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Ehrman RR, Bredell BX, Harrison NE, Favot MJ, Haber BD, Welch RD, Levy PD, Sherwin RL. Increasing illness severity is associated with global myocardial dysfunction in the first 24 hours of sepsis admission. Ultrasound J 2022; 14:32. [PMID: 35900610 PMCID: PMC9334514 DOI: 10.1186/s13089-022-00282-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 07/19/2022] [Indexed: 11/11/2022] Open
Abstract
Background Septic cardiomyopathy was recognized more than 30 years ago, but the early phase remains uncharacterized as no existing studies captured patients at the time of Emergency Department (ED) presentation, prior to resuscitation. Therapeutic interventions alter cardiac function, thereby distorting the relationship with disease severity and outcomes. The goal of this study was to assess the impact of illness severity on cardiac function during the first 24 h of sepsis admission. Methods This was a pre-planned secondary analysis of a prospective observational study of adults presenting to the ED with suspected sepsis (treatment for infection plus either lactate > 2 mmol/liter or systolic blood pressure < 90 mm/Hg) who received < 1L IV fluid before enrollment. Patients had 3 echocardiograms performed (presentation, 3, and 24 h). The primary outcome was the effect of increasing sepsis illness severity, defined by ED Sequential Organ Failure Assessment (SOFA) score, on parameters of cardiac function, assessed using linear mixed-effects models. The secondary goal was to determine whether cardiac function differed between survivors and non-survivors, also using mixed-effects models. Results We enrolled 73 patients with a mean age of 60 (SD 16.1) years and in-hospital mortality of 23%. For the primary analysis, we found that increasing ED SOFA score was associated with worse cardiac function over the first 24 h across all assessed parameters of left-ventricular systolic and diastolic function as well as right-ventricular systolic function. While baseline strain and E/e' were better in survivors, in the mixed models analysis, the trajectory of Global Longitudinal Strain and septal E/e′ over the first 24 h of illness differed between survivors and non-survivors, with improved function at 24 h in non-survivors. Conclusions In the first study to capture patients prior to the initiation of resuscitation, we found a direct relationship between sepsis severity and global myocardial dysfunction. Future studies are needed to confirm these results, to identify myocardial depressants, and to investigate the link with adverse outcomes so that therapeutic interventions can be developed. Supplementary Information The online version contains supplementary material available at 10.1186/s13089-022-00282-6.
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Ehrman RR, Ottenhoff JD, Favot MJ, Harrison NE, Khait L, Welch RD, Levy PD, Sherwin RL. Do septic patients with reduced left ventricular ejection fraction require a low-volume resuscitative strategy? Am J Emerg Med 2021; 52:187-190. [PMID: 34952322 DOI: 10.1016/j.ajem.2021.11.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/24/2021] [Accepted: 11/28/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Many clinicians are wary of administering 30 cc/kg of intravenous fluid (IVF) to septic patients with reduced left-ventricular ejection fraction (rLVEF), fearing volume overload. Prior studies have used history of heart failure, rather than LVEF measured at presentation, thereby potentially distorting the relationship between rLVEF, IVF, and adverse outcomes. Our goal was to assess the relationship between IVF volume and outcomes in patients with, versus without, rLVEF. METHODS This was a prospective observational study performed at an urban Emergency Department (ED). Included patients were adults with suspected sepsis, defined as being treated for infection plus either systolic blood pressure <90 mm/Hg or lactate >2 mmol/L. All patients had LVEF assessed by ED echocardiogram, prior to receipt of >1 l IVF. MEASUREMENTS AND MAIN RESULTS We enrolled 73 patients, of whom 33 had rLVEF, defined as <40%. Patients with rLVEF were older, had greater initial lactate, more ICU admission, and more vasopressor use. IVF volume was similar between LVEF groups at 3-h (2.2 (IQR 0.8) vs 2.0 (IQR 2.4) liters) while patients with rLVEF were more likely to achieve 30 cc/kg (61% (CI 44-75) vs 45% (CI 31-60). In the reduced versus not-reduced LVEF groups, hospital days, ICU days, and ventilator days were similar: 8 (IQR 7) vs 6.5 (8.5) days, 7 (IQR 7) vs 5 (4) days, and 4 (IQR 8) vs. 5 (10) days, respectively. CONCLUSIONS Septic patients with rLVEF at presentation received similar volume of IVF as those without rLVEF, without an increase in adverse outcomes attributable to volume overload. While validation is needed, our results suggest that limiting IVF administration in the setting of rLVEF is not necessary.
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Affiliation(s)
- Robert R Ehrman
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI 48201, United States of America.
| | - Jakob D Ottenhoff
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI 48201, United States of America
| | - Mark J Favot
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI 48201, United States of America
| | - Nicholas E Harrison
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI 48201, United States of America
| | - Lyudmila Khait
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI 48201, United States of America
| | - Robert D Welch
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Detroit Receiving Hospital, United States of America
| | - Philip D Levy
- Department of Emergency Medicine, Wayne State University School of Medicine; Integrative Biosciences Center, Detroit, MI 48201, United States of America
| | - Robert L Sherwin
- Department of Emergency Medicine, Wayne State University School of Medicine; Detroit Medical Center/Sinai-Grace Hospital, 4201 St. Antoine, Suite 6G, Detroit, MI 48201, United States of America
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Ibrahim N, Chen-Tournoux A, Christenson RH, Gaggin HK, Hollander JE, Levy PD, Mang A, Masson S, Nagurney JT, Nowak R, Pang PS, Peacock WF, Rolny V, Walters EL, Januzzi JL. P5005Diagnostic and prognostic utilities of insulin-like growth factor-binding protein-7 in patients presenting to the emergency department with dyspnea: results from the ICON-RELOADED study. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Increased activity of insulin-like growth factor–binding protein-7 (IGFBP7) is associated with cellular senescence, tissue aging, and obesity. Prior studies in chronic heart failure (HF) have linked IGFBP7 to impaired myocardial relaxation. The role of IGFBP7 measurement in acute HF remains unclear.
Purpose
To examine whether concentrations of IGFBP7 in patients presenting with dyspnea to the emergency department (ED) will aid in the diagnosis and prognosis of acute HF beyond N-terminal pro- B type natriuretic peptide (NT-proBNP).
Methods
The ICON-RELOADED (International Collaborative of NT-proBNP- Re-evaluation of Acute Diagnostic Cut-Offs in the Emergency Department) study was a prospective, multicenter clinical trial conducted at 19 sites in North America that enrolled subjects ≥22 years of age presenting to ED with complaints of dyspnea. Subjects were blindly adjudicated for the diagnosis of acute HF. A blood sample was taken at enrollment. Six-month prognosis for death/repeat hospitalization was obtained. IGFBP7 was measured using a pre-clinical research use only assay.
Results
Among 1449 patients (n=274 with acute HF), those with IGFBP7 concentrations in the highest quartile (>123.7 ng/mL) were older, more likely to be male and to have a history of hypertension and HF (all p<0.001). They also had lower estimated glomerular filtration rate (eGFR) and the lowest left ventricular ejection fraction (41% ± 21%) prior to study enrollment (all p<0.001). Independent predictors of IGFBP7 included age, male sex, history of diabetes, history of HF, and eGFR (all p<0.001). Median concentrations of NT-proBNP (2844 vs. 99 ng/mL) and IGFBP7 (146.1 vs. 86.1 ng/mL) were significantly higher in those with acute HF (both p<0.001); addition of IGFBP7 to NT-proBNP concentrations improved discrimination, increasing the area under the receiver operating curve for diagnosis of acute HF (from 0.91 to 0.94; p<0.001) (Figure 1). Addition of IGFBP7 to a complete model of independent predictors of acute HF (including NT-proBNP) improved model calibration; IGFBP7 also significantly re-classified acute HF diagnosis beyond NT-proBNP alone (net reclassification improvement +0.25; p<0.001). Higher log2-IGFBP7 concentrations predicted death/rehospitalization at 6 months (hazard ratio 1.74 per log2-standard deviation, 95% confidence interval 1.26–2.40, p=0.001). In Kaplan-Meier analyses, supramedian concentrations of IGFBP7 were associated with shorter event-free survival (log-rank p<0.001).
ROC curve for diagnosis of acute HF
Conclusions
Among patients with acute dyspnea, concentrations of IGFBP7 add to NT-proBNP for diagnosis of acute HF and provide added prognostic utility for short-term risk.
Acknowledgement/Funding
Funding for this study was provided by Roche Diagnostics (Risch-Rotkreuz, Switzerland).
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Affiliation(s)
- N Ibrahim
- Massachusetts General Hospital, Cardiology, Boston, United States of America
| | | | - R H Christenson
- University of Maryland, Pathology, Baltimore, United States of America
| | - H K Gaggin
- Massachusetts General Hospital, Cardiology, Boston, United States of America
| | - J E Hollander
- Thomas Jefferson University, Emergency Medicine, Philadelphia, United States of America
| | - P D Levy
- Wayne State University, Emergency Medicine, Detroit, United States of America
| | - A Mang
- Roche Diagnostics, Risch-Rotkreuz, Switzerland
| | - S Masson
- Roche Diagnostics, Risch-Rotkreuz, Switzerland
| | - J T Nagurney
- Massachusetts General Hospital, Emergency Medicine, Boston, United States of America
| | - R Nowak
- University of Michigan, Emergency Medicine, Ann Arbor, United States of America
| | - P S Pang
- Indiana University School of Medicine, Emergency Medicine, Cardiology, Indianapolis, United States of America
| | - W F Peacock
- Baylor College of Medicine, Emergency Medicine, Houston, United States of America
| | - V Rolny
- Roche Diagnostics, Risch-Rotkreuz, Switzerland
| | - E L Walters
- Loma Linda University Medical Center, Emergency Medicine, Loma Linda, United States of America
| | - J L Januzzi
- Massachusetts General Hospital, Cardiology, Boston, United States of America
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Wilson TT, Williams-Johnson J, Gossel-Williams M, Goldberg EM, Wilks R, Dasgupta S, Gordon-Strachan GM, Williams EW, Levy PD. Elevated blood pressure and illness beliefs: a cross-sectional study of emergency department patients in Jamaica. Int J Emerg Med 2018; 11:30. [PMID: 29846823 PMCID: PMC5976560 DOI: 10.1186/s12245-018-0187-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 05/15/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Elevated blood pressure (BP) is common among emergency department (ED) patients. While some data exist on the association between ED BP and hypertension (HTN) in the USA, little is known about this relationship in Afro-Caribbean nations. The aim of the study was to evaluate the relationship between elevated systolic BP in the ED and a previous diagnosis of HTN, accounting for potential factors that could contribute to poor HTN control among those with a previous diagnosis: socioeconomic status, health-seeking behavior, underlying HTN illness beliefs, medication adherence, and perceived adherence self-efficacy. METHODS This was a cross-sectional survey over 6 weeks, from November 19 through December 30, 2014. Those surveyed were non-critically ill or injured adult ED patients (≥ 18 years) presenting to an Afro-Caribbean hospital. Descriptive statistics were derived for study patients as a whole, by HTN history and by presenting BP subgroup (with systolic BP ≥ 140 mmHg considered elevated). Data between groups were compared using chi-square and t tests, where appropriate. RESULTS A total of 307 patients were included: 145 (47.2%) had a prior history of HTN, 126 (41.4%) had elevated BP, and 89 (61.4%) of those presenting with elevated blood pressure had a previous diagnosis of HTN. Those with less formal education were significantly more likely to present with elevated BP (52.1 vs. 28.8% for those with some high school and 19.2% for those with a college education; p = 0.001). Among those with a history of HTN, only 56 (30.9%) had a normal presenting BP. Those with a history of HTN and normal ED presenting BP were no different from patients with elevated BP when comparing the in duration of HTN, medication compliance, location of usual follow-up care, and HTN-specific illness beliefs. CONCLUSIONS In this single-center study, two out of every five Jamaican ED patients had elevated presenting BP, the majority of whom had a previous diagnosis of HTN. Among those with a history of HTN, 60% had an elevated presenting BP. The ED can be an important location to identify patients with chronic disease in need of greater disease-specific education. Further studies should evaluate if brief interventions provided by ED medical staff improve HTN control in this patient population.
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Affiliation(s)
- Taneisha T. Wilson
- Alpert School of Medicine, Brown University, Emergency Medicine, Rhode Island Hospital, 55 Claverick St. #2, Providence, RI 02903 USA
- University Emergency Medicine Foundation, Kingston, Jamaica
| | - Jean Williams-Johnson
- University Hospital, University of the West Indies, Mona, Kingston, Jamaica
- The University Hospital of the West Indies, Mona, Kingston, West Indies Jamaica
| | - Maxine Gossel-Williams
- Department of Basic Medical Sciences, University of the West Indies, Mona, Kingston, Jamaica
- The University of the West Indies, Mona, Kingston, West Indies Jamaica
| | - Elizabeth M. Goldberg
- Alpert School of Medicine, Brown University, Emergency Medicine, Rhode Island Hospital, 55 Claverick St. #2, Providence, RI 02903 USA
- University Emergency Medicine Foundation, Kingston, Jamaica
| | - Rainford Wilks
- The University of the West Indies, Mona, Kingston, West Indies Jamaica
- Tropical Medicine Research Institute, University of the West Indies, Mona, Kingston, Jamaica
| | - Shuvra Dasgupta
- University Hospital, University of the West Indies, Mona, Kingston, Jamaica
- The University Hospital of the West Indies, Mona, Kingston, West Indies Jamaica
| | | | - Eric W. Williams
- University Hospital, University of the West Indies, Mona, Kingston, Jamaica
- The University Hospital of the West Indies, Mona, Kingston, West Indies Jamaica
| | - Philip D. Levy
- Department of Emergency Medicine, Wayne State University, Detroit, MI USA
- Emergency Medicine, 6G4 University Health Center, Detroit, MI 48201 USA
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Abstract
Acute heart failure (AHF) is one of the most important causes of mortality, morbidity and rising healthcare costs. Despite this, there has been minimal advancement in the management of AHF and the treatment continues to focus on symptomatic improvement using vasodilators, diuretics and inotropes, none of which have shown any mortality benefits. Though originally thought of as a reproductive hormone, relaxin is now recognized as a potent vasodilator that modulates systemic and renal vascular tone, resulting in pre- and after-load reduction and a decrease in cardiac workload. A single intravenous infusion of relaxin over 48 hours has been shown to provide significant dyspnea relief among AHF patients, with an ongoing study to evaluate its potential for mortality benefit. This article provides an insight into the pharmacology of this novel therapy for AHF with an eye towards future clinical applications.
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Affiliation(s)
- V A Kumar
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - S S Wilson
- Department of Pharmacy, Detroit Receiving Hospital, Detroit, Michigan, USA
| | - S I Ayaz
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - P D Levy
- Department of Emergency Medicine and Cardiovascular Research Institute, Wayne State University School of Medicine, Detroit, Michigan, USA.
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Gheorghiade M, Erdmann E, Ferrari R, Filippatos G, Levy PD, Maggioni A, Mebazaa A, Nowack C. Treatment of acute decompensated heart failure with the soluble guanylate cyclase activator cinaciguat: The COMPOSE program – three randomized, controlled, phase IIb studies. J Card Fail 2011. [DOI: 10.1016/j.cardfail.2011.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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