Appropriate interpretation of changes in markers of kidney function is essential during the treatment of acute and chronic heart failure. Historically, kidney function was primarily assessed by serum ...creatinine and the calculation of estimated glomerular filtration rate. An increase in serum creatinine, also termed worsening renal function, commonly occurs in patients with heart failure, especially during acute heart failure episodes. Even though worsening renal function is associated with worse outcome on a population level, the interpretation of such changes within the appropriate clinical context helps to correctly assess risk and determine further treatment strategies. Additionally, it is becoming increasingly recognized that assessment of kidney function is more than just glomerular filtration rate alone. As such, a better evaluation of sodium and water handling by the renal tubules allows to determine the efficiency of loop diuretics (loop diuretic response and efficiency). Also, though neurohumoral blockers may induce modest deteriorations in glomerular filtration rate, their use is associated with improved long‐term outcome. Therefore, a better understanding of the role of cardio–renal interactions in heart failure in symptom development, disease progression and prognosis is essential. Indeed, perhaps even misinterpretation of kidney function is a leading cause of not attaining decongestion in acute heart failure and insufficient dosing of guideline‐directed medical therapy in general. This position paper of the Heart Failure Association Working Group on Cardio‐Renal Dysfunction aims at improving insights into the interpretation of renal function assessment in the different heart failure states, with the goal of improving heart failure care.
Organ injury and impairment are commonly observed in patients with acute heart failure (AHF), and congestion is an essential pathophysiological mechanism of impaired organ function. Congestion is the ...predominant clinical profile in most patients with AHF; a smaller proportion presents with peripheral hypoperfusion or cardiogenic shock. Hypoperfusion further deteriorates organ function. The injury and dysfunction of target organs (i.e. heart, lungs, kidneys, liver, intestine, brain) in the setting of AHF are associated with increased risk for mortality. Improvement in organ function after decongestive therapies has been associated with a lower risk for post‐discharge mortality. Thus, the prevention and correction of organ dysfunction represent a therapeutic target of interest in AHF and should be evaluated in clinical trials. Treatment strategies that specifically prevent, reduce or reverse organ dysfunction remain to be identified and evaluated to determine if such interventions impact mortality, morbidity and patient‐centred outcomes. This paper reflects current understanding among experts of the presentation and management of organ impairment in AHF and suggests priorities for future research to advance the field.
While there has been a global decrease in rates of heart failure (HF) prevalence between 1990 and 2019, the Eastern Mediterranean region (EMR) is experiencing an increase. In 2019, approximately ...1,229,766 individuals lived with moderate to severe HF in the EMR. Despite the growth in the utilization of advanced heart failure (AHF) therapies in the EMR in the past two decades, current volumes are yet to meet the growing AHF burden in the region. Heart transplantation (HT) volumes in EMR have grown from 9 in the year 2000 to 179 HTs in 2019. However, only a few centers provide the full spectrum of AHF therapies, including durable mechanical circulatory support (MCS) and HT. Published data on the utilization of left ventricular assist devices (LVAD) in the EMR are scarce. Notably, patients undergoing LVAD implantation in the EMR are on average, 13 year younger, and more likely to present with critical cardiogenic shock, as compared to their counterparts in the Western world. Furthermore, AHF care in the region is hampered by the paucity of multidisciplinary HF programs, inherent costs of AHF therapies, limited access to short and long-term MCS, organ shortage, and lack of public awareness and acceptance of AHF therapeutics. All stakeholders in the EMR should work together to strategize tackling the challenging AHF burden in the region.
Right ventricular (RV) dysfunction frequently occurs and independently prognosticates in left-sided heart failure. It is not clear which RV afterload measure has the greatest impact on RV function ...and prognosis. We examined the determinants, prognostic role, and response to treatment of pulmonary arterial capacitance (PAC, ratio of stroke volume over pulmonary pulse pressure), in relation to pulmonary vascular resistance (PVR) in heart failure.
We reviewed 724 consecutive patients with heart failure who underwent right heart catheterization between 2000 and 2005. Changes in PAC were explored in an independent cohort of 75 subjects treated for acute decompensated heart failure. PAC showed a strong inverse relation with PVR (r=-0.64) and wedge pressure (r=-0.73), and provides stronger prediction of significant RV failure than PVR (area under the curve ROC 0.74 versus 0.67, respectively, P=0.003). During a mean follow-up of 3.2±2.2 years, both lower PAC (P<0.0001) and higher PVR (P<0.0001) portend more adverse clinical events (all-cause mortality and cardiac transplantation). In multivariate analysis, PAC (but not PVR) remains an independent predictor (Hazard ratio=0.92 95% CI: 0.84-1.0, P=0.037). Treatment of heart failure resulted in a decrease in PVR (270±165 to 211±88 dynes·s(-1)·cm(-5), P=0.002), a larger increase in PAC (1.65±0.64 to 2.61±1.42 mL/mm Hg, P<0.0001), leading to an increase in pulmonary arterial time constant (PVR×PAC) (0.29±0.12 to 0.37±0.15 second, P<0.0001).
PAC bundles the effects of PVR and left-sided filling pressures on RV afterload, explaining its strong relation with RV dysfunction, poor long-term prognosis, and response to therapy.
This study sought to determine whether changes in intra-abdominal pressure (IAP) with aggressive diuretic or vasodilator therapy are associated with improvement in renal function in acute ...decompensated heart failure (ADHF).
Elevated IAP (>or=8 mm Hg) is associated with intra-abdominal organ dysfunction. There is potential for ascites and visceral edema causing elevated IAP in patients with ADHF.
Forty consecutive patients admitted to a specialized heart failure intensive care unit for management of ADHF with intensive medical therapy were studied. The IAP was measured using a simple transvesical technique at time of admission and before removal of the pulmonary artery catheter.
In our study cohort (mean age 59 +/- 13 years, mean left ventricular ejection fraction 19 +/- 9%, baseline serum creatinine 2.0 +/- 0.9 mg/dl), the mean baseline IAP was 8 +/- 4 mm Hg, with 24 (60%) patients having elevated IAP. Elevated IAP was associated with worse renal function (p = 0.009). Intensive medical therapy resulted in improvement in both hemodynamic measurements and IAP. A strong correlation (r = 0.77, p < 0.001) was observed between reduction in IAP and improved renal function in patients with baseline elevated IAP. However, changes in IAP or renal function did not correlate with changes in any hemodynamic variable.
Elevated IAP is prevalent in patients with ADHF and is associated with impaired renal function. In the setting of intensive medical therapy for ADHF, changes in IAP were better correlated with changes in renal function than any hemodynamic variable.
Sodium Nitroprusside for Advanced Low-Output Heart Failure Mullens, Wilfried, MD; Abrahams, Zuheir, MD, PhD; Francis, Gary S., MD, FACC ...
Journal of the American College of Cardiology,
07/2008, Letnik:
52, Številka:
3
Journal Article
Recenzirano
Odprti dostop
Sodium Nitroprusside for Advanced Low-Output Heart Failure Wilfried Mullens, Zuheir Abrahams, Gary S. Francis, Hadi N. Skouri, Randall C. Starling, James B. Young, David O. Taylor, W. H. Wilson Tang ...Inotropic drugs are often preferred over vasodilators in patients with end-stage, low-output heart failure. We reviewed consecutive patients admitted between 2000 and 2005 with acute decompensated heart failure with a cardiac index ≤2 l/min/m2 . Compared with control patients, treatment with sodium nitroprusside was associated with greater improvement in hemodynamics, higher rates of transitioning oral vasodilators at discharge, and lower rates of all-cause mortality and all-cause mortality/cardiac transplant without increase in rehospitalization, inotropic use, or worsening renal function.
Noninvasive Imaging in Myocarditis Skouri, Hadi N.; Dec, G. William; Friedrich, Matthias G. ...
Journal of the American College of Cardiology,
11/2006, Letnik:
48, Številka:
10
Journal Article
Recenzirano
Odprti dostop
Noninvasive Imaging in Myocarditis
Hadi N. Skouri, G. William Dec, Matthias G. Friedrich, Leslie T. Cooper
Increased recognition of the role of inflammation in acute and chronic dilated ...cardiomyopathy has revived an interest in noninvasive imaging for detection of myocarditis. Diagnostic strategies that are based on molecular imaging promise to further advance our understanding and improve diagnostic precision. This article reviews the strengths and limitations of common clinical tests used for the diagnosis of myocarditis, with a focus on the emerging role of cardiovascular magnetic resonance imaging. Novel imaging modalities that are currently in preclinical development are discussed with recommendations for future clinical research.
Increased recognition of the role of inflammation in acute and chronic dilated cardiomyopathy has revived an interest in noninvasive imaging for detection of myocarditis. Diagnostic strategies that are based on molecular imaging promise to further advance our understanding and improve diagnostic precision. This article reviews the strengths and limitations of common clinical tests used for the diagnosis of myocarditis, with a focus on the emerging role of cardiovascular magnetic resonance imaging. Novel imaging modalities that are currently in preclinical development are discussed with recommendations for future clinical research.
Elevated Intra-Abdominal Pressure in Acute Decompensated Heart Failure: A Potential Contributor to Worsening Renal Function? Wilfried Mullens, Zuheir Abrahams, Hadi N. Skouri, Gary S. Francis, David ...O. Taylor, Randall C. Starling, Emil Paganini, W. H. Wilson Tang We measured intra-abdominal pressure (IAP) using a simple transvesical technique in 40 consecutive patients admitted for acute decompensated heart failure without overt abdominal symptoms. Among them, 60% had elevated IAP (≥8 mm Hg). Elevated IAP was directly associated with worse renal function, and intensive medical therapy resulted in improvement in both hemodynamic measures and IAP. However, reduction in IAP is better correlated with improvement in renal function than any hemodynamic variable, suggesting a potential contribution of elevated IAP in the pathophysiology of the cardiorenal syndrome.
The Program for the Evaluation and Management of Cardiac Events in the Middle East and North Africa (PEACE MENA) is a prospective registry program in Arabian countries that involves in patients with ...acute myocardial infarction (AMI) or acute heart failure (AHF).
This prospective, multi-center, multi-country study is the first report of the baseline characteristics and outcomes of inpatients with AMI who were enrolled during the first 14-month recruitment phase. We report the clinical characteristics, socioeconomic, educational levels, and management, in-hospital, one month and one-year outcomes.
Between April 2019 and June 2020, 1377 patients with AMI were enrolled (79.1% males) from 16 Arabian countries. The mean age (± SD) was 58 ± 12 years. Almost half of the population had a net income < $500/month, and 40% had limited education. Nearly half of the cohort had a history of diabetes mellitus, hypertension, or hypercholesterolemia; 53% had STEMI, and almost half (49.7%) underwent a primary percutaneous intervention (PCI) (lowest 4.5% and highest 100%). Thrombolytics were used by 36.2%. (Lowest 6.45% and highest (90.9%). No reperfusion occurred in 13.8% of patients (lowest was 0% and highest 72.7%).Primary PCI was performed less frequently in the lower income group vs. high income group (26.3% vs. 54.7%; P<0.001). Recurrent ischemia occurred more frequently in the low-income group (10.9% vs. 7%; P = 0.018). Re-admission occurred in 9% at 1 month and 30% at 1 year, whereas 1-month mortality was 0.7% and 1-year mortality 4.7%.
In the MENA region, patients with AMI present at a young age and have a high burden of cardiac risk factors. Most of the patients in the registry have a low income and low educational status. There is heterogeneity among key performance indicators of AMI management among various Arabian countries.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background Androgen deprivation therapy (ADT) is the mainstay of treatment for advanced prostate cancer, improving symptoms and prolonging survival. There is an association between ADT use and ...cardiovascular (CV) events, particularly in patients with preexisting risk factors. In men diagnosed with prostate cancer, CV disease is the principal non-cancer-related cause of death. There are no definite guidelines to stratify patients based on CV risk prior to ADT initiation. This is the first study on cardiac risks and events in patients with prostate cancer treated with ADT from the Middle East region, a population known to have a high prevalence of CV risk factors. Results A retrospective study of 234 patients with prostate cancer, who received ADT therapy at a tertiary care centre in Lebanon was conducted. CV risk factors at baseline and CV events on ADT were reviewed. The median age was 68 years (48–92 years). The majority of patients had stage 4 diseases at diagnosis (49.6%) with a median duration of 12 months on ADT. In our cohort, 24.4% had body mass index > 30, 52.1% had smoking history, 25.6% were diabetic, 19.7% had history of coronary artery disease, 9.8% had heart failure history and 52.9% had hypertension. Less than half of the patients had a documented lipid profile at baseline. Twenty-two patients (9.5%) had documented cardiac events following ADT initiation. Conclusions In this cohort of patients from the Middle East, we found that one third of the population had established coronary artery disease at baseline and 9.5% had documented cardiac events on ADT initiation. Our study highlights the gaps in CV risk assessment for this high-risk group of patients with prostate cancer in addition to high prevalence of CV comorbidities. Risk and resource-stratified algorithms are needed before starting ADT therapy for optimal CV health. Increased awareness, collaboration and referral mechanisms between oncologists, urologists and cardiologists are also needed to provide optimal care.
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