Role of renin-angiotensin-aldosterone system inhibitors in heart failure and chronic kidney disease.

Renin-angiotensin-aldosterone system (RAAS) inhibitors are the key medications for patients with heart failure and chronic kidney disease. Multiple randomized controlled trials have demonstrated their benefits in an outpatient setting for the treatment of chronic heart failure. Additional advantages in acute heart failure treatment during inpatient hospitalization are less clear but a small number of non-randomized studies have favored their use. Conditions that result in stoppage of RAAS inhibitors during inpatient stay are an increase in serum creatinine, hyperkalemia, and hemodynamic instability such as hypotension. The role of RAAS inhibitors in chronic kidney disease has also been documented in multiple randomized controlled trials, with their use in hypertension and proteinuria being unambiguous. This narrative review summarizes the role of RAAS inhibitors in acute and chronic heart failure and chronic kidney disease.

Current Overview on Hypercoagulability in COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has brought many unique pathologies, such as coagulopathy, prompting a desperate need for effective management. COVID-19-associated coagulopathy (CAC) can cause various thromboembolic complications, especially in critically ill patients. The pathogenesis is likely due to endothelial injury, immobilization, and an increase in circulating prothrombotic factors. Data on treatment are limited, although prophylactic anticoagulation is advised in all hospitalized patients. Herein, we have comprehensively reviewed the current literature available on CAC and highlight the pathogenesis, clinical features, and management of CAC.

Chest Physiotherapy in Acute Muco-obstructive Lung Disease.

Acute mucus plugging is a pulmonary emergency associated with increased mortality and often requires rapid bronchoscopic intervention which may not be readily available in all centers. Furthermore, the role and efficacy of alternate conventional measures such as mechanical percussive therapies are uncertain. Herein, we present a patient who rapidly progressed to respiratory distress; a chest X-ray revealed left lobar atelectasis highly suggestive of acute mucus plugging. In the absence of rapid bronchoscopic intervention, bedside chest percussion was initiated with improvement in clinical status. Our case demonstrates the successful utilization of chest physiotherapy in the resolution of acute mucus plugging in an urgent situation and highlights the need for careful attention to respiratory status in high-risk patients who are also undergoing fluid removal with dialysis therapies.

Continuation of Chronic Heart Failure Therapies During Heart Failure Hospitalization - a Review.

Randomized controlled trials have demonstrated the benefits of guideline-directed medical therapy in the outpatient setting for treatment of chronic heart failure. However, the benefits of continuation (or discontinuation) of major chronic heart failure therapies when treating acute heart failure during hospitalization are less clear. Real and anticipated worsening renal function, hyperkalemia and hypotension are the three major reasons for discontinuation of renin-angiotensin-aldosterone system inhibitors during hospitalization, and a failure to resume renin-angiotensin-aldosterone system inhibitors before discharge could worsen cardiovascular outcomes. Available data, mostly observational, shows that continuation or initiation of renin-angiotensin-aldosterone system inhibitors appears efficacious, safe, and well tolerated in majority of acute heart failure patients during hospitalization. Worsening renal function portends poor prognosis only if associated with congestion in acute heart failure, and clinicians should not de-escalate diuretic therapy routinely for worsening renal function.

Static pressures, intra-access blood flow and dynamic Kt/V profiles in the prediction of dialysis access function.

BACKGROUND: Hemodialysis machine-generated circuit pressures and clearance profiles are potential predictors of quality assurances. In our practice, we previously we observed that elevated static access pressures were associated with abnormal Kt/V values, high access recirculation and deviation of the Kt/V profile (Abnormal Kt/V profile) from normally expected values (Normal Kt/V profile). AIM: To hypothesize that static or derived access pressures would correlate with direct intra-access blood flow rates and that clearance (Kt/V) profiles would correlate with measured Kt/V values. METHODS: Static access pressures, real-time adequacy of dialysis and intra-access blood flow were investigated in end stage renal disease patients undergoing hemodialysis. Wilcoxon-Mann-Whitney test, chi-square test or Fisher's exact test was used to investigate differences between the groups; Spearman's rank correlation test to investigate relationships between static pressures, direct intra-access pressures and Kt/V profiles; and multinomial logistic regression models to identify the independent effect of selected variables on Kt/V profiles. Odds ratio were calculated to measure the association between the variables and Kt/V profiles. RESULTS: One hundred and seven patients were included for analysis. There were no significant differences between genders, and types of vascular access between the normal vs. abnormal clearance (Kt/V) profile groups. No significant correlation could be demonstrated between static access pressures and Kt/V profiles, static access pressures and intra-access blood flow, intra-access blood flow and Kt/V profiles, measured Kt/V and Kt/V profiles or recirculation and Kt/V profiles. CONCLUSION: In this study utilizing measured versus estimated data, we could not validate that dialysis machine generated elevated static pressures predict intra-access blood flow disturbances or that abnormal Kt/V profiles predict access recirculation or inadequate dialysis. These parameters, though useful estimates, cannot be accepted as quality assurance for dialysis adequacy or access function without further evidences.

Office orthostatic blood pressure measurements and ambulatory blood pressure monitoring in the prediction of autonomic dysfunction.

BACKGROUND: In this retrospective analysis we investigated the predictive performance of orthostatic hypotension (OH) and ambulatory blood pressure monitoring (ABP) to predict autonomic dysfunction. METHODS: Statistical associations among the candidate variables were investigated and comparisons of predictive performances were performed using Receiver Operating Characteristics (ROC) curves. RESULTS: Ninety-four patients were included for analysis. No significant correlations could be demonstrated between OH and components of ABP (reversal of circadian pattern, postprandial hypotension and heart rate variability), nor between OH and autonomic reflex screen. Reversal of circadian pattern did not demonstrate significant correlation (r = 0.12, p = 0.237) with autonomic reflex screen, but postprandial hypotension (r = 0.39, p = 0.003) and heart rate variability (r = 0.27, p = 0.009) demonstrated significant correlations. Postprandial hypotension was associated with a five-fold (OR 4.83, CI95% 1.6-14.4, p = 0.005) increased risk and heart rate variability with a four-fold (OR 3.75, CI95% 1.3-10.6, p = 0.013) increased risk for autonomic dysfunction. Per ROC curves, heart rate variability (0.671, CI95% 0.53-0.81, p = 0.025) and postprandial hypotension (0.668, CI95% 0.52-0.72, p = 0.027) were among the best predictors of autonomic dysfunction in routine clinical practice. CONCLUSION: Postprandial hypotension and heart rate variability on ambulatory blood pressure monitoring are among the best predictors of autonomic dysfunction in routine clinical practice.

Fluid balance as an early indicator of acute kidney injury in CV surgery.

BACKGROUND: We hypothesized that positive fluid balance (FB) is the result of intraoperative kidney injury and associated renal vasoconstriction, and therefore may be an early clinical indicator of acute kidney injury (AKI). Since rapid changes in fluid volume occur during cardiovascular (CV) surgery, we investigated the influence of immediate postoperative FB on AKI. MATERIALS AND METHODS: Data from the Nesiritide Study were retrospectively analyzed to investigate the association between FB and AKI. RESULTS: Patients were classified into a negative FB (NegFB, median -1,221 ml, IQR -1,974 to -653 ml, n = 71) and a PosFB (median 849 ml, IQR 328 - 1,552 ml, n = 19) group based on FB status in the first 24 h postoperatively. The PosFB group had a higher incidence of AKI (NegFB 25.3% vs. PosFB 47.3%, p = 0.090) compared to the NegFB group. The difference in the incidence of AKI was significantly higher (NegFB 25.3% vs. high- PosFB 80%, p = 0.001) in the subset of patients who had FB ≥ 849 ml (highPosFB, n = 10). The highPosFB group demonstrated a significantly elevated risk for AKI in both unadjusted (OR = 9.8, 95% CI 1.9 - 51.2, p = 0.007) and multivariate models (OR = 8.1, 95% CI 1.5 - 45.1, p = 0.03). CONCLUSIONS: PosFB in the immediate postoperative period may be an independent early indicator of AKI in patients undergoing CV surgery.