RESUMO
Chronic kidney disease (CKD) is a major contributor to morbidity and mortality in India. CKD often coexists with heart failure (HF), diabetes, and hypertension. All these comorbidities are risk factors for renal impairment. HF and CKD are pathophysiologically intertwined, and the deterioration of one can worsen the prognosis of the other. There is a need for safe renal pharmacological therapies that target both CKD and HF and are also useful in hypertension and diabetes. Neurohormonal activation achieved through the activation of the sympathetic nervous system (SNS), the renin-angiotensin-aldosterone system (RAAS), and the natriuretic peptide system (NPS) is fundamental in the pathogenesis and progression of CKD and HF. Angiotensin receptor neprilysin inhibitor (ARNi), sodium-glucose cotransporter 2 inhibitors (SGLT-2i), and selective ß1-blocker (B1B) bisoprolol suppress this neurohormonal activation. They also have many other cardiorenal benefits across a wide range of CKD patients with or without concomitant HF, diabetes, or hypertension. This consensus statement from India explores the place of ARNi, SGLT-2i, and bisoprolol in the management of CKD patients with or without HF and other comorbidities.
Assuntos
Antagonistas de Receptores de Angiotensina , Bisoprolol , Insuficiência Renal Crônica , Inibidores do Transportador 2 de Sódio-Glicose , Humanos , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/tratamento farmacológico , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico , Índia/epidemiologia , Bisoprolol/uso terapêutico , Antagonistas de Receptores de Angiotensina/uso terapêutico , Consenso , Antagonistas de Receptores Adrenérgicos beta 1/uso terapêuticoRESUMO
Heart failure (HF) is a global health concern that is prevalent in India as well. HF is reported at a younger age in Indian patients with comorbidity of type 2 diabetes (T2DM) in approximately 50% of patients. Sodium-glucose cotransporter-2 inhibitors (SGLT2i), originally approved for T2DM, are new guideline-recommended and approved treatment strategies for HF. Extensive evidence highlights that SGLT2i exhibits profound cardiovascular (CV) benefits beyond glycemic control. SGLT2i, in conjunction with other guideline-directed medical therapies (GMDT), has additive effects in improving heart function and reducing adverse HF outcomes. The benefits of SGLT2i are across a spectrum of patients, with and without diabetes, suggesting their potential place in broader HF populations irrespective of ejection fraction (EF). This consensus builds on the updated evidence of the efficacy and safety of SGLT2i in HF and recommends its place in therapy with a focus on Indian patients with HF.
Assuntos
Diabetes Mellitus Tipo 2 , Insuficiência Cardíaca , Inibidores do Transportador 2 de Sódio-Glicose , Humanos , Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Índia , Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/complicaçõesRESUMO
In India, heart failure (HF) is an important health concern affecting younger age groups than the western population. A limited number of Indian patients receive guideline-directed medical therapy (GDMT). Selective ß-1 blockers (BB) are one of the GDMTs in HF and play an important role by decreasing the sympathetic overdrive. The BB reduces heart rate (HR) reverse the adverse cardiac (both ventricular and atrial), vascular, and renovascular remodeling seen in HF. Bisoprolol, a ß-1 blocker, has several advantages and can be used across a wide spectrum of HF presentations and in patients with HF and comorbid conditions such as coronary artery disease (CAD), atrial fibrillation (AF), post-myocardial infarction (MI), uncontrolled diabetes, uncontrolled hypertension, and renal impairment. Despite its advantages, bisoprolol is not optimally utilized for managing HF in India. This consensus builds on updated evidence on the efficacy and safety of bisoprolol in HF and recommends its place in therapy with a focus on Indian patients with HF.
Assuntos
Antagonistas de Receptores Adrenérgicos beta 1 , Bisoprolol , Insuficiência Cardíaca , Humanos , Bisoprolol/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Índia , Antagonistas de Receptores Adrenérgicos beta 1/uso terapêutico , ConsensoRESUMO
OBJECTIVES: There is limited data regarding outcomes after in-hospital cardiac arrest among coronavirus disease 2019 patients. None of the studies have reported the outcomes of in-hospital cardiac arrest in coronavirus disease 2019 patients in the United States. We describe the characteristics and outcomes of in-hospital cardiac arrest in coronavirus disease 2019 patients in rural Southwest Georgia. DESIGN: Retrospective cohort study. SETTING: Single-center, multihospital. PATIENTS: Consecutive coronavirus disease 2019 patients who experienced in-hospital cardiac arrest with attempted resuscitation. INTERVENTIONS: Attempted resuscitation with advanced cardiac life support. MEASUREMENT AND MAIN RESULTS: Out of 1,094 patients hospitalized for coronavirus disease 2019 during the study period, 63 patients suffered from in-hospital cardiac arrest with attempted resuscitation and were included in this study. The median age was 66 years, and 49.2% were males. The majority of patients were African Americans (90.5%). The most common comorbidities were hypertension (88.9%), obesity (69.8%), diabetes (60.3%), and chronic kidney disease (33.3%). Eighteen patients (28.9%) had a Charlson Comorbidity Index of 0-2. The most common presenting symptoms were shortness of breath (63.5%), fever (52.4%), and cough (46%). The median duration of symptoms prior to admission was 14 days. During hospital course, 66.7% patients developed septic shock, and 84.1% had acute respiratory distress syndrome. Prior to in-hospital cardiac arrest, 81% were on ventilator, 60.3% were on vasopressors, and 39.7% were on dialysis. The majority of in-hospital cardiac arrest (84.1%) occurred in the ICU. Time to initiation of advanced cardiac life support protocol was less than 1 minute for all in-hospital cardiac arrest in the ICU and less than 2 minutes for the remaining patients. The most common initial rhythms were pulseless electrical activity (58.7%) and asystole (33.3%). Although return of spontaneous circulation was achieved in 29% patients, it was brief in all of them. The in-hospital mortality was 100%. CONCLUSIONS: In our study, coronavirus disease 2019 patients suffering from in-hospital cardiac arrest had 100% in-hospital mortality regardless of the baseline comorbidities, presenting illness severity, and location of arrest.
Assuntos
COVID-19/mortalidade , Reanimação Cardiopulmonar/mortalidade , Parada Cardíaca/mortalidade , Idoso , COVID-19/complicações , Feminino , Georgia , Parada Cardíaca/etiologia , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Medição de Risco , Estados UnidosRESUMO
OBJECTIVES: To investigate the incidence, characteristics, and outcomes of in-hospital cardiac arrest in patients with coronavirus disease 2019 and to describe the characteristics and outcomes for patients with in-hospital cardiac arrest within the ICU, compared with non-ICU patients with in-hospital cardiac arrest. Finally, we evaluated outcomes stratified by age. DATA SOURCES: A systematic review of PubMed, EMBASE, and preprint websites was conducted between January 1, 2020, and December 10, 2020. Prospective Register of Systematic Reviews identification: CRD42020203369. STUDY SELECTION: Studies reporting on consecutive in-hospital cardiac arrest with a resuscitation attempt among patients with coronavirus disease 2019. DATA EXTRACTION: Two authors independently performed study selection and data extraction. Study quality was assessed with the Newcastle-Ottawa Scale. Data were synthesized according to the Preferred Reporting Items for Systematic Reviews guidelines. Discrepancies were resolved by consensus or through an independent third reviewer. DATA SYNTHESIS: Eight studies reporting on 847 in-hospital cardiac arrest were included. In-hospital cardiac arrest incidence varied between 1.5% and 5.8% among hospitalized patients and 8.0-11.4% among patients in ICU. In-hospital cardiac arrest occurred more commonly in older male patients. Most initial rhythms were nonshockable (83.9%, [asystole = 36.4% and pulseless electrical activity = 47.6%]). Return of spontaneous circulation occurred in 33.3%, with a 91.7% in-hospital mortality. In-hospital cardiac arrest events in ICU had higher incidence of return of spontaneous circulation (36.6% vs 18.7%; p < 0.001) and relatively lower mortality (88.7% vs 98.1%; p < 0.001) compared with in-hospital cardiac arrest in non-ICU locations. Patients greater than or equal to 60 years old had significantly higher in-hospital mortality than those less than 60 years (93.1% vs 87.9%; p = 0.019). CONCLUSIONS: Approximately, one in 20 patients hospitalized with coronavirus disease 2019 received resuscitation for an in-hospital cardiac arrest. Hospital survival after in-hospital cardiac arrest within the ICU was higher than non-ICU locations and seems comparable with prepandemic survival for nonshockable rhythms. Although the data provide guidance surrounding prognosis after in-hospital cardiac arrest, it should be interpreted cautiously given the paucity of information surrounding treatment limitations and resource constraints during the pandemic. Further research is into actual causative mechanisms is needed.
Assuntos
COVID-19/mortalidade , COVID-19/terapia , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Mortalidade Hospitalar , Resultado do Tratamento , Causas de Morte , Humanos , IncidênciaRESUMO
BACKGROUND: Therapeutic plasma exchange (TPE) utilizes an extracorporeal circuit to remove pathologic proteins causing serious illness. When processing a patient's entire blood volume through an extracorporeal circuit, proteins responsible for maintaining hemostatic system homeostasis can reach critically low levels if replacement fluid types and volumes are not carefully titrated, which may increase complications. METHODS: The charts from 27 patients undergoing 46 TPE procedures were reviewed to evaluate the accuracy of our predictive mathematical model, utilizing the following patient information: weight, hematocrit, pre- and post-TPE factor levels (fibrinogen, n = 46, and antithrombin, n = 23), process volume and volumes of fluids (eg, plasma, albumin, and normal saline) administered during TPE and adverse events during and after TPE. RESULTS: Altogether, 25% of patients experienced minor adverse events that resolved spontaneously or with management. There were no bleeding or thrombotic complications. The mean difference between predicted and measured post-TPE fibrinogen concentrations was -0.29 mg/dL (SD ±23.0, range -59 to 37), while percent difference between measured and predicted fibrinogen concentration was 0.94% (SD ±10.8, range of -22 to 19). The mean difference between predicted and measured post-TPE antithrombin concentrations were 0.89% activity (SD ±10.0, range -23 to 14), while mean percent difference between predicted and measured antithrombin concentrations was 3.87% (SD ±14.5, range -25 to 38). CONCLUSIONS: Our model reliably predicts post-TPE fibrinogen and antithrombin concentrations, and may help optimize patient management and attenuate complications.
Assuntos
Antitrombinas/sangue , Fibrinogênio/análise , Troca Plasmática/métodos , Anticoagulantes/uso terapêutico , Automação , Hematócrito/métodos , Hemorragia/etiologia , Hemostasia , Homeostase , Humanos , Modelos Teóricos , Plasmaferese/métodos , Risco , TromboseRESUMO
BACKGROUND: Central venous access devices are commonly used in extracorporeal photopheresis, but their performance has not been systematically evaluated. The primary objective of this study was to compare pressures at various flow rates for central venous access devices in an ex vivo simulation of photopheresis. STUDY DESIGN AND METHODS: Diluted, heparinized red blood cells were circulated through central access devices in series with a photopheresis system, and pressures at several flow rates were recorded. The devices tested were the Trifusion catheter (Hickman), the Vortex single-lumen and dual-lumen ports (Angiodynamics), and the TidalPort device (Norfolk). Flow rates were also compared for silicone and polyurethane catheters and for different catheter internal diameters. RESULTS: The Vortex dual-lumen port generated pressure alarms above flow rates of 60 mL/minute. Throughout flow rates from 5 to 100 mL/minute, the Trifusion catheter and the TidalPort device operated at lower pressures than the Vortex ports. Within typical clinical flow rates, neither catheter material nor internal diameter substantially affected pressure. CONCLUSION: Central venous access devices show large differences in pressure within flow rates used routinely in clinical settings. These differences cannot be fully attributed to catheter material composition or catheter internal diameter.
Assuntos
Cateterismo Venoso Central/instrumentação , Cateteres Venosos Centrais , Fotoferese/instrumentação , Humanos , Técnicas In VitroRESUMO
BACKGROUND: Remarkable improvement in the treatment of Peripheral Arterial Disease (PAD) has led to changes in revascularization strategies from traditional open surgery to less invasive endovascular management. However, few studies are available on gender disparities in patients with PAD treated via an endovascular approach. This study was designed to analyze gender related differences with respect to in-hospital outcomes in PAD patients. METHODS: Our data was obtained from National Inpatient Sample (NIS) 2012 through 2014. We used International Classification of Diseases, 9th Revision, Clinical Modification diagnostic and procedural codes appropriate for PAD and endovascular treatment. Endovascular treatment included drug eluting stent, bare metal stent, atherectomy or angioplasty of lower extremity arteries. A propensity score matching was performed to adjust for imbalances between variables. RESULTS: Females presented late with more comorbidities and underwent more emergent/urgent procedures. After performing propensity score matched analysis, 25 758 patients were included in each group. There was no difference in in-hospital mortality between males and females in matched cohorts (2.3% vs 2.4%, P = 0.25). Acute renal failure, gangrene, infection, and composite of all complications were higher in males. Only blood transfusion was noted higher in females. CONCLUSION: This study revealed no difference in in-hospital mortality between males and females undergoing endovascular peripheral intervention. Males have a higher rate of complications compared to females which explains the higher cost of care in males. Further research with long-term follow up is needed to see if there is any difference with regards to long-term outcomes and re-admission.
Assuntos
Doença Arterial Periférica/terapia , Injúria Renal Aguda/epidemiologia , Idoso , Transfusão de Sangue/estatística & dados numéricos , Procedimentos Endovasculares , Feminino , Gangrena/epidemiologia , Inquéritos Epidemiológicos , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Fatores Sexuais , Stents , Estados Unidos/epidemiologiaRESUMO
Acquired QT prolongation can be caused by cardiac and noncardiac medications. Macrolides are known to prolong QT interval. Rarely, it can be fatal. We report a case of torsades de pointes in a patient taking clarithromycin as a part of Helicobacter pylori eradication regimen.
Assuntos
Antibacterianos/efeitos adversos , Claritromicina/efeitos adversos , Torsades de Pointes/induzido quimicamente , Antibacterianos/uso terapêutico , Claritromicina/uso terapêutico , Eletrocardiografia , Feminino , Infecções por Helicobacter/tratamento farmacológico , Humanos , Pessoa de Meia-Idade , Torsades de Pointes/diagnósticoRESUMO
BACKGROUND AND AIM OF THE STUDY: Infective endocarditis (IE) is a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD). The study aim was to evaluate the demographic, clinical, microbiological and inpatient mortality data of IE in hemodialysis patients. METHODS: Data were analyzed for all IE patients admitted to the authors' 800-bed tertiary care hospital between January 2001 and December 2014. These data included demographics, comorbidities, clinical and microbiological characteristics, echocardiographic findings, complications, outcomes, and in-patient mortality. RESULTS: A total of 296 patients, including 52 on hemodialysis, was admitted with a diagnosis of IE. The median age of patients with ESRD (28 females, 24 males) was 55.9 ± 15.47 years. The prevalences of comorbidities such as hypertension (80%) and diabetes mellitus (46%) were significantly higher in ESRD patients, whereas other comorbidities were similarly distributed in both groups. The mitral valve was the most commonly involved (55.8%), followed by aortic (21.7%), tricuspid (21.2%) and pulmonary (1.9%) valves. Staphylococcus aureus was the most common organism (40%), followed by Enterococcus sp. (13.7%), Gram-negative staphylococci (13.7%), coagulase-negative staphylococci (11.5%), and Streptococcus sp. (5.7%). Polymicrobes were found in 11.5% of patients and cultures were negative in 19%. The mean ejection fraction in these patients was 42 ± 4.19% and the mean area of vegetation was 63.5 ± 40 mm2. The in-hospital course of 11 patients was complicated by embolic events, while three patients had acute heart failure and one patient had heart block secondary to IE. A total of four patients (7.7%) died during the index hospitalization. CONCLUSIONS: IE in patients receiving chronic hemodialysis is a very frequent occurrence. Its diagnosis is complex and its presence should be considered in all hemodialysis patients with bacteremia. In the present study the etiology was shown to be multifactorial, with the mitral valve being the most commonly involved and S. aureus the most common organism.
Assuntos
Bactérias/isolamento & purificação , Endocardite Bacteriana/microbiologia , Valvas Cardíacas/microbiologia , Falência Renal Crônica/terapia , Diálise Renal , Adulto , Idoso , Bactérias/classificação , Técnicas Bacteriológicas , Comorbidade , Ecocardiografia , Endocardite Bacteriana/diagnóstico por imagem , Endocardite Bacteriana/mortalidade , Endocardite Bacteriana/terapia , Feminino , Valvas Cardíacas/diagnóstico por imagem , Mortalidade Hospitalar , Humanos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , New Jersey , Prevalência , Diálise Renal/efeitos adversos , Diálise Renal/mortalidade , Estudos Retrospectivos , Fatores de Risco , Centros de Atenção Terciária , Fatores de Tempo , Resultado do TratamentoRESUMO
ARVD/C and CPVT are rare inheritable sudden cardiac death syndromes predominantly expressed in younger individuals. ARVD/C is characterized by a progressive fibrofatty replacement of the myocardium that predisposes to ventricular tachycardia while CPVT is characterized by exercise induced bidirectional/polymorphic ventricular tachycardia (VT) and a structurally normal heart. A mutation in different genes causes these syndromes but recently, mutation in a common gene RYR2 has been associated with both disorders and it has been suggested that CPVT and ARVD/C represent a phenotypic spectrum. We present a case unique in expressing both these phenotypes.
Assuntos
Displasia Arritmogênica Ventricular Direita/complicações , Displasia Arritmogênica Ventricular Direita/diagnóstico , Eletrocardiografia/métodos , Taquicardia Ventricular/complicações , Adulto , Displasia Arritmogênica Ventricular Direita/genética , Displasia Arritmogênica Ventricular Direita/terapia , Morte Súbita Cardíaca/prevenção & controle , Diagnóstico Diferencial , Evolução Fatal , Feminino , Predisposição Genética para Doença/genética , Humanos , Taquicardia Ventricular/genética , Taquicardia Ventricular/terapiaRESUMO
BACKGROUND: The COVID-19 pandemic has claimed over 6.4 million lives globally. Finding effective medications to reduce mortality in hospitalized COVID-19 patients remains critical. No previous study has been published on the effects of statin use in a majority African American COVID-19 patient population. OBJECTIVE: This study aims to assess the relationship between in-hospital statin use and mortality in this population. METHODS: A retrospective chart review of patients diagnosed with COVID-19 from March 2020 to June 2020 admitted to the Phoebe Putney Health System in Albany, Georgia, an early epicenter of the COVID-19 pandemic, was conducted. The outcomes of 735 hospitalized COVID-19 positive patients from over 40 counties in Georgia were analyzed. The primary outcome of interest was all-cause mortality, with secondary outcomes of interest of ICU care, length of ICU stay, need for mechanical ventilator, duration of intubation, and need for dialysis. Multivariate logistic regression and Cox proportional hazards analysis were conducted to examine the effect of in-hospital statin use and mortality. RESULTS: 186 of 735 total patients were prescribed statins in-hospital. 83.8% were African American. Multivariate logistic regression found in-hospital statin use was not significantly associated with the primary outcome - all-cause mortality (p=0.23). Similar findings were seen in need for ICU care, length of ICU stay, need for mechanical ventilator, duration of intubation, and need for dialysis (p>0.05). Additionally, results from a Cox proportional hazards model found in-hospital statin use was not associated with survival time. Sensitivity analysis conducted on only African American patients validated that in-hospital statin use was not associated with all-cause mortality in these patients. Of note, immunosuppression and severe disease presentation were associated with a six-fold increase in risk of mortality and the largest decreases in survival time. CONCLUSION: It is possible statins have no mortality benefit for this patient population, but further research beyond this association study would need to be conducted to determine this conclusively. From this study, the best clinical recommendation would be to continue statins for COVID-19 patients with pre-hospital statin use and to launch a randomized clinical trial to definitively determine the efficacy of statins in the treatment of hospitalized COVID-19 patients.
Assuntos
COVID-19 , Inibidores de Hidroximetilglutaril-CoA Redutases , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Estudos Retrospectivos , Negro ou Afro-Americano , Pandemias , Hospitais , Mortalidade HospitalarAssuntos
Eletrocardiografia , Sistema de Condução Cardíaco/fisiopatologia , Frequência Cardíaca/fisiologia , Taquicardia Ventricular/fisiopatologia , Antiarrítmicos/uso terapêutico , Diagnóstico Diferencial , Humanos , Masculino , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/tratamento farmacológico , Verapamil/uso terapêutico , Adulto JovemRESUMO
BACKGROUND: Neurological symptoms are common manifestation in acute COVID-19. This includes hyper- and hypokinetic movement disorders. Data on their outcome, however, is limited. METHODS: Cases with new-onset COVID-19-associated movement disorders were identified by searching the literature. Authors were contacted for outcome data which were reviewed and analyzed. RESULTS: Movement disorders began 12.6 days on average after the initial onset of COVID-19. 92% of patients required hospital admission (mean duration 23 days). In a fraction of patients (6 of 27; 22%; 4 males/2 females, mean age 66.8 years) the movement disorder (ataxia, myoclonus, tremor, parkinsonism) was still present after a follow-up period of 7.5 ± 3 weeks. Severe COVID-19 in general and development of encephalopathy were risk factors, albeit not strong predictors, for the persistence. CONCLUSIONS: The prognosis of new-onset COVID-19-associated movement disorder appears to be generally good. The majority recovered without residual symptoms within several weeks or months. Permanent cases may be due to unmasking of a previous subclinical movement disorder or due to vascular/demyelinating damage. Given the relatively low response rate of one third only and the heterogeneity of mechanisms firm conclusions on the (long-term) outome cannot, however, be drawn.
Assuntos
COVID-19 , Transtornos dos Movimentos , Masculino , Feminino , Humanos , Idoso , COVID-19/complicações , Seguimentos , Transtornos dos Movimentos/etiologia , Fatores de Risco , Tremor/complicaçõesRESUMO
Poly(furfuryl isocyanate) (PFIC), which includes the reactive furan group, was synthesized by anionic polymerization using a sodium benzhydroxide (Na-BH), self-assembly initiator. We determined the optimum polymerization conditions by varying both the reaction time and the molar ratio of the monomer to the initiator. Block copolymer, poly(furfuryl isocyanate)-b-poly(n-hexyl isocyanate), was synthesized under optimized polymerization conditions. The PFIC was modified by Diels-Alder reactions with C60 for functionalization. Transmission electron microscopy (TEM) was used to study the self-assembly of block copolymers and modified block copolymer with C60. C60 formed highly ordered aggregates on the PFIC domains via self-assembly of the block copolymer.