Automatic implantable cardioverter defibrillator: when not to implant.

The implantable cardioverter-defibrillator (ICD) is the mainstay therapy for primary prevention of sudden cardiac death in patients with heart failure with a reduced ejection fraction. Current indications for prophylactic ICD are based on the results of randomized controlled trials dating back to 15-20 years ago, which have usually enrolled highly selected patients with few comorbidities and only a small number of patients aged >75 years. Existing literature suggest an age-dependent attenuation of the efficacy of the ICD. Because of the ageing of the population, there is need for data addressing device efficacy among older patients that also considers the impact of geriatric syndromes on health status. The assessment of frailty may be of value in identifying elderly patients who may or may not benefit from ICD placement for primary prevention of sudden cardiac death

Prognostic impact of digoxin use for rate control of atrial fibrillation in patients ≥75 years of age

Digoxin use remains a common therapeutic option in the pharmacological control of heart rate in patients with atrial fibrillation, endorsed in current guidelines with the same level of evidence than beta-blockers in patients with and without heart failure. Digoxin has a narrow therapeutic range and is influenced by drug‐to‐drug interactions, serum electrolyte concentrations, and renal function. Conflicting data exist regarding adverse outcomes that are associated with digoxin use in patients with atrial fibrillation. It remains unclear whether the association between digoxin use and worse clinical outcome is causal or may be the result of confounding by differences in the characteristics of patents including age, comorbidities and treatment. Particularly in older patients with atrial fibrillation, who are frequently prescribed a multitude of agents for stroke prevention, treatment of cardiovascular disease and other comorbidities, use of digoxin should be cautious and instituted with assessment of drug concentrations

Role and efficacy of cardiac rehabilitation in patients with heart failure

Despite improvements in treatments, the prognosis of heart failure remains poor. Elderly patients with heart failure are burdened with multiple co-morbidities and polypharmacy. Multidisciplinary disease-management programs are recommended as standard care for patients at high risk of hospitalization. Cardiac rehabilitation is defined a coordinated multidimensional intervention that integrates the basic elements in multidisciplinary management programs with a continuing program of physical activity and exercise training. Cardiac rehabilitation services can be provided on an inpatient or outpatient basis according to the clinical characteristics and severity of the disease. Data support the usefulness of inpatient cardiac rehabilitation interventions soon after hospitalization for acute decompensated heart failure as a “transition care service” to overcome the particularly high risk “vulnerable” phase. Although in the elderly, physical activity is conditioned by the general clinical conditions, the presence of comorbidities and frailty, several data underscore the importance of improving exercise capacity in the elderly vulnerable patient

A multicenter, randomized, controlled trial on short-term feasibility and impact on functional capacity, symptoms and neurohumoral activation

RE-START is a multicenter, randomized, prospective, open, controlled trial aiming to evaluate the feasibility and the short- and medium-term effects of an earlystart AET program on functional capacity, symptoms and neurohormonal activation in chronic heart failure (CHF) patients with recent acute hemodynamic decompensation. Study endpoints will be: 1) safety of and compliance to AET; 2) effects of AET on i) functional capacity, ii) patient- reported symptoms and iii) AET-induced changes in beta-adrenergic receptor signaling and circulating angiogenetic and inflammatory markers. Two-hundred patients, randomized 1:1 to training (TR) or control (C), will be enrolled. Inclusion criteria: 1) history of systolic CHF for at least 6 months, with ongoing acute decompensation with need of intravenous diuretic and/or vasodilator therapy; 2) proBNP >1000 pg/ml at admission. Exclusion criteria: 1) ongoing cardiogenic shock; 2) need of intravenous inotropic therapy; 3) creatinine >2.5 mg/dl at admission. After a 72-hour run-in period, TR will undergo the following 12-day early-start AET protocol: days 1-2: active/passive mobilization (2 sessions/day, each 30 minutes duration); days 3-4: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 5-10 minutes duration); days 5-8: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 15-20 minutes duration); days 9-12: as days 1-2 + bedside cycle ergometer at 10-20 W (3 sessions/day, each 15-20 minutes duration). During the same period, C will undergo the same activity protocol as in days 1-2 for TR. All patients will undergo a 6- minWT at day 1, 6, 12 and 30 and echocardiogram, patient- reported symptoms on 7-point Likert scale and measurement of lymphocyte G protein coupled receptor kinase, VEGF, angiopoietin, TNF alfa, IL-1, IL-6 and eNOS levels at day 1, 12 and 30

Description and performance of track and primary-vertex reconstruction with the CMS tracker

A description is provided of the software algorithms developed for the CMS tracker both for reconstructing charged-particle trajectories in proton-proton interactions and for using the resulting tracks to estimate the positions of the LHC luminous region and individual primary-interaction vertices. Despite the very hostile environment at the LHC, the performance obtained with these algorithms is found to be excellent. For tbar t events under typical 2011 pileup conditions, the average track-reconstruction efficiency for promptly-produced charged particles with transverse momenta of pT > 0.9GeV is 94% for pseudorapidities of |η| < 0.9 and 85% for 0.9 < |η| < 2.5. The inefficiency is caused mainly by hadrons that undergo nuclear interactions in the tracker material. For isolated muons, the corresponding efficiencies are essentially 100%. For isolated muons of pT = 100GeV emitted at |η| < 1.4, the resolutions are approximately 2.8% in pT, and respectively, 10μm and 30μm in the transverse and longitudinal impact parameters. The position resolution achieved for reconstructed primary vertices that correspond to interesting pp collisions is 10–12μm in each of the three spatial dimensions. The tracking and vertexing software is fast and flexible, and easily adaptable to other functions, such as fast tracking for the trigger, or dedicated tracking for electrons that takes into account bremsstrahlung

Transthoracic echocardiographic assessment of cardiac output in mechanically ventilated critically ill patients by intensive care unit physicians

Background and objectives: Transthoracic echocardiography may potentially be useful to obtain a prompt, accurate and non-invasive estimation of cardiac output. We evaluated whether non-cardiologist intensivists may obtain accurate and reproducible cardiac output determination in hemodynamically unstable mechanically ventilated patients. Methods: We studied 25 hemodynamically unstable mechanically ventilated intensive care unit patients with a pulmonary artery catheter in place. Cardiac output was calculated using the pulsed Doppler transthoracic echocardiography technique applied to the left ventricular outflow tract in apical 5 chamber view by two intensive care unit physicians who had received a basic Transthoracic Echocardiography training plus a specific training focused on Doppler, left ventricular outflow tract and velocity-time integral determination. Results: Cardiac output assessment by transthoracic echocardiography was feasible in 20 out of 25 enrolled patients (80%) and showed an excellent inter-operator reproducibility (Pearson correlation test r= 0.987; Cohen's K=0.840). Overall, the mean bias was 0.03 L.min(-1), with limits of agreement -0.52 and +0.57 L.min(-1). The concordance correlation coefficient (rho(c)) was 0.986 (95% IC 0.966-0.995) and 0.995 (95% IC 0.986-0.998) for physician 1 and 2, respectively. The value of accuracy (C-b) of COTTE measurement was 0.999 for both observers. The value of precision (rho) of CO (TEE) measurement was 0.986 and 0.995 for observer 1 and 2, respectively. Conclusions: A specific training focused on Doppler and VTI determination added to the standard basic transthoracic echocardiography training allowed non-cardiologist intensive care unit physicians to achieve a quick, reproducible and accurate snapshot cardiac output assessment in the majority of mechanically ventilated intensive care unit patients. (C) 2018 Sociedade Brasileira de Anestesiologia

Transthoracic echocardiographic assessment of cardiac output in mechanically ventilated critically ill patients by intensive care unit physicians

Background and objectives: Transthoracic echocardiography may potentially be useful to obtain a prompt, accurate and non-invasive estimation of cardiac output. We evaluated whether non-cardiologist intensivists may obtain accurate and reproducible cardiac output determination in hemodynamically unstable mechanically ventilated patients. Methods: We studied 25 hemodynamically unstable mechanically ventilated intensive care unit patients with a pulmonary artery catheter in place. Cardiac output was calculated using the pulsed Doppler transthoracic echocardiography technique applied to the left ventricular outflow tract in apical 5 chamber view by two intensive care unit physicians who had received a basic Transthoracic Echocardiography training plus a specific training focused on Doppler, left ventricular outflow tract and velocity-time integral determination. Results: Cardiac output assessment by transthoracic echocardiography was feasible in 20 out of 25 enrolled patients (80%) and showed an excellent inter-operator reproducibility (Pearson correlation test r = 0.987; Cohen's K = 0.840). Overall, the mean bias was 0.03 L.min−1, with limits of agreement −0.52 and +0.57 L.min−1. The concordance correlation coefficient (ρc) was 0.986 (95% IC 0.966–0.995) and 0.995 (95% IC 0.986–0.998) for physician 1 and 2, respectively. The value of accuracy (Cb) of COTTE measurement was 0.999 for both observers. The value of precision (ρ) of COTTE measurement was 0.986 and 0.995 for observer 1 and 2, respectively. Conclusions: A specific training focused on Doppler and VTI determination added to the standard basic transthoracic echocardiography training allowed non-cardiologist intensive care unit physicians to achieve a quick, reproducible and accurate snapshot cardiac output assessment in the majority of mechanically ventilated intensive care unit patients. Resumo: Justificativa e objetivos: A ecocardiografia transtorácica pode ser potencialmente útil para obter uma estimativa rápida, precisa e não invasiva do débito cardíaco. Avaliamos se os intensivistas não cardiologistas podem obter uma determinação precisa e reprodutível do débito cardíaco em pacientes mecanicamente ventilados e hemodinamicamente instáveis. Métodos: Avaliamos 25 pacientes em unidade de terapia intensiva, mecanicamente ventilados, hemodinamicamente instáveis, com cateteres de artéria pulmonar posicionados. O débito cardíaco foi calculado usando a técnica de ecocardiografia transtorácica com Doppler pulsátil aplicada à via de saída do ventrículo esquerdo no corte apical (5-câmaras) por dois médicos intensivistas que receberam treinamento básico em ecocardiografia transtorácica e treinamento específico focado em Doppler, via de saída do ventrículo esquerdo e determinação da integral de tempo-velocidade. Resultados: A avaliação do débito cardíaco pelo ecocardiograma transtorácico foi factível em 20 dos 25 pacientes inscritos (80%) e mostrou excelente reprodutibilidade entre operadores (teste de correlação de Pearson r = 0,987; K de Cohen = 0,840). No geral, o viés médio foi de 0,03 L.min−1, com limites de concordância de −0,52 e +0,57 L.min−1. O coeficiente de correlação de concordância (ρc) foi 0,986 (95% IC 0,966–0,995) e 0,995 (95% IC 0,986–0,998) para os médicos 1 e 2, respectivamente. O valor de precisão (Cb) da mensuração de COTTE foi de 0,999 para ambos os observadores. O valor de precisão (ρ) da mensuração de COTTE foi de 0,986 e 0,995 para os observadores 1 e 2, respectivamente. Conclusões: Um treinamento específico focado na determinação do Doppler e VTI, adicionado ao treinamento padrão em ecocardiografia transtorácica básica, permitiu que médicos não cardiologistas da unidade de terapia intensiva obtivessem uma avaliação rápida, reprodutível e precisa do débito cardíaco instantâneo na maioria dos pacientes mecanicamente ventilados em unidade de terapia intensiva. Keywords: Cardiac output, Transthoracic echocardiography, Pulmonary artery catheter, Intensive Care Unit, Palavras-chave: Débito cardíaco, Ecocardiografia transtorácica, Cateter de artéria pulmonar, Unidade de Terapia Intensiv