusetts Institute of Technology, 77 Massachusetts Ave., Cambridge, MA, 02139, USA. .,Institute of Medical Engineering and Science, Massachusetts Institute of Technology, 77 Massachusetts Ave., Cambridge, MA, 02139, USA. .,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA. .,Division of Cardiology, Massachusetts General Hospital, 55 Fruit St., Boston, MA, 02114, USA.
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7
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Durmaz E, Karpuz MH, İkitimur B, Karadag B, Koca D, Ohtaroglu Tokdil K, Raimoglu U, Gulfidan A, Incesu G, Tokdil H, Pirdal BZ, Ongen Z. The validation of left atrial strain imaging for the assessment of diastolic functions in patients with ST-segment elevation myocardial infarction. Int J Cardiovasc Imaging 2022; 38:2109-2114. [PMID: 37726461 PMCID: PMC9116073 DOI: 10.1007/s10554-022-02628-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/18/2022] [Indexed: 01/28/2023]
Abstract
Assessment of left ventricular filling pressure (LVFP) is crucial in patients with ST-segment elevation myocardial infarction (STEMI). Since current guideline recommended echocardiographic parameters have limited value, more comprehensive assessment methods are required in this patient subset.In this study, we aimed to investigate the clinical utility of left atrial reservoir strain (LARS) imaging in patients treated with primary percutaneous coronary intervention (pPCI). Patients who underwent successful pPCI were included. Left ventricular end-diastolic pressure (LVEDP) was measured invasively following pPCI. Left atrial strain imaging was performed following pPCI within 24 h of pPCI. Normal LARS value was accepted as above 23%. We prospectively enrolled 69 patients; there were 18 patients with LARS below 23% who were included into group 1 and rest of the study population included into group 2. There was no significant difference between groups in terms of comorbidities.Troponin and pro-BNP levels were significantly higher in group 1 (p: 0.036 and 0.047 respectively). Left atrial volume and tricuspid regurgitation velocity were similar between groups (p: 0.416 and p: 0.351 respectively). Septal tissue velocity was higher (p: 0.001) and Septal E/e' ratio was lower (p: 0.004) in group 2. Left ventricular (LV) global longitudinal strain value was higher in group 1 which is consistent with observed lower ejection (LVEF) fraction in group 1 (p: 0.001 for LV strain and p: 0.001 for LVEF). Estimated mean LVFP was also higher in group 1 (p: 0.003).Correlation analyses revealed moderate correlation between LARS and LVEDP (r: - 0.300). Our results indicate that left atrial strain imaging is a promising tool for the assessment of left atrial pressure in patients with STEMI.
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Affiliation(s)
- Eser Durmaz
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Fatih, Istanbul, 34098, Turkey.
| | - Mehmet Hakan Karpuz
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Fatih, Istanbul, 34098, Turkey
| | - Baris İkitimur
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Fatih, Istanbul, 34098, Turkey
| | - Bilgehan Karadag
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Fatih, Istanbul, 34098, Turkey
| | - Damla Koca
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Fatih, Istanbul, 34098, Turkey
| | - Kardelen Ohtaroglu Tokdil
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Fatih, Istanbul, 34098, Turkey
| | - Utku Raimoglu
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Fatih, Istanbul, 34098, Turkey
| | - Aslı Gulfidan
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Fatih, Istanbul, 34098, Turkey
| | - Gunduz Incesu
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Fatih, Istanbul, 34098, Turkey
| | - Hasan Tokdil
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Fatih, Istanbul, 34098, Turkey
| | - Betul Zehra Pirdal
- Department of Public Health, Cerrahpasa School of Medicine, I Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Zeki Ongen
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Fatih, Istanbul, 34098, Turkey
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8
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Palazzuoli A, Ruocco G, Valente S, Stefanini A, Carluccio E, Ambrosio G. Non-invasive assessment of acute heart failure by Stevenson classification: Does echocardiographic examination recognize different phenotypes? Front Cardiovasc Med 2022; 9:911578. [PMID: 36237905 PMCID: PMC9551647 DOI: 10.3389/fcvm.2022.911578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 08/31/2022] [Indexed: 12/05/2022] Open
Abstract
Background Acute heart failure (AHF) presentation is universally classified in relation to the presence or absence of congestion and the peripheral perfusion condition according to the Stevenson diagram. We sought to evaluate a relationship existing between clinical assessment and echocardiographic evaluation in patients with AHF. Materials and methods This is a retrospective blinded multicenter analysis assessing both clinical and echocardiographic analyses during the early hospital admission for AHF. Patients were categorized into four groups according to the Stevenson presentation: group A (warm and dry), group B (cold and dry), group C (warm and wet), and group D (cold and wet). Echocardiographic evaluation was executed within 12 h from the first clinical evaluation. The following parameters were measured: left ventricular (LV) volumes, LV ejection fraction (LVEF); pattern Doppler by E/e1 ratio, pulmonary artery systolic pressure (PASP), tricuspid annular plane systolic excursion (TAPSE), and inferior cave vein diameter (ICV). Results We studied 208 patients, 10 in group A, 16 in group B, 153 in group C, and 29 in group D. Median age of our sample was 81 [69–86] years and the patients enrolled were mainly men (66.8%). Patients in groups C and A showed significant higher levels of systolic arterial pressures with respect to groups B and D (respectively, 130 [115–145] mmHg vs. 122 [119–130] mmHg vs. 92 [90–100] mmHg vs. 95 [90–100] mmHg, p < 0.001). Patients in groups A and C (warm) demonstrated significant higher values of LVEF with respect to patients in groups B and D (43 [34–49] vs. 42 [30–49] vs. 27 [15–31] vs. 30 [22–42]%, p < 0.001). Whereas group B experienced significant lower TAPSE values compared with other group (14 [12–17] mm vs. A: 17 [16–21] mm vs. C: 18 [14–20] mm vs. D: 16 [12–17] mm; p = 0.02). Finally, echocardiographic congestion score including PASP ≥ 40 mmHg, ICV ≥ 21, mm and E/e’ > 14 did not differ among groups. Follow-up analysis showed an increased mortality rate in D group (HR 8.2 p < 0.04). Conclusion The early Stevenson classification remains a simple and universally recognized approach for the detection of congestion and perfusion status. The combined clinical and echocardiographic assessment may be useful to better define the patients’ profile.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio Thoracic Department, Le Scotte Hospital, University of Siena, Siena, Italy
- *Correspondence: Alberto Palazzuoli,
| | - Gaetano Ruocco
- Cardiology Unit, Riuniti of Valdichiana Hospitals, USL-SUD-EST Toscana, Montepulciano, Italy
| | - Serafina Valente
- Cardiology Unit, Cardio Thoracic Department, Le Scotte Hospital, University of Siena, Siena, Italy
| | - Andrea Stefanini
- Cardiovascular Diseases Unit, Cardio Thoracic Department, Le Scotte Hospital, University of Siena, Siena, Italy
| | - Erberto Carluccio
- Division of Cardiology and Center for Clinical and Translational Research – CERICLET, University of Perugia, Perugia, Italy
| | - Giuseppe Ambrosio
- Division of Cardiology and Center for Clinical and Translational Research – CERICLET, University of Perugia, Perugia, Italy
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Respiratory Subsets in Patients with Moderate to Severe Acute Respiratory Distress Syndrome for Early Prediction of Death. J Clin Med 2022; 11:jcm11195724. [PMID: 36233592 PMCID: PMC9570540 DOI: 10.3390/jcm11195724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/19/2022] [Accepted: 09/24/2022] [Indexed: 12/16/2022] Open
Abstract
Introduction: In patients with acute respiratory distress syndrome (ARDS), the PaO2/FiO2 ratio at the time of ARDS diagnosis is weakly associated with mortality. We hypothesized that setting a PaO2/FiO2 threshold in 150 mm Hg at 24 h from moderate/severe ARDS diagnosis would improve predictions of death in the intensive care unit (ICU). Methods: We conducted an ancillary study in 1303 patients with moderate to severe ARDS managed with lung-protective ventilation enrolled consecutively in four prospective multicenter cohorts in a network of ICUs. The first three cohorts were pooled (n = 1000) as a testing cohort; the fourth cohort (n = 303) served as a confirmatory cohort. Based on the thresholds for PaO2/FiO2 (150 mm Hg) and positive end-expiratory pressure (PEEP) (10 cm H2O), the patients were classified into four possible subsets at baseline and at 24 h using a standardized PEEP-FiO2 approach: (I) PaO2/FiO2 ≥ 150 at PEEP < 10, (II) PaO2/FiO2 ≥ 150 at PEEP ≥ 10, (III) PaO2/FiO2 < 150 at PEEP < 10, and (IV) PaO2/FiO2 < 150 at PEEP ≥ 10. Primary outcome was death in the ICU. Results: ICU mortalities were similar in the testing and confirmatory cohorts (375/1000, 37.5% vs. 112/303, 37.0%, respectively). At baseline, most patients from the testing cohort (n = 792/1000, 79.2%) had a PaO2/FiO2 < 150, with similar mortality among the four subsets (p = 0.23). When assessed at 24 h, ICU mortality increased with an advance in the subset: 17.9%, 22.8%, 40.0%, and 49.3% (p < 0.0001). The findings were replicated in the confirmatory cohort (p < 0.0001). However, independent of the PEEP levels, patients with PaO2/FiO2 < 150 at 24 h followed a distinct 30-day ICU survival compared with patients with PaO2/FiO2 ≥ 150 (hazard ratio 2.8, 95% CI 2.2−3.5, p < 0.0001). Conclusions: Subsets based on PaO2/FiO2 thresholds of 150 mm Hg assessed after 24 h of moderate/severe ARDS diagnosis are clinically relevant for establishing prognosis, and are helpful for selecting adjunctive therapies for hypoxemia and for enrolling patients into therapeutic trials.
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10
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Kataoka Y, Fukuda Y, Peterson J, Shelly I, Alexander J, Sunagawa K. System Design for Optimizing Drug Infusions Using Cardiovascular Space Mapping for Acute Heart Failure. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:1388-1393. [PMID: 36086004 DOI: 10.1109/embc48229.2022.9871694] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Acute heart failure is caused by various factors and requires multiple drug therapies to remedy underlying causes. Due to the complexity of pharmacologic effects of cardiovascular agents, few studies have theoretically addressed the multidrug optimization problem. This paper proposes a drug infusion system for acute heart failure that controls cardiovascular performance metrics (cardiac output, left atrial pressure, and mean arterial pressure) within desired ranges as dictated by the cardiovascular parameters (systemic vascular resistance, cardiac contractility, heart rate, and stressed blood volume). The key to our system design is modeling and controlling cardiovascular parameters to yield the desired cardiovascular metrics. A 'tailored drug infusion' technique controls parameters by solving the optimization problem in order to conquer the complexity of multi-dependencies and the different dosage limits among multiple drugs. A 'cardiovascular space mapping' technique identifies the desired parameters from the desired metrics by deriving the analytical solutions of the metrics as functions of the parameters. To facilitate clinical discussions, parameters were set to realistic values in 5,600 simulated patients. Our results showed not only that the optimized drug combinations and dosages controlled the cardiovascular metrics to within the desired ranges, but also that they mostly corresponded to the recommended clinical use guidelines. An additional value of our system is that it proactively predicts the limitations of the tailored drug therapy, which supports the clinical decision of pivoting to alternative treatment strategies such as mechanical circulatory support.
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11
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Mathew R, Fernando SM, Hu K, Parlow S, Di Santo P, Brodie D, Hibbert B. Optimal Perfusion Targets in Cardiogenic Shock. JACC. ADVANCES 2022; 1:100034. [PMID: 38939320 PMCID: PMC11198174 DOI: 10.1016/j.jacadv.2022.100034] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/26/2022] [Accepted: 04/27/2022] [Indexed: 06/29/2024]
Abstract
Cardiology shock is a syndrome of low cardiac output resulting in end-organ dysfunction. Few interventions have demonstrated meaningful clinical benefit, and cardiogenic shock continues to carry significant morbidity with mortality rates that have plateaued at upwards of 40% over the past decade. Clinicians must rely on clinical, biochemical, and hemodynamic parameters to guide resuscitation. Several features, including physical examination, renal function, serum lactate metabolism, venous oxygen saturation, and hemodynamic markers of right ventricular function, may be useful both as prognostic markers and to guide therapy. This article aims to review these targets, their utility in the care of patients with cardiology shock, and their association with outcomes.
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Affiliation(s)
- Rebecca Mathew
- Division of Cardiology, University of Ottawa, Ottawa, Ontario, Canada
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Shannon M. Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kira Hu
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Simon Parlow
- Division of Cardiology, University of Ottawa, Ottawa, Ontario, Canada
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Pietro Di Santo
- Division of Cardiology, University of Ottawa, Ottawa, Ontario, Canada
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, New York, USA
| | - Benjamin Hibbert
- Division of Cardiology, University of Ottawa, Ottawa, Ontario, Canada
- CAPITAL Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
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12
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Haemodynamic monitoring in acute heart failure - what you need to know. Adv Cardiol 2022; 18:90-100. [PMID: 36051835 PMCID: PMC9421519 DOI: 10.5114/aic.2022.118524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/05/2022] [Indexed: 12/03/2022]
Abstract
Acute heart failure (AHF) is a sudden, life-threatening condition, defined as a gradual or rapid onset of symptoms and/or signs of HF. AHF requires urgent medical attention, being the most frequent cause of unplanned hospital admission in patients above 65 years of age. AHF is associated with a 4–12% in-hospital mortality rate and a 21–35% 1-year mortality rate post-discharge. Considering the serious prognosis in AHF patients, it is very important to understand the mechanisms and haemodynamic status in an individual AHF patient, thus preventing end-organ failure and death. Haemodynamic monitoring is a serial assessment of cardiovascular function, intended to detect physiologic abnormalities at the earliest stages, determine which interventions could be most effective, and provide the basis for initiating the most appropriate therapy and evaluate its effects. Over the past decades, haemodynamic monitoring techniques have evolved greatly. Nowadays, they range from very invasive to non-invasive, from intermittent to continuous, and in terms of the provided parameters. Invasive techniques contain pulmonary artery catheterization and transpulmonary thermodilution. Minimally invasive techniques include oesophageal Doppler and noncalibrated pulse wave analysis. Non-invasive techniques contain echocardiography, bioimpedance, and bioreactance techniques as well as non-invasive pulse contour methods. Each of these techniques has specific indications and limitations. In this article, we aimed to provide a pathophysiological explanation of the physical terms and parameters used for haemodynamic monitoring in AHF and to summarize the working principles, advantages, and disadvantages of the currently used methods of haemodynamic monitoring.
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13
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Milwidsky A, Greidinger D, Frydman S, Hochstadt A, Topilsky Y. Response to: "From Killip To Forester To Echocardiography: Beyond Myocardial Infarction" by Abbas AE. J Am Soc Echocardiogr 2021; 35:444. [PMID: 34954050 DOI: 10.1016/j.echo.2021.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Assi Milwidsky
- Department of Cardiology, Tel-Aviv Sourasky Medical Center affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, ISRAEL
| | - Dahlia Greidinger
- Department of Cardiology, Tel-Aviv Sourasky Medical Center affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, ISRAEL; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, ISRAEL
| | - Shir Frydman
- Department of Cardiology, Tel-Aviv Sourasky Medical Center affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, ISRAEL
| | - Aviram Hochstadt
- Department of Cardiology, Tel-Aviv Sourasky Medical Center affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, ISRAEL
| | - Yan Topilsky
- Department of Cardiology, Tel-Aviv Sourasky Medical Center affiliated to Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, ISRAEL
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14
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Saku K, Nakata J. How Should We Develop New Risk Scores for Cardiogenic Shock? Circ J 2021; 86:695-698. [PMID: 34911898 DOI: 10.1253/circj.cj-21-0953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute
| | - Jun Nakata
- Division of Cardiovascular Intensive Care, Nippon Medical School
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15
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Izumo M. Value of Echocardiography in the Treatment of Patients With Acute Heart Failure. Front Cardiovasc Med 2021; 8:740439. [PMID: 34869645 PMCID: PMC8634439 DOI: 10.3389/fcvm.2021.740439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/14/2021] [Indexed: 11/25/2022] Open
Abstract
Heart failure (HF) is a burden in pandemic medicine resulting in high mortality and morbidity. Because acute HF is a life-threatening event, its diagnosis and choice of optimal treatment are important to improve outcomes. Furthermore, understanding the cause and hemodynamics of acute HF is important in selecting the optimal treatment for these patients. Echocardiography is widely used in daily clinical practice because of its non-invasive nature and excellent portability to understand cardiac function and hemodynamics. Echocardiography is highly recommended by guidelines in the practice of HF, but evidence is limited. In this review, I would like to share clinical value of echocardiography in the treatment of patients with acute HF and discuss the usefulness of echocardiography.
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Affiliation(s)
- Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
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16
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Abbas AE, Health B, Oak R. From Killip To Forrester To Echocardiography: Beyond Myocardial Infarction. J Am Soc Echocardiogr 2021; 35:443-444. [PMID: 34875313 DOI: 10.1016/j.echo.2021.11.015] [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: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Amr E Abbas
- Oakland University William Beaumont School of Medicine, Auburn Hills, MI
| | - Beaumont Health
- Oakland University William Beaumont School of Medicine, Auburn Hills, MI
| | - Royal Oak
- Oakland University William Beaumont School of Medicine, Auburn Hills, MI
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17
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Kim K, Jentzer JC, Wiley BM, Miranda WR, Bennett C, Barsness GW, Oh JK. Diamond-Forrester classification using echocardiography haemodynamic assessment in cardiac intensive care unit patients. ESC Heart Fail 2021; 8:4933-4943. [PMID: 34535970 PMCID: PMC8712910 DOI: 10.1002/ehf2.13527] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/28/2021] [Accepted: 07/08/2021] [Indexed: 11/29/2022] Open
Abstract
AIMS We sought to determine whether the Diamond-Forrester classification using non-invasive haemodynamic measurements by 2-D and Doppler echocardiography would predict hospital mortality in cardiac intensive care unit (CICU) patients. METHODS AND RESULTS We retrospectively analysed unique patients admitted to the CICU at Mayo Clinic Rochester from 2007 to 2018. Doppler-derived cardiac index (CI) and ratio of mitral valve E velocity to medial mitral annulus e' velocity (E/e' ratio) were used to classify patients into four profiles: Profile I (warm/dry), Profile II (warm/wet), Profile III (cold/dry), and Profile IV (cold/wet). Logistic regression was used to determine predictors of hospital mortality, and Cox proportional-hazards analysis was used to determine predictors of mortality during one year of follow-up. We included 4563 patients with a mean age of 68.3 ± 14.3 years, including 36.2% female patients. The distribution of each profile was as follows: I, 47.4%; II, 36.2%; III, 7.9%; IV, 8.5%. A total of 5.8% patients died during hospitalization, and 18.1% died by 1 year. Patients with either low CI or elevated E/e' ratio had higher in-hospital and 1 year mortality. Patients with elevated E/e' ratio (i.e. Profiles II and IV) had an increased risk of death during hospitalization and at 1 year after multivariate adjustment (adjusted hazard ratio 1.72 and 2.17 for 1 year mortality, respectively, compared with Profile I, P < 0.01). CONCLUSIONS Simple Doppler echocardiographic assessment can be used to identify haemodynamic profiles defined by the Diamond-Forester classification in patients admitted in CICU. These profiles predict outcomes and may be used to guide therapy in critically ill patients.
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Affiliation(s)
- Kyung‐Hee Kim
- Department of Cardiovascular Medicine, Echocardiography LaboratoryMayo Clinic200 First St SWRochesterMN55905USA
- Division of Cardiovascular DiseaseIncheon Sejong HospitalIncheonSouth Korea
| | - Jacob C. Jentzer
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineMayo ClinicRochesterMNUSA
| | - Brandon M. Wiley
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineMayo ClinicRochesterMNUSA
| | - William R. Miranda
- Department of Cardiovascular Medicine, Echocardiography LaboratoryMayo Clinic200 First St SWRochesterMN55905USA
| | - Courtney Bennett
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineMayo ClinicRochesterMNUSA
| | - Gregory W. Barsness
- Department of Cardiovascular MedicineMayo ClinicRochesterMNUSA
- Division of Pulmonary and Critical Care Medicine, Department of Internal MedicineMayo ClinicRochesterMNUSA
| | - Jae K. Oh
- Department of Cardiovascular Medicine, Echocardiography LaboratoryMayo Clinic200 First St SWRochesterMN55905USA
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18
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Schwaiger JP, Reinstadler SJ, Holzknecht M, Tiller C, Reindl M, Begle J, Lechner I, Lamina C, Mayr A, Graziadei I, Bauer A, Metzler B, Klug G. Prognostic value of depressed cardiac index after STEMI: a phase-contrast magnetic resonance study. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 11:53-61. [PMID: 34750623 DOI: 10.1093/ehjacc/zuab098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/14/2021] [Accepted: 10/18/2021] [Indexed: 11/15/2022]
Abstract
AIMS An invasively measured cardiac index (CI) of ≤2.2 L/min/m2 is one of the strongest prognostic indicators after ST-elevation myocardial infarction (STEMI), however, knowledge is mainly based on invasive evaluations performed in the pre-stent era. Velocity-encoded phase-contrast cardiac magnetic resonance (PC-CMR) allows non-invasive determination of CI. METHODS AND RESULTS In this prospective study, CMR was performed in 406 stable and contemporarily revascularized patients a median of 3 days after STEMI. Forward stroke volume was assessed at the level of the ascending aorta by PC-CMR. Left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) were determined by cine CMR. Major adverse cardiac events (MACE) were defined as the composite of death, myocardial infarction, or hospitalization for heart failure. Median CI was 2.52 L/min/m2 and 27% of patients had ≤2.2 L/min/m2. Median LVEF was 53% and median GLS was -12.2%. During a median follow-up of 14.2 [95% confidence interval (95% CI) 13.6-14.7] months, 41 patients (10.1%) experienced a MACE. A depressed CI was significantly associated with MACE after adjustment for LVEF, GLS, Thrombolysis in Myocardial Infarction (TIMI) risk score, and infarct size [hazard ratio = 3.15 (95% CI 1.53-6.47); P = 0.002] and led to significant discrimination improvement [net reclassification improvement 0.61 (95% CI 0.25-0.97); P < 0.001]. CONCLUSIONS A CI of 2.2 L/min/m2 or less as measured by PC-CMR was present in 27% of clinically stable patients after STEMI and strongly and independently predicted medium-term MACE. The prognostic value of a depressed CI was superior and incremental to LVEF, GLS, TIMI risk score, and infarct size.
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Affiliation(s)
- Johannes P Schwaiger
- Department of Internal Medicine, Academic Teaching Hospital Hall in Tirol, Milser Strasse 10, 6060 Hall in Tirol, Austria
| | - Sebastian J Reinstadler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Magdalena Holzknecht
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Christina Tiller
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Martin Reindl
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Jana Begle
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Ivan Lechner
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Claudia Lamina
- Department of Genetics and Pharmacology, Institute of Genetic Epidemiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Agnes Mayr
- Department of Radiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Ivo Graziadei
- Department of Internal Medicine, Academic Teaching Hospital Hall in Tirol, Milser Strasse 10, 6060 Hall in Tirol, Austria
| | - Axel Bauer
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Bernhard Metzler
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Gert Klug
- University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
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Kalra S, Ranard LS, Memon S, Rao P, Garan AR, Masoumi A, O'Neill W, Kapur NK, Karmpaliotis D, Fried JA, Burkhoff D. Risk Prediction in Cardiogenic Shock: Current State of Knowledge, Challenges and Opportunities. J Card Fail 2021; 27:1099-1110. [PMID: 34625129 DOI: 10.1016/j.cardfail.2021.08.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/30/2021] [Accepted: 08/03/2021] [Indexed: 12/22/2022]
Abstract
Cardiogenic shock (CS) is a condition associated with high mortality rates in which prognostication is uncertain for a variety of reasons, including its myriad causes, its rapidly evolving clinical course and the plethora of established and emerging therapies for the condition. A number of validated risk scores are available for CS prognostication; however, many of these are tedious to use, are designed for application in a variety of populations and fail to incorporate contemporary hemodynamic parameters and contemporary mechanical circulatory support interventions that can affect outcomes. It is important to separate patients with CS who may recover with conservative pharmacological therapies from those in who may require advanced therapies to survive; it is equally important to identify quickly those who will succumb despite any therapy. An ideal risk-prediction model would balance incorporation of key hemodynamic parameters while still allowing dynamic use in multiple scenarios, from aiding with early decision making to device weaning. Herein, we discuss currently available CS risk scores, perform a detailed analysis of the variables in each of these scores that are most predictive of CS outcomes and explore a framework for the development of novel risk scores that consider emerging therapies and paradigms for this challenging clinical entity.
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Affiliation(s)
- Sanjog Kalra
- The Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
| | - Lauren S Ranard
- Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, New York
| | - Sehrish Memon
- Einstein Medical Center Philadelphia, Philadelphia, Pennsylvania
| | - Prashant Rao
- Beth Israel Deaconess Medical Center, Boston, Masschusetts
| | - A Reshad Garan
- Beth Israel Deaconess Medical Center, Boston, Masschusetts
| | - Amirali Masoumi
- Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, New York
| | | | - Navin K Kapur
- Tufts University Medical Center, Boston, Massachusetts
| | - Dimitri Karmpaliotis
- Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, New York; Cardiovascular Research Foundation, New York, New York
| | - Justin A Fried
- Columbia University Irving Medical Center/New York Presbyterian Hospital, New York, New York
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20
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Durmaz E, Ikitimur B, Karadag B, Koca D, Ohtaroglu Tokdil K, Raimoglu U, Soysal AU, Incesu G, Belpinar MS, Mutlu D, Yurtseven E, Atici A, Ongen Z. Echocardiographic assessment of left ventricular filling pressure in patients with acute ST elevation myocardial infarction: an invasive validation study. Int J Cardiovasc Imaging 2021; 37:1587-1594. [PMID: 33624230 DOI: 10.1007/s10554-020-02138-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/14/2020] [Indexed: 01/28/2023]
Abstract
Backgrounds Assessment of left ventricular filling pressure (LVFP) is of clinical importance in patients with ST elevation myocardial infarction (STEMI). Although several echocardiographic parameters are recommended for the assessment of LVFP, validation of these parameters in patients with STEMI is missing. We aimed to investigate the clinical utility of these parameters in acute settings. Methods: We prospectively included consecutive patients with STEMI. LV end-diastolic pressure (LVEDP) was measured following primary PCI and echocardiographic examination was performed within 24 hours. Mean left atrial pressure (mLAP) was calculated both invasively using Yamamoto's formula and non-invasively using Naugeh's formula. Mean LAP was considered increased when exceeded 18 mmHg. Results: Patients were grouped according to LVEDP, group 1(41 patients) and group 2(114 patients).There was no significant difference between groups in terms of comorbidities. NT pro-BNP levels (p < 0.001) and peak level of Hs-TnT (p-value: 0.002) were significantly higher in group 2. Average E/e' ratio was significantly higher in group 2 (10.19 ± 3.15 vs. 12.04 ± 4.83, p: 0.046). Isovolumetric relaxation time was longer in group 2 (p < 0.001) and left atrial volume index (LAVI) was also significantly higher in group 2 (p < 0.001). Regression analyses revealed that septal, lateral and average E/e' ratio, tricuspid regurgitation velocity, LAVI and left ventricular volume are correlated with mLAP. Among group 2 patients only 14 Patients fulfilled the increased LVFP criteria suggested by current guidelines. Conclusions Echocardiographic parameters indicating increased LVFP require validation and may need to be modified in patients with STEMI. Moreover, current algorithms underestimate the actual number of patients with increased LVFP.
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Affiliation(s)
- Eser Durmaz
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Cerrahpasa/Fatih, 34098, Istanbul, Turkey.
| | - Baris Ikitimur
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Cerrahpasa/Fatih, 34098, Istanbul, Turkey
| | - Bilgehan Karadag
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Cerrahpasa/Fatih, 34098, Istanbul, Turkey
| | - Damla Koca
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Cerrahpasa/Fatih, 34098, Istanbul, Turkey
| | - Kardelen Ohtaroglu Tokdil
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Cerrahpasa/Fatih, 34098, Istanbul, Turkey
| | - Utku Raimoglu
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Cerrahpasa/Fatih, 34098, Istanbul, Turkey
| | - Ali Ugur Soysal
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Cerrahpasa/Fatih, 34098, Istanbul, Turkey
| | - Gündüz Incesu
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Cerrahpasa/Fatih, 34098, Istanbul, Turkey
| | - Mehmet Semih Belpinar
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Cerrahpasa/Fatih, 34098, Istanbul, Turkey
| | - Deniz Mutlu
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Cerrahpasa/Fatih, 34098, Istanbul, Turkey
| | - Ece Yurtseven
- Department of Cardiology, Koc University, Istanbul, Turkey
| | - Adem Atici
- Goztepe Research and Training Hospital, Istanbul, Turkey
| | - Zeki Ongen
- Department of Cardiology, Cerrahpasa School of Medicine, Istanbul University-Cerrahpasa, Kocamustafapasa Street, Cerrahpasa/Fatih, 34098, Istanbul, Turkey
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21
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Omori T, Uno G, Shimada S, Rader F, Siegel RJ, Shiota T. Impact of New Grading System and New Hemodynamic Classification on Long-Term Outcome in Patients With Severe Tricuspid Regurgitation. Circ Cardiovasc Imaging 2021; 14:e011805. [PMID: 33517670 DOI: 10.1161/circimaging.120.011805] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND A new grading of tricuspid regurgitation (TR) beyond severe has been proposed. However, few studies assessing the validity of such a new grading scheme of TR have been conducted. Therefore, we evaluated associations of TR grades beyond severe with patient outcome and hemodynamics. METHODS We retrospectively studied patients who underwent 2-dimensional echocardiography and were diagnosed with severe TR between January 2014 and December 2015. According to the vena contracta width of TR (VC), the patients were classified into 2 groups: VC under 14 mm (VC<14 mm) and VC 14 mm or greater (VC≥14 mm). Hemodynamic parameters were estimated by echocardiography and were obtained by right heart catheterization. Cardiovascular events were defined as cardiovascular death or admission for heart failure. RESULTS A total of 679 patients (mean 72±17 years, 56% women) were included. During follow-up (median, 158 days; range, 29-891), 210 patients experienced cardiovascular events. By multivariate analysis, VC≥14 mm and left ventricular ejection fraction were independent predictors of cardiovascular events (hazard ratio, 1.57 [1.06-2.33]; hazard ratio, 0.99 [0.98-0.99], respectively). Patients with VC≥14 mm had significantly lower cardiac index (median, 1.8 versus 2.1 L/min per m2, P=0.001) and a higher prevalence of right atrial pressure 15 mm Hg (74% versus 60%, P<0.001) on echocardiography. Also, right heart catheterization confirmed higher right atrial pressure in patients with VC≥14 mm than those with VC<14 mm (16±8 versus 12±6 mm Hg, P=0.004). The new subset classification developed by cardiac index and right atrial pressure both on echocardiography predicted cardiovascular events (Log-rank P<0.001). CONCLUSIONS The relationship of VC≥14 mm to adverse outcome and poor hemodynamics showed the clinical relevance and need of a new grading system beyond severe. The new hemodynamic subset classification provides additional prognostic value for cardiovascular events in patients with severe TR.
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Affiliation(s)
- Taku Omori
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (T.O., G.U., S.S., F.R, R.J.S., T.S.)
| | - Goki Uno
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (T.O., G.U., S.S., F.R, R.J.S., T.S.)
| | - Shunsuke Shimada
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (T.O., G.U., S.S., F.R, R.J.S., T.S.)
| | - Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (T.O., G.U., S.S., F.R, R.J.S., T.S.).,University of California, Los Angeles, CA (F.R, R.J.S., T.S.)
| | - Robert J Siegel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (T.O., G.U., S.S., F.R, R.J.S., T.S.).,University of California, Los Angeles, CA (F.R, R.J.S., T.S.)
| | - Takahiro Shiota
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (T.O., G.U., S.S., F.R, R.J.S., T.S.).,University of California, Los Angeles, CA (F.R, R.J.S., T.S.)
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22
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Normative Reference Values of Cardiac Output by Pulsed-Wave Doppler Echocardiography in Adults. Am J Cardiol 2021; 140:128-133. [PMID: 33144167 DOI: 10.1016/j.amjcard.2020.10.046] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/25/2020] [Accepted: 10/27/2020] [Indexed: 11/21/2022]
Abstract
Cardiac output (CO) is routinely assessed by pulsed-wave Doppler echocardiography, yet reference values in adults are lacking. We aim to establish normative values of CO and cardiac index (CI) by pulsed-wave Doppler-echocardiography and to analyze their relation with gender and age in nonobese and obese adults. We included 4,040 adults (mean age: 55 years, 53% women, 950 obese [body mass index ≥30 kg/m²]) with normal blood pressure, no history of cardiovascular disease, and normal transthoracic echocardiography. Normative reference CO and CI values for were calculated in 3,090 nonobese patients by quantile regression. CO normal limits were lower in females than in males (lower limit: 3.3 vs 3.5 L/min, upper limit: 7.3 vs 8.2 L/min). CI normal limits were identical for both genders (lower limit: 1.9 L/min/m², upper limit: 4.3 L/min/m²). Although the relation of CO to age was weak and observed only in women, CI of both genders was not influenced by age. CO of obese patients was significantly greater than that of their nonobese counterparts. CI of obese patients was not influenced by age and gender and was not significantly different than that of nonobese patients (lower limit 1.8 L/min/m², upper limit 4.1 L/min/m² for both genders). In conclusion, in a large adult population we establish normative reference values for CO and CI measured by Doppler-echocardiography. CI is a remarkably stable parameter that is not influenced by age, gender, and body size and should be used to define low- and high-output states.
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23
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Haberkorn S, Uwarow A, Haurand J, Jung C, Kelm M, Westenfeld R, Horn P. Percutaneous left ventricular assist support is associated with less pulmonary congestion and lower rate of pneumonia in patients with cardiogenic shock. Open Heart 2020; 7:openhrt-2020-001385. [PMID: 33132209 PMCID: PMC7607612 DOI: 10.1136/openhrt-2020-001385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 11/10/2022] Open
Abstract
Objectives The aim of this study was to investigate the impact of acute left ventricular unloading by percutaneous left ventricular assist device on pulmonary congestion and pneumonia in patients with cardiogenic shock (CS). Methods In this retrospective study, we analysed patients with CS who received the Impella percutaneous left ventricular assist device (n=50) compared with those who received intra-aortic balloon pump (IABP) support (n=50). Pulmonary congestion was longitudinally assessed while on support by calculating characteristic findings on the chest X-ray using the Halperin score. The rate of pneumonia and early mortality were assessed as a secondary endpoint. Results The groups (Impella vs IABP) did not differ in terms of age, Sequential Organ Failure Assessment (SOFA) score, Acute Physiology, Chronic Health Evaluation (APACHE) II score or serum lactate levels. Pulmonary congestion decreased in patient treated with Impella at each time point postimplantation. No change in congestion status was observed in patients supported with IABP. Multivariate analysis indicated Impella support as an independent predictor for pulmonary decongestion (OR 4.06, 95% CI 1.15 to 14.35, p=0.030). The rate of early pneumonia was lower in the Impella group compared with the IABP group (54% vs 74%, p=0.037). Failure of pulmonary decongestion during mechanical circulatory support independently predicted early pneumonia (OR 0.28, 95% CI 0.12 to 0.70, p=0.006). Conclusion Pulmonary decongestion may facilitate treatment of pneumonia in patients with CS. Left ventricular unloading by Impella device might support pulmonary decongestion, although a larger prospective trial in this patient population is required.
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Affiliation(s)
- Sandra Haberkorn
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Angelika Uwarow
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Jean Haurand
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.,Cardiovascular Research Institute, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Ralf Westenfeld
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Patrick Horn
- Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
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24
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Onoue T, Iwataki M, Araki M, Akashi J, Kitano T, Nabeshima Y, Hei S, Nagata Y, Hayashi A, Tsuda Y, Sonoda S, Fujino Y, Levine RA, Otsuji Y. Novel noninvasive estimation of mixed venous oxygen saturation by echocardiography and expired gas analysis. Am J Physiol Heart Circ Physiol 2020; 319:H1078-H1086. [PMID: 32946269 DOI: 10.1152/ajpheart.00429.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Mixed venous oxygen (O2) saturation ([Formula: see text]) is an important measure for evaluating the sufficiency of cardiac output (CO) relative to whole body O2 consumption (V̇o2), while clinical use is limited to the required invasive catheterization. According to Fick's equation, V̇o2 (mL/min) = CO (L/min) × Hb (g/dL) × 1.36 (mL/g) × ([Formula: see text] - [Formula: see text])/10 (Hb = hemoglobin concentration, [Formula: see text] = arterial blood O2 saturation). Because V̇o2, CO, Hb, and [Formula: see text] can be measured noninvasively with expired gas analysis, echocardiography, a simple blood test, and percutaneous O2 saturation, respectively, [Formula: see text] can be calculated noninvasively. We hypothesized that noninvasively calculated [Formula: see text] shows a significant correlation and agrees well with invasively measured [Formula: see text]. In 47 patients (29 men; mean age, 70 ± 12 yr) who underwent right heart catheterization, [Formula: see text] was directly measured by sampling pulmonary artery blood. Noninvasively calculated [Formula: see text] was also obtained by the method described above. The calculated [Formula: see text] was significantly correlated with the measured [Formula: see text] (r = 0.79, P < 0.001) and was significantly smaller than the measured [Formula: see text] (70 ± 5.1 vs. 72.1 ± 4.9%, P < 0.001). Bias at [Formula: see text] was -2.2% (95% confidence interval, -3.2 to -1.1%) with limits of agreement from -9.5 to 5.2%, demonstrating acceptable agreement. The optimal cutoff value of calculated [Formula: see text] was 69% for reduced measured [Formula: see text] < 70% with an area under the curve of 0.94. Reduced calculated [Formula: see text] < 69% indicated a sensitivity of 92.9% and a specificity of 90.9% for reduced measured [Formula: see text] < 70%. Noninvasive [Formula: see text] calculated from echocardiography, expired gas analysis, percutaneous arterial blood O2 saturation, and hemoglobin level significantly correlated and agreed well with direct [Formula: see text] measured by catheterization. This novel method allows for practical evaluation of [Formula: see text] to assess the sufficiency of CO according to whole body metabolism.NEW & NOTEWORTHY Clinical use of mixed venous oxygen saturation ([Formula: see text]) is limited to the required invasive procedure. With Fick's equation, expired gas analysis, echocardiography, simple blood tests, and percutaneous oxygen saturation, [Formula: see text] can be calculated noninvasively. We hypothesized that noninvasively calculated [Formula: see text] shows a significant correlation and agrees well with invasively measured [Formula: see text]. The present study examined the relationship between measured [Formula: see text] and calculated [Formula: see text] in patients who underwent right heart catheterization and demonstrated acceptable agreement. This novel method can expand the indication of evaluating [Formula: see text].
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Affiliation(s)
- Takeshi Onoue
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Mai Iwataki
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Masaru Araki
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Jun Akashi
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Tetsuji Kitano
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yosuke Nabeshima
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Soshi Hei
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yasufumi Nagata
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Atsushi Hayashi
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yuki Tsuda
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shinjo Sonoda
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshihisa Fujino
- Department of Environmental Epidemiology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts
| | - Yutaka Otsuji
- Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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25
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Kapur NK, Thayer KL, Zweck E. Cardiogenic Shock in the Setting of Acute Myocardial Infarction. Methodist Debakey Cardiovasc J 2020; 16:16-21. [PMID: 32280413 DOI: 10.14797/mdcj-16-1-16] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Cardiogenic shock in the setting of acute myocardial infarction remains a major cause of morbidity and mortality. In fact, acute myocardial infarction accounts for 81% of patients in cardiogenic shock. Despite advances in pharmacologic and device-based approaches to support patients with cardiogenic shock, no significant improvement in mortality has been observed over the past 20 years, although multiple registries are providing new insight into this complex syndrome. Key elements for optimal treatment include integration of hemodynamic and metabolic data for diagnosis and risk stratification, early evaluation and appropriate initiation of acute mechanical circulatory support devices, and an organized algorithmic approach to decision making.
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26
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Nakayama A, Iwama K, Makise N, Domoto Y, Ishida J, Morita H, Komuro I. Use of a Non-invasive Cardiac Output Measurement in a Patient with Low-output Dilated Cardiomyopathy. Intern Med 2020; 59:1525-1530. [PMID: 32132339 PMCID: PMC7364242 DOI: 10.2169/internalmedicine.4271-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
A 49-year-old man was diagnosed with acute cardiac insufficiency based on evidence of congestive heart failure. The non-invasive measurement of the cardiac output using an AESCULON® mini showed low cardiac output (CO, 3.9 L/min). We administered an intravenous diuretic for cardiac edema and dobutamine drip for low cardiac output. Soon after starting dobutamine at 3.2 γ (microg/kg/min), the CO improved to 6.8 L/min. Combination therapy of diuretic and dobutamine resolved the heart failure. CO measurement by an AESCULON® mini was safe, cost-effective, and convenient. Data output correlates with the CO by Swan-Ganz catheterization. The non-invasive measurement of the CO permitted a smooth recovery without recurrence in this patient.
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Affiliation(s)
- Atsuko Nakayama
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Japan
| | - Kentaro Iwama
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Japan
| | - Naohiro Makise
- Department of Pathology, The University of Tokyo Hospital, Japan
| | - Yukako Domoto
- Department of Pathology, The University of Tokyo Hospital, Japan
| | - Junichi Ishida
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Japan
| | - Hiroyuki Morita
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo Hospital, Japan
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27
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Harada R, Mantha Y, Hieda M. Back to Basics: Key Physical Examinations and Theories in Patients with Heart Failure. Heart Fail Clin 2020; 16:139-151. [PMID: 32143759 DOI: 10.1016/j.hfc.2019.12.001] [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
Heart failure (HF) is a leading cause of hospitalization. Suitable pharmacologic management is critical. Distinct physical findings such as congestion and peripheral hypoperfusion need to be considered in selecting pharmacologic therapy. By applying the pretest probability and likelihood ratios of unique physical findings of HF to a Markov model, a definite posttest probability can be obtained. This article focuses on the findings of S3, jugular venous pressure, proportional pulse pressure, bendopnea, trepopnea, and various heart murmurs. Incorporating statistical precision in physical assessments, diagnoses of HF can be further refined, providing a sophisticated approach to evaluate patients hemodynamics status noninvasively.
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Affiliation(s)
- Rakushumimarika Harada
- Department of Internal Medicine, Texas Health Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, TX, 75231, USA
| | - Yogamaya Mantha
- Department of Internal Medicine, Texas Health Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, TX, 75231, USA
| | - Michinari Hieda
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, University of Texas Southwestern Medical Center, 7232 Greenville Avenue, Dallas, TX 75231, USA.
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28
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Sato H, Kawasaki M, Tanaka R, Yoshizane T, Ono K, Tadokoro M, Yano Y, Kondou T, Kariya T, Nagata K, Gotoh K, Sawada S, Noda T, Watanabe S. Relationships among pulmonary capillary wedge pressure, dry weight and natriuretic peptide in patients undergoing hemodialysis: a three-dimensional speckle tracking echocardiography study. J Echocardiogr 2020; 18:160-168. [PMID: 31997088 DOI: 10.1007/s12574-020-00461-1] [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: 10/02/2019] [Revised: 12/15/2019] [Accepted: 01/09/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND Although the evaluation of fluid status in hemodialysis (HD) patients is useful, relationship among pulmonary capillary wedge pressure (PCWP), dry body weight (DW) and natriuretic peptide has not been elucidated. In addition, there has been no objective marker for instantaneously monitoring hemodynamic improvement in response to HD. We previously reported that PCWP and time constant of left ventricular pressure decline (Tau) can be noninvasively estimated (ePCWP and eTau) by speckle tracking echocardiography (STE). The aim of this study was to elucidate the relationship among ePCWP, eTau, DW and natriuretic peptide in patients undergoing HD. METHODS We measured ePCWP and body weight (BW) by STE in 81 patients and ANP and BNP by blood examination in 31 patients just before and after HD during sinus rhythm. RESULTS The ePCWP decreased after HD, and this was associated with reductions in ln ANP, eTau and BW (r = 0.523, 0.271 and 0.814, respectively, p < 0.05). The % change in ePCWP was not correlated with the % change in ln BNP (p = 0.47). The change in ePCWP had a stronger correlation with the % change in BW than the change in any other parameters. CONCLUSIONS The ePCWP is more sensitive to estimate the change in BW during HD than any other parameters such as ANP and BNP. These results indicated that a substantial amount of excess fluid can be assessed real-time by STE using ePCWP.
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Affiliation(s)
- Hidemaro Sato
- Department of Internal Medicine, Sawada Hospital, Gifu, Japan
| | - Masanori Kawasaki
- Cardiovascular Medicine, Gifu Heart Center, 4-14-4 Yabuta-minami, Gifu, 500-8384, Japan.
| | - Ryuhei Tanaka
- Department of Cardiology, Asahi University Hospital, Gifu, Japan
| | - Takashi Yoshizane
- Department of Cardiology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Koji Ono
- Department of Cardiology, Gifu Prefectural General Medical Center, Gifu, Japan
| | | | - Yoko Yano
- Department of Internal Medicine, Sawada Hospital, Gifu, Japan
| | - Takehito Kondou
- Department of Internal Medicine, Sawada Hospital, Gifu, Japan
| | - Tatsuya Kariya
- Department of Internal Medicine, Sawada Hospital, Gifu, Japan
| | - Kijun Nagata
- Department of Internal Medicine, Sawada Hospital, Gifu, Japan
| | - Koshi Gotoh
- Department of Internal Medicine, Sawada Hospital, Gifu, Japan
| | - Shigeki Sawada
- Department of Internal Medicine, Sawada Hospital, Gifu, Japan
| | - Toshiyuki Noda
- Department of Cardiology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Sachiro Watanabe
- Department of Cardiology, Gifu Prefectural General Medical Center, Gifu, Japan
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29
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Kaufmann T, Castela Forte J, Hiemstra B, Wiering MA, Grzegorczyk M, Epema AH, van der Horst ICC. A Bayesian Network Analysis of the Diagnostic Process and Its Accuracy to Determine How Clinicians Estimate Cardiac Function in Critically Ill Patients: Prospective Observational Cohort Study. JMIR Med Inform 2019; 7:e15358. [PMID: 31670697 PMCID: PMC6913745 DOI: 10.2196/15358] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Hemodynamic assessment of critically ill patients is a challenging endeavor, and advanced monitoring techniques are often required to guide treatment choices. Given the technical complexity and occasional unavailability of these techniques, estimation of cardiac function based on clinical examination is valuable for critical care physicians to diagnose circulatory shock. Yet, the lack of knowledge on how to best conduct and teach the clinical examination to estimate cardiac function has reduced its accuracy to almost that of "flipping a coin." OBJECTIVE The aim of this study was to investigate the decision-making process underlying estimates of cardiac function of patients acutely admitted to the intensive care unit (ICU) based on current standardized clinical examination using Bayesian methods. METHODS Patient data were collected as part of the Simple Intensive Care Studies-I (SICS-I) prospective cohort study. All adult patients consecutively admitted to the ICU with an expected stay longer than 24 hours were included, for whom clinical examination was conducted and cardiac function was estimated. Using these data, first, the probabilistic dependencies between the examiners' estimates and the set of clinically measured variables upon which these rely were analyzed using a Bayesian network. Second, the accuracy of cardiac function estimates was assessed by comparison to the cardiac index values measured by critical care ultrasonography. RESULTS A total of 1075 patients were included, of which 783 patients had validated cardiac index measurements. A Bayesian network analysis identified two clinical variables upon which cardiac function estimate is conditionally dependent, namely, noradrenaline administration and presence of delayed capillary refill time or mottling. When the patient received noradrenaline, the probability of cardiac function being estimated as reasonable or good P(ER,G) was lower, irrespective of whether the patient was mechanically ventilated (P[ER,G|ventilation, noradrenaline]=0.63, P[ER,G|ventilation, no noradrenaline]=0.91, P[ER,G|no ventilation, noradrenaline]=0.67, P[ER,G|no ventilation, no noradrenaline]=0.93). The same trend was found for capillary refill time or mottling. Sensitivity of estimating a low cardiac index was 26% and 39% and specificity was 83% and 74% for students and physicians, respectively. Positive and negative likelihood ratios were 1.53 (95% CI 1.19-1.97) and 0.87 (95% CI 0.80-0.95), respectively, overall. CONCLUSIONS The conditional dependencies between clinical variables and the cardiac function estimates resulted in a network consistent with known physiological relations. Conditional probability queries allow for multiple clinical scenarios to be recreated, which provide insight into the possible thought process underlying the examiners' cardiac function estimates. This information can help develop interactive digital training tools for students and physicians and contribute toward the goal of further improving the diagnostic accuracy of clinical examination in ICU patients. TRIAL REGISTRATION ClinicalTrials.gov NCT02912624; https://clinicaltrials.gov/ct2/show/NCT02912624.
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Affiliation(s)
- Thomas Kaufmann
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - José Castela Forte
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, Netherlands
| | - Bart Hiemstra
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Marco A Wiering
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, Netherlands
| | - Marco Grzegorczyk
- Bernoulli Institute for Mathematics, Computer Science and Artificial Intelligence, University of Groningen, Groningen, Netherlands
| | - Anne H Epema
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.,Department of Intensive Care, Maastricht University Medical Center+, Maastricht University, Maastricht, Netherlands
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30
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Long B, Koyfman A, Gottlieb M. Diagnosis of Acute Heart Failure in the Emergency Department: An Evidence-Based Review. West J Emerg Med 2019; 20:875-884. [PMID: 31738714 PMCID: PMC6860389 DOI: 10.5811/westjem.2019.9.43732] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 09/09/2019] [Indexed: 01/01/2023] Open
Abstract
Heart failure is a common presentation to the emergency department (ED), which can be confused with other clinical conditions. This review provides an evidence-based summary of the current ED evaluation of heart failure. Acute heart failure is the gradual or rapid decompensation of heart failure, resulting from either fluid overload or maldistribution. Typical symptoms can include dyspnea, orthopnea, or systemic edema. The physical examination may reveal pulmonary rales, an S3 heart sound, or extremity edema. However, physical examination findings are often not sensitive or specific. ED assessments may include electrocardiogram, complete blood count, basic metabolic profile, liver function tests, troponin, brain natriuretic peptide, and a chest radiograph. While often used, natriuretic peptides do not significantly change ED treatment, mortality, or readmission rates, although they may decrease hospital length of stay and total cost. Chest radiograph findings are not definitive, and several other conditions may mimic radiograph findings. A more reliable modality is point-of-care ultrasound, which can facilitate the diagnosis by assessing for B-lines, cardiac function, and inferior vena cava size. These modalities, combined with clinical assessment and gestalt, are recommended.
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Affiliation(s)
- Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, Fort Sam Houston, Texas
| | - Alex Koyfman
- University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
| | - Michael Gottlieb
- Rush University Medical Center, Department of Emergency Medicine, Chicago, Illinois
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31
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Chapman B, DeVore AD, Mentz RJ, Metra M. Clinical profiles in acute heart failure: an urgent need for a new approach. ESC Heart Fail 2019; 6:464-474. [PMID: 31021532 PMCID: PMC6487835 DOI: 10.1002/ehf2.12439] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 03/04/2019] [Indexed: 12/11/2022] Open
Abstract
Acute heart failure (HF) is a major public health concern, responsible for >26 million hospitalizations per year worldwide. Many trials have investigated new therapeutic options for acute HF, with most revealing equivocal results. Successful innovations in therapy for acute HF have remained limited, and standard of care has remained largely unchanged over the past decade, suggesting the need for a new approach for therapeutic decision making and clinical trial design in acute HF. This manuscript focuses on one approach that could prove useful in the development and application of novel therapies: classification of patients based on clinical profiles. While previous attempts at developing clinical profiles were successful in stratifying patients based on clinical and laboratory variables, they have not been utilized for personalized treatment strategies that improve patient outcomes. We suggest a new approach to the creation of clinical profiles that could stratify patients based on their underlying aetiology and their response to novel interventions. We also investigate novel analytic approaches to the creation of new clinical profiles that both investigators and clinicians alike could utilize to inform clinical trial design and the application of new therapies. Despite a large number of clinical trials for new therapeutic options, the treatment of acute HF has seen few advances over the past decades. Innovative approaches to patient selection through the use of clinical profiles could help to identify patients most likely to benefit from novel interventions and lead to the discovery of new therapeutic options.
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Affiliation(s)
| | - Adam D DeVore
- Duke Clinical Research Institute, 2400 Pratt Street, NP-8064, Durham, NC, 27705, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Robert J Mentz
- Duke Clinical Research Institute, 2400 Pratt Street, NP-8064, Durham, NC, 27705, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Schenone AL, Chen K, Gheyath B, Borges N, Li Bs Mss M, Wang X, Duggal A, Menon V. Invasive Hemodynamics and Outcomes in Cardiac Arrest Survivors Undergoing Targeted Temperature Management. Am J Cardiol 2019; 123:1255-1261. [PMID: 30770091 DOI: 10.1016/j.amjcard.2019.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 01/11/2019] [Accepted: 01/15/2019] [Indexed: 11/19/2022]
Abstract
Most important prognostic factors in the postcardiac arrest patients who underwent targeted temperature management (TTM) derive from the periarrest period. Whether early invasive hemodynamics predict survival or neurologic outcomes remains unknown. We retrospectively reviewed all comatose survivors of cardiac arrest who underwent TTM at the Coronary Intensive Care Unit of a Quaternary Center between January 2015 and June 2017. Patients were required to have a set of invasive hemodynamics available at initiation of TTM to be included. Those with cooling initiated before admission and temperature of <36°C before obtaining hemodynamics were excluded. Univariate logistic and multivariate regression were conducted to test whether cardiac index (Fick-cardiac index ≥2.2 vs <2.2 L/min/m2), pulmonary capillary wedge pressure (PCWP ≥18 vs <18 mm Hg), systemic vascular resistance (SVR >1200 vs 800 to 1200 vs <800 dynes⋅s/cm5) or Forrester hemodynamic profiles were predictive of survival and favorable neurologic outcomes at hospital discharge. Total of 52 consecutive arrest survivors who underwent TTM were studied demonstrating a wide variability in invasive hemodynamic parameters. There was no association between cardiac index (p = 0.45 and p = 0.10), PCWP (p = 0.90 and p = 0.60), SVR (0.95 and p = 0.17) or Forrester hemodynamic profiles (p = 0.40 and p = 0.42) and survival or favorable neurologic outcome at discharge. In conclusion, comatose arrest survivors who underwent TTM presents with a wide spectrum of invasive hemodynamics highlighting the heterogeneity of the postcardiac arrest syndrome. Early invasive hemodynamics did not predict survival or favorable neurologic outcomes at hospital discharge.
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Affiliation(s)
- Aldo L Schenone
- Cardiovascular Medicine Department, Cleveland Clinic, Cleveland, Ohio.
| | - Kevin Chen
- Internal Medicine Department, Cleveland Clinic, Cleveland, Ohio
| | - Bashaer Gheyath
- Internal Medicine Department, Cleveland Clinic, Cleveland, Ohio
| | - Nyal Borges
- Cardiovascular Medicine Department, Cleveland Clinic, Cleveland, Ohio
| | - Manshi Li Bs Mss
- Quantitative Health Sciences Department, Cleveland Clinic, Cleveland, Ohio
| | - Xiaofeng Wang
- Quantitative Health Sciences Department, Cleveland Clinic, Cleveland, Ohio
| | - Abhijit Duggal
- Pulmonary and Critical Care Medicine Department, Cleveland Clinic, Cleveland, Ohio
| | - Venu Menon
- Cardiovascular Medicine Department, Cleveland Clinic, Cleveland, Ohio
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Wu H, Cao G, Wang Y, Tian H, Du R. Increased Serum CA125 and Brain-Derived Neurotrophic Factor (BDNF) Levels on Acute Myocardial Infarction: A Predictor for Acute Heart Failure. Med Sci Monit 2019; 25:913-919. [PMID: 30706901 PMCID: PMC6367886 DOI: 10.12659/msm.912642] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background This study was conducted to see whether increased values of serum CA125 and BDNF (brain-derived neurotrophic factor) on acute myocardial infarction (AMI) act as predictor for acute heart failure (AHF). Material/Methods Seventy-eight patients with clinically diagnosed cardiac function II–IV; and AHF were considered as the study group of this retrospective study and patients who had cardiac function I (without AHF) were considered the control group (n=82). The values of CA125 and BDNF were measured using enzyme-linked immunosorbent assay (ELISA) for developing the correlation with the Killip classification, and the diagnostic value of AHF. Results Statistically insignificant difference was noticed between baseline information e.g., blood pressure or smoking status of participants in study group and control group (P>0.05). The higher values of CA125 (5.68±1.8 U/mL or BDNF (19.48±5.3 pg/mL) in the study group had advantage over the control after independent sample t-test (P<0.001). A positive correlation was observed between values of the test substances and Killip classifications (I–IV) of cardiac functioning was observed (r=0.745, P<0.001; Spearman’s rank correlation coefficient). The sensitivity and specificity of area under the curve (AUC) combined with serum CA125 and BDNF levels in the diagnosis of AHF was 91.02% and 81.63%, respectively. Conclusions Increased serum level of the test substances indicates severity of AHF-leading AMI. Thus, monitoring is needed to avoid risk of AHF.
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Affiliation(s)
- Haibo Wu
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, Hebei, China (mainland)
| | - Guangyun Cao
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, Hebei, China (mainland)
| | - Yuncan Wang
- Department of Ultrasound, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China (mainland)
| | - Huanping Tian
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, Hebei, China (mainland)
| | - Rongpin Du
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, Hebei, China (mainland)
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Eyeington CT, Lloyd-Donald P, Chan MJ, Eastwood GM, Young H, Peck L, Jones DA, Bellomo R. Rapid response team review of hemodynamically unstable ward patients: The accuracy of cardiac index assessment. J Crit Care 2018; 49:187-192. [PMID: 30482613 DOI: 10.1016/j.jcrc.2018.09.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/23/2018] [Accepted: 09/03/2018] [Indexed: 11/18/2022]
Abstract
PURPOSE Intensive care doctors commonly attend rapid response team (RRT) reviews of hospital-ward patients with hemodynamic instability and estimate the patient's likely cardiac index (CI). We aimed to non-invasively measure the CI of such patients and assess the level of agreement between such measurements and clinically estimated CI categories (low <2L/min/m2, normal 2-2.99L/min/m2 or high ≥3L/min/m2). MATERIALS AND METHODS A prospective, observational study of non-invasive measurement and clinical estimation of CI categories in 50 adult hospital-ward patients who activated the RRT for 'hemodynamic instability' (tachycardia > 100BPM or hypotension < 90mmHg or both). RESULTS The CI was measured in 47/50(94%) patients and the mean CI was 3.5(95% CI 3.2-3.7) L/min/m2. Overall, 30(64%) patients had a high CI, 13(28%) and 4(9%) had a normal and a low CI, respectively. The level of agreement between measured and clinically estimated CI categories was low(19.2%). Sensitivity and positive predictive values of clinical estimation were low(0% and 3.3% for high CI, and 0% and 50% for low CI, respectively). CONCLUSIONS Non-invasive CI measurement was possible in almost all hospital-ward patients triggering RRT review for hemodynamic instability. In such patients, the CI was high, and intensive care clinicians were unable to identify a low or a high CI state.
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Affiliation(s)
| | | | - Matthew J Chan
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia; ANZIC Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Helen Young
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.
| | - Leah Peck
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.
| | - Daryl A Jones
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia; ANZIC Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia; Intensive Care Research, Austin Hospital, Melbourne, Victoria, Australia; Co-director ANZICS Research Centre, Monash University, Melbourne, Australia; Intensive Care, The University of Melbourne, Melbourne, Australia; Medicine, Monash University, Melbourne, Australia.
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Naughton MT. Rebuttal to Javaheri, Brown and Khayat. J Clin Sleep Med 2018; 14:927-929. [PMID: 29852918 DOI: 10.5664/jcsm.7152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 04/13/2018] [Indexed: 11/13/2022]
Affiliation(s)
- Matthew T Naughton
- Department of Respiratory Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
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Abstract
PURPOSE OF REVIEW In the acute setting of circulatory shock, physicians largely depend on clinical examination and basic laboratory values. The daily use of clinical examination for diagnostic purposes contrasts sharp with the limited number of studies. We aim to provide an overview of the diagnostic accuracy of clinical examination in estimating circulatory shock reflected by an inadequate cardiac output (CO). RECENT FINDINGS Recent studies showed poor correlations between CO and mottling, capillary refill time or central-to-peripheral temperature gradients in univariable analyses. The accuracy of physicians to perform an educated guess of CO based on clinical examination lies around 50% and the accuracy for recognizing a low CO is similar. Studies that used predefined clinical profiles composed of several clinical examination signs show more reliable estimations of CO with accuracies ranging from 81 up to 100%. SUMMARY Single variables obtained by clinical examination should not be used when estimating CO. Physician's educated guesses of CO based on unstructured clinical examination are like the 'flip of a coin'. Structured clinical examination based on combined clinical signs shows the best accuracy. Future studies should focus on using a combination of signs in an unselected population, eventually to educate physicians in estimating CO by using predefined clinical profiles.
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Teneggi V, Sivakumar N, Chen D, Matter A. Drugs’ development in acute heart failure: what went wrong? Heart Fail Rev 2018; 23:667-691. [DOI: 10.1007/s10741-018-9707-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Dini FL, Bajraktari G, Zara C, Mumoli N, Rosa GM. Optimizing Management of Heart Failure by Using Echo and Natriuretic Peptides in the Outpatient Unit. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1067:145-159. [PMID: 29374825 DOI: 10.1007/5584_2017_137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Chronic heart failure (HF) is an important public health problem and is associated with high morbidity, high mortality, and considerable healthcare costs. More than 90% of hospitalizations due to worsening HF result from elevations of left ventricular (LV) filling pressures and fluid overload, which are often accompanied by the increased synthesis and secretion of natriuretic peptides (NPs). Furthermore, persistently abnormal LV filling pressures and a rise in NP circulating levels are well known indicators of poor prognosis. Frequent office visits with the resulting evaluation and management are most often needed. The growing pressure from hospital readmissions in HF patients is shifting the focus of interest from traditionally symptom-guided care to a more specific patient-centered follow-up care based on clinical findings, BNP and echo. Recent studies supported the value of serial NP measurements and Doppler echocardiographic biomarkers of elevated LV filling pressures as tools to scrutinize patients with impending clinically overt HF. Therefore, combination of echo and pulsed-wave blood-flow and tissue Doppler with NPs appears valuable in guiding ambulatory HF management, since they are potentially useful to distinguish stable patients from those at high risk of decompensation.
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Affiliation(s)
- Frank Lloyd Dini
- Cardiovascular and Thoracic Department, University of Pisa, Pisa, Italy. .,Unità Operativa Malattie Cardiovascolari 1, Dipartimento Cardio, Toracico e Vascolare, Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy.
| | - Gani Bajraktari
- Department of Public Health and Clinical Medicine, Umeå University and Heart Centre, Umeå, Sweden.,Clinic of Cardiology, University Clinical Centre of Kosova, Prishtina, Kosovo
| | - Cornelia Zara
- Cardiovascular and Thoracic Department, University of Pisa, Pisa, Italy
| | - Nicola Mumoli
- Department of Internal Medicine, Livorno Hospital, Livorno, Italy
| | - Gian Marco Rosa
- Department of Internal Medicine and Medical Specialities, University of Genoa, Genoa, Italy
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Dini FL, Carluccio E, Montecucco F, Rosa GM, Fontanive P. Combining echo and natriuretic peptides to guide heart failure care in the outpatient setting: A position paper. Eur J Clin Invest 2017; 47. [PMID: 29044493 DOI: 10.1111/eci.12846] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 10/12/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Chronic heart failure (HF) is a relevant and growing public health problem. Although the prognosis has recently improved, it remains a lethal disease, with a mortality that equals or exceeds that of many malignancies. Furthermore, chronic HF is costly, representing a large and growing drain on healthcare resources. METHODS This narrative review is based on the material searched for and obtained via PubMed up to May 2017. The search terms we used were as follows: "heart failure, echocardiography, natriuretic peptides" in combination with "treatment, biomarkers, guidelines." RESULTS Recent studies have supported the value of natriuretic peptides (NPs) and Doppler echocardiographic biomarkers of increased left ventricular (LV) filling pressures or pulmonary congestion as tools to scrutinize patients with impending clinically overt HF. Therefore, combination of pulsed-wave tissue and blood flow Doppler with NPs appears valuable in guiding HF management in the outpatient setting. In as much as both the echo and the plasma levels of NPs may reflect the presence of fluid overload and elevations of LV filling pressures, integrating NP and echocardiographic biomarkers with clinical findings may help the cardiologist to identify high-risk patients, that is to recognize whether a patient is stable or the condition is likely to evolve into decompensated HF, to optimize treatment, to improve the prognosis and to reduce rehospitalization. CONCLUSION We discussed the rationale and the clinical significance of combining follow-up echo and NP assessment to guide management of ambulatory patients with chronic HF.
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Affiliation(s)
- Frank L Dini
- Cardiovascular and Thoracic Department, University of Pisa, Pisa, Italy
| | - Erberto Carluccio
- Divisions of Cardiology, School of Medicine, University of Perugia, Perugia, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy.,Ospedale Policlinico San Martino, Genoa, Italy.,Centre of Excellence for Biomedical Research (CEBR), University of Genoa, Genoa, Italy
| | - Gian Marco Rosa
- Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa, Italy
| | - Paolo Fontanive
- Cardiovascular and Thoracic Department, University of Pisa, Pisa, Italy
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Hiemstra B, Eck RJ, Koster G, Wetterslev J, Perner A, Pettilä V, Snieder H, Hummel YM, Wiersema R, de Smet AMGA, Keus F, van der Horst ICC. Clinical examination, critical care ultrasonography and outcomes in the critically ill: cohort profile of the Simple Intensive Care Studies-I. BMJ Open 2017; 7:e017170. [PMID: 28963297 PMCID: PMC5623575 DOI: 10.1136/bmjopen-2017-017170] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 05/22/2017] [Accepted: 06/07/2017] [Indexed: 01/08/2023] Open
Abstract
PURPOSE In the Simple Intensive Care Studies-I (SICS-I), we aim to unravel the value of clinical and haemodynamic variables obtained by physical examination and critical care ultrasound (CCUS) that currently guide daily practice in critically ill patients. We intend to (1) measure all available clinical and haemodynamic variables, (2) train novices in obtaining values for advanced variables based on CCUS in the intensive care unit (ICU) and (3) create an infrastructure for a registry with the flexibility of temporarily incorporating specific (haemodynamic) research questions and variables. The overall purpose is to investigate the diagnostic and prognostic value of clinical and haemodynamic variables. PARTICIPANTS The SICS-I includes all patients acutely admitted to the ICU of a tertiary teaching hospital in the Netherlands with an ICU stay expected to last beyond 24 hours. Inclusion started on 27 March 2015. FINDINGS TO DATE On 31 December 2016, 791 eligible patients fulfilled our inclusion criteria of whom 704 were included. So far 11 substudies with additional variables have been designed, of which six were feasible to implement in the basic study, and two are planned and awaiting initiation. All researchers received focused training for obtaining specific CCUS images. An independent Core laboratory judged that 632 patients had CCUS images of sufficient quality. FUTURE PLANS We intend to optimise the set of variables for assessment of the haemodynamic status of the critically ill patient used for guiding diagnostics, prognosis and interventions. Repeated evaluations of these sets of variables are needed for continuous improvement of the diagnostic and prognostic models. Future plans include: (1) more advanced imaging; (2) repeated clinical and haemodynamic measurements; (3) expansion of the registry to other departments or centres; and (4) exploring possibilities of integration of a randomised clinical trial superimposed on the registry. STUDY REGISTRATION NUMBER NCT02912624; Pre-results.
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Affiliation(s)
- Bart Hiemstra
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ruben J Eck
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Geert Koster
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jørn Wetterslev
- The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ville Pettilä
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harold Snieder
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Yoran M Hummel
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Renske Wiersema
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Anne Marie G A de Smet
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Abbas AE, Khoury Abdulla R, Aggrawal A, Crile J, Lester SJ, Boura J. A novel echocardiographic hemodynamic classification of heart failure based on stroke volume index and left atrial pressure. Echocardiography 2017; 34:1417-1425. [DOI: 10.1111/echo.13642] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Amr E. Abbas
- Department of Cardiovascular Medicine; Beaumont Health; Royal Oak MI USA
- Oakland University William Beaumont School of Medicine; Auburn Hills MI USA
| | | | - Anshul Aggrawal
- Department of Cardiovascular Medicine; Beaumont Health; Royal Oak MI USA
| | - Jason Crile
- Department of Cardiovascular Medicine; Beaumont Health; Royal Oak MI USA
| | - Steven J. Lester
- Division of Cardiovascular Diseases; Mayo Clinic; Phoenix AZ, USA
| | - Judy Boura
- Oakland University William Beaumont School of Medicine; Auburn Hills MI USA
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Tanimura M, Dohi K, Fujimoto N, Moriwaki K, Omori T, Sato Y, Sugiura E, Kumagai N, Nakamori S, Kurita T, Fujii E, Yamada N, Ito M. Effect of Anemia on Cardiovascular Hemodynamics, Therapeutic Strategy and Clinical Outcomes in Patients With Heart Failure and Hemodynamic Congestion. Circ J 2017. [PMID: 28626160 DOI: 10.1253/circj.cj-17-0171] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND We investigated the effect of anemia on cardiovascular hemodynamics, therapeutic strategies and clinical outcomes in heart failure (HF) patients.Methods and Results:We divided 198 consecutive HF patients who underwent right heart catheterization before in-hospital HF treatment into 2 groups according to the presence or absence of hemodynamic congestion (HC: mean pulmonary capillary wedge pressure ≥15 mmHg and/or mean right atrial pressure ≥10 mmHg). The hemoglobin level correlated with the cardiac index (CI) and systemic vascular resistance index (SVRI) (r=-0.34 and 0.42, P<0.05, respectively), and was the strongest contributor of SVRI only in the HC group. Anemic patients more frequently required intravenous inotropic support despite having higher CI and lower SVRI than non-anemic patients in the HC group. The novel hemodynamic subsets based on mean right atrial pressure and estimated left ventricular stroke work index but not Forrester subsets appropriately predicted the need for intravenous inotropic support. The probability of hospitalization for worsening HF during 2-year follow-up period was significantly higher in anemic patients than in non-anemic patients in the HC group. CONCLUSIONS Anemia had a direct effect on cardiovascular hemodynamics and thus can confound therapeutic planning in HF patients with HC. The novel hemodynamic subsets can be applied in daily clinical practice regardless of the presence or absence of anemia.
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Affiliation(s)
- Muneyoshi Tanimura
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Naoki Fujimoto
- Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine
| | - Keishi Moriwaki
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Taku Omori
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Yuichi Sato
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Emiyo Sugiura
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Naoto Kumagai
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Shiro Nakamori
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Tairo Kurita
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Eitaro Fujii
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Norikazu Yamada
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Masaaki Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
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Naughton MT, Kee K. Sleep apnoea in heart failure: To treat or not to treat? Respirology 2016; 22:217-229. [PMID: 27998040 DOI: 10.1111/resp.12964] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 10/26/2016] [Indexed: 01/28/2023]
Abstract
Heart failure (HF) and sleep apnoea are common disorders which frequently coexist. Two main types of apnoea occur: one is obstructive which, through recurring episodes of snoring, hypoxaemia, large negative intra-thoracic pressures and arousals from sleep leading to downstream inflammatory and autonomic nervous system changes, is thought to be a causative factor to the development of systemic hypertension and HF. The other type of apnoea, Cheyne-Stokes respiration with central sleep apnoea (CSR-CSA), is characterized by an oscillatory pattern of ventilation with a prevailing hyperventilation-induced hypocapnia, often in the absence of significant hypoxaemia and snoring, and is thought to be a consequence of advanced HF-related low cardiac output, high sympathetic nervous system activation and pulmonary congestion. CSR-CSA may be a compensatory response to advanced HF. Rostral fluid shift during sleep may play an important role in the pathogenesis of both obstructive sleep apnoea (OSA) and CSA. Studies of positive airway pressure (PAP) treatment of OSA and CSA in HF have shown short-term improvements in cardiac and autonomic function; however, there is no evidence of improved survival. Loop gain may provide useful marker of continuous PAP (CPAP) responsiveness in patients with central apnoea. A greater understanding of the pathophysiology of the interaction between obstructive and central apnoea and the various types of HF, and the mechanisms of therapies, such as PAP, is required to develop new strategies to overcome the disabling symptoms, and perhaps improve the mortality, that accompany HF with sleep apnoea.
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Affiliation(s)
- Matthew T Naughton
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Kirk Kee
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Central Clinical School, Monash University, Melbourne, Victoria, Australia
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Nieminen MS, Buerke M, Cohen-Solál A, Costa S, Édes I, Erlikh A, Franco F, Gibson C, Gorjup V, Guarracino F, Gustafsson F, Harjola VP, Husebye T, Karason K, Katsytadze I, Kaul S, Kivikko M, Marenzi G, Masip J, Matskeplishvili S, Mebazaa A, Møller JE, Nessler J, Nessler B, Ntalianis A, Oliva F, Pichler-Cetin E, Põder P, Recio-Mayoral A, Rex S, Rokyta R, Strasser RH, Zima E, Pollesello P. The role of levosimendan in acute heart failure complicating acute coronary syndrome: A review and expert consensus opinion. Int J Cardiol 2016; 218:150-157. [PMID: 27232927 DOI: 10.1016/j.ijcard.2016.05.009] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 04/18/2016] [Accepted: 05/12/2016] [Indexed: 01/09/2023]
Abstract
Acute heart failure and/or cardiogenic shock are frequently triggered by ischemic coronary events. Yet, there is a paucity of randomized data on the management of patients with heart failure complicating acute coronary syndrome, as acute coronary syndrome and cardiogenic shock have frequently been defined as exclusion criteria in trials and registries. As a consequence, guideline recommendations are mostly driven by observational studies, even though these patients have a particularly poor prognosis compared to heart failure patients without signs of coronary artery disease. In acute heart failure, and especially in cardiogenic shock related to ischemic conditions, vasopressors and inotropes are used. However, both pathophysiological considerations and available clinical data suggest that these treatments may have disadvantageous effects. The inodilator levosimendan offers potential benefits due to a range of distinct effects including positive inotropy, restoration of ventriculo-arterial coupling, increases in tissue perfusion, and anti-stunning and anti-inflammatory effects. In clinical trials levosimendan improves symptoms, cardiac function, hemodynamics, and end-organ function. Adverse effects are generally less common than with other inotropic and vasoactive therapies, with the notable exception of hypotension. The decision to use levosimendan, in terms of timing and dosing, is influenced by the presence of pulmonary congestion, and blood pressure measurements. Levosimendan should be preferred over adrenergic inotropes as a first line therapy for all ACS-AHF patients who are under beta-blockade and/or when urinary output is insufficient after diuretics. Levosimendan can be used alone or in combination with other inotropic or vasopressor agents, but requires monitoring due to the risk of hypotension.
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Affiliation(s)
| | - Michael Buerke
- Department of Internal Medicine II, St. Marien Hospital Siegen, Siegen, Germany
| | | | - Susana Costa
- Department of Cardiology, Coimbra Hospital and University Centre, Coimbra, Portugal
| | - István Édes
- Department of Cardiology, University of Debrecen, Debrecen, Hungary
| | - Alexey Erlikh
- Laboratory of Clinical Cardiology, Scientific Research Institute of Physical-Chemical Medicine, Moscow, Russia
| | - Fatima Franco
- Department of Cardiology, Coimbra Hospital and University Centre, Coimbra, Portugal
| | | | - Vojka Gorjup
- Department of Intensive Internal Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Fabio Guarracino
- Department of Cardiothoracic Anesthesia and Intensive Care, University Hospital of Pisa, Pisa, Italy
| | | | - Veli-Pekka Harjola
- Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Trygve Husebye
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Kristjan Karason
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Igor Katsytadze
- Cardiological Intensive Care Unit, Alexandrovski Central Clinical Hospital, Kiev, Ukraine
| | - Sundeep Kaul
- Department of Intensive Care and Respiratory Medicine, The Royal Brompton & Harefield Hospitals NHS Trust, London, UK
| | - Matti Kivikko
- Critical Care Proprietary Products, Orion Pharma, Espoo, Finland
| | - Giancarlo Marenzi
- Cardiological Intensive Care Unit, Cardiological Center Monzino, Milan, Italy
| | - Josep Masip
- Department of Intensive Care Medicine, Consorci Sanitari Integral, University of Barcelona, Barcelona, Spain
| | - Simon Matskeplishvili
- Department of Cardiology, University Clinic, Lomonosov Moscow State University, Moscow, Russia
| | - Alexandre Mebazaa
- Department of Anaesthesia and Burn and Critical Care, Saint-Louis-Lariboisière Hospital, AP-HP, University Paris-Diderot, Paris, France
| | - Jacob E Møller
- Department of Cardiology, Odense University Hospital, Denmark
| | - Jadwiga Nessler
- Jagiellonian University Medical College, Faculty of Medicine, Institute of Cardiology, Department of Coronary Heart Disease and Heart Failure, John Paul II Hospital, Cracow, Poland
| | - Bohdan Nessler
- Jagiellonian University Medical College, Faculty of Health Sciences, Division of Rescue Medicine, Department of Coronary Heart Disease and Heart Failure, John Paul II Hospital, Cracow, Poland
| | - Argyrios Ntalianis
- Department of Cardiology, Alexandra General Hospital of Athens, Athens, Greece
| | - Fabrizio Oliva
- Department of Cardiology II, Niguarda Ca' Granda Hospital, Milan, Italy
| | | | - Pentti Põder
- Department of Cardiology, North Estonia Medical Center, Tallinn, Estonia
| | | | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - Richard Rokyta
- Department of Cardiology, University Hospital and Faculty of Medicine Pilsen, Charles University Prague, Czech Republic
| | - Ruth H Strasser
- University of Dresden, Heart Center Dresden, University Hospital, Dresden, Germany
| | - Endre Zima
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Piero Pollesello
- Critical Care Proprietary Products, Orion Pharma, Espoo, Finland
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46
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Sairaku A, Nakano Y, Uchimura Y, Tokuyama T, Kawazoe H, Watanabe Y, Matsumura H, Kihara Y. Increased left atrial pressure in non-heart failure patients with subclinical hypothyroidism and atrial fibrillation. Endocr Connect 2016; 5:101-6. [PMID: 26902318 PMCID: PMC5002958 DOI: 10.1530/ec-16-0012] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 02/19/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND The impact of subclinical hypothyroidism on the cardiovascular risk is still debated. We aimed to measure the relationship between subclinical hypothyroidism and the left atrial (LA) pressure. METHODS The LA pressures and thyroid function were measured in consecutive patients undergoing atrial fibrillation (AF) ablation, who did not have any known heart failure, structural heart disease, or overt thyroid disease. RESULTS Subclinical hypothyroidism (4.5≤ thyroid-stimulating hormone <19.9 mIU/L) was present in 61 (13.0%) of the 471 patients included. More subclinical hypothyroidism patients than euthyroid patients (55.7% vs 40.2%; P=0.04).'euthyroid patients had persistent or long-standing persistent AF (55.7% vs 40.2%; P = 0.04). The mean LA pressure (10.9 ± 4.7 vs 9.1 ± 4.3 mmHg; P = 0.002) and LA V-wave pressure (17.4 ± 6.5 vs 14.3 ± 5.9 mmHg; P < 0.001) were, respectively, higher in the patients with subclinical hypothyroidism than in the euthyroid patients. After an adjustment for potential confounders, the LA pressures remained significantly higher in the subclinical hypothyroidism patients. A multiple logistic regression model showed that subclinical hypothyroidism was independently associated with a mean LA pressure of >18 mmHg (odds ratio 3.94, 95% CI 1.28 11.2; P = 0.02). CONCLUSIONS Subclinical hypothyroidism may increase the LA pressure in AF patients.
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Affiliation(s)
- Akinori Sairaku
- Department of Cardiovascular MedicineHiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Yukiko Nakano
- Department of Cardiovascular MedicineHiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Yuko Uchimura
- Department of Cardiovascular MedicineHiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Takehito Tokuyama
- Department of Cardiovascular MedicineHiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Hiroshi Kawazoe
- Department of Cardiovascular MedicineHiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Yoshikazu Watanabe
- Department of Cardiovascular MedicineHiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Hiroya Matsumura
- Department of Cardiovascular MedicineHiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Yasuki Kihara
- Department of Cardiovascular MedicineHiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
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47
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Ural D, Çavuşoğlu Y, Eren M, Karaüzüm K, Temizhan A, Yılmaz MB, Zoghi M, Ramassubu K, Bozkurt B. Diagnosis and management of acute heart failure. Anatol J Cardiol 2015; 15:860-89. [PMID: 26574757 PMCID: PMC5336936 DOI: 10.5152/anatoljcardiol.2015.6567] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Acute heart failure (AHF) is a life threatening clinical syndrome with a progressively increasing incidence in general population. Turkey is a country with a high cardiovascular mortality and recent national statistics show that the population structure has turned to an 'aged' population.As a consequence, AHF has become one of the main reasons of admission to cardiology clinics. This consensus report summarizes clinical and prognostic classification of AHF, its worldwide and national epidemiology, diagnostic work-up, principles of approach in emergency department,intensive care unit and ward, treatment in different clinical scenarios and approach in special conditions and how to plan hospital discharge.
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Affiliation(s)
- Dilek Ural
- Department of Cardiology, Medical Faculty of Kocaeli University; Kocaeli-Turkey.
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48
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49
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Naughton MT. Respiratory sleep disorders in patients with congestive heart failure. J Thorac Dis 2015; 7:1298-310. [PMID: 26380758 DOI: 10.3978/j.issn.2072-1439.2015.07.02] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 06/15/2015] [Indexed: 11/14/2022]
Abstract
Respiratory sleep disorders (RSD) occur in about 40-50% of patients with symptomatic congestive heart failure (CHF). Obstructive sleep apnea (OSA) is considered a cause of CHF, whereas central sleep apnea (CSA) is considered a response to heart failure, perhaps even compensatory. In the setting of heart failure, continuous positive airway pressure (CPAP) has a definite role in treating OSA with improvements in cardiac parameters expected. However in CSA, CPAP is an adjunctive therapy to other standard therapies directed towards the heart failure (pharmacological, device and surgical options). Whether adaptive servo controlled ventilatory support, a variant of CPAP, is beneficial is yet to be proven. Supplemental oxygen therapy should be used with caution in heart failure, in particular, by avoiding hyperoxia as indicated by SpO2 values >95%.
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Affiliation(s)
- Matthew T Naughton
- 1 General Respiratory and Sleep Medicine, Department of Allergy, Immunology and Respiratory Medicine, 2 Department of Medicine, Monash University, The Alfred Hospital, Melbourne, VIC 3004, Australia
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50
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"Do-it-yourself in vitro vasculature that recapitulates in vivo geometries for investigating endothelial-blood cell interactions". Sci Rep 2015. [PMID: 26202603 PMCID: PMC4894411 DOI: 10.1038/srep12401] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Investigating biophysical cellular interactions in the circulation currently requires choosing between in vivo models, which are difficult to interpret due in part to the hemodynamic and geometric complexities of the vasculature; or in vitro systems, which suffer from non-physiologic assumptions and/or require specialized microfabrication facilities and expertise. To bridge that gap, we developed an in vitro "do-it-yourself" perfusable vasculature model that recapitulates in vivo geometries, such as aneurysms, stenoses, and bifurcations, and supports endothelial cell culture. These inexpensive, disposable devices can be created rapidly (<2 hours) with high precision and repeatability, using standard off-the-shelf laboratory supplies. Using these "endothelialized" systems, we demonstrate that spatial variation in vascular cell adhesion molecule (VCAM-1) expression correlates with the wall shear stress patterns of vascular geometries. We further observe that the presence of endothelial cells in stenoses reduces platelet adhesion but increases sickle cell disease (SCD) red blood cell (RBC) adhesion in bifurcations. Overall, our method enables researchers from all disciplines to study cellular interactions in physiologically relevant, yet simple-to-make, in vitro vasculature models.
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