Exclusion Of Heart Failure Research Articles

Reliability of BNP to exclude heart failure

Reliability of BNP to exclude heart failure

Cardiac biomarkers and their clinical relevance

Cardiac biomarkers are an integral, guideline-recommended part of the diagnosis and follow-up of heart diseases. High sensitivity tests for troponin I or T allow for the early diagnosis of myocardial infarction. Rule-in and rule-out algorithms based on the dynamic of plasma concentrations in the first hour after admission improve safe, evidence-based decision making for patients with acute chest pain. Low concentrations of brain natriuretic peptides (BNP or NT-proBNP) reliably exclude heart failure. Elevated BNP/NT-proBNP concentrations are part of the definition of all types of heart failure but require additional tests to diagnose heart failure. Chronic elevations of troponins and BNP/NT-proBNP identify subpopulations at increased risk of cardiovascular events even in the absence of manifest cardiac disease. Whether and how this risk can be reduced requires further evaluation. Several novel biomarkers were recently discovered and characterised. Their place in cardiovascular medicine has yet to be defined.

Risk of death associated with incident heart failure in patients with known or suspected chronic coronary syndrome.

Traditional adverse events in chronic coronary syndrome (CCS) include atherothrombotic events but usually exclude heart failure (HF). Data are scarce about how new-onset HF modifies mortality risk. We aimed to determine the incidence of HF and compare its long-term mortality risk with myocardial infarction (MI) and stroke in patients with known or suspected CCS. We prospectively evaluated 5811 consecutive HF-free patients submitted to vasodilator stress cardiac magnetic resonance (CMR) for known or suspected CCS. Ischaemic burden and left ventricular ejection fraction were assessed by CMR. HF included outpatient diagnosis or acute HF hospitalization. The mortality risk for the incident events and their cross-comparisons were evaluated using a Markov illness-death model with transition-specific survival models. The mean age was 55±11years, and 38.9% were female. At a median follow-up of 5.44 (IQR=2.53-8.55) years, 591 deaths were registered (1.79 per 100 P-Y). The rates of new-onset HF were higher compared with MI and stroke [1.02, 0.62, and 0.51, respectively (P<0.05)]. The adjusted association between new-onset HF, MI, and stroke, and subsequent mortality was time dependent. The risk increased almost linearly for HF and became significant by the third year. By Year 10, the mortality risk attributable to new-onset HF was more than 2.5-fold (HR: 2.68, 95% CI=1.74-4.12). For MI, there was a significant increase in mortality risk up to the second year, followed by a monotonic decrease. For stroke, the mortality risk increased for the entire follow-up but became significant by the third year. A cross-comparison among incident endpoints HF outnumbers risk for those with MI by the sixth year (HRyear6.3 : 1.88, 95% CI=1.03-3.43). There was no difference in mortality risk between incident HF and stroke. In patients with CCS, long-term rates of incident HF were higher than MI and stroke. Patients with new-onset HF showed a higher risk of long-term mortality.

Does a normal electrocardiogram exclude heart failure with reduced left ventricular ejection fraction?

Abstract Background In the ESC guidelines for chronic heart failure an electrocardiogram (ECG) is part of the diagnostic set-up (1). A normal ECG makes the diagnosis unlikely. But can a normal ECG exclude heart failure with reduced left ventricular ejection fraction (HFrEF) and be a gatekeeper to echocardiography? Methods Patients referred from primary care to the cardiac outpatient clinic with suspicion of heart failure were consecutively included in the study, during a period of one year. With the referral from primary care was included an ECG which was assessed by a senior cardiologist and divided into two groups: 1) Patients with normal ECG; 2) Patients with pathologically ECG. Subsequently, an echocardiographic examination was performed in a blinded fashion and left ventricular ejection fraction (LVEF) was measured. Results Overall, 403 patients were included in the study. A normal ECG was present in 155 (38%) patients and a pathological ECG was present in 248 (62%) patients. In total, an echocardiographic examination identified 55 (14%) patients with an LVEF below 60% and 33 patients (8%) with LVEF below 50%. In patients with a normal ECG, only two patients had heart failure with a mildly reduced ejection fraction (41–49%), Figure 1. Thus, the ECG had a sensitivity of 94% and a negative predictive value of 99%, Figure 2. Conclusion A normal electrocardiogram has a high diagnostic sensitivity and negative predictive value for excluding heart failure with reduced LVEF and could be a gatekeeping tool in the prioritization of patients referred to echocardiography examination from primary care. Funding Acknowledgement Type of funding sources: Private hospital(s). Main funding source(s): Department of Cardiovascular research, OUH, Svendborg Hospital

Beta-blockers in patients without heart failure after myocardial infarction.

Beta-blockers in patients without heart failure after myocardial infarction.

DIFFUSE ALVEOLAR HEMORRHAGE IN A PATIENT WITH PRIMARY ANTIPHOSPHOLIPID SYNDROME: A RARE BUT SERIOUS ENTITY

TOPIC: Pulmonary Vascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: We present a case of a middle-aged female diagnosed with antiphospholipid syndrome (APS) with biopsy-proven pulmonary capillaritis coming with dyspnea and hemoptysis. CASE PRESENTATION: 66 years female with a history of APS with pulmonary vasculitis, multiple hospitalizations for recurrent pneumonia presented to Emergency Department (ED) with 2 weeks of worsening dyspnea, coughing out of blood clots, & nose bleeds for a day. She denied fever, chills, chest pain, and bleeding from elsewhere. ED vitals includes oxygen saturation of 70% on room air, otherwise afebrile with stable hemodynamics. Physical exam showed diffuse wheezing & crackles over bilateral lungs. Lab revealed pancytopenia requiring blood transfusion. Serology showed persistently positive antiphospholipid antibodies (ACL, Beta 2 Glycoprotein) but negative ANA, dsDNA, C-ANCA, P-ANCA, Anti-GBM antibody, hemolysis labs with normal complement 3 & 4, and ESR/CRP markers. Chest x-ray & CT chest showed diffuse ground-glass opacities. Echo revealed EF 71-75% with pulmonary hypertension. She was admitted to the ICU and started on pulse steroid & broad-spectrum antibiotics. She underwent 4 cycles of plasmapheresis followed by mycophenolate & rituximab for vasculitis flare. After a week, she improved without further need of supplemental oxygen and was discharged with mycophenolate, rituximab & oral steroid. DISCUSSION: Diffuse alveolar hemorrhage (DAH) can be a rare but fatal (21% mortality) manifestation of APS ( a hypercoagulable condition) where antiphospholipid antibodies (aPL) mediated pulmonary endothelial injury causes RBCs to leak into the alveoli [1,2]. The patient may recurrently present with dyspnea, fever, cough, hemoptysis with diffuse ground-glass opacity in chest film and dropping hematocrit [1,2,3]. A thorough history, examination, lab/imaging studies, or sometimes biopsy may be required to diagnose the underlying etiology so that specific treatment can be directed along with supportive care. Serological work-up should include ANCA Abs, ANA, dsDNA, Anti-GBM, complement 3 & 4 levels to identify underlying systemic vasculitis and cardiac echo should exclude heart failure [1]. Patient with this condition has persistently elevated & high titer of aPL antibodies [1,2]. Persistent bloody fluid in bronchoscopy with bronchoalveolar lavage supports DAH [1,3]. Though not recommended routinely, tissue biopsy shows pulmonary capillaritis more often than microvascular thrombosis in APS [1,2]. Respiratory support, maintenance of hemodynamics, temporary avoidance of anticoagulants, exclusion of infection, and initiation of high dose systemic steroid with immunosuppressive agents with or without plasma exchange are key to the management in patients with DAH secondary to capillaritis from underlying autoimmune condition [1,2,3]. CONCLUSIONS: Though rare, DAH should be suspected in patient with APS to direct the appropriate treatment timely. REFERENCE #1: Stoots SA, Lief L, Erkan D. Clinical Insights into Diffuse Alveolar Hemorrhage in Antiphospholipid Syndrome. Curr Rheumatol Rep. 2019;21(10):56. Published 2019 Sep 6. doi:10.1007/s11926-019-0852-7 REFERENCE #2: Deane KD, West SG. Antiphospholipid antibodies as a cause of pulmonary capillaritis and diffuse alveolar hemorrhage: a case series and literature review. Semin Arthritis Rheum. 2005 Dec;35(3):154-65. doi: 10.1016/j.semarthrit.2005.05.006. PMID: 16325656. REFERENCE #3: Gertner E. Diffuse alveolar hemorrhage in the antiphospholipid syndrome: spectrum of disease and treatment. J Rheumatol. 1999 Apr;26(4):805-7. PMID: 10229400. DISCLOSURES: No relevant relationships by Varun tej Gonuguntla, source=Web Response No relevant relationships by Resha Khanal, source=Web Response No relevant relationships by Sharad Oli, source=Web Response No relevant relationships by Shital Oli, source=Web Response No relevant relationships by kiran para, source=Web Response No relevant relationships by Ankur Sinha, source=Web Response No relevant relationships by husnain waseem, source=Web Response

162 Relationship Between NT Pro BNP Levels and Heart Failure in Patients &amp;gt;85 Years of Age

Abstract Introduction Around 920,000 people in the UK have been Diagnosed with Heart Failure with a median age of diagnosis been 77 years. The most commonly used test used to diagnose and measure prognosis in HF is BNP levels. B—Type Natriuretic Peptide is a hormone which is released in response to pressure changes in the ventricles. It causes Natriuresis which means removing sodium (salt) and water from the body thereby reducing the strain on the heart. It has a high negative predictive value to exclude heart failure with the following cut-off values. High levels—NTproBNP &amp;gt;2000 pg/ml. Raised levels—NTproBNP 400–2000 pg/ml. Normal levels—NTproBNP &amp;lt;400 pg/ml. The Aim of the study was to see if the cut off values of NT pro BNP Levels, which is the non-active pro hormone released from the same molecule that produces BNP are accurate in the elderly to diagnose Heart Failure. Method A retrospective study was carried out using 50 patients, age &amp;gt; 85 years with a diagnosis of heart failure. A comparison was made to look at NT pro BNP values and Ejection fraction (EF) [1] of these patients. A cut off of 50% EF was taken as diagnosing Heart Failure. Results Out of 50 patients, only 39 were suitable for the study as the rest did not have either a BNP value or an TransThoracic ECHO to assess Ejection Fraction. Age group taken was 85–97 years. 22.5% patients with a NT pro BNP level &amp;gt; 400 had an ejection fraction &amp;gt;50%. Conclusion Although we could only involve 39 patients, the data above shows that in patients aged &amp;gt;85 years with NT pro BNP values &amp;gt;400 around 25% have a normal ejection fraction. This suggest that increasing the cut off values for NT pro BNP to 750 in the elderly should be considered to diagnose Heart Failure, hence reducing cost and getting a high positive predictive value. Although more work is needed on the same. Reference 1. EF - in simple terms is amount of blood the heart is pumping into the body.

Galectin-3 as a Biomarker of Heart Failure in Children with Congenital Heart Disease

Background: Heart failure is defined as a clinical and pathophysiologic syndrome results from ventricular dysfunction, volume, or pressure overload, alone or both. Galectin-3 is a novel biomarker that mediates fibrosis in many organs like the heart that interest in galactin3 as a potential heart failure biomarker that reflects ongoing ventricular remodeling. Objective: To see if galectin-3 acts as a biomarker of heart failure in congenital heart disease and evaluate if there is a correlation between galectin-3 and severity of HF detected by Ross classification and echocardiogram. Patients and Methods: The present study included 38 cases with HF due to CHD admitted to PICU and pediatric department at Zagazig University Hospital from July 2018 to July 2019. Patients were selected to exclude heart failure other than congenital heart disease. Results: Galectin-3 level was significantly higher in children with CHD than age and sex-matched healthy children. There were statistically significant positive correlations between Galectin 3 and ROSS so higher Galectin-3 levels were associated with measures of HF severity. The level was significantly elevated in children with HF in comparison to those without HF, with a significant correlation with the disease severity. Galectin 3 had sensitivity 80%, specificity 100%, PPV 100% and PPN 71.4%. Conclusion: Galectin-3 has short term prognosis and can be used as a tool to help in HF diagnosis in children as a marker of disease severity (positive correlation between Ross classification and galectin-3 serum level was proved) and staging patients with acute HF due to congenital heart diseases.

NT-proBNP to exclude heart failure in primary care – a pragmatic, cluster-randomized study

Heart failure (HF) is difficult to recognize in primary care. N-terminal pro B-type natriuretic peptide (NT-proBNP) can be used as a rule-out test in HF due to its high negative predictive value. We aim to determine whether the number per 1000 patients of HF diagnoses increase among patients referred from primary care to an outpatient HF clinic, if general practitioners (GPs) were offered NT-proBNP in a real-life setting. All GP practices covered by Randers Regional Hospital were randomized to an intervention group (34 GP practices) and a control group (35 GP practices) in this pragmatic, cluster-randomized controlled trial. The main outcome was the number of patients referred to echocardiography and diagnosed with HF in each group. The number of patients per 1000 diagnosed with HF in the two groups was the same (0.09 (0.02–0.16) vs. 0.14 (0.07–0.21), p = .3541). A total of 700 NT-proBNP analyses, of which 611 were unique, were requested from 31 GP practices in 17.5 months. A total of 184 patients were referred to echocardiography on suspicion of HF. The number of patients per 1000 referred in the intervention group was significantly higher (p < .010). NT-proBNP was measured in 36.6% of referred patients in the intervention group. Significantly more women were diagnosed with HF in the intervention group (56.3% vs. 0%, p = .019). Hence, increased diagnostic effectiveness could not be shown in this real-life setting.

Roles of Procalcitonin and N-Terminal Pro-B-Type Natriuretic Peptide in Predicting Catheter-Related Bloodstream Infection in Severe Burn Injury Patients.

Objective To investigate the characteristics of early catheter-related bloodstream infection (CRBSI) in severe burn injury patients induced by a massive aluminum dust explosion. Methods Sixty-eight severe burn injury patients experienced a massive dust explosion in Kunshan were included in this study. Patients received central venous catheter placement, arterial catheterization to monitor blood pressure and PiCCO cardiac monitoring, tracheostomy, mechanical ventilation, analgesics and sedation treatment, and fluid resuscitation. Clinical data including age, gender, burn surface area, fluid intake and output, urine temperature, and APACHE II score information were collected from each patient. Ultrasound screening was performed to exclude heart failure, which may lead to the change of NT-proBNP. When CRBSI was suspected, 10 ml central venous blood and peripheral arterial blood were sent for testing. For patients with suspected CRBSI, the level of PCT and NT-proBNP were monitored every day until the infection was controlled. Results Among the 68 patients, 29 showed CRBSI. The most common pathogenic bacteria of CRBSI were A. baumannii (39.8%), P. aeruginosa (26.4%), and K. pneumoniae (13.7%). Procalcitonin (PCT) (2.98 ng/ml) and NT-proBNP (355 pg/ml) were significantly associated with CRBSI results. The sensitivity of PCT, NT-proBNP, WBC, and CRP was 94.2%, 89.7%, 88.3%, and 90.5%, respectively (P < 0.05). The area under curve (AUC) of PCT combined with NT-proBNP for prediction of CRBSI was 0.981, and the sensitivity and specificity was 0.812 and 0.857, respectively. Conclusion PCT and NT-proBNP combination improves the diagnosis of CRBSI. PCT and NT-proBNP may be alternative candidates for potential prediction of CRBSI in patients with severe injury.

The heart catheter table is not the operating table : Intraindividual comparison of pulmonary artery pressures

Patients undergoing cardiac surgery need extensive and invasive monitoring, which needs to be individually adapted for each patient and requires a diligent risk-benefit analysis. The use of a pulmonary artery catheter (PAC) seems to be justifiable in certain cases; therefore, the preoperative diagnosis of pulmonary hypertension represents an indication for perioperative monitoring with PAC in the S3 guidelines of the German Society for Anesthesiology and Intensive Care Medicine (DGAI). In many cases, however, this preoperative diagnosis cannot be confirmed intraoperatively. We wanted to find out whether this is just an impression or whether there actually are significant differences between preoperative, intraoperative and postoperative pulmonary artery pressures. After obtaining ethical approval, we retrospectively compared the pulmonary pressures of cardiac surgery patients with an elevated pulmonary pressure during preoperative right heart catheterization with those obtained intraoperatively and postoperatively by means of a PAC. All patients with apreoperatively documented pulmonary artery pressure of 40mmHg or above and an intraoperative use of a PAC during a4-year period were included. Exclusion criteria were intracardiac shunts, cardiogenic shock, emergency procedures, pulmonary hypertension of non-cardiac origin and atime span of more than 1year between right heart catheterization and surgery. We included 90patients. In the whole group and in the subgroups (according to diagnosis, time elapsed between heart catheterization and operation and pulmonary pressure), there were significant differences between preoperative and intraoperative pulmonary and systemic pressures. Systemic and pulmonary artery pressures were significantly higher during preoperative catheterization than intraoperatively. The systemic systolic pressure/systolic pulmonary pressure ratio, however, remained constant. The intraoperative and postoperative systemic and pulmonary artery pressures showed no significant differences. As anormal ejection fraction does not exclude heart failure with preserved ejection fraction and as we did not have any information on this condition, we did not group the patients according to the ejection fraction. An elevated pulmonary pressure obtained preoperatively during right heart catheterization is not indicative of an elevated pulmonary pressure either intraoperatively or postoperatively. There are various explanations for the differences (e.g., different physiological and pathophysiological settings, such as sedation with potential hypercapnia versus anesthesia with vasodilation when measured; newly prescribed medication coming into effect between the right heart catheterization and surgery; intraoperative positioning). Even though the inherent risks of aPAC seem to be low, we recommend refraining from using aPAC in patients with aonce documented elevated pulmonary pressure by default. As an alternative we suggest estimating the pulmonary pressure by transesophageal echocardiography (TEE) as an aid to decide whether the patient will benefit from the use of aPAC. Especially if it is not possible to identify tricuspid valve regurgitation for determining the peak gradient, it is helpful to check for additional signs of pulmonary hypertension. But we also have to bear in mind that in the postoperative period only aPAC can provide continuous measurement of pulmonary pressure.

Diagnostic accuracy of natriuretic peptides for acute heart failure: a review.

The rising incidence of and the cost associated with heart failure have made it increasingly imperative to accurately diagnose heart failure upon presentation. Correctly identifying heart failure in an Emergency Department is extremely challenging, and according to estimates, is only confirmatory in approximately 40-50% of patients. For an accurate diagnosis of heart failure and the consequent treatment, there needs to be more accurate test relying on biochemical factors as opposed to general symptoms that patients are experiencing. Natriuretic peptides are now utilized in routine tests for heart disease diagnosis in emergency departments as it is relatively low cost, easy to use and is a quick way to exclude heart failure as a reason for dyspnea. In this review, we detail the role and value of individual natriuretic peptides, particularly BNP, NT-proBNP, and MR-proANP, in diagnosing acute heart failure.

Efficient selective screening for heart failure in elderly men and women from the community: A diagnostic individual participant data meta-analysis.

BackgroundPrevalence of undetected heart failure in older individuals is high in the community, with patients being at increased risk of morbidity and mortality due to the chronic and progressive nature of this complex syndrome. An essential, yet currently unavailable, strategy to pre-select candidates eligible for echocardiography to confirm or exclude heart failure would identify patients earlier, enable targeted interventions and prevent disease progression. The aim of this study was therefore to develop and validate such a model that can be implemented clinically.Methods and resultsIndividual patient data from four primary care screening studies were analysed. From 1941 participants >60 years old, 462 were diagnosed with heart failure, according to criteria of the European Society of Cardiology heart failure guidelines. Prediction models were developed in each cohort followed by cross-validation, omitting each of the four cohorts in turn. The model consisted of five independent predictors; age, history of ischaemic heart disease, exercise-related shortness of breath, body mass index and a laterally displaced/broadened apex beat, with no significant interaction with sex. The c-statistic ranged from 0.70 (95% confidence interval (CI) 0.64–0.76) to 0.82 (95% CI 0.78–0.87) at cross-validation and the calibration was reasonable with Observed/Expected ratios ranging from 0.86 to 1.15. The clinical model improved with the addition of N-terminal pro B-type natriuretic peptide with the c-statistic increasing from 0.76 (95% CI 0.70–0.81) to 0.89 (95% CI 0.86–0.92) at cross-validation.ConclusionEasily obtainable patient characteristics can select older men and women from the community who are candidates for echocardiography to confirm or refute heart failure.

Heart failure and the discrepancy between trials of intensive blood pressure management: an analysis of individual patient data.

ACCORD and SPRINT are the best randomized controlled trial data evaluating the effects of blood pressure targets below 140mmHg. These trials had contradictory results regarding the benefits of intensive antihypertensive therapy. We investigate if this discordance was driven by SPRINT's inclusion of Heart Failure in its primary outcome, as this is a parameter not included in ACCORD's original primary outcome. This analysis helps to resolve a significant area of contention. Individual patient data from 4733 participants in ACCORD were analyzed from time of randomization. All participants were diabetic and at increased cardiovascular risk. Participants were assigned to their original intervention, a standard blood pressure target of less than 140mmHg or an intensive target of less than 120mmHg. Primary composite outcome was defined as in SPRINT: a composite of first occurrence of myocardial infarction, stroke, heart failure, death from cardiovascular causes, and other acute coronary syndromes. Primary outcome was not significantly different between standard and intensive groups [HR: 0.89; 95% CI: (0.76-1.03); p = 0.108]. The primary composite outcome occurred in 370 participants in the standard group (15.6%) and 324 participants in the intensive group (13.7%), with an event rate of 3.38% per year for the standard group and 3.01% per year for the intensive group. Differing results between ACCORD and SPRINT are not attributable to ACCORD's exclusion of Heart Failure from its original primary outcome measurement. No significant differences in primary outcome were observed between intensive and standard blood pressure groups in the ACCORD patients under the SPRINT primary outcome definition. Caution should be taken in extrapolating the intensive blood pressure control benefits of SPRINT to the diabetic population.

Circulating Biomarkers in Heart Failure.

Biological markers have served for diagnosis, risk stratification and guided therapy of heart failure (HF). Our knowledge regarding abilities of biomarkers to relate to several pathways of HF pathogenesis and reflect clinical worsening or improvement in the disease is steadily expanding. Although there are numerous clinical guidelines, which clearly diagnosis, prevention and evidence-based treatment of HF, a strategy regarding exclusion of HF, as well as risk stratification of HF, nature evolution of disease is not well established and requires more development. The aim of the chapter is to discuss a role of biomarker-based approaches for more accurate diagnosis, in-depth risk stratification and individual targeting in treatment of patients with HF.

2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America.

Glenn N. Levine, MD, FACC, FAHA, Chair Patrick T. O’Gara, MD, FACC, FAHA, Chair-Elect Jonathan L. Halperin, MD, FACC, FAHA, Immediate Past Chair [‡‡][1] Sana M. Al-Khatib, MD, MHS, FACC, FAHA Kim K. Birtcher, PharmD, MS, AACC Biykem Bozkurt, MD, PhD, FACC, FAHA Ralph G. Brindis, MD,

Evaluating the scripts and thresholds of general practitioners for diagnosing heart failure in elderly people.

BackgroundMultiple diagnostic algorithms for heart failure exist. However, it is unclear whether these algorithms are incorporated in the ‘scripts’ clinicians use in every day practice. Scripts are networks of organised knowledge that are acquired and accumulated during clinical training and are refined with each clinical encounter. This study was conducted to evaluate the scripts and thresholds that GPs use to diagnose heart failure in patients aged 75 years and older.MethodsThe scripts and thresholds of 130 Belgian GPs in training and 63 experienced trainers were compared using an online questionnaire based on the same principles as the script concordance test. Two major cases with an open question and 19 minor cases with closed questions were presented. For the minor cases, all of the respondents were asked to assign a diagnostic power to individual cues. Based on these powers, a diagnostic threshold was calculated for each respondent for the two major cases.ResultsThe trainers and trainees used the same scripts to diagnose heart failure in the two major cases. Only ~50 % of the participants used natriuretic peptides in their scripts, although they judged it as the most powerful marker to demonstrate or exclude heart failure. The power that respondents gave to several cues differed significantly according to the context in which these cues were presented. In general, the average exclusive power of different cues was lower than the demonstrative power of the cues. There was no difference in diagnostic threshold between the trainers and trainees.ConclusionYoung, inexperienced GPs used the same scripts as older, more experienced GPs. In general, technical investigations were less frequently queried, compared to elements of the medical history and the clinical examination. The clinical context had a strong impact on the diagnostic power that was assigned to different factors.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0481-4) contains supplementary material, which is available to authorized users.

Uncovering heart failure with preserved ejection fraction in patients with type 2 diabetes in primary care: time for a change.

Undetected heart failure appears to be an important health problem in patients with type 2 diabetes and aged ≥ 60 years. The prevalence of previously unknown heart failure in these patients is high, steeply rises with age, and is overall higher in women than in men. The majority of the patients with newly detected heart failure have a preserved ejection fraction. A diagnostic algorithm to detect or exclude heart failure in these patients with variables from the medical files combined with items from history taking and physical examination provides a good to excellent accuracy. Annual screening appears to be cost-effective. Both unrecognised heart failure with reduced and with preserved ejection fraction were associated with a clinically relevant lower health status in patients with type 2 diabetes. Also the prognosis of these patients was worse than of those without heart failure. Existing disease-management programs for type 2 diabetes pay insufficient attention to early detection of cardiovascular diseases, including heart failure. We conclude that more attention is needed for detection of heart failure in older patients with type 2 diabetes.

Dyspnea in airway and pulmonary diseases

The subjective perception of pulmonary dyspnea varies based on behavioral and physiological responses. Acute pulmonary dyspnea is the most common symptom of diseases of the airways and the lungs and the differential diagnosis includes harmless causes, such as lack of training as well as acute life-threatening diseases, such as thromboembolism, obstruction of the upper or lower airway, pneumonia, pulmonary hemorrhage and pneumothorax. Most cases of chronic pulmonary dyspnea result from asthma, chronic obstructive pulmonary disease (COPD), pulmonary arterial hypertension, pulmonary fibrosis and pleural disorders. Listening to the patient's "language of dyspnea" may already provide indications for the diagnosis. Initial testing includes chest radiography, spirometry, complete blood count and the basic metabolic panel. Measurement of brain natriuretic peptide levels may help to exclude heart failure in COPD and D-dimer testing may help rule out pulmonary embolisms. Computed tomography of the chest is the most appropriate imaging procedure for diagnosing pulmonary embolism and interstitial lung disease. To diagnose pulmonary arterial hypertension echocardiography and right heart catheterization may be necessary.

Abstract 11133: The Incidence and Predicting Factors of Heart Failure After First Acute Myocardial Infarction: A Population[[Unable to Display Character: &amp;#8208;]]Based Study in Taiwan

Background: Early coronary revascularization and medical therapy advancement improve the survival of patients (pts) with acute myocardial infarction (AMI). However, survivors of AMI are at heightened risk of developing heart failure (HF) and there is a paucity of information regarding this issue in Asian countries. This study described the temporal trends in the incidence of HF after the first AMI and the predicting factors of HF development in Taiwan. Methods: We conducted a nationwide population-based cohort study by using 1999 to 2009 National Health Insurance Research Database. Pts aged≧18 years, with no history of HF, who hospitalized with a first AMI between January 2002 and December 2008 were identified and followed up for one year. The primary outcome was HF. We evaluated the incidence of HF during the index hospitalization, 30 days, 6 months, and one year after the discharge. The predicting factors of HF were identified by Cox proportional hazard model. Results: Overall, 42,011 first AMI pts (mean age 64.4 ± 13.8 years; male 75.0%) from 2002 to 2008 were identified. The HF incidence during the index hospitalization was 14.8%. After exclusion of HF during the hospitalization, the overall HF prevalence at 30 days, 6 months, and 1 year was 9.6%, 14.2%, and 16.8%, respectively. The HF prevalence at 1 year declined from 17.9% to 14.9% (p&lt;0.05) from 2002 to 2008. The independent predicting factors of HF after the first AMI were elder age (≧65 years) (adjusted HR 1.81, 95% CI 1.51-2.18), diabetes mellitus (adjusted HR 1.30, 95% CI 1.21-1.41), chronic kidney disease (adjusted HR 1.41, 95% CI 1.20-1.65), use of loop diuretics within 30 days after the discharge (adjusted HR 2.21, 95% CI 2.00-2.43), and recurrent AMI (adjusted HR 2.43, 2.16-2.74). Conclusions: Survivors of AMI without prior HF remain at risk of developing HF in Taiwan and most episodes occur within 6 months after AMI. Five important clinical factors of HF were identified that may help us for risk stratification.