Clinical assessment and management of patients with multimorbidity.

Internal medicine specialists, also known as general internal medicine specialists are specialist physicians trained to manage particularly complex or multisystem disease conditions that single-organ-disease specialists may not be trained to deal with. The management of multimorbidity, however, is often complex, and requires specific clinical skills and corresponding experience in appropriate diagnostic and therapeutic procedures. Multimorbidity is associated with a decline in many aspects of health and in consequence with an increase in hospital admissions, polypharmacy, and use of health care and social resouces. When prescribing medicine to patients with multimorbidity, all the risks and benefits, as well as possible interactions should be carefully considered. The prescription appropriateness can be assessed by validated tools like STOPP-START criteria. Beneficial part of good prescribing is deprescribing - planned and supervised process of dose reduction or withdrawal of medications that are no longer needed in the circumstances of the patient.

What is new for internists in the updated guidelines on the diagnosis and management of pulmonary embolism 2019?

The new guidelines on the diagnosis and management of pulmonary embolism developed in collaboration with the European Respiratory Society were presented on the congress od European society of cardiology in 2019. Are internists concerned, when these guidelines were presented at the congress of cardiologic society? Management of acute pulmonary embolism is less „cathlab dependent“than management of acute coronary syndromes - and pulmonary embolism patients are often treated by internists. Moreover, differential diagnosis of dyspnoea is a everyday problem solved by internists. What is new in the updated guidelines? Refinements in interpretation of Ddimer testing will help us to avoid unnecessary pulmonary angiograms. Nonvitamin K antagonist oral anticoagulants (NOACs) are now the preferred agents for treating the majority of patients with PE, both in the acute phase and over the long term, including selected patients with malignancy. Further important updates include recurrence scores and guidance on extended anticoagulation after PE. A new comprehensive algorithm is proposed for patient followup after acute PE to prevent, detect and treat late sequelae of venous thromboembolism.

Hyperuricemia treatment in acute heart failure patients does not improve their long-term prognosis: A propensity score matched analysis from the AHEAD registry.

BACKGROUND: Hyperuricemia is associated with a poorer prognosis in heart failure (HF) patients. Benefits of hyperuricemia treatment with allopurinol have not yet been confirmed in clinical practice. The aim of our work was to assess the benefit of allopurinol treatment in a large cohort of HF patients. METHODS: The prospective acute heart failure registry (AHEAD) was used to select 3160 hospitalized patients with a known level of uric acid (UA) who were discharged in a stable condition. Hyperuricemia was defined as UA ≥500 µmoL/L and/or allopurinol treatment at admission. The patients were classified into three groups: without hyperuricemia, with treated hyperuricemia, and with untreated hyperuricemia at discharge. Two- and five-year all-cause mortality were defined as endpoints. Patients without hyperuricemia, unlike those with hyperuricemia, had a higher left ventricular ejection fraction, a better renal function, and higher hemoglobin levels, had less frequently diabetes mellitus and atrial fibrillation, and showed better tolerance to treatment with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and/or beta-blockers. RESULTS: In a primary analysis, the patients without hyperuricemia had the highest survival rate. After using the propensity score to set up comparable groups, the patients without hyperuricemia had a similar 5-year survival rate as those with untreated hyperuricemia (42.0% vs 39.7%, P = 0.362) whereas those with treated hyperuricemia had a poorer prognosis (32.4% survival rate, P = 0.006 vs non-hyperuricemia group and P = 0.073 vs untreated group). CONCLUSION: Hyperuricemia was associated with an unfavorable cardiovascular risk profile in HF patients. Treatment with low doses of allopurinol did not improve the prognosis of HF patients.

Positive influence of being overweight/obese on long term survival in patients hospitalised due to acute heart failure.

BACKGROUND: Obesity is clearly associated with increased morbidity and mortality rates. However, in patients with acute heart failure (AHF), an increased BMI could represent a protective marker. Studies evaluating the "obesity paradox" on a large cohort with long-term follow-up are lacking. METHODS: Using the AHEAD database (a Czech multi-centre database of patients hospitalised due to AHF), 5057 patients were evaluated; patients with a BMI <18.5 kg/m2 were excluded. All-cause mortality was compared between groups with a BMI of 18.5-25 kg/m2 and with BMI >25 kg/m2. Data were adjusted by a propensity score for 11 parameters. RESULTS: In the balanced groups, the difference in 30-day mortality was not significant. The long-term mortality of patients with normal weight was higher than for those who were overweight/obese (HR, 1.36; 95% CI, 1.26-1.48; p<0.001)). In the balanced dataset, the pattern was similar (1.22; 1.09-1.39; p<0.001). A similar result was found in the balanced dataset of a subgroup of patients with de novo AHF (1.30; 1.11-1.52; p = 0.001), but only a trend in a balanced dataset of patients with acute decompensated heart failure. CONCLUSION: These data suggest significantly lower long-term mortality in overweight/obese patients with AHF. The results suggest that at present there is no evidence for weight reduction in overweight/obese patients with heart failure, and emphasize the importance of prevention of cardiac cachexia.

[Regional registry of pulmonary embolism]. / Regionální registr plicní embolie.

INTRODUCTION: Pulmonary embolism (PE) together with coronary heart disease and arterial hypertension are most common diseases of cardiovascular system. Due to its high mortality rate it is worth of attention. AIM: to describe characteristics of patients with PE, provide data about treatment and inpatient mortality rate. Also to identify an occurence of right-sided heart thrombi in patients with PE and efficiency/safety of thrombolytic therapy in this subpopulation. To evaluate effectiveness/importance of basic oncology screening in patients with PE (meaning efficiency of provided examinations to uncover hidden malignancy). METHODS: Our registry is based on observation of consecutive patients with PE hospitalized in our hospital (catchment area of Znojmo region, 130,000 inhabitants) since July 2011 until April 2014. We collected data about 188 patients diagnosed with acute or subacute PE by perfusion lung scan, CT angiography or typical symptoms with echocardiography findings. RESULTS: In the cohort there were 71 men (37.8%) and 117 women (62.2%), average age 66 years (16-94), 72.9% of patients were older than 60 years of age. History of thromboembolic disease was present in 37 patients (19.7%), malignancy in 36 of them (19.1%), signs of deep vein thrombosis in 36 patients (19.1%), hereditary thrombophilia in 11 (5.9%), recent injury with immobilisation in 10 (5.3%), recent surgery in 14 patients (7.4%) and atrial fibrillation in 22 patients (11.7%). Right heart thrombi were found in 3 patients (1.6%) out of 176 who were examined. Hospital mortality rate reached 5.6%, 3 months mortality rate was 9.4% (data collected from 85.1% of all patients) and 1 year mortality rate was 19.1% (data from 61.2% of all patients). An occult cancer was diagnosed during hospital stay only in 3 patients (1.6%), another 6 malignancies manifested themselves after longer period of time. Median length of hospital stay was 7 days. Thrombolysis was used in 14 patients (7.4%). Bleeding complications of anticoagulant or thrombolytic therapy occured in 4 patients (2.1%) during hospital care--epistaxis, severe haematoma of extremities with necessity of surgical treatment and haematemesis in 2 patients. Cerebral hemorrhage was not present in our cohort of patients. CONCLUSION: PE isnt rare condition, we can encounter it in various medical fields, but due to its diversity of symptoms and unclear prognosis, it continues to be serious clinical problem. Hospital mortality rate is higher in patients with PE than in those with acute coronary syndrome, which is in accordance with published data. Detection of right-sided heart thrombi is about half of that described in literature. Prevalence of dyspnoe and chest pain are consistent with reported data, but occurence of syncope and hemoptysis in our registry is far less common. Screening of occult cancer could be more effective. The therapy seems to be safe, a life threatening bleeding was not present even when thrombolysis was used.