Effect of a Therapeutic Strategy Guided by Lung Ultrasound on 6-Month Outcomes in Patients with Heart Failure: Randomized, Multicenter Trial (EPICC Study)

INTRODUCTION AND OBJECTIVES

Pulmonary congestion (PC) is associated with an increased risk of hospitalization and death in patients with heart failure (HF). Lung ultrasound has shown to be highly sensitive for detecting PC in HF. The aim of this study is to evaluate whether lung ultrasound-guided therapy improves 6-month outcomes in patients with HF compared with conventional treatment.

MATERIALS AND METHODS

Randomized, multicenter, single-blind clinical trial in patients discharged from Internal Medicine Departments after hospitalization for decompensated HF. Participants will be assigned 1:1 to receive treatment guided according to the presence of lung ultrasound signs of congestion (semi-quantitative evaluation of B lines and the presence of pleural effusion) versus clinical assessment of congestion. The primary outcome is the combination of cardiovascular death and readmission for HF at 6 months.

CONCLUSIONS

The results of this study will provide more evidence about the impact of lung ultrasound on treatment monitoring in patients with chronic HF.

Ruta graveolens L. toxicity in Vampirolepis nana infected mice

OBJECTIVE

To determine possible toxic effects of Ruta graveolens hydroalcoholic extract in gastrointestinal parasitic infection.

MATERIALS AND METHODS

A total of 100 g plant leaves and seeds were powdered and extracted with 1500 mL alcohol/water and administered by gavage to Swiss albino mice infected with Vampirolepis nana. Anti-parasitic evaluation and toxicity assays were carried out in six groups of ten animals each. Treatments were scheduled with both the leaves and the seeds' extracts at doses of 2.5, 5, and 10 mg per gram body weight. Toxicity was comparatively analyzed to a vehicle control group (n = 10) and to a Praziquantel(®) treated. On the fifth day, all the individuals were killed by euthanasia and parasite scores were correlated, giving rise to a relative percentage of elimination to each treatment. Toxicity was achieved by hematology and by clinical chemistry determinations.

RESULTS

The use of the R. graveolens hydroalcoholic extract to treat V. nana infected mice resulted in a mild-to-moderate hepatoxicity associated to a poor anti-parasitic effect. The major proglottids elimination (E%) was achieved at the lowest crude extract concentration with a mild anti-parasitic efficacy from the highest dose; that did not cause a significant elimination of parasites. A decrease of circulating polymorphonuclear-neutrophils associated with a normochromic-normocytic anemia was detected as the extract dose was augmented. The blood aspartate-aminotransferase and alanine-aminotransferase tended be slightly augmented with 100 mg R. graveolens extract.

CONCLUSION

R. graveolens is an unsafe natural anti-parasitic medicine as its active constituents may be poorly extracted by the popular crude herb infusion. Although it presented a mild anti-parasitic effect in mice, symptoms of natural-products-induced-liver-disease confirmed that its self-medication should be avoided.

[Value of the use of milrinone in the treatment of acute crisis in patients with congestive heart failure]

PURPOSE

To assess the hemodynamic effects of milrinone in a 48h intravenous infusion in patients with severe congestive heart failure (CHF) (NYHA class III or IV).

METHODS

Forty patients with CHF were sequentially evaluated. Right heart catheterization was performed in order to measure, before and after administration of milrinone, several hemodynamic parameters (cardiac index, pulmonary wedge pressure, systemic and pulmonary vascular resistance).

RESULTS

There was a significant improvement in hemodynamic parameters (cardiac index, cardiac output), and a decrease in systemic vascular resistance and pulmonary vascular resistance. Serious side effects were not observed in these patients.

CONCLUSION

These findings indicate that milrinone is effective in the treatment of deteriorating phases of CHF and suggest that milrinone should be used in these select patients.

[Surgical management of the aortic valve in patients older than 70 years of age]

PURPOSE

To assess the short and long-term benefits of patients who were submitted to isolated aortic valve replacement or valve replacement (VR) concomitant myocardial revascularization (MR); to evaluate the incidence of postoperative complications, hospital mortality and late mortality.

METHODS

From January 1985, through December 1989, 20 consecutive patients underwent surgical intervention, 15 male (75%) and 5 female (25%), the mean age was 74.8% (ranging from 70 to 86 years old), and the aortic valve gradient ranged between 78 and 180 mmHg (mean = 97 mmHg). They presented preoperative diagnosis to have either isolated aortic stenosis (AS) or As and coronary artery disease (CAD). No patient was in NYHA functional class I; 3 patients (15%) were in class II, 14 (70%) in class III and 3 (15%) in class IV.

RESULTS

The most frequent post-operative complications found were: extended intubation in 7 patients (35%), bleeding in 4 (20%), acute renal failure in 3 (15%) and ventricular arrhythmia in 3 (15%). Hospital mortality occurred in 2 patients (10%) who had been submitted to VR and concomitant MR. Late mortality occurred in 1 patient (5%). Through December 1989, 11 patients (64%) were in functional class I (NYHA), 3 (18%) in class II, 3 (18%) in class III and none in class IV.

CONCLUSION

We concluded that the surgical treatment is indicate to elderly patients with isolated AS os with AS and concomitant CAD. There was a significant post-operative improvement of the functional class (NYHA) to the surviving patients.

[Acute myocardial infarction in patients under 40 years of age]

PURPOSE

To evaluate the short and long-term prognosis of a group of patients aged 40 and under, who developed an acute myocardial infarction.

PATIENTS AND METHODS

In the last 15 years we studied a group of 73 patients aged 40 and under with a confirmed diagnosis of first acute myocardial infarction. Patients with infarctions caused by coronary embolisms or to revascularization procedures were excluded.

RESULTS

Ninety percent were male and mean the age was 35. The most frequent risk factors observed were cigarette smoking in 64 (88%), hypertension in 16 (22%), hypercholesterolemia in 12 (16%) and diabetes in 3 (4%). Seven (9%) patients had no risk factors. The myocardial infarction was anterior em 50 (68%) cases and inferior in the remaining 23 (32%). Severe heart failure (Killip III and IV) was present in 3 (4%). Angiographic studies were performed in 63 (86%). Cineangiography showed critical coronary lesions (obstruction greater than 70%) in one vessel in 38 (60%) patients, multivessel disease in 18 (28%) and 7 (12%) had normal coronary vessels. In-hospital mortality was 5% (3 patients died due to severe heart failure and 1 due to cerebro-vascular accident). The 56 survivors were followed-up to 15 years, with overall survival of 74%. Fourty-nine (71%) were asymptomatic and 7 (10%) had recurrent chest pain. There were 7 (10%) late deaths and follow-up was lost in 6 (9%). Reinfarctions were observed in 5 cases (7%). Revascularization procedures were performed in 12 (17%) patients (bypass-graft surgery in 9 and coronary angioplasty in 3).

CONCLUSION

Young patients with acute myocardial infarction have a low mortality rate in the early phase and a favorable outcome after the discharge of the hospital.