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Balen F, Lamy S, Froissart L, Mesnard T, Sanchez B, Dubucs X, Charpentier S. Risk factors and effect of dyspnea inappropriate treatment in adults' emergency department: a retrospective cohort study. Eur J Emerg Med 2024; 31:276-280. [PMID: 38364038 DOI: 10.1097/mej.0000000000001129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
Dyspnea is a frequent symptom in adults' emergency departments (EDs). Misdiagnosis at initial clinical examination is common, leading to early inappropriate treatment and increased in-hospital mortality. Risk factors of inappropriate treatment assessable at early examination remain undescribed herein. The objective of this study was to identify clinical risk factors of dyspnea and inappropriate treatment in patients admitted to ED. This is an observational retrospective cohort study. Patients over the age of 15 who were admitted to adult EDs of the University Hospital of Toulouse (France) with dyspnea were included from 1 July to 31 December 2019. The primary end-point was dyspnea and inappropriate treatment was initiated at ED. Inappropriate treatment was defined by looking at the final diagnosis of dyspnea at hospital discharge and early treatment provided. Afterward, this early treatment at ED was compared to the recommended treatment defined by the International Guidelines for Acute Heart Failure, bacterial pneumonia, chronic obstructive pulmonary disease, asthma or pulmonary embolism. A total of 2123 patients were analyzed. Of these, 809 (38%) had inappropriate treatment in ED. Independent risk factors of inappropriate treatment were: age over 75 years (OR, 1.46; 95% CI, 1.18-1.81), history of heart disease (OR, 1.32; 95% CI, 1.07-1.62) and lung disease (OR, 1.47; 95% CI, 1.21-1.78), SpO 2 <90% (OR, 1.64; 95% CI, 1.37-2.02), bilateral rale (OR, 1.25; 95% CI, 1.01-1.66), focal cracklings (OR, 1.32; 95% CI, 1.05-1.66) and wheezing (OR, 1.62; 95% CI, 1.31-2.03). In multivariate analysis, under-treatment significantly increased in-hospital mortality (OR, 2.13; 95% CI, 1.29-3.52) compared to appropriate treatment. Over-treatment nonsignificantly increased in-hospital mortality (OR, 1.43; 95% CI, 0.99-2.06). Inappropriate treatment is frequent in patients admitted to ED for dyspnea. Patients older than 75 years, with comorbidities (heart or lung disease), hypoxemia (SpO 2 <90%) or abnormal pulmonary auscultation (especially wheezing) are at risk of inappropriate treatment.
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Affiliation(s)
- Frederic Balen
- Emergency Department, Toulouse University Hospital
- CERPOP - EQUITY, INSERM
| | | | | | | | | | - Xavier Dubucs
- Emergency Department, Toulouse University Hospital
- CERPOP - EQUITY, INSERM
- Toulouse III - Paul Sabatier University, Toulouse, France
| | - Sandrine Charpentier
- Emergency Department, Toulouse University Hospital
- CERPOP - EQUITY, INSERM
- Toulouse III - Paul Sabatier University, Toulouse, France
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2
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Scholten M, Midlöv P, Halling A. Disparities in prevalence of heart failure between the genders in relation to age, multimorbidity and socioeconomic status in southern Sweden: a cross-sectional study. Scand J Prim Health Care 2023; 41:160-169. [PMID: 37052877 DOI: 10.1080/02813432.2023.2197951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023] Open
Abstract
OBJECTIVE Prior studies have reported that heart failure typically affects elderly, multimorbid and socioeconomically deprived men. Women with heart failure are generally older, have a higher EF (ejection fraction) and have more heart failure-related symptoms than men. This study explored the disparities in the prevalence of heart failure between men and women in relation to age, multimorbidity level and socioeconomic status of the population in southern Sweden. DESIGN A register-based, cross-sectional cohort study.Setting and subjects: The inhabitants from 20 years of age onwards (N = 981,383) living in southern Sweden in 2015.Main outcome measure: Prevalence and mean probability of having heart failure in both genders. CNI (Care Need Index) percentiles depend on the socioeconomic status of their listed primary healthcare centres. RESULTS Men had a higher OR for HF - 1.70 (95% CI 1.65-1.75) - than women. The probability of men having heart failure increased significantly compared to women with advancing age and multimorbidity levels. At all CNI levels, the multimorbid patients had a higher prevalence of heart failure in men than in women. The disparity in the mean probability of heart failure between the most affluent and deprived CNI percentile was more apparent in women compared to men, especially from 80 years. CONCLUSIONS The prevalence of heart failure differs significantly between the genders. Men had an increasing mean probability of heart failure with advancing age and multimorbidity level compared to women. Socioeconomic deprivation was more strongly associated with heart failure in women than in men. The probability of having heart failure differs between the genders in several aspects.Key PointsIndependently of socioeconomic status, men had a higher prevalence of heart failure than women among the multimorbid patients.The mean probability of men having heart failure increased significantly compared to women with advancing age and multimorbidity level.Socioeconomic status was more strongly associated with heart failure in women than in men.
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Affiliation(s)
- Mia Scholten
- Center for Primary Health Care Research, Department of Clinical Sciences, Malmö, Lund University, Sweden
| | - Patrik Midlöv
- Center for Primary Health Care Research, Department of Clinical Sciences, Malmö, Lund University, Sweden
| | - Anders Halling
- Center for Primary Health Care Research, Department of Clinical Sciences, Malmö, Lund University, Sweden
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3
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Chou EY, Pelz BJ, Chiu AM, Soung PJ. All that Wheezes is not Asthma or Bronchiolitis. Crit Care Clin 2022; 38:213-229. [DOI: 10.1016/j.ccc.2021.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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4
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Sobanski PZ, Krajnik M, Goodlin SJ. Palliative Care for People Living With Heart Disease-Does Sex Make a Difference? Front Cardiovasc Med 2021; 8:629752. [PMID: 33634172 PMCID: PMC7901984 DOI: 10.3389/fcvm.2021.629752] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 01/14/2021] [Indexed: 12/26/2022] Open
Abstract
The distribution of individual heart disease differs among women and men and, parallel to this, among particular age groups. Women are usually affected by cardiovascular disease at an older age than men, and as the prevalence of comorbidities (like diabetes or chronic pain syndromes) grows with age, women suffer from a higher number of symptoms (such as pain and breathlessness) than men. Women live longer, and after a husband or partner's death, they suffer from a stronger sense of loneliness, are more dependent on institutionalized care and have more unaddressed needs than men. Heart failure (HF) is a common end-stage pathway of many cardiovascular diseases and causes substantial symptom burden and suffering despite optimal cardiologic treatment. Modern, personalized medicine makes every effort, including close cooperation between disciplines, to alleviate them as efficiently as possible. Palliative Care (PC) interventions include symptom management, psychosocial and spiritual support. In complex situations they are provided by a specialized multiprofessional team, but usually the application of PC principles by the healthcare team responsible for the person is sufficient. PC should be involved in usual care to improve the quality of life of patients and their relatives as soon as appropriate needs emerge. Even at less advanced stages of disease, PC is an additional layer of support added to disease modifying management, not only at the end-of-life. The relatively scarce data suggest sex-specific differences in symptom pathophysiology, distribution and the requisite management needed for their successful alleviation. This paper summarizes the sex-related differences in PC needs and in the wide range of interventions (from medical treatment to spiritual support) that can be considered to optimally address them.
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Affiliation(s)
- Piotr Z Sobanski
- Palliative Care Unit and Competence Center, Department of Internal Medicine, Spital Schwyz, Schwyz, Switzerland
| | - Malgorzata Krajnik
- Department of Palliative Care, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Sarah J Goodlin
- Geriatrics and Palliative Medicine, Veterans Affairs Portland Health Care System, Department of Medicine, Oregon Health and Sciences University, Patient-Centered Education and Research, Portland, OR, United States
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5
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Toth PP, Gauthier D. Heart failure with preserved ejection fraction: strategies for disease management and emerging therapeutic approaches. Postgrad Med 2020; 133:125-139. [PMID: 33283589 DOI: 10.1080/00325481.2020.1842620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Approximately 50% of patients with heart failure (HF) have a preserved ejection fraction (HFpEF), and the incidence of HFpEF is increasing relative to HF with reduced ejection fraction (HFrEF). Both types of HF are associated with reduced survival and increased risk for hospitalization. However, in contrast to HFrEF, there are no approved treatments specifically indicated for HFpEF, and current therapy is largely focused on management of symptoms and comorbidities. Diagnosis of HFpEF in the outpatient setting also presents unique challenges compared with HFrEF because of factors including a high burden of comorbidities in HFpEF and difficulties in distinguishing HFpEF from normal aging. Primary care providers (PCPs) play a pivotal role in the delivery of holistic, patient-centric care from diagnosis to management and palliative care. As the prevalence of HF continues to rise in an aging population, PCPs will need to play a greater role in HFpEF care. This article will review HFpEF etiology and pathophysiology, diagnostic workup, and management of symptoms and comorbidities, with a focus on the critical role of PCPs throughout the clinical course of HFpEF.
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Affiliation(s)
- Peter P Toth
- Preventive Cardiology, CGH Medical Center, Rock Falls, IL, USA.,Cicarrone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Diane Gauthier
- Section of Cardiology, Boston University School of Medicine, Boston, MA, USA
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6
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Abstract
Heart failure (HF) and chronic obstructive pulmonary disease (COPD) represent the most important differential diagnoses of dyspnea in elderly people. Heart failure is the inability of the heart to pump sufficient amounts of blood through the cardiovascular system. Pump failure is caused by compromised contractility and/or filling of the ventricles leading to forward and backward failure and subsequently to dyspnea. In COPD, the destruction and remodeling processes of the bronchiolar architecture inhibit proper exhalation of air, thereby leading to exhaustion of the thoracic muscles, insufficient oxygen diffusion, and dyspnea. Despite these fundamental differences in the pathophysiology of both disorders, their clinical presentation may be very similar. This renders accurate and timely diagnosis and therapy, especially in patients with coexisting disease, difficult. This clinical review summarizes typical problems in the diagnosis of COPD, HF, and coincident disease, and describes strategies that help avoid misdiagnosis and ineffective treatment.
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7
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Raj L, Maidman SD, Adhyaru BB. Inpatient management of acute decompensated heart failure. Postgrad Med J 2019; 96:33-42. [PMID: 31515438 DOI: 10.1136/postgradmedj-2019-136742] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/07/2019] [Accepted: 09/02/2019] [Indexed: 12/25/2022]
Abstract
Acute decompensated heart failure (ADHF) is the leading cause of hospital admissions in patients older than 65 years. These hospitalisations are highly risky and are associated with poor outcomes, including rehospitalisation and death. The management of ADHF is drastically different from that of chronic heart failure as inpatient treatment consists primarily of haemodynamic stabilisation, symptom relief and prevention of short-term morbidity and mortality. In this review, we will discuss the strategies put forth in the most recent American College of Cardiology/American Heart Association and Heart Failure Society of America guidelines for ADHF as well as the evidence behind these recommendations.
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Affiliation(s)
- Leah Raj
- Medicine - Cardiovascular Medicine, University of Southern California, Los Angeles, California, USA
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8
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Differential Diagnosis of Asthma. ALLERGY AND ASTHMA 2019. [PMCID: PMC7123211 DOI: 10.1007/978-3-030-05147-1_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Asthma is one of the most common chronic syndromes worldwide (Moorman et al., Vital Health Stat 3(35), 2012). It is not a diagnosis but a clinical syndrome based on a constellation of signs and symptoms (Li et al., Ann Allergy Asthma Immunol 81:415–420(IIa), 1998). The classic symptoms of asthma include chest tightness, wheeze, cough, and dyspnea (Moorman et al., Vital Health Stat 3(35), 2012). The term asthma encompasses a spectrum of pulmonary diseases sharing the hallmark of reversible airway obstruction and can be classified as allergic or non-allergic (Löwhagen, J Asthma. 52(6):538–44, 2015). Asthma designated allergic is due to an immunoglobulin E (IgE)-mediated process, but as noted not all asthma is allergic in etiology (Romanet-Manent et al., Allergy 57:607–13, 2002). The differential diagnosis for asthma is broad and requires a detailed history with supportive pulmonary function tests to be properly diagnosed.
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9
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So JY, Mamary AJ, Shenoy K. Asthma: Diagnosis and Treatment. EUROPEAN MEDICAL JOURNAL 2018. [DOI: 10.33590/emj/10313763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Asthma is an obstructive lung disease affecting >230 million people worldwide and a significant cause of morbidity in patients of all ages. It is a heterogeneous disease with a complex pathophysiology and phenotype. Diagnosis is made with thorough history-taking and physical examination, and the condition is characterised by variable airflow obstruction and airway hyper-responsiveness. Understanding the severity of the disease is important, and treatment is aimed at symptom control and the prevention of future exacerbations. Pharmacologic treatment with beta-agonists for intermittent asthma and inhaled corticosteroids and a combination of inhaled corticosteroids and long-acting beta-2 agonists for persistent asthma are recommended. Additional and alternative treatments with leukotriene modifiers, anticholinergics, biologics, and bronchial thermoplasty are also available. However, understanding an individual’s disease phenotype, endotype, and comorbidities is necessary for asthma treatment, with appropriate consultation with asthma specialists required for those with severe asthma.
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Affiliation(s)
- Jennifer Y. So
- Division of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Albert J. Mamary
- Division of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, Pennsylvania, USA
| | - Kartik Shenoy
- Division of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, Pennsylvania, USA
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10
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Eisenberg E, Di Palo KE, Piña IL. Sex differences in heart failure. Clin Cardiol 2018; 41:211-216. [PMID: 29485677 DOI: 10.1002/clc.22917] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/24/2018] [Accepted: 02/02/2018] [Indexed: 12/17/2022] Open
Abstract
Heart failure (HF) numbers continue to grow in the United States and approximately 50% of patients living with HF are women. For the provider, it is critical to understand the role that gender plays in recognition, diagnosis, and management. The purpose of this literature review is to highlight the prevalence of heart failure in women and discuss gender variations in epidemiology, symptoms, pharmacology, and treatment as well as examine the representation of women in clinical trials.
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Affiliation(s)
- Evann Eisenberg
- Department of Cardiology, Cedars-Sinai Medical Center, California, Los Angeles
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11
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Pinto P, Rothnie KJ, Lui K, Timmis A, Smeeth L, Quint JK. Presentation, management and mortality after a first MI in people with and without asthma: A study using UK MINAP data. Chron Respir Dis 2018; 15:60-70. [PMID: 28393591 PMCID: PMC5802653 DOI: 10.1177/1479972317702140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 02/10/2017] [Accepted: 02/23/2017] [Indexed: 01/07/2023] Open
Abstract
Asthma has been associated with a higher incidence of myocardial infarction (MI), higher prevalence of MI risk factors and higher burden of cardiovascular diseases. However, detailed associations between the presentation and initial management at the time of MI and post-MI outcomes in people with asthma compared to the general population have not been studied. A total of 300,161 people were identified with a first MI over the period 2003-2013 in the Myocardial Ischaemia National Audit Project database, of whom 8922 (3%) had asthma. Logistic regression was used to compare presentation, in-hospital care, in-hospital and 180-day post-discharge all-cause mortality in people with and without asthma adjusting for demographics and comorbidities, diagnosis on arrival and secondary prevention. People with asthma were more likely to have a delay in their MI diagnosis following an STEMI (ST-elevation myocardial infarction; odds ratio (OR) 1.38, confidence interval CI 1.06-1.79) but not an nSTEMI (non-ST-elevation myocardial infarction; OR 1.04, CI 0.92-1.17) compared to people without asthma and a delay in reperfusion (OR 1.19, CI 1.09-1.30) following an STEMI. They were much less likely to be discharged on a beta blocker following an STEMI or nSTEMI (OR 0.24, CI 0.21-0.28 and OR 0.27, CI 0.24-0.30, respectively). There was no difference in in-hospital or 180-day mortality (OR 0.98, CI 0.59-1.62 and OR 0.99, CI 0.72-1.36) following an STEMI or nSTEMI (OR 0.89, CI 0.47-1.68 and OR 1.05, CI 0.85-1.28). Although people with asthma were more likely to have a delay in diagnosis following an STEMI but not an nSTEMI compared to the general population, were more likely to have a delay in reperfusion therapy and were much less likely to receive beta blockers following an STEMI or nSTEMI, there was no difference in the prescriptions of other secondary prevention medications. None of the differences in presentation or management were associated with an increase in all-cause in-hospital or 180-day mortality in people with asthma compared to the general population.
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Affiliation(s)
- Paulo Pinto
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kieran J Rothnie
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Kelvin Lui
- Faculty of Life Sciences, University College London, London, UK
| | - Adam Timmis
- Barts NIHR Biomedical Research Unit, Queen Mary University of London, London, UK
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Jennifer K Quint
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
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12
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Helby J, Nordestgaard BG, Benfield T, Bojesen SE. Asthma, other atopic conditions and risk of infections in 105 519 general population never and ever smokers. J Intern Med 2017; 282:254-267. [PMID: 28547823 DOI: 10.1111/joim.12635] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Individuals with atopic conditions may have increased susceptibility to infections outside the organs directly affected by their atopic condition. OBJECTIVE We tested the hypothesis that atopic conditions overall, and stratified by smoking history, are associated with increased risk of hospitalization for infections. METHODS We collected information on smoking history and self-reported atopic conditions from 105 519 individuals from the general population and followed them for up to 23 years for infectious disease hospitalizations and deaths. For asthma, we focused on never smokers with asthma diagnosed before age 50 (early asthma) to minimize confounding by chronic obstructive pulmonary disease. RESULTS During follow-up, 11 160 individuals had infections. Never smokers with early asthma versus no atopic conditions had significantly increased risks of any infection (hazard ratio 1.65; 95% confidence interval 1.40-1.94), pneumonia (2.44; 1.92-3.11) and any non-respiratory tract infection (1.36; 1.11-1.67); results were similar in ever smokers. Never smokers with any asthma had significantly increased risks of any infection (1.44; 1.24-1.66) and pneumonia (1.99; 1.62-2.44). Neither atopic dermatitis (1.00; 0.91-1.10) nor hay fever (1.00; 0.93-1.07) was associated with risk of any infection. In never smokers, risk estimates for any infection were comparable between asthma and diabetes, as were the population attributable fractions of 2.2% for any asthma and 2.9% for diabetes. CONCLUSION Early asthma was associated with significantly increased risks of any infection, pneumonia and any non-respiratory tract infection in never and ever smokers. In never smokers, risk estimates as well as population attributable fractions for any infection were comparable between asthma and diabetes, suggesting that asthma may be a substantial risk factor for infections in the general population.
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Affiliation(s)
- J Helby
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - B G Nordestgaard
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,The Copenhagen City Heart Study, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - T Benfield
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Infectious Diseases, Hvidovre Hospital, Copenhagen University Hospital, Hvidovre, Denmark
| | - S E Bojesen
- Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,The Copenhagen General Population Study, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,The Copenhagen City Heart Study, Bispebjerg and Frederiksberg Hospital, Copenhagen University Hospital, Copenhagen, Denmark
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13
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Caravita S, Vachiéry JL. Obstructive Ventilatory Disorder in Heart Failure-Caused by the Heart or the Lung? Curr Heart Fail Rep 2016; 13:310-318. [PMID: 27817003 DOI: 10.1007/s11897-016-0309-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Heart failure (HF) is a clinical syndrome frequently associated with airway obstruction, either as a respiratory comorbidity or as a direct consequence of HF pathophysiology. Recognizing the relative contribution of an underlying airway disease as opposed to airway obstruction due to volume overload and left atrial pressure elevation is of importance for the appropriate management of patients affected by HF. This review focuses on "les liaisons dangereuses" between the heart and the lungs, outlying recent advances linking in a vicious circle of chronic obstructive lung disease (COPD) and obstructive sleep apnea (OSA) on one side and HF on the other side. It also discusses the role of pivotal diagnostic tools such as pulmonary function tests and cardiopulmonary exercise test to determine the contribution of HF and COPD to symptoms and clinical status. Treatment implications are discussed as well.
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Affiliation(s)
- Sergio Caravita
- Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy.,Pulmonary Hypertension and Heart Failure Clinic, Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium
| | - Jean-Luc Vachiéry
- Pulmonary Hypertension and Heart Failure Clinic, Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Brussels, Belgium. .,Department of Cardiology, CUB Hôpital Erasme, 808 Route de Lennik, 1070, Brussels, Belgium.
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14
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Arques S, Roux E. [Usefulness of natriuretic peptide testing and Doppler echocardiography at bedside in the diagnosis of acute heart failure]. Ann Cardiol Angeiol (Paris) 2016; 65:334-339. [PMID: 27693163 DOI: 10.1016/j.ancard.2016.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 09/02/2016] [Indexed: 06/06/2023]
Abstract
Acute heart failure is a common condition that leads to hospital admission, with important mortality and readmission rates. A prompt and accurate diagnosis of this condition by hospitalists is essential for an early and tailored medical management. The use of natriuretic peptide testing (BNP and NT-proBNP) through a two cut-point strategy is currently recommended as the first-line diagnostic complement to the initial clinical evaluation in the acute care setting. Transthoracic Doppler echocardiography is an other noninvasive method that can be used at bedside, especially in patients with intermediate, inconclusive natriuretic peptides levels. In this regard, left ventricular ejection fraction and several simple Doppler indexes (restrictive mitral filling pattern, spectral tissue Doppler E/e' ratio), have been validated in the emergency diagnosis of acute heart failure. The aim of the present review is to overview the respective contribution of natriuretic peptides and Doppler echocardiography at bedside to the diagnosis of acute heart failure in the acute care setting.
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Affiliation(s)
- S Arques
- Service de cardiologie, centre hospitalier Édmond-Garcin, avenue des Sœurs-Gastine, 13400 Aubagne, France.
| | - E Roux
- Service de cardiologie, centre hospitalier Édmond-Garcin, avenue des Sœurs-Gastine, 13400 Aubagne, France
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15
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Dharmarajan K, Strait KM, Tinetti ME, Lagu T, Lindenauer PK, Lynn J, Krukas MR, Ernst FR, Li SX, Krumholz HM. Treatment for Multiple Acute Cardiopulmonary Conditions in Older Adults Hospitalized with Pneumonia, Chronic Obstructive Pulmonary Disease, or Heart Failure. J Am Geriatr Soc 2016; 64:1574-82. [PMID: 27448329 DOI: 10.1111/jgs.14303] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To determine how often hospitalized older adults principally diagnosed with pneumonia, chronic obstructive pulmonary disease (COPD), or heart failure (HF) are concurrently treated for two or more of these acute cardiopulmonary conditions. DESIGN Retrospective cohort study. SETTING 368 U.S. hospitals in the Premier research database. PARTICIPANTS Individuals aged 65 and older principally hospitalized with pneumonia, COPD, or HF in 2009 or 2010. MEASUREMENTS Proportion of diagnosed episodes of pneumonia, COPD, or HF concurrently treated for two or more of these acute cardiopulmonary conditions during the first 2 hospital days. RESULTS Of 91,709 diagnosed pneumonia hospitalizations, 32% received treatment for two or more acute cardiopulmonary conditions (18% for HF, 18% for COPD, 4% for both). Of 41,052 diagnosed COPD hospitalizations, 19% received treatment for two or more acute cardiopulmonary conditions (all of which involved additional HF treatment). Of 118,061 diagnosed HF hospitalizations, 38% received treatment for two or more acute cardiopulmonary conditions (34% for pneumonia, 9% for COPD, 5% for both). CONCLUSION Hospitalized older adults diagnosed with pneumonia, COPD, or HF are frequently treated for two or more acute cardiopulmonary conditions, suggesting that clinical syndromes often fall between traditional diagnostic categories. Research is needed to evaluate the risks and benefits of real-world treatment for the many older adults whose presentations elicit diagnostic uncertainty or concern about coexisting acute conditions.
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Affiliation(s)
- Kumar Dharmarajan
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Kelly M Strait
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Mary E Tinetti
- Section of Geriatrics, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.,Section of Chronic Disease Epidemiology, Yale University School of Public Health, New Haven, Connecticut
| | - Tara Lagu
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts.,Division of General Internal Medicine, Baystate Medical Center, Springfield, Massachusetts.,Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Peter K Lindenauer
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts.,Division of General Internal Medicine, Baystate Medical Center, Springfield, Massachusetts.,Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Joanne Lynn
- Altarum Institute, Washington, District of Columbia
| | | | - Frank R Ernst
- Premier Research Services, Premier, Inc., Charlotte, North Carolina
| | - Shu-Xia Li
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.,Section of Health Policy and Administration, Yale University School of Public Health, New Haven, Connecticut.,Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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Britto RR, Vieira DSR, Botoni FA, Botoni ALAS, Velloso M. The Presentation of Respiratory Failure in Elderly Individuals. CURRENT GERIATRICS REPORTS 2015. [DOI: 10.1007/s13670-015-0130-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Güder G, Brenner S, Störk S, Hoes A, Rutten FH. Chronic obstructive pulmonary disease in heart failure: accurate diagnosis and treatment. Eur J Heart Fail 2014; 16:1273-82. [DOI: 10.1002/ejhf.183] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Revised: 09/08/2014] [Accepted: 09/12/2014] [Indexed: 01/08/2023] Open
Affiliation(s)
- Gülmisal Güder
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
- Comprehensive Heart Failure Center; University of Würzburg; Würzburg Germany
- Department of Internal Medicine-Cardiology; University Hospital Würzburg; Germany
| | - Susanne Brenner
- Comprehensive Heart Failure Center; University of Würzburg; Würzburg Germany
- Department of Internal Medicine-Cardiology; University Hospital Würzburg; Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center; University of Würzburg; Würzburg Germany
- Department of Internal Medicine-Cardiology; University Hospital Würzburg; Germany
| | - Arno Hoes
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
| | - Frans H. Rutten
- Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
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18
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Güder G, Rutten FH. Comorbidity of Heart Failure and Chronic Obstructive Pulmonary Disease: More than Coincidence. Curr Heart Fail Rep 2014; 11:337-46. [DOI: 10.1007/s11897-014-0212-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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19
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Point-of-care ultrasound diagnoses acute decompensated heart failure in the ED regardless of examination findings. Am J Emerg Med 2014; 32:385-8. [DOI: 10.1016/j.ajem.2013.12.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 12/11/2013] [Indexed: 11/19/2022] Open
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20
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Ding Q, Yehle KS, Edwards NE, Griggs RR. Geriatric Heart Failure: Awareness, Evaluation, and Treatment in Primary Care. J Nurse Pract 2014. [DOI: 10.1016/j.nurpra.2013.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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21
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Alkhuja S, Gazizov N, Alexander ME. Bronchodilator responsiveness in patients with chronic heart failure. Heart Lung 2013; 42:387-8. [DOI: 10.1016/j.hrtlng.2013.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 06/03/2013] [Indexed: 11/24/2022]
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22
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Diagnosing heart failure among acutely dyspneic patients with cardiac, inferior vena cava, and lung ultrasonography. Am J Emerg Med 2013; 31:1208-14. [PMID: 23769272 DOI: 10.1016/j.ajem.2013.05.007] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 05/07/2013] [Accepted: 05/07/2013] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Rapid diagnosis (dx) of acutely decompensated heart failure (ADHF) may be challenging in the emergency department (ED). Point-of-care ultrasonography (US) allows rapid determination of cardiac function, intravascular volume status, and presence of pulmonary edema. We test the diagnostic test characteristics of these 3 parameters in making the dx of ADHF among acutely dyspneic patients in the ED. METHODS This was a prospective observational cohort study at an urban academic ED. Inclusion criteria were as follows: dyspneic patients, at least 18 years old and able to consent, whose differential dx included ADHF. Ultrasonography performed by emergency sonologists evaluated the heart for left ventricular ejection fraction (LVEF), the inferior vena cava for collapsibility index (IVC-CI), and the pleura sampled in each of 8 thoracic regions for presence of B-lines. Cutoff values for ADHF were LVEF less than 45%, IVC-CI less than 20%, and at least 10 B-lines. The US findings were compared with the final dx determined by 2 emergency physicians blinded to the US results. RESULTS One hundred one participants were enrolled: 52% male, median age 62 (25%-75% interquartile, 53-91). Forty-four (44%) had a final dx of ADHF. Sensitivity and specificity (including 95% confidence interval) for the presence of ADHF were as follows: 74 (65-90) and 74 (62-85) using LVEF less than 45%, 52 (38-67) and 86 (77-95) using IVC-CI less than 20%, and 70 (52-80) and 75 (64-87) using B-lines at least 10. Using all 3 modalities together, the sensitivity and specificity were 36 (22-51) and 100 (95-100). As a comparison, the sensitivity and specificity of brain natriuretic peptide greater than 500 were 75 (55-89) and 83 (67-92). CONCLUSION In this study, US was 100% specific for the dx of ADHF.
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23
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Tanabe T, Rozycki HJ, Kanoh S, Rubin BK. Cardiac asthma: new insights into an old disease. Expert Rev Respir Med 2013; 6:705-14. [PMID: 23234454 DOI: 10.1586/ers.12.67] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cardiac asthma has been defined as wheezing, coughing and orthopnea due to congestive heart failure. The clinical distinction between bronchial asthma and cardiac asthma can be straight forward, except in patients with chronic lung disease coexisting with left heart disease. Pulmonary edema and pulmonary vascular congestion have been thought to be the primary causes of cardiac asthma but most patients have a poor response to diuretics. There appears to be limited effectiveness of classical asthma medications like bronchodilators or corticosteroids in treating cardiac asthma. Evidence suggests that circulating inflammatory factors and tissue growth factors also lead to airway obstruction suggesting the possibility of developing novel therapies.
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Affiliation(s)
- Tsuyoshi Tanabe
- Department of Pediatrics, Virginia Commonwealth University School of Medicine and the Children's Hospital of Richmond at VCU, Richmond, VA, USA
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24
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Tanabe T, Kanoh S, Moskowitz WB, Rubin BK. Cardiac asthma: transforming growth factor-β from the failing heart leads to squamous metaplasia in human airway cells and in the murine lung. Chest 2013; 142:1274-1283. [PMID: 22505689 DOI: 10.1378/chest.11-1710] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Cardiac asthma describes symptoms of airflow obstruction due to heart failure. Chronic heart failure is associated with decreased FEV 1 , and FEV 1 improves after heart transplantation. Fibrotic remodeling of the heart and airways is mediated, in part, through transforming growth factor (TGF)- β . Blood TGF- b 1 concentration correlates with ventricular remodeling in cardiac disease, and TGF- β decreases after repair. METHODS We established a coculture of normal human bronchial epithelial (NHBE) cells differentiated at air-liquid interface with submerged basal cardiomyoblasts. Airway cells were immunostained with cytokeratin, actin, and involucrin. TGF- β synthesis was assayed using enzyme-linked immunosorbent assay. Phosphorylation of Smad in NHBE cells was determined by Western blotting.Mice given doxorubicin developed cardiac failure, and their airways were histologically examined. RESULTS Coculture induced involucrin-positive squamous metaplasia of NHBE cells, and this was attenuated by TGF- β antibody. Total TGF- β 1 was increased in coculture conditioned medium( P < .001). After 14 days of exposure to recombinant TGF- β 1 , there was squamous transformation of NHBE cells. One week after removing cardiomyoblasts from culture, squamous metaplasia resolved into normal ciliated epithelia. Smad was phosphorylated in NHBE cells with cardiomyoblasts or with recombinant TGF- β 1 exposure. The airways of mice with heart failure also demonstrated involucrin-positive squamous transformation. CONCLUSIONS TGF- β from cardiomyoblasts or from the failing heart can cause airway squamous metaplasia via Smad signaling, and this is blocked by anti-TGF- b antibody and reversed when cardiac cells are removed from culture. This appears to be an important mechanism for airflow obstruction with heart failure, sometimes described as cardiac asthma.
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Affiliation(s)
- Tsuyoshi Tanabe
- Department of Pediatrics, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Soichiro Kanoh
- Department of Pediatrics, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - William B Moskowitz
- Department of Pediatrics, Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Bruce K Rubin
- Department of Pediatrics, Virginia Commonwealth University School of Medicine, Richmond, VA.
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25
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Morbid obesity: obscuring the diagnosis of aortic stenosis in a patient with cardiogenic wheezing. J Gen Intern Med 2013; 28:155-9. [PMID: 22810357 PMCID: PMC3539027 DOI: 10.1007/s11606-012-2155-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 06/16/2012] [Accepted: 06/19/2012] [Indexed: 10/28/2022]
Abstract
We report the case of a morbidly obese 65-year-old female who presented with repeated hypotensive episodes following dialysis. She was misdiagnosed as suffering from asthma, and eventually was found to have severe aortic stenosis. Obesity has become a common and formidable obstacle to gathering important diagnostic information in patients. Modern diagnostic lab tests and imaging modalities such as transthoracic echocardiography (TTE) can provide spurious data in the morbidly obese population, which can ultimately lead to misdiagnosis. In this clinical vignette, we discuss the relationship between the basic pathophysiologic mechanisms underlying aortic stenosis and patient clinical presentation. We also review the relevant literature and discuss the impact of obesity on the diagnosis of this condition.
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26
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Inomata M, Kawagishi Y, Tokui K, Masaki Y, Taka C, Kambara K, Okazawa S, Imanishi S, Ichikawa T, Suzuki K, Yamada T, Iwata M, Usui I, Sumi S, Origasa H, Matsui S, Hayashi R, Tobe K. A history of ischemic heart disease is a common cause of wheezing in the elderly of a Japanese local community. Intern Med 2011; 50:2975-81. [PMID: 22185988 DOI: 10.2169/internalmedicine.50.6201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE We conducted a cross-sectional study to investigate which factors have a significant impact on wheezing and QOL in the elderly of a Japanese local community. METHODS In 2008, 527 participants (250 participants aged 45 to 64 years and 277 participants aged 65 to 88 years) responded to the questionnaire regarding wheezing and disease history. QOL was evaluated by the Short Form-8. The participants underwent airway reversibility testing. The plasma levels of IgE were measured. The plasma levels of N-terminal-pro-B-type natriuretic peptide were measured in twenty-one participants with a history of ischemic heart disease and in thirty-five age-matched participants without that history. RESULTS Wheezing was reported by 50 (9.5%) participants and was associated with a lower score of QOL. In multivariate analysis, wheezing was associated with sex (OR 3.12, CI 1.10-9.67) and a history of bronchial asthma (OR 22.3, CI 6.50-84.0) among participants aged 45 to 64 years. Among participants aged 65 and over, wheezing was associated with a history of bronchial asthma (OR 4.86, CI 1.39-15.1) and ischemic heart disease (OR 5.12, CI 1.61-15.0). Participants with both a history of ischemic heart disease and wheezing showed higher levels of N-terminal-pro-B-type natriuretic peptide. Airway reversibility was only associated with a history of ischemic heart disease (OR 4.65, CI 1.26-17.6). CONCLUSION It is suggested that bronchial asthma and heart disease are both significant causes of wheezing and affect the QOL in the elderly of a Japanese local community.
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Affiliation(s)
- Minehiko Inomata
- The First Department of Internal Medicine, University of Toyama, Japan
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27
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Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, Jeejeebhoy FM, Gabrielli A. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S829-61. [PMID: 20956228 DOI: 10.1161/circulationaha.110.971069] [Citation(s) in RCA: 392] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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28
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Zechner PM, Aichinger G, Rigaud M, Wildner G, Prause G. Prehospital lung ultrasound in the distinction between pulmonary edema and exacerbation of chronic obstructive pulmonary disease. Am J Emerg Med 2010; 28:389.e1-2. [PMID: 20223411 DOI: 10.1016/j.ajem.2009.07.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2009] [Accepted: 07/20/2009] [Indexed: 10/19/2022] Open
Abstract
We present 2 cases of dyspneic patients, where prehospital lung ultrasound helped to distinguish between pulmonary edema and acute exacerbation of chronic obstructive pulmonary disease.
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29
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Teixeira A, Legrain S, Ray P. Diagnostic étiologique de la dyspnée aiguë du sujet âgé : place des biomarqueurs en urgence. Presse Med 2009; 38:1506-15. [DOI: 10.1016/j.lpm.2008.12.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Revised: 10/29/2008] [Accepted: 12/18/2008] [Indexed: 11/28/2022] Open
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30
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Vader JM, Drazner MH. Clinical assessment of heart failure: utility of symptoms, signs, and daily weights. Heart Fail Clin 2009; 5:149-60. [PMID: 19249684 DOI: 10.1016/j.hfc.2008.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Heart failure is a clinical syndrome defined by the presence of characteristic signs and symptoms. History taking and physical examination have particular utility in assessing patients who have heart failure. In recent years the validity of conventional signs and symptoms of heart failure has been tested in large population studies and in clinical trials, providing an evidence basis for their utility in the clinical assessment of the patient who has known or suspected heart failure. There also has been progress in characterizing the process of acute decompensation from a previously chronic stable state. This article addresses the usefulness of signs and symptoms and daily weights in the assessment and management of patients who have heart failure.
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Affiliation(s)
- Justin M Vader
- University of Texas Southwestern Medical Center, Dallas, TX 75390-9047, USA
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31
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Ray P, Delerme S, Jourdain P, Chenevier-Gobeaux C. Differential diagnosis of acute dyspnea: the value of B natriuretic peptides in the emergency department. QJM 2008; 101:831-43. [PMID: 18664534 DOI: 10.1093/qjmed/hcn080] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Congestive heart failure (CHF) is the main cause of acute dyspnea in patients presenting to an emergency department (ED) and is associated with high morbidity and mortality. B-type natriuretic peptide (BNP) is a polypeptide, released by ventricular myocytes in direct proportion to wall tension, which lowers renin-angiotensin-aldosterone activation. For the diagnosis of CHF, both BNP and the biologically inactive NT-proBNP have similar accuracy. Threshold values are higher in an elderly population, and in patients with renal dysfunction. They might also have a prognostic value. Studies have demonstrated that the use of BNP or NT-proBNP in dyspneic patients early following admission to the ED, reduced the time to discharge and total treatment cost. BNP and NT-proBNP should be available in every ED 24 h a day, because the literature strongly suggests the beneficial impact of an early appropriate diagnosis and treatment in dyspneic patients. The purpose of this review is to indicate recent developments in biomarkers of heart failure and to evaluate their impact on clinical use in the emergency setting.
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Affiliation(s)
- P Ray
- Service d'Accueil des Urgences, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
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32
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Chenevier-Gobeaux C, Delerme S, Allo JC, Arthaud M, Claessens YE, Ekindjian OG, Riou B, Ray P. B-type natriuretic peptides for the diagnosis of congestive heart failure in dyspneic oldest-old patients. Clin Biochem 2008; 41:1049-54. [DOI: 10.1016/j.clinbiochem.2008.05.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2008] [Revised: 05/28/2008] [Accepted: 05/29/2008] [Indexed: 11/25/2022]
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Abstract
Acute respiratory failure (ARF) in patients over 65 years is common in emergency departments (EDs) and is one of the key symptoms of congestive heart failure (CHF) and respiratory disorders. Searches were conducted in MEDLINE for published studies in the English language between January 1980 and August 2007, using 'acute dyspnea', 'acute respiratory failure (ARF)', 'heart failure', 'pneumonia', 'pulmonary embolism (PE)' keywords and selecting articles concerning patients aged 65 or over. The age-related structural changes of the respiratory system, their consequences in clinical assessment and the pathophysiology of ARF are reviewed. CHF is the most common cause of ARF in the elderly. Inappropriate diagnosis that is frequent and inappropriate treatments in ED are associated with adverse outcomes. B-type natriuretic peptides (BNPs) help to determine an accurate diagnosis of CHF. We should consider non-invasive ventilation (NIV) in elderly patients hospitalised with CHF or acidotic chronic obstructive pulmonary disease (COPD) who do not improve with medical treatment. Further studies on ARF in elderly patients are warranted.
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Affiliation(s)
- Samuel Delerme
- Emergency Department, CHU Pitié-Salpétriêre, 47-83 boulevard de l'hopital, 75013 Paris, Université Pierre et Marie Curie-Paris 6, France
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34
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Delerme S, Chenevier-Gobeaux C, Doumenc B, Ray P. The Diagnostic Value of B Natriuretic Peptide in Elderly Patients with Acute Dyspnea. Clin Med Cardiol 2008. [DOI: 10.4137/cmc.s525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- S. Delerme
- Department of Emergency Medicine and Surgery, Centre Hospitalo-Universitaire Pitié-Salpětrière, Assistance-Publique Hôpitaux de Paris (AP-HP), 47-83 boulevard de l'hôpital, 75013 Paris, Université Pierre et Marie Curie Paris 6, France
| | - C. Chenevier-Gobeaux
- Department of Biochemistry A, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), 27 rue du Faubourg Saint-Jacques, 75679 Paris Cedex 14, France
| | - B. Doumenc
- Department of Emergency Medicine, Centre Hospitalo-Universitaire de Bicetre, Assistance-Publique Hôpitaux de Paris (AP-HP), 94270 Kremlin-Bicetre, Université Paris Sud 11, France
| | - P. Ray
- Department of Emergency Medicine and Surgery, Centre Hospitalo-Universitaire Pitié-Salpětrière, Assistance-Publique Hôpitaux de Paris (AP-HP), 47-83 boulevard de l'hôpital, 75013 Paris, Université Pierre et Marie Curie Paris 6, France
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35
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Delerme S, Chenevier-Gobeaux C, Doumenc B, Ray P. Useulness of B Natriuretic Peptides and Procalcitonin in Emergency Medicine. Biomark Insights 2008; 3:203-217. [PMID: 19578505 PMCID: PMC2688345 DOI: 10.4137/bmi.s499] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Congestive heart failure (CHF) is the main cause of acute dyspnea in patients presented to an emergency department (ED), and it is associated with high morbidity and mortality. B-type natriuretic peptide (BNP) is a polypeptide, released by ventricular myocytes directly proportional to wall tension, for lowering renin-angiotensin-aldosterone activation. For diagnosing CHF, both BNP and the biologically inactive NT-proBNP have similar accuracy. Threshold values are higher in elderly population, and in patients with renal dysfunction. They might have also a prognostic value. Studies demonstrated that the use of BNP or NT-proBNP in dyspneic patients early in the ED reduced the time to discharge, total treatment cost. BNP and NT-proBNP should be available in every ED 24 hours a day, because literature strongly suggests the beneficial impact of an early appropriate diagnosis and treatment in dyspneic patients. Etiologic diagnosis of febrile patients who present to an ED is complex and sometimes difficult. However, new evidence showed that there are interventions (including early appropriate antibiotics), which could reduce mortality rate in patients with sepsis. For diagnosing sepsis, procalcitonin (PCT) is more accurate than C-reactive protein. Thus, because of its excellent specificity and positive predictive value, an elevated PCT concentration (higher than 0.5 ng/mL) indicates ongoing and potentially severe systemic infection, which needs early antibiotics (e.g. meningitis). In lower respiratory tract infections, CAP or COPD exacerbation, PCT guidance reduced total antibiotic exposure and/or antibiotic treatment duration.
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Affiliation(s)
- S Delerme
- Department of Emergency Medicine and Surgery, Centre Hospitalo-Universitaire Pitié-Salpêtrière, Assistance-Publique Hôpitaux de Paris (AP-HP), 47-83 boulevard de l'hôpital, 75013 Paris, Université Pierre et Marie Curie Paris 6, France
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