Signs Of Congestion Research Articles

Performance evaluation of terminal airspace system safety, delay and predictability of Muritala Mohammed International Airport, Ikeja Lagos, Nigeria

This paper outlines a multi-dimensional user-oriented performance metrics approach in evaluating the operation of the terminal airspace system to aid in the airport and airspace planning and decision making. Safety, delay and predictability metrics contribute to the analytical framework. From the findings, the occurrence of air incidence has a high severity level at departure, and arrival phases of flight, higher likelihood at the radar room and much of the incidences were as a result of faulty equipment and inherent absence of modern airspace infrastructure. Also, in Lagos terminal airspace, the number of incidences has no close correlation with the level of traffic complexity. Total schedule arrival delay ranges from 1-392 minutes representing an average of 7.8-17.9 minutes per aircraft that arrived Lagos airport at that period. Besides, the total approach contact time ranges from 1-57 minutes, translating to 4.6-7.1 minutes per aircraft. However, variability in arrival time of 1-5 minutes is common from published airline arrival scheduled time. In the same vein, the variability of 1-5 minutes is common from approach contact times of aircraft. These figures indicate sound arrival predictability signature for Lagos airport. Also, departure time variability above 30 minutes is familiar from the ATC clearance time for the various routes under study. However, there is about or more 25% variability of more than 15 minutes, and this indicates possible inconsistency of predicting departure times from the times ATC clearance was acquired. Above all, the predictability of departure times in Lagos airport is weak compared to those of the arrival. Taken by it, this may be a sign of airspace congestion or ATC deficiencies at the Lagos airport. This is an indication of the lack of users' confidence in Nigeria's air transport industry to deliver just-in-time service.

Prognostic value of the ultrasonic determination of the degree of interstitial edema in patients with intermediate ejection fraction of the left ventricle after treating acute decompensation of heart failure

Aim To study ultrasonic characteristics of lung tissue in patients with heart failure with left ventricular (LV) mid-range ejection fraction (HFmEF) and predictive value of these characteristics after reversing acute decompensated heart failure (ADHF).Material and methods Ultrasonic characteristics of lung tissue were studied by prospective observation in 71 patients (mean age, 65.2±3.6 years; men, 64.3 %) with HFmEF (LVEF from 40 to 49 %) following ADHF reversal. Semiquantitative evaluation of B-lines was performed by the E. Picano (2016) method at 5+2 days after hospitalization and on discharge from the hospital. The distance between B-lines was 3 mm (В3 lines) and 7 mm (В7 lines). Patients' catamnesis was studied for determining the predictive value of lung tissue ultrasonic characteristics for two years since the index hospitalization. Statistical analysis was performed using the McNemar's χ2 test (for evaluation of linked samples and of changes in the presence/absence of B-lines as determined by lung ultrasound examination (USE)) and the Wilcoxon test (for evaluation of quantitative changes). Differences were considered significant at p<0.05.Results B7-lines characteristic of interstitial component of pulmonary parenchymal edema prevailed in patients with HFmEF. В3-lines characteristic of alveolar edema were found in a small amount. In the anterior-superior segment, B7-lines predominated over B3-lines (80 % vs. 20 %, p<0.01) on the right; however, on the lest, significant differences were not observed (64 % vs. 36 %, p>0.05). In the anterior-inferior segment, В7-lines prevailed over В3-lines on the right (75 % vs. 25 %, p<0.05); however, on the left, the difference was not significant (67 % vs. 33 %, p=0.05). In the lateral superior segment on the right, В7-lines predominated over В3-lines (75 % vs. 25 %, p<0.01); in contrast, on the left, there were no differences (67 % vs. 33 %, p>0.05). In lateral-basal segments on both sides, significant differences were present (73 % vs. 27 % on the right, p<0.05; 72 % vs. 28 % on the lest, p<0.05). The results of lung ultrasound were also used for evaluation of the B-line predictive value in patients with ADHF and mid-range EF on discharge from the hospital after reversal of X-ray and clinical symptoms of pulmonary congestion. In the next two years, 35 patients (49.2 % of sample) were rehospitalized with signs of ADHF (39 hospitalizations, 1.1 hospitalizations per patient). The rehospitalized patients were divided into two subgroups, with an increased number of B-lines and small congestion on discharge (6-15 В-lines) and without signs of congestion (<5 В-lines). For patients with a minimal (small) congestion on pulmonary ultrasound but regression of clinical and X-ray congestion, the number of rehospitalizations was 25 vs. 11 in patients with the number of B7-lines <5. In the ROC-analysis, the area under the curve was 0.706, which corresponded to the expert assessment as "good". The position sensitivity was 78.6 % and the specificity was 79.7 %.Conclusion "Ultrasonic pulmonary edema syndrome" in patients with LV mid-range ejection fraction after reversing ADHF was characterized by predomination of the interstitial component, despite the absence of X-ray congestion, correlated with the blood level of NT-proBNP measured at the same time, and was associated with rehospitalizations.

Effects on congestion, natriuretic peptides, diuretic efficiency, and renal function during different dose and administration of intravenous loop diuretic: preliminary data of DIUR-AHF Trial

Abstract Background Although loop diuretic is the cornerstone of treatment in acute heart failure (AHF) there is no consensus about the best modality and amount to be used during acute phase. Current Guidelines do not provide specific insights regarding timing course and target dose. Usually physicians double the oral domestic amount when they start intravenous infusion, but a precise algorithm does not exist. Aims To compare admission and pre discharge clinical congestion and BNP trend in relation to furosemide amount and modality administration; 2- to evaluate diuretic efficiency and renal function in the four arms and the potential effects on outcome. Methods This is a multicentre prospective Trial (DIUR-AHF) designed in order to clarify the correct loop diuretic target avoiding potential side effects. The study enrolled patients with AHF BNP level >100 pg/ml and congestion signs. Patients were divided in four arms in accordance with modality administration: Continuous (Ci) vs Bolus (Bi) and dose administered Low (LD) vs High (HD) considering a cutoff 125 mg/die. All patients executed a clinical congestion evaluation and Chest radiography at admission and pre discharge, BNP sample and renal function were measured during the first 12 hours and before discharge. Diuretic efficiency (DE) defined as weight change per 40 mg of furosemide during infusional period. DE was estimated as the net fluid output produced per 40 mg of furosemide equivalents, Follow up were obtained by direct visit or phone contact at 30 and 60 days after discharge Results We included 268 hospitalized patients with a mean BNP level 987±440 pg /ml, mean congestion score (3.5±2) creatinine and GFR value were 1.6±0.7 mg/dl; and 48±20 ml/min/m2 respectively. At admission BNP and Creatinine were modestly increased in HD (P<0.01) compared with all other groups. Pre discharge Congestion score were increased in Bi and HD groups (2.5±1 vs 1±1), similarly BNP levels were increased in Bi and HD with respect to Ci and LD (454±215 and 413±223 vs 288±170 and 312±248 p<0.05). Whereas DE were significantly increased in Ci compared with the other arms (−1.23 vs −0.55 p<0.01). In all groups, low DE, residual congestion and BNP reduction <30% resulted in escalation of diuretic strategies and impaired outcome (HR 1.88 [1.16–204]; 2.1 [1.4–2.8]; 1.3 [0.88–2.1]). A significant correlation between poor DE and residual congestion was recruited (r=0.76). Worsening Renal function (WRF) occurred much more in HD and Ci compared to LD and Bi (HD 44%, Ci 35% vs LD 33% and Bi 23% p<0.01) without significant effects on outcome. Conclusions HD and Bi of furosemide are both related with reduced congestion and invreased BNP level before discharge. In all groups low DE residual congestion and poor BNP reduction appear associated with higher rate of adverse events. Current data provide additional features for AHF patients during intravenous loop diuretic administration Funding Acknowledgement Type of funding source: None

Prognostic value of integrated cardiopulmonary ultrasound in inpatients with acute heart failure with preserved and reduced ejection fraction and without heart failure

Abstract Objective To assess the prognostic value of B-lines integrated with echocardiography in patients admitted to a Cardiology Department, with and without acute heart failure (AHF). Background Lung-ultrasound (LUS) B-lines are sonographic signs of pulmonary congestion and can be used in the differential diagnosis of dyspnea to rule in or rule out AHF. Their prognostic value at admission is less established, as well as the different role in AHF with reduced and preserved ejection fraction (HFrEF and HFpEF), or patients admitted for cardiac conditions but without overt signs and symptoms of AHF. Methods A total of 1021 consecutive in-patients (69±12 years) admitted for various cardiac conditions were enrolled. Patients were classified into three groups: 1) acute HFrEF; 2) acute HFpEF; 3) no AHF. All patients underwent on the admission an echocardiogram coupled with LUS, according to standardised protocols. Results Patients were followed-up for a median of 14.4 months (interquartile range: 4.6–24.3) for death and HF readmission (composite endpoint). During the follow-up, 126 events occurred. Kaplan-Meier survival analyses showed admission B-lines >30 identified patients with worse outcome at follow-up in the overall population and each of the three groups (Figure). At multivariable analysis (Table), admission B-lines >30, EF <50%, tricuspid regurgitation velocity >2.8 m/s and tricuspid annular plane systolic excursion (TAPSE) <17 mm resulted in independent predictors of the composite endpoint. B-lines >30 had a strong predictive value in HFpEF and non-AHF, but not in HFrEF. Conclusions Ultrasound B-lines can detect subclinical pulmonary interstitial edema in patients thought to be free of congestion, and provide useful information not only for the diagnosis but also for the prognosis in different cardiac conditions. Their added prognostic value among standard echocardiographic parameters is stronger in patients with HFpEF compared to HFrEF. Figure 1 Funding Acknowledgement Type of funding source: None

Impact of caval vein implantation on severity of tricuspid regurgitation, renal and hepatic function in patients with severe secondary tricuspid regurgitation

Abstract Background Severe tricuspid regurgitation (TR) is an important determinant for functional capacity and survival. It frequently occurs in patients with advanced heart failure resulting in progressive venous congestion with cardiorenal and cardiohepatic syndrome. The prospective, randomized TRICAVAL study reported the effect of inferior caval vein implantation of an Edwards Sapien XT valve (CAVI) in comparison to optimal medical therapy (OMT) in patients with severe TR. The study did not detect a superior functional outcome after CAVI, but a significant improvement in quality of life. Due to safety concerns, the study was stopped prematurely after 4 periprocedural complications. Purpose We hypothesised that CAVI reduces reflux into the inferior vena cava and leads to an increase in systolic right atrial pressure, which may result in an improvement of TR severity. The present subanalysis of the TRICAVAL study evaluates the impact of inferior caval vein implantation on TR severity, right heart parameters and renal and hepatic function. Methods Twenty-eight patients with severe TR were randomized in either CAVI group (n=14) with caval vein implantation of an Edwards Sapien XT valve or OMT group (n=14). Medical history, clinical examination, laboratory testing and echocardiographic measurements were analysed in patients with completed FUP (OMT [n = 10], CAVI [n = 8]). Follow-up examinations were performed at baseline and three months after enrolment. Results After three months, the CAVI group exhibited a significant reduction of systolic hepatic vein reflux volume (5.0 [1.3–11.0] ml vs. 14.0 [10.3–18.0] ml, p<0.05) and hepatic vein diameter (10.8 [10.0–12.0] mm vs. 14.0 [11.5–15.0] mm, p<0.05) in comparison to OMT. Compared to baseline, CAVI improved body weight (80.7 [69.0–87.7] kg versus 75.5 [63.8–84.6] kg, p<0.05) and abdominal circumference (101.5±13.8 cm versus 96.3±15.4 cm, p≤0.01) paralleled by a trend to lower doses of diuretics. However, over the FUP period, there were no significant changes regarding TR severity, right heart function and morphology as well as renal and hepatic function within both groups, nor in the comparison between CAVI and OMT. Conclusion As a proof of our concept, CAVI resulted in a decrease in systolic hepatic vein reflux, hepatic vein diameter and clinical signs of venous congestion. However, TR severity, right heart function and morphology as well as renal and hepatic function remained stable. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Edwards Lifesciences, Incorporated (Irvine, CA)

Estimation of the right atrial pressure by ultrasound-assessed internal jugular vein in patients with advanced chronic heart failure

Abstract Background In patients with systolic chronic heart failure (CHF) clinical signs of congestion cannot always be evident at clinical examination. Right atrial pressure (RAP) measured by right heart catheterization (RHC) is an accurate and reproducible marker of blood volume. A non-invasive accurate tool to identify CHF patients with normal RAP would be desirable to tailor therapy. Purpose To validate an ultrasound (US)-assessed internal jugular vein distensibility (JVD) ratio to identify patients with normal mean RAP (defined as 7 mmHg or less) measured by RHC. Methods We first identify the JVD ratio that allows the most accurate identification of patients with normal RAP in a prospective calibration cohort of 100 patients with systolic CHF. Then, we tested the JVD ratio threshold to identify patients with normal RAP in a validation cohort of 101 consecutive patients with systolic CHF. All patients had a left ventricular ejection fraction (LVEF)<50% and underwent RHC in the setting of heart transplant work-up. At the time of jugular vein puncture, we recorded the internal jugular vein diameter by conventional linear probes. JVD ratio was calculated as the ratio between maximum diameter (during Valsalva maneuver) and rest diameter of the vein (FIGURE). Finally, we assessed the prognostic value of the JVD ratio in the follow up of the first 100 patients. Results In the calibration cohort (mean age 53 years, 13% female; median LVEF 25%, 81% in NYHA class III/IV) we define the best threshold of the JVD ratio to identify patients with normal RAP that has 1.6 with an area under the curve (AUC of 0.74; p<0.0001). Based on this JVD ratio threshold we defined patients with low JVD ratio (≤1.6; n=58; median RAP 8 mmHg) and patients with high JVD ratio (>1.6, n=42; median RAP 4 mmHg). High JVD ratio and low JVD ratio groups had similar clinical and laboratory characteristics. In the validation cohort (mean age 55 years, 13% female; median LVEF 25%; 56% in NYHA class III/IV) using the previously defined 1.6 JVD ratio threshold, we identified 51 patients with low JVD ratio (median RAP 8 mmHg) and 50 patients with high JVD ratio (median RAP 3 mmHg; p<0.0001) The JVD ratio threshold has an accuracy to identify patients with a normal RAP with an AUC of 0.82 (p<0.0001); a predictive positive value of 0.94, negative predictive value of 0.51, specificity of 0.90, and sensitivity of 0.65. Finally, in the calibration cohort, the CHF patients with low JVD ratio (≤1.6) had a higher cumulative incidence of overall death, heart transplant, or left ventricular assist device (42.7% vs. 16.1% in the high JVD ratio group, p log-rank 0.006) at a median of 13-month follow-up. Conclusions We found that US-assessed JVD ratio is a convenient and accurate diagnostic tool to identify patients with advanced systolic CHF with normal vs. increased RAP. This tool could be tested in the ambulatory setting to modulate therapies, particularly diuretics and vasodilators. Figure 1 Funding Acknowledgement Type of funding source: None

Perinatal Arterial Ischemic Stroke in Fetal Vascular Malperfusion: A Case Series and Literature Review.

Fetal vascular malperfusion includes a continuum of placental histologic abnormalities increasingly associated with perinatal brain injury, namely arterial ischemic stroke. Here, we describe the clinical-neuroimaging features of 5 neonates with arterial ischemic stroke and histologically proved fetal vascular malperfusion. All infarcts involved the anterior territories and were multiple in 2 patients. In 2 neonates, there were additional signs of marked dural sinus congestion, thrombosis, or both. A mixed pattern of chronic hypoxic-ischemic encephalopathy and acute infarcts was noted in 1 patient at birth. Systemic cardiac or thrombotic complications were present in 2 patients. These peculiar clinical-radiologic patterns may suggest fetal vascular malperfusion and should raise the suspicion of this rare, underdiagnosed condition carrying important implications in patient management, medicolegal actions, and future pregnancy counseling.

Dual Vasopressin Receptor Antagonism to Improve Congestion in Patients With Acute Heart Failure: Design of the AVANTI Trial

BackgroundLoop diuretics are the main treatment for patients with acute heart failure, but are associated with neurohormonal stimulation and worsening renal function and do not improve long-term outcomes. Antagonists to arginine vasopressin may provide an alternative strategy to avoid these effects. The AVANTI study will investigate the efficacy and safety of pecavaptan, a novel, balanced dual-acting V1a/V2 vasopressin antagonist, both as adjunctive therapy to loop diuretics after admission for acute heart failure, and later as monotherapy. Methods and ResultsAVANTI is a double-blind, randomized phase II study in 571 patients hospitalized with acute heart failure and signs of persistent congestion before discharge. In part A, patients will receive either pecavaptan 30 mg/d or placebo with standard of care for 30 days. In part B, eligible patients will continue treatment or receive pecavaptan or diuretics as monotherapy for another 30 days. The primary end points for part A are changes in body weight and serum creatinine; for part B, changes in body weight and blood urea nitrogen/creatinine ratio. ConclusionsThis study will provide the first evidence that a balanced V1a/V2 antagonist may safely enhance decongestion, both as an adjunct to loop diuretics and as an alternative strategy. Trial registration numberNCT03901729

Elevated plasma endothelin-1 is related to low natriuresis, clinical signs of congestion, and poor outcome in acute heart failure.

AimsEndothelin‐1 (ET‐1) is a potent vasoconstrictor, which regulates renal and vascular function. We aimed to relate plasma levels of ET‐1 with the clinical picture and outcomes in acute heart failure (AHF).Methods and resultsWe studied 113 patients with AHF [mean age 65 ± 13 (years), median (upper and lower quartiles) N‐terminal pro‐B‐type natriuretic peptide, 5422 (2689; 8582) (pg/mL)], in whom plasma levels of ET‐1 were serially measured at admission (10.8 ± 5.2), Day 1 (9.5 ± 3.4), and Day 2 (8.9 ± 3.8) (pg/mL). The population was divided into tertiles across baseline ET‐1 levels. Patients in the highest ET‐1 tertile had predominant clinical signs of peripheral congestion; however, no difference was observed in pulmonary congestion and severity of dyspnoea. They also presented lower spot urine sodium at admission (75 ± 35 vs. 99 ± 43 vs. 108 ± 30), 6 h (84 ± 34 vs. 106 ± 43 vs. 106 ± 35), and Day 1 (75 ± 38 vs. 96 ± 36 vs. 100 ± 35) (mmol/L), when compared with the second and first tertile, respectively (all P < 0.05); furthermore, they received higher doses of intravenous furosemide from Day 2 and had longer intravenous diuretics, as median switch to oral furosemide was 4 (3; 4) vs. 3 (2; 4) vs. 2 (2; 3) (days), respectively, P < 0.05. There was no difference in serum creatinine, urea, and renal injury biomarkers (kidney injury molecule‐1, serum cystatin C, and urine neutrophil gelatinase‐associated lipocalin) between the ET‐1 tertiles. Higher values of ET‐1 measured at each time point were related with a higher risk of 1 year mortality.ConclusionsElevation of ET‐1 is related to clinical signs of peripheral congestion, low urine sodium excretion, and poor outcome in AHF.

The development of chronic diuretic resistance can be predicted during a heart-failure hospitalization. Results from the REDIHF registry.

IntroductionDiuretic resistance (DR) is a common condition during a heart failure (HF) hospitalization, and is related to worse prognosis. Although the risk factors for DR during a HF hospitalization are widely described, we do not know whether the risk of chronic DR could be predicted during admission.Material and methodsWe conducted a multicenter, prospective observational study between July 2017 and July 2019. All patients admitted for acute HF with intravenous diuretic treatment and at least one criterion of congestion on admission were invited to participate. Patients on renal replacement therapy, under intravenous diuretic treatment for >72 hours before screening and those who were unable to sign the informed consent were excluded. We monitored decongestion (physical exam, hemoconcentration, NTproBNP change and lung ultrasound) and DR (diuresis and weight loss per unit of 40mg furosemide and fractional excretion of sodium) on the fifth day of admission. Chronic DR was evaluate two months after hospitalization and was defined as persistent signs of congestion despite ≥80 mg furosemide per day. We compared variables from the hospitalization between patients with and without chronic DR. A multivariate logistic regression analysis was conducted to find predictors of chronic DR.ResultsA total of 105 patients were included in the study. Mean age was 74.5±12.0 years, 64.8% were male and mean LVEF was 46±17%. In the two months follow-up, five patients have died and one patient has had a heart transplant. Of the 99 remaining patients, 21 patients (21.2%) had chronic DR. The dose of furosemide before admission and the decrease in NT-proBNP ≤30% during admission were predictors of chronic DR in the multivariate analysis.ConclusionsWe can predict during a HF hospitalization which patients will develop chronic DR. The dose of furosemide before admission and the change in NT-proBNP are independent predictors of chronic DR.

Clinical significance of spleen stiffness in patients with acute decompensated heart failure.

AimsCongestive splenomegaly is a classic sign of organ congestion in acute decompensated heart failure (ADHF). Shear wave elastography (SWE) allows the measurement of spleen stiffness (SS). We hypothesized that SS could quantify the severity of splenic congestion and predict adverse events in ADHF.Methods and ResultsThis study included two cohorts: a haemodynamic cohort (62 HF patients) and an outcome cohort (115 ADHF patients). SS was measured by two‐dimensional SWE on the same day of right heart catheterization in the haemodynamic cohort. Right atrial pressure (RAP) independently correlated with SS (β = 0.32, P = 0.002). SS was measured in the outcome cohort before discharge. The 115 patients were divided into three groups on the basis of the tertile value of SS. The third tertile SS group had a higher prevalence of severe tricuspid regurgitation, higher N‐terminal B‐type natriuretic peptide (NT pro‐BNP), and larger right ventricular diastolic diameter, than had the first tertile group and the second tertile group. During a median follow‐up period of 105 (77–135) days, adverse events occurred in 25 patients (one death and 24 rehospitalizations for HF). The third tertile SS group had a significantly higher rate of adverse events (P < 0.001). A higher SS was independently associated with adverse events after adjusting for conventional validated risk score, liver function test, liver stiffness, and estimated RAP.ConclusionsThe degree of SS at discharge can be used as a marker of residual splenic congestion, which is predictive of adverse events in patients with ADHF.

Retinal and Optic Nerve Deformations Due to Orbital Versus Intracranial Venous Hypertension.

Abnormal forces around the optic nerve head (ONH) due to orbital diseases, intracranial hypertension (IH), glaucoma, and space travel, are associated with alterations of the ONH shape. Elevated cerebral and ophthalmic venous pressure can contribute to stress and strain on the ONH and peripapillary retina. We hypothesize that IH and elevated ophthalmic venous pressure without IH cause different ONH and retinal changes. We compared MRI and spectral domain optical coherence tomography (SDOCT) findings in patients with cavernous sinus arteriovenous shunts (CSAVSs), where orbital venous pressure is known to be elevated, with patients with intracranial dural venous sinus thrombosis and secondary IH. We also compared the results to those obtained in the Idiopathic IH (IIH) Treatment Trial. Among 18 patients with dural venous sinus thrombosis, the MRI/magnetic resonance venography displayed partial empty sella (61%) and optic nerve sheath distension (67%). None exhibited ophthalmic vein dilation or signs of orbital congestion. SDOCT of these eyes and IIH eyes showed a similar frequency of abnormal thickening of the mean retinal nerve fiber layer, anterior displacement of the basement membrane opening, peripapillary wrinkles, retinal folds (RF), and choroidal folds (CF). Among 21 patients with CSAVSs, MRI showed ipsilateral dilated superior ophthalmic vein (76%) and orbital congestion (52%) without distension of the optic nerve sheath or globe distortion. SDOCT showed CF (19%), one with overlying RF, and no ONH deformations. SDOCT findings for dural venous sinus thrombosis are similar to those seen with IIH but distinct from changes due to local ophthalmic venous hypertension. These data support the concept that IH even if due to a vascular cause and local orbital venous hypertension cause different stresses and strains on the ONH.

Distinct clinical phenotypes of congestion in acute heart failure: characteristics, treatment response, and outcomes.

AimsPatients with acute heart failure (AHF) are included into clinical trials regardless of differences in baseline clinical characteristics. The aim of this study was to assess patients with AHF according to the presence of central and/or peripheral congestion at hospital admission and evaluate treatment response and outcomes in studied phenotypes.Methods and resultsWe investigated retrospectively 352 patients (mean age: 68 ± 13 years, 77% men) hospitalized due to AHF with the signs of congestion on admission. Patients were divided according to the type of signs of congestion into three groups: A, isolated pulmonary congestion (n = 52, 15%); B, isolated peripheral congestion (n = 31, 9%); and C, signs of mixed (peripheral and central) congestion (n = 269, 76%). Patients from Group A had lower concentration of urea, bilirubin, and gamma‐glutamyl transferase whereas higher level of haematocrit, albumin, and leukocytes on admission. The highest baseline N‐terminal pro‐B‐type natriuretic peptide level (median: 4113 vs. 3634 vs. 6093 pg/mL) and percentage of patients with chronic heart failure (56 vs. 58 vs. 74%; A vs. B. vs. C, respectively, all P < 0.01) were observed in Group C. There were no differences in terms of demographics, co‐morbidities, left ventricular ejection fraction, and applied treatment between studied groups. Patients from Group A had the highest systolic blood pressure on admission (145 ± 37 vs. 122 ± 20 vs. 130 ± 29 mmHg) and the biggest decrease in systolic blood pressure [−22 (−45 to −4) vs. −2 (−13 to 2) vs. −10 (−25 to 0) mmHg] and heart rate [−16 (−35 to −1.5) vs. −1 (−10 to 5) vs. −7 (−20 to 0) b.p.m.] with the lowest weight change [−1.0 (−1.0 to 0) vs. −2.9 (−3.8 to −0.9) vs. −2.0 (−3.0 to −1.0) kg; all P < 0.01] after 48 h of hospitalization. There were differences in short‐term and long‐term outcomes with favourable results in Group A. Group A experienced less frequent in‐hospital heart failure worsening during the first 48 h (4 vs. 23 vs. 7%), had shorter length of hospital stay [6 (5–8) vs. 7 (5–11) vs. 7 (6–11) days], and had lower 1 year all‐cause mortality (12 vs. 28 vs. 29%; all P < 0.05). Presence of peripheral congestion on admission was independent predictor for all‐cause mortality within 1 year [hazard ratio (95% confidence interval): 2.68 (1.06–6.79); P = 0.04].ConclusionsPatterns of congestion in AHF are associated with differences in clinical characteristics, treatment response, and outcomes. It needs to be considered once planning clinical trials in AHF.

Formularization of entropy and anticipation of metastable states using mutual information in one-dimensional traffic flow

Both macro and micro states of Newtonian particles are used to define entropy. However, in previous research studies, which focused on traffic flow from the perspective of thermodynamics and information theory, researchers did not fully determine how entropy can be defined for self-driven particles that do not satisfy Newton’s laws. One attempt to formularize entropy in a one-dimensional traffic flow has been based on information theory. Entropy has been defined by focusing only on the location variation of the vehicles but not on the velocity variation of the vehicles. Moreover, no study has succeeded in considering the time evolution of entropy in a self-driven particle system. In this study, we redefine the entropy and mutual information in one-dimensional traffic flow from the information theoretical perspective, focusing on the velocity variation of vehicles. Moreover, we advance the thermodynamic analysis of one-dimensional traffic flow by examining the time evolution of the new formularized entropy. To observe the time evolution of the formularized entropy, we conducted numerical simulations using both stochastic optimal velocity (SOV) and zero-range process with a slow-start-rule (ZRP+SLS) models that can reproduce a metastable state, which occurs before the congestion begins at a high average velocity and short headway. Moreover, we used the mutual information to anticipate a metastable state – a sign of congestion – by calculating experimental data from three following vehicles on a real expressway to demonstrate the practical application of the formularized mutual information. Thus, we analyzed traffic flow both macroscopically and microscopically using the new formularized entropy to contribute to the studies of self-driven particle systems in both ways of thermodynamics and statistical mechanics or information theory.

Molecular, Cellular, and Clinical Evidence That Sodium-Glucose Cotransporter 2 Inhibitors Act as Neurohormonal Antagonists When Used for the Treatment of Chronic Heart Failure.

Sodium‐glucose cotransporter 2 (SGLT2) inhibitors reduce the risk of cardiovascular death and hospitalization for heart failure in patients with chronic heart failure. Initially, these drugs were believed to have a profile similar to diuretics or hemodynamically active drugs, but they do not rapidly reduce natriuretic peptides or cardiac filling pressures, and they exert little early benefit on symptoms, exercise tolerance, quality of life, or signs of congestion. Clinically, the profile of SGLT2 inhibitors resembles that of neurohormonal antagonists, whose benefits emerge gradually during sustained therapy. In experimental models, SGLT2 inhibitors produce a characteristic pattern of cellular effects, which includes amelioration of oxidative stress, mitigation of mitochondrial dysfunction, attenuation of proinflammatory pathways, and a reduction in myocardial fibrosis. These cellular effects are similar to those produced by angiotensin converting enzyme inhibitors, β‐blockers, mineralocorticoid receptor antagonists, and neprilysin inhibitors. At a molecular level, SGLT2 inhibitors induce transcriptional reprogramming of cardiomyocytes that closely mimics that seen during nutrient deprivation. This shift in signaling activates the housekeeping pathway of autophagy, which clears the cytosol of dangerous cytosolic constituents that are responsible for cellular stress, thereby ameliorating the development of cardiomyopathy. Interestingly, similar changes in cellular signaling and autophagic flux have been seen with inhibitors of the renin‐angiotensin system, β‐blockers, mineralocorticoid receptor antagonists, and neprilysin inhibitors. The striking parallelism of these molecular, cellular, and clinical profiles supports the premise that SGLT2 inhibitors should be regarded as neurohormonal antagonists when prescribed for the treatment of heart failure with a reduced ejection fraction.

Lung Ultrasound and Pulmonary Congestion During Stress Echocardiography

ObjectivesThe purpose of this study was to assess the functional and prognostic correlates of B-lines during stress echocardiography (SE). BackgroundB-profile detected by lung ultrasound (LUS) is a sign of pulmonary congestion during SE. MethodsThe authors prospectively performed transthoracic echocardiography (TTE) and LUS in 2,145 patients referred for exercise (n = 1,012), vasodilator (n = 1,054), or dobutamine (n = 79) SE in 11 certified centers. B-lines were evaluated in a 4-site simplified scan (each site scored from 0: A-lines to 10: white lung for coalescing B-lines). During stress the following were also analyzed: stress-induced new regional wall motion abnormalities in 2 contiguous segments; reduced left ventricular contractile reserve (peak/rest based on force, ≤2.0 for exercise and dobutamine, ≤1.1 for vasodilators); and abnormal coronary flow velocity reserve ≤2.0, assessed by pulsed-wave Doppler sampling in left anterior descending coronary artery and abnormal heart rate reserve (peak/rest heart rate) ≤1.80 for exercise and dobutamine (≤1.22 for vasodilators). All patients completed follow-up. ResultsAccording to B-lines at peak stress patients were divided into 4 different groups: group I, absence of stress B-lines (score: 0 to 1; n = 1,389; 64.7%); group II, mild B-lines (score: 2 to 4; n = 428; 20%); group III, moderate B-lines (score: 5 to 9; n = 209; 9.7%) and group IV, severe B-lines (score: ≥10; n = 119; 5.4%). During median follow-up of 15.2 months (interquartile range: 12 to 20 months) there were 38 deaths and 28 nonfatal myocardial infarctions in 64 patients. At multivariable analysis, severe stress B-lines (hazard ratio [HR]: 3.544; 95% confidence interval [CI]: 1.466 to 8.687; p = 0.006), abnormal heart rate reserve (HR: 2.276; 95% CI: 1.215 to 4.262; p = 0.010), abnormal coronary flow velocity reserve (HR: 2.178; 95% CI: 1.059 to 4.479; p = 0.034), and age (HR: 1.031; 95% CI: 1.002 to 1.062; p = 0.037) were independent predictors of death and nonfatal myocardial infarction. ConclusionsSevere stress B-lines predict death and nonfatal myocardial infarction. (Stress Echo 2020–The International Stress Echo Study [SE2020]; NCT03049995)

Prevalence and prognostic impact of subclinical pulmonary congestion at discharge in patients with acute heart failure.

AimsResidual pulmonary congestion at hospital discharge can worsen the outcomes in patients with heart failure (HF) and can be detected by lung ultrasound (LUS). The aim of this study was to analyse the prevalence of subclinical pulmonary congestion at discharge and its impact on prognosis in patients admitted for acute HF.Methods and resultsThis is a post‐hoc analysis of the LUS‐HF trial. LUS was performed by the investigators in eight chest zones with a pocket device. Physical exam was subsequently performed by the treating physicians. Primary outcome was a combined endpoint of rehospitalization, unexpected visit for HF worsening or death at 6‐ month follow‐up. Subclinical pulmonary congestion at discharge was defined as the presence of ≥5 B‐lines in LUS in absence of rales in the auscultation employing the area under the ROC curve. At discharge, 100 patients (81%) did not show clinical signs of pulmonary congestion. Of these, 41 had ≥5 B‐lines. Independent factors related with the presence of subclinical pulmonary congestion were anaemia, higher New York Heart Association (NYHA) class, and N terminal pro brain natriuretic peptide (NT‐proBNP). After adjusting by propensity score analysis including age, renal insufficiency, atrial fibrillation, NYHA class, NT‐proBNP levels, clinical congestion, and the trial intervention, the presence of subclinical pulmonary congestion at discharge was a risk factor for the occurrence of the primary outcome (hazard ratio 2.63; 95% confidence interval: 1.08–6.41; P = 0.033).ConclusionsUp to 40% of patients considered ‘dry’ according to pulmonary auscultation presents subclinical congestion at hospital discharge that can be detected by LUS and implies a worse prognosis at 6‐ month follow‐up. Comorbidities, high values of natriuretic peptides, and higher NYHA class are the factors related with its presence.

Controle de insuficiência cardíaca congestiva e arritmias ventriculares em um cão com cardiomiopatia dilatada – relato de caso

Abstract: We report a case of a dog, male, eleven year old, american cocker spaniel with a history of acute dyspnea and exercise intolerance. The electrocardiography examination revealed the presence of ventricular arrhytmias, and, through echocardiographic examination, the patient was diagnosed with dilated cardiomyopathy and congestive heart failure. Treatment was performed, with improvement in congestive signs and arrhytmias. Ventricular arrhytmias are difficult to control in patients treated only for underlying heart disease, without the administration of antiarrythmics. The patient survived for fifteen months, emphasizing the need for early diagnosis and treatment, in order to obtain an improvement in life expectancy of patients with heart disease.

P1249SEVERE HEMODYNAMIC INSTABILITY DURING DIALYSIS - DRY, STUNNED OR ALLERGIC? STATE OF THE ART ECHOCARDIOGRAPHY COMBINED WITH SIMULTANEOUS LUNG ULTRASOUND

Abstract Background and Aims Intradialytic hypotension is a fairly common and serious adverse phenomenon. Associated comorbidities include e.g. heart failure, hypovolemia, allergic reactions with the dialysis apparatus and electrolyte disturbancies. Excessive ultrafiltration may explain later onset hypotension, but early-onset hemodynamic collapse remains poorly understood. Preventive interventions may include incremental dialysis, increasing dry weight, increasing dialysis time and changing dialysis membranes/apparatus. This study combines Echocardiography (Echo) and Lung Ultrasound (LUS) for hemodynamic phenotyping of patients with severe, early onset intra-dialytic hypotension. The aim is to figure out possible preventive strategies depending on underlying abnormalities. Method We enrolled dialysis patients with a symptomatic decrease in systolic arterial pressure &amp;lt; 90 mmHg requiring norepinephrine during the first 60 minutes of at least two consecutive dialysis sessions in our dialysis department. Echo + LUS was done simultaneously to everyone at baseline, i.e. BEFORE dialysis begun, and later at onset of a hypotension episode during dialysis. Patients with active bleeding or any other obvious temporary etiology for hypotension were excluded. Echo concentrated especially on volemic state and filling pressures, while LUS evaluated the lungs and pleurae for signs of pulmonary congestion. Cardiac structure and function (e.g. valves, ejection fraction) was also evaluated. Results Between 1.10.2019 - 31.12.2019 10 patients were enrolled. All patients eventually required norepinephrine despite fluid challenge. No patients had signs or symptoms of an allergic reaction, such as urticaria or stridor/obstructive respiration, nor significant electrolyte disturbancies. 5/10 patients had severe systolic cardiac dysfunction at baseline (LVEF &amp;lt; 30 %) and these 5 patients also simultaneously showed signs of congestion and fluid overload on ultrasound. On the contrary, the other 5/10 patients without severe cardiac failure all had low left-sided filling pressures and a collapsed inferior vena cava on Echo ALREADY at baseline, i.e. before initiation of dialysis. All of these hypovolemic patients had an excellent residual diuresis (&amp;gt; 1500ml/d). All 10 patients in this study showed a significant drop in body volume measurement (BVM) -curves and left-sided filling pressures on Echo prior to onset of hypotension. Of the 5 patients with severe cardiac dysfunction, 2/5 were transmitted into palliative care without dialysis, while 3/5 could be managed without future norepinephrine by longer, more frequent dialysis sessions using more convective and less diffusive dialysis. Of the latter 5 “dry” patients without severe cardiac dysfunction, 3/5 had no more hypotensive episodes after increasing dry weight and using incremental dialysis programs, and the remaining 2 dry patients could be completely switched off dialysis due to vivid residual function. 3/5 of the “dry patients” had a baseline pulse pressure &amp;gt; 120 mmHg and 3 had coronary artery disease, both possibly predisposing to diastolic under-filling. No patients in this study presented with significant myocardial stunning, defined as a &amp;gt; 10 % decrease in LVEF compared to baseline. Conclusion Severe, intra-dialytic hypotension requiring vasopressors may be prevented by individual tailoring of dialysis prescription. Ultrasound may help phenotyping patients requiring different dialysis strategies, including stopping dialysis entirely. Stunning and allergic reactions seemed rare. At baseline, patients seemed to be mainly 1) either over-dialyzed (hypovolemic or hypo-osmotic) or 2) having significant cardiac disease, naturally requiring quite opposite preventive strategies. A decrease in left ventricular preload furthermore occurred in all patients at onset of hypotension, suggesting crossover of a patient-specific preload threshold.

Reduced Diuretic Dose in Patients Treated With Eplerenone: Data From the EPHESUS Trial.

Loop diuretics are used for congestion relief, and dose adaptations are usually a consequence of the clinicians' clinical judgement about the congestive status of the patient. In EPHESUS (Eplerenone in Patients With Systolic Dysfunction After Myocardial Infarction), many patients required diuretics for congestion relief. We thus hypothesized that blinded allocation to eplerenone would lead clinicians to reduce loop diuretics, as a consequence of the improvement in patients' status. Cox and mixed-effects models were used over a median follow-up of 1.3 years in 6632 patients. A total of 6632 patients were included; at baseline, 3352 (50.5%) did not have diuretics, 2195 (33.1%) had diuretic doses between 1 and 40 mg/day, and 1085 (16.4%) had diuretic doses >40 mg/day. Patients with higher furosemide equivalent doses had a worse clinical status. Both baseline and follow-up incremental loop diuretic doses were associated with worse prognosis. Eplerenone treatment was associated with lower prescribed loop diuretic doses throughout the follow-up; lower doses were observed at 90 days and decreased further at 180 days and beyond. Eplerenone treatment led to a mean furosemide equivalent dose reduction of -2.2 mg/day (-2.9 to -1.6) throughout the follow-up. Eplerenone was effective in reducing morbidity and mortality regardless of the baseline loop diuretic dose used: hazard ratio for the outcome of cardiovascular death or heart failure hospitalization was 0.83 ([95% CI, 0.75-0.92]; P for interaction, 0.54). Eplerenone treatment led to a loop diuretic dose reduction during follow-up without evidence of treatment effect modification by loop diuretics. These findings suggest that eplerenone reduces congestive signs and symptoms, which enables clinicians to reduce loop diuretic doses.