RESUMO
Background and Aims: Functional capacity is reduced in mitral stenosis (MS) patients. Previous studies showed a correlation between left atrial strain and functional capacity in this population. However, currently, no left ventricle (LV) echocardiographic parameters were associated with functional capacity in patients with MS. Noninvasive LV pressure-strain loop analysis is a new echocardiographic method for evaluating LV function, integrating longitudinal strain from speckle-tracking analysis and noninvasively measured blood pressure to estimate myocardial work (MW) that overcomes the preload-dependent characteristics conventional parameters by integrating afterload. This study aimed to evaluate the association between MW and functional capacity measured using exercise tests in patients with severe MS and preserved LV ejection fraction (LVEF). Methods: Adult patients with symptomatic severe rheumatic MS (mitral valve area <1.5 cm2), and preserved LVEF (>50%) and sinus rhythm who underwent echocardiography and exercise stress test in our hospital from 2019 to 2021 were included. Exclusion criteria were suboptimal image quality for myocardial deformation analysis, significant mitral regurgitation or aortic valve lesions, coronary artery disease, intracardiac shunt, and atrial fibrillation. Standard echocardiographic parameters were measured, and all MW parameters were included. Exercise treadmill testing was performed using the modified Bruce protocol. Results: A total of 33 individuals with isolated severe rheumatic MS in sinus rhythm (age 39.8 ± 9.8 years) were included in the study. Patients with severe isolated MS showed significantly impaired LV-global longitudinal strain values compared to normal reference values. Furthermore, patients with severe MS showed significantly lower values of global work index, global constructive work, and efficiency compared to normal values and higher wasted work. Global work efficiency was significantly correlated to the duration of exercise (P = 0.025, Pearson's r = 0.389). Conclusions: In stable patients with isolated severe mitral stenosis, MW efficiency significantly correlated with functional capacity measured objectively through exercise testing.
RESUMO
OBJECTIVES: In Indonesia, the poor prognosis and high hospital readmission rates of patients with heart failure (HF) have yet to receive focused attention. However, machine learning (ML) approaches can help to mitigate these problems. We aimed to determine which ML models best predicted HF severity and hospital readmissions and could be used in a patient self-monitoring mobile application. METHODS: In a retrospective cohort study, we collected the data of patients admitted with HF to the Siloam Diagram Heart Center in 2020, 2021, and 2022. Data was analyzed using the Orange data mining classification method. ML support algorithms, including artificial neural network (ANN), random forest, gradient boosting, Naïve Bayes, tree-based models, and logistic regression were used to predict HF severity and hospital readmissions. The performance of these models was evaluated using the area under the curve (AUC), accuracy, and F1-scores. RESULTS: Of the 543 patients with HF, 3 (0.56%) were excluded due to death on admission. Hospital readmission occurred in 138 patients (25.6%). Of the six algorithms tested, ANN showed the best performance in predicting both HF severity (AUC = 1.000, accuracy = 0.998, F1-score = 0.998) and readmission for HF (AUC = 0.998, accuracy = 0.975, F1-score = 0.972). Other studies have shown variable results for the best algorithm to predict hospital readmission in patients with HF. CONCLUSIONS: The ANN algorithm performed best in predicting HF severity and hospital readmissions and will be integrated into a mobile application for patient self-monitoring to prevent readmissions.
RESUMO
Background: The current technique used in severe mitral regurgitation in children can occasionally lead to residual regurgitation. To address this issue, the posterior annulus elevation technique was developed to enhance coaptation and reduce residual lesions. This study aims to evaluate the effectiveness of this technique in reducing residual regurgitation during mitral valve repair in children. Methods: A total of 64 patients aged <18 years old undergoing mitral valve repair were randomized into two groups: the intervention (with posterior annulus elevation) group and the control group, which underwent conventional repair techniques. Various parameters, including coaptation area, residual mitral regurgitation, clinical outcomes, metabolic, and hemolytic markers, were measured on days 0, 5, 2 weeks, and 3 months after surgery. Results: The intervention group (n = 32) showed a significant reduction in residual mitral regurgitation compared with the control group (n = 32) on each evaluation. At three months after surgery, we found that the posterior annulus elevation technique could be a protective factor that reduces the chance of residual regurgitation compared with the control group (RR = 0.31; confidence interval: 0.18-0.54; P ≤ .001). Coaptation length and index were also found to be significantly higher in the intervention group (P ≤ .001). Clinical outcomes, metabolic markers, and hemolysis marker did not show any significant differences between the two groups. Conclusions: The posterior annulus elevation technique demonstrated effectiveness in reducing residual mitral regurgitation and improving coaptation area in pediatric mitral valve repair. This technique showed better short-term surgical outcomes in children with mitral regurgitation compared with the conventional technique.
Assuntos
Insuficiência da Valva Mitral , Valva Mitral , Humanos , Insuficiência da Valva Mitral/cirurgia , Masculino , Feminino , Valva Mitral/cirurgia , Criança , Pré-Escolar , Resultado do Tratamento , Anuloplastia da Valva Mitral/métodos , Seguimentos , Lactente , Adolescente , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Cardíacos/efeitos adversosRESUMO
BACKGROUND: Assessment of left ventricular (LV) function plays a pivotal role in the management of patients with valvular heart disease, including those caused by rheumatic heart disease. Noninvasive LV pressure-strain loop analysis is emerging as a new echocardiographic method to evaluate global LV systolic function, integrating longitudinal strain by speckle-tracking analysis and noninvasively measured blood pressure to estimate myocardial work. The aim of this study was to characterize global LV myocardial work efficiency in patients with severe rheumatic mitral stenosis (MS) with preserved ejection fraction (EF). METHODS: We retrospectively included adult patients with severe rheumatic MS with preserved EF (> 50%) and sinus rhythm. Healthy individuals without structural heart disease were included as a control group. Global LV myocardial work efficiency was estimated with a proprietary algorithm from speckle-tracking strain analyses, as well as noninvasive blood pressure measurements. RESULTS: A total of 45 individuals with isolated severe rheumatic MS with sinus rhythm and 45 healthy individuals were included. In healthy individuals without structural heart disease, the mean global LV myocardial work efficiency was 96% (standard deviation [SD], 2), Compared with healthy individuals, median global LV myocardial work efficiency was significantly worse in MS patients (89%; SD, 4; p < 0.001) although the LVEF was similar. CONCLUSIONS: Individuals with isolated severe rheumatic MS and preserved EF, had global LV myocardial work efficiencies lower than normal controls.
RESUMO
BACKGROUND AND AIMS: Traditional cardiovascular risk factors are established predictors of heart failure (HF). However, the human gut microbiota is suggested to potentially interact with the cardiovascular system through the "gut-heart axis", which induces inflammation and contributes to HF pathogenesis. This systematic review aims to confirm the interconnection between the gut microbiome in HF patients. METHODS: Peer-reviewed human studies comparing the gut microbiota profile in adult patients with HF and healthy controls (HCs) up to April 18, 2022, were searched in Ovid MEDLINE, Ovid EMBASE, SCOPUS, and the Cochrane Library. The quality of the included studies was assessed using the Newcastle-Ottawa Scale (NOS). RESULTS: A total of nine studies, including 317 HF patients and 510 HCs, were included in the review. Decreased gut microbiota richness and similar microbial diversity (alpha diversity), and significantly different gut microbiota composition (beta diversity) were observed between HF patients and HCs. In comparison to HCs, HF patients had a greater abundance of Actinobacteria, Proteobacteria, and Synergistetes phyla; Enterococcus, Escherichia, Klebsiella, Lactobacillus, Streptococcus, and Veilonella genera and Ruminococcus gnavus, Streptococcus sp., and Veilonella sp. species. In contrast, there was decreased abundance of Firmicutes phylum; Blautia, Eubacterium, Faecalibacterium, and Lachnospiraceae FCS020 genera; and Dorea longicatena, Eubacterium rectale, Faecalibacterium prausnitzii, Oscillibacter sp., and Sutterella wadsworthensis species in HF patients. CONCLUSIONS: Gut microbiota diversity, richness, and composition in HF patients differ significantly from the healthy population. Overall, short-chain fatty acid (SCFA)-producing gut microbiota was depleted in HF patients. However, different underlying comorbidities, environments, lifestyles, and dietary choices could affect gut microbiota heterogeneity.
Assuntos
Microbioma Gastrointestinal , Insuficiência Cardíaca , Adulto , Humanos , Dieta , Bactérias , Insuficiência Cardíaca/diagnóstico , InflamaçãoRESUMO
Background: Mitral regurgitation (MR) burdens the left and right ventricles with a volume or pressure overload that leads to a series of compensatory adaptations that eventually lead to ventricular dysfunction, and it is well known that in rheumatic heart disease (RHD) that the inflammatory process not only occurs in the valve but also involves the myocardial and pericardial layers. However, whether the inflammatory process in rheumatic MR is associated with ventricular function besides hemodynamic changes is not yet established. Purpose: Evaluate whether rheumatic etiology is associated with ventricular dysfunction in patients with chronic MR. Methods: The study population comprised patients aged 18 years or older included in the registry who had echocardiography performed at the National Cardiovascular Center Harapan Kita in Indonesia during the study period with isolated primary MR due to rheumatic etiology and degenerative process with at least moderate regurgitation. Results: The current study included 1,130 patients with significant isolated degenerative MR and 276 patients with rheumatic MR. Patients with rheumatic MR were younger and had a higher prevalence of atrial fibrillation and pulmonary hypertension, worse left ventricle (LV) ejection fraction and tricuspid annular plane systolic excursion (TAPSE) value, and larger left atrium (LA) dimension compared to patients with degenerative mitral regurgitation (MR). Gender, age, LV end-systolic diameter, rheumatic etiology, and TAPSE were independently associated with more impaired LV ejection fraction. Whereas low LV ejection fraction, LV end-systolic diameter, and tricuspid peak velocity (TR) peak velocity >3.4 m/s were independently associated with more reduced right ventricle (RV) systolic function (Table 3). Conclusions: Rheumatic etiology was independently associated with more impaired left ventricular function; however, rheumatic etiology was not associated with reduced right ventricular systolic function in a patient with significant chronic MR.
Assuntos
Insuficiência da Valva Mitral , Disfunção Ventricular , Humanos , Insuficiência da Valva Mitral/diagnóstico por imagem , Insuficiência da Valva Mitral/epidemiologia , Insuficiência da Valva Mitral/etiologia , Função Ventricular Direita , Ecocardiografia , Função Ventricular Esquerda , Volume SistólicoRESUMO
Purpose: On-pump coronary artery bypass graft (CABG) causes myocardial ischemia, through the cardiopulmonary bypass (CPB) and aortic cross-clamping (AoX). Glutamine supplementation protects cardiac cells during cardiac ischemia. This study analysed the correlation between cardiac index (CI), plasma troponin I, myocardial histopathology, CPB and AoX duration in low ejection fraction patients receiving glutamine and no glutamine undergoing elective on-pump CABG. Material and Methods: This was a secondary analysis of a double-blind, randomised controlled trial of 60 patients, split into control and intervention (glutamine) groups. Glutamine was administered at a dose of 0.5 g/kg/24 hours. There were 29 patients in each respective groups after a total of two patients dropped out. Results: A negative correlation (p = 0.037) was observed between CPB duration and CI at 6 hours after CPB in the glutamine group. A positive correlation (p = 0.002) was also observed between AoX duration and plasma troponin I at 6 hours after CPB in the control group. However, no correlation was observed between myocardial histopathology and plasma troponin I level at 5 minutes after CPB. Conclusion: Significant negative correlation between CPB duration and CI at 6 hours after CPB in the glutamine group, along with significant positive correlation between AoX duration and plasma troponin I level at 6 hours after CPB in the control group demonstrated the myocardial protection qualities of intravenous glutamine administration in patients with low ejection fraction undergoing elective on-pump CABG surgeries.
Assuntos
Doença da Artéria Coronariana , Isquemia Miocárdica , Humanos , Ponte Cardiopulmonar/efeitos adversos , Troponina I , Volume Sistólico , Ponte de Artéria Coronária/efeitos adversos , MiocárdioRESUMO
BACKGROUND: Despite being the oldest therapy for heart failure, the use of digoxin is still controversial due to the narrow margin of safety. In Indonesia, digoxin is still considered one of the treatments for heart failure. However, analysis of intoxication has never been reported. This study aims to analyze the occurrence of digoxin intoxication, rate of rehospitalization and one-year survival in heart failure patients under digoxin treatment. METHODS: A cross section-observational study was conducted at Harapan Kita National Cardiovascular Centre from January 2017 to December 2018 on heart failure patients who received digoxin therapy and had data on serum digoxin level. Intoxication was defined as the presence of specific ECG alteration(s), at least one extra-cardiac symptom(s) and further classified as definite (serum digoxin >2 ng/mL), probable (serum digoxin 0.91-1.99 ng/mL), or possible (serum digoxin 0.5-0.9 ng/mL). Risk factors of intoxication were analyzed by Chi-square test, and one-year survival was analyzed with Kaplan Meyer method. RESULTS: 54 of 195 patients (27.69%) were classified as having intoxication, consisting of 32 (16.41%) definite, 19 (9.74%) probable, and 3 (1.54%) possible. Renal insufficiency was revealed as a significant influencing factor of digoxin intoxication with RR 2.48 (CI 1.13-5.464, p=0.016). Overall one-year survival of patients receiving digoxin was 259 days in the intoxication group and 307 days in the non-intoxication group. One-year rehospitalization was 11.8% in patients who received digoxin and 29.2% in those without digoxin (p=0.085). CONCLUSION: The proportion of digoxin intoxication in heart failure patients was 27.69%. Renal insufficiency was revealed as a significant influencing factor of intoxication. There was a tendency of reduced hospitalization in those who received digoxin.
Assuntos
Insuficiência Cardíaca , Insuficiência Renal , Humanos , Digoxina/efeitos adversos , Readmissão do Paciente , Indonésia/epidemiologia , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/induzido quimicamente , Progressão da DoençaRESUMO
Background: Heart failure (HF) has been described as an emerging pandemic as its prevalence continues to rise with a growing and aging population. HF patients are more vulnerable to infections with higher risk of hospitalisation, morbidity, and mortality. During this COVID-19 pandemic, telemedicine has emerged as an alternative to usual out-patient care. This study aimed to systematically review available literature regarding the effect of telemedicine on mortality, health-related quality of life (HR-QoL), and hospitalisation rate of HF patients. Method: A literature search was conducted on five databases (PubMed, Medline, EMBASE, SCOPUS and Cochrane Central Database) up to 21st May 2022. Data from studies that fulfilled the eligibility criteria were collected and extracted. Included studies were critically appraised using suitable tools and extracted data were synthesized qualitatively. Results: A total of 27 studies were included in the qualitative synthesis with a total of 21,006 patients and sufficient level of bias. Reduction in the mortality rate, HF-related hospitalisation rate, and improvement in the HR-QoL were shown in most of the studies, although only some were statistically significant. Conclusions: The use of telemedicine is a promising and beneficial method for HF patients to acquire adequate health care services. Further studies in this field are needed, especially in developing countries and with standardized method, to provide better services and protections for HF patients. Telemonitoring and patient-centred partnership via interactive communication between healthcare team and patients is central to successful telemedicine implementation. PROSPERO Registration Number: CRD42021271540.
Assuntos
COVID-19 , Insuficiência Cardíaca , Telemedicina , Humanos , Idoso , Qualidade de Vida , Distanciamento Físico , Pandemias , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Telemedicina/métodosRESUMO
Background: Iron deficiency anemia (IDA) in heart failure (HF) is associated with poor functional capacity. Several studies reported the benefit of iron therapy in HF with IDA on improving functional capacity. Therefore, we attempt to investigate the effect of oral iron supplementation on functional capacity in HF patients with IDA. Results: A double blind randomized controlled trial was conducted in National Cardiovascular Center Harapan Kita Hospital Universitas Indonesia. A total of 54 HFREF patients with IDA were enrolled and randomized to either oral Ferrous Sulphate (FS) 200 mg three times a day or placebo with 1:1 ratio for 12 weeks. Primary outcome was functional capacity measured by a six-minute walk test. There were 41 participants completed the study (FS n = 22, placebo n = 19). Ferrous sulphate significantly improved functional capacity changes (46.23 ± 35 m vs -13.7 ± 46 m, p < 0.001, CI -86.8 to -33.2) compared with placebo groups respectively after 12 weeks intervention. Conclusions: Oral FS supplementation for 12 weeks significantly improved functional capacity in HF patients with IDA. Trial registration: clinicaltrials.gov, NCT02998697. Registered 14 December 2016 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02998697.
Assuntos
Anemia Ferropriva , Insuficiência Cardíaca , Humanos , Anemia Ferropriva/tratamento farmacológico , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/tratamento farmacológico , Volume Sistólico , Ferro/uso terapêuticoRESUMO
BACKGROUND: The accuracy of an artificial intelligence model based on echocardiography video data in the diagnosis of heart failure (HF) called LIFES (Learning Intelligent for Effective Sonography) was investigated. METHODS: A cross-sectional diagnostic test was conducted using consecutive sampling of HF and normal patients' echocardiography data. The gold-standard comparison was HF diagnosis established by expert cardiologists based on clinical data and echocardiography. After pre-processing, the AI model is built based on Long-Short Term Memory (LSTM) using independent variable estimation and video classification techniques. The model will classify the echocardiography video data into normal and heart failure category. Statistical analysis was carried out to calculate the value of accuracy, area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratio (LR). RESULTS: A total of 138 patients with HF admitted to Harapan Kita National Heart Center from January 2020 to October 2021 were selected as research subjects. The first scenario yielded decent diagnostic performance for distinguishing between heart failure and normal patients. In this model, the overall diagnostic accuracy of A2C, A4C, PLAX-view were 92,96%, 90,62% and 88,28%, respectively. The automated ML-derived approach had the best overall performance using the 2AC view, with a misclassification rate of only 7,04%. CONCLUSION: The LIFES model was feasible, accurate, and quick in distinguishing between heart failure and normal patients through series of echocardiography images.
Assuntos
Inteligência Artificial , Insuficiência Cardíaca , Estudos Transversais , Ecocardiografia/métodos , Insuficiência Cardíaca/diagnóstico por imagem , Humanos , UltrassonografiaRESUMO
Background: Plasma volume (PV) expansion hallmarks the syndrome of heart failure (HF) but is difficult to be quantified noninvasively. Estimated plasma volume status (ePVS) has marked prognostic utility in the failing left heart, however its use in right heart failure (RHF) remains unknown. This study aims to investigate the prognostic value of ePVS among isolated RHF patients. Methods: We retrospectively collected 208 patients admitted for RHF in our hospital from the electronic database from 2017 to 2019. ePVS was calculated using the Hakim formula. Patients were divided into low and high groups based on their PV value. Logistic regression was used to compare the odds of in-hospital mortality between these groups. Results: The overall in-hospital mortality was 12.5%, tripled from the low group to the high group (6.7% vs. 18.3%), within a median of 6 (3-19) days. High ePVS significantly predicted mortality in RHF, even after being adjusted for demographic, hemodynamic, chemistry, and medication variables (adjusted OR: 5.83, 95% CI: 1.62-20.95, p < 0.01). Conclusion: ePVS is associated with in-hospital mortality among isolated RHF patients. Given not only the wide accessibility of hemogram but also the low cost and the rapid quantification of relative PV, this simple tool can potentially aid in optimizing RHF management, especially in rural area, although further evaluation is warranted.
Assuntos
Insuficiência Cardíaca , Volume Plasmático , Humanos , Indonésia/epidemiologia , Prognóstico , Estudos RetrospectivosRESUMO
Purpose: Myocardial injury due to on-pump coronary artery bypass grafting (CABG) in patients with low ejection fraction (EF) is associated with poor outcomes. This study determines whether intravenous glutamine could protect the myocardium during on-pump CABG in patients with low EF. Materials and Methods: This was a double-blind, randomized controlled trial to assess glutamine as a myocardial protector during on-pump CABG in patients with left ventricle EF of 31-50%, conducted from January to October 2021. Patients in the glutamine group (n = 30) received 0.5 g/kg of 20% glutamine solution diluted with 0.9% NaCl up to 500 mL in total volume over a period of 24 hours. Patients in the control group (n = 30) received 0.9% NaCl over the same period. The primary outcomes were plasma troponin I and plasma glutamine levels. Secondary outcomes included α-ketoglutarate (α-KG) levels and histopathology scoring of the right atrial appendage tissue, plasma lactate levels, hemodynamic measurement, and morbidity. Results: Twenty-nine patients from each group (58 in total) were included in the analysis. Plasma troponin I levels at 6 and 24 hours after cardiopulmonary bypass (CPB) were significantly lower in the glutamine than the control group (mean 3.43 ± 1.51 ng/mL vs mean 4.41 ± 1.89 ng/mL; p = 0.034; median 3.08 ng/mL [min-max: 1.30-6.59] vs median 3.77 ng/mL [min-max: 0.00-36.53]; p = 0.038, respectively). Plasma glutamine levels at 24 hours after CPB were significantly higher in the glutamine than the control group (mean 935.42 ± 319.10 µmol/L vs mean 634.79 ± 243.89 µmol/L, p = 0.001). Plasma lactate levels at 6 and 24 hours after CPB were significantly lower in the glutamine than the control group (median 5.30 mmol/L [min-max: 1.20-9.50] vs median 5.70 mmol/L [min-max: 2.80-11.30], p = 0.042; mean 2.08 ± 0.67 mmol/L vs mean 2.46 ± 0.69 mmol/L, p = 0.044, respectively). Myocardial injury score was significantly lower in the glutamine than the control group (mean 1.30 ± 0.24 vs mean 1.48 ± 0.26, p = 0.011). Conclusion: Perioperative administration of 0.5 g/kg intravenous glutamine solution over the period of 24 hours has myocardial protection effect in patients with low EF who undergo elective on-pump CABG.
Assuntos
Glutamina , Troponina I , Ponte de Artéria Coronária/efeitos adversos , Humanos , Ácido Láctico , Miocárdio/patologia , Solução Salina , Volume SistólicoRESUMO
Background: Although there have been several studies investigating prognostic factors for mortality in COVID-19, there have been lack of studies in low- and middle-income countries, including Indonesia. To date, the country has the highest mortality rate among Asian countries. Objective: We sought to identify the prognostic factors of mortality in hospitalized patients with COVID-19 in Jakarta. Methods: In this retrospective cohort study, we included all adult inpatients (≥18 years old) with confirmed COVID-19 from Koja General Hospital (North Jakarta, Indonesia) who had been hospitalized between March 20th and July 31st, 2020. Demographic, clinical, laboratory, and radiology data were extracted from the medical records and compared between survivors and non-survivors. Univariate and multivariate logistic regression analysis were used to explore the prognostic factors associated with in-hospital death. Results: Two hundred forty-three patients were included in the study, of whom 32 died. Comorbid of hypertension (OR 3.59; 95% CI 1.12-11.48; p = 0.031), obesity (OR 6.34; 95% CI 1.68-23.98; p = 0.007), immediate need of HFNC and/or IMV (OR 64.93; 95% CI 11.08-380.61; p < 0.001), abnormal RDW (OR 3.68; 95% CI 1.09-12.34; p = 0.035), ALC < 1,000/µL (OR 3.51; 95% CI 1.08-11.44; p = 0.038), D-dimer > 500 ng/mL (OR 9.36; 95% CI 1.53-57.12; p = 0.015) on admission, as well as chloroquine treatment (OR 3.61; 95% CI 1.09-11.99; p = 0.036) were associated with greater risk of overall mortality in COVID-19 patients. The likelihood of mortality increased with increasing number of prognostic factors. Conclusion: The potential prognostic factors of hypertension, obesity, immediate need of HFNC and/or IMV, abnormal RDW, ALC < 1,000/µL, D-dimer > 500 ng/mL, and chloroquine treatment could help clinicians to identify COVID-19 patients with poor prognosis at an early stage.
Assuntos
COVID-19 , Doenças Cardiovasculares , Adolescente , Adulto , Mortalidade Hospitalar , Humanos , Indonésia/epidemiologia , Morbidade , Prognóstico , Estudos RetrospectivosRESUMO
The natural history of coronary heart disease (CAD) commonly begins with atherosclerosis, progressing to chronic coronary syndrome (CCS), acute coronary syndrome (ACS), and eventually, heart failure. Despite advancements in preventive and therapeutic strategies, there is room for further cardiovascular risk reduction. Recently, inflammation has emerged as a potential therapeutic target. The neutrophil-to-lymphocyte ratio (NLR) is a novel inflammatory biomarker which predicts poor prognosis in several conditions such as metabolic syndrome, sepsis, malignancy and CAD. In atherosclerosis, a high NLR predicts plaque vulnerability and severe stenosis. This is consistent with observations in CCS, where an elevated NLR predicts long-term major adverse cardiac events (MACEs). In ACS patients, high NLR levels are associated with larger infarct sizes and poor long-term outcomes. Possible reasons for this include failure of fibrinolysis, ischemia-reperfusion injury and in-stent restenosis, all of which are associated with raised NLR levels. Following myocardial infarction, an elevated NLR correlates with pathological cardiac remodeling which propagates chronic heart failure. Finally, in heart failure patients, an elevated NLR predicts long-term MACEs, mortality, and poor left ventricular assist device and transplant outcomes. Further studies must evaluate whether the addition of NLR to current risk-stratification models can better identify high-risk CAD patients.
Assuntos
Doença da Artéria Coronariana/sangue , Linfócitos/classificação , Neutrófilos/classificação , Idoso , Doença da Artéria Coronariana/complicações , Feminino , Humanos , Contagem de Leucócitos/métodos , Contagem de Leucócitos/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Fatores de RiscoRESUMO
INTRODUCTION: Acute coronary syndrome (ACS) patients residing in rural areas are predisposed to higher risk of poor outcomes due to substantial delays in disease management, emphasising the importance of emerging telecardiology technologies in delivering emergency services in such settings. This meta-analysis aimed to investigate the impacts of prehospital telecardiology strategies on the clinical outcomes of rural ACS patients. METHODS: A literature search was performed of articles published up to April 2020 through six databases. Included studies were assessed for bias risk using the ROBINS-I tool, and a random-effects model was utilised to estimate effect sizes. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). RESULTS: Twelve studies with a total of 3989 patients were included in this review. Prehospital telecardiology in the form of tele-electrocardiography (tele-ECG) enabled prompt diagnosis and triage, resulting in a decreased door-to-balloon (DTB) time (mean difference = -25.53 minutes, 95% confidence interval (CI) -36.08 to -14.97 minutes; I2 = 98%), as well as lower in-hospital mortality (odds ratio (OR) = 0.57, 95% CI 0.36-0.92) and long-term mortality (OR = 0.52, 95% CI 0.39-0.69) rates, both with negligible heterogeneity (I2 = 0%). GRADE assessment yielded very low to moderate certainty of evidence.Conclusion Prehospital tele-ECG appeared to be an effective and worthwhile approach in the management of rural ACS patients, as shown by moderate quality evidence on lower long-term mortality. Given the uncertainties of the evidence quality on DTB time and in-hospital mortality, future studies with a higher quality of evidence are required to confirm our findings.
Assuntos
Síndrome Coronariana Aguda , Serviços Médicos de Emergência , Telemedicina , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/terapia , Eletrocardiografia/métodos , Serviços Médicos de Emergência/métodos , Humanos , Telemedicina/métodos , Triagem/métodosRESUMO
Background: Heart failure remains a considerable burden to healthcare in Asia. Early intervention, mainly using echocardiography, to assess cardiac function is crucial. However, due to limited resources and time, the procedure has become more challenging during the COVID-19 pandemic. On the other hand, studies have shown that artificial intelligence (AI) is highly potential in complementing the work of clinicians to diagnose heart failure accurately and rapidly. Methods: We systematically searched Europe PMC, ProQuest, Science Direct, PubMed, and IEEE following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and our inclusion and exclusion criteria. The 14 selected works of literature were then assessed for their quality and risk of bias using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies). Results: A total of 2105 studies were retrieved, and 14 were included in the analysis. Five studies posed risks of bias. Nearly all studies included datasets in the form of 3D (three dimensional) or 2D (two dimensional) images, along with apical four-chamber (A4C) and apical two-chamber (A2C) being the most common echocardiography views used. The machine learning algorithm for each study differs, with the convolutional neural network as the most common method used. The accuracy varies from 57% to 99.3%. Conclusions: To conclude, current evidence suggests that the application of AI leads to a better and faster diagnosis of left heart failure through echocardiography. However, the presence of clinicians is still irreplaceable during diagnostic processes and overall clinical care; thus, AI only serves as complementary assistance for clinicians.
RESUMO
BACKGROUND AND AIM: The coronavirus disease 2019 pandemic has brought deteriorating physical and mental burdens to health care workers (HCWs) in Indonesia, mainly attributed to the lack of protection and screening among HCWs, patients' concealment of their travel and medical history, and perceived social stigma and discrimination. Hence, we deliver our perspectives and recommendations based on the current situation in Indonesia to enforce their safeties. We encourage stakeholders to implement a systematic approach by employing stringent prevention strategies, ensuring adequate personal protective equipment (PPE) provision and equitable PPE distribution, and routine HCWs screening to prevent nosocomial clusters, in addition to the provision of psychosocial support to HCWs by offering social aids and psychological sessions. Furthermore, social stigma and discrimination toward HCWs and patients should also be addressed and mitigated, thus preventing concealments of patients' history and alleviating emotional burdens. We believe that providing continuous support to HCWs would lead to key benefits in ensuring a winning battle against the COVID-19 pandemic. RELEVANCE FOR PATIENTS: HCWs are pivotal players in winning the battle against the COVID- 19 pandemic. Ensuring their safety and well-being will enable them to deliver better healthcare services, thus resulting in mutual benefit for themselves, the patients, and the nation's recovery.
RESUMO
Coronavirus disease 2019 infection has spread worldwide and causing massive burden to our healthcare system. Recent studies show multiorgan involvement during infection, with direct insult to the heart. Worsening of the heart function serves as a predictor of an adverse outcome. This finding raises a particular concern in high risk population, such as those with history of preexisting heart failure with or without implantable device. Lower baseline and different clinical characteristic might raise some challenge in managing either exacerbation or new onset heart failure that might occur as a consequence of the infection. A close look of the inflammatory markers gives an invaluable clue in managing this condition. Rapid deterioration might occur anytime in this setting and the need of cardiopulmonary support seems inevitable. However, the use of cardiopulmonary support in this patient is not without risk. Severe inflammatory response triggered by the infection in combination with the preexisting condition of the worsening heart and implantable device might cause a hypercoagulability state that should not be overlooked. Moreover, careful selection and consideration have to be met before selecting cardiopulmonary support as a last resort due to limited resource and personnel. By knowing the nature of the disease, the interaction between the inflammatory response and different baseline profile in heart failure patient might help clinician to salvage and preserve the remaining function of the heart.
RESUMO
Recent advances in the diagnosis and management of pulmonary arterial hypertension (PAH) have led to a significant improvement in the outcomes for patients with PAH. However, prompt and accurate diagnosis of PAH remains an unmet challenge due to lack of awareness and lack of meticulous data to profile the etiology and pathophysiology of this rare progressive disease, especially in low- and middle-income country. In Indonesia, the true prevalence and incidence of different subtypes of PAH in general population is still unknown. The Congenital HeARt Disease in adult and Pulmonary Hypertension (COHARD-PH) registry was the first single-center prospective registry in Indonesia, which indicated that almost 80% of adult patients with congenital heart disease (CHD) had experienced PAH and even Eisenmenger syndrome due to delayed diagnosis. Screening for early detection of asymptomatic CHD in children is yet to be systematically established in Indonesia, leading to undiagnosed and uncorrected CHD in adulthood. There are no specific national guidelines focusing on diagnostic workup and treatment of PAH in Indonesia. Furthermore, the lack of adequate diagnostic facilities, limited treatment availability, and limited drug coverage under the National Health Insurance Scheme are key issues that remain unaddressed. This review focuses on the diagnosis, treatment, and management of PAH associated with CHD in Indonesia as per international guidelines. We have proposed recommendations to effectively control and prevent PAH associated with CHD in Indonesia. The paper should be of interest to readers in the area of medical management and policy makers especially in low- and middle-income countries. Key Highlights: Pulmonary arterial hypertension (PAH) is a rare progressive subtype of pulmonary hypertension with poor overall prognosis and outcomes.Prompt and accurate diagnosis of PAH remains an unmet challenge in low- and middle-income countries due to poor knowledge about the etiology and pathophysiology of this syndrome. Also, the symptoms and signs of early-stage PAH are usually nonspecific or undetectable in newborn and infants, thus presenting a challenge for physicians to establish early diagnoses of PAH.The challenging factors in low- and middle-income countries, especially Indonesia archipelago are limitations of healthcare infrastructure, limited expertise, lack of awareness, lack of timely PAH screening strategies, poor antenatal care and unpredictable availability of PAH medications.There are no specific national guidelines focusing on diagnostic workup and treatment of PAH in Indonesia. Under-utilization of treatment guidelines and lack of adequate diagnostic treatment facilities have resulted in sub-optimal management of PAH patients in Indonesia.Adherence to international guidelines is an important aspect of PAH management in Indonesia. Updated disease and functional classifications of PAH as per international guidelines along with new research findings on prognostic factors can help in making better management decisions for PAH patients at different stages of the disease.