High-sensitivity troponin is associated with high risk clinical profile and outcome in acute heart failure

Background: The aim of the study was to evaluate the value of high-sensitivity cardiac troponin (hs-cTn) for identifying high-risk patients. Methods and results: One hundred and eighty-seven patients admitted with acute heart failure (HF) (without myocardial infarction) were consecutively included; hs-cTn was measured at admission; the relation between elevated hs-cTn and the clinical outcome during hospitalization and at 90 days was analyzed; 93% (n = 174) had hs-cTn above the maximal normal value (14 ng/L); median hs-cTn was 42 ng/L (IQR 24–81). Patients with ejection fraction (EF) ≤ 45% had higher hs-cTn values (p = 0.0004). Patients with low cardiac output syndrome (LCOS) or shock had higher troponin levels compared with those with less severe clinical presentations (p = 0.004). Patients who required inotropic presented higher troponin values (p = 0.002), troponin values were also higher in those requiring complex therapies (intra-aortic balloon pump, mechanical ventilation or hemodialysis, p = 0.002). At 90-day follow-up, 28 (15.5%) patients died and 27 rehospitalizations occurred (55 events). The risk of events was greater in patients with hs-cTn > 42 ng/L (0.021), low blood pressure at admission (p = 0.002), LCOS or shock (p < 0.0001), EF ≤ 45% (p = 0.005) and inotropic use (p < 0.0001). In multivariate analysis, only inotropic agents requirements was associated independently with a high risk of death or rehospitalizations at 90 days (p = 0.007). Conclusions: Elevation of hs-cTn is a finding almost constant in patients with decompensated HF. In subjects with higher troponin levels ventricular dysfunction is frequent. The use of hs-cTn for risk stratification at admission helps to identify populations with poor outcome during hospitalization and increased risk of death or rehospitalizations during follow-up who will require rapid implementation of aggressive treatment.

Impacto del equipo multidisciplinario “ECMO Team” en el pronóstico de pacientes sometidos a membrana de oxigenación extracorpórea venoarterial por choque cardiogénico o paro cardiorrespiratorio refractario

Objectives. Veno-arterial Extracorporeal membrane oxygenation (VA ECMO) is a salvage intervention in patients with cardiogenic shock (CS), and cardiac arrest  (CA) refractory to standard therapies. The design of ECMO Teams has achieved the standardization of processes, although its impact on survival and prognosis is unknown. Objective: We aimed to analyze whether the creation of an ECMO Team has modified the prognosis of patients undergoing VA ECMO for refractory CS or CA. Materials and methods. We conducted a single-center retrospective cohort study. Patients with refractory CS or CA who underwent VA ECMO were divided in two consecutive periods: from 2014 to April 2019 (pre-ECMO T) and from May 2019 to December 2022 (Post ECMO T). The main outcomes were survival on ECMO, in-hospital survival, complications, and annual ECMO volume. Results. Eighty-three patients were included (36 pre-ECMO T and 47 post-ECMO T). The mean age was 53 +/-13 years. The most common reason for  device indication was different:  postcardiotomy shock (47.2%) pre-ECMO T and refractory cardiogenic shock (29.7%) post-ECMO T. The rate of extracorporeal  cardiopulmonary resuscitation was 14.5%.  The median duration of VA ECMO was longer after ECMO team implementation: 8 days (IQR 5-12.5) vs. five days (IQR 2-9, p=0.04). Global in-hospital survival was 45.8% (38.9% pre-ECMO T vs. 51.1% post-ECMO T; p=0.37),  and the survival rate from VA ECMO was 60.2% (55.6% pre-ECMO T vs 63.8% post-ECMO T; p= 0.50). The volume of VA ECMO implantation was significantly higher in the post-ECMO team period (13.2  +/3.5 per year vs. 6.5 +/-3.5 per year, p: 0.02). The rate of complications was similar in both groups. Conclusions. After the implementation of an ECMO team, there was no statistical difference in the survival rate of patients treated with VA ECMO. However, a significant increase in the number of patients supported per year was observed after the implementation of this multidisciplinary team. Post-ECMO T, the most common reason for device indication was cardiogenic shock, with longer run times and a higher rate of extracorporeal cardiopulmonary resuscitation.Introducción. La oxigenación por membrana extracorpórea venoarterial (ECMO VA) es una intervención de rescate utilizada en choque cardiogénico (CC) o paro cardiorrespiratorio (PCR) refractario. La creación de equipos multidisciplinarios ECMO Teams (ECMO T), ha permitido la estandarización de procesos, aunque se desconoce su impacto en  sobrevida y pronóstico. Objetivo: El propósito es analizar si la creación del ECMO Team ha modificado el pronóstico de los pacientes sometidos a ECMO VA por CC o PCR refractario. Materiales y métodos. Estudio observacional, unicéntrico, retrospectivo, que comparó los resultados del implante de ECMO VA por CC o PCR refractario en dos períodos consecutivos: entre 2014 y abril de 2019 (pre-ECMO T), y entre mayo de 2019 y diciembre de 2022 (pos-ECMO T). Como puntos finales, se evaluó la sobrevida intrahospitalaria y en ECMO, complicaciones, y volumen de ECMO anual. Resultados. Se analizaron 83 pacientes (36 pre-ECMO T, y 47 pos-ECMO T), con edad de 53 +/-13 años. La causa más frecuente de asistencia fue: poscardiotomía pre-ECMO T (47,2%) y CC refractario pos-ECMO T (29,7%). En el 14,5% se realizó ECMO en PCR. La mediana de asistencia fue mayor pos-ECMO T (8 días, RIC 5-12,5 vs. 5 días, RIC 2-9 pre-ECMO T; p:0,04). La supervivencia al alta fue del 45,8% (38,9% pre-ECMO T vs. 51,1% pos-ECMO T;p:0,37) y en ECMO VA del 60,2% (55,6% pre-ECMO T y 63,8% pos-ECMO T; p:0,50). El volumen de ECMO VA fue significativamente mayor pos-ECMO T (13,2+/3,5 por año vs. 6,5+/-3,5 por año, p: 0,02). La tasa de complicaciones fue similar en ambos períodos. Conclusiones.Luego de la implementación del ECMO Team no se observó una diferencia significativa en la sobrevida en pacientes asistidoscon ECMO VA. Sin embargo, luego de su creación se evidenció un aumento significativo del volumen de pacientes asistidos por año. Pos-ECMO T se asistió mayor número de pacientes por choque cardiogénico, en PCR y con más días de asistencia

Nivel de alexitimia en los estudiantes de Enfermería: primera aproximación al objeto de conocimiento.

Enfermería debe brindar un cuidado integral e integrado, contextualizado a la realidad y culturalmente aceptable. Un eje de intervención favorecedor de lo planteado es la comunicación afectuosa y eficaz, lo que permite empatizar. A pesar de lo expuesto, en general se observa mayor focalización en las necesidades físicas y en menor grado en las psico–emocionales y espirituales, dificultades en el establecimiento de comunicación efectiva con pacientes y equipo profesional, como así también, déficit en la expresión de emociones –sentimientos. Por lo tanto, el objetivo del presente estudio fue conocer el grado de alexitimia que presentan los estudiantes; la alexitimia es un trastorno que impide expresar los sentimientos, esto puede favorecer la aparición del estrés y la ansiedad, también confusiones en las relaciones sociales, ya que las personas que la padecen son incapaces de demostrar su apoyo.Fil: Piovano, Mirta. Universidad Nacional de Córdoba. Facultad de Ciencias Médicas. Escuela de Enfermería; Argentina.Fil: Giacone, Marta. Universidad Nacional de Córdoba. Facultad de Ciencias Médicas. Escuela de Enfermería; Argentina.Fil: Soria, Valeria Cecilia. Universidad Nacional de Córdoba. Facultad de Ciencias Médicas. Escuela de Enfermería; Argentina.Fill: Linell, Axel. Universidad Nacional de Córdoba. Facultad de Ciencias Médicas. Escuela de Enfermería; Argentina.Fil: Tejerina, Rosana Mariela. Universidad Nacional de Córdoba. Facultad de Ciencias Médicas. Escuela de Enfermería; Argentina.Fil: Díaz, Estela del Valle. Universidad Nacional de Córdoba. Facultad de Ciencias Médicas. Escuela de Enfermería; Argentina.Fil: Fernandez Diez, Marina. Universidad Nacional de Córdoba. Facultad de Ciencias Médicas. Escuela de Enfermería; Argentina.Enfermerí

Molecular Identification of Trypanosma cruzi discrete Typing Units in end-Stage Chronic Chagas Heart Disease and Reactivation after Heart Transplantation

One hundred years after the discovery of Chagas disease, it remains a major neglected tropical disease. Chronic Chagas heart disease is the most severe manifestation. Heart trasplantation is the proper treatment for end-stage heart failure. T. cruzi strains cluster into 6 discrete typing units assosiated with different geographical distribution, transmission cycles and varying disease symptoms.In the southern cone of South America, T. cruzi II, V and VI popuations appear to be assosiated with Chagas disease and T. cruzi I with sylvatic cycles.Fil: Burgos, Juan Miguel. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - la Plata. Instituto de Investigaciones Biotecnológicas. Instituto de Invest. Biotec. (subsede San Martin) | Universidad Nacional de San Martin. Instituto de Investigaciones Biotecnológicas. Instituto de Invest. Biotec. (subsede San Martin); Argentina. Laboratorio Biología Molecular de Enfermedad de Chagas; ArgentinaFil: Diez, Mirta. Universidad Favaloro; ArgentinaFil: Vigliano, Carlos. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Universidad Favaloro; ArgentinaFil: Bisio, Margarita María Catalina. Gobierno de la Ciudad de Buenos Aires. Instituto Multidisciplinario de Investigaciones en Patologías Pediátricas. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto Multidisciplinario de Investigaciones en Patologías Pediátricas; ArgentinaFil: Risso, Marikena Guadalupe. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Instituto de Investigaciones Bioquímicas de Buenos Aires. Fundación Instituto Leloir. Instituto de Investigaciones Bioquímicas de Buenos Aires; ArgentinaFil: Duffi, Tomas. Laboratorio Biología Molecular de Enfermedad de Chagas; ArgentinaFil: Cura, Carolina Inés. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Investigación en Ingeniería Genética y Biología Molecular "Dr. Héctor N. Torres". Grupo Vinculado al INGEBI- Laboratorio de Biocatálisis y Biotransformaciones - LBB - UNQUI; ArgentinaFil: Brusés, Bettina Laura. Universidad Nacional del Nordeste. Instituto de Medicina Regional; ArgentinaFil: Favaloro, Liliana Ethel. Universidad Favaloro; ArgentinaFil: Leguizamon, María Susana. Dirección Nacional de Instituto de Investigación.Administración Nacional de Laboratorios e Institutos de Salud "Dr. Carlos G. Malbrán"; ArgentinaFil: Lucero, Raúl Horacio. Universidad Nacional del Nordeste. Instituto de Medicina Regional; ArgentinaFil: Laguens, Rubén. Universidad Favaloro; ArgentinaFil: Levin, Mariano Jorge. Consejo Nacional de Investigaciones Científicas y Técnicas. Instituto de Investigación en Ingeniería Genética y Biología Molecular "Dr. Héctor N. Torres". Grupo Vinculado al INGEBI- Laboratorio de Biocatálisis y Biotransformaciones - LBB - UNQUI; ArgentinaFil: Favaloro, Roberto René. Universidad Favaloro; ArgentinaFil: Schijman, Alejandro Gabriel. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Laboratorio Biología Molecular de Enfermedad de Chagas; Argentin

Accurate Real-Time PCR Strategy for Monitoring Bloodstream Parasitic Loads in Chagas Disease Patients

Infection with the parasite Trypanosoma cruzi (T. cruzi), causing American trypanosomiasis or Chagas disease, remains a major public health concern in 21 endemic countries of America, with an estimated prevalence of 8 million infected people. Chagas disease shows a variable clinical course, ranging from asymptomatic to chronic stages with low parasitaemias, whose severest form is heart disease. Diagnosis at the asymptomatic and chronic stages is based on serological detection of anti-T. cruzi antibodies, because conventional parasitological methods lack sensitivity. Current chemotherapies are more effective in recent infections than in the chronic adult population. The criterion of cure relies on serological conversion to negative, which may occur only years after treatment, requiring long-term follow-up. In this context, we aimed to develop a real-time PCR assay targeted to repetitive sequences of T. cruzi for sensitive quantitation of parasitic load in peripheral blood of infected patients. It was applied to monitor treatment response of infected children, allowing rapid evaluation of drug efficacy as well as detection of treatment failure. It was also used for early diagnosis of chagasic reactivation in end-stage heart disease patients who received immunosuppressive drugs after cardiac transplantation. This laboratory strategy may constitute a novel parasitological tool for prompt and sensitive evaluation of anti-parasitic treatment of Chagas disease

Effects of dapagliflozin on symptoms, function and quality of life in patients with heart failure and reduced ejection fraction: results from the DAPA-HF trial

Background: Goals of management in patients with heart failure and reduced ejection fraction include reducing death and hospitalizations, and improving health status (symptoms, physical function, and quality of life). In the DAPA-HF trial (Dapagliflozin and Prevention of Adverse-Outcomes in Heart Failure), sodium–glucose cotransporter-2 inhibitor, dapagliflozin, reduced death and hospitalizations, and improved symptoms in patients with heart failure and reduced ejection fraction. In this analysis, we examine the effects of dapagliflozin on a broad range of health status outcomes, using the Kansas City Cardiomyopathy Questionnaire (KCCQ). Methods: KCCQ was evaluated at randomization, 4 and 8 months. Patients were divided by baseline KCCQ total symptom score (TSS); Cox proportional hazards models examined the effects of dapagliflozin on clinical events across these subgroups. We also evaluated the effects of dapagliflozin on KCCQ-TSS, clinical summary score, and overall summary score. Responder analyses were performed to compare proportions of dapagliflozin versus placebo-treated patients with clinically meaningful changes in KCCQ at 8 months. Results: A total of 4443 patients had available KCCQ at baseline (median KCCQ-TSS, 77.1 [interquartile range, 58.3–91.7]). The effects of dapagliflozin vs placebo on reducing cardiovascular death or worsening heart failure were consistent across the range of KCCQ-TSS (lowest to highest tertile: hazard ratio, 0.70 [95% CI, 0.57–0.86]; hazard ratio, 0.77 [95% CI, 0.61–0.98]; hazard ratio, 0.62 [95% CI, 0.46–0.83]; P for heterogeneity=0.52). Patients treated with dapagliflozin had greater improvement in mean KCCQ-TSS, clinical summary score, and overall summary score at 8 months (2.8, 2.5 and 2.3 points higher versus placebo; P<0.0001 for all). Fewer patients treated with dapagliflozin had a deterioration in KCCQ-TSS (odds ratio, 0.84 [95% CI, 0.78–0.90]; P<0.0001); and more patients had at least small, moderate, and large improvements (odds ratio, 1.15 [95% CI, 1.08–1.23]; odds ratio, 1.15 [95% CI, 1.08–1.22]; odds ratio, 1.14 [95% CI, 1.07–1.22]; number needed to treat=14, 15, and 18, respectively; P<0.0001 for all; results consistent for KCCQ clinical summary score and overall summary score). Conclusions: Dapagliflozin reduced cardiovascular death and worsening heart failure across the range of baseline KCCQ, and improved symptoms, physical function, and quality of life in patients with heart failure and reduced ejection fraction. Furthermore, dapagliflozin increased the proportion of patients experiencing at least small, moderate, and large improvements in health status; these effects were clinically important

Effects of dapagliflozin in DAPA-HF according to background heart failure therapy

Aims In the DAPA-HF trial, the SGLT2 inhibitor dapagliflozin reduced the risk of worsening heart failure (HF) and death in patients with HF and reduced ejection fraction. We examined whether this benefit was consistent in relation to background HF therapy. Methods and results In this post hoc analysis, we examined the effect of study treatment in the following yes/no subgroups: diuretic, digoxin, mineralocorticoid receptor antagonist (MRA), sacubitril/valsartan, ivabradine, implanted cardioverter-defibrillating (ICD) device, and cardiac resynchronization therapy. We also examined the effect of study drug according to angiotensin-converting enzyme inhibitor/angiotensin receptor blocker dose, beta-blocker (BB) dose, and MRA (≥50% and <50% of target dose). We analysed the primary composite endpoint of cardiovascular death or a worsening HF event. Most randomized patients (n = 4744) were treated with a diuretic (84%), renin–angiotensin system (RAS) blocker (94%), and BB (96%); 52% of those taking a BB and 38% taking a RAS blocker were treated with ≥50% of the recommended dose. Overall, the dapagliflozin vs. placebo hazard ratio (HR) was 0.74 [95% confidence interval (CI) 0.65–0.85] for the primary composite endpoint (P < 0.0001). The effect of dapagliflozin was consistent across all subgroups examined: the HR ranged from 0.57 to 0.86 for primary endpoint, with no significant randomized treatment-by-subgroup interaction. For example, the HR in patients taking a RAS blocker, BB, and MRA at baseline was 0.72 (95% CI 0.61–0.86) compared with 0.77 (95% CI 0.63–0.94) in those not on all three of these treatments (P-interaction 0.64). Conclusion The benefit of dapagliflozin was consistent regardless of background therapy for HF

Efficacy of dapagliflozin in heart failure with reduced ejection fraction according to body mass index

Background: In heart failure with reduced ejection fraction (HFrEF), there is an “obesity paradox”, where survival is better in patients with a higher body mass index (BMI) and weight loss is associated with worse outcomes. We examined the effect of a SGLT2 inhibitor according to baseline BMI in the Dapagliflozin And Prevention of Adverse-outcomes in Heart Failure trial (DAPA-HF). Methods and Results: BMI was examined using standard categories i.e. underweight (<18.5 kg/m2); normal weight (18.5-24.9 Kg/m2); overweight (25.0-29.9 Kg/m2); obesity class I (30.0-34.9 Kg/m2); class II (35.0-39.9 Kg/m2) and class III (≥40 Kg/m2). The primary outcome in DAPA-HF was the composite of worsening heart failure or cardiovascular death. Overall, 1348 patients (28.4%) were under/normal-weight, 1722 (36.3%) overweight, 1013 (21.4%) obesity class I and 659 (13.9%) obesity class II/III. The unadjusted hazard ratio (95% CI) for the primary outcome with obesity category 1, the lowest risk group, as reference was: under-/normal-weight 1.41 (1.16-1.71), overweight 1.18 (0.97-1.42), obesity class II/III 1.37 (1.10-1.72). Patients with class I obesity were also at lowest risk of death. The effect of dapagliflozin on the primary outcome and other outcomes did not vary by baseline BMI e.g., HR for primary outcome: under-/normal-weight 0.74 (0.58-0.94), overweight 0.81 (0.65-1.02), obesity class I 0.68 (0.50-0.92), obesity class II/III 0.71 (0.51-1.00); P for interaction=0.79. The mean decrease in weight at 8 months with dapagliflozin was 0.9 (0.7-1.1) Kg (p<0.001). Conclusion: We confirmed an “obesity survival paradox” in HFrEF. We showed that dapagliflozin was beneficial across the wide range of BMI studied. Clinical Trial Registration: ClinicalTrials.gov number NCT03036124 (https://clinicaltrials.gov/ct2/show/NCT03036124

Effect of dapagliflozin according to baseline systolic blood pressure in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial (DAPA-HF)

Aims: Concern about hypotension often leads to withholding of beneficial therapy in patients with heart failure and reduced ejection fraction (HFrEF). We evaluated the efficacy and safety of dapagliflozin, which lowers systolic blood pressure (SBP),according to baseline SBP in Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure trial (DAPA-HF). Methods and results: Key inclusion criteria were: New York Heart Association Class II−IV, left ventricular ejection fraction ≤ 40%, elevated N-terminal pro-B-type natriuretic peptide level, and SBP ≥95 mmHg. The primary outcome was a composite of worsening heart failure or cardiovascular death. The efficacy and safety of dapagliflozin were examined using SBP as both a categorical and continuous variable. A total of 1205 patients had a baseline SBP <110 mmHg; 981 ≥ 110 < 120; 1149 ≥ 120 < 130; and 1409 ≥ 130 mmHg. The placebo-corrected reduction in SBP from baseline to 2 weeks with dapagliflozin was −2.54 (−3.33 to −1.76) mmHg (P < 0.001), with a smaller between-treatment difference in patients in the lowest compared to highest SBP category. Patients in the lowest SBP category had a much higher rate (per 100 person-years) of the primary outcome [20.6, 95% confidence interval (95% CI) 17.6–24.2] than those in the highest SBP category (13.8, 11.7–16.4). The benefit and safety of dapagliflozin was consistent across the range of SBP; hazard ratio (95% CI) in each SBP group, lowest to highest: 0.76 (0.60–0.97), 0.76 (0.57–1.02), 0.81 (0.61–1.08), and 0.67 (0.51–0.87), P interaction = 0.78. Study drug discontinuation did not differ between dapagliflozin and placebo across the SBP categories examined. Conclusion: Dapagliflozin had a small effect on SBP in patients with HFrEF and was superior to placebo in improving outcomes, and well tolerated, across the range of SBP included in DAPA-HF. Clinical Trial Registration: ClinicalTrials.gov NCT03036124