Integrating international policy standards in the implementation of postnatal care: a rapid review.

INTRODUCTION: International legal and political documents can assist policy-makers and programme managers in countries to create an enabling environment to promote maternal and newborn health. This review aimed to map and summarise international legal and political documents relevant to the implementation of the WHO recommendations on maternal and newborn care for a positive postnatal experience. METHODS: Rapid review of relevant international legal and political documents, including legal and political commitments (declarations, resolutions and treaties) and interpretations (general comments, recommendations from United Nations human rights treaty bodies, joint United Nations statements). Documents were mapped to the domains presented in the WHO postnatal care (PNC) recommendations; relating to maternal care, newborn care, and health systems and health promotion interventions, and by type of human right implied and/or stated in the documents. RESULTS: Twenty-nine documents describing international legal and political commitments and interpretations were mapped, out of 45 documents captured. These 29 documents, published or entered into force between 1944 and 2020, contained content relevant to most of the domains of the PNC recommendations, most prominently the domains of breastfeeding and health systems interventions and service delivery arrangements. The most frequently mapped human rights were the right to health and the right to social security. CONCLUSION: Existing international legal and political documents can inform and encourage policy and programme development at the country level, to create an enabling environment during the postnatal period and thereby support the provision and uptake of PNC and improve health outcomes for women, newborns, children and families. Governments and civil society organisations should be aware of these documents to support efforts to protect and promote maternal and newborn health.

Progress in achieving SDG targets for mortality reduction among mothers, newborns, and children in the WHO South-East Asia Region.

As we reach midway towards the 2030 Sustainable Developmental Goals (SDG), this paper reviews the progress made by the WHO South-East Asia Region (SEAR) and member countries towards achieving the SDG targets for maternal, newborn and child mortality under the regional flagship initiative. Indicators for mortality and service coverage were obtained for all countries and progress assessed in comparison to other regions and between countries. Equity analysis was conducted to focus on the impact on marginalized populations. The article also informs about the priority actions taken by the WHO SEAR office and countries in accelerating reductions in maternal, newborn and child mortality. Moving forward, the region and countries must strategize to sustain the gains made so far and also address challenges of inequities, sub-optimal quality of care, newer priorities like stillbirths, birth defects, early childhood development, and public health emergencies and adverse effects of climate change on human health.

Antenatal corticosteroids for early preterm birth: implementation strategy lessons from the WHO ACTION-I trial.

The WHO ACTION-I trial, the largest placebo-controlled trial on antenatal corticosteroids (ACS) efficacy and safety to date, reaffirmed the benefits of ACS on mortality reduction among early preterm newborns in low-income settings. We discuss here lessons learned from ACTION-I trial that are relevant to a strategy for ACS implementation to optimize impact. Key elements included (i) gestational age dating by ultrasound (ii) application of appropriate selection criteria by trained obstetric physicians to identify women with a likelihood of preterm birth for ACS administration; and (iii) provision of a minimum package of care for preterm newborns in facilities. This strategy accurately identified a large proportion of women who eventually gave birth preterm, and resulted in a 16% reduction in neonatal mortality from ACS use. Policy-makers, programme managers and clinicians are encouraged to consider this implementation strategy to effectively scale and harness the benefits of ACS in saving preterm newborn lives.

Universal screening for hyperbilirubinemia in term healthy newborns at discharge: A systematic review and meta-analysis.

Background: All term healthy neonates are screened for jaundice before hospital discharge as a standard clinical practice, but methods vary from clinical screening (visual inspection and/or risk factor assessment) to transcutaneous bilirubin (TcB) or total serum bilirubin (TSB) testing, depending on the setting. Methods: This systematic review of randomized and non-randomized studies evaluated the effectiveness of universal TcB and universal TSB screening at discharge compared to clinical screening alone for term healthy neonates. The outcomes were neonatal mortality, readmission for jaundice, severe hyperbilirubinemia (>20 mg/dL), jaundice requiring exchange transfusion, and bilirubin-induced neurological dysfunction (BIND). We searched MEDLINE via Ovid, EBM reviews, Embase, CINAHL, clinical trials databases, and reference lists of retrieved articles. Two authors separately evaluated the risk of bias, extracted data, and synthesized effect estimates using relative risk (RR) for randomized and odds ratio (OR) for non-randomized studies. Results: For universal TcB at discharge, we included one randomized trial enrolling 1858 participants and four non-randomized studies enrolling 375 956 participants. No study reported neonatal mortality. The randomized trial suggested that universal TcB at discharge may decrease readmission for jaundice (risk ratio (RR) = 0.24, 95% confidence interval (CI) = 0.13 to 0.46; low certainty evidence) and severe hyperbilirubinemia (RR = 0.27, 95% CI = 0.08 to 0.97; low certainty evidence), but the effect on jaundice requiring exchange transfusion (RR = 0.20, 95% CI = 0.01 to 41.6) and BIND (RR = 0.33, 95% CI = 0.01 to 8.17) was uncertain. Meta-analysis of non-randomized studies suggested that TcB may decrease severe hyperbilirubinemia (odds ratio (OR) = 0.25, 95% = CI 0.12 to 0.52; low certainty evidence) and jaundice requiring exchange transfusion (OR = 0.28, 95% CI = 0.19 to 0.42; low certainty evidence), but the effect on readmission for jaundice was uncertain (OR = 1.01, 95% CI = 0.38 to 2.7; very low certainty evidence). For universal TSB, we included three studies from the United States enrolling 490 426 participants. The effect on severe hyperbilirubinemia (OR = 0.37, 95% CI = 0.15 to 0.88), jaundice requiring exchange transfusion (OR = 0.53, 95% CI = 0.13 to 2.25) and readmission for jaundice (OR = 1.01, 95% CI = 0.62 to 1.67) was uncertain. Conclusions: Universal TcB at discharge may improve clinical outcomes for term healthy neonates. Evidence for universal TSB is uncertain. Registration: PROSPERO 2020 CRD42020187279.

Universal newborn eye screening: a systematic review of the literature and review of international guidelines.

Background: This systematic review assessed the effectiveness of universal screening for newborn eye abnormalities compared with no screening in improving infant vision and health outcomes. Methods: We searched CENTRAL (Cochrane Library), MEDLINE, Embase, Global Health, Global Index Medicus, clinical trials databases, and bibliographies of relevant articles. We included randomized and observational studies of all newborns, regardless of illness or risk factors, that compared universal screening for any eye abnormality by eight weeks of age with no universal screening. Two authors independently selected studies, extracted data, and evaluated the risk of bias. We used GRADE to assess the certainty of evidence. We also reviewed available recommendations on newborn eye screening. Results: Fourteen studies were identified but only three compared universal red reflex screening with no screening. Findings suggest that universal red reflex testing in maternity wards (MWs) may increase the number of newborns with congenital cataracts referred for eye care from MWs or well-baby clinics (WBCs) in the first year of life (risk ratio (RR) = 9.83, 95% confidence interval (CI) = 1.36-71.20; low certainty evidence). However, the effect of screening in WBC is uncertain (RR = 6.62, 95% CI = 0.87-50.09). The effect of MW or WBC screening on referral from any health care facility (MWs, WBCs, paediatrician clinic, other) in the first year is uncertain (MW screening: RR = 1.22, 95% CI = 0.63-2.39; WBC screening: RR = 0.97, 95% CI = 0.46-2.05). However, referral or surgery by 6 weeks of age may be higher with universal MW screening (early referral: RR = 4.61, 95% CI = 1.12-19.01; early surgery: RR = 8.23, 95% CI = 1.13-59.80; low certainty evidence). The effect of WBC screening on early referral and surgery is uncertain (early referral: RR = 1.98, 95% CI = 0.43-9.19; early surgery: RR = 3.97, 95% CI = 0.50-31.33; very low certainty evidence). Universal red reflex testing may increase clinical conjunctivitis (OR = 1.22, 95% CI = 1.01-1.47; low certainty evidence) but the effect on confirmed bacterial conjunctivitis is uncertain (OR = 1.20, 95% CI = 0.76-1.90; very low-certainty evidence). Nine guidelines recommended universal newborn eye screening using red reflex testing. Conclusions: Evidence supports the role of red reflex testing shortly after birth to increase early identification, referral, and surgery for congenital cataracts.

Effect of whole-body massage on growth and neurodevelopment in term healthy newborns: A systematic review.

Background: Infant massage is commonly practiced in many parts of the world. However, the effectiveness of this intervention has not been reviewed for term, healthy newborns. Methods: This systematic review of randomized and quasi-randomized controlled trials assessed the effect of whole-body massage with or without oil, compared to no massage in term healthy newborns. Key outcomes were neonatal mortality, systemic infections, growth, behaviour (crying or fussing time, sleep duration), and neurodevelopment. We searched MEDLINE via PubMed, Cochrane CENTRAL, EMBASE, and CINAHL (updated till November 2021), and clinical trials databases and reference lists of retrieved articles. Two authors separately evaluated the risk of bias, extracted data, and synthesized effect estimates using mean difference (MD) and standardized mean difference (SMD). The GRADE approach was used to assess the certainty of evidence. Results: We included 31 randomized and quasi-randomized trials involving 3860 participants. Infant massage was performed by different care providers starting in the neonatal period and continuing for 1-2 months in most studies. Thirteen studies reported the use of oil with body massage. No study reported neonatal mortality or systemic infections. Meta-analyses suggested that whole-body massage may increase infant length at the end of the intervention period (median assessment age 6 weeks; mean difference (MD) = 1.6 cm, 95% confidence interval (CI) = 1.4 to 1.7 cm; low certainty evidence), but the effect on weight (MD = 340 g, 95% CI = 240 to 441 g), head circumference (MD = 0.8 cm, 95% CI = 0.6 to 1.1 cm), sleep duration (MD = 0.62 hours/d, 95% CI = 0.12 to 1.12 hours/d) and bilirubin levels (MD = -31.8 mmol/L or -1.8 mg/dL, 95% CI = -23.5 to -40.0 mmol/L) was uncertain. The effect on crying/fussing time at median 3 months of age, sleep duration at 6 months of age, weight, length, and head circumference at 6-12 months follow-up, and neurodevelopment outcomes, both at the end of the intervention period and follow-up was uncertain. Conclusions: Whole-body massage may improve the infant length at the end of the intervention period (median age 6 weeks, range 1-6 months) but the effect on other short- or long-term outcomes is uncertain. There is a need for further well-designed trials in future. Registration: Priyadarshi M, Balachander B, Rao S, Gupta S, Sankar MJ. Effect of body massage on growth and neurodevelopment in term healthy newborns: a systematic review. PROSPERO 2020 CRD42020177442.

Short-term neurodevelopment and growth outcomes of very and moderate preterm Indian infants.

OBJECTIVE: To study the growth and neurodevelopmental outcome of very and moderate preterm infants (VMPT) compared to term appropriate-for-age (term AGA) infants at 18-months corrected age. METHODS: This prospective cohort study enrolled consecutively born 212 VMPT infants and 250 term AGA controls delivered during study period. OUTCOME MEASURES: Major neurodevelopmental impairment (NDI) defined as any one of cerebral palsy, motor (MoDQ) or mental developmental quotient (MoDQ) <70 on Developmental Assessment Scale for Indian infants, visual or hearing impairment, or epilepsy, and growth outcomes. RESULTS: Among 195 VMPT and 240 term AGA infants who completed follow-up, the frequency of major NDI was 12.8% and 2.5% respectively (RR 5.1; 95% CI [2.13-12.19]). Major NDI was higher among infants <28 weeks gestation (39%) and birthweight <1000 grams (27%). A quarter of VMPT infants exhibited wasting and 18% stunting than 7% each among controls. CONCLUSION: VMPT infants had a higher frequency of major NDI and growth failure at 18-months.

Timing of first bath in term healthy newborns: A systematic review.

Background: This systematic review of intervention trials and observational studies assessed the effect of delaying the first bath for at least 24 hours after birth, compared to conducting it within the first 24 hours, in term healthy newborns. Methods: We searched MEDLINE via PubMed, Cochrane CENTRAL, Embase, CINAHL (updated till November 2021), and clinical trials databases and reference lists of retrieved articles. Key outcomes were neonatal mortality, systemic infections, hypothermia, hypoglycaemia, and exclusive breastfeeding (EBF) rates. Two authors separately evaluated the risk of bias, extracted data, and synthesized effect estimates using relative risk (RR) or odds ratio (OR). The GRADE approach was used to assess the certainty of evidence. Results: We included 16 studies (two trials and 14 observational studies) involving 39 020 term or near-term healthy newborns. Delayed and early baths were defined variably in the studies, most commonly as >24 hours (six studies) and as ≤6 hours (12 studies), respectively. We performed a post-hoc analysis for studies that defined early bath as ≤6 hours. Low certainty evidence suggested that bathing the newborn 24 hours after birth might reduce the risk of infant mortality (OR = 0.46, 95% confidence interval (CI) = 0.28 to 0.77; one study, 789 participants) and neonatal hypothermia (OR = 0.50, 95% CI = 0.28-0.88; one study, 660 newborns), compared to bathing within first 24 hours. The evidence on the effect on EBF at discharge was very uncertain. Delayed bath beyond 6 hours (at or after nine, 12, or 24 hours) after birth compared to that within 6 hours might reduce the risk of hypothermia (OR = 0.47, 95% CI = 0.36-0.61; four studies, 2711 newborns) and hypoglycaemia (OR = 0.39, 95% CI = 0.23-0.66; three studies, 2775 newborns) and improve the incidence of EBF at discharge (OR = 1.12, 95% CI = 1.08-1.34; six studies, 6768 newborns); the evidence of the effect on neonatal mortality was very uncertain. Conclusion: Delayed first bath for at least 24 hours may reduce infant mortality and hypothermia. Delayed bath for at least 6 hours may prevent hypothermia and hypoglycaemia and improve EBF rates at discharge. However, most of these conclusions are limited by low certainty evidence. Registration: PROSPERO 2020 CRD42020177430.

Global newborn health research priorities identified in 2014: A review to evaluate the uptake.

Background: In 2014, World Health Organization published global research priorities for newborn health till 2025. We conducted this review to summarize completed or ongoing research on the twenty priorities. Methods: We conducted searches for twenty questions on MEDLINE via PubMed, Cochrane CENTRAL, Web of Science, clinical trial registries, and funder websites between July 2014 and May 2022. Studies addressing research questions using adequate design were included. Adequacy of uptake of a priority was assessed based on predefined criteria. Findings: The uptake of research priorities was high for 8 (40%), moderate for 11 (55%), and one priority, effectiveness of training community health workers (CHWs) to treat neonatal sepsis at home remains unaddressed. Priorities with moderate uptake include effectiveness of simplified neonatal resuscitation programme, simple clinical algorithms for CHWs to neonatal infection, CHWs training in basic neonatal resuscitation, community-initiated kangaroo mother care, perinatal audits, and novel tocolytic agents, scaling-up chlorhexidine cord application, stable surfactant with simpler administration, accurate, affordable methods to diagnose fetal distress, strategies for prevention and treatment of intrauterine growth retardation, and causal pathways for antenatal stillbirths. Interpretation: Adequate research was undertaken on pressing global concerns in newborn health. Funders and researchers should reflect on and address less researched areas. Funding: None.

Topical emollient application in term healthy newborns: A systematic review.

Background: This systematic review of randomized trials assessed the effect of emollient application compared to no emollient application in term or near-term healthy newborns. Methods: We searched MEDLINE via PubMed, Cochrane CENTRAL, Embase, and CINAHL (updated until November 2021), clinical trials databases, and reference lists of retrieved articles. Key outcomes were neonatal mortality, systemic infections, atopic dermatitis, skin condition, and adverse events. Two authors separately evaluated the risk of bias, extracted data, and synthesized effect estimates using relative risks (RR). The GRADE approach was used to assess the certainty of evidence. Results: We screened 19 243 records and included 16 eligible trials involving 5643 participants. Five trials recruited 3352 healthy newborns (term = 728; gestation ≥35 weeks = 2624); and 11 trials included 2291 term newborns who were 'at risk' for developing atopy but were otherwise healthy. We conducted a separate analysis for these two groups of newborns. Emollient application (creams or nut, seed, and vegetable oils) started in the neonatal period and continued for four weeks to two years across studies. Meta-analysis for term healthy newborns suggests that topical emollient application may have little to no effect on atopic dermatitis (RR = 1.29, 95% CI = 0.96-1.72; two trials, 1408 newborns; low certainty evidence). Effects on food allergy (RR = 0.84; 95% CI = 0.42-1.70; one trial, 233 newborns), allergic sensitization to food allergens (RR 1.31; 95% CI 1.03 to 1.68; one trial, 234 newborns) and inhalational allergens (RR = 0.97; 95% CI = 0.44, 2.14; 1 trial, 234 newborns), skin dryness (RR = 0.74, 95% CI = 0.55-1.00; two trials, 294 newborns), and skin problems (RR = 0.92, 95% CI = 0.81-1.05; two trials, 292 newborns) were uncertain. Meta-analysis for 'at-risk' newborns suggests that intervention probably lowers the risk of atopic dermatitis (RR = 0.74, 95% CI = 0.63-0.86; 11 studies, 1988 infants; moderate certainty evidence), but may have little or no effect on food allergy and allergic sensitization to food or inhalation allergens. The effect on skin dryness and skin rash was uncertain. Conclusions: Topical emollient application may not prevent atopic dermatitis in term healthy newborns. There is little data for other skin and allergic outcomes. Registration: Priyadarshi M, Balachander B, Rao S, Gupta S, Sankar MJ. Use of emollients in term healthy newborns: A systematic review. PROSPERO 2020 CRD42020177437.

Association Between Cirrhosis and 30-Day Rehospitalization After Index Hospitalization for Heart Failure.

There are limited data on clinical outcomes in patients re-admitted with decompensated heart failure (HF) with concomitant liver cirrhosis. We conducted a cross sectional analysis of the Nationwide Readmissions Database (NRD) years 2010 thru 2012. An Index admission was defined as a hospitalization for decompensated heart failure among persons aged ≥ 18 years with an alive discharge status. The main outcome was 30 - day all-cause rehospitalization. Survey logistic regression provided the unadjusted and adjusted odds of 30 - day rehospitalization among persons with and without cirrhosis, accounting for age, gender, kidney dysfunction and other comorbidities. There were 2,147,363 heart failure (HF) hospitalizations among which 26,156 (1.2%) had comorbid cirrhosis. Patients with cirrhosis were more likely to have a diagnosis of acute kidney injury (AKI) during their index hospitalization (18.4% vs 15.2%). There were 469,111 (21.9%) patients with readmission within 30 - days. The adjusted odds of a 30 - day readmission was significantly higher among patients with cirrhosis compared to without after adjusting for comorbid conditions (adjusted Odds Ratio [aOR], 1.3; 95% Confidence Interval [CI}: 1.2 to 1.4). The relative risk of 30 - day readmission among those with cirrhosis but without renal disease (aOR, 1.3; 95% CI: 1.3 to 1.3) was lower than those with both cirrhosis and renal disease (aOR, 1.8; 95% CI: 1.6 to 2.0) when compared to persons without either comorbidities. Risk of 30 - day rehospitalization was significantly higher among patients with heart failure and underlying cirrhosis. Concurrent renal dysfunction among patients with cirrhosis hospitalized for decompensated HF was associated with a greater odds of rehospitalization.

Mechanical Circulatory Support in Women.

A number of devices can now provide mechanical circulatory support (MCS) to patients with acute cardiogenic shock (CS) and chronic end-stage heart failure (HF). Women differ from men in pathophysiology and natural history of CS and HF, and are usually sicker at admission. Current evidence suggests that women benefit as much as men, if not more, from both temporary and durable MCS for appropriate indications. Yet, women have been under-represented in clinical trials of MCS devices. Limited evidence suggests that women benefit more from temporary MCS in CS associated with acute myocardial infarction. However, in patients with durable left ventricular assist devices (LVADs), women are more likely to experience thromboembolic events and right HF. This review aims to study available evidence and determine areas for further research on gender differences in (a) use of temporary MCS for CS and (b) use of durable LVADs. Use of MCS in conditions specific to, or more common in women (pregnancy, takotsubo cardiomyopathy, peripartum cardiomyopathy, and spontaneous coronary artery dissection) is also discussed.

Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries.

BACKGROUND: The safety and efficacy of antenatal glucocorticoids in women in low-resource countries who are at risk for preterm birth are uncertain. METHODS: We conducted a multicountry, randomized trial involving pregnant women between 26 weeks 0 days and 33 weeks 6 days of gestation who were at risk for preterm birth. The participants were assigned to intramuscular dexamethasone or identical placebo. The primary outcomes were neonatal death alone, stillbirth or neonatal death, and possible maternal bacterial infection; neonatal death alone and stillbirth or neonatal death were evaluated with superiority analyses, and possible maternal bacterial infection was evaluated with a noninferiority analysis with the use of a prespecified margin of 1.25 on the relative scale. RESULTS: A total of 2852 women (and their 3070 fetuses) from 29 secondary- and tertiary-level hospitals across Bangladesh, India, Kenya, Nigeria, and Pakistan underwent randomization. The trial was stopped for benefit at the second interim analysis. Neonatal death occurred in 278 of 1417 infants (19.6%) in the dexamethasone group and in 331 of 1406 infants (23.5%) in the placebo group (relative risk, 0.84; 95% confidence interval [CI], 0.72 to 0.97; P = 0.03). Stillbirth or neonatal death occurred in 393 of 1532 fetuses and infants (25.7%) and in 444 of 1519 fetuses and infants (29.2%), respectively (relative risk, 0.88; 95% CI, 0.78 to 0.99; P = 0.04); the incidence of possible maternal bacterial infection was 4.8% and 6.3%, respectively (relative risk, 0.76; 95% CI, 0.56 to 1.03). There was no significant between-group difference in the incidence of adverse events. CONCLUSIONS: Among women in low-resource countries who were at risk for early preterm birth, the use of dexamethasone resulted in significantly lower risks of neonatal death alone and stillbirth or neonatal death than the use of placebo, without an increase in the incidence of possible maternal bacterial infection. (Funded by the Bill and Melinda Gates Foundation and the World Health Organization; Australian and New Zealand Clinical Trials Registry number, ACTRN12617000476336; Clinical Trials Registry-India number, CTRI/2017/04/008326.).

Causes, Trends, and Predictors of 90-Day Readmissions After Spontaneous Coronary Artery Dissection (from A Nationwide Readmission Database).

Spontaneous coronary artery dissection (SCAD) is a frequently missed diagnosis in patients presenting with acute coronary syndrome (ACS). Our aim was to evaluate the causes, trends, and predictors of 90-day hospital readmission in patients presenting with SCAD. The Nationwide Readmissions Database (2013 to 2014) was utilized to identify patients with primary discharge diagnosis of SCAD using the International Classification of Diseases, Ninth Revision, Clinical Modification, diagnostic code 414.12. The primary outcome was 90-day readmission. Among 11,228 patients admitted with the primary diagnosis of SCAD, 2,424 patients (21.6%) were readmitted within 90 days (68% women, 82% <65 years of age). Common causes for 90-day readmission were ACS (25%), acute heart failure (11%), acute respiratory failure (7%), and arrhythmias (5%). Multivariate predictors of 90-day readmissions were hypertension, chronic obstructive pulmonary disease, peripheral arterial disease, discharge to facility and increased length of stay (LOS) during index admission. Multivariate predictors of increased healthcare-related costs were older age, female gender, discharge to facility, and increased LOS. Over half of the readmissions (52%) occurred in first 30 days after discharge. In conclusion, we found a high rate of rehospitalization among SCAD patients, particularly within the first 30 days of index hospitalization. ACS, heart failure, and acute respiratory failure were the most common reasons for readmission. Hypertension, chronic obstructive pulmonary disease, peripheral arterial disease, and increased LOS were independent predictors of readmission. Further studies are warranted to confirm these predictors of readmission in this high-risk population.

Invasive Hemodynamic Predictors of Renal Outcomes after Percutaneous Coronary Interventions.

OBJECTIVES: To determine the association of right heart invasive hemodynamic parameters with post-percutaneous coronary intervention (PCI) acute kidney injury (AKI). BACKGROUND: AKI after PCI is associated with a high morbidity and mortality. Various mechanisms are implicated in AKI after PCI. However, the association between filling pressures and invasive hemodynamic measures of right heart function with post-PCI AKI has not been described. METHODS: This is a retrospective single-center analysis of patients of who underwent simultaneous right heart catheterization (RHC) and left heart catheterization with PCI at the Einstein Medical Center, Philadelphia, between January 2010 and December 2016. We included patients who had hemodynamic parameters from the concomitant RHC as well as measurements of kidney function up to 1 month after the procedure. We excluded patients with ST elevation myocardial infarction, end-stage renal disease, cardiogenic shock, and PCI with a need for mechanical circulatory device support. Multivariate linear regression analysis was used to analyze the association between the various right ventricular hemodynamic parameters and eGFR within 1 week and 1 month after catheterization after adjusting for age, race, gender, diabetes and hypertension, contrast volume, cardiac index, and baseline eGFR. RESULTS: Right atrial (RA) pressure was inversely associated with eGFR within 1 week (ß = -1.66; 95% CI -3.06 to -0.25; p = 0.021) and 1 month after PCI (ß = -2.14; 95% CI -4.08 to -0.20; p = 0.031). CONCLUSION: Elevated RA pressure is associated with a worsening kidney function after cardiac catheterization and PCI.

Cardiorenal syndrome in heart failure with preserved ejection fraction-an under-recognized clinical entity.

Cardiorenal syndrome (CRS) results from the complex and bidirectional interaction between the failing heart and the kidneys. Limited information exists about the pathophysiology and treatment options for worsening kidney function in the setting of heart failure with preserved ejection fraction (HFpEF). This review summarizes the salient pathophysiological pathways in CRS in patients with HFpEF, with emphasis on type 1 and type 2 phenotypes, and outlines diagnostic and therapeutic strategies that are applicable in this population. Elevated central venous and intra-abdominal pressure, left ventricular hypertrophy, LV strain, RAAS activation, oxidative injury, pulmonary hypertension, and RV dysfunction play key roles in the pathogenesis of CRS in the backdrop of HFpEF. The availability of biomarkers of renal and cardiac injury offer a new dimension in accurately diagnosing and quantifying end organ damage in CRS and will improve the accuracy of goal-directed therapies in this population. Novel targeted therapies such as the development of angiotensin/neprilysin inhibitors and sodium-glucose cotransporter-2 (SGLT-2) inhibitors offer new territory in realizing potential benefits in reduction of cardio-renal adverse outcomes in this population. Future studies focusing exclusively on renal outcomes in patients with HFpEF are crucial in delivering optimal therapies in this subset of patients.

Echocardiographic and Hemodynamic Parameters Associated with Diminishing Renal Filtration among Patients with Heart Failure with Preserved Ejection Fraction.

BACKGROUND: Renal dysfunction is an important predictor of poor outcomes in patients with heart failure with preserved ejection fraction (HFpEF). Right ventricular (RV) dysfunction is implicated as one of the explanations for worsening renal function in cardiorenal syndrome. Novel right heart catheterization (RHC) parameters such as pulmonary artery pulsatility index (PAPi) and right atrial to pulmonary capillary wedge pressure ratio (RA:PCWP) have been found as predictors of RV dysfunction. However, most studies investigating these parameters have been done in the setting of myocardial infarction or left ventricular assist device implantation, with limited data on these metrics in patients with HFpEF. OBJECTIVE: The purpose of this study was to determine whether novel RHC parameters such as RA:PCWP and PAPi correlate with long-term renal outcomes among patients with HFpEF. METHODS: A retrospective single-center study of adult patients with a documented diagnosis of heart failure who had RHC was performed between January 2006 and December 2010 at Einstein Med ical Center Philadelphia. Selected patients also had a serum B-type natriuretic peptide level ≥100 pg/mL and a PCWP ≥15 mm Hg. Patients with an ejection fraction < 50%, including those with recovered ejection fraction, and end-stage renal disease were excluded. RESULTS: A total of 81 patients with a clinical diagnosis of HFpEF were identified who met the inclusion criteria. On multivariate analysis, after adjusting for age, sex, race, diabetes, hypertension, and cardiac index, PAPi was associated with long-term estimated glomerular filtration rate (eGFR) (ß = 3.43, 95% CI = 0.635-6.23, p = 0.017), and RA:PCWP showed a trend towards significance (ß = 14.81, 95% CI = -0.096-29.73, p = 0.051). The results were unchanged after further adjustment for eGFR at the time of RHC. CONCLUSION: Novel hemodynamic indices obtained by RHC may have predictive value for long-term renal dysfunction in patients with HFpEF.

Usefulness of the Echocardiographic Calcium Score to Refine Risk of Major Adverse Cardiovascular Events Beyond the Traditional Framingham Risk Score.

Echocardiographic calcifications are associated with major adverse cardiovascular events (MACE). A recently described semiquantitative Global Cardiac Calcium Score (GCCS) has been associated with mortality and stroke, with increasing scores associated with increasing risk. This score assigns points for calcium in the aortic root and valve, mitral valve and annulus, and submitral apparatus, with additional points for restricted leaflet mobility. We tested the hypothesis that the GCCS could improve prediction of MACE beyond traditional risk scores. This was a retrospective study of 216 subjects from a general echocardiography database (mean age 59 ± 15; 51% male). Follow-up was 3.8 ± 1.7 years. The Framingham Risk Score (FRS) and Pooled Cohort Equations (PCE) were applied to each patient. Mean GCCS was 3.2 ± 2. In the total cohort, GCCS predicted MACE (myocardial infarction, stroke, all-cause mortality), even after adjusting for FRS (odd ratio 1.19, p = 0.03). There were 106 subjects (49%) in the low-risk FRS group, 71 (33%) in the intermediate-risk group, and 39 (18%) in the high-risk group. GCCS ≥3 was associated with increased MACE (vs <3) in the low-risk group (p = 0.03), while GCCS <3 was associated with decreased MACE (vs ≥3) in the high-risk group (p = 0.04). When applied to the PCE risk estimate (dichotomized at <7.5% vs ≥7.5%) the GCCS similarly refined risk prediction. In conclusion, the semiquantitative GCCS appears to be a marker of additional unaccounted risk factors; it is easily applied and can further stratify risk of MACE beyond traditional FRS or PCE estimates.