A Global Perspective with Systematic Review and Meta-Analysis of Observational Studies

Acute cardiovascular disease after community-acquired pneumonia is a well-accepted complication for which definitive treatment strategies are lacking. These complications share some common features but have distinct diagnostic and treatment approaches. We therefore undertook an updated systematic review and meta-analysis of observational studies reporting the incidence of overall complications, acute coronary syndromes, new or worsening heart failure, new or worsening arrhythmias and acute stroke, as well as short-term mortality outcomes. To set a framework for future research, we further included a holistic review of the interplay between the two conditions. From 1984 to 2019, thirty-nine studies were accrued, involving 92,188 patients, divided by setting (inpatients versus outpatients) and clinical severity (low risk versus high risk). Overall cardiac complications occurred in 13.9% (95% confidence interval (CI) 9.6-18.9), acute coronary syndromes in 4.5% (95% CI 2.9-6.5), heart failure in 9.2% (95% CI 6.7-12.2), arrhythmias in 7.2% (95% CI 5.6-9.0) and stroke in 0.71% (95% CI 0.1-3.9) of pooled inpatients. During this period, meta-regression analysis suggests that the incidence of overall and individual cardiac complications is decreasing. After adjusting for confounders, cardiovascular events taking place after community-acquired pneumonia independently increase the risk for short-term mortality (range of odds-ratio: 1.39-5.49). These findings highlight the need for effective, large trial based, preventive and therapeutic interventions in this important patient population.publishersversionpublishe

Usando Troponina de Alta Sensibilidade para Melhorar a Previsão de Risco após Cirurgia Não Cardíaca – Já Chegamos Lá?

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beyond reasonable doubt?

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A review for clinical and interventional cardiologists

persons Copyright © 2023 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome, especially among young to middle-aged women with few traditional cardiovascular risk factors and low pretest probability for atherosclerotic coronary artery disease. Diagnosis by invasive coronary angiography is the gold standard and conservative therapy is generally recommended, with percutaneous or surgical revascularization being reserved for cases of clinical instability, high-risk anatomy or as bailout. Unlike atherothrombotic coronary artery disease, strong evidence on optimal medical therapy is scarce, posing unique challenges in cases of pregnancy-associated SCAD. The follow-up strategy is also of major importance, as recurrent SCAD is not infrequent, lifestyle changes and pharmacological therapy should be planned for the long term, and SCAD-associated conditions need to be addressed. This review aims to provide a practical management approach to SCAD patients for both clinical and interventional cardiologists.publishersversionepub_ahead_of_prin

CATÁSTROFE DA PAREDE ABDOMINAL, ESTRATÉGIA TERAPÊUTICA – RELATO DE UM CASO CLÍNICO E REVISÃO DA LITERATURA

A complete abdominal wall defect (AWD) is life-threatening, has a functional and cosmetic impact on patients’ quality of life and represents a significant challenge for surgeons, requiring a multidisciplinary treatment strategy. The goals of the reconstructive surgery in the management of these defects are to provide stable coverage of the abdominal contents, restore function and achieve complete wound closure. We present a case that shows that the use of a biological mesh (porcine dermis), negative wound pressure therapy (NPWT) and split skin grafting is suitable to manage such defects when visceral exposure is present. A biological mesh is a good and less aggressive alternative to the use of free flaps, closing the AWD in a tension-free manner in an infected field or in one that is suspected of being infected and it has been shown to be better tolerated than synthetic meshes in open abdomens, with the ability to provide vascular ingrowth and incorporate itself into the native tissue. On the other hand, NPWT showed to provide a firm bandage for the patient and a closed, moist environment, protected from the invasion of bacteria, while eliminating excessive exudation, stimulating angiogenesis and reducing the wound surface area. Um defeito completo da parede abdominal (AWD) ameaça a vida, tem um impacto funcional e cosmético na vida dos doentes e representa um grande desafio para os cirurgiões, exigindo uma estratégia de tratamento multidisciplinar. Os objetivos da cirurgia reconstrutiva no tratamento destes defeitos são fornecer uma cobertura estável do conteúdo abdominal, restaurar a função da parede abdominal e atingir um encerramento completo da ferida. Apresentamos um caso clínico que mostra que o uso de uma prótese biológica (derme suína), terapia de pressão negativa (NPWT) e enxertos cutâneos é adequado para tratar estes defeitos quando o doente tem exposição visceral. O uso de uma prótese biológica é uma alternativa boa e menos agressiva em comparação com o uso de retalhos livres, encerrando o AWD sem tensão num terreno infetado, e mostrou ser melhor tolerado do que o uso de próteses sintéticas num abdómen aberto, com a capacidade de fornecer um meio para crescimento vascular e de se incorporar aos tecidos do doente. Por outro lado, a NPWT mostrou fornecer um ambiente firme, fechado e húmido, protegido da invasão de bactérias, ao mesmo tempo que elimina a exsudação excessiva, estimula a angiogénese e reduz a área de superfície da ferida.&nbsp

Early changes in diaphragmatic function evaluated using ultrasound in cardiac surgery patients: a cohort study.

Little is known about the evolution of diaphragmatic function in the early post-cardiac surgery period. The main purpose of this work is to describe its evolution using ultrasound measurements of muscular excursion and thickening fraction (TF). Single-center prospective study of 79 consecutive uncomplicated elective cardiac surgery patients, using motion-mode during quiet unassisted breathing. Excursion and TF were measured sequentially for each patient [pre-operative (D1), 1 day (D2) and 5 days (D3) after surgery]. Pre-operative median for right and left hemidiaphragmatic excursions were 1.8 (IQR 1.6 to 2.1) cm and 1.7 (1.4 to 2.0) cm, respectively. Pre-operative median right and left thickening fractions were 28 (19 to 36) % and 33 (22 to 51) %, respectively. At D2, there was a reduction in both excursion (right: 1.5 (1.1 to 1.8) cm, p < 0.001, left: 1.5 (1.1 to 1.8), p = 0.003) and thickening fractions (right: 20 (15 to 34) %, p = 0.021, left: 24 (17 to 39) %, p = 0.002), followed by a return to pre-operative values at D3. A positive moderate correlation was found between excursion and thickening fraction (Spearman's rho 0.518 for right and 0.548 for left hemidiaphragm, p < 0.001). Interobserver reliability yielded a bias below 0.1 cm with limits of agreement (LOA) of ± 0.3 cm for excursion and - 2% with LOA of ± 21% for thickening fractions. After cardiac surgery, the evolution of diaphragmatic function is characterized by a transient impairment followed by a quick recovery. Although ultrasound diaphragmatic excursion and thickening fraction are correlated, excursion seems to be a more feasible and reproducible method in this population

Assessment of perioperative mortality risk in patients with infective endocarditis undergoing cardiac surgery: performance of the EuroSCORE I and II logistic models

OBJECTIVES: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) has been established as a tool for assisting decision- making in surgical patients and as a benchmark for quality assessment. Infective endocarditis often equires surgical treatment and is associated with high mortality. This study was undertaken to (i) validate both versions of the EuroSCORE, the older logistic EuroSCORE I and the recently developed EuroSCORE II and to compare their performances; (ii) identify predictors other than those included in the EuroSCORE models that might further improve their performance. METHODS: We retrospectively studied 128 patients from a single-centre registry who underwent heart surgery for active infective endocarditis between January 2007 and November 2014. Binary logistic regression was used to find independent predictors of mortality and to create a new prediction model. Discrimination and calibration of models were assessed by receiver-operating characteristic curve analysis, calibration curves and the Hosmer–Lemeshow test. RESULTS: The observed perioperative mortality was 16.4% (n = 21). The median EuroSCORE I and EuroSCORE II were 13.9% interquartile range (IQ) (7.0–35.0) and 6.6% IQ (3.5–18.2), respectively. Discriminative power was numerically higher for EuroSCORE II {area under the curve (AUC) of 0.83 [95% confidence interval (CI), 0.75–0.91]} than for EuroSCORE I [0.75 (95% CI, 0.66–0.85), P = 0.09]. The Hosmer– Lemeshow test showed good calibration for EuroSCORE II (P = 0.08) but not for EuroSCORE I (P = 0.04). EuroSCORE I tended to overpredict and EuroSCORE II to under-predict mortality. Among the variables known to be associated with greater infective endocarditis severity, only prosthetic valve infective endocarditis remained an independent predictor of mortality [odds ratio (OR) 6.6; 95% CI, 1.1–39.5; P = 0.04]. The new model including the EuroSCORE II variables and variables known to be associated with greater infective endocarditis severity showed an AUC of 0.87 (95% CI, 0.79–0.94) and differed significantly from EuroSCORE I (P = 0.03) but not from EuroSCORE II (P = 0.4). CONCLUSIONS: Both EuroSCORE I and II satisfactorily stratify risk in active infective endocarditis; however, EuroSCORE II performed better in the overall comparison. Specific endocarditis features will increase model complexity without an unequivocal improvement in predictive ability.info:eu-repo/semantics/publishedVersio

Are we giving it too much credit?

BACKGROUND: COVID-19 is a new form of acute respiratory failure leading to multiorgan failure and ICU admission. Gathered evidence suggests that a 3-fold rise in D-dimer concentrations may be linked to poor prognosis and higher mortality. PURPOSE: To describe D-dimer admission profile in severe ICU COVID19 patients and its predictive role in outcomes and mortality. METHODS: Single-center retrospective cohort study. All adult patients admitted to ICU with COVID19 were divided into 3 groups: (1) Lower-values group (D-dimer levels < 3-fold normal range value [NRV] [500ng/mL]), Intermediate-values group (D-dimer ≥3-fold and <10-fold NRV) and Higher-value group (≥10-fold NRV). RESULTS: 118 patients (mean age 63 years, 73% males) were included (N = 73 Lower-values group, N = 31 Intermediate-values group; N = 11 Higher-values group). Mortality was not different between groups (p = 0.51). Kaplan-Meier survival curves revealed no differences (p = 0.52) between groups, nor it was verified even when gender, age, ICU length of stay, and SOFA score were considered as covariables. CONCLUSIONS: In severe COVID19 patients, the D-dimer profile does not retain a predictive value regarding patients' survivability and should not be used as a surrogate of disease severity.publishersversionpublishe

An unattended sepsis population with high mortality risk

©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.BACKGROUND: Coronavirus disease 2019 (COVID-19) can be associated with life-threatening organ dysfunction due to septic shock, frequently requiring intensive care unit (ICU) admission, respiratory and vasopressor support. Therefore, clear clinical criteria are pivotal for early recognition of patients more likely to need prompt organ support. Although most patients with severe COVID-19 meet the Sepsis-3.0 criteria for septic shock, it has been increasingly recognized that hyperlactatemia is frequently absent, possibly leading to an underestimation of illness severity and mortality risk. AIM: To identify the proportion of severe COVID-19 patients with vasopressor support requirements, with and without hyperlactatemia, and describe their clinical outcomes and mortality. METHODS: We performed a single-center prospective cohort study. All adult patients admitted to the ICU with COVID-19 were included in the analysis and were further divided into three groups: Sepsis group, without both criteria; Vasoplegic Shock group, with persistent hypotension and vasopressor support without hyperlactatemia; and Septic Shock 3.0 group, with both criteria. COVID-19 was diagnosed using clinical and radiologic criteria with a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive RT-PCR test. RESULTS: 118 patients (mean age 63 years, 87% males) were included in the analysis (n = 51 Sepsis group, n = 26 Vasoplegic Shock group, and n = 41 Septic Shock 3.0 group). SOFA score at ICU admission and ICU length of stay were different between the groups (P < 0.001). Mortality was significantly higher in the Vasoplegic Shock and Septic Shock 3.0 groups when compared with the Sepsis group (P < 0.001) without a significant difference between the former two groups (P = 0.713). The log rank tests of Kaplan-Meier survival curves were also different (P = 0.007). Ventilator-free days and vasopressor-free days were different between the Sepsis vs Vasoplegic Shock and Septic Shock 3.0 groups (both P < 0.001), and similar in the last two groups (P = 0.128 and P = 0.133, respectively). Logistic regression identified the maximum dose of vasopressor therapy used (AOR 1.046; 95%CI: 1.012-1.082, P = 0.008) and serum lactate level (AOR 1.542; 95%CI: 1.055-2.255, P = 0.02) as the major explanatory variables of mortality rates (R 2 0.79). CONCLUSION: In severe COVID-19 patients, the Sepsis 3.0 criteria of septic shock may exclude approximately one third of patients with a similarly high risk of a poor outcome and mortality rate, which should be equally addressed.publishersversionpublishe

Eight years of experience

Copyright © 2017 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.INTRODUCTION: Aortic stenosis is the most prevalent type of valvular disease in Europe. Surgical aortic valve replacement (SAVR) is the standard therapy, while transcatheter aortic valve implantation (TAVI) is an alternative in patients at unacceptably high surgical risk. Assessment by a heart team is recommended by the guidelines but there is little published evidence on this subject. The purpose of this paper is to describe the experience of a multidisciplinary TAVI program that began in 2008. METHODS: The heart team prospectively assessed 473 patients using a standardized approach. A total of 214 patients were selected for TAVI and 80 for SAVR. Demographic, clinical and procedural characteristics and long-term success rates were compared between the groups. RESULTS: TAVI patients were older than the SAVR group (median 83 vs. 81 years), and had higher surgical risk scores (median EuroSCORE II 5.3 vs. 3.6% and Society of Thoracic Surgeons score 5.1 vs. 3.1%), as did the patients under medical treatment only. These scores were unable to assess multiple comorbidities. Patients' outcomes were different between the three groups (mortality with SAVR 25% vs. TAVI 37.6% vs. conservative therapy 57.6%, p=0.001). CONCLUSIONS: The heart team program was able to select candidates appropriately for TAVI, SAVR and conservative treatment, taking into account the risk of both invasive treatments. The use of a prospective standardized heart team approach is recommended, but requires continuous monitoring to ensure effectiveness in a timely manner.publishersversionpublishe