Absence Of Congestive Heart Failure Research Articles

Comorbidities and mortality risk in COVID-19 patients with congestive heart failure: A comprehensive analysis

The COVID-19 pandemic has posed unprecedented challenges to global healthcare systems, resulting in alarming incidence and mortality rates among patients with comorbidities, including heart failure. Understanding the characteristics of heart failure and other comorbidities during the COVID-19 pandemic is crucial for effective prevention and treatment. However, the current understanding of these characteristics among different racial groups remains incomplete. In this study, we investigated a cohort of 4711 patients, classifying them into congestive heart failure (CHF) and non-CHF groups. Biomarker analysis revealed noteworthy variations in blood urea nitrogen, aspartate aminotransferase, and white blood cell levels based on the presence or absence of CHF. Stratified by three racial groups, univariate logistic regression analysis identified significant differences in multiple variables, including CHF. Subsequent univariate Cox regression and Kaplan-Meier analysis demonstrated variations in mortality factors among distinct populations, with age and comorbidity playing prominent roles. This study utilized a large-scale database to investigate the characteristics of heart failure and related variables during the COVID-19 pandemic. The findings revealed distinctive mortality risk factors among various racial groups, emphasizing the significance of customized risk assessment and management approaches for diverse populations. These findings also provide a valuable resource for the development of targeted interventions and the promotion of equitable healthcare outcomes in the context of the COVID-19 pandemic.

Outcomes among hospitalized patients with colorectal cancer and comorbid congestive heart failure: A United States population-based cohort study.

e24019 Background: Colorectal cancer is one of the leading causes of cancer related deaths in the United States. Advances in chemotherapeutics have improved survival in these patients, although with the potential for more adverse effects. Congestive heart failure continues to be an important comorbidity in patients with colorectal cancer. However, its impact on outcomes in this subgroup needs further exploration. Methods: We utilized the 2020 National Inpatient Sample (NIS) Database in conducting this retrospective cohort study. We identified patients with colorectal cancer and congestive heart failure using appropriate ICD-10 diagnostic codes. We stratified patients with colorectal cancer based on the presence or absence of congestive heart failure. A survey multivariable logistic and linear regression analysis was used to calculate adjusted odds ratios (ORs) for the primary and secondary outcomes. A p value of < 0.05 was considered statistically significant. The aim of this study was to investigate the impact of congestive heart failure on in-hospital mortality, hospital length of stay (LOS), and total hospitalization charge among hospitalized patients with colorectal cancer. Results: We identified a total of 77130 hospitalized patients with colorectal cancer, of which 10.08% (7755/77130) had comorbid congestive heart failure. The overall in-hospital mortality among patients with colorectal cancer was 2.74% (2115/77130). Among those with comorbid congestive heart failure, the mortality rate was significantly higher at 6.5% (504/7755, p < 0.001). Utilizing a stepwise survey multivariable logistic regression model that adjusted for patient and hospital level confounders, congestive heart failure was found to be an independent predictor of increased in-hospital mortality (adjusted OR 1.79; 95% (confidence interval [CI], 1.33-2.41; p < 0.001), longer LOS (coefficient 2.42; CI 1.91-2.92; p < 0.001), and higher total hospitalization charge (coefficient $22464; CI $15132- $29795; p < 0.001). Conclusions: Our analysis demonstrated that congestive heart failure is widely prevalent in patients with colorectal cancer, and significantly worsens outcomes including increased in-hospital mortality, LOS, and cost of healthcare utilization. Early diagnosis and management of heart failure using guideline directed medical therapy along with close follow up may improve outcomes. Further prospective multicentric studies are warranted to better describe these associations.

Application of computed tomographic angiography and echocardiography in predicting left atrial appendage thrombosis in patients with non-valvular atrial fibrillation.

We aimed to explore the application of computed tomographic angiography (CTA) and echocardiography in predicting left atrial appendage (LAA) thrombosis in patients with non-valvular atrial fibrillation. The clinical data of 164 atrial fibrillation patients receiving cardiac CTA and real-time three-dimensional transoesophageal echocardiography (RT-3D-TEE) were retrospectively analysed. The patients were divided into group A (anticoagulant treatment group, n = 112) and group B (selective anticoagulant treatment group, n = 52) according to the CHA2DS2-VASc score, which scored for the presence or absence of congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke/transient ischaemic attack, vascular disease, age 65-74 years and gender (female). The CHA2DS2-VASc score was used to predict risk of thromboembolism from atrial fibrillation. The correlations of CHA2DS2-VASc score with CTA-based LAA classification and RT-3D-TEE measurement parameters were explored using Spearman's analysis. Receiver operating characteristic (ROC) curves were plotted to explore the predictive value of CTA and RT-3D-TEE for LAA thrombus. There were significant differences in age, disease course, hypertension, diabetes mellitus, coronary heart disease, heart failure, stroke/transient ischaemic attack/thromboembolism, vascular disease, B-type natriuretic peptide and serum uric acid levels, CHA2DS2-VASc score, LAA classification, left ventricular ejection fraction (LVEF), left atrial diameter (LAD), maximum diameter of LAA orifice, minimum diameter of LAA orifice and LAA length (p < 0.05). CHA2DS2- VASc score was positively correlated with cauliflower LAA, LAD, maximum diameter of LAA orifice, minimum diameter of LAA orifice and LAA length, and negatively correlated with LVEF (p < 0.001). ROC curve analysis indicated that CTA, RT-3D-TEE and CHA2DS2-VASc score had similar predictive values for risk of LAA thrombosis in atrial fibrillation patients, with the areas under the curve being 0.778, 0.814 and 0.792, respectively. Both CTA and RT-3D-TEE had high predictive values for LAA thrombosis in atrial fibrillation patients.

An evaluation of a potential calcium channel blocker–lower-extremity edema–loop diuretic prescribing cascade

ObjectivesDihydropyridine calcium channel blockers (DH-CCB) are associated with lower-extremity edema (LEE). Loop diuretics have been used inappropriately to treat DH-CCB–associated LEE, constituting a prescribing cascade (PC). The aim of this work was to identify the prevalence and factors associated with potential DH-CCB–LEE–loop diuretic PC. MethodsThe 2014 National Ambulatory Medical Care Survey was used to identify patient visits in which a DH-CCB was continued. The definition of a potential PC was the continuation or initiation of a loop diuretic in the absence of congestive heart failure, cancer, obstructive sleep apnea, chronic kidney disease or end-stage renal disease, obesity, or resistant hypertension. Multivariable logistic regression was used to identify factors related to a potential PC, including demographic information, number of medications, number of patient visits in the previous 12 months, and comorbid conditions. ResultsAmong the estimated 47.5 million patient visits in which a DH-CCB was continued, 4.6% had a potential PC. Visits in patients 65 to 84 years of age (odds ratio [OR] 2.56, 95% CI 1.20–5.43) and 85 years of age and older (OR 3.89, 95% CI 1.76–8.61) were more likely to have potential PC compared with patients 18 to 64 years of age. Visits in patients with 5 to 7 (OR 3.75, 95% CI 1.72–8.19), 8 to 11 (OR 2.20, 95% CI 1.09–4.44), and 12 or more (OR 5.23, 95% CI 2.29–11.94) medications were more likely to have potential PC compared with patients with 4 or fewer medications. ConclusionA potential DH-CCB–associated LEE loop diuretic PC was present in approximately 2.2 million patient visits in which DH-CCB was continued. Older age and an increasing number of concomitant medications were associated with this potential PC.

Short‐term Changes in Left Ventricular Dyssynchrony Leads to Congestive Heart Failure

Ventricular dyssynchrony (VD) may lead to congestive heart failure (CHF). VD is characterized by a difference in the timing of contractions in the ventricles of the heart and has become a prominent pathophysiological feature of CHF. While studies have been done to understand the long‐term effects of VD that lead to CHF, little is known on the short‐term changes associated with VD. This study explores the acute effects of induced VD in‐vivo. Animals will undergo left ventricular pacing to induce VD and changes in mitochondrial structure and function will be analyzed to determine if abnormalities lead to apoptosis and cardiac remodeling. In this study, tissue homogenates from control and paced animals will be used to perform western blot analysis to investigate the changes in expression of mitochondrial respiratory chain complexes and proteins involved in apoptosis. We will measure adenosine triphosphate levels (ATP) to assess overall mitochondrial function. It is expected that VD increases cell death as a result of mitochondrial dysfunction, leading to activation of a fibrotic response. Immunohistochemistry will be used to investigate neutrophil infiltration and myofibroblast formation to confirm the activation of a fibrotic response. We will also evaluate reactive oxygen species and matrix metalloproteinases activities, which implicate cell injury and death that results in cardiac remodeling. We hypothesize that induced left ventricular pacing in a non‐congestive heart failure model will create short‐term changes that alter cardiovascular structure and metabolism. It is important to understand the short‐term physiological changes that result from dyssynchrony because electro‐mechanical conditions found in the absence of CHF can result in long‐term effects that may eventually lead to CHF.Support or Funding InformationThis research project will be supported through FATSA funding by Dr. Katrina Yamazaki.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Update in Critical Care Medicine: Evidence Published in 2016.

U PDATE Update in Critical Care Medicine: Evidence Published in 2016 Mark Hepokoski, MD, and Atul Malhotra, MD W e summarize key articles in critical care medicine published in 2016. We used an informal survey of academic and community intensivists to identify novel articles from high-impact journals that had important effects on clinical practice. In addition, we searched the most accessed journals from the American College of Physicians' JournalWise database to find articles that were particularly relevant to internal medicine clinicians. We included 2 studies on acute respiratory distress syndrome (ARDS) that solidified the need to better un- derstand the epidemiology of this disorder by demon- strating high rates of underrecognition and disparities in care. A novel noninvasive ventilation (NIV) device that may benefit patients with early ARDS was also identified, and lower oxygen targets may be appropri- ate. Studies of patients with severe sepsis showed no benefit of adjunctive steroid therapy; however, contin- uous infusion of antibiotics may significantly reduce mortality. Intensive blood pressure control does not seem to improve neurologic outcome in patients with acute intracerebral hemorrhage (ICH), and length of hospital stay may predict poor neurologic outcome and mortality in patients with in-hospital cardiac arrest. Progress was made in our understanding of the man- agement of critically ill patients with acute kidney injury (AKI), as a randomized trial suggested that earlier initi- ation of renal replacement therapy (RRT) decreases mortality. Finally, depressive symptoms were shown to be highly prevalent in caregivers of critically ill patients, and strategies that provide social support to these per- sons should be identified. ARDS and Acute Respiratory Failure ARDS Often Goes Unrecognized or Underappreciated, Even in ICUs Bellani G, Laffey JG, Pham T, et al; LUNG SAFE Investigators. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315:788-800. [PMID: 26903337] doi:10.1001/jama.2016.0291 Background: Acute respiratory distress syndrome is de- fined by acute onset of bilateral alveolar or interstitial infiltrates, with impaired gas exchange in the absence of congestive heart failure (1). In patients with known ARDS, lung protective ventilation has proven benefit (2, 3), but evidence suggests that many patients for which this therapy would be appropriate are not receiv- Ann Intern Med. 2017;166:W20-W26. doi:10.7326/M17-0138 For author affiliations, see end of text. This article was published at Annals.org on 30 March 2017. ing it (4, 5). Whether a diagnosis of ARDS affects what therapies the patient receives is also unclear, emphasiz- ing the need for further epidemiologic data on this condition. Findings: This multinational cohort included more than 29 000 patients admitted to participating intensive care units (ICUs). Of these patients, 10.4% fulfilled the crite- ria for ARDS, and most episodes occurred within 48 hours. Clinical recognition of ARDS varied from 51.3% in mild ARDS to 78.5% in severe ARDS. However, fewer than two thirds of patients with ARDS received a tidal volume of 8 mL per kg of ideal body weight or less, and plateau pressure was recorded in only 40.1%. Hospital mortality was 34.9% among patients with mild ARDS, 40.3% among those with moderate ARDS, and 46.1% among those with severe ARDS. The use of some ad- junctive therapies that are recommended by some ex- perts, such as neuromuscular blockade and prone po- sitioning, increased with clinical recognition. Cautions: The observational nature of this study pre- cludes conclusions regarding the appropriateness of the interventions that patients received. In addition, an emerging literature suggests that individualized ther- apy for mechanical ventilation in ARDS may be reason- able (3, 6). Thus, analyses of large cohorts using a one-size-fits-all approach may result in inappropriate assumptions, because the therapeutic decisions that treating clinicians make on the basis of bedside obser- vations and individual patient characteristics may be justifiable and reasonable. Implications: Acute respiratory distress syndrome re- mains common and underrecognized, with substantial associated mortality. Treating clinicians should be aware of the epidemiology of ARDS so that proven therapies (lung protective ventilation) may be instituted promptly with early disease recognition and other ther- apies considered. Future ARDS trials will also depend on accurate and timely diagnosis. ARDS-Related Mortality Is Decreasing, on the Basis of National Death Certificate Data Cochi SE, Kempker JA, Annangi S, et al. Mortality trends of acute respiratory distress syndrome in the United States from 1999 to 2013. Ann Am Thorac Soc. 2016;13:1742-51. [PMID: Background: Substantial advances have been made in the treatment and understanding of ARDS over the past 2 decades (7–9). However, recent assessments of mor- bidity and mortality trends have been mostly limited to single-center studies in specific geographic regions (10, 11). Temporal and demographic trends in ARDS are also underinvestigated. Annals of Internal Medicine W20 © 2017 American College of Physicians Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/936156/ by a University of California San Diego User on 06/20/2017

Nutrition Support for Children Undergoing Congenital Heart Surgeries: A Narrative Review.

Energy imbalance in infants and children with congenital heart disease (CHD) is common and influenced by age, underlying cardiac diagnoses, and presence or absence of congestive heart failure. During the surgical hospitalization period, these children are prone to nutritional deterioration due to stress of surgery, anesthetic/perfusion techniques, and postoperative care. Poor nutrition is associated with increased perioperative morbidity and mortality. This review aims to examine various aspects of nutrition in critically ill children with CHD, including (1) energy expenditure, (2) perioperative factors that contribute to energy metabolism, (3) bedside practices that are potentially able to optimize nutrient delivery, and (4) medium- to long-term impact of energy balance on clinical outcomes. We propose a nutrition algorithm to optimize nutrition of these children in the perioperative period where improvements in nutrition status will likely impact surgical outcomes.

Prävention nach akutem Koronarsyndrom

Mortality is increased in acute coronary syndrome (ACS) related to the extent of myocardial injury even if percutaneous coronary intervention (PCI) was successful. The development of congestive heart failure (CHF) after PCI in ACS is of prognostic interest. Non-invasive imaging plays a major role for determination of structural myocardial damage and loss of function. Secondary prevention regarding pharmacologic and non-pharmacologic therapy is dependent on myocardial function and the presence or absence of CHF. Exercise training as part of the non-pharmacological therapy plays an important role in rehabilitation after ACS according to the severity of injury.

Customized Prediction of Short Length of Stay Following Elective Cardiac Surgery in Elderly Patients Using a Genetic Algorithm

ObjectiveTo develop a customized short LOS (<6 days) prediction model for geriatric patients receiving cardiac surgery, using local data and a computational feature selection algorithm.DesignUtilization of a machine learning algorithm in a prospectively collected STS database consisting of patients who received cardiac surgery between January 2002 and June 2011.SettingUrban tertiary-care center.ParticipantsGeriatric patients aged 70 years or older at the time of cardiac surgery.InterventionsNone.Measurements and Main ResultsPredefined morbidity and mortality events were collected from the STS database. 23 clinically relevant predictors were investigated for short LOS prediction with a genetic algorithm (GenAlg) in 1426 patients. Due to the absence of an STS model for their particular surgery type, STS risk scores were unavailable for 771 patients. STS prediction achieved an AUC of 0.629 while the GenAlg achieved AUCs of 0.573 (in those with STS scores) and 0.691 (in those without STS scores). Among the patients with STS scores, the GenAlg features significantly associated with shorter LOS were absence of congestive heart failure (CHF) (OR = 0.59, p = 0.04), aortic valve procedure (OR = 1.54, p = 0.04), and shorter cross clamp time (OR = 0.99, p = 0.004). In those without STS prediction, short LOS was significantly correlated with younger age (OR = 0.93, p < 0.001), absence of CHF (OR = 0.53, p = 0.007), no preoperative use of beta blockers (OR = 0.66, p = 0.03), and shorter cross clamp time (OR = 0.99, p < 0.001).ConclusionWhile the GenAlg-based models did not outperform STS prediction for patients with STS risk scores, our local-data-driven approach reliably predicted short LOS for cardiac surgery types that do not allow STS risk calculation. We advocate that each institution with sufficient observational data should build their own cardiac surgery risk models.

Bronchomalacia in Dogs with Myxomatous Mitral Valve Degeneration

Cough in the geriatric small breed dog with myxomatous mitral valve degeneration (MMVD), a large left atrium, and absence of heart failure often is attributed to compression of the left mainstem bronchus by the left atrium. Studies investigating this syndrome are lacking in dogs. Airway collapse is independent of left atrial enlargement. A total of 16 dogs presenting with chronic cough in the absence of congestive heart failure. Group 1 dogs (n = 10) had moderate-to-severe left atrial enlargement based on an echocardiographically calculated left atrial:aortic surface area [LA:Ao(a)] > 6. Group 2 dogs (n = 6) had no to mild left atrial enlargement [LA:Ao(a) ≤ 6]. Dogs were prospectively evaluated. CBC, biochemistry, urinalysis, cervical and thoracic radiographs, fluoroscopy, echocardiography, and bronchoscopy were performed. Bronchoscopic abnormalities were compared between groups using Fisher's Exact Test. P < .05 was considered significant. Fluoroscopy identified airway collapse in both groups. Bronchoscopic evidence of airway collapse >50% was observed in multiple bronchi with no difference between groups. All dogs had inflammation on airway cytology with respiratory infection in 1 dog in group 2. Left atrial size was interpreted radiographically as enlarged in 9 of 10 group 1 dog and in 2 of 6 group 2 dogs. VHS was above normal in both groups of dogs regardless of echocardiographic evidence of cardiomegaly. Results failed to identify an association between left atrial enlargement and airway collapse in dogs with MMVD, but did suggest that airway inflammation is common in dogs with airway collapse.

Hyponatremia, Hypernatremia, and Mortality in Patients With Chronic Kidney Disease With and Without Congestive Heart Failure

Hyponatremia is common in patients with conditions such as congestive heart failure and is associated with increased mortality in hospitalized patients. Congestive heart failure is common in patients with chronic kidney disease, but the association of serum sodium concentration with mortality in such patients is not well characterized. We examined the association of serum sodium concentration with all-cause mortality in a nationally representative cohort of 655 493 US veterans with non-dialysis-dependent chronic kidney disease (95 961 [15%] of them with congestive heart failure). Associations were examined in time-dependent Cox models with adjustment for potential confounders. During a median follow-up of 5.5 years, a total of 193 956 patients died (mortality rate, 62.5/1000 patient-years; 95% confidence interval, 62.2-62.8). The association of serum sodium level with mortality was U-shaped, with the lowest mortality seen in patients with sodium level of 140 mEq/L and with both lower and higher levels showing significant associations with increased mortality. Patients with serum sodium levels of <130, 130 to 135.9, 145.1 to 150, and ≥150 mEq/L compared with 136 to 145 mEq/L had multivariable-adjusted mortality hazard ratios (95% confidence interval) of 1.93 (1.83-2.03), 1.28 (1.26-1.30), 1.33 (1.28-1.38), and 1.56 (1.33-1.83) (P<0.001 for all). The associations remained consistent in subgroups of patients with and without congestive heart failure. Both lower and higher serum sodium levels are independently associated with higher mortality in patients with non-dialysis-dependent chronic kidney disease, irrespective of the presence or absence of congestive heart failure.

Rapid fluid removal during dialysis is associated with cardiovascular morbidity and mortality

Patients receiving hemodialysis have high rates of cardiovascular morbidity and mortality that may be related to the hemodynamic effects of rapid ultrafiltration. Here we tested whether higher dialytic ultrafiltration rates are associated with greater all-cause and cardiovascular mortality, and hospitalization for cardiovascular disease. We used data from the Hemodialysis Study, an almost-7-year randomized clinical trial of 1846 patients receiving thrice-weekly chronic dialysis. The ultrafiltration rates were divided into three categories: up to 10 ml/h/kg, 10-13 ml/h/kg, and over 13 ml/h/kg. Compared to ultrafiltration rates in the lowest group, rates in the highest were significantly associated with increased all-cause and cardiovascular-related mortality with adjusted hazard ratios of 1.59 and 1.71, respectively. Overall, ultrafiltration rates between 10-13 ml/h/kg were not associated with all-cause or cardiovascular mortality; however, they were significantly associated among participants with congestive heart failure. Cubic spline interpolation suggested that the risk of all-cause and cardiovascular mortality began to increase at ultrafiltration rates over 10 ml/h/kg regardless of the status of congestive heart failure. Hence, higher ultrafiltration rates in hemodialysis patients are associated with a greater risk of all-cause and cardiovascular death.

Statin use after first myocardial infarction in UK men and women from 1997 to 2006: Who started and who continued treatment?

Background and aimsTo examine trends in initiation and continuation of statin treatment after myocardial infarction (MI) and their determinants, during a period of increasing usage. Methods and results9367 patients aged 30–84 with a first Myocardial Infarction (MI) in 1997–2006 were identified in DIN-LINK, an anonymised, UK primary care database. We assessed statin initiation (prescription within 6 months of MI) and continued therapy (% covered by a prescription on a given day of those prescribed a statin within 6 months). The influences of co-morbidities and socio-economic deprivation (Index of Multiple Deprivation) were examined.Statin initiation increased from 37% for MIs in 1997 to 92% in 2006. Continuation at 1 year remained stable over successive cohorts at approximately 80%, settling to about 76% in patients with 5–10 years follow up. Younger age, affluence, revascularisation in 6 months after MI, and absence of congestive heart failure, predicted higher initiation and continuation; a diagnosis of hypertension or diabetes predicted higher initiation, while smoking was associated with poorer continuation. Men had higher initiation and continued therapy, but these effects were largely explained by their younger age. Type of statin initially prescribed did not influence continued usage. ConclusionStatin use after MI increased markedly between 1997 and 2006, whilst continued therapy remained high and stable. Importantly, first choice of statin had no effect on continuation. Whilst the high current levels of initiation may have reached a ceiling, increasing continuation rates among smokers, older patients and those from lower socio-economic groups, should remain a priority.

295: Accuracy of Various Methods of B-Line Assessment In the Diagnosis of Congestive Heart Failure Compared by Receiver Operating Characteristic Curves

295: Accuracy of Various Methods of B-Line Assessment In the Diagnosis of Congestive Heart Failure Compared by Receiver Operating Characteristic Curves

Correlates of NT‐proBNP concentration in patients with essential hypertension in absence of congestive heart failure

N-terminal proBNP (NT-proBNP) is widely used as a diagnostic biomarker and for the risk stratification of patients with heart failure (HF). Its role in the evaluation of patients with essential hypertension (EHT) is less clear. We examined the relationship between NT-proBNP concentrations and various clinical characteristics in hypertensive patients without HF. This study included 186 consecutive patients with EHT and no history of HF, ischemic heart disease, or atrial fibrillation. Single and multiple variable regression analyses were performed in search of clinical correlates of NT-proBNP concentrations. In patients with EHT, median serum concentration of NT-proBNP was 73 pg/ml, and interquartile range (IQR) was 40-128 pg/ml. NT-proBNP was significantly higher (P<0.001) in women (87 pg/ml; IQR 55-137 pg/ml) than in men (52 pg/ml; IQR 24-115 pg/ml). Age (r=0.371, P<0.001), precordial QRS voltage (r=0.223, P<0.001), hemoglobin (Hgb) concentration, (r=-0.208, P=0.023) and estimated glomerular filtration rate (r=-0.139, P=0.044) were correlated with log-transformed NT-proBNP by multiple variable analysis. In men, age (r=0.453, P<0.001) and QRS voltage (r=0.283, P=0.004), and in women age (r=0.299, P=0.006), QRS voltage (r=0.212, P=0.019), Hgb (r=-0.182, P=0.049), and estimated glomerular filtration rate (r=-0.272, P=0.009) were correlated with serum concentrations of NT-proBNP. Age, gender, Hgb, left ventricular hypertrophy and renal function were correlated with NT-proBNP in patients with EHT.

Association of B-Type Natriuretic Peptide Levels With Estimated Glomerular Filtration Rate and Congestive Heart Failure

The causes of elevated B-Type natriuretic peptide (BNP) levels are multifactorial. Renal dysfunction has been shown to affect BNP levels in some studies and the diagnostic value of BNP levels in the presence of chronic kidney disease has been questioned. Prior studies have involved small patient populations with variable outcomes noted. This study evaluated the association of BNP levels with an estimated glomerular filtration rate (eGFR) and presence or absence of congestive heart failure (CHF). A retrospective, cross-sectional study in which medical records were electronically screened, identified patients with a BNP level and serum creatinine measurement on the same day between December 2002 and March 2006. Of 1739 eligible patients, 537 were positive for CHF and 1202 were negative for CHF by our criteria. There was a clear trend for BNP to be higher with the advancement of CHF, as determined by New York Heart Association (NYHA) classification (P<0.001). Median BNP levels increased from 65 pg/mL in patients without CHF to 496 pg/mL in patients with NYHA class IV CHF (P <0.001), and there was a strong inverse association with eGFR (P <0.001). BNP levels show a strong inverse association with eGFR in both CHF and non-CHF patients. Currently best practice at most institutions involves use of BNP cutoff diagnostic levels not adjusted for eGFR. The data presented underlines that eGFR is a significant confounder of BNP measurement especially when renal status is compromised and interpretation of clinical significance in the presence of elevated BNP measures should take renal status into consideration.

Pharmacokinetics of conivaptan hydrochloride, a vasopressin V 1A/V 2-receptor antagonist, in patients with euvolemic or hypervolemic hyponatremia and with or without congestive heart failure from a prospective, 4-day open-label study

Background: Conivaptan is a nonpeptide vasopressin V 1A/V 2-receptor antagonist that produces a controlled increase in serum sodium concentration in hospitalized patients with euvolemic or hyper-volemic hyponatremia. Objective: This study evaluated the pharmacokinetics of conivaptan in patients with euvolemic or hypervolemic hyponatremia and with or without underlying congestive heart failure who were participating in an efficacy and tolerability clinical trial. Methods: Data from an open-label, multicenter study were used to evaluate the pharmacokinetics of conivaptan in hyponatremic patients. Patients received a 20-mg loading dose intravenously over 30 minutes, followed by a continuous 4-day infusion of 20 or 40 mg/d. In the entire cohort, plasma conivaptan concentrations were determined at baseline, at the end of the loading dose (0.5 hour), at 24 hours, on days 3 and 4, and at the follow-up visit on day 11. A subset of patients at 2 study sites (the “pharmacokineticrich” subset) provided additional samples for pharmacokinetic analysis on day 1 at 1, 4, and 24 hours; on day 2 at 24 hours; and on day 5 at 1, 2, 7, 12, and 24 hours. Results: Plasma conivaptan concentrations were evaluated in 31 patients who received conivaptan 20 mg/d (mean [SD] age, 73.1 [14.3] years; weight, 68.1 [17.2] kg; 71.0% female; 87.1% white, 9.7% black, 3.2% other) and 172 patients who received co-nivaptan 40 mg/d (mean [SD] age, 71.5 [14.4] years; weight, 65.6 [15.9] kg; 64.0% female; 90.1% white, 6.4% black, 3.5% other). The pharmacokinetic-rich subset included 8 patients who received conivap-tan 20 mg/d (mean [SD] age, 76.3 [12.4] years; weight, 71.5 [14.7] kg; 87.5% female; 100% white) and 8 who received conivaptan 40 mg/d (mean [SD] age, 78.3 [7.9] years; weight, 71.3 [15.6] kg; 37.5% female; 100% white). In the overall patient group, plasma conivaptan concentrations were the highest after the 30-minute (C 0.5h) loading dose (mean [SD] C 0.5h = 733 [323] and 701 [343] ng/mL with conivap-tan 20 and 40 mg/d, respectively) and then declined during day 1 to concentrations (C 24h) (mean [SD] C 24h = 84 [78] and 215 [129] ng/mL with conivaptan 20 and 40 mg/d, respectively) that were maintained by the continuous infusion of 20 or 40 mg/d. At the end of infusion (96 hours), the mean (SD) plasma conivaptan concentrations were 176 (196) and 308 (321) ng/mL for conivaptan 20 and 40 mg/d, respectively. A ratio of 1.75 indicated near dose proportionality; however, interpatient variability was evident. No apparent differences in plasma conivaptan concentrations measured at 0.5 or 96 hours were observed between patients with euvolemic or hypervolemic hypona-tremia or between patients with or without congestive heart failure. In the pharmacokinetic-rich subset, for conivaptan 20 and 40 mg/d, respectively, conivaptan clearance was 18.7 and 9.5 L/h, the elimination t1/2 was 5.3 and 10.2 hours, and exposure to conivaptan in terms of AUC ∞ was 6996 and 30,771 ng · h/mL. Conclusion: The results of this study suggest that the pharmacokinetics of conivaptan 20 and 40 mg/d do not differ by volume status or the presence or absence of congestive heart failure.

The clinical value of rapid assay for plasma B-type natriuretic peptide in differentiating congestive heart failure from pulmonary causes of dyspnoea

B-type natriuretic peptide (BNP) is a cardiac neurohormone secreted from the cardiac ventricles in response to pressure overload. To evaluate the optimal cutoff point of plasma BNP in diagnosing congestive heart failure (CHF). We conducted a prospective study of 195 patients who were hospitalised with dyspnoea. Pulmonary capillary wedge pressure (PCWP) was measured with a Swan-Ganz catheterisation and plasma BNP level was obtained by a rapid immunofluorescence assay in all patients. PCWP >12 mmHg was chosen as the golden standard for left ventricular dysfunction in this study. The subjects were divided into two groups by the criteria, one group with dyspnoea caused by CHF (n=134) and the other caused by lung diseases (n=61). (1) BNP cutoff point of 100 pg/ml had a sensitivity of 94.34%, a specificity of 92.13% and an accuracy of 93.33% for differentiating CHF from pulmonary dyspnoea. (2) By multiple logistic-regression analysis, measurements of BNP added significantly independent predictive power to other clinical variables in models predicting which patients had CHF. A value of 100 pg/ml or more for a rapid BNP assay may be the most accurate independent predictor of the presence or absence of CHF.

Radiology Residents’ On-Call Interpretation of Chest Radiographs for Congestive Heart Failure

This study was designed to evaluate the performance of radiology residents in interpreting emergency department (ED) chest radiographs for congestive heart failure and to characterize the factors associated with a subsequent amended interpretation by an attending radiologist. We retrospectively reviewed all amended reports for ED chest radiographs between January 2004 and July 2005 and identified those with discrepant interpretations regarding the diagnosis of congestive heart failure. A total of 1.9% (476 of 24,600) of chest radiographs were amended over the study period. Forty-eight patients (75% female, mean age 66 years) whose chest radiograph was amended for the diagnosis of congestive heart failure and were available for review formed the study population. A control group of 35 patients (69% female, mean age 67 years) were individually matched to a convenience subset of patients by age, gender, clinical indication, and radiographic projection. Chest radiographs were in the anteroposterior projection in 62% (30 of 48) of study patients and 60% (21 of 35) of controls. A blinded expert panel of three board-certified cardiothoracic radiologists jointly reviewed each chest radiograph for the presence or absence of congestive heart failure and its specific radiographic findings. The expert panel diagnosed congestive heart failure in 19% (9 of 48) of study patients and in 23% (8 of 35) of controls (P = .65). When present, congestive heart failure was mild to moderate in severity in both the study and control groups (P = 1.00). There was a significant difference in the expert panel agreement between the attending versus the resident interpretation (65% versus 35%, P = .008), for the study group. This resulted in fair agreement (kappa = 0.29) between the expert panel and the attending interpretation and no agreement (kappa = -0.29) between the expert panel and the resident interpretation. In contrast, the expert panel agreed with the joint resident/attending interpretation in 83% (29 of 35) of controls, yielding substantial agreement (kappa = 0.72). Interpretation of chest radiographs for congestive heart failure by radiology residents has a low error rate. The majority of chest radiographs with discrepant resident and attending interpretations were portable films of female patients with subtle radiographic findings of congestive heart failure, and were inherently difficult to interpret.

Efficacy of Azimilide for the Maintenance of Sinus Rhythm in Patients With Paroxysmal Atrial Fibrillation in the Presence and Absence of Structural Heart Disease

Azimilide hydrochloride (azimilide), an investigational antiarrhythmic drug, has shown variable efficacy in preventing atrial fibrillation (AF). This study was designed to assess its efficacy in maintaining sinus rhythm in patients with paroxysmal AF and heart disease. Patients with symptomatic paroxysmal AF were screened for 1 month by transtelephonic monitoring. After recording 1 episode of AF in the screening period, they were randomized to receive azimilide 125 mg or placebo once daily. Patients were stratified by the presence or absence of congestive heart failure or coronary heart disease (CHF/CHD). A maximum of 220 patients without CHF/CHD were randomized, with the remainder having CHF/CHD. Patients with CHF/CHD were monitored for 3 days during loading. The primary efficacy analysis was the time to the first symptomatic recurrence of AF in the CHF/CHD group. Secondary analyses were the time to the first recurrence in the entire population and the time to the first recurrence in those with significant structural heart disease. The median time to recurrence of AF in the CHF/CHD group was 10 days in the 2 treatment arms. Nonsignificant trends were seen toward efficacy of azimilide in the CHF/CHD group (hazard ratio 1.28, 95% confidence interval 0.97 to 1.70, p=0.087), structural heart disease group (hazard ratio 1.22, 95% confidence interval 0.96 to 1.56, p=0.11), and overall group (hazard ratio 1.22, 95% confidence interval 1.00 to 1.49, p=0.053). No patient died. In conclusion, azimilide showed a nonsignificant trend toward efficacy in maintaining sinus rhythm in patients with AF.