Episodes Of Acute Decompensation Research Articles

Plasma BNP and renal failure as prognostic factors of mid-term clinical outcome in congestive heart failure patients

Risk stratification in patients suffering chronic congestive heart failure (CHF) is based on a variety of clinical and laboratory variables. Indeed, several prognostic parameters have been identified, including age, New York Heart Association (NYHA) class, renal function, comorbidity such as atrial fibrillation, diabetes mellitus and ischemic heart disease [1]. In acute decompensated heart failure (ADHF) episodes, the degree of renal dysfunction and arterial hypotension easily stratified patients with worst clinical outcome [2]. A single determination of Brain Natriuretic Peptide (BNP) plasma level represents a reliable risk stratification procedure and its increase is considered a sensitive diagnostic marker of left ventricular dysfunction [3,4] and predicted cardiovascular events in congestive heart failure (CHF) patients [5–8] and even in asymptomatic subjects [9]. The objective of this study was to analyse if renal dysfunction and plasma BNP predict mid-term clinical outcome in CHF patients discharged after an ADHF episode. This prospective cohort study, approved by the local ethics committees, included 237 patients (64.5% males, age 71) with a diagnosis of CHF after an acute decompensation episode discharged from the Heart Failure Unit fromApril 2008 up to August 2010. Death by any cause, cardiac transplantation andworsening heart failure requiring readmission to the hospital were considered cardiovascular events [events group 34 (14.3%) subjects and a no-event group 203 (85.7%) patients]. The follow-up of this study lasted 408±255 days. BNP at discharge resulted 401.3±501.7 pg/ml. During the 14-month follow-up 15 (6.3%) patients died, one (0.4%) underwent cardiac transplantation and 18 (7.6%)were readmitted for CHF (event group); in 203 (85.6%) no eventswere observed (no-event group). HigherNYHAclass (2.1±0.7 vs 1.9±0.4 p=0.01), BNP at discharge (750.2±527.3 pg/ml vs 340.7± 474.3 pg/ml, p=0.002) and impaired renal function (creatinine 1.7± 0.6 vs 1.2±0.8 mg/dl, p=0.004) were noticed in the event group. At multivariate Cox analysis only LVEF (p=0.0009), plasma creatinine (p=0.006) and BNP at discharge (p=0.001) were significantly associated with adverse mid-term outcome. The Kaplan–Meier survival curves demonstrated that adding two parameters (creatinine bor N1.5 mg/dl and BNPbor N250 pg/ml), four different survival curves were obtained (p=0.0001; log rank 21.09), inwhich the clinical weight of renal function clearly emerged (Fig. 1). From this study emerged that CHF patients discharged after an acute decompensation had a severe adverse clinical outcome (death, cardiac transplantation and hospital readmission) in 14.3% during a follow-up lasted 14 months. Elderly patients with CHF represent most of subjects (70%) admitted to hospitals for acute cardiac decompensation; the length of hospitalization lasts usuallyN2 weeks in geriatric wards and readmission is frequent [10]. Recently, the OPTIMIZE -HF study [11] included more than 30,000 CHF patients discharge from 215 hospitals, described the short length of hospitalization (4 days) but a 21.3% of rate of readmission within 30-day. The study evidenced as an early (oneweek) outpatient clinical follow-up after discharge had lower probability to be readmitted within 30-day. The first strong prognostic parameter in those patients was a plasma BNP value at discharge≥250 pg/ml (p=0.001, log rank 10.7). This data confirm previous reports [8,12] in which the pre-discharge values of BNP identified an adverse outcome (death or hospital re-admission) at 6-month follow-up. According to the practical approaches to treating CHF patients published by Maisel [13], it could be identified a ‘wet BNP’ in patients with CHF and fluid overload and a ‘dry BNP’ after optimization of therapy. In our population only the ‘dry BNP’ (at discharge) predicted cardiovascular events, because it identified the real state of neurohormonalmodulation due to the systolic, diastolic heart dysfunction and left ventricle enlargement. The second strong predictor of adverse outcomewas renal dysfunction. The presence of a chronic cardio-renal syndrome, recently classified as type 2 of the cardio-renal syndromes [14], has been reported in 63% of patients admitted for CHF [15,16]. Moreover, the ADHERE registry highlighted as the in-hospital mortality risk incredibly increased in patients with urea nitrogen≥43 mg/dl and plasma creatinine≥2.75 mg/dl [17]. In our population serum creatinine was higher in the event group (pb0.01) and alone identified (divided into three groups b1.5 mg/dl, between 1.5–2 mg/dl and finally N2 mg/dl) three different cumulative survival curves. Moreover, adding data of renal function with discharge plasma BNP, four different cumulative survival curves emerged (BNPb250 pg/ml and creatinineb1.5 mg/dl, BNPb250 pg/ml and creatinineN1.5 mg/dl, BNPN250 pg/ml and creatinineb1.5 mg/dl and finally BNPN250 pg/ml and creatinineN1.5 mg/dl), in which clearly appeared the prognostic weight of a serum creatinineN1.5 mg/dl. Therefore, this analysis identified a simple and practical combination of two markers for identifying a high-risk CHF patient at discharge for a medium-term follow-up, which should be strictly monitored and controlled in order to avoid adverse clinical outcome. The authors of themanuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [18].

Effect of home-based telemonitoring using mobile phone technology on the outcome of heart failure patients after an episode of acute decompensation: randomized controlled trial.

BackgroundTelemonitoring of patients with chronic heart failure (CHF) is an emerging concept to detect early warning signs of impending acute decompensation in order to prevent hospitalization.ObjectiveThe goal of the MOBIle TELemonitoring in Heart Failure Patients Study (MOBITEL) was to evaluate the impact of home-based telemonitoring using Internet and mobile phone technology on the outcome of heart failure patients after an episode of acute decompensation.MethodsPatients were randomly allocated to pharmacological treatment (control group) or to pharmacological treatment with telemedical surveillance for 6 months (tele group). Patients randomized into the tele group were equipped with mobile phone–based patient terminals for data acquisition and data transmission to the monitoring center. Study physicians had continuous access to the data via a secure Web portal. If transmitted values went outside individually adjustable borders, study physicians were sent an email alert. Primary endpoint was hospitalization for worsening CHF or death from cardiovascular cause.ResultsThe study was stopped after randomization of 120 patients (85 male, 35 female); median age was 66 years (IQR 62-72). The control group comprised 54 patients (39 male, 15 female) with a median age of 67 years (IQR 61-72), and the tele group included 54 patients (40 male, 14 female) with a median age of 65 years (IQR 62-72). There was no significant difference between groups with regard to baseline characteristics. Twelve tele group patients were unable to begin data transmission due to the inability of these patients to properly operate the mobile phone (“never beginners”). Four patients did not finish the study due to personal reasons. Intention-to-treat analysis at study end indicated that 18 control group patients (33%) reached the primary endpoint (1 death, 17 hospitalizations), compared with 11 tele group patients (17%, 0 deaths, 11 hospitalizations; relative risk reduction 50%, 95% CI 3-74%, P = .06). Per-protocol analysis revealed that 15% of tele group patients (0 deaths, 8 hospitalizations) reached the primary endpoint (relative risk reduction 54%, 95% CI 7-79%, P= .04). NYHA class improved by one class in tele group patients only (P< .001). Tele group patients who were hospitalized for worsening heart failure during the study had a significantly shorter length of stay (median 6.5 days, IQR 5.5-8.3) compared with control group patients (median 10.0 days, IQR 7.0-13.0; P= .04). The event rate of never beginners was not higher than the event rate of control group patients.ConclusionsTelemonitoring using mobile phones as patient terminals has the potential to reduce frequency and duration of heart failure hospitalizations. Providing elderly patients with an adequate user interface for daily data acquisition remains a challenging component of such a concept.

Are scores useful in advanced heart failure?

Advanced heart failure (HF) is becoming an increasingly challenging problem as more patients with this disease are living longer, yet experiencing its inexorable progression. Adding to this complex matter, there are different views on how to define advanced HF, whereby an acute decompensation episode does not necessarily indicate advanced disease. Several scores have been described aiming at a better prognostic performance across the HF spectrum. These include the Heart Failure Survival Score, the Seattle Heart Failure Model, the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure predictive schemes, the Acute Decompensated Heart Failure National Registry regression tree discrimination, among others. Most scoring systems have been built based on outpatient populations or recently hospitalized HF subjects. The setting of advanced HF has not gained much attention as far as prognostication is concerned, and yet there lies potentially challenging decision-making situations where issues, such as heart transplantation, use of costly devices and end-of-life questions, are raised.

Hepatic assist devices: Will they ever be successful?

Hepatic assist remains elusive. Bioartificial livers (BALs), consisting of liver cells or tissue in a synthetic housing, have been promising but have not proven successful in clinical trials. Artificial livers that consist of sophisticated sorbents and membranes cannot support a failing liver but may shorten episodes of acute decompensation in patients with stable cirrhosis. These artificial livers are most likely to find a place as temporary support prior to transplantation. True liver support will require a BAL. This article proposes goals for making a clinically useful BAL, with attention to systems biology and potential sources of hepatocytes.

Hepatitis E virus as an etiology of acute exacerbation of previously unrecognized asymptomatic patients with hepatitis B virus‐related chronic liver disease

Hepatitis E virus (HEV) has recently been implicated in episodes of acute decompensation in patients having underlying chronic liver disease (CLD) of varying etiology. However, HEV as a cause of acute exacerbation of previously asymptomatic and unrecognized hepatitis B virus (HBV)-infected patients is less well described. The aim of the present study was to investigate the etiology of acute exacerbation of previously asymptomatic and unrecognized HBV-infected patients and to evaluate the relative role of HEV. We also investigated the effect of superinfection on the clinical spectrum of underlying HBV infection. Forty-three patients presented with the following were retrospectively analyzed: (i) clinical features suggestive of acute hepatitis; (ii) with hepatitis B surface antigen (HBsAg) (+); (iii) IgM hepatitis B core antibody (IgM anti-HBc) (-); (iv) no previous history of liver disease; (v) no features suggestive of CLD at presentation; (vi) HBsAg remaining (+) for at least 12 months on follow up; and (vii) having a follow-up biopsy during the convalescent phase showing evidence of chronic hepatitis B. Of the 43 patients, 21 were hepatitis e antigen (HBeAg) (+) (Gr.1) and 22 HBeAg (-) (Gr.2) at presentation. In Gr.1, only two (9.5%) had superinfection (both with hepatitis A virus), whereas in Gr.2, 11 (50%) had superinfection (27.3% hepatitis E, 13.6% hepatitis A and 9.1% both) (P = 0.007). In Gr.1, the remaining 19 (90.5%) patients had spontaneous exacerbation (immune clearance with spontaneous seroconversion) whereas in Gr.2, the remaining 11 (50%) had spontaneous exacerbation (due to reactivation). Overall, HEV superinfection contributed to 20% of acute exacerbation episodes and, in particular, 36% of episodes in initially HBeAg (-) patients. Time to alanine aminotransferase normalization was longer in patients with superinfection (n = 13) as compared to spontaneous exacerbation (n = 30) (median [range] 36 [8-48]vs 16 [6-36] weeks, P = 0.001). During convalescence, there was no significant difference between histological activity index score (median [range] 8 [4-11]vs 8 [4-16] weeks, P = 0.629) and fibrosis scores (median [range] 3.5 [1-4]vs 2 [1-4] weeks, P = 0.099] on liver biopsy after recovery among patients with acute exacerbation due to superinfection and spontaneous exacerbation. Acute exacerbations in HBeAg (+) patients are most often due to spontaneous viral activation, while in HBeAg (-) patients, superinfection with non-B hepatitis viruses and spontaneous viral activation are equally common. HEV is an important cause of acute exacerbation in previously asymptomatic and unrecognized patients with HBV-related CLD.

Lack of decrease in plasma N-terminal pro-brain natriuretic peptide identifies acute heart failure patients with very poor outcome

Background Optimal risk stratification in heart failure patients surviving an episode of acute decompensation has not yet been established. We investigated whether a lack of significant decrease in plasma levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) during hospital stay can identify patients at high risk of poor outcome. Methods We studied 103 consecutive patients with acute heart failure (86 men, age: 64 ± 13 years, LVEF: 28 ± 8%). The primary end-point was all-cause mortality at 1-year follow-up. Results Median plasma NT-proBNP on admission was 6116 pg/mL (upper/lower quartiles: 3575, 10,958) vs. 2930 pg/mL (1674, 5794) after clinical stabilization (7 ± 3 days after admission). During the 1-year follow-up 29 (28%) patients died. A decrease in plasma NT-proBNP during clinical recovery (expressed as percentage of NT-proBNP on admission) predicted favorable outcome in the single predictor analysis ( p < 0.001) and multivariable analyses ( p < 0.001). Receiver operating characteristic curve analysis revealed that 65% was the cut-off value for NT-proBNP decrease having best prognostic accuracy for predicting death (sensitivity 90%, specificity 37%, AUC = 0.65, 95% CI: 0.54–0.74). Kaplan–Meier analysis showed that 12-month survival was 92% (95% CI: 81–100%) for patients with ≥ 65% NT-proBNP decrease vs 66% (95% CI: 56–76%) in those with < 65% NT-proBNP decrease ( p = 0.02). Conclusions The magnitude of plasma NT-proBNP decrease in patients with acute heart failure is helpful in discrimination of patients at high risk of death. Plasma NT-proBNP level monitoring is important for risk stratification in this group of patients.

Optimizing Treatment and Outcomes in Acute Heart Failure: Beyond Initial Triage

Heart failure contributes substantially to health care costs in the United States due to its prevalence and frequent necessity for repeat hospitalizations to manage episodes of acute decompensation. Heart failure overwhelmingly impacts Medicare costs, as the highest proportion of heart failure patients are older than 65 years of age. Efforts to reduce morbidity, mortality, and health care resource utilization have been achieved successfully through emergency department-based heart failure observation units. For select patients, the observation unit can provide care with effective oral agents, including angiotensin-converting enzyme inhibitors, beta-adrenergic receptor blockers, and diuretics, as well as administration of other vasoactive agents, followed by a discharge plan of effective heart failure education and rigorous follow-up management. As advanced pharmacologic and diagnostic therapies continue to emerge, the observation unit staff can play an integral role in the critical education and self-management tools that are needed by the patient to ultimately improve outcomes and quality of life.

Heart Failure Observation Units: Optimizing Care

Heart failure causes substantial morbidity and mortality in the United States and accounts for a higher proportion of Medicare costs than any other disease. Most of these costs result from the high rate of hospital admissions and protracted length of stay associated with episodes of acute decompensation of heart failure. Thus, effective clinical strategies to obviate hospitalization and readmission can result in substantial savings. A specialized heart failure observation unit, in which patients receive rapid, goal-directed emergency care for heart failure symptoms, can be a critical component in this effort, providing intensive therapeutic monitoring and education. In institutions with specialized heart failure observation units, patients are triaged to this setting shortly after presentation to the emergency department (ED), and clinic referrals can be directed to this unit after minimal ED evaluation. Aggressive follow-up is also arranged at discharge. Recent additions to the therapeutic armamentarium and future advances in diagnostics and monitoring will continue to improve patient care and prevent avoidable hospitalizations.

299 Mobile telemonitoring for heart failure patients following an episode of acute decompensation: influence of WAP-based telemonitoring on heart failure therapy

299 Mobile telemonitoring for heart failure patients following an episode of acute decompensation: influence of WAP-based telemonitoring on heart failure therapy

Neurohumoral Pathways in Heart Failure With Preserved Systolic Function

Other than natriuretic peptides, neurohumoral markers have not been studied adequately in heart failure with preserved systolic function. There is little evidence of chronic activation of the renin-angiotensin-aldosterone and sympathetic nervous systems, as in heart failure with reduced systolic function. These and other neurohumoral pathways may, however, become excessively stimulated by exercise and during episodes of acute decompensation. Blood natriuretic peptide concentrations are chronically elevated in patients with heart failure and preserved systolic function but not to the same extent as in patients with reduced systolic function. The role of neurohumoral antagonists in the treatment of heart failure and preserved systolic function has yet to be fully investigated.

Metabolic Disorders Associated With Neonatal Hypoglycemia

After completing this article, readers should be able to: 1. Describe four sources of glucose available to the neonate in the first 24 postnatal hours. 2. Select the best routine diagnostic test to recognize fatty acid oxidation defects. 3. List three or more metabolic disorders that can be identified by newborn screening performed using tandem mass spectrometry. Hypoglycemia is a common problem in neonates that has many causes. This review focuses on metabolic disorders that may be associated with hypoglycemia in the neonatal period. During intrauterine life, the fetus derives fuel, as glucose, from the mother via the placenta. After birth, the energy demands on the former fetus increase dramatically. The baby now must maintain its own body temperature and must undertake the work of breathing and other activities. Further, the maintenance of blood glucose levels requires glycogenolysis and gluconeogenesis. Postnatally, there are four sources of glucose: dietary glucose; glucose derived from the cleavage of more complex sugars in the gut (eg, lactose to glucose and galactose); glucose released from glycogen stores (primarily in the liver); and gluconeogenesis, in which glucose is synthesized from carbon skeletons derived from certain amino acids using energy derived from catabolism of fatty acids. Most term infants have sufficient glycogen stores to maintain blood glucose levels for several hours before gluconeogenesis is required. Infants who are breastfed in the United States typically are offered only water as a supplement to human milk during the first few postnatal days, a period when the mother’s milk supply is not yet established. In contrast, formula-fed babies receive calories by mouth by the end of the first postnatal day. Consequently, the metabolic stress of prolonged fasting occurs more frequently in breastfed than in formula-fed babies. Although breastfed babies have higher levels of ketone bodies that appear to provide adequate energy during this …

Quetiapine in the Treatment of Borderline Personality Disorder

Affective dysregulation, impulsivity and cognitiveperceptual difficulties are the psychopathological nuclear dimensions of Borderline Personality Disorder (BPD). Psychopharmacological treatment may become necessary during episodes of acute decompensation in which suicidal or self-destructive behaviour erupts. Some classes of psychotropic drugs have demonstrated efficacy in diminishing symptom severity and optimising functioning, such as antidepressants, mood stabilizers, benzodiazepines, opiate antagonists and antipsychotics. Conventional antipsychotics are the best-studied psychotropic medications for BPD, but nonadherence is often due to their severe side effects. Preliminary data reveal efficacy of atypical antipsychotics in BPD. We describe the impact of the novel antipsychotic drug quetiapine on severe self-mutilation in two female patients with the diagnoses of BPD. In both cases, monotherapeutic treatment with quetiapine was well tolerated and resulted in a marked improvement of impulsive behaviour and, over time, overall level of function. Though promising, our findings have to be regarded as preliminary. Due to the overall paucity of data there is still insufficient evidence to make a strong recommendation concerning continuation and maintenance therapy with atypical antipsychotics in BPD. Thus, there is a clear need for further controlled studies to evaluate pharmacological treatment options for this disorder.

Prognostic value of Doppler transmittal flow patterns and cardiac natriuretic peptides in patients with chronic congestive heart failure admitted for episodes of acute decompensation.

This study was designed to determine whether the restrictive filling transmitral flow velocity pattern is associated with increased plasma levels of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP). It was also designed to evaluate the prognostic value of these parameters from patients with chronic congestive heart failure (CHF) admitted for episodes of acute decompensation. We performed Doppler echocardiography, measured plasma levels of ANP and BNP in 33 patients at the time of admission, and assessed the subsequent cardiac mortality for 3 months. Eleven patients (33%) had a restrictive filling pattern of deceleration time (DcT) < 120ms. Plasma ANP and BNP levels were markedly increased in all patients to 189 +/- 145 pg/ml and 865 +/- 559 pg/ml, respectively. Seventeen patients (52%) showed more than 700 pg/ml of plasma levels of BNP. There was a significant correlation of DcT with the plasma ANP level (r = -0.41, P = 0.017), and a better correlation of DcT with the plasma BNP level (r =-0.50, P = 0.003). The combined index of both shorter DcT (< 120 ms) and higher plasma BNP levels (>700 pg/ml) was the best predictor of cardiac mortality by Cox univariate analysis (chi2 = 5.87, P = 0.015). Furthermore, the sensitivity and specificity of this index for the detection of cardiac mortality were 80% and 86%, respectively. In conclusion, the combined analysis of the Doppler transmitral flow velocity pattern and measurement of the plasma BNP level is noteworthy since it is noninvasive and convenient. Moreover, it is extremely useful in predicting the prognosis for patients with chronic CHF admitted for episodes of acute decompensation.

Noninvasive Nasal Mask Ventilation Beyond the ICU for an Exacerbation of Chronic Respiratory Insufficiency

To assess the usefulness of noninvasive nasal mask ventilation (NMV) in the treatment of an exacerbation of chronic respiratory insufficiency in patients stable enough to be admitted to a non-ICU ward. A prospective study in which the beneficial effect of NMV was compared with conservative treatment. A ward of respiratory medicine of a tertiary-referral teaching hospital. The study group included 15 patients with acute respiratory acidosis. These patients had pH less than 7.35 and PaCO2 more than 60 mm Hg, respiratory rate of 30 breaths or less per minute, hemodynamic stability, and alertness and willingness of cooperation with the NMV treatment. The control group consisted of 16 patients who fulfilled the same arterial blood gas requirements, retrospectively selected from the discharge forms of the ward of respiratory medicine for the year 1993. Patients underwent NMV for two sessions per day (one in the morning and one in the afternoon), each session lasting 4 h. A volumetric respirator (Monnal D; Taema; Paris, France) was used in four patients with restrictive disease. A positive-pressure ventilator (DP90; Taema; Paris, France) was used in 11 patients with obstructive disease. Control patients received standard medical, oxygen, and chest physical therapy. As compared with pre-NMV values, mean pH was significantly higher at 4 h of NMV after the patient's ventilatory adaptation (t = 8.814, p < 0.001) and at the end of NMV (t = 12.06, p < 0.001). Ventilatory support also produced a significant improvement in hypercapnia (pre-NMV vs NMV after the patient's ventilatory adaptation, t = 6.675, p < 0.001; pre-NMV vs post-NMV, t = 6.976, p < 0.001). Posttreatment pH and PaCO2 values were significantly higher and lower, respectively, in NMV-treated patients than in controls. At the end of treatment, a significantly higher PaO2/FIO2 ratio was documented in the study group than in controls (post-NMV vs posttreatment, t = 2.846, p < 0.01). NMV associated with standard treatment may be more beneficial than conservative treatment alone for improving blood gas exchange in patients with chronic respiratory insufficiency admitted to the hospital (but not the ICU) for an episode of acute decompensation and respiratory acidosis.