Intra-abdominal pressure and its relationship with markers of congestion in patients admitted for acute decompensated heart failure

Systemic congestion is one of the mechanisms involved in acute decompensated heart failure (ADHF). Increased intra-abdominal pressure (IAP), elicited by abdominal congestion, has been related to acute kidney injury and prognosis. Nonetheless, the link between diuretic response, surrogate markers of congestion and renal function remains poorly understood. We measured IAP in 43 patients from a non-interventional, exploratory, prospective, single center study carried out in patients admitted for ADHF. IAP was measured with a calibrated electronic manometer through a catheter inserted in the bladder. Normal IAP was defined as 12 mmHg at 72 h. In patients with ADHF, higher IAP at admission is associated with poorer baseline renal function and impaired diuretic response. The persistence of IAP at 72 h above 12 mmHg associates to longer length of hospital stay and higher 1-year all-cause mortality

Implicación de la congestión venosa sistémica en la insuficiencia cardíaca

Systemic venous congestion has gained significant importance in the interpretation of the pathophysiology of acute heart failure, especially in the development of renal function impairment during exacerbations. In this study, we review the concept, clinical characterisation and identification of venous congestion. We update current knowledge on its importance in the pathophysiology of acute heart failure and its involvement in the prognosis. We pay special attention to the relationship between abdominal congestion, the pulmonary interstitium as filtering membrane, inflammatory phenomena and renal function impairment in acute heart failure. Lastly, we review decongestion as a new therapeutic objective and the measures available for its assessment

Influencia de la presión arterial al inicio de las descompensaciones en el pronóstico de pacientes con insuficiencia cardiaca

Fundamento y objetivo: Existe una relación inversa entre las cifras de presión arterial en las descompensaciones y el pronóstico de la insuficiencia cardiaca (IC). Las características de esta relación no son bien conocidas. El objetivo del estudio fue analizar si esta relación se mantiene en una cohorte no seleccionada de pacientes con IC y si el tratamiento la modifica. Material y métodos: Estudio prospectivo de cohortes de pacientes ingresados por IC descompensada en un servicio de Medicina Interna y seguidos ambulatoriamente en una consulta monográfica. Los pacientes fueron agrupados en función de la presión arterial sistólica (PAS) y diastólica (PAD); se analizaron las características clínicas, la mortalidad global y los reingresos al primer, tercer y sexto mes de seguimiento. Resultados: Se incluyeron 221 pacientes tras un ingreso índice por IC. Media de edad: 79, 5 años (DE 8, 09); varones: 115. No hubo diferencias significativas en las características basales de los pacientes en función de los cuartiles de PAS. Los pacientes con menor PAS (Q1) tenían mayor mortalidad (20%, p < 0, 05). No se encontraron diferencias para la PAD. Sin embargo, el análisis de Kaplan-Meier mostró una mayor mortalidad global en los pacientes con menor PAS y PAD (log-rank = 0, 011 y 0, 041, respectivamente). Las características del tratamiento farmacológico no diferían entre los grupos del estudio. Conclusión: En pacientes con IC no seleccionados, las cifras elevadas de PAS al ingreso se asocian con una menor mortalidad durante el seguimiento. El tratamiento farmacológico de la IC no parece influir en la relación inversa entre la PAS al ingreso y la mortalidad. Background and objective An inverse relationship has been described between blood pressure and the prognosis in heart failure (HF). The characteristics of this relationship are not well unknown. The objective of this study was to determine if this relationship is maintained in a non-selected cohort of patients with HF and if it can be modified by treatment. Material and methods Prospective study of cohorts including patients hospitalized for decompensated HF in Internal Medicine departments and followed as outpatients in a monographic consultation. Patients were classified according to their levels of systolic (SBP) and diastolic blood pressure (DBP). Clinical characteristics, all-cause mortality and readmissions after the first, third and sixth month of follow-up were analysed. Results Two hundred and twenty-one patients were included after their admission to the hospital for acute HF. Mean patient age was 79.5 years(SD 8.09); 115 patients were male. No significant differences between SBP quartiles and basal characteristics were found. Patients with lower SBP (Q1) had higher mortality rates (20%, P < .05). No significant differences between mortality/readmissions and DBP were found. However, the Kaplan-Meier analysis showed higher all-cause mortality rates for the group of patients with lower SBP and DBP (log-rank = 0.011 and 0.041, respectively). The pharmacological treatment did not differ significantly between both study groups. Conclusion For non-selected patients suffering HF, higher SBP upon the admission is associated with significantly lower all-cause mortality rates during follow-up. Pharmacological treatment of HF does not seem to influence this inverse relationship between SBP at admission and patient mortality

Valor pronóstico de la desnutrición en pacientes con insuficiencia cardíaca aguda y su influencia en la interpretación de marcadores de congestión venosa sistémica

Antecedentes La desnutrición es frecuente en los pacientes con insuficiencia cardíaca (IC). Dicha situación contribuye al incremento de la congestión sistémica dificultando el manejo clínico. Cuantificar la desnutrición y su relación con la congestión sistémica, es importante para optimizar el tratamiento durante la fase aguda. Material y métodos Estudio de cohortes retrospectivo en pacientes con diagnóstico de IC aguda. La población se estratificó según los índices de nutrición de CONUT (Controlling Nutritional Status) y PNI (Prognostic Nutritional Index) con el objetivo de analizar su relación con parámetros objetivos de congestión y el valor pronóstico al año de seguimiento. Resultados Se incluyeron un total de 309 pacientes, presentando más de la mitad algún grado de desnutrición al ingreso. El grado de congestión fue significativamente superior en los pacientes desnutridos, con una mayor proporción de «líneas b» y un mayor volumen plasmático relativo. Las concentraciones de la prohormona N-terminal del péptido natriurético cerebral (NT-proBNP), tanto al ingreso como al alta, también fueron significativamente superiores en los pacientes desnutridos, independientemente de la escala empleada. El análisis univariante identificó el índice de CONUT y PNI, como factores asociados a la mortalidad al año para todas las causas (HR 1, 62 [1, 22-2, 14]; p = 0, 001) y de PNI (HR 0, 65 [0, 53-0, 80]; p = < 0, 001), respectivamente. Conclusiones Un mayor grado de desnutrición (determinado mediante los índices de CONUT y PNI) en pacientes con IC aguda, se asoció a una mayor presencia de parámetros objetivos de congestión y a una mayor mortalidad al año para todas las causas. Background Malnutrition is frequent in patients with heart failure (HF) and contributes to increased systemic congestion, but also hinders its correct assessment, especially during decompensations. Estimating the degree of malnutrition and its relationship with systemic congestion is important to optimize treatment during decompensations. Material and methods Retrospective cohort study in patients with acute HF. The population was stratified according to CONUT (Controlling Nutritional Status) and PNI (Prognostic Nutritional Index) nutrition indices in order to analyse their relationship with objective parameters of congestion and the prognostic value of malnutrition. Results 309 patients were included. More than half presented some degree of malnutrition upon admission. The degree of congestion was significantly higher in malnourished patients, with a higher proportion of «comet tail artifacts» and a higher relative plasma volume. NT-proBNP concentrations, both on admission and at discharge, were also significantly higher in malnourished patients, regardless of the scale used. The univariate analysis identified the CONUT and PNI index as factors associated with one-year mortality from any cause (HR 1.62 [1.22-2.14]; p = 0.001) and PNI (HR 65 [0.53-0.80]; p = < 0.001), respectively. Conclusions A higher degree of malnutrition (determined by means of the CONUT and PNI indices) in patients with acute HF was associated with a higher presence of objective parameters of congestion and a higher one-year all-cause mortality

Ausencia de implicación de la cistatina C en el remodelado ventricular y la insuficiencia cardiaca

La cistatina C (CisC) es una proteasa codificada por genes de mantenimiento («housekeeping genes»). Aunque su valor pronóstico en la insuficiencia cardiaca (IC) es bien conocido, se debate si es debido a su mayor precisión en la estimación del filtrado glomerular, o a su implicación en el remodelado ventricular patológico. El propósito de este estudio fue comprobar si la expresión de CisC se modificaba en el miocardio de fetos de diferentes edades y en el de adultos con diversas enfermedades cardiovasculares, así como analizar la correlación entre sus concentraciones séricas y la estructura y morfología cardiaca en un grupo de pacientes con IC.Pacientes y métodosSe analizaron las correlaciones (test de Pearson y Spearman) entre la CisC sérica y los parámetros ecocardiográficos de 351 pacientes con IC. También se realizó una tinción inmunohistoquímica para CisC, metaloproteinasa 9 (MMP-9) y desmina en 9 muestras de tejido cardiaco procedentes de las autopsias de 4 fetos con diferente edad gestacional y 5 adultos sanos o con enfermedad cardiovascular.ResultadosEn pacientes con IC no se encontró correlación entre las concentraciones de CisC y los parámetros cardiacos medidos por ecocardiografía 2 D. La inmunohistoquímica mostró una débil tinción de fondo para CisC en todas las muestras, independientemente de la edad y la presencia o no de enfermedades cardiovasculares.ConclusionesNuestros resultados sugieren que la CisC no tiene un papel significativo en el remodelado patológico del ventrículo izquierdo en la IC. Cystatin C (CysC) is a protease encoded by housekeeping genes. Although its prognostic value in heart failure (HF) is well known, it is debatable whether this value is due to the greater accuracy of CysC in calculating the glomerular filtration rate or to its involvement in pathological ventricular remodelling. The aim of this study was to determine whether CysC expression changes in the myocardium of foetuses of different ages and in the myocardium of adults with various cardiovascular diseases, as well as to analyse the correlation between its serum concentrations and cardiac structure and morphology in a patient group with HF. Patients and methods We analysed the correlations (Pearson''s r and Spearman''s test) between the serum CysC levels and echocardiographic parameters of 351 patients with HF. We also performed immunohistochemical staining for CysC, metalloproteinase-9 (MMP-9) and desmin in 9 cardiac tissue samples from autopsies of 4 foetuses of different gestational ages and 5 healthy adults or adults with cardiovascular disease. Results For the patients with HF, there was no correlation between the CysC concentrations and the cardiac parameters measured by 2 D echocardiography. The immunohistochemistry showed a weak background staining for CysC in all samples, regardless of age and the presence or absence of cardiovascular diseases. Conclusions Our results suggest that CysC does not have a significant role in the pathological remodelling of the left ventricle in HF

Multiple approaches at admission based on lung ultrasound and biomarkers improves risk identification in COVID-19 patients

Background: Risk stratification of COVID-19 patients is fundamental to improving prognosis and selecting the right treatment. We hypothesized that a combination of lung ultrasound (LUZ-score), biomarkers (sST2), and clinical models (PANDEMYC score) could be useful to improve risk stratification. Methods: This was a prospective cohort study designed to analyze the prognostic value of lung ultrasound, sST2, and PANDEMYC score in COVID-19 patients. The primary endpoint was in-hospital death and/or admission to the intensive care unit. The total length of hospital stay, increase of oxygen flow, or escalated medical treatment during the first 72 h were secondary endpoints. Results: a total of 144 patients were included; the mean age was 57.5 ± 12.78 years. The median PANDEMYC score was 243 (52), the median LUZ-score was 21 (10), and the median sST2 was 53.1 ng/mL (30.9). Soluble ST2 showed the best predictive capacity for the primary endpoint (AUC = 0.764 (0.658–0.871); p = 0.001), towards the PANDEMYC score (AUC = 0.762 (0.655–0.870); p = 0.001) and LUZ-score (AUC = 0.749 (0.596–0.901); p = 0.002). Taken together, these three tools significantly improved the risk capacity (AUC = 0.840 (0.727–0.953); p = 0.001). Conclusions: The PANDEMYC score, lung ultrasound, and sST2 concentrations upon admission for COVID-19 are independent predictors of intra-hospital death and/or the need for admission to the ICU for mechanical ventilation. The combination of these predictive tools improves the predictive power compared to each one separately. The use of decision trees, based on multivariate models, could be useful in clinical practice. © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/)

Presión intraabdominal y empeoramiento de la función renal durante las descompensaciones de la insuficiencia cardiaca. Un informe preliminar del estudio PIA.

Antecedentes: El aumento de la presión intraabdominal (PIA) que tiene lugar durante la insuficiencia cardiaca aguda parece estar directamente relacionado con un empeoramiento de la función renal, lo que conduce a peores resultados clínicos. Nuestro objetivo fue analizar la relación entre la PIA y los determinantes de la función renal para la insuficiencia cardiaca aguda descompensada (ICAD) durante el ingreso en un pabellón de medicina interna convencional. Pacientes y métodos: Estudio descriptivo y prospectivo. Se incluyó a aquellos pacientes con una tasa de filtración glomerular > 30 mL/min/1,73 m2, dispuestos a participar en el estudio y que otorgaron su consentimiento informado. El protocolo (PI 15 0227) fue aprobado por el Comité de Ética de Aragón. Resultados: Presentamos los resultados de un análisis preliminar llevado a cabo con los primeros 28 pacientes incluidos en el estudio. Los pacientes se segregaron en 2 grupos según la mediana de la PIA, alta (PIA > 15 mmHg) y baja (PIA < 15 mmHg), medida durante las primeras 24 h tras el ingreso por ICAD. Cada grupo estuvo integrado por 14 pacientes. No hubo diferencias entre los grupos en cuanto a características clínicas de referencia, comorbilidades ni tratamiento. Los pacientes con PIA superior a los 15 mmHg presentaron una tasa de filtración glomerular basal significativamente baja (70,7 vs. 44,4 mL/min/1,73 m2 con p = 0,004; urea en sangre 36 vs. 83 mg/dL con p = 0,002; creatinina sérica 0,87 vs. 1,3 mg/dL con p = 0,004 y cistatina C 1,2 vs. 1,94 mg/dL con p = 0,002). Además, estos pacientes mostraron las concentraciones de ácido úrico más altas (5,7 vs. 8,0; p = 0,046), las de hemoglobina resultaron más bajas (11,7 vs. 10,5 g/L; p = 0,04) y la estancia hospitalaria más larga (6,5 vs. 9,6 días; p = 0,017). Conclusiones: El aumento de la PIA parece ser un hallazgo frecuente en pacientes ingresados por ICAD. Independientemente de la PIA, los pacientes comparten un perfil clínico similar, si bien el aumento de la PIA se asoció con un empeoramiento significativo de la función renal de referencia. Background: An increase in intraabdominal pressure (IAP) during acute heart failure, seems to be directly related to worsening renal function, which leads to worse clinical outcomes. We aimed to analyze the relationship between IAP and determinants of renal function during admission for acute decompensation of heart failure (ADHF) in a conventional Internal Medicine Ward. Patients and methods: Descriptive and prospective study. Patients admitted for ADHF with an estimated glomerular filtration rate > 30 mL/min/1.73 m2, willing to participate and who gave their informed consent were included. Ethics Committee of Aragon approved the protocol (PI 15 0227). Results: We hereby report the results of an interim analysis of the first 28 patients included. Patients were divided in 2 groups according to the median of IAP measured during the first 24 h after admission for ADHF, namely high IAP (IAP>15 mmHg) and low (IAP< 15 mmHg). Fourteen patients were included in each group. No differences were found in baseline clinical characteristics, comorbidities or treatment between both groups. Patients with IAP above 15 mmHg, showed a significant lower baseline estimated glomerular filtration rate (70.7 vs. 44.4 mL/min/1.73 m2 with p=0.004], blood urea 36 vs. 83 mg/dL with p=0.002]; serum creatinine 0.87 vs. 1.3 mg/dL with p=0.004 and cystatin C 1.2 vs. 1.94 mg/dL with p= 0.002. Additionally, these patients had higher uric acid (5.7 vs. 8.0, p=0.046), lower hemoglobin concentrations (11.7 vs. 10.5 g/L, p=0.04) and longer length of hospital stay (6.5 vs. 9.6 days, p=0.017). Conclusions: The increase in IAP seems to be a frequent finding in patients admitted for ADHF. Patients share similar clinical profile irrespective of IAP, although the increase in IAP is associated with a significant baseline impairment of renal function

Lack of clinical usefulness of interleukin-6 in long-term follow-up of acutely decompensated heart failure

ABSTRACT Introduction: Interleukin-6 (IL -6) has been identified as a predictor of death, new heart failure (HF) episodes and need for heart transplantation in patients with advanced HF. The aim of this study was to examine th