Phaeohyphomycosis in Kidney Transplant Recipients: Highlighting the Importance of Early Recognition and Surgical Debridement.

Fungal infections are a recognized complication of immunosuppression in solid organ transplant recipients. Phaeohyphomycoses are fungal infections caused by a diverse group of dematiaceous fungi. Methods: We share the learning points from 2 Australian cases of phaeohyphomycosis secondary to Phaeacreomonium species (spp). A literature review was performed using Medline, Embase, and Google Scholar to identify this condition among kidney transplant recipients. Results: With the 2 cases reported in this article, a total of 17 cases were identified in the literature. Phaeacremonium spp is ubiquitous in humid and temperate flora, including Australia. Minor trauma is likely the source of inoculation in most cases and diagnosis is often delayed. Presently, no guidelines for management exist given the rarity of this condition. Most known cases have been treated with surgical debulking combined with long-course antifungal therapy. Conclusion: This paper describes 2 Australian cases of phaeohyphomycosis in kidney transplant recipients. A high index of suspicion, especially in the immunosuppressed, is essential for timely diagnosis in kidney transplant recipients. There are several diagnostic and therapeutic challenges that remain with this condition.

Ischemia With Nonobstructive Coronary Arteries: Insights From the ISCHEMIA Trial.

BACKGROUND: Ischemia with nonobstructive coronary arteries (INOCA) is common clinically, particularly among women, but its prevalence among patients with at least moderate ischemia and the relationship between ischemia severity and non-obstructive atherosclerosis severity are unknown. OBJECTIVES: The authors investigated predictors of INOCA in enrolled, nonrandomized participants in ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches), sex differences, and the relationship between ischemia and atherosclerosis in patients with INOCA. METHODS: Core laboratories independently reviewed screening noninvasive stress test results (nuclear imaging, echocardiography, magnetic resonance imaging or nonimaging exercise tolerance testing), and coronary computed tomography angiography (CCTA), blinded to results of the screening test. INOCA was defined as all stenoses <50% on CCTA in a patient with moderate or severe ischemia on stress testing. INOCA patients, who were excluded from randomization, were compared with randomized participants with ≥50% stenosis in ≥1 vessel and moderate or severe ischemia. RESULTS: Among 3,612 participants with core laboratory-confirmed moderate or severe ischemia and interpretable CCTA, 476 (13%) had INOCA. Patients with INOCA were younger, were predominantly female, and had fewer atherosclerosis risk factors. For each stress testing modality, the extent of ischemia tended to be less among patients with INOCA, particularly with nuclear imaging. There was no significant relationship between severity of ischemia and extent or severity of nonobstructive atherosclerosis on CCTA. On multivariable analysis, female sex was independently associated with INOCA (odds ratio: 4.2 [95% CI: 3.4-5.2]). CONCLUSIONS: Among participants enrolled in ISCHEMIA with core laboratory-confirmed moderate or severe ischemia, the prevalence of INOCA was 13%. Severity of ischemia was not associated with severity of nonobstructive atherosclerosis. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

A First Case Report of Cytomegalovirus Infection Presenting With Perianal Fistula and Abscess Formation in a Kidney Transplant Recipient.

Cytomegalovirus infection after transplant has been dramatically reduced in the modern era with improved understanding of immunosuppression and perioperative transplant care. However, cytomegalovirus syndrome with or without tissue invasive disease can still lead to significant morbidity and mortality. Several organs can be involved: most commonly, the gastrointestinal tract, liver, pancreas, lung, and the transplanted renal allograft. Postoperative cytomegalovirus colitis after renal transplant is well recognized and described, with symptoms including abdominal pain, nausea, and diarrhea. Biochemistry can demonstrate pancytopenia with a leukopenia with or without histopathology confirmation. A high index of suspicion is required for a timely diagnosis. This is the first published case report of a patient with cytomegalovirus tissue invasion presenting with a perianal fistula and abscess formation.The diagnosis and management ofthis case with a literature review is discussed.

Kidney Allograft Retrieval in Donations After Cardiac Death Following Type A0 Dissection Extending to Both Renal Origins.

Controlled organ retrieval in donors after cardiac death has been increasing in Australia to help bridge the gap in demand and supply. Donation of organs from donors with acute aortic syndrome has been scarcely reported. Several concerns exist related to ischemic insults before retrieval from malperfusion, systemic inflammatory state in dissection, and involvement of donor organ vessels that may preclude the ability of surgeons to perform successful anastomosis of healthy vessels. Here, we have described a case in which both kidneys were successfully retrieved from a donor after cardiac death who had a type A0 aortic dissection. Despite radiological malperfusion and concern about vessel integrity, donor organs were unaffected and had immediate graft function.

Long-term adjustable gastric band with resultant megaoesophagus causing cardiac compression.

Oesophageal dilatation following laparoscopic-assisted gastric banding (LAGB) is a well-described complication reported in up to 80% of LAGB patients [ 1, 2]. Severe oesophageal dilatation in addition to aperistalsis is known as megaoesophagus. Symptomatic compression cardiac compression from oesophageal dilatation as a complication of LAGB is an extremely rare complication and is presented in this case report.

Optical coherence tomography imaging of coronary atherosclerosis is affected by intraobserver and interobserver variability.

AIMS: Optical coherence tomography (OCT) has emerged as a novel imaging modality that allows plaque classification through identification of features including lipid, calcification and fibrous cap. However, subtle changes in light attenuation as the optical beam traverses the plaque in vivo are challenging to interpret and data on strength of observer agreement are minimal. Thus, we sought to assess both the intra and interobserver variability for plaque composition/classification using OCT. METHODS: OCT imaging was performed in 50 patients prior to percutaneous coronary intervention. Analysis was performed offline by two independent, experienced OCT operators. Target lesion luminal dimensions and plaque composition were assessed at minimal luminal area (MLA) and at five 1-mm longitudinal intervals proximal and distal to the MLA. An OCT thin-capped fibroatheroma (OCT-TCFA) was defined as greater than 90 degree lipid arc with minimal fibrous cap thickness less than 0.85 µm. RESULTS: Overall, 540 frames of OCT were included and exceptional consistency was seen for all measures of luminal geometry [all intraclass correlation coefficients (ICC) >0.97, P < 0.001]. Intraobserver agreements for calcification and lipid arc were strong (both ICC >0.84, P < 0.001), whereas interobserver agreement was higher for calcium (ICC 0.76) than lipid (ICC 0.69). Interobserver agreement of minimal fibrous cap thickness was moderate (ICC 0.52, 95% confidence interval 0.45-0.58, P < 0.001], but improved as cap thickness decreased. Overall, intra and interobserver agreements for OCT-defined plaque classification were strong (K = 0.86 and 0.71, respectively). CONCLUSION: Luminal dimensions and plaque compositional features identified by OCT are minimally affected by observer variability, permitting dependable plaque classification.

Does a combined procedure for cardiac surgery and thyroidectomy offer acceptable outcomes?

This best evidence topic on cardiothoracic surgery was written using a structured protocol. The question addressed was: 'in an adult patient requiring cardiac surgery, can a thyroidectomy for a large retrosternal goitre be performed with good outcomes as a combined procedure?' Of 150 papers identified through the literature search, 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, study type, patient group studied, relevant outcomes and results were tabulated. This paper includes 3 Level 4 papers and 13 case reports. All papers reported postoperative outcomes and five papers reported intraoperative outcomes. Of a total cohort of 32 patients, 25 were euthyroid prior to combined surgery. Twenty-nine of 32 thyroid surgeries were performed immediately prior to cardiac surgery in the combined procedure sequence. Post-procedural complications including transient recurrent laryngeal palsy and tracheomalacia were reported in 8 patients. There was one intraoperative death. Where reported, all patients were euthyroid on follow-up. All identified papers reported good outcomes with combined thyroidectomy and cardiac surgery.

Is low serum albumin associated with postoperative complications in patients undergoing oesophagectomy for oesophageal malignancies?

A best evidence topic was written according to a structured protocol. The question addressed was: in patients undergoing oesophagectomy for oesophageal malignancy, is low serum albumin associated with postoperative complications? Altogether, 87 papers were found using the reported search, of which 16 demonstrated the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. This paper includes 2 level 2 papers, 12 level 3 papers and 2 level 4 papers. All the papers compared either all or some of the following postoperative complications: mortality, morbidity, anastomotic leak, respiratory and non-respiratory complications, and length of hospital stay. Eleven of the 16 papers found an association between low serum albumin and postoperative complications. Of these, one study showed that low serum albumin combined with low fibrinogen levels (FA score) was predictive of postoperative recurrence of oesophageal cancer. Another study showed that when combined with white cell count and C-reactive protein (CRP, NUn score), serum albumin had a high diagnostic accuracy for major complications after postoperative day 3. The largest study compared the in-hospital mortality in 7227 patients who underwent oesophageal surgery for malignancy. The percentage of in-hospital mortality was associated with low serum albumin (<15.0 vs >35.0 g/l, 21.0 vs 11.3%, P <0.001). Five of the 16 papers found no significant association between low serum albumin and postoperative complications. Of these papers, one showed that low serum albumin was not an independent risk factor, while four others found no association between low serum albumin with respiratory complications, anastomotic leak and postoperative mortality. Instead, these studies found other factors responsible for postoperative complications such as: CRP, smoking, disease duration, malnutrition and low T-cell levels. Taken together, while low serum albumin is associated with postoperative complications, opinion regarding the prognostic value of low serum albumin and nutritional support remains conflicted. Because of the confounding factors encountered in these studies, the clinician should consider the finding of low serum albumin in patients, together with disease and surgical factors to provide optimal care for these patients.

Open surgical repair for chronic type B aortic dissection: a systematic review.

BACKGROUND: The treatment of chronic type B aortic dissection (CBAD) remains complicated. Thoracic endovascular aortic repair (TEVAR) has supplanted open surgical repair (OSR) as the preferred surgical treatment for CBAD. Despite TEVAR's superior short-term results, much less is understood about its long-term outcomes. As much of the understanding of OSR originates from historical report, contemporary series, with modern surgical techniques and technologies, may present an alternative to TEVAR. The present systematic review will assess the short- and long-term outcomes of historic and contemporary series of OSR for CBAD. METHODS: Electronic searches were performed using six databases from their inception to March 2014. Relevant studies with OSRs for chronic type B dissection were identified. Data were extracted by two independent reviewers and analyzed according to predefined clinical endpoints. Studies were sub-classified into the pre-endovascular (historic series) and endovascular era (contemporary series) depending on whether the majority of cases were performed after 1999. RESULTS: Nineteen studies were identified for inclusion for quantitative analysis. Pooled short-term mortality was 11.1% overall, and 7.5% in the nine contemporary studies. Stroke, spinal cord ischemia, renal dysfunction, and reoperation for bleeding were 5.9%, 4.9%, 8.1%, and 8.1%, respectively, for the contemporary series. Absolute late reintervention was identified in 13.3% of patients overall, and in 11.3% of patients in the contemporary series. Aggregated survival at 1-, 3-, 5-, and 10-years of all patients were 82.1%, 74.1%, 66.3%, and 50.8%, respectively. CONCLUSIONS: OSR for chronic type B dissection in the contemporary era offers acceptable results. Management approaches should be considered carefully, taking into account both short-term and long-term complications. More research is required to clarify specific indications for OSR and TEVAR in chronic type B dissections.

Atherosclerotic disease of the abdominal aorta and its branches: prognostic implications in patients with heart failure.

Aortic atherosclerosis reduces compliance in the systemic circulation and increases peripheral resistance, afterload and left ventricular wall stress. In patients with heart failure, these changes can impair left ventricular systolic function and energy efficiency, which could reduce exercise capacity. Though the interaction and the impact of aortic atherosclerosis on left ventricular function have been investigated, its prognostic implications in patients with heart failure are unclear. We used cardiac magnetic resonance imaging and gadolinium-enhanced abdominal aortography to investigate the prevalence and prognostic impact of atherosclerotic disease of the abdominal aorta and its side branches in 355 patients with heart failure. Sclerotic abdominal aortic disease was defined as a luminal narrowing >50% of the aorta and its side branches or the presence of abdominal aortic aneurysm. Patients with disease of the aorta and its branches were older (P < 0.0001), had overall longer stay in hospital (P = 0.006) and had more admissions (P = 0.001) and worse prognosis (hazard ratio: 1.97, 95% confidence interval: 1.29-3.00, P = 0.002) than those without. In a multivariable model, increasing age and pulse pressure, diabetes mellitus and increasing left ventricular end-diastolic volume were associated with a worse prognosis, but sclerotic abdominal aortic disease was not independently related to outcome (hazard ratio: 1.06; 95% confidence interval: 0.64-1.74; P = 0.823). These data demonstrate that atherosclerosis of the abdominal aorta and its side branches is common and associated with increased morbidity in patients with chronic heart failure. How such disease should be managed remains uncertain, but its recognition and characterisation are the first steps in finding out.

Prevalence of scarred and dysfunctional myocardium in patients with heart failure of ischaemic origin: a cardiovascular magnetic resonance study.

BACKGROUND: Cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE) can provide unique data on the transmural extent of scar/viability. We assessed the prevalence of dysfunctional myocardium, including partial thickness scar, which could contribute to left ventricular contractile dysfunction in patients with heart failure and ischaemic heart disease who denied angina symptoms. METHODS: We invited patients with ischaemic heart disease and a left ventricular ejection fraction < 50% by echocardiography to have LGE CMR. Myocardial contractility and transmural extent of scar were assessed using a 17-segment model. RESULTS: The median age of the 193 patients enrolled was 70 (interquartile range: 63-76) years and 167 (87%) were men. Of 3281 myocardial segments assessed, 1759 (54%) were dysfunctional, of which 581 (33%) showed no scar, 623 (35%) had scar affecting ≤50% of wall thickness and 555 (32%) had scar affecting > 50% of wall thickness. Of 1522 segments with normal contractile function, only 98 (6%) had evidence of scar on CMR. Overall, 182 (94%) patients had ≥1 and 107 (55%) patients had ≥5 segments with contractile dysfunction that had no scar or ≤50% transmural scar suggesting viability. CONCLUSIONS: In this cohort of patients with left ventricular systolic dysfunction and ischaemic heart disease, about half of all segments had contractile dysfunction but only one third of these had > 50% of the wall thickness affected by scar, suggesting that most dysfunctional segments could improve in response to an appropriate intervention.

Stent sizing by coronary computed tomographic angiography: comparison with conventional coronary angiography in an experienced setting.

OBJECTIVES: The goal was to compare stent sizing by coronary computed tomographic angiography (CCTA) with that deployed in an experienced setting based upon conventional coronary angiography (CA). BACKGROUND: Stent sizing is currently performed by visual estimation, with infrequent guidance by intravascular ultrasound. CCTA permits quantitative determination of stent length (Stent L) and diameter (Stent D). METHODS: Projected L (CTA-Stent L) and D (CTA-Stent D) were determined from CCTA obtained in 248 patients with 352 lesions undergoing percutaneous coronary intervention within 4 months of the CCTA, and were compared to the Stent-L and Stent-D of the actually deployed stents. The effects of lesion modification and calcified plaque were also evaluated. RESULTS: There were significant correlations between CTA-Stent L and Stent L (r = 0.656, P < 0.0001) and between CTA-Stent D and Stent D (r = 0.40, P < 0.001). Median predicted CTA-Stent L was slightly longer (20 mm vs. 18 mm, P < 0.0001) and predicted CTA-Stent D was slightly smaller (3.0 mm vs. 3.2 mm, P < 0.0001) than Stent-L and Stent-D, respectively. The differences were unchanged in stents with lesion modification by pre-dilation or intracoronary nitroglycerin. CTA Stent-L and CTA Stent-D increased significantly with increasing calcium (P < 0.0001 and P = 0.019, respectively). CONCLUSIONS: (1) There are significant correlations between CCTA and CA based stent sizing in an experienced setting. (2) CCTA projects slightly longer and slightly smaller diameter stents than those deployed during PCI irrespective of lesion modification; the small differences are unlikely to have clinical significance. (3) CCTA may offer a noninvasive alternative to intravascular ultrasound for stent planning.

Epidemiology, associated factors, and prognostic outcomes of renal artery stenosis in chronic heart failure assessed by magnetic resonance angiography.

Our aim was to determine the prevalence, morbidity, and mortality associated with the presence of significant renal artery stenosis (RAS) in patients with chronic heart failure (HF), and to explore the use of angiotensin-converting enzyme (ACE) inhibitors and diuretics in this population during a 3-year follow-up period. We identified 97 patients with significant renal dysfunction (RD, defined as a calculated glomerular filtration rate of <60 ml/min) and 38 patients without RD, with ejection fractions of <40%. A stenosis of >50% using magnetic resonance angiography of the renal arteries was used to define significant RAS. Seventy-three (54%) patients had significant RAS of >or=1 artery. Mean follow-up time was 37.3 (+/- 7.9) months. Compared with patients with no significant RAS, these patients were on higher doses of diuretics, lower doses of ACE inhibitors, had prolonged hospital admissions, were admitted with exacerbation of HF, and had a higher mortality (p = 0.007 for mortality). In conclusion, RAS is common in patients with chronic HF, especially among patients with RD and is a predictor of a poor clinical outcome. Interventional trials on renal revascularization are underway that contain subsets of patients with HF that may provide evidence on how best to manage RAS in this setting.

Prevalence of ECG abnormalities in an international survey of patients with suspected or confirmed heart failure at death or discharge.

BACKGROUND: Most patients suspected of having heart failure (HF) will get a 12-lead electrocardiogram (ECG) but its utility for excluding HF or assisting in its management has rarely been investigated. METHODS: The EuroHeart Failure survey identified 11,327 patients hospitalised with a suspected diagnosis of HF from 115 hospitals in 24 countries. ECGs were obtained from 9315 patients, of whom 5934 had cardiac imaging tests. The utility of the ECG was assessed for excluding or diagnosing major structural heart disease (MSHD) or major left ventricular systolic dysfunction (MLVSD) and for therapeutic decision making. FINDINGS: MSHD was present in 70% and MLVSD in 54% of patients overall but in only 21% and 5%, respectively, if the ECG was entirely normal. However, <2% of patients had a normal ECG. No single ECG characteristic identified a probability <25% of MSHD or <20% of MLVSD. Patients with QRS width >or=120 ms or anterior pathological Q-waves had a probability >80% of MSHD and >70% of MLVSD. Diagnostic models suggested that electrocardiographic criteria alone were not accurate for the diagnosis or exclusion of important heart disease in this population. However, 2468 patients (42%) had an electrocardiographic finding that should be used to guide the choice of therapy. CONCLUSIONS: A normal ECG is rare in patients with suspected HF but has limited diagnostic value in this setting. The ECG has an important role in guiding therapy.

Effects of applying a standardised management algorithm for moderate to severe renal dysfunction in patients with chronic stable heart failure.

BACKGROUND: No specific guidelines exist on how to manage renal dysfunction (RD) in patients with chronic heart failure (CHF). AIMS: To identify the proportion of patients with moderate to severe RD and CHF who showed an improvement in their renal function in response to a systematic management algorithm. METHODS: Stable patients with CHF and RD (defined by a serum creatinine (SCr) of >130 micromol/l (>1.5 mg/dl)) were enrolled into a systematic management algorithm. The following changes were implemented: switching aspirin to clopidogrel, halving the dose of both diuretics and angiotensin converting enzyme (ACE) inhibitors and switching between bisoprolol and carvedilol. RESULTS: Two thirds of patients in whom diuretics were reduced, and one fifth of patients in whom ACE inhibitors were reduced, improved their SCr by >25.5 micromol/l (0.3 mg/dl). All these changes were more marked in the presence of bilateral renal artery stenosis. Compared to a reference group, in whom no changes were implemented, the treatment group showed an improvement in their mean SCr by 35 micromol/l (0.4 mg/dl), p<0.001. CONCLUSION: Manipulation of pharmacological therapy for patients with CHF and RD results in a substantial recovery of renal function in a minority of patients.

Anemia, renal dysfunction, and their interaction in patients with chronic heart failure.

Anemia and renal dysfunction (RD) are frequent complications seen in chronic heart failure (HF). However, the prevalence and interaction of these co-morbidities in a representative population of outpatients with chronic HF is poorly described. In this study, it was sought to determine the association between RD and anemia in patients with HF enrolled in a community-based HF program. Nine hundred fifty-five patients with HF due to left ventricular systolic dysfunction were investigated for the prevalence of anemia and its cause and followed for a median of 531 days. Anemia was defined as hemoglobin < 12.0 g/dl in women and < 13.0 g/dl in men. RD was defined as a calculated glomerular filtration rate of < 60 ml/min. The prevalence of anemia was 32%. Fifty-three percent of patients with and 27% of those without anemia had > or = 1 test suggesting hematinic deficiency. The prevalence of RD was 54%. Forty-one percent of patients with and 22% of patients without RD had anemia, with similar proportions associated with iron deficiency in the presence or absence of RD. Anemia and RD independently predicted a worse outcome, and this effect was additive. In conclusion, in outpatients with chronic HF, anemia and RD are common and co-exist but confer independent prognostic information. A deficiency of conventional hematinic factors may cause about 1/3 of anemia in this clinical setting.

Left ventricular morphology, global and longitudinal function in normal older individuals: a cardiac magnetic resonance study.

BACKGROUND: The heart transforms structurally and functionally with age but the nature and magnitude of reported changes appear inconsistent. This study was designed to assess left ventricular (LV) morphology, global and longitudinal function in healthy older men and women using cardiac magnetic resonance (CMR). METHODS: Ninety-five healthy subjects (age 62+/-16 years, range 22-91 years) underwent breath-hold cine CMR. LV end-diastolic volume (EDV), end-systolic volume (ESV), myocardial mass, ejection fraction (EF), mass-to-volume ratio, mean midventricular wall motion, thickness and thickening were calculated from short-axis data sets. Average mitral annular displacement was measured to assess longitudinal LV function. RESULTS: Subjects were divided according to age (< 65 and > or = 65 years) and sex. EDV and ESV indices (corrected for body surface area) decreased whilst EF increased with age. There was no difference in LV myocardial mass index between the age groups, but midventricular wall thickness was significantly higher in older people. Mass-to-volume ratio also increased with age. In contrast to EF, mitral annular displacement declined with age. Midventricular LV wall thickness, myocardial mass index and mass-to-volume ratio were higher in men than in women but there were no differences in measures of global and longitudinal LV systolic function. CONCLUSIONS: Due to smaller LV volumes but higher wall thickness, myocardial mass remains unchanged with age. We have found an age-related increase in EF and reduction in longitudinal LV function in apparently normal subjects. This must be borne in mind when assessing older patients with possible heart failure and normal LV systolic function. Men have higher myocardial mass than women.

Incidence of renal dysfunction over 6 months in patients with chronic heart failure due to left ventricular systolic dysfunction: contributing factors and relationship to prognosis.

AIMS: To determine the prevalence and incidence of renal dysfunction (RD) in patients with chronic heart failure (CHF), to identify contributory factors and predictors of worsening renal function (WRF), and to explore the relationship between RD and mortality. METHODS AND RESULTS: Prospective data on 1216 patients with CHF were analysed. The glomerular filtration rate (GFR) was used to determine renal function, and WRF was defined as an increase in serum creatinine of >26.5 micromol/L (>0.3 mg/dL). The prevalence of RD defined as a GFR of <60 mL/min was 57%. During 6 months, WRF occurred in 161 (13.0%) patients. Predictors of WRF were vascular disease, the use of thiazide diuretics, and a baseline urea >9 mmol/L. Two hundred and sixty-three (21.6%) patients died, and baseline RD and WRF both predicted a higher mortality (P<0.001), whereas an improvement in renal function over the first 6 months predicted a lower mortality (hazard ratio 0.8, 95% confidence interval 0.6-1.0). CONCLUSION: In ambulatory patients with CHF, RD is common, commonly deteriorates over a relatively short period of time, is unlikely to recover substantially, and augurs a poor prognosis.

Atherosclerotic renovascular disease in chronic heart failure: should we intervene?

Renal artery stenosis (RAS) is most commonly caused by atherosclerosis, which is also the most common cause of chronic heart failure (CHF). One-third of patients with CHF are reported to have significant renovascular disease. The presence of RAS confers a worse outcome in studies of hypertension and coronary disease, though data are lacking for patients with CHF. As the kidney is intricately involved in the fluid retention that occurs in CHF, an adverse effect of RAS on outcome would be expected. Presentations of RAS in CHF include flash pulmonary oedema, hypertension, worsening of CHF, and worsening renal function. RAS commonly progresses and may cause worsening of renal function in patients with CHF and previously stable renal function. A variety of investigations that can safely and accurately identify RAS in CHF are available, although none is recommended in current guidelines for the management of CHF. Treatment for RAS, whether for hypertension, for renal dysfunction, or for pulmonary oedema, is at the discretion of the physician due to the lack of adequate randomized controlled trials demonstrating the efficacy and safety of intervention. As it is not clear how RAS should be managed in CHF, screening cannot be advocated. Currently, a multicentre randomized outcome trial, which includes a cohort of patients with RAS and CHF, is in progress to provide answers in this area of uncertainty.