An anti-angiogenic cleaved prolactin fragment is considered causal for peripartum cardiomyopathy (PPCM). Experimental and first clinical observations suggested beneficial effects of the prolactin ...release inhibitor bromocriptine in PPCM.
In this multicentre trial, 63 PPCM patients with left ventricular ejection fraction (LVEF) ≤35% were randomly assigned to short-term (1W: bromocriptine, 2.5 mg, 7 days) or long-term bromocriptine treatment (8W: 5 mg for 2 weeks followed by 2.5 mg for 6 weeks) in addition to standard heart failure therapy. Primary end point was LVEF change (delta) from baseline to 6 months assessed by magnetic resonance imaging. Bromocriptine was well tolerated. Left ventricular ejection fraction increased from 28 ± 10% to 49 ± 12% with a delta-LVEF of + 21 ± 11% in the 1W-group, and from 27 ± 10% to 51 ± 10% with a delta-LVEF of + 24 ± 11% in the 8W-group (delta-LVEF: P = 0.381). Full-recovery (LVEF ≥ 50%) was present in 52% of the 1W- and in 68% of the 8W-group with no differences in secondary end points between both groups (hospitalizations for heart failure: 1W: 9.7% vs. 8W: 6.5%, P = 0.651). The risk within the 8W-group to fail full-recovery after 6 months tended to be lower. No patient in the study needed heart transplantation, LV assist device or died.
Bromocriptine treatment was associated with high rate of full LV-recovery and low morbidity and mortality in PPCM patients compared with other PPCM cohorts not treated with bromocriptine. No significant differences were observed between 1W and 8W treatment suggesting that 1-week addition of bromocriptine to standard heart failure treatment is already beneficial with a trend for better full-recovery in the 8W group.
ClinicalTrials.gov, study number: NCT00998556.
Purpose
Insufficient antimicrobial exposure is associated with worse outcomes in sepsis. We evaluated whether therapeutic drug monitoring (TDM)-guided antibiotic therapy improves outcomes.
Methods
...Randomized, multicenter, controlled trial from January 2017 to December 2019. Adult patients (
n
= 254) with sepsis or septic shock were randomly assigned 1:1 to receive continuous infusion of piperacillin/tazobactam with dosing guided by daily TDM of piperacillin or continuous infusion with a fixed dose (13.5 g/24 h if eGFR ≥ 20 mL/min). Target plasma concentration was four times the minimal inhibitory concentration (range ± 20%) of the underlying pathogen, respectively, of
Pseudomonas aeruginosa
in empiric situation. Primary outcome was the mean of daily total Sequential Organ Failure Assessment (SOFA) score up to day 10.
Results
Among 249 evaluable patients (66.3 ± 13.7 years; female, 30.9%), there was no significant difference in mean SOFA score between patients with TDM (7.9 points; 95% CI 7.1–8.7) and without TDM (8.2 points; 95% CI 7.5–9.0) (
p
= 0.39). Patients with TDM-guided therapy showed a lower 28-day mortality (21.6% vs. 25.8%, RR 0.8, 95% CI 0.5–1.3,
p
= 0.44) and a higher rate of clinical (OR 1.9; 95% CI 0.5–6.2,
p
= 0.30) and microbiological cure (OR 2.4; 95% CI 0.7–7.4,
p
= 0.12), but these differences did not reach statistical significance. Attainment of target concentration was more common in patients with TDM (37.3% vs. 14.6%, OR 4.5, CI 95%, 2.9–6.9,
p
< 0.001).
Conclusion
TDM-guided therapy showed no beneficial effect in patients with sepsis and continuous infusion of piperacillin/tazobactam with regard to the mean SOFA score. Larger studies with strategies to ensure optimization of antimicrobial exposure are needed to definitively answer the question.
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in clinical practice and is known to be associated with significant morbidity and mortality. Previous studies suggested a link ...between inflammation and AF by findings of increased inflammatory markers in AF patients. However, it has not been finally clarified whether inflammation is a systemic or a local phenomenon reflecting an active inflammatory process in the heart. To address this subject, human left atrial appendage tissues were obtained from 10 patients who underwent cardiac surgery and subjected to immunohistochemical analysis. The number of inflammatory CD3-positive T cells significantly increased from patients with sinus rhythm to paroxysmal AF and persistent AF, respectively. Interestingly, in patients with persistent AF, these cells were frequently arranged in small clusters. Subsequently, the number of inflammatory CD3-positive T cells decreased and was significantly lower in patients with permanent AF than in patients with persistent AF. Inflammatory CD20-positive B cells could only be detected very occasionally in all AF subgroups and were not locatable in patients with SR. Hence, our data emphasize the potential prominent role of the cellular component of the immune system in the development and perpetuation of AF.
...it is a potentially lifesaving treatment for patients that would die without; secondly, ECMO treatment is highly resource intensive and therefore may have an impact on the availability of ...resources for other patients 2. Thoughtful and responsible planning should include making information about free hospital and ICU beds and other potentially scarce healthcare resources, like ventilators or ECMO, at the local, regional and national level easily available to physicians. SEE PDF Registries monitoring the availability of ICU beds and definition of regional clusters for patient allocation help to ease pressure from overburdened hospitals, too.
Temperature control is recommended after out of hospital cardiac arrest (OHCA) by international guidelines. This survey aimed to investigate current clinical practice and areas of uncertainty.
Online ...survey targeting members of three medical emergency and critical care societies in Germany (April 21-June 6, 2022) assessing post-cardiac arrest temperature control management.
Of 341 completed questionnaires 28% (n = 97) used temperature control with normothermic target and 72% (n = 244) temperature control with hypothermic target. The definition of fever regarding patients with cardiac arrest ranged from ≥ 37.7 to 39.0 °C. Temperature control was mainly started in the ICU (80%, n = 273) and most commonly core cooling (74%, n = 254) and surface cooling (39%, n = 134) with feedback were used. Temperature control was maintained for 24 h in 18% (n = 61), 48 h in 28% (n = 94), 72 h in 42% (n = 143) and longer than 72 h in 13% (n = 43). 7% (n = 24) were using different protocols for OHCA with initial shockable and non-shockable rhythm. Additional 14% (n = 48) were using different temperature control protocols after in-hospital cardiac arrest (IHCA) compared with OHCA. Overall, 37% (n = 127) changed practice after the publication of the ERC-2021 guidelines and 33% (n = 114) after the recent publication of the revised ERC-ESICM guideline on temperature control.
One-third of the respondents changed clinical practice since recent guideline update. However, a majority of physicians further trusts in temperature control with a hypothermic target. Of interest, 14% used different temperature control strategies after IHCA compared with OHCA and 7% for shockable and non-shockable initial rhythm. A more individualized approach in post resuscitation care may be warranted.
Zusammenfassung
Im Jahr 2021 wurden die aktuellen europäischen Leitlinien zur kardiopulmonalen Reanimation veröffentlicht. Die Leitlinie, welche in 12 Kapitel unterteilt ist, wurde um die Kapitel ...„Epidemiologie“ und „Lebensrettende Systeme“ erweitert. Im folgenden Beitrag wird auf die Empfehlungen zu Basismaßnahmen, erweiterten Maßnahmen der Erwachsenenreanimation und auf die Postreanimationsbehandlung eingegangen.
Background
Improved imaging modalities contributed to increasing awareness of cardiac amyloidosis. Contemporary data on frequency trends in Germany are lacking.
Methods
In a retrospective study using ...health claims data of a German statutory health insurance, patients with diagnostic codes of amyloidosis and concomitant heart failure between 2009 and 2018 were identified.
Results
Prevalence increased from 15.5 to 47.6 per 100,000 person-years, and incidence increased from 4.8 to 11.6 per 100,000 person-years, with a continuous steepening in the slope of incidence trend. In patients with amyloidosis and heart failure age and proportion of men significantly increased, whereas the frequency of myeloma and nephrotic syndrome significantly decreased over time. Median (IQR) survival time after first diagnosis was 2.5 years (0.5–6 years), with a 9% (95% CI 2–15%,
p
= 0.008) reduced risk of death in the second compared to the first 5 years of observation. In the 2 years prior and 1 year after diagnosis, mean total health care costs were 6568 €, 11,872 € and 21,955 € per person and year.
Conclusion
The rise in cardiac amyloidosis has continuously accelerated in the last decade. Considering the adverse outcome and high health care burden, further effort should be put on early detection of the disease to implement available treatment.
Psychological distress is common in patients with cardiovascular disease and negatively impacts outcome.
Psychological distress is high in acute high risk cardiac patients eligible for a WCD, and ...associated with low quality of life. Distress is aggravated by WCD.
Consecutive patients eligible for a WCD were included in the prospective, multicenter "Cologne Registry of External Defibrillator" registry. Quality of life (Short Form-12), depressive symptoms (Beck-Depression Inventory II) and anxiety (State Trait Anxiety Inventory) were assessed at enrollment and 6-weeks, and associations with WCD prescription were analyzed.
123 patients (mean SD age 59 ± 14 years, 75% male) were included, 85 (69%) of whom received a WCD. At enrollment 21% showed clinically significant depressive symptoms and 52% anxiety symptoms, respectively. At 6 weeks, depressive and anxious symptoms significantly decreased to 7% and 25%, respectively. Depressive symptoms at enrollment and changes at 6 weeks showed significant associations with health-related quality of life, whereas anxious symptoms did not. There was a trend for better improvement of depression scores in patients with WCD (mean SD change in score points: -4.1 6.1 vs -1.8 3.9; p = 0.09), whereas change of the anxiousness score was not different (-4.6 9.5) vs -3.7 9.1, p = 0.68).
In patients eligible for a WCD, depressive and anxiety symptoms were initially common and depressive symptoms showed a strong association with reduced health-related quality of life contributing to their clinical relevance. WCD recipients showed at least similar improvement of depression and anxiety at 6 weeks when compared to non recipients.
Abstract Purpose Accurate assessment of coronary stents using non-invasive CT imaging remains challenging despite new stent materials and improvements in CT technology. Virtual monoenergetic (monoE) ...images reconstructed from dual energy CT acquisitions potentially decrease artifacts caused by coronary stents. A novel spectral detector technology provides monoE and conventional images simultaneously for all conducted scans. The purpose of our study was to systematically investigate the influence of different monoE reconstructions on the visualization of coronary stent lumen in comparison to conventional images. Method and materials Ten different coronary stents (diameter 3.0 mm) embedded in plastic tubes filled with contrast agent (500 HU) were scanned with a 128-row spectral detector CT (IQon, Philips, 120 kV, 125 mAs). Images were reconstructed (0.67 mm slice thickness, 0.35 mm increment) with a stent-specific conventional reconstruction kernel and 6 different monoE settings (60, 70, 80, 90, 100, 150 keV). Image quality for each stent and reconstruction was quantified using established parameters: image noise (standard deviation (SD) within a standardized ROI), in-stent attenuation difference (mean attenuation difference between stented and non-stented lumen) and visible lumen diameter (mean visible diameter of the stented tube). Results Image noise was significantly lower in all monoE data dets compared to conventional images (conventional: 13.41, 60 keV: 11.62, 70 keV: 11.67, 80 keV: 11.69, 90 keV: 11.71, 100 keV: 11.75, 150 keV: 11.80 HU SD; p < 0.01). The in-stent attenuation difference was significantly smaller in monoE data with higher keV levels than in conventional images (conventional: 148.18, 60 keV: 154.13 p = 0.036, 70 keV: 143.43 p = 0.109, 80 keV: 137.25 p = 0.052, 90 keV: 133.02 p = 0.043, 100 keV: 130.12 p = 0.039, 150 keV: 123.99 HU p = 0.035). The visible lumen diameter was significantly greater in monoE data with higher keV levels than in conventional images (conventional: 0.65, 60 keV: 0.68 p = 0.542, 70 keV: 0.71 p = 0.053, 80 keV: 0.74 p < 0.01, 90 keV: 0.77 p < 0.01, 100 keV: 0.82 p < 0.01, 150 keV: 0.87 mm p < 0.01). Conclusion In comparison to conventional CT images, well-established parameters for objective assessment of CT image quality for coronary stents are significantly improved by utilization of monoE reconstructions with adequate keV levels derived from data acquired on a novel spectral detector CT platform.
Identification of individuals at risk for developing atrial fibrillation (AF) will help to target screening and preventive interventions. We aimed to validate the CHARGE-AF model (including variables ...age, race, height, weight, blood pressure, smoking, antihypertensive medication, diabetes, myocardial infarction and heart failure) for prediction of five-year incident AF in a representative European population with a wide age range.
The CHARGE-AF model was calculated in 24,020 participants of the population-based EPIC Norfolk study with 236 cases of hospitalization with diagnosis of AF within five years. The model showed good discrimination (c-statistic 0.81, 95% confidence interval (CI) 0.75-0.85), but weak calibration (Chi(2)-statistic 142) with an almost two-fold overestimation of AF incidence. A recalibration to characteristics of the European Prospective Investigation into Cancer and Nutrition (EPIC) Norfolk cohort improved calibration considerably (Chi(2)-statistic 13.3), with acceptable discrimination in participants both >65 and ≤65 years of age (c-statistics 0.70, 95% CI 0.61-0.77 and 0.83, 95% CI 0.74-0.88). The recalibrated model also showed good discrimination in participants free of cardiovascular disease (c-statistics 0.80, 95% CI 0.75-0.84). Categories of predicted risk (<2.5%, 2.5-5% or >5%) showed good concordance with observed five-year AF incidence of 0.62%, 3.49% and 8.74% (log rank test p < 0.001), respectively.
A recalibration of the CHARGE-AF model is necessary for accurate predictions of five-year risk of AF in the EPIC Norfolk population. The recalibrated model showed good discrimination across a wide age range and in individuals free of cardiovascular disease, and hence is broadly applicable in primary care to identify people at risk for development of AF.
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