Decompensated Congestive Heart Failure Research Articles

The clinical prognosis of elderly patients with decompensated congestive heart failure greatly improved for 7 years after introduction of our unique clinical pathway

Abstract Background In Japan, especially in rural areas where our facility is located, the number of elderly decompensated congestive heart failure(DCHF) cases is increasing remarkably. Their hospitalization period tends to prolonged due to various complications peculiar to the elderly, and after discharge, they often admit in a short period with DCHF. In August 2015, we introduced the clinical pathway (PATH), which stipulates the efficient medical care for DCHF and comprehensive patient education by multidisciplinary staff. We have previously reported its effect about wide shortening of mean hospitalization period and significant reduction of rehospitalization in CHF patients admitted to our hospital. Purpose In this study, we re-examined the short-term and long-term clinical effects of PATH in elderly DCHF patients for 7 years, and also considered the residual problems about them. Methods We enrolled 929 DCHF cases (1128 admissions) aged 75 years or older who ware admitted to our hospital from April 2014 to July 2022. We divided them into two groups: 152 cases(199 admissions) admitted before the introduction of PATH (N-group) and 667 cases(929 admissions) applied PATH (P-group). About two groups we compared the acute care situation for DCHF, mean hospitalization period(HP), and DCHF readmission rate within 1 year after discharge(RA). Results The mean age of the P-group was slightly older. There were no significant differences between the two groups in the living conditions before admission, the proportion of each underlying disease or clinical data at admission. The performance rate of each treatment procedure in the acute phase was lower, and these performance period ware all shorter in P-group. The introduction rate of cardiac rehabilitation was higher and start timing was earlier in P-group. (Figure1) As a result, HP was significantly shorter), and the RA rate was lower in P-group. However, even in P-group, the cases who could not be discharged from the hospital to home(OTHER-group) took more time to adjust for hospital transfer or nursing home admission, so their HP was longer than that of the cases who could be directly discharged to home(HOME-group). And the RA rate of cases with past history of hospitalization for DCHF(PH-group) was higher than that of cases without history(NPH- group). (Figure2) Conclusion In the 7 years after the introduction of unique clinical pathway for acute phase treatment of decompensated congestive heart failure, even in elderly patients, it confirmed that each acute phase treatment had become more efficient, and the mean hospitalization period had been widely shortened. In addition, comprehensive lifestyle guidance to prevent worsening of their condition has seemed to reduce the rehospitalization rate for heart failure after discharge. However, we also confirmed f a few residual problems to be solved about the cases who could not discharged at home for any reason or repeated re-admission for heart failure.Figure 2

Examination about clinical efficacy and safety of active use of tolvaptan for decompensated congestive heart failure cases

Abstract Background In Japan, Tolvaptan is approved for use as a potent oral diuretic, mainly for severe congestive heart failure. However, over time since the launch of Tolvaptan, there have been many reports of its usefulness when used earlier in milder cases. Based on this background, in August 2015, our facility introduced a clinical pathway (PATH) for acute care for cases with decompensated congestive heart failure (DCHF), in which immediate use of tolvaptan with conventional diuretics ware stipulated to keep patient’s activity by early diuresis. Purpose In this study, we verified the clinical usefulness and safety of PATH for DCHF that prescribes the active use of tolvaptan. Methods From April 2014 to July 2022, 846 DCHF cases admitted to our hospital for the first time were included. They were divided into two groups, N-group(154 cases before introduction of PATH) and P-group(692 cases introduced PATH and prescribed Tolvaptan as stipulated). We investigated their implementation status of each medical treatment in acute phase and hospitalization period(HP), and compared the difference between the two groups. And in P-group, we investigated the occurrence of adverse event(AE), deterioration of renal function (R-event) and hypernatremia (N-event) that required unplanned discontinuation of tolvaptan use, and we investigated the clinical features about the cases with each adverse event. Results There was almost no difference in the patient background before admission or the patient's condition at admission. In P-group, the performance rate of each acute medical care for DCHF was lower and their performance period was shorter compared in N-group. The performance rate of cardiac rehabilitation was higher and its starting time was earlier in P-group. (Figure 1) As a result, HP was significantly shorter in P-group. AE incidence in P-group were 2.2%(R-event) and 4.8%(N-event). Mean age tended to be higher and cognitive function was lower in both AE cases. Cases with R-event were more likely to have pre-existing renal insufficiency. In N-event cases, their activity level before admission was lower and blood sodium level at admission was higher. Most of the N-event(85%) occurred within 7 days.(Figure 2) Conclusions With the introduction of unique clinical pathway that stipulates the active use of tolvaptan, the acute care of cases with decompensated congestive heart failure had been greatly simplified and streamlined, and the hospitalization period had been shortened. Although it is unlikely that all the results were due to the medicinal effects of Tolvaptan, it was thought that the realization of early mobilization due to its strong diuretic effect was linked to these results. A certain rate of feared adverse events, especially hypernatremia, was found to occur, but the rate appeared to be acceptable. However, in elderly and cognitively impaired cases, special caution seemed to be required for several days after the start of tolvaptan use.Figure 1Figure 2

Use of metolazone as an adjunct therapy to loop diuretics in diuretic resistant acute decompensation of heart failure: A systematic review and meta-analysis

Loop diuretics are the first-line treatment for volume overload in acute decompensation of congestive heart failure (AHF). Loop diuretic resistance is common due to pharmacologic tachyphylaxis. Therefore, thiazide and thiazide-like diuretics are often used as add-on therapy to combine two different pharmacologic mechanisms. This systemic review and meta-analysis aimed to synthesize the current evidence on the efficacy and safety of metolazone and other thiazide-like diuretics in AHF. PRISMA guidelines were followed in conducting this systematic review. PubMed, Scopus, PubMed Central, and Embase databases were searched using relevant keywords for studies published before 5 Jan 2022. Abstract and title screening was performed, followed by full-text screening using the Covidence software. Data were extracted, and analysis was done using Cochrane Review Manager (RevMan v5.1). The results were reported in odds ratio and mean difference with 95% confidence intervals. Out of 2999 studies identified by database search, eight studies met the inclusion criteria (2 RCTs and 6 cohort studies). Pooled analysis using a random-effects model showed no difference in mean difference among the metolazone group and control group for 24 hours total urine output (MD 69.32, 95% CI -638.29 to 776.94; n = 551; I2 = 84%), change in urine output in 24 hours (MD -284.09, 95% CI -583.99 to 15.81; n = 345; I2 = 0%), 48 hours total urine output (MD -465.62, 95% CI -1302.22 to 370.99; n = 242; I2 = 0%) and urine output at 72 hours (MD -13.24, 95% CI -90.88 to 64.40; n = 205; I2 = 0%). However, studies with furosemide only in the comparator arm, 24 hours of total urine outcome favored metolazone (MD 692.70, 95% CI 386.59 to 998.82; n = 334; I2 = 0%). There was no difference between the two groups in the rate of adverse events, loss of weight, mortality, or readmission rates. Metolazone therapy in diuretic resistant AHF may improves urine output and facilitates achieving a net negative balance. Thus, metolazone and thiazide-like diuretics can be used as add-on therapy in acute decompensation of heart failure, especially in diuretic resistance.

Abstract 081: Pulse Wave Velocity And Blood Pressure Variability As Prognostic Indicators In Very Elderly Patients With Advanced Chronic Conditions

The prognostic value of BP elevation in very old patients with other chronic comorbidities is uncertain. We aimed to assess the prognostic impact of 24-hour BP (both brachial and central), BP variability, and pulse wave velocity (PWV) in very elderly patients hospitalized due to a chronic disease decompensation. We included 249 patients older than 80 years, admitted to the hospital due to decompensation of congestive heart failure (149), chronic obstructive pulmonary disease (60), chronic kidney disease with acute kidney injury (26), or other decompensated chronic conditions (14). During hospital stay, 24-h BP monitoring was performed (Mobil-O-Graph PWV). Mean values of brachial and central BP, aortic PWV, and BP variability (24-hour SD) were obtained in all participants. After discharge, patients were followed-up for one year. The primary outcome was total mortality. Hazard ratio (HR) of BP estimates (for 1 SD increase) were obtained through Cox models, adjusted for clinical confounders. During follow-up 72 patients (29%) died. Progression of heart failure (58%) was the most frequent cause of death. No differences were observed in 24-h BP between those who died or remained alive. Systolic BP-SD, and PWV were higher in patients who subsequently died, while 24-hour HR- SD was lower (Table). In fully adjusted models, PWV (HR: 3.54; 95%CI: 2.37-5.28), SD of 24-h brachial systolic BP (1.29; 1.00-1.67) and SD of 24-h heart rate (0.65; 0.46-0.91) were associated with the risk of mortality. We conclude that PWV, SBP and heart rate variabilities, but not the level of BP are associated with mortality in very old patients with advanced chronic conditions

Transcatheter Aortic Valve Replacement in High-Risk Surgical Patient with Severe Aortic Insufficiency

Background: Transcatheter aortic valve replacement (TAVR) is approved by the FDA for severe aortic stenosis (AS) in patients of all surgical risk categories but has yet to be studied for its utility in aortic insufficiency (AI), despite the need for a safe alternative to surgery for prohibitive surgical risk patients. Case Report: We describe a case of a female patient who presented with acute decompensated congestive heart failure (CHF) with New York Heart Association (NYHA) Class IV symptoms. She was found to have severe AI leading to acute decompensation. Two years prior to this, she had aortic valve endocarditis that had potentially resulted in severe AI. Considering her underling comorbidities including diabetes mellitus, hypertension, morbid obesity and multiple myeloma on active chemotherapy at the time of evaluation, the patient was a high-risk surgical candidate for surgical aortic valve repair (SAVR) in view of elevated risk of mortality, infection, and poor wound healing. After critical and comprehensive assessment, transcatheter aortic valve intervention was considered to be an appropriate choice of treatment. TAVR was successfully performed that resulted in immediate improvement of aortic valve function. On subsequent follow-ups, she demonstrated markedly improved symptoms and reduced status to NYHA Class II HF symptoms. Conclusion: TAVR is a potential treatment modality for patients with severe AI who are poor surgical candidates for SAVR. We hope our case contributes to the growing pool of studies investigating the utility of TAVR procedure in patients with severe AI.

Congestive heart failure masquerading as acute abdomen: A case report

Rationale: As an uncommon manifestation of congestive heart failure, congestive hepatopathy requires an early diagnosis in order to render appropriate care. Misdiagnosis as intraabdominal sepsis may lead to erroneous initial intervention, such as fluid boluses, that can potentially tip an already sick patient with poor reserves over into an extreme state.Patient’s Concern: A 65-year-old man was brought to the emergency department for excruciating abdominal pain, vomiting and jaundice. He also had lower limb pitting edema and was hypotensive en route.Diagnosis: Congestive hepatopathy.Interventions: Intravenous furosemide and fluid restriction.Outcomes: The patient declined admission to the cardiology ward and discharged himself against medical advice after his condition was improved in the emergency department.Lessons: It is important to pay attention to acute abdominal pain induced by extraabdominal pathologies. In this case of acute decompensated congestive heart failure, early recognition of the cause makes a difference to the management.

ACUTE RESPIRATORY DISTRESS: A RARE PRESENTATION OF URETERAL RUPTURE

TOPIC: Signs and Symptoms of Chest Diseases TYPE: Medical Student/Resident Case Reports INTRODUCTION: Cardiorespiratory disorders usually present with acute respiratory distress; likewise, ureteral rupture usually presents as an acute abdomen [1]. We report a case of ureteral rupture presenting with acute respiratory distress leading to a delayed diagnosis. CASE PRESENTATION: An 82 y/o M with a history of congestive heart failure (CHF), chronic obstructive pulmonary disease, chronic renal failure and recently diagnosed COVID -19 pneumonia, was admitted for progressive dyspnea and abdominal discomfort for 2 days. Arterial blood gas showed hypercapnic hypoxic respiratory failure. Chest computed tomographic (CT) scan without contrast showed moderate right-sided pleural effusion but pulmonary embolism (PE) could not be ruled out. He also had a left leg deep venous thrombosis with worsening renal function and B-type natriuretic peptide (BNP) of 139pg/ml.His symptoms were thought to be due to acute decompensated CHF, COVID-19 pneumonia and possible PE. He failed to improve with intravenous furosemide, bilevel positive airway pressure ventilation and empiric anticoagulation. Due to worsening renal function and abdominal pain, an abdominal CT was done which showed right ureteral rupture with retroperitoneal collection and multiple non-obstructing renal calculi. The patient had placement of a double J stent with prompt resolution of respiratory distress. DISCUSSION: There are very few case reports of ureteral rupture occurring spontaneously and causing marked dyspnea. Respiratory distress may occur if the extravasated urine leads to an urinothorax or abdominal compartment syndrome [1]. Suspicion of non-cardiorespiratory causes of acute dyspnea in patients with underlying congestive heart failure includes respiratory distress disproportionate to the size of pleural effusion, unilateral effusions or effusions of markedly disparate size, absence of pulmonary vascular congestion and cardiomegaly, worsening renal function, ascites, urinary retention or anuria, abdominal pain, failure of the effusion to respond to management of heart failure, fever or pleuritic chest pain, and low or near-normal natriuretic peptides [2,3].When there are concerns for non-cardiorespiratory causes of respiratory distress, the diagnosis can be made with thoracentesis and imaging such as abdominal ultrasound, or CT [2]. CONCLUSIONS: This case illustrates a rare presentation of ureteral rupture causing respiratory distress and the key points that should elicit high clinical suspicion for non-cardiorespiratory causes of acute respiratory distress. When these findings are present, appropriate investigations and urgent intervention may be life-saving. REFERENCE #1: Choi SK, Lee S, Kim S, et al. A rare case of upper ureter rupture: ureteral perforation caused by urinary retention. Korean J Urol. 2012;53(2):131-133. doi:10.4111/kju.2012.53.2.131 REFERENCE #2: Leonidas Laskaridis, Spyridon Kampantais, Chrysovalantis Toutziaris, Basileios Chachopoulos, Ioannis Perdikis, Anastasios Tahmatzopoulos, Georgios Dimitriadis, "Urinothorax—An Underdiagnosed Cause of Acute Dyspnea: Report of a Bilateral and of an Ipsilateral Urinothorax Case", Case Reports in Emergency Medicine, vol. 2012, Article ID 395653, 3 pages, 2012. https://doi.org/10.1155/2012/395653 REFERENCE #3: Porcel JM. Pleural effusions from congestive heart failure. Semin Respir Crit Care Med. 2010 Dec;31(6):689-97. DOI: 10.1055/s-0030-1269828. Epub 2011 Jan 6. PMID: 21213200. DISCLOSURES: No relevant relationships by sharmela Brijmohan, source=Web Response No relevant relationships by Angelica Medina-Pena, source=Web Response No relevant relationships by Noura Semreen, source=Web Response

Abstract 16279: Impact of Race and Socioeconomic Status on Rates of Congestive Heart Failure Admissions, Readmissions, and Length of Stay

Introduction: Health disparities due to race and socioeconomic status persist among congestive heart failure (CHF) patients. Our hospital in the Philadelphia area is uniquely situated to study disparities as it sits on the border of a diverse inner city and suburban population. The area west of our hospital is known to have a drastically higher median income than the area to the east. We aimed to evaluate differences in rates of CHF admissions, readmissions, and length of stay (LOS) for patients based on race and socioeconomic status. Methods: From 3/1/2018 to 3/31/2020, 6,785 total patients were admitted to our hospital due to acute decompensated CHF. To compare rates of admission, readmission and a LOS > 5 days based on race and socioeconomic status, we used the SlicerDicer function of the EPIC electronic record platform. For race, we compared data for white and black patients. For socioeconomic status, we included a 10-mile radius around our hospital and used public records to collect median household income for 11 zip codes to the east and 11 to the west. The average yearly median household income for the east and west zip codes were USD $27,171 and $134,390, respectively. Outcomes are expressed as percentages and compared using a Chi-square test of independence and 95% confidence interval (CI) for differences. Significance was assessed at the 0.05 level. Results: Admission rates were significantly higher among Black patients at 67% compared to White patients at 58% (95% CI 7-11%, p<0.05). There was no significant difference between rates of readmission (60% for Black vs. 58% for White patients, 95% CI 0-4%, p=0.11) or LOS > 5 days (56% for Black vs. 55% for White patients, 95% CI 0-3%, p=0.42). Admission rates were significantly higher among patients from low income areas at 70% compared to high income areas at 56% (95% CI 11-17%, p<0.05). Readmission rates were not significantly different, 57% for low income and 56% for high income areas (95% CI 0-4%, p=0.82). Patients from low income areas were significantly more likely to have a LOS > 5 days at 57% compared to patients from high income areas at 53% (95% CI 0.8-8%, p<0.05). Conclusions: Race and socioeconomic status continue to impact CHF patients’ health outcomes including rates of admissions, readmissions, and length of stay.

CARDIAC ARREST CAUSED BY IATROGENIC AIR EMBOLISM FOLLOWING COMPUTED TOMOGRAPHY

SESSION TITLE: Medical Student/Resident Imaging Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: The presence of air within the circulatory system is a rare event that is typically iatrogenic in origin and often follows invasive or diagnostic procedures. CASE PRESENTATION: An 85-year-old male with a past medical history significant for hypertension, hypothyroidism, and osteoarthritis was admitted to the hospital for acute decompensated congestive heart failure. The etiology of his heart failure was determined to be due to severe aortic stenosis, based on a transthoracic echocardiogram. Once the patient was stabilized, he underwent a CT scan of his chest to determine if he would be a candidate for a trans-catheter catheter aortic valve replacement (TAVR). After the patient was returned to his room, he suffered PEA arrest while being assisted from the gurney to his bed. A code was called and the patient was intubated and received CPR. Return of spontaneous circulation was quickly obtained and he was transferred to the medical ICU. The patient was weaned from the ventilator and suffered no neurological consequences of the arrest. Images from the CT scan showed that his arrest was caused by acute right heart failure from a large air embolism occluding the right ventricle and pulmonary arteries. The patient was discharged home in stable condition. As an outpatient, he completed the rest of the TAVR work-up and successfully had his aortic valve replaced without complication. DISCUSSION: One of the most common causes of the introduction of air into the venous system occurs after contrast medium is injected for a CT scan. Based on previous case reports, the volume of air necessary to cause a fatality ranges from 200-300 mL, but symptoms have been reported with amounts as low as 50mL. Lethal air emboli are large enough to cause obstruction of the right ventricular outflow tract causing a drop in cardiac preload, which then leads to falling blood pressure, myocardial infarction and cerebral ischemia. The treatment of a symptomatic air embolus is to perform the Durant maneuver, which involves placing the patient in the left lateral decubitus position with the head down and the legs raised, which will alleviate the obstruction by having the air rise to the apex of the right ventricle. CONCLUSIONS: In this case, the patient was initially protected from the injected air due to his remaining supine until he returned to his room and sat upright. At that point, all of the air which had been pressed against the anterior portion of the right ventricle ascended and occluded the right ventricular outflow tract, triggering his cardiac arrest. The prevention of air emboli during CT scan typically involves constant monitoring of the pressure infusion devices to ensure that only contrast is injected into the patient. Reference #1: Durant TM, Oppenheimer MJ, Webster MR, Long J. Arterial air embolism. American Heart Journal. 1949;38(4):481-500. Reference #2: Malik N, Claus PL, Illman JE, Kligerman SJ, Moynagh MR, Levin DL et al. Air embolism: diagnosis and management. Future Cardiology. 2017;13(4):365-378. DISCLOSURES: No relevant relationships by Karl Andersen, source=Web Response No relevant relationships by Amanda Kamar, source=Web Response No relevant relationships by Arvey Stone, source=Web Response

Abstract 329: Cholecystalgia: an Atypical Presenting Symptom of Congestive Heart Failure

Acute acalculous cholecystitis is defined as acute inflammatory disease of the gallbladder without evidence of gallstones or cystic duct obstruction. Imaging studies typically show a distended acalculous gallbladder with thickened walls. Heart failure is well known to cause congestive hepatopathy and can be associated with isolated gallbladder edema which is often difficult to differentiate from acalculous cholecystitis. We present a case of cholecystalgia secondary to isolated gallbladder edema without hepatic congestion in a patient with non-ischemic cardiomyopathy mimicking the presentation of acalculous cholecystitis. A 46-year-old female with a past medical history of recently diagnosed non-ischemic cardiomyopathy during a prior hospitalization. Echocardiogram showed biventricular heart failure with EF of 15 to 20% with severe left and right ventricular dilatation and global hypokinesis. Left heart catherization showed no angiographic evidence of coronary artery disease and right heart catheterization demonstrated pulmonary hypertension secondary to left heart disease. She left against medical advice and was non-compliant with her medications. Approximately one month later, she presented with shortness of breath and orthopnea. On physical examination, jugular venous distention, S3 gallop, diffuse crackles and anasarca were noted. Labs showed BNP of 12,735. Chest CT revealed cardiomegaly and diffuse interstitial edema with bilateral pleural effusions and no signs of pulmonary embolus. Metoprolol and bumetanide were initiated for management of her acutely decompensated congestive heart failure. Several days after admission, she developed severe sharp RUQ pain associated with nausea and vomiting. She was tachypneic, diaphoretic with severe tenderness in the RUQ. Abdominal ultrasound revealed no signs of congestive hepatopathy but revealed a diffuse, edematous thickening of the gallbladder wall without evidence of stones. Hepatobiliary scintigraphy revealed preserved gallbladder function with an EF of 88%. The remainder of her care was focused on optimization of the patient’s congestive heart failure with complete resolution of her symptoms. Acute decompensation of congestive heart failure can result in an increase in pulmonary or systemic venous pressure, which may result in vascular congestion. The vascular distention can lead to isolated distention of the gallbladder wall that can mimic symptoms of acalculous cholecystitis. In such patient’s cholecystectomy or percutaneous cholecystostomy is not warranted. Radiographic evidence and symptoms usually resolve with optimization of congestive heart failure treatment. This case details the under-recognized presentation of secondary cholecystalgia in a patient with acute RUQ pain and underlying congestive heart failure.

Epidemiology Characteristics and Outcome of Patients With Clinically Diagnosed Acute Myocarditis

BACKGROUNDThere are controversial data regarding the outcome and management of patients hospitalized with clinically diagnosed acute myocarditis. METHODSWe retrospectively evaluated data of 322 consecutive patients admitted to the Sheba Medical Center with clinically suspected acute myocarditis from January 2005 to December 2017. Patients were subdivided into 2 groups based on their left ventricular ejection fraction (LVEF) at presentation: 1) patients with an LVEF <50% (n = 60) and 2) patients with an LVEF ≥50% (n = 260). We aimed to evaluate the clinical characteristics, management, and in-hospital outcome as well as short-term and 1-year outcome of patients admitted with acute myocarditis. RESULTSThe mean age of the study population was 37 ± 14 years, most of them (84%) males. Although chest pain was the main complaint in 89% of the patients at presentation, only 35% had typical pericardial pain. Patients with a LVEF <50% were more likely to demonstrate ST depression or T wave inversion on their electrocardiogram (ECG) at presentation (33% vs 18%, P = 0.007), and have higher levels of admission and peak troponin compared to those with LVEF ≥50%,(12.7 μ/L ± 15 µ/L vs 5.5 μ/L ± 9.2 μ/L, P = 0.001 for admission troponin, 18.8 μ/L ± 19.9 μ/L vs 8.4 μ/L ± 11.6 μ/L, P <0.001, for peak troponin). Univariate analysis showed that patients with an LVEF <50% were more likely to suffer from adverse cardiovascular events, defined as a composite of the following: 1) acute decompensated congestive heart failure; 2) ventricular arrhythmias; and 3) in-hospital mortality, compared to those with an LVEF ≥50% (15 [25%] vs10 [4%], P <0.001). Consistently, multivariable analysis showed that patients with an LVEF <50% had a 4-fold increased risk of adverse cardiovascular events compared to those patients with an LVEF ≥50% (heart rate [HR] = 4.30; 95% confidence interval [CI] 1.59-11.49; P <0.001). CONCLUSIONSPatients with clinical acute myocarditis seem to have an overall good prognosis. Although patients with an LVEF <50% are at a higher risk of in-hospital adverse events compared to those with an LVEF ≥50%, this propensity is not reflected during 1-year of follow-up.

Interactive and potentially independent roles of renin-angiotensin-aldosterone system blockade and the development of cardiorenal syndrome type 1 on in-hospital mortality among elderly patients admitted with acute decompensated congestive heart failure.

PurposeCardiorenal syndrome type 1 (CRS1), defined as worsening renal function from acute decompensated congestive heart failure (ADCHF), is complicated by the fact that CRS1 limits the use of common therapeutic strategies, such as angiotensin converting-enzyme inhibitors (ACEIs) or angiotensin II-receptor blockers (A2RB). The present study examines retrospectively the role of ACEI/A2RB usage on in-hospital mortality among elderly ADCHF patients, in particular those who developed CRS1.MethodsWe retrospectively examined the effects of ACEI/A2RB usage and CRS1 development (in-hospital change in serum creatinine ≥0.3 mg/dL or ≥0.5 mg/dL), as well as their potential interaction, on in-hospital mortality among elderly ADCHF patients (aged ≥65 years). Employing univariate and multivariate analyses, we performed risk-factor analysis on a cohort of 419 patients (51 nonsurvivors [12.2%]) for whom we had complete clinical and laboratory data (median follow-up 5 days) from 2,361 consecutive elderly ADCHF patients (106 nonsurvivors [4.6%]).ResultsBy multivariate analysis, the two strongest independent predictors of in-hospital mortality were CRS1 development (OR 7.8, 95% CI 3.9–15.5; P=0.00001) and lack of ACEI/A2RB usage (OR 0.49, CI 0.25–0.93; P=0.043). The effect of CRS1 was graded, with increasing CRS1 severity associated with increased mortality. On multivariate subgroup analysis, the association between lack of ACEI/A2RB usage and increased mortality remained a significant independent predictor among patients not developing CRS1 (OR 0.24, CI 0.083–0.721; P=0.011).ConclusionOur data suggest that development of CRS1 and lack of ACEI/A2RB usage are statistically independent predictors of in-hospital mortality for elderly ADCHF patients, with CRS1 being the stronger of the two risk factors. While it remains unclear whether lack of ACEI/ A2RB usage is causally related to increased mortality or reflects another risk factor inducing physicians to forego ACEIs/A2RBs, our findings nevertheless indicate the need to address this issue in future prospective studies.

Moving Beyond Diagnostic Accuracy With Systematic Reviews and Meta-analyses.

In this issue of Academic Emergency Medicine, Viau et al.1 assess the yield of computed tomography (CT) of the head among patients presenting with syncope. The systematic review included a total of 17 studies (15 retrospective chart reviews and two prospective) that included adult emergency department (ED) patients presenting with the chief complaint of syncope or those admitted to the hospital for syncope. Approximately half of these ED patients underwent head CT with a 1.2 and 3.8% yield of serious intracranial conditions identified in admitted patients and ED patients, respectively. Serious intracranial conditions were selected based on clinical relevance, previous literature, and consensus among the coauthors.1 While this systematic review is not directly a diagnostic accuracy trial, it gives us an opportunity to discuss how to appraise the evidence pertaining to diagnostic tests within the context of clinical efficiencies in an era of value-based purchasing. Over the past 20 years there has been a shift in the understanding and approach to diagnostic testing in medicine. 1. Tests rarely produce yes and no answers. Better understanding of diagnostic test interpretation in the clinical setting has resulted in dismissing the notion of yes or no answers (i.e., rule in or rule out). Diagnostic tests, which include history, physical exam, labs, and imaging, typically change the probability of the disease or condition and the concept of test and treatment thresholds originated to assist in managing these posttest probabilities. If a test result increases the probability of the condition to a level beyond the treatment threshold, the probability is high enough to indicate that the benefits of treatment outweigh the harms. If the diagnostic test result reduces the probability of the disease below the test threshold (i.e., acceptable miss rate), the presence of the disease is unlikely enough that the clinician should consider other diagnoses to explain the patient's symptoms. In cases where the posttest probability of the condition falls between these thresholds, additional testing will typically be necessary. These thresholds vary based on factors such as the severity of the medical condition and the potential benefits and harms associated with treatment.2 For example, the treatment threshold for uncomplicated urinary tract infection in a healthy young woman3 would be quite different from the treatment threshold for acute pulmonary embolism.4 In fact, statistical models can produce test and treatment thresholds for most medical conditions based on the operating characteristics of the tests as well as benefits and harms of treatment.5 For example, the test (synovial fluid white blood cell analysis) and treatment thresholds for septic arthritis in adults have been reported to be approximately 5 and 39%, respectively.6 This means that if the clinical probability of septic arthritis is below 5%, further testing might not be helpful (or even harmful). On the other hand, if the probability of septic arthritis is above 39%, treatment should be started as further diagnostic testing is not likely to increase the yield and could potentially harm the patient.6 2. Using likelihood ratios to measure probability of the disease. Likelihood ratios are the tools that are used to manage probability of the disease in diagnostic testing.7 This initial probability of a disease is usually determined based on the prevalence of the disease or from previous studies and is called pretest probability. The pretest probability is determined before any medical history is obtained, any physical examination is performed, or any test is ordered. Each additional pertinent positive or negative information or test will change the pretest probability and produce a new probability called posttest or posterior probability. The change from one probability to another is possible because of likelihood ratios. The likelihood ratio for a positive test increases the probability of the disease and the likelihood ratio for a negative test decreases the probability of the disease. The extent by which the probabilities are changed depends on the numerical value of the likelihood ratios.3, 7 As a rule of thumb, positive likelihood ratios more than 10 significantly increase the disease probability and negative likelihood ratios less than 0.1 significantly reduce it.7 3. Focusing on what matters. Another shift in paradigm pertaining to diagnostic testing is measuring the value of a diagnostic test by its impact on patient-centered outcomes. Nowadays patients, clinicians, and payers require more than analytical or technical characteristics and accuracy from a diagnostic test. They would also expect the test to lead to health benefits.8 Highly accurate tests might not change the outcome of the patients. For example, N-terminal-pro brain natriuretic peptide (NT-proBNP) and brain natriuretic peptide (BNP) are very sensitive diagnostic tests in identifying acute decompensated congestive heart failure. However, the knowledge of these values rarely affect the patient-centered outcomes of patients with this condition.9 Coronary angiography, a highly accurate diagnostic test in diagnosing coronary artery stenosis, might not be beneficial or could even be harmful (number needed to harm of 50 for major hemorrhage, myocardial infarction, or stroke because of the procedure) in patients with stable coronary artery disease.10 This is probably the most important change in approach to diagnostic testing as clinicians are more mindful of the concept of overdiagnosis and the harms associated with it.11 Simple “routine” tests might pose significant inconvenience and harm to patients. For example, performing routine preadmission chest x-rays or routine chest x-rays in patients with chest pain could result in accidental findings such as benign nodules. These findings automatically put the patients on a path that requires multiple doctor visits and potentially significant radiation exposure (follow-up CT scans of chest). The psychological harms associated with these findings and the prolonged stress until the nodules are deemed benign should be emphasized more. 4. Diagnostic yield. In addition to accuracy, the value of a diagnostic test lies in the probability that it provides the information needed to establish a definitive diagnosis. The difference between diagnostic accuracy and diagnostic yield is that the latter varies in each clinical scenario.12 The diagnostic yield of CT scan of the head in patients with a focal neurologic deficit and for diagnosing stroke might be quite different from that of CT scan of the head for syncope for identifying a possible etiology. Diagnostic yield is generally higher when the probability of the disease is higher, and the test is used in a proper clinical context.12 This is impacted by spectrum bias: when patients are at the milder end of the disease spectrum, many tests are not definitive. Overuse of the test, whether because of a “just-in-case” strategy or defensive medical practice, significantly reduces the diagnostic yield. Routine ordering of coagulation profile (PT and PTT) in patients who are not on anticoagulants or have no evidence of liver failure is an example of a low-yield test.13 Blindly ordering tests with low diagnostic yield in any clinical scenario has implications for the patients, physicians, and also the laboratory. Overuse of tests and “overdiagnosing” may make the patients’ management more confusing and problematic. This practice may produce unexplained, abnormal results that generate additional testing that could be harmful to the patient. However, these harms are rarely measured as a quality indicator. In addition to overburdening the laboratories and radiology suites, overtesting certainly contributes to already inflated health care costs. 5. Do no harm. There is an increasing awareness that preventing medical harm must become one of the pillars of modern health care. Similar to treatment strategies, diagnostic tests are associated with harms.11 No test is perfect, so patients require nuanced decisions rather than groupthink conformity. Understanding of this concept has resulted in the proposal of a strategy called “deliberate clinical inertia.”14, 15 This refers to the art of doing nothing as a positive response. Adopting deliberate clinical inertia, i.e., the art of not intervening, as a specific measurable indicator, would be a novel patient-centered quality initiative that could counterbalance the current perspective of overtesting. This overtesting reflects our cultural intolerance of uncertainty that drives imaging requests. Developing skills in dealing with uncertainty, competing diagnostic approaches, harm–benefit trade-offs, societal pressures, and shared decision making is essential in developing deliberate clinical inertia. When these issues are explained to patients in a patient-friendly format, patients often choose the “less is more” option.14, 15 This approach is particularly important for heterogeneous conditions such as syncope. The systematic review by Viau et al.1 likely overreports the proportion having a serious diagnosis as the proportion of syncope cases undergoing head CT was only about half. It is very likely that patients with higher pretest probability of serious intracranial pathology were selected for head CT. This also means that doctors are already making patient-centered decisions without high-quality evidence, using information derived from experience and intuition (which is also a component of evidence-based medicine). Clinical training needs to go beyond robotic rule following to hone expert clinical judgment. Getting information (e.g., CT head) in the absence of judgment can be misleading, as we must have a pretest probability. 6. Using systematic reviews for assessing the accuracy of diagnostic tests. Systematic reviews with or without meta-analysis remain the highest level of evidence for assessing the diagnostic accuracy of diagnostic tests. However, the process is not as straightforward as interventions. Some of the challenges facing such systematic reviews are related to the method of reporting the results. It is not always feasible to distinguish the limitations in methodology of the original trials from limitations of reporting the results. Recently, most journals encourage investigators to follow specific guidelines for reporting their findings such as those recommended by STARD (Standards for Reporting of Diagnostic Accuracy) statement.16 Following these guidelines are a positive move toward standardized reporting of such trials, reducing the confusion when distinguishing methodologic flaws from reporting flaws. Unfortunately, such guidelines are frequently ignored in emergency medicine diagnostic trials.17 Another challenge of systematic reviews addressing diagnostic tests are difficulty in measuring publication bias.18 Currently, there is no registry for trials measuring the accuracy of diagnostic tests and it is not possible to predict which diagnostic test trial gets published and which ones do not. Commonly, there are many differences in the design and quality of diagnostic accuracy studies. These differences (also known as heterogeneity) could affect the interpretation of their results. Heterogeneity may reflect differences between the studies in their definition of a positive test, study design, patient characteristics, place of test in diagnostic pathway, etc.19 Excessive heterogeneity might result in systematic biases and affect the estimates of diagnostic performance. Therefore, a structured appraisal of methodologic quality of studies included in the systematic reviews and meta-analyses is a critical step. The quality assessment is performed with the objective of evaluating the effects of potential sources of bias on estimates of test accuracy. Additionally, quality assessment allows for evaluating the effect of hypothesized clinical sources of heterogeneity on estimates of test accuracy. Unfortunately, when it comes to diagnostic testing accuracy, the use of statistical tests of heterogeneity does not reliably indicate absence of heterogeneity. It is recommended that the authors of systematic reviews assume the presence of heterogeneity and develop models that can identify heterogeneity and account for it.19 While this systematic review fails to produce an exact diagnostic yield for CT scan of the head in patients with syncope due to certain limitations, it produces valuable information that could be used in clinical practice.1 The authors of the systematic review recommend estimating a pretest probability for serious intracranial pathologies for each patient with syncope before ordering the test. This pretest probability is estimated based on patients’ risk factors, possibility of other pathologies mimicking syncope (e.g., seizure), and also preferences. The authors suggest that when this assessment generates a low pretest probability, CT scan of the head should be deferred.1 This systematic review also provides the opportunity to broaden our views of diagnostic testing in light of many recent paradigm shifts. There are many elements beyond diagnostic accuracy that should be considered before a test is ordered or interpreted. When benefits of the test in question are not clear or the possible harms are considerable, adopting a deliberate clinical inertia strategy might be a reasonable alternative to diagnostic testing. The benefits of this strategy should be explained to the patients and their families to ensure respect for the patient's circumstances and preferences, and to incorporate them in the shared clinical decision-making process. In summary, diagnostic strategies require adopting a global view and diligent consideration of patient-centered factors. As an anonymous proverb indicates, “For most diagnoses all that is needed is an ounce of knowledge, an ounce of intelligence, and a pound of thoroughness.”

Determining the role of intravenous hydration on hospital readmissions for acute congestive heart failure.

The role of intravenous hydration on hospital readmissions due to acute exacerbation of congestive heart failure (CHF) has not been studied sufficiently to the best of our knowledge. We sought to determine the possible role of intravenous hydration on hospital readmissions for acute CHF and fluid overload and explain how an intravenous fluid (IVF) restriction strategy may help reduce hospital readmission rates. We retrospectively studied the electronic medical records of 98-patient cohort who had hospital readmission due to acute decompensated congestive heart failure (ADHF) during the period of January 1, 2016 to July 9, 2016. These patients were admitted with reasons other than ADHF during the index admission. The patients were divided into two groups; those with ADHF readmissions within 15 days of index admission (group A) and those after 15 days (group B). Various factors affecting CHF readmissions as outlined in the results were compared between these two groups. Cohort of 98 patients (53 females, 54.1%; 76.4±11.6 years) re-admitted during the study period of 1/1/2016 to 7/9/2016 were analyzed. 71 patients had only received IVF during index admission. These were subdivided into group A (12 females, 54.5 %; mean age 75.9±12.9 years) and group B (25 females, 51.02%; mean age 76.08±11.90 years) based on readmission ≤15 days or &gt;15 days from the index admission. There was no statistically significant difference (P=0.97) in amount of IVF prescribed between two subgroups but the duration of prescribed IVF significantly affected readmission in group A compared to group B (P=0.03). While the drop in albumin and rise in creatinine were not significant, the mean hemoglobin (Hb) drop in group A compared to group B was significant at P=0.008. Type of IVF and nature of CHF (heart failure with reduced ejection fraction, HFrEF/heart failure with preserved ejection fraction, HFpEF) were not found to significantly affect early readmissions associated with IV hydration. In patients with history of CHF, duration of IVF prescribed during the index admission seems to play important role in early CHF readmission (defined as &lt;15 days in our study).

Optymalna rozbudowa dwujamowego układu stymulującego u pacjentki z utrwalonym migotaniem przedsionków

In patients with sick sinus syndrome, and previously implanted dual-chamber pacemaker, the occurrence of atrial fibrillation finally assessed as permanent is most commonly regarded as a natural course of the disease. The inappropriate heart rate control and right ventricular pacing can both negatively influence left ventricle mechanical performance leading to cardiomyopathy and heart failure. It was presented the case of a 72-year-old woman with permanent atrial fibrillation with narrow QRS complex, after dual-chamber pacemaker implantation, admitted to our department with signs and symptoms of acute decompensated congestive heart failure. The modification of pharmacotherapy allowed to compensate heart failure, however with only small influence on structural remodelling and patient’s symptoms. The successful upgrade of the pacing system to the direct His-bundle pacing enabled the restoration of proper function of the heart and full symptoms relief. The direct His-bundle pacing is an approach of choice in such a group of patients.

Perioperative management of a patient with glanzmann's thrombasthenia for mitral valve repair under cardiopulmonary bypass

A 30-year-old male patient presented with Glanzmann's thrombasthenia and mitral valve prolapse. He was in acute decompensated congestive heart failure due to severe mitral and tricuspid regurgitation. After his cardiac failure had been stabilized, the patient was subjected to mitral and tricuspid valve repair. His transfusion requirements were guided by thrombelastography and his bleeding disorder was managed by infusing single donor plasmapheresed platelet transfusions in the perioperative period. The patient underwent surgery uneventfully.

Newly diagnosed and decompensated congestive heart failure is associated with increased rates of pneumonia, reintubation, and death following laparoscopic cholecystectomy: A NSQIP database review of 143,761 patients

BackgroundLaparoscopic cholecystectomy (LC) is routinely performed as an outpatient operation. NSQIP tracks acute or symptomatic congestive heart failure (CHF) within 30 days of the index operation. This study aims to quantify adverse events after LC and determine if patients with CHF may benefit from pre-operative optimization or post-operative admission. Materials and methodsThis is a retrospective NSQIP database review of all adults undergoing LC between 2008 and 2012. Comorbidities examined were acute or decompensated CHF, along with coronary artery disease, chronic obstructive pulmonary disease, diabetes, dyspnea, obesity, and smoking status. Bivariate and multivariate analyses determined the impact of these conditions on complications. ResultsLCs were performed electively in 131,081 patients and emergently in 12,680 patients. Pneumonia, reintubation or death in CHF patients occurred in 9% and 18% of these operations, respectively. The odds ratios, among those with CHF compared to those without, for pulmonary complications was 4.7 (p < 0.01, 95%CI: 3.38–6.6) in the elective and 3.7 (p < 0.01, 95%CI: 1.89–7.07) in the emergent populations. ConclusionsPatients with acute or decompensated CHF may benefit from pre-operative cardiac optimization and post-operative admission to decrease the risk of pulmonary complications.

VA-ECMO in Cardiogenic Shock in Adults: Indications and Outcomes

&#x0D; &#x0D; &#x0D; Background&#x0D; Use of veno-arterial extra-corporeal membrane oxygenation (VA-ECMO) has become increasingly common as a means of providing hemodynamic support for patients in cardiogenic shock. Data regarding the efficacy of VA-ECMO are provided almost exclusively by single-center, retrospective analyses. These retrospective analyses vary significantly with regards to documentation of the underlying pathophysiologic process resulting in cardiogenic shock.&#x0D; Methods&#x0D; Relevant published studies were identified by using a comprehensive search of English-language MEDLINE from 1966 to November 2015. Relevant references found cited in these studies were also analyzed. These studies were analyzed with regard to the indications the authors used for initiation of ECMO, as well as the outcomes for each indication in each individual study.&#x0D; Results&#x0D; Analysis of multiple relevant studies regarding the indications for ECMO support demonstrated that there is a great deal of variability with regard to the use of different indications for initiation of ECMO support.&#x0D; Conclusions&#x0D; Data regarding the efficacy of VA-ECMO is derived largely from single-center, retrospective analyses. In order to gain a better understanding of the efficacy of VA-ECMO in different patient populations, a more standardized format of documenting the indication for VA-ECMO should be used in centers that provide VA-ECMO. In general, all patients supported with VA-ECMO are in cardiogenic shock. In our experience, the underlying processes leading to cardiogenic shock can be classified as: cardiac arrest, acute decompensated congestive heart failure, acute on chronic congestive heart failure, myocardial infarction, acute pulmonary embolism, right ventricular failure not secondary to acute pulmonary embolism, and post-cardiotomy syndrome.&#x0D; &#x0D; &#x0D;

3D Printed Modeling for Patient-Specific Mitral Valve Intervention: Repair With a Clip and a Plug.

A 62-year-old man with peripheral vascular disease, chronic kidney disease (glomerular filtration rate <30 ml/min), previous coronary artery bypass grafting, and recent treatment for bacterial endocarditis was referred for refractory decompensated congestive heart failure (New York Heart

[Regulatory Adaptive Status in Assessment of Efficacy of Pharmacotherapy and Prognostication of Complications in Functional Class III Chronic Heart Failure].

to elucidate significance of regulatory adaptive status (RAS) for assessment of effectiveness of medical treatment and prediction of cardiovascular complications in functional class (FC) III congestive heart failure (CHF). We included into this study 100 patients with hypertensive disease (HD) or ischemic heart disease (IHD) and FC III CHF with compromised systolic left ventricular (LV) function. All patients were randomized into two groups. In addition to complex background therapy (quinapril, torasemide, spironolactone) patients of group 1 (n=56, age 57.5+/-21.7 years) were given metoprolol succinate (59.1+/-12.1 mg/day) and patients of group 2 (n=44, age 57.1+/-21.4 years) - ivabradine (12.1+/-4.6 mg/day). Examination at baseline and after 6 months included cardiorespiratory synchronism test (in order to quantitatively define RAS), echocardiography, treadmill test, six minute walk test. Cardiovascular complications (CVC) were registered during 12 months of study treatment. Both schemes of complex therapy equally improved structural and functional state of the myocardium, increased tolerance to physical exercise, reduced neurohumoral hyperactivation. Positive impact on RAS was more pronounced in ivabradine group. Clinical efficacy of therapy as well as number of hospitalizations because of CHF decompensation, ischemic strokes, and cardiovascular deaths did not differ substantially between groups. Initially low or unsatisfactory RAS was associated with higher incidence of CVC while initial unsatisfactory RAS was associated with elevated risk of sudden death. The data obtained reflect independent value of determination of RAS for assessment of efficacy of pharmacotherapy and prognosis of CVC in patients with FCIII CHF.