Les nouvelles recommandations 2016 dans l’insuffisance cardiaque & Présentation d'une étude de Télémédecine

Epidémiologie, diagnostic et Approche médicamenteuse. Dr M. Melissopoulou (CHR de liège) • Approche non médicamenteuse & comorbidités. Dr Troisfontaines (CHR de Liège) • Insuffisance cardiaque aigue & Insuffisance cardiaque terminale. Dr V. D’Orio (CHU de Liège) • Présentation de l’étude Télémédecine Dr A. Ancion (CHU de Liège

Acetazolamide in Acute Decompensated Heart Failure with Volume Overload

BACKGROUND: Whether acetazolamide, a carbonic anhydrase inhibitor that reduces proximal tubular sodium reabsorption, can improve the efficiency of loop diuretics, potentially leading to more and faster decongestion in patients with acute decompensated heart failure with volume overload, is unclear.METHODS: In this multicenter, parallel-group, double-blind, randomized, placebo-controlled trial, we assigned patients with acute decompensated heart failure, clinical signs of volume overload (i.e., edema, pleural effusion, or ascites), and an N-terminal pro-B-type natriuretic peptide level of more than 1000 pg per milliliter or a B-type natriuretic peptide level of more than 250 pg per milliliter to receive either intravenous acetazolamide (500 mg once daily) or placebo added to standardized intravenous loop diuretics (at a dose equivalent to twice the oral maintenance dose). Randomization was stratified according to the left ventricular ejection fraction (≤40% or &gt;40%). The primary end point was successful decongestion, defined as the absence of signs of volume overload, within 3 days after randomization and without an indication for escalation of decongestive therapy. Secondary end points included a composite of death from any cause or rehospitalization for heart failure during 3 months of follow-up. Safety was also assessed.RESULTS: A total of 519 patients underwent randomization. Successful decongestion occurred in 108 of 256 patients (42.2%) in the acetazolamide group and in 79 of 259 (30.5%) in the placebo group (risk ratio, 1.46; 95% confidence interval [CI], 1.17 to 1.82; P&lt;0.001). Death from any cause or rehospitalization for heart failure occurred in 76 of 256 patients (29.7%) in the acetazolamide group and in 72 of 259 patients (27.8%) in the placebo group (hazard ratio, 1.07; 95% CI, 0.78 to 1.48). Acetazolamide treatment was associated with higher cumulative urine output and natriuresis, findings consistent with better diuretic efficiency. The incidence of worsening kidney function, hypokalemia, hypotension, and adverse events was similar in the two groups.CONCLUSIONS: The addition of acetazolamide to loop diuretic therapy in patients with acute decompensated heart failure resulted in a greater incidence of successful decongestion. (Funded by the Belgian Health Care Knowledge Center; ADVOR ClinicalTrials.gov number, NCT03505788.).</p

Image of the Month. Isolated Single Coronary Artery or Blockage of the Common Arterial Trunk and Branches?

peer reviewe

Clinical Case of the Month. Precordialgia Evoking a Coronary Instability Syndrome, a Diagnostic Danger

peer reviewedChest pain represents a frequent motivation for consultation in which the differential diagnosis is not always easy. We present a case where a misdiagnosis lead to serious complications. Therefore we review the clinical and electrocardiographic characteristics of the evoked diagnosis

Chronique de l'Institut Supérieur de Philosophie

Deschepper Jean-Pierre, Troisfontaines Claude, Bastit Michel. Chronique de l'Institut Supérieur de Philosophie. In: Revue Philosophique de Louvain. Quatrième série, tome 99, n°4, 2001. pp. 771-810

Chronique de l'Institut Supérieur de Philosophie

Deschepper Jean-Pierre, Troisfontaines Claude, Bastit Michel. Chronique de l'Institut Supérieur de Philosophie. In: Revue Philosophique de Louvain. Quatrième série, tome 99, n°4, 2001. pp. 771-810

Prognostic importance of exercise-induced changes in mitral regurgitation in patients with chronic ischemic left ventricular dysfunction

Background-In the post-myocardial infarction phase, mortality risk is related to the severity of mitral regurgitation (MR). Ischemic MR is a dynamic condition that can be studied during exercise. Whether the assessment of exercise-induced changes in the degree of MR provides prognostic information is unknown. Methods and Results-Ninety-eight consecutive patients with chronic ischemic left ventricular dysfunction and at least mild MR who prospectively underwent quantitative measurement of the regurgitant volume and the effective regurgitant orifice (ERO) of MR at rest and during semisupine exercise test were followed up for 19+/-8 months. The 16 patients who underwent surgery were censored at the time of operation. Of the 82 patients who were medically treated, 9 (11%) died. No clinical data demonstrated a distinction between survivors and nonsurvivors. By multivariate Cox regression analysis, independent predictors of cardiac death were an increase in ERO by greater than or equal to13 mm(2) (P=0.0045) during exercise, an ERO >20 mm(2) at rest (P=0.01), and a shorter mitral deceleration time (P=0.044). Half of the patients with exercise-induced significant increases in MR who died had moderate MR at rest. In contrast, none of the 14 patients with a decrease in MR at exercise displayed cardiac death. Conclusions-In patients with ischemic MR and left ventricular dysfunction, quantitative assessment of exercise-induced changes in the degree of MR provides independent prognostic information. Significant exercise-induced increases in MR unmask patients at high risk of poor outcome

The in- and out-of-hospital management of HF patients: results from a nationwide Belgian survey.

We conducted a nationwide survey to describe the in-and out-of-hospital flow (diagnosis, treatment and follow-up) of patients with heart failure with reduced ejection fraction (HFrEF). A survey was developed with five dedicated HF cardiologists. The data are all self-reported by cardiologists. The response rate was 84%. Presence of a dedicated HF cardiologist or HF nurse was indicated by 49% and 46% of the hospitals respectively. Devices ( 75% of the target dose seems easier for angiotensin converting enzyme inhibitor/angiotensin receptor blockers (ACEI/ARB) (22%) and mineralocorticoid receptor antagonists (25%), compared to β-blockers (10%) and angiotensin receptor neprilysin inhibitors (7%). 62%, 49% and 4% of the cardiologists indicated to use subtypes of angiotensin converting enzyme inhibitors, angiotensin receptor blockers and β-blockers respectively not validated in the HF population. In the acute setting, dedicated HF cardiologists (23%) are less influenced by blood parameters for decongestion compared to non-dedicated HF cardiologists (39%). They tend to change patients more to guideline-recommended drugs (60% vs 47%). Six minutes walk test and ergospirometry are significantly more used by dedicated compared to non-dedicated HF cardiologists for HF drug change (17% and 29% vs 2% and 4%). This survey showed that a minority of hospitals have HF care. Those that do, report a higher implementation of guideline-recommended diagnosis, treatment and follow-up of HF patients. Competent authorities could use this survey as a tool to improve HF care