Post-diuretic spot urine sodium assessment in acute heart failure: a retrospective analysis.

AIMS: To provide real-world data on post-diuretic spot urine sodium concentration (UNa) assessment in acute heart failure (AHF) and its implications for treatment. METHODS AND RESULTS: Automated query of the electronic medical record identified patients admitted to the cardiac intensive care unit of a single tertiary care hospital between November 2018 and December 2021, who received intravenous loop diuretics. Detailed manual chart review confirmed the AHF diagnosis. Stratification was performed based on whether post-diuretic UNa was assessed within 24 h of admission. AHF was confirmed in 340/380 identified patients. Post-diuretic UNa was assessed in 117 (34%), more frequently when ejection fraction was reduced and heart failure more advanced. Patients with versus without post-diuretic UNa assessment received higher doses of intravenous loop diuretics and more frequently acetazolamide and thiazide-like diuretics (p < 0.001 for all), resulting in similar urine output despite more advanced heart failure [2,488 mL (1,740-4,033 mL) vs. 2,400 mL (1,553-3,250 mL), respectively; p = 0.170]. Diuretic therapy remained more intense at discharge in the post-diuretic UNa group, with also a higher prescription rate of angiotensin-neprilysin inhibitors (p = 0.021). Serum creatinine increases/decreases were similarly frequent irrespectively from UNa assessment, with more dynamic changes observed in patients with UNa ≤ 80 mmol/L versus ≥ 81 mmol/L. After adjustments for baseline characteristics, the risk for death or heart failure readmission was similar in patients with versus without UNa assessment [HR (95%CI) = 1.43 (0.88-2.32); p = 0.150]. CONCLUSION: Post-diuretic UNa assessment in AHF was associated with more intense diuretic regimens, preserving urine output despite its use in a sicker population.

Complete atrioventricular block with diastolic mitral regurgitation due to severe lithium intoxication. A case report.

BACKGROUND: Lithium remains the first line therapy for treatment of bipolar disorder and is widely used in psychiatry despite its narrow therapeutic window. Cardiac side effects are uncommon, but when they are present, they can vary from benign repolarization changes to life threatening tachyarrhythmias as well as conduction time abnormalities. In extremely rare cases complete atrioventricular block with cardiogenic shock can be seen. METHODS: We report the clinical course and outcome of a 79-year-old patient who presented with bradyarrhythmias and a complete atrioventricular block due to severe lithium intoxication. The patient was admitted to ICU where fluid resuscitation and intermittent haemodialysis were performed. Interestingly, the cardiac ultrasound on ICU showed a diastolic mitral regurgitation which was related to the underlying complete atrioventricular block. RESULTS: After two cycles of haemodialysis lithium blood levels were normalised and 24 h later sinus rhythm was restored without any signs of atrioventricular block. The patient recovered completely. CONCLUSION: Lithium is widely used for the treatment of bipolar disorder and it can rarely lead to complete atrioventricular block. If the physician encounters a patient with a history of lithium use, who also shows cardiac arrhythmias, then lithium intoxication should always be ruled out. Haemodialysis is the treatment of choice in severe lithium intoxication. Diastolic mitral regurgitation can hint towards underlying atrioventricular conduction disturbances.

Streptococcal pharyngitis associated myocarditis (SPAM): the perfect ST-segment elevation myocardial infarction (STEMI) mimic in young individuals. A case series.

BACKGROUND: The mean prevalence of ST-segment elevation myocardial infarction (STEMI) in the absence of obstructive coronary artery disease is 5-6%, while one third of these cases is attributed to myocarditis. Streptococcal pharyngitis associated myocarditis (SPAM) is a rare form of myocarditis which appears shortly after a streptococcal pharyngitis and presents as a STEMI on the surface electrocardiogram. METHODS: We present the clinical course and outcome of two young and previously healthy individuals, diagnosed with SPAM. Both of them had a positive throat culture for streptococcus with a typical ST-segment elevation myocardial infarction (STEMI) on surface electrocardiogram. The coronary angiogram was normal, while cardiac imaging tests revealed myocarditis. The patients were treated with intravenous antibiotics and made a full clinical recovery within a couple of days. Echocardiography after discharge showed no residual ventricle wall hypokinesia. RESULTS: Streptococcal pharyngitis associated myocarditis (SPAM) presents as STEMI on surface ECG, with recent history of streptococcal pharyngitis, evidence of myocardial injury and normal epicardial coronary arteries. CONCLUSION: SPAM is an infrequent cause of myocarditis presenting as a STEMI and most commonly affects young individuals. Clinical examination and anamnesis can hint towards ongoing or recent pharyngitis whereas coronary angiography remains obligatory to exclude obstructive coronary artery disease. Positive throat culture and cardiac imaging compatible with myocarditis can confirm the diagnosis. Group A streptococcus is potentially the most frequent cause and Group B Streptococcus could be considered as a rare cause. Short-term prognosis appears to be favourable.