The five-point Likert scale for dyspnea can properly assess the degree of pulmonary congestion and predict adverse events in heart failure outpatients

OBJECTIVES: Proper assessment of dyspnea is important in patients with heart failure. Our aim was to evaluate the use of the 5-point Likert scale for dyspnea to assess the degree of pulmonary congestion and to determine the prognostic value of this scale for predicting adverse events in heart failure outpatients. METHODS: We undertook a prospective study of outpatients with moderate to severe heart failure. The 5-point Likert scale was applied during regular outpatient visits, along with clinical assessments. Lung ultrasound with ≥15 B-lines and an amino-terminal portion of pro-B-type natriuretic peptide (NT-proBNP) level >;1000 pg/mL were used as a reference for pulmonary congestion. The patients were then assessed every 30 days during follow-up to identify adverse clinical outcomes. RESULTS: We included 58 patients (65.5% male, age 43.5±11 years) with a mean left ventricular ejection fraction of 27±6%. In total, 29.3% of these patients had heart failure with ischemic etiology. Additionally, pulmonary congestion, as diagnosed by lung ultrasound, was present in 58% of patients. A higher degree of dyspnea (3 or 4 points on the 5-point Likert scale) was significantly correlated with a higher number of B-lines (p = 0.016). Patients stratified into Likert = 3-4 were at increased risk of admission compared with those in class 1-2 after adjusting for age, left ventricular ejection fraction, New York Heart Association functional class and levels of NT-proBNP >;1000 pg/mL (HR = 4.9, 95% CI 1.33-18.64, p = 0.017). CONCLUSION: In our series, higher baseline scores on the 5-point Likert scale were related to pulmonary congestion and were independently associated with adverse events during follow-up. This simple clinical tool can help to identify patients who are more likely to decompensate and whose treatment should be intensified

Antithrombotic therapies in patients with prosthetic heart valves: guidelines translated for the clinician

Patients with prosthetic heart valves require chronic oral anticoagulation. In this clinical scenario, physicians must be mindful of the thromboembolic and bleeding risks related to chronic anticoagulant therapy. Currently, only vitamin K antagonists are approved for this indication. This paper reviews the main heart valve guidelines focusing on the use of oral anticoagulation in these patients

Fetal tachyarrhythmia with 1:1 atrioventricular conduction. Adenosine infusion in the umbilical vein as a diagnostic test

This is the report of a case of fetal tachyarrhythmia with 1:1 atrioventricular conduction detected by pre-natal echocardiography in a fetus at 25-weeks gestation. Adenosine infusion via cordocentesis was performed as a diagnostic test to differentiate between atrioventricular nodal reentrant supraventricular tachyarrhythmia and atrial flutter. After infusion, transient 2:1 atrioventricular dissociation was obtained and the diagnosis of atrial flutter was made. Transplacental therapy with digoxin and amiodarone was then successfully used

Pulmonary congestion evaluated by lung ultrasound predicts decompensation in heart failure outpatients

BACKGROUND: Pulmonary congestion is the main cause of hospital admission among heart failure (HF) patients. Lung ultrasound (LUS) assessment of B-lines has been recently proposed as a reliable and easy tool for evaluating pulmonary congestion. OBJECTIVE: To determine the prognostic value of LUS in predicting adverse events in HF outpatients. METHODS: Single-center prospective cohort of 97 moderate-to-severe systolic HF patients (53\ub113years; 61% males) consecutively enrolled between November 2011 and October 2012. LUS evaluation was performed during the regular outpatient visit to evaluate the presence of pulmonary congestion, determined by B-lines number. Patients were followed up for 4months to assess admission due to acute pulmonary edema. RESULTS: During follow-up period (106\ub112days), 21 hospitalizations for acute pulmonary edema occurred. At Cox regression analysis, B-lines number 6530 (HR 8.62; 95%CI: 1.8-40.1; p=0.006) identified a group at high risk for acute pulmonary edema admission at 120days, and was the strongest predictor of events compared to other established clinical, laboratory and instrumental findings. No acute pulmonary edema occurred in patients without significant pulmonary congestion at LUS (number of B-lines<15). CONCLUSION: In a HF outpatient setting, B-line assessment by LUS identifies patients more likely to be admitted for decompensated HF in the following 4months. This simple evaluation could allow prompt therapy optimization in those patients who, although asymptomatic, carry a significant degree of extravascular lung water

Técnica cirúrgica simplificada pode ser eficaz no tratamento da fibrilação atrial crônica secundária a lesão valvar mitral?

INTRODUÇÃO: Fibrilação atrial tem sido tratada pelo procedimento do Labirinto (Cox) e suas modificações. Há, no entanto, evidências de que o isolamento dos óstios das veias pulmonares ou exclusão do átrio esquerdo poderia ser eficaz para este fim. CASUÍSTICA E MÉTODOS: Avaliamos os resultados iniciais da técnica simplificada de isolamento cirúrgico dos óstios das veias pulmonares para tratar fibrilação atrial crônica em pacientes operados por lesão valvar mitral. Foram tratados 7 pacientes por esta técnica (grupo IVP) e comparados com série prévia de 57 casos submetidos a cirurgia do Labirinto (Cox 3). RESULTADOS: A idade média foi de 49±8 anos vs 49±11 anos, (IVP vs. Cox3), sendo 71% e 72% (IVP vs. Cox 3) do sexo feminino. Dimensões do átrio esquerdo 5,5±0,7 cm vs. 6,0±1,1 cm (IVP vs. Cox 3). Fração de ejeção ventricular 63±10% vs. 64±6% (IVP vs. Cox 3). Tempo CEC 91±33 min vs. 104±29 min (IVP vs. Cox 3). Tempo de isquemia71±23 min vs. 83±26 min (IVP vs. Cox 3). Ritmo pós-operátório sinusal/atrial n(%): 6(86) vs. 46(80) (IVP vs. Cox 3). Ritmo marcapasso n(%):1 (14) vs. 4 (7) (IVP vs. Cox 3). Fibrilação atrial n(%): 0 vs. 7 (13) (IVP vs. Cox 3). CONCLUSÕES: Resultados iniciais mostram reversão a ritmo sinusal na maioria dos casos em ambos procedimentos e manutenção do ritmo a longo prazo. Foi iniciado estudo prospectivo randomizado para avaliar o IVP comparativamente ao procedimento Cox 3