Practical approaches to building up a cardiorenal clinic

Cardiorenal clinics; Cardiorenal disease; Cardiorenal programClínicas cardiorrenales; Enfermedad cardiorrenal; Programa cardiorrenalClíniques cardiorenals; Malaltia cardiorenal; Programa cardiorenalThe population with concomitant heart and kidney disease (often termed ‘cardiorenal’ disease) is expected to grow, significantly impacting public health and healthcare utilization. Moreover, the cardiorenal nexus encompasses a bidirectional relationship that worsens prognosis and may complicate pharmacological management in often elderly and frail patients. Therefore, a more cohesive multidisciplinary team approach aiming to provide holistic, coordinated and specialized care would be a positive shift towards improving patient outcomes and optimizing healthcare resources. This article aims to define the organizational aspects and key elements for setting up a multidisciplinary cardiorenal clinical program as a potential healthcare model adapted to the particular characteristics of patients with cardiorenal disease

Case report: Alternative approach for management of refractory volume overload in heart failure: usefulness of venous leg compression

BackgroundManagement of patients with refractory congestion, is one of the most important challenges in the field of heart failure (HF). Diuretic therapy remains the most widely used therapy to achieve euvolemia. However, some patients experience fluid overload despite the use of high-dose diuretics and new strategies to overcome diuretic resistance are needed.Case SummaryWe report an 85 years-old male patient admitted for decompensated HF with persistent tissue fluid overload (peripheral edema) for more than two weeks despite high dose of intravenous furosemide with the combination of other diuretics. At this point, we performed leg venous compression using elastic bandages for three days. After 72 h, edema disappeared, and additional weight loss was achieved (1 kg/day). No side effects were observed and the patient was discharged home euvolemic.ConclusionVenous leg compression may be an alternative therapy in patients with persistent tissue fluid overload resistant to diuretics

Usefulness of Serial Multiorgan Point-of-Care Ultrasound in Acute Heart Failure: Results from a Prospective Observational Cohort.

Background and Objectives: Acute heart failure (AHF) is a common disease and a cause of high morbidity and mortality, constituting a major health problem. The main purpose of this study was to determine the impact of multiorgan ultrasound in identifying pulmonary hypertension (PH), a major prognostic factor in patients admitted due to AHF, and assess whether there are significant changes in the venous excess ultrasonography (VE US) score or femoral vein Doppler at discharge. Materials and Methods: Patients were evaluated with a standard protocol of lung ultrasound, echocardiography, inferior vena cava (IVC) and hepatic, portal, intra-renal and femoral vein Doppler flow patterns at admission and on the day of discharge. Results: Thirty patients were enrolled during November 2021. The mean age was seventy-nine years (Standard Deviation–SD 13.4). Seven patients (23.3%) had a worsening renal function during hospitalization. Regarding ultrasound findings, VE US score was calculated at admission and at discharge, unexpectedly remaining unchanged or even worsened (21 patients, 70.0%). The area under the curve for the lung score was 83.9% (p = 0.008), obtaining a cutoff value of 10 that showed a sensitivity of 82.6% and a specificity of 71.4% in the identification of intermediate and high PH. It was possible to monitor significant changes between both exams on the lung score (16.5 vs. 9.3; p < 0.001), improvement in the hepatic vein Doppler pattern (2.4 vs. 2.1; p = 0.002), improvement in portal vein Doppler pattern (1.7 vs. 1.4; p = 0.023), without significant changes in the intra-renal vein Doppler pattern (1.70 vs. 1.57; p = 0.293), VE US score (1.3 vs. 1.1; p = 0.501), femoral vein Doppler pattern (2.4 vs. 2.1; p = 0.161) and IVC collapsibility (2.0 vs. 2.1; p = 0.420). Conclusions: Our study results suggest that performing serial multiorgan Point-of-Care ultrasound can help us to better identify high and intermediate probability of PH patients with AHF. Currently proposed multi-organ, venous Doppler scanning protocols, such as the VE US score, should be further studied before expanding its use in AHF patients.post-print2977 K

Practical approaches to building up a cardiorenal clinic

The population with concomitant heart and kidney disease (often termed 'cardiorenal' disease) is expected to grow, significantly impacting public health and healthcare utilization. Moreover, the cardiorenal nexus encompasses a bidirectional relationship that worsens prognosis and may complicate pharmacological management in often elderly and frail patients. Therefore, a more cohesive multidisciplinary team approach aiming to provide holistic, coordinated and specialized care would be a positive shift towards improving patient outcomes and optimizing healthcare resources. This article aims to define the organizational aspects and key elements for setting up a multidisciplinary cardiorenal clinical program as a potential healthcare model adapted to the particular characteristics of patients with cardiorenal disease

Frequency of hereditary transthyretin amyloidosis among elderly patients with transthyretin cardiomyopathy

Transthyretin amyloid cardiomyopathy (ATTR-CM) is increasingly recognized as a cause of heart failure in the elderly. Although wild-type transthyretin amyloidosis is the most frequent form of ATTR-CM found in the elderly, hereditary transthyretin amyloidosis (ATTRv) can also occur. We sought to determine the prevalence of ATTRv among elderly ATTR-CM patients, identify predictors of ATTRv and evaluate the clinical consequences of positive genetic testing in this population. Prevalence of ATTRv in elderly ATTR-CM patients (≥70 years) was assessed in a cohort of 300 consecutive ATTR-CM patients (median age 78 years at diagnosis, 82% ≥70 years, 16% female, 99% Caucasian). ATTRv was diagnosed in 35 (12%; 95% confidence interval [CI] 3.1–8.8) and 13 (5.3%; 95% CI 5.6–26.7) patients in the overall cohort and in those ≥70 years, respectively. Prevalence of ATTRv among elderly female patients with ATTR-CM was 13% (95% CI 2.1–23.5). Univariate analysis identified female sex (odds ratio [OR] 3.66; 95% CI 1.13–11.85; p = 0.03), black ancestry (OR 46.31; 95% CI 3.52–Inf; p = 0.005), eye symptoms (OR 6.64; 95% CI 1.20–36.73; p = 0.03) and polyneuropathy (OR 10.05; 95% CI 3.09–32.64; p<0.001) as the only factors associated with ATTRv in this population. Diagnosis of ATTRv in elderly ATTR-CM patients allowed initiation of transthyretin-specific drug treatment in 5 individuals, genetic screening in 33 relatives from 13 families, and identification of 9 ATTRv asymptomatic carriers. Hereditary transthyretin amyloidosis is present in a substantial number of ATTR-CM patients aged ≥70 years. Identification of ATTRv in elderly patients with ATTR-CM has clinical meaningful therapeutic and diagnostic implications. These results support routine genetic testing in patients with ATTR-CM regardless of ageThis study has been funded by Instituto de Salud Carlos III (ISCIII) through the projects ‘PI18/0765 & PI20/01379’ (co-funded by European Regional Development Fund/European Social Fund ‘A way to make Europe’/‘Investing in your future’). AMB receives grant support by ISCIII (CM20/002209). The CNIC is supported by the ISCIII, MCIN, the Pro-CNIC Foundation, and the Severo Ochoa grant (CEX2020-001041-S

Correction to: Usefulness of Genetic Testing in Hypertrophic Cardiomyopathy: an Analysis Using Real-World Data

post-print123 K

Usefulness of genetic testing in hypertrophic cardiomyopathy. An analysis using real-world data.

Aims: This study sought to determine the usefulness of genetic testing to predict evolution in hypertrophic cardiomyopathy (HCM) and to assess the role of genetic testing in clinical practice. Methods and Results: Genetic results of 100 HCM patients tested for mutations in ≥10 HCM-causing genes were evaluated. Patients were classified as with poor (Group A) or favourable(Group B) clinical course. Forty-five pathogenic mutations (PM) were identified in 28 patients (56%) from Group A and in 23 (46%) from Group B (p=0.317). Only 40 patients (40%) exhibited PM that had been previously reported and only 15 (15%) had PM reported in ≥10 individuals. PM associated with poor prognosis were identified in just 5 patients from Group A (10%). Conclusion: Genetic findings are not useful to predict prognosis in most HCM patients. By contrast, real-world data reinforce the usefulness of genetic testing to provide genetic counselling and to enable cascade genetic screening.pre-print298 K

Documento de consenso y recomendaciones sobre cuidados paliativos en insuficiencia cardiaca de las Secciones de Insuficiencia Cardiaca y Cardiología Geriátrica de la Sociedad Española de Cardiología

Review[Abstract] Heart failure is a complex entity, with high morbidity and mortality. The clinical course and outcome are uncertain and difficult to predict. This document, instigated by the Heart Failure and Geriatric Cardiology Working Groups of the Spanish Society of Cardiology, addresses various aspects related to palliative care, where most cardiovascular disease will eventually converge. The document also establishes a consensus and a series of recommendations with the aim of recognizing and understanding the need to implement and progressively apply palliative care throughout the course of the disease, not only in the advanced stages, thus improving the care provided and quality of life. The purpose is to improve and adapt treatment to the needs and wishes of each patient, who must have adequate information and participate in decision-making.[Resumen] La insuficiencia cardiaca es una entidad compleja, que conlleva elevada morbilidad y mortalidad y cuyo curso y evolución son inciertos y difíciles de predecir. Este trabajo, impulsado por las Secciones de Insuficiencia Cardiaca y Cardiología Geriátrica de la Sociedad Española de Cardiología, aborda los diferentes aspectos relacionados con los cuidados paliativos en el campo de la insuficiencia cardiaca, vía final común de la mayoría de las enfermedades cardiovasculares. También establece un consenso y una serie de recomendaciones con el objetivo de reconocer y comprender la necesidad de implementar y aplicar, de modo progresivo, este tipo de cuidados a lo largo del curso de la enfermedad, y no únicamente en sus estadios avanzados, para mejorar la atención que reciben los pacientes y su calidad de vida. La finalidad es mejorar y adecuar los tratamientos a las necesidades y los deseos de cada paciente, que debe contar con información adecuada y ser partícipe de la toma de decisiones

Clinical characteristics of wild-type transthyretin cardiac amyloidosis: disproving myths.

Wild-type transthyretin amyloidosis (ATTRwt) is mostly considered a disease predominantly of elderly male, characterized by concentric LV hypertrophy, preserved LVEF, and low QRS voltages. We sought to describe the characteristics of a large cohort of ATTRwt patients to better define the disease. Clinical findings of consecutive ATTRwt patients diagnosed at 2 centres were reviewed. ATTRwt was diagnosed histologically or non-invasively (LV hypertrophy ≥12 mm, intense cardiac uptake at 99mTc-DPD scintigraphy and AL exclusion). Mutations in TTR were excluded in all cases. The study cohort comprised 108 patients (78.6 ± 8 years); 67 (62%) diagnosed invasively and 41 (38%) non-invasively. Twenty patients (19%) were females. An asymmetric hypertrophy pattern was observed in 25 (23%) patients. Mean LVEF was 52 ± 14%, with 39 patients (37%) showing a LVEF < 50%. Atrial fibrillation (56%) and a pseudo-infarct pattern (63%) were the commonest ECG findings. Only 22 patients fulfilled QRS low-voltage criteria while 10 showed LV hypertrophy on ECG. Although heart failure was the most frequent profile leading to diagnosis (68%), 7% of individuals presented with atrioventricular block and 11% were diagnosed incidentally. Almost one third (35; 32%) were previously misdiagnosed. The clinical spectrum of ATTRwt is heterogeneous and differs from the classic phenotype: women are affected in a significant proportion; asymmetric LV hypertrophy and impaired LVEF are not rare and only a minority have low QRS voltages. Clinicians should be aware of the broad clinical spectrum of ATTRwt to correctly identify an entity for which a number of disease-modifying treatments are under investigation.This work was supported in part by the Spanish Society of Cardiology [Grant 2016 to E.G-L.] and by the Instituto de Salud Carlos III (ISCIII) [grants RD012/0042/0066 and CB16/11/00432] and by the Spanish Ministry of Economy and Competitiveness [grant SAF2015-71863-REDT]. Grants are supported by the Plan Estatal de IþDþI 2013-2016–European Regional Development Fund (FEDER) “A way of making Europe”.S

Clinical characteristics of wild-type transthyretin cardiac amyloidosis – Disproving myths.

Aims: Wild-type transthyretin amyloidosis (ATTRwt) is mostly considered a disease predominantly of elderly male, characterised by concentric LV hypertrophy, preserved LVEF and low QRS voltages. We sought to describe the characteristics of a large cohort of ATTRwt patients to better define the disease. Methods and Results: Clinical findings of consecutive ATTRwt patients diagnosed at 2 centres were reviewed. ATTRwt was diagnosed histologically or non-invasively (LV hypertrophy 12mm, intense cardiac uptake at 99mTc-DPD scintigraphy and AL exclusion). Mutations in TTR were excluded in all cases. The study cohort comprised 108 patients (78.68 years); 67 (62%) diagnosed invasively and 41 (38%) non-invasively. Twenty patients (19%) were females. An asymmetric hypertrophy pattern was observed in 25 (23%) patients. Mean LVEF was 5214%, with 39 patients (37%) showing a LVEF<50%. Atrial fibrillation (56%) and a pseudo-infarct pattern (63%) were the commonest ECG findings. Only 22 patients fulfilled QRS low-voltage criteria while 10 showed LV hypertrophy on ECG. Although heart failure was the most frequent profile leading to diagnosis (68%), 7% of individuals presented with atrioventricular block and 11% were diagnosed incidentally. Almost one third (35; 32%) were previously misdiagnosed. Conclusion: The clinical spectrum of ATTRwt is heterogeneous and differs from the classic phenotype: women are affected in a significant proportion; asymmetric LV hypertrophy and impaired LVEF are not rare and only a minority have low QRS voltages. Clinicians should be aware of the broad clinical spectrum of ATTRwt to correctly identify an entity for which a number of disease-modifying treatments are under investigation.pre-print833 K