Episodes Of Congestive Heart Failure Research Articles

Clinical presentation, management, and survival in dogs with persistent atrial standstill in the United Kingdom

ObjectivesTo investigate the clinical and echocardiographic presentation of dogs with persistent atrial standstill (PAS), identify variables measured at first presentation that could predict their survival, and document the progression of the disease after pacing. Materials and methodsRetrospective study of medical records of dogs diagnosed with PAS at three referral hospitals of the United Kingdom over seven years. ResultsTwenty-six dogs were diagnosed with PAS during the study period. Median age of the population was three years (range: seven months–12.5 years). The most common clinical sign was syncope (14/26). Twenty-four dogs received artificial pacemakers (PM). Major complications after PM implantation were observed in four dogs (four/24). Serial echocardiographic examinations showed that cardiac dimensions of PAS dogs with left atrial or left ventricular dilation at first presentation did not return to reference range after pacing. Further dilation of the cardiac chambers, recurrence of congestive heart failure (CHF), or development of new episodes of CHF were documented in seven, four, and 10 PAS dogs, respectively, despite pacing. Median survival time for cardiac-related deaths after PM implantation was 1512 days (18–3207). Neither CHF nor echocardiographic variables at presentation predicted survival after PM implantation in PAS dogs. ConclusionsPersistent atrial standstill (PAS) is an uncommon bradyarrhythmia, occurring in young adult dogs. Affected dogs were often presented with syncope. Whilst syncope resolved, cardiac remodeling persisted after PM implantation. Long-term survival was favorable after PM implantation and was not predicted by congestive status or cardiac chamber size at first presentation.

AA Amyloidosis Secondary to Horton's Disease Complicated by Pulmonary Fibrosis: A Very Challenging Diagnosis and Therapy

AA amyloidosis is a classic and serious complication of many chronic inflammatory processes, whether of infectious, autoimmune, or neoplastic origin. It is frequently complicated by kidney damage, often in the form of a nephrotic syndrome. Giant cell arteritis is a common inflammatory arteritis in the elderly; however, it rarely causes AA amyloidosis. We report a rare case of Horton disease causing AA amyloidosis in an elderly patient with history of myopericarditis and repeated episodes of congestive heart failure. Patient was treated initially with dual therapy based on corticosteroids and anti TNF therapy (Tocilizumab) associated with heart failure therapy recommended by the European society of cardiology (ESC 2021 guidelines on Heart Failure). The initial outcome was favorable but later complicated by the involvement of the lungs; pulmonary fibrosis, responsible for repeated episodes of pleural effusion non controlled in spite of high dose of loop diuretics and repeated pleural punction. Patient died shortly after her second hospitalization due to respiratory insufficiency.

Non-invasive coronary flow velocity reserve assessment predicts adverse outcome in women with unstable angina without obstructive coronary artery stenosis.

Evaluation of coronary flow velocity reserve (CFVR) is the physiological approach to assess the severity of coronary stenosis and microvascular dysfunction. Impaired CFVR occurs frequently in women with suspected or known coronary artery disease. The aim of this study was to assess the role of CFVR to predict long-term cardiovascular event rate in women with unstable angina (UA) without obstructive coronary artery stenosis. CFVR in left anterior descending coronary artery was assessed by adenosine transthoracic echocardiograhy in 161 women admitted at our Department with UA and without obstructive coronary artery disease. During a mean FU of 32.5 ± 19.6 months, 53 cardiac events occurred: 6 nonfatal acute myocardial infarction, 22 UA, 7 coronary revascularization by percutaneous transluminal coronary angioplasty, 1 coronary bypass surgery, 3 ischemic stroke, and 8 episodes of congestive heart failure with preserved ejection fraction and 6 cardiac deaths. Using a ROC curve analysis, CFVR 2.14 was the best predictor of cardiac events and was considered as abnormal CFVR. Abnormal CFVR was associated with lower cardiac event-free survival (30 vs 80%, p < 0.0001). During FU, 70% of women with reduced CFVR had cardiac events whereas only 20% with normal CFVR (p = 0.0001). At multivariate Cox analysis, smoke habitus (p = 0.003), metabolic syndrome (p = 0.01), and CFVR (p < 0.0001) were significantly associated with cardiac events at FU. Noninvasive CFVR provides an independent predictor of cardiovascular prognosis information in women with UA without obstructive coronary artery disease whereas, impaired CFVR seems to be associated with higher CV events at FU.

Autopsy Findings of Endocardial Fibroelastosis in an Adult

Background: Endocardial fibroelastosis (EFE) is commonly presented with diffuse endocardial thickening due todeposition of collagen and elastin, usually affecting the left ventricle of the heart. Case presentation: A 59-year-oldgentleman who had no known medical illness had collapsed while performing house chores at home. Autopsyexamination showed cyanosed lips and nail beds. The heart weighed 360 gm with distinct presence of whitish,firm and thickened endocardium of the left ventricle. The anterior descending coronary artery showed an almostcomplete occlusion by atheroma, in keeping with coronary artery disease. Mild pulmonary oedema was present.Histological examination revealed fibroelastosis forming plaque-like covering of the inner ventricle, with patchymyocardial fibrosis. Numerous ‘heart failure’ cells were present in the intraalveolar spaces. Conclusions: Thiscase showed remarkable autopsy findings of EFE in adult with evidence of congestive heart failure episodes inhis lifetime.

A Multi-Class Approach for the Automatic Detection of Congestive Heart Failure in Windowed ECG.

Congestive heart failure (CHF) is a chronic heart disease that causes debilitating symptoms and leads to higher mortality and morbidity. In this paper, we present HARPER, a novel automatic detector of CHF episodes able to distinguish between Normal Sinus Rhythm (NSR), CHF, and no-CHF. The main advantages of HARPER are its reliability and its capability of providing an early diagnosis. Indeed, the method is based on evaluating real-time features and observing a brief segment of ECG signal. HARPER is an independent tool meaning that it does not need any ECG annotation or segmentation algorithms to provide detection. The approach was submitted to complete experimentation by involving both the intra- and inter-patient validation schemes. The results are comparable to the state-of-art methods, highlighting the suitability of HARPER to be used in modern IoMT systems as a multi-class, fast, and highly accurate detector of CHF. We also provide guidelines for configuring a temporal window to be used in the automatic detection of CHF episodes.

Heart Failure Associated with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease of the joints. Extra-articular features are very common. We report a case of RA first diagnosed after an episode of congestive heart failure (CHF) and the evolution of left ventricular function after conventional treatment of CHF and immunosuppressive drugs. The patient, a 52-year-old man, with history of epilepsy and a stroke 6 years before, presented to the emergency department with increasing dyspnea. He had polyarthralgia 2 months before. The lower extremities had mild pitting edema. The musculoskeletal examination revealed synovial thickening of the metacarpophalangeal and proximal interphalangeal&#x0D; joints, but there was no joint tenderness. The patient’s alanine aminotransferase, troponin levels and CRP were slightly elevated. His renal function was preserved. The electrocardiogram (EKG) was normal. An echocardiogram performed in showed a global hypokinetic dilated cardiomyopathy with an ejection fraction of 15–20%, with apical thrombus. The patient was diagnosed with exacerbation&#x0D; of congestive heart failure (CHF) and was treated with intravenous diuretics. This led to symptomatic improvement. He got a conventional heart failure treatment with vit K antagonists. Coronarography was normal. Viral serologies were negative. The martial, phosphocalcic and thyroid markers were normal. However, the immunologic tests showed positive rheumatoid factor and anti-CCP. The diagnosis of dilated cardiomyopathy due to rheumatoid arthritis was retained. The patient was treated by corticosteroids and immunosuppressive agents. Patient was seen during routine follow-up after 6 months. Interestingly, echocardiographic findings were totally normal with left ventricular ejection fraction &gt;50% and normal LV size.

Effect of cilobradine in cats with a first episode of congestive heart failure due to primary cardiomyopathy

IntroductionHeart rate (HR) is often elevated in cats with cardiomyopathies (CMPs). Pharmacologic modulation of HR may reduce cardiac morbidity and mortality. ObjectivesTo investigate the effects of cilobradine vs. placebo, regarding time to cardiac mortality or morbidity in cats with first episode of congestive heart failure (CHF) due to primary CMP. AnimalsThree hundred and sixty-seven client-owned cats with primary CMP that had presented with a first episode of CHF at 50 centers in Europe. Per-protocol population comprised 193 cats (n = 89 cilobradine, n = 104 placebo). An interim analysis for futility was planned. MethodsProspective, randomized, placebo-controlled, double-blinded, multicenter clinical trial. Primary outcome variable was the time to a composite of cardiac mortality or cardiac morbidity. ResultsMedian time to primary outcome was 84 days (95% confidence interval [CI]: 63–219 days) in the cilobradine group (CG) and 203 days in the placebo group (95% CI: 145–377 days) with observed hazard ratio of 1.44, indicating a higher hazard for the CG (P = 0.057). Mean HR was 28 beats per minute (bpm) lower at Day 7 (P < 0.0001) and remained 29 bpm lower at Day 360 (P = 0.026) in the CG than that in the placebo group. Although the number of adverse events did not differ, there were more serious adverse events in the CG. ConclusionsHeart rate reduction by cilobradine in cats with a first episode of CHF due to primary CMP did not reduce cardiac mortality and morbidity.

Predictors of reoccurrence of congestive signs within 180 days after successful treatment of the first episode of congestive heart failure in dogs with myxomatous mitral valve disease

IntroductionMyxomatous mitral valve disease (MMVD) is the most common cause of left-sided congestive heart failure in dogs. We sought to identify predictors of first reoccurrence of congestive signs (CS) within 180 days in dogs with MMVD and clinically stable heart failure. AnimalsA total of 445 dogs affected by stable American College of Veterinary Internal Medicine (ACVIM)–Stage-C MMVD were included, 106 in the reoccurrence group (RG) and 339 in no reoccurrence group (NRG). Patients were considered “stable” if medical treatment had been unchanged for at least 4 weeks since the first identification of CS. MethodsMedical records of dogs with stable ACVIM–Stage-C MMVD included in a registry of dogs affected by MMVD were reviewed. Follow-up was required for inclusion in this investigation. Logistic regression was used to identify clinical and echocardiographic variables that independently predict first reoccurrence of CS. ResultsBaseline left atrial-aortic ratio (p=0.022, OR: 1.89, 90% CI: 1.20–2.98), left ventricular internal diameter at end-diastole (LVIDd_N) (p=0.014, OR: 2.84, 90% CI: 1.41–5.77), peak velocity of early diastolic transmitral flow (p=0.049, OR: 1.81, 90% CI: 1.10–3.00) and furosemide daily dosage (p=0.039, OR: 1.19, 90% CI: 1.04–1.37) were associated with reoccurrence of CS in univariable analyses. The LVIDd_N (p=0.014) remained significant in the multivariable analysis, but the area under the receiver operator characteristic curve was 0.57. ConclusionThis study failed to identify accurate predictors of reoccurrence of CS. However, dogs with larger value of LVIDd_N are more likely to have reoccurrence of CS within 180 days.

Incidence, prognostic impact, and predictive factors of a readmission for congestive heart failure one year after transcatheter aortic valve replacement, a prospective study

TAVR is indicated in patients with severe symptomatic aortic stenosis in whom surgery is considered intermediate risk. In a retrospective study (2010-2014), 24% of patients were rehospitalized for heart failure (HF) one year after TAVI. We aimed to assess the incidence, prognostic impact, and predictive factors of readmission for congestive heart failure (CHF) one year after TAVR in an intermediate risk population. All patients who underwent transfemoral TAVR from mars 2018 to october 2018 were included. Prospective follow-up was achieved at 1 year and included, MACCE, readmission for CHF, clinical and echocardiographic data. This study included 102 patients. Medial aging, sex ratio and medial logistic euroSCORE were respectively 85 [81–87] years, 50% and 13%[9-19,1]. One year after TAVR, 39 patients (39%) had been readmitted at least once, and 9 (9%) for CHF, one patient was readmitted twice. On multivariate analysis, a previous episode of CHF was the only factor close to be associated with CHF readmission at 1 year (hazard ratio: 10,52 (0,74–149,35), P = 0.06). The incidence of readmission for CHF decrease between 2014 and 2018. A previous episode of CHF is the only factor associated with CHF readmission in our study.

Incidence, prognostic impact, and predictive factors of readmission for congestive heart failure (CHF) one year after transfemoral TAVR: A prospective monocentric cohort

TAVR is indicated in patients with severe symptomatic aortic stenosis in whom surgery is considered intermediate risk. In a retrospective study (2010-2014), 24% of patients were rehospitalized for heart failure (HF) one year after TAVI. We aimed to assess the incidence, prognostic impact, and predictive factors of readmission for congestive heart failure (CHF) one year after TAVR in an intermediate risk population. All patients who underwent transfemoral TAVR from March 2018 to October 2018 were included. Prospective follow-up was achieved at 1 year and included, MACCE, readmission for CHF, clinical and echocardiographic data. This study included 102 patients. Medial aging, sex ratio and medial logistic euroSCORE were respectively 85 [81-87] years, 50% and 13%[9-19,1]. One year after TAVR, 39 patients (39%) had been readmitted at least once, and 9 (9%) for CHF, one patient was readmitted twice. On multivariate analysis, a previous episode of CHF was the only factor close to be associated with CHF readmission at 1 year (hazard ratio: 10,52 (0,74–149,35), P = 0.06). The incidence of readmission for CHF decrease between 2014 and 2018. A previous episode of CHF is the only factor associated with CHF readmission in our study.

Efficacy of adding ramipril (VAsotop) to the combination of furosemide (Lasix) and pimobendan (VEtmedin) in dogs with mitral valve degeneration: The VALVE trial.

BackgroundTriple therapy (TT) consisting of furosemide, pimobendan, and an angiotensin‐converting enzyme inhibitor (ACEI) frequently is recommended for the treatment of congestive heart failure (CHF) attributable to myxomatous mitral valve disease (MMVD). However, the effect of adding an ACEI to the combination of pimobendan and furosemide (dual therapy [DT]) so far has not been evaluated prospectively.HypothesisTriple therapy will extend survival time compared to DT in dogs with CHF secondary to MMVD.AnimalsClient‐owned dogs presented with the first episode of CHF caused by MMVD.MethodsProspective, single‐blinded, randomized multicenter study. One‐hundred and fifty‐eight dogs were recruited and prospectively randomized to receive either DT (furosemide and pimobendan) or TT (furosemide, pimobendan, and ramipril). The primary endpoint was a composite of cardiac death, euthanasia for heart failure, or treatment failure.ResultsSeventy‐seven dogs were randomized to receive DT and 79 to receive TT. Two dogs were excluded from analysis. The primary endpoint was reached by 136 dogs (87%; 66 dogs, DT; 70 dogs, TT). Median time to reach the primary endpoint for all dogs in the study was 214 days (95% confidence interval [CI], 168‐259 days). Median time to reach the primary endpoint was not significantly different between the DT group (227 days; interquartile range [IQR], 103‐636 days) compared with TT group (186 days; IQR, 72‐453 days; P = .42).Conclusions and Clinical ImportanceAddition of the ACEI ramipril to pimobendan and furosemide did not have any beneficial effect on survival time in dogs with CHF secondary to MMVD.

Tolerance of torasemide in cats with congestive heart failure: a retrospective study on 21 cases (2016\u20132019)

BackgroundIn dogs with congestive heart failure (CHF), the efficacy of torasemide, a loop diuretic, has been demonstrated. However, unlike in dogs and humans little has been described about the use of torasemide in the cat with spontaneous CHF. The objectives of this retrospective study were therefore to describe the therapeutic use of oral torasemide in cats with spontaneous CHF, document its potential adverse effects while reporting the clinical course of this feline population following torasemide administration in addition to standard medical therapy.ResultsMedical records of 21 client-owned cats with CHF (median age = 10.6 years [interquartile range (IQR) = 6.5–11.2]) receiving torasemide were reviewed. Data collected included torasemide dosages, other concurrent medications, physical examination features, echocardiographic data, and potential adverse effects during follow-up. A survival analysis was performed to estimate the time from diagnosis to cardiac death. Dyspnea related to CHF was identified in all cats (pleural effusion [8/21], pulmonary edema [5/21] or both [8/21]), associated with ascites in 4/21 cats. The CHF cause was determined by echocardiography in all cats: hypertrophic (n = 10), restrictive (n = 6), arrhythmogenic right ventricular (n = 3), dilated (n = 1) cardiomyopathies, and aortic valve abnormality (n = 1). At initiation, median torasemide dosage was 0.21 mg/kg [IQR = 0.17–0.23] q24h. Clinical signs declined in most cats (20/21) during the first 2 weeks with no remarkable adverse events. Median survival time after torasemide prescription was 182 days [IQR = 46–330]. A contemporary control group including 54 cats with CHF, receiving furosemide as sole loop diuretic treatment was compared with the study group. Median (IQR) survival time of cats in the control group was not significatively different (p = 0.962) from that of the torasemide group, i.e., 148 days (9–364), although the torasemide group included significantly more cats with recurrent episodes of CHF (52%) that the control group (19%).ConclusionsThis case series demonstrates that torasemide can be used in cats with spontaneous CHF. This therapeutic interest needs to be confirmed by prospective clinical trials.

P1708Therapeutic hypothermia in cardiac arrest survivors with pre-existing heart failure is nephroprotective

Abstract Introduction The impact of therapeutic hypothermia on kidneys in cardiac arrest survivors with known congestive heart failure (CHF) is not known. Weak evidence suggests higher risk of acute kidney injury with hypothermia. Purpose The effect of hypothermia on organ function in cardiac arrest patients with preexisting CHF Methods This analysis includes 1417 comatose cardiac arrest survivors that achieved achieved return of spontaneous circulation on hospitalization and had a previous left ventricular ejection fraction (LVEF) assessment within last 1 year. Detailed chart review of these patients was performed. CHF was defined as either prior episode of congestive heart failure or presence of LVEF &lt;50%. Odds ratio (OR) and 95% confidence intervals (CI) for association of hypothermia and acute kidney injury as well as hemodialysis at discharge among patients with and without CHF were computed using multivariable adjusted logistic regression. Results Overall, 1417 cardiac arrest patients (mean age 62.5±14.6 years, 60.2% males, 67.2% white and 29.7% black) were included in this analysis, out of which 467 (33.0%) were treated with therapeutic hypothermia and known CHF was present in 624 (44%). AKI developed in 25.2% of CHF patients that were not treated with hypothermia while, only in 18.0% among CHF patients treated with hypothermia (OR 0.56; 95% CI 0.32–0.96, p=0.03). There was an decrease in trend of requiring hemodialysis at discharge among CHF patients treated with hypothermia compared with CHF patients that were not treated with hypothermia (8.1% vs. 19.62%, p=0.019) among CHF patients not treated with hypothermia. However, there was no significant result. Conclusions Hypothermia is associated with nephroprotective effects among patients with cardiac survivors with pre-existing CHF. Future research is needed to identify subgroups that derive benefit from therapeutic hypothermia after cardiac arrest.

2402Reduced heart rate variability is linked to clinical status in patients with a systemic right ventricle

Abstract Background Adult patients with congenital heart disease and a systemic right ventricle (sRV) are prone to develop heart failure. Decreased heart rate variability (HRV), a measure of autonomic dysfunction, is associated with morbidity and mortality in patients with congestive heart failure. The standard deviation of all intervals between normal sinus beats (SDNN) is a HRV parameter commonly reported as an indicator of autonomic function in these patients. Data about HRV and its clinical implications in patients with a sRV are scarce. Purpose To compare HRV parameters between patients with a sRV and healthy controls, and to assess their association with clinical status. Methods All available 24-hour Holter monitoring records of sRV patients under follow-up in our center and one record per healthy control subject were analysed. Holters with non-sinus rhythm were excluded. Time and frequency domain parameters were calculated and compared between both groups. Clinical landmarks such as arrhythmias or an episode of congestive heart failure, which occurred up until the time of the ambulatory ECG, were combined in a clinical event score. Determinants of SDNN were investigated with mixed model linear regression in the patients and with multivariate linear regression in the controls. Baseline characteristics, medication use, global longitudinal strain, validity as measured with bicycle exercise testing, and the clinical event score were taken into account. Results 113 Holters of 43 patients and 39 Holters of healthy controls were analysed. The patient group included 30 patients (70%) late after Mustard or Senning correction for transposition of the great arteries, and 13 patients with congenitally corrected transposition of the great arteries (30%). Age and gender were comparable in patients and controls. Several HRV parameters were significantly worse in patients compared with controls, including SDNN (138 in patients vs. 161 in controls, p=0.021). In the patients, clinical event score was the only significant determinant of a lower SDNN (p&lt;0.001). In the controls, age was the only significant determinant of a lower SDNN (p=0.039). Conclusion Contrary to the healthy population, in patients with a sRV, HRV is associated with clinical status rather than age. This indicates that disease progression affects autonomic function more than ageing in this group. Further research is needed to clarify the relation between clinical outcome and autonomic function in sRV patients. Acknowledgement/Funding The Department of Cardiology of the LUMC received research grants from Medtronic, Biotronik, Boston Scientific and Edwards Lifesciences

Cyclical cardiorenal syndrome in late-stage kidney disease .

In patients with late-stage chronic kidney disease (LS-CKD, estimated glomerular filtration rate (eGFR) < 30 mL/min) there is a high prevalence of congestive heart failure (CHF). We have observed a cyclical nature in the "cardiorenal syndrome" in LS-CKD, not previously described. The purpose of this article is to describe the syndrome and review its characteristics. Patients enrolled in the Northwell Health Healthy Transitions in Late Stage Kidney Disease Program (HT) were followed, all with eGFR 0 - 30 mL/min. Patients were observed for a 1-year period for signs of destabilized cardiorenal syndrome. The primary outcome of interest was an episode of cyclical cardiorenal syndrome (CCRS), defined as CHF symptoms leading to increased diuretic dose or increased renin-angiotensin-aldosterone system inhibitors (RAASi) followed within 60 days by acute kidney failure (AKI), or, conversely, an episode of AKI with reduction in diuretic or RAASi, followed within 60 days by worsening of CHF. Of 302 HT patients, 63 (20.9%) patients had at least one episode of CCRS. Of the 63 patients, there were 89 CCRS episodes (ranging 1 - 3 per patient) and 32 (35.0%) associated hospitalizations for CHF. Of 89 CCRS episodes, 67 (75.3%) started with an episode of CHF, 22 (24.7%) started with AKI. Of 67 cases of CHF with subsequent AKI, the associated medication change was a diuretic dose increase in 61 cases (91.0%), increase in RAASi dose in 3 cases (4.5%), and increases in both in 3 cases (4.5%). Of 22 cases of AKI leading to subsequent CHF, the associated medication change was a diuretic dose decrease in 19 (86.4%) and a decrease in both diuretic and RAASi dose in 3 (13.6%). CCRS occurs in ~ 1/5 of late-stage CKD patients with CHF. Further study would help to elucidate the extent to which fragmented care between cardiologists and nephrologists contributes to the problem. .

SAFETY AND EFFICACY OF PIOGLITAZONE AMONG TYPE 2 DIABETES MELLITUS PATIENTS RECEIVING LONG TERM HEMODIALYSIS

Background: Type 2 diabetes mellitus (T2DM) frequently causes end stage renal disease (ESRD). Glucose-lowering treatment options for patients with T2DM with ESRD are limited. Thiazolidinedione is an oral glucose lowering agent used to treat patients with ESRD. We evaluated the potential for pioglitazone in combination with other hypoglycemic medications among patients with T2DM receiving long term hemodialysis Objectives: To evaluate the safety and efficiency of pioglitazone among patients with ESRD receiving hemodialysis. Methods: The retrospective study was conducted in the outpatient clinic of Phramongkutklao Hospital during 2006 and 2015. HemoglobinA1C (HbA1c), fasting plasma glucose (FPG), body weight, hematocrit and history of diagnosed chronic heart failure were evaluated after starting medication and 1 year of follow-up Results: Data for hemodialysis patients on pioglitazone were analyzed (n=50). Mean FPG changes from baseline were -28.8+-80.0 mg/dL after 12 weeks (p=0.018) and -59.2+-80.0 mg/dL after 12 months of treatment (p &lt; 0.001). Mean HbA1c changes from baseline were also-0.25+-1.62% after 12 weeks (p=0.318) and -1.52+-1.77% after 12 months of treatment (p &lt; 0.001). The differences in mean body weight (63.2+-13.0 kg; p= 0.139) and hematocrit (33.4+-5.5 vs. 33.6+-5.3; p= 0.929) at baseline and 12 months were not significant, while episodes of congestive heart failure were low (4%). No serious adverse effects such as hypoglycemia with hospitalization or liver failure were observed in any of the patients Conclusion: These data suggest that adding pioglitazone to standard hypoglycemic agents patients with T2DM undergoing hemodialysis glucose control and was well tolerated

Cardiac Auscultation for Noncardiologists: Application in Cardiac Rehabilitation Programs: PART I: PATIENTS AFTER ACUTE CORONARY SYNDROMES AND HEART FAILURE.

During outpatient cardiac rehabilitation after an acute coronary syndrome or after an episode of congestive heart failure, a careful, periodic evaluation of patients' clinical and hemodynamic status is essential. Simple and traditional cardiac auscultation could play a role in providing useful prognostic information.Reduced intensity of the first heart sound (S1), especially when associated with prolonged apical impulse and the appearance of added sounds, may help identify left ventricular (LV) dysfunction or conduction disturbances, sometimes associated with transient myocardial ischemia. If both S1 and second heart sound (S2) are reduced in intensity, a pericardial effusion may be suspected, whereas an increased intensity of S2 may indicate increased pulmonary artery pressure. The persistence of a protodiastolic sound (S3) after an acute coronary syndrome is an indicator of severe LV dysfunction and a poor prognosis. In patients with congestive heart failure, the association of an S3 and elevated heart rate may indicate impending decompensation. A presystolic sound (S4) is often associated with S3 in patients with LV failure, although it could also be present in hypertensive patients and in patients with an LV aneurysm. Careful evaluation of apical systolic murmurs could help identifying possible LV dysfunction or mitral valve pathology, and differentiate them from a ruptured papillary muscle or ventricular septal rupture. Friction rubs after an acute myocardial infarction, due to reactive pericarditis or Dressler syndrome, are often associated with a complicated clinical course.During cardiac rehabilitation, periodic cardiac auscultation may provide useful information about the clinical-hemodynamic status of patients and allow timely detection of signs, heralding possible complications in an efficient and low-cost manner.

Complement and contact system activation in acute congestive heart failure patients.

Recent experimental data indicate a pathogenic role of complement activation in congestive heart failure (CHF). The aim of this study was to evaluate contact and complement systems activation in patients hospitalized for an acute episode of CHF. Forty-two of 80 consecutive patients admitted at our hospital with confirmed diagnosis of acute CHF were enrolled. They underwent blood sampling within 24 h from admission (T0) and at clinical stability (T1). Patients were stratified for ejection fraction (EF) based on echocardiographic test. We measured plasma levels of C3, C4, sC5b-9 and cleaved high molecular weight kininogen (contact activation marker). At T1, C3 levels increased significantly compared to T0 (97±2 versus 104±3% of total pooled plasma, P < 0·01). Classifying patients according to EF, only patients with preserved EF presented a significant increase of C3 from T0 to T1 (99±3 versus 108±4%, P=0·03). When the sample was stratified according to clinical outcome, C3 (98±3 versus 104±4%, P=0·03) and sC5b-9 levels (204±10 versus 230±11 ng/ml, P=0·03) were increased in patients who had positive outcome after hospitalization. CHF patients with preserved EF and positive outcome after hospitalization showed higher levels of sC5b-9 in the T1 period compared with T0 (211±14 versus 243±14 ng/ml, P=0·04). Our results suggest that the complement system reacts differently if CHF occurs with preserved or reduced EF. This finding is interesting if we consider the difference in epidemiology, pathogenesis and possible therapeutic approaches of these two clinical entities.

Early Endocarditis and Delayed Left Ventricular Pseudoaneurysm Complicating a Transapical Transcatheter Mitral Valve-in-Valve Implantation: Percutaneous Closure Under Local Anesthesia and Echocardiographic Guidance.

A 72-year-old man was referred because of suspected infective endocarditis. Fifteen years earlier, he had undergone mitral valve replacement with a 33-mm Hancock valve for severe mitral regurgitation. Three months ago, he presented with a first episode of congestive heart failure caused by severe mitral regurgitation reflecting degeneration of the bioprosthetic valve without sign of endocarditis. Because of a high surgical risk based on an estimated Euroscore I of 42.96% and The Society of Thoracic Surgeons (STS) score of 29% (main comorbidity is an advanced Parkinson disease), valve-in-valve implantation was planned. A 29-mm Edwards Sapien 3 (S3) balloon-expandable valve was successfully implanted through transapical puncture of the left ventricle (LV) after direct surgical exposure by mini thoracotomy. Patient was discharged 10 days after the procedure without complications. On his admission, the patient was febrile and examination revealed a purulent discharge at the site of thoracotomy. Transthoracic echocardiography (TTE) and transesophageal echocardiography showed a 15-mm mobile vegetation on the leaflet of the S3 (Movie I in the Data Supplement) and a pseudoaneurysm at the apex of the left ventricle (LVPA) flowing by a large apical defect (Figure 1; Movie II in the Data Supplement). Computed tomographic (CT) scanning confirmed the LVPA free from any thrombus and identified the surgical suture tip in its deep (Figures 1 and 2; Movie III in the Data Supplement). 18F positron-emission tomography demonstrated an uptake on the S3 and LVPA (Figure 2). Blood cultures were positive for Staphylococcus aureus . Antibiotherapy with co-trimoxazole for 6 weeks and clindamycin for 1 week was started, and a quick clinical and biological …

Obesity Paradox in Off-Pump Coronary Artery Bypass Surgery: Does It Benefit the Elderly?

The obesity paradox is a well-known phenomenon in cardiovascular disease; how it interferes with coronary artery revascularization remains controversial. The purpose of this study was to investigate the impact of obesity body mass index (BMI > 30; in kg/m2) on short- and long-term survival and major adverse cardiovascular event (MACE)-free survival in obese patients after off-pump coronary artery bypass operation. We retrospectively reviewed our prospective cohort of 1,400 consecutive and systematic patients whounderwent off-pump coronary artery bypass operation between September 1996 and November 2007 and identified 448 (32%) with preoperative BMI greater than30. Patients with BMI greater than 30 patients were younger and had a higher prevalence of diabetes, dyslipidemia, hypertension, and percutaneous coronary interventions than patients with BMI less than 30. Thirty-day mortality and perioperative myocardial infarction were similar in both groups. No significant difference was observed for wound infections, sternal dehiscence, and reoperation for bleeding. Overall, long-term survival was comparable in the two groups, although obese patients older than 65 years had a better survival than the nonobese patients even after correction for risk factors (p= 0.04). MACE-free survival at 10 years was 65.3% ± 5.7% in obese and 76.3% ± 2.3% in nonobese patients (p= 0.007). Statistical significance was maintained (p=0.008) after correction for risk factors. Among MACE, only new episodes of congestive heart failure were more prevalent in obese patients (p= 0.002). In our series of off-pump coronary artery bypass operation, obesity was not an independent cause of short- and long-term mortality and was shown beneficial for older patients. However, obese patients had a lower MACE-free survival because of an increased incidence of rehospitalization for congestive heart failure.