Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee ...has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.
Depuis la parution des Lignes directrices sur l’insuffisance cardiaque (IC) de la Société canadienne de cardiologie en 2006, les soins aux patients atteints de ce trouble ont connu d’importants changements. Au cours de la dernière décennie, le Comité des lignes directrices sur l’IC a publié des mises à jour périodiques. Toutefois, en raison des changements importants qui sont survenus, le Comité des lignes directrices a jugé qu’il était nécessaire de procéder à une réévaluation exhaustive des recommandations sur la prise en charge de l’IC afin de produire un ensemble complet de lignes directrices à jour. Les membres des comités primaire et secondaire sur l’IC de la Société canadienne de cardiologie, ainsi que des spécialistes externes, ont passé en revue la littérature pertinente afin d’indiquer aux cliniciens la marche à suivre. Les lignes directrices de 2017 donnent des indications sur le diagnostic et la prise en charge (autosoins, traitements pharmacologiques et non pharmacologiques, dispositifs et orientation des patients) destinées à faciliter la prise de décisions quotidiennes en matière de soins aux patients atteints d’IC. Parmi les questions abordées figurent notamment les cotes de risque, les différences de prise en charge selon qu’il s’agit d’IC à fraction d’éjection préservée ou réduite, l’activité physique et la réadaptation, les dispositifs implantables, la revascularisation, la dysfonction ventriculaire droite, l’anémie et la carence en fer, le syndrome cardiorénal, l’apnée du sommeil, les cardiomyopathies, l’IC pendant la grossesse, la cardio-oncologie et la myocardite. Le comité a apporté une attention particulière aux stratégies et aux traitements visant à prévenir l’IC, à l’organisation des soins aux patients atteints d’IC, à la prise en charge des comorbidités, ainsi qu’à des questions pratiques concernant les délais d’orientation du patient et les soins de suivi. La reconnaissance et le traitement de l’IC au stade avancé, et notamment le choix des thérapies à ce stade et les considérations en matière de fin de vie, représentent un autre aspect important de cette mise à jour. Enfin, le comité reconnaît les lacunes dans les données probantes qui subsistent et devront être comblées par les recherches futures.
Abstract The Canadian Cardiovascular Society Heart Failure (HF) Guidelines Program has generated annual HF updates, including formal recommendations and supporting Practical Tips since 2006. Many ...clinicians indicate they routinely use the Canadian Cardiovascular Society HF Guidelines in their daily practice. However, many questions surrounding the actual implementation of the Guidelines into their daily practice remain. A consensus-based approach was used, including feedback from the Primary and Secondary HF Panels. This companion is intended to answer several key questions brought forth by HF practitioners such as appropriate timelines for initial assessments and subsequent reassessments of patients, the order in which medications should be added, how newer medications should be included in treatment algorithms, and when left ventricular function should be reassessed. A new treatment algorithm for HF with reduced ejection fraction is included. Several other practical issues are addressed such as an approach to management of hyperkalemia/hypokalemia, treatment of gout, when medications can be stopped, and whether a target blood pressure or heart rate is suggested. Finally, elements and teaching of self-care are described. This tool will hopefully function to allow better integration of the HF Guidelines into clinical practice.
Abstract The 2014 Canadian Cardiovascular Society Heart Failure Management Guidelines Update provides discussion on the management recommendations on 3 focused areas: (1) anemia; (2) biomarkers, ...especially natriuretic peptides; and (3) clinical trials that might change practice in the management of patients with heart failure. First, all patients with heart failure and anemia should be investigated for reversible causes of anemia. Second, patients with chronic stable heart failure should undergo natriuretic peptide testing. Third, considerations should be given to treat selected patients with heart failure and preserved systolic function with a mineralocorticoid receptor antagonist and to treat patients with heart failure and reduced ejection fraction with an angiotensin receptor/neprilysin inhibitor, when the drug is approved. As with updates in previous years, the topics were chosen in response to stakeholder feedback. The 2014 Update includes recommendations, values and preferences, and practical tips to assist the clinicians and health care workers to best manage patients with heart failure.
High level of cardiac Troponin T (hs-cTnT) in geriatric population has been considered as an age-related phenomenon, which may question the interpretation of the increase of hs-cTnT in this ...population. The challenge is what is the primary cause of the increased hs-cTnT levels in elderly patients without AMI.
The aim of the current study was to determine the impact of aging on hs-cTnT levels in elderly patients without acute cardiac events but in the presence of comorbidities.
Sociodemographic and clinical data were collected from 6977 medical records of patients aged ≥65 years without acute coronary events but for whom hs-cTnT measurements were available. The patients were stratified based on age, troponin levels and the number of comorbidities.
The results suggested that the likelihood of increased hs-cTnT was related to the presence of comorbidities independently of their number (p < 0.05). The adjusted odds ratio (AOR) for both advanced age and having comorbidity was statistically significant, however for the old group (74 ≥ age ≥ 84 years) the chance of having elevated troponin regarding age compared to the presence of comorbidity was 1.070 vs. 1.216, whereas for the old-old group (≥85 years) it was found to be 1.071 vs. 1.311. Besides statistical significance for age, from a clinical standpoint, the AOR of 1.070 may not be considered clinically relevant.
Increased hs-cTnT levels were associated with the presence of pre-existing comorbidities independently of age. Increased hs-cTnT levels in the elderly should always be considered as pathological, and a specific etiology should be searched.
Abstract
Background
Two-dimensional speckle-tracking echocardiography (STE) may help detect coronary artery disease (CAD) when combined with dobutamine stress echocardiography. However, few studies ...have explored STE with exercise stress echocardiography (ESE). We aimed to evaluate the feasibility, reliability, and incremental value of STE combined with treadmill ESE compared to treadmill ESE alone to detect CAD.
Methods
We conducted a case–control study of all consecutive patients with abnormal ESE in 2018–2020 who subsequently underwent coronary angiography within a six-month interval. We 1:1 propensity score-matched these patients to those with a normal ESE. Two blinded operators generated a 17-segment bull's-eye map of longitudinal strain (LS). We utilized the mean differences between stress and baseline LS values in segments 13–17, segment 17, and segments 15–16 to create receiver operator curves for the overall examination, the left anterior descending artery (LAD), and the non-LAD territories, respectively.
Results
We excluded 61 STEs from 201 (30.3%) eligible ESEs; 47 (23.4%) because of suboptimal image quality and 14 (7.0%) because of excessive heart rate variability precluding the calculation of a bull's-eye map. After matching, a total of 102 patients were included (51 patients in each group). In the group with abnormal ESE patients (mean age 66.4 years, 39.2% female), 64.7% had significant CAD (> 70% stenosis) at coronary angiogram. In the group with normal ESE patients (mean age 65.1 years, 35.3% female), 3.9% were diagnosed with a new significant coronary stenosis within one year. The intra-class correlation for global LS was 0.87 at rest and 0.92 at stress, and 0.84 at rest, and 0.89 at stress for the apical segments. The diagnostic accuracy of combining ESE and STE was superior to visual assessment alone for the overall examination (area under the curve (AUC) = 0.89 vs. 0.84,
p
= 0.025), the non-LAD territory (AUC = 0.83 vs. 0.70,
p
= 0.006), but not the LAD territory (AUC = 0.79 vs. 0.73,
p
= 0.11).
Conclusions
Two-dimensional speckle-tracking combined with treadmill ESE is relatively feasible, reliable, and may provide incremental diagnostic value for the detection and localization of significant CAD.
Acute decompensated heart failure Lepage, Serge, MD
Canadian journal of cardiology,
07/2008, Letnik:
24, Številka:
Suppl B
Journal Article
Recenzirano
Odprti dostop
Acute decompensated heart failure is the most common cause of hospitalization for patients older than 65 years of age. Although treatment of this condition has improved over the past two decades, the ...specific approach to patients in the acute setting has not evolved in the same way. A patient facing acute decompensation is experiencing a serious medical condition that is associated with a poor prognosis. In addition, acute decompensated heart failure results in significant costs to the health care system. Significant morbidity and mortality are associated with patients who are readmitted within a year of the first hospitalization. Because of this important problem, further research on improving the prognosis for this condition is warranted. The present article will focus on the risk factors associated with acute decompensation and the importance of this condition, both on prognosis and economics.
The Bezold-Jarisch reflex is a parasympathetic reflex induced by intense mechanical stimulation of the ventricular myocytes. Exceptionally, cases have been described in patients receiving dobutamine ...infusion during a stress echocardiography. All were healthy middle-aged women and recovered without sequelae. A healthy 60-year-old woman suffered two 5.9-second episodes of asystole during her 20 mcg/kg/min infusion of dobutamine. Recovery was quick and without sequelae. Echocardiography and coronary angiography were both normal. In conclusion, this is the fourth documented case of a severe Bezold-Jarisch reflex causing asystole during dobutamine infusion. Diagnosis can only be made after excluding all other possible diagnoses, most importantly ischemia. This serves as a reminder of the importance of close monitoring during dobutamine infusion.
Background The Canadian Cardiology Society recommends that patients should be seen within 2 weeks after an emergency department (ED) visit for heart failure (HF). We sought to investigate whether ...patients who had an ED visit for HF subsequently consult a physician within the current established benchmark, to explore factors related to physician consultation, and to examine whether delay in consultation is associated with adverse events (AEs) (death, hospitalization, or repeat ED visit). Methods Patients were recruited by nurses at 8 hospital EDs in Québec, Canada, and interviewed by telephone within 6 weeks of discharge and subsequently at 3 and 6 months. Clinical variables were extracted from medical charts by nurses. We used Cox regression in the analysis. Results We enrolled 410 patients (mean age 74.9 ± 11.1 years, 53% males) with a confirmed primary diagnosis of HF. Only 30% consulted with a physician within 2 weeks post-ED visit. By 4 weeks, 51% consulted a physician. Over the 6-month follow-up, 26% returned to the ED, 25% were hospitalized, and 9% died. Patients who were followed up within 4 weeks were more likely to be older and have higher education and a worse quality of life. Patients who consulted a physician within 4 weeks of ED discharge had a lower risk of AEs (hazard ratio 0.59, 95% CI 0.35-0.99). Conclusion Prompt follow-up post-ED visit for HF is associated with lower risk for major AEs. Therefore, adherence to current HF guideline benchmarks for timely follow-up post-ED visit is crucial.
We describe a case of very late transcatheter heart valve(THV) thrombosis of a first-generation SAPIEN prosthesis(Edwards Lifesciences, Irvine, CA) implanted in a 64-yearold woman with severe ...symptomatic aortic stenosis. More than 54 mo after implantation, she presented with severe symptomatic prosthesis dysfunction(stenosis) which was successfully treated with oral anticoagulation. To our knowledge, this is the tardiest case of THV thrombosis ever reported. This case should increase clinical awareness for THV thrombosis even beyond the first two-year period following implantation.
PDF
