Acute heart failure - an EFIM guideline critical appraisal and adaptation for internists.

BACKGROUND: Over the past two decades, several studies have been conducted that have tried to answer questions on management of patients with acute heart failure (AHF) in terms of diagnosis and treatment. Updated international clinical practice guidelines (CPGs) have endorsed the findings of these studies. The aim of this document was to adapt recommendations of existing guidelines to help internists make decisions about specific and complex scenarios related to AHF. METHODS: The adaptation procedure was to identify firstly unresolved clinical problems in patients with AHF in accordance with the PICO (Population, Intervention, Comparison and Outcomes) process, then conduct a critical assessment of existing CPGs and choose recommendations that are most applicable to these specific scenarios. RESULTS: Seven PICOs were identified and CPGs were assessed. There is no single test that can help clinicians in discriminating patients with acute dyspnoea, congestion or hypoxaemia. Performing of echocardiography and natriuretic peptide evaluation is recommended, and chest X-ray and lung ultrasound may be considered. Treatment strategies to manage arterial hypotension and low cardiac output include short-term continuous intravenous inotropic support, vasopressors, renal replacement therapy, and temporary mechanical circulatory support. The most updated recommendations on how to treat specific patients with AHF and certain comorbidities and for reducing post-discharge rehospitalization and mortality are provided. Overall, 51 recommendations were endorsed and the rationale for the selection is provided in the main text. CONCLUSION: Through the use of appropriate tailoring process methodology, this document provides a simple and updated guide for internists dealing with AHF patients.

Point­of­Care Ultrasound in internal medicine.

Point-of-Care ultrasound (POCUS) is bedside ultrasound examination performed by a clinician. POCUS is a suitable tool for rapid diagnosis and monitoring of the condition of many patients examined by internists in emergency departments and inpatient departments. POCUS allows the examining physician to supplement the physical examination with additional information obtained in real time, and is a useful tool for differential diagnosis of a number of acute conditions (shock, shortness of breath, etc.). Chest POCUS includes an indicative assessment of cardiac function and evaluation of the lung parenchyma, including exclusion of pericardial effusion, pneumothorax or fluidothorax. One of the most common applications of POCUS is to assess the state of the venous filling by examining the inferior vena cava. When examining the abdomen, the internist should at least be able to diagnose fluid in the abdominal cavity and exclude congestion in the hollow system of the kidney. POCUS for internists also includes examination of main venous trunks to rule out proximal venous thrombosis. Even when performing conventional invasive procedures, we cannot do without ultrasound at the bedside, whether it is a puncture of ascites or pleural effusion, or cannulation of the central vein. The advantage of POCUS is the immediate availability of the examination and the possibility to repeat scans when needed for monitoring the patient's condition.

How much POCUS for Czech internists?

The introduction of point-of-care ultrasonography into practice in internal medicine and subsequently into the educational program for our specialty brought the need to define a curriculum for training in this method. We solve the question of "what to teach" - i.e. what core ultrasound competencies internists should learn for their practice. It is also necessary to define the procedure "how to teach" - the form and content of the education program, what the basic course should contain, and above all how the subsequent training should take place in practice. The third major problem to be solved is "who should teach", i.e. the definition of the requirements for trainers who will lead the training.

Statement of the Expert Discussion Panel of the 1st Expert Conference on Point­of­Care ultrasound.

The document summarizes the statement of the expert discussion panel of the 1st Point- of-Care Ultrasonography, which took place on 14 November 2022 in Prague and which led to the foundation of the Czech Multidisciplinary Task Force Group for standards,education and research in Point-of-Care ultrasound (Czech POCUS group).

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.

How to run an internal medicine department: head physician - trainer.

Internal medicine is the core medical discipline that is responsible for the care of adults with complex illness. Therefore, the preparation for the internal medicine specialty is demanding and requires close cooperation of trainees with the educational supervisor, who is usually the head of the internal medicine department. In addition to his medical work, the head of the department is also director of the training programme. Educational activities should have their allocated time, and all doctors who act as trainers should recognise their responsibility to participate in the postgraduate training of future physicians. Comprehensive assessment of trainees progress must be an integral part of the training programme. Almost one quarter of trainees fail board certification in internal medicine. Training institutions offering postgraduate education in internal medicine should focus on to improve their performance.

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.

Worse prognosis of real-world patients with acute heart failure from the Czech AHEAD registry in comparison to patients from the RELAX-AHF trial.

AIMS: The randomized clinical trial RELAX-AHF demonstrated a positive effect of vasodilator therapy with serelaxin in the treatment of AHF patients. The aim of our study was to compare clinical characteristics and outcomes of patients from the AHEAD registry who met criteria of the RELAX-AHF trial (relax-comparable group) with the same characteristics and outcomes of patients from the AHEAD registry who did not meet those criteria (relax-non-comparable group), and finally with characteristics and outcomes of patients from the RELAX-AHF trial. METHODS AND RESULTS: A total of 5856 patients from the AHEAD registry (Czech registry of AHF) were divided into two groups according to RELAX-AHF criteria: relax-comparable (n = 1361) and relax-non-comparable (n = 4495). As compared with the relax-non-comparable group, patients in the relax-comparable group were older, had higher levels of systolic and diastolic blood pressure, lower creatinine clearance, and a higher number of comorbidities. Relax-comparable patients also had significantly lower short-term as well as long-term mortality rates in comparison to relax-non-comparable patients, but a significantly higher mortality rate in comparison to the placebo group of patients from the RELAX-AHF trial. Using AHEAD score, we have identified higher-risk patients from relax-comparable group who might potentially benefit from new therapeutic approaches in the future. CONCLUSIONS: Only about one in five of all evaluated patients met criteria for the potential treatment with the new vasodilator serelaxin. AHF patients from the real clinical practice had a higher mortality when compared with patients from the randomized clinical trial.

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.