Readmission following both cardiac and non-cardiac acute dyspnoea is associated with a striking risk of death

Readmission and mortality are the most common and often combined endpoints in acute heart failure (AHF) trials, but an association between these two outcomes is poorly investigated. The aim of this study was to determine whether unplanned readmission is associated with a greater subsequent risk of death in patients with acute dyspnoea due to cardiac and non-cardiac causes.; Derivation cohort (1371 patients from the LEDA study) and validation cohort (1986 patients from the BASEL V study) included acute dyspnoea patients admitted to the emergency department. Cox regression analysis was used to determine the association of 6 month readmission and the risk of 1 year all-cause mortality in AHF and non-AHF patients and those readmitted due to cardiovascular and non-cardiovascular causes. In the derivation cohort, 666 (49%) of patients were readmitted at 6 months and 282 (21%) died within 1 year. Six month readmission was associated with an increased 1 year mortality risk in both the derivation cohort [adjusted hazard ratio (aHR) 3.0 (95% confidence interval, CI 2.2-4.0), P < 0.001] and the validation cohort (aHR 1.8, 95% CI 1.4-2.2, P < 0.001). The significant association was similarly observed in AHF (aHR 3.2, 95% CI 2.1-4.9, P < 0.001) and other causes of acute dyspnoea (aHR 2.9, 95% CI 1.9-4.5, P < 0.001), and it did not depend on the aetiology [aHR 2.2, 95% CI 1.6-3.1 for cardiovascular readmissions; aHR 4.1, 95% CI 2.9-5.7 for non-cardiovascular readmissions (P < 0.001 for both)] or timing of readmission. CONCLUSION​S: Our study demonstrated a long-lasting detrimental association between readmission and death in AHF and non-AHF patients with acute dyspnoea. These patients should be considered 'vulnerable patients' that require personalized follow-up for an extended period

Which clinical findings can be crucial to differentiate pulmonary embolism and acute heart failure in patients presented with acute dyspnea?

Introduction: Dyspnea is a common symptom in patients hospitalized with acute cardiopulmonary diseases. Unnecessary diagnostic tests are usually ordered to prove the diagnosis for patients with dyspnea. There is still a lack of knowledge which set of clinical findings could precisely indicate acute pulmonary embolism (PE) or acute heart failure (AHF). Aim: To investigate the value of clinical findings collected in the emergency department as the crucial predictors of adjudicated diagnosis. Methods: A prospective observational cohort study enrolled 668 consecutive patients admitted to the emergency department with acute dyspnea between March 2015 and September 2017. In total 38 (5,69%) patients were included in the analysis after the hospitalization and discharge with the final diagnosis of PE. Using random number generator, as a control group, 40 (5,98%) patients were included with the final diagnosis of AHF. Patients presenting with dyspnea related to cardiac arrhythmias, pulmonary infection, acute coronary syndrome, chronic obstructive pulmonary disease, cancer, hypertension, anxiety were excluded. Tested parameters: dyspnea severity score, the presence of atrial fibrillation (AF) and the value of left ventricular ejection fraction (LVEF) were collected at the admission. Patients were asked to rate dyspnea by visual-analogue dyspnea scale (VADS) from 1 to 10 points. Subsequently, data of 78 patients were analyzed using SPSS v.23 statistical package. Results: The mean age in the analysed PE and AHF groups were 70.6±13.2 years, 45 pts. (57.7%) were male. The data analysis revealed that there was a difference between the age of patients, which was diagnosed in PE and AHF groups: 68.0±14.1 vs. 73.1±12.0 (p=0,039), respectively. Moreover, there were differences between the dyspnoea score and LEVF in analysed PE and AHF cohorts: 9.0±1.4 vs. 7.4±4.1 (p=0.027); and 48.6±15.3% vs. 32.2±15.1% (p<0.01), respectiv[...]

Ischemic cardiomyopathy: possibilities of surgical treatment

The high morbidity and mortality in patients with serious heart failure is a therapeutic challenge for current medicine. The leading cause of left ventricular dysfunction remains ischemic heart disease. Coronary artery bypass surgery is a treatment of choice in moderate-to-severe ischemic cardiomyopathy. The scarcity of completed prospective randomized clinical trials and high surgical risks create significant uncertainty concerning the optimal current treatment strategy. The role of imaging techniques of assessment for myocardial viability based on current guidelines may be very important in clinical decision-making. Present paper reviews some of the relevant literature concerning surgical treatment of ischemic cardiomyopathy and current evidence-based recommendations on this method of treatment. In advanced heart failure, coronary revascularization alone is an insufficient treatment modality. In the presence of moderate-to-severe ischemic mitral regurgitation, mitral valve repair or replacement should be considered at coronary artery bypass grafting surgery. One of the most common mechanisms of ischemic mitral regurgitation is Carpentier’s type IIIb dysfunction, in which an undersized mitral anuloplasty might be helpful. Surgery of left ventricular shape and volume restoration leads to improvement of left ventricular function in patients with ischemic cardiomyopathy. When the results from three ongoing prospective randomized studies – the Surgical Treatment for Ischemic Heart Disease trial, Heart Failure Revascularization trial, the PET and Recovery Following Revascularization-2 trial – determining outcome of revascularization versus medical therapy are available, clinicians will have reliable data for making decisions concerning the optimum treatment strategy. At present, the choice of management still remains based on the data obtained from available retrospective trials or the state of art in the field

Characteristics and management of acute heart failure patients in a single university hospital center

Objective. To evaluate the causes of acute heart failure, complications, management, and outcomes.Material and methods. A total of 200 patients with diagnosed de novo acute heart failure (27.5%) or worsening chronic heart failure (72.5%) were treated at the Department of Cardiology, Hospital of Kaunas University of Medicine, which was participating in the Euro Heart Failure Survey-II (EHFS-II). The patients were divided into five groups: 1) chronic decompensated heart failure (66.0%); 2) pulmonary edema (13.0%); 3) hypertensive heart failure (7.5%); 4) cardiogenic shock (11.0%); and 5) right heart failure (2.5%). Results. Hypertensive and coronary heart diseases were the most common underlying conditions of acute heart failure. Noncompliance with the prescribed medications was present as the most frequent precipitating factor in more than half of the cases. Left ventricular ejection fraction of &gt;45% was found in 28.64% of cases. Intravenous diuretics (74.5%), nitrates (44.0%), and heparin (71.0%) were the most widely used in the acute phase. At discharge from hospital, 96.69% of patients were given diuretics; 80.11%, angiotensin-converting enzyme inhibitors; and 62.43%, beta-blockers. The mean duration of inhospital stay was 13 days; death rate was 9.5%: after 3 months and 12 months, it was 7.5% and 11.5%, respectively. Conclusion. Preserved systolic function, multiple concomitant diseases, and high mortality rates were observed in a substantial proportion of the patients hospitalized due to acute heart failure. The management of the patients in a university hospital center was performed in accordance with the international guidelines

Correalation between subjective evaluation of dyspnoea and objective clinical signs of respiratory insufficiency in patients with acute dyspnoea

Introduction: Dyspnoea is one of the most frequent symptoms, causing patients (pts) to present to the emergency department (ED) [1]. It is a subjective symptom and for this reason, physicians have a difficult task—to assess dyspnoea objectively along with respiratory failure (RF) signs (respiratory rate (RR) higher than 25 breaths per minute, blood oxygen saturation (SaO2) less than 90%) and determine the underlying primary cause of dyspnoea. Therefore, it is very important to identify the correlation between a subjective symptom—shortness of breath (SOB), as described by the pts—and objective signs of RF [2–4]. Aim: To evaluate acute dyspnoea and compare its severity with clinical signs of RF for pts presenting at the ED. Objectives: 1. To evaluate acute dyspnoea using visual analogy scale (VAS) and its correlation with objective RF parameters, such as RR, SaO2, heart rate (HR), systolic blood pressure (SPB) and lung auscultation parameters. 2. To determine the most common reasons for dyspnea at the ED. Methods: We evaluated 147 pts with acute dyspnoea who presented to the ED at the Hospital of Lithuanian University of Health Sciences. Objective symptoms of RF that were evaluated included RR, SaO2, HR, SBP and lung auscultation parameters. Pts had to respond to the question: “On a scale from 0 to 10, how bad is your SOB, with score 1 being weak SOB and score 10—the worst SOB you could ever imagine?” according to the use of VAS methodology. In our statistical analysis P < ,05 was considered significant. Results: From a sample of 147 pts, 25 participants (17%) rated dyspnoea score of 5 points, 18 pts (12,2%)—6 points, 22 pts (15%)—7 points, 30 pts (20,4%)—8 points and 19 pts (12,9%)—9 points; other VAS scores were chosen by few pts (less than 10%). According to Spearman correlation coefficient, pts with higher dyspnoea score had lower SaO2 (r = −0,197; P = ,024) and higher RR[...]

Acid-base balance disorders are associated with increased 1-month and 3-month mortality in patients with acute heart failure

Background/Introduction: Arterial blood gas (ABG) analysis is one of the main tests for decision-making in patients with severe dyspnea. However, the significance of ABG analysis on the prognosis for the acute heart failure (AHF) patients remains unclear. Purpose: The study evaluated whether acid-base balance disorders at the time of admission are associated with 1- and 3-month rehospitalisation and mortality rates of AHF patients. Methods: A prospective observational cohort study enrolled consecutive patients with acute dyspnea from March, 2015 till August, 2016. The exclusion criterion was a suspected acute coronary syndrome. Data of 144 study patients with adjudicated diagnosis of AHF, available ABG and biochemical blood analyses at admission and completed 3-months follow up were included in the analysis. Outcomes were eval- uated with Kaplan-Meier curves and Cox proportional hazard model to estimate survival rates, hazard ratios (HR) and 95% confidence intervals (CI). Data were anal- ysed using SPSS v23 statistical package. Results: 71 (49.3%) patients were male and 73 (50.7%) female. Acid-base balance disorders were found in 90 (62.5%) patients: 25 (17.3%) patients had acidosis (15 [10.4%] metabolic, 10 [6.9%] respiratory), 58 patients (40.3%) had alkalosis (7 [4.9%] metabolic, 51 [35.4%] respiratory), 7 (4.9%) patients had a mixed A-B disorder. Both respiratory and metabolic acidosis (HR=4.65, 95% CI: 1.42; 15.25, P=0.011) and mixed A-B disorders (HR=4.66, 95% CI: 1.05; 21.58, P=0.049) at admission were significantly associated with 1-month mortality (total number of deaths – 8). Metabolic acidosis (HR=7.63, 95% CI: 2.46; 23.67, P < 0.001) and mixed A-B dis- orders (HR=5.52, 95% CI: 1.55; 19.57, P=0.008) also displayed a significant effect on 3-month mortality (total 12 deaths). On-admission A-B disorders had no impact on 1- and 3-month rehospitalisation rates. The cumulative 90-day survival was 85% for patients with A-B disorders and 93% [...

Evaluation of a chronic fatigue in patients with moderate-to-severe chronic heart failure

The aim of the study. To evaluate the chronic fatigue and its relation to the function of hypothalamus-pituitary-adrenal axis in patients with New York Heart Association (NYHA) functional class III–IV chronic heart failure. Material and methods. A total of 170 patients with NYHA functional class III–IV chronic heart failure completed MFI-20L, DUFS, and DEFS questionnaires assessing chronic fatigue and underwent echocardiography. Blood cortisol concentration was assessed at 8:00 AM and 3:00 PM, and plasma N-terminal brain natriuretic pro-peptide (NT-proBNP) concentration was measured at 8:00 AM. Neurohumoral investigations were repeated before cardiopulmonary exercise test and after it. Results. The results of all questionnaires showed that 100% of patients with NYHA functional class III–IV heart failure complained of chronic fatigue. The level of overall fatigue was 54.5±31.5 points; physical fatigue – 56.8±24.6 points. Blood cortisol concentration at 8:00 AM was normal (410.1±175.1 mmol/L) in majority of patients. Decreased concentration was only in four patients (122.4±15.5 mmol/L); one of these patients underwent heart transplantation. In the afternoon, blood cortisol concentration was insufficiently decreased (355.6±160.3 mmol/L); reaction to a physical stress was attenuated (D 92.9 mmol/L). Plasma NTproBNP concentration was 2188.9±1852.2 pg/L; reaction to a physical stress was diminished (D 490.3 pg/L). Conclusion. All patients with NYHA class III–IV heart failure complained of daily chronic fatigue. Insufficiently decreased blood cortisol concentration in the afternoon showed that in the presence of chronic fatigue in long-term cardiovascular organic disease, disorder of a hypothalamus-pituitary-adrenal axis is involved

Impact of a long-term complex rehabilitation on chronic fatigue and cardiorespiratory parameters in patients with chronic heart failure

The aim of the study was to evaluate the impact of a long-term rehabilitation on chronic fatigue and cardiorespiratory parameters in patients with chronic heart failure. Material and methods. One hundred seventy patients with class III–IV (NYHA) chronic heart failure were examined. The study population was divided into two groups: long-term rehabilitation group and control group. They underwent cardiopulmonary exercise test and completed questionnaires on chronic fatigue (MFI- 20L, DUFS, and DEFS). Measurements were repeated 3 and 6 months after long-term complex rehabilitation. Results. According to the data of MFI-20L, DUFS, and DEFS questionnaires, 170 patients (100%) with class III–IV (NYHA) chronic heart failure complained of fatigue. Overall daily fatigue was 56.8±28.5 points on a 100-point scale, and after 6-month rehabilitation, this parameter was statistically significantly reduced on all scales (P<0.05). Physical fatigue and self-care improved in controls. Cardiopulmonary exercise test showed that parameters of hyperventilation, ventilatory equivalents, and pCO2 were significantly improved in rehabilitation group after 6 months as compared to baseline data (P<0.05), but not in the control group. Conclusion. Patients with class III–IV (NYHA) chronic heart failure experience chronic fatigue, which reduces their motivation and self-care abilities. Long-term complex rehabilitation programs improve all parameters of chronic fatigue, respiratory efficiency, and prognostic indicator of chronic heart failure – ventilatory equivalent for carbon dioxide

Long term survival of patient with primary cardiac sarcoma. Cardiac magnetic resonance place for diagnosis and follow-up

Aim To present a rare case of cardiac sarcoma. Methods Clinical case of a 48-year-old female with dyspnea and palpitations over the last two months. Results Patient ECG showed left ventricular hypertrophy. Her laboratory findings: anemia and elevated LDH. Transthoracic echocardiography demonstrated large masses in the left ventricle (LV) partially obstructing LV outflow tract. Additional smaller tumor was seen left atrium. Cardiovascular magnetic resonance (CMR) was performed. Specific characteristics of masses showed a heterogeneous 71×45×21 mm tumor in the LV, isointense on non-contrast T1, hyperintense on T2, heterogeneous enhancement on LGE. The mass was partially infiltrating LV myocardium. The diagnosis of malignant cardiac sarcoma was suspected. Computed tomography (CT) of chest and abdomen was performed, there were no distant metastasis. Cytoreductive surgery was performed. Histology revealed undifferentiated pleomorphic sarcoma. Post-surgery CMR revealed remaining tumor masses in LV. Chemotherapy with Doxorubicin and Ifosfamide was initiated. Totally, 7 cycles performed. Echocardiography and CMR were performed to assess response to chemotherapy and revealed very good partial response. Repeated CT showed no metastasis. Follow up was done every 3 months with no evidence of progression. Patient is still alive with no evidence of disease progression after 13 months after diagnosis. Conclusion The diagnosis of primary cardiac tumors is frequently challenging. Echocardiography remains the first-choice imaging modality. CMR improves noninvasive characterization of cardiac masses. Extremely good response to chemotherapy granted patient prolonged survival compared with median survival only about 6 months