Comparison between inferior vena cava ultrasound, lung ultrasound, bioelectric impedance analysis, and natriuretic peptides in chronic heart failure.

BACKGROUND: Heart failure (HF) is an important healthcare problem. Knowing volume status in outpatients with chronic HF to adjust treatment and to avoid decompensations is a challenge. The aim of this study is comparing the usefulness of inferior vena cava (IVC) ultrasound, lung ultrasound, bioelectrical impedance analysis (BIA), and natriuretic peptides in the follow-up of outpatients with chronic HF. METHODS: This was a prospective cohort study. Ninety-nine patients with chronic HF were included consecutively as they attended scheduled medical visits. The different techniques were performed on the day of the clinic visit, and the result was hidden from the patients and the responsible medical team. Follow-up time was 1 year. Outcome events checked were a combination of death or hospitalization, due to HF. RESULTS: Thirty-six patients (36.4%) died or were hospitalized for HF. They had a significantly lower IVC collapse, and a greater number of lung B-lines and higher NTproBNP levels compared to patients who remained stable. There were no differences in the BIA parameters. After multivariable analysis, cut-off points of IVC collapse <30%, number of pulmonary B lines greater than 5, and NTproBNP levels greater than 2000 pg/ml were associated with increased risk of HF death or admission. NTproBNP had the best area under the curve. CONCLUSION: Evaluation of congestion in outpatients with chronic HF may be based on NTproBNP, IVC ultrasound, or lung ultrasound; they are useful in identifying patients at high risk of hospitalization or death due to HF.

Usefulness of inferior vena cava ultrasonography in outpatients with chronic heart failure.

BACKGROUND: Inferior vena cava (IVC) ultrasonography has been used for the diagnosis and prognosis of acute heart failure (HF). Its usefulness in chronic HF is less known. HYPOTHESIS: IVC ultrasonography is a useful tool in the care of patients with chronic HF. METHODS: For this prospective cohort study, 95 patients with chronic HF were included consecutively as they attended scheduled medical visits. Ultrasound was done with a 5-MHz convex probe device, calculating IVC collapse index (IVCCI). Follow-up time was 1 year. Outcome events were worsening HF, hospital admission for HF, HF mortality, and all-cause mortality. RESULTS: Worsening HF occurred in 70.9% of patients with IVCCI <30% and 39.1% of patients with IVCCI >50%, with a hazard ratio (HR) of 2.8 (95% CI: 1.3-6.2) adjusted by multivariable analysis. Regarding hospitalization, 45.3% of patients with IVCCI <30% required admission, compared with 5.9% of patients with IVCCI >50%; the adjusted HR was 13.9 (95% CI: 1.7-113.0). Mortality was higher in the IVCCI <30% group, with 25.7% all-cause mortality and 18.6% HF mortality, whereas in the IVCCI >50% group these values were 13% and 4.7%, respectively. However, these differences did not reach statistical significance. ROC analysis was performed and the AUC for IVCCI was not higher than that for NTproBNP for any of the outcomes studied. CONCLUSIONS: IVC ultrasonography is a useful tool in follow-up of patients with chronic HF, allowing identification of patients at high risk of worsening and hospitalization. However, its usefulness is not higher than that of NTproBNP.

Amino-terminal pro-B-type natriuretic peptide, inferior vena cava ultrasound, and biolectrical impedance analysis for the diagnosis of acute decompensated CHF.

BACKGROUND: Both Framingham criteria and natriuretic peptides (NPs) may worsen their diagnostic validity for acute decompensated heart failure (ADHF) in elderly patients with comorbidities, mainly renal failure. Ultrasound of inferior vena cava (IVCu) and bioelectrical impedance analysis (BIA) are useful tools for detecting ADHF, although their utility compared with NP is not fully established. METHODS AND RESULTS: We conducted a prospective study with 96 patients who presented at the emergency department with dyspnea and were classified as ADHF and non-ADHF groups. Inferior vena cava ultrasonography measured maximum and minimum inferior vena cava diameters and collapsibility index (CIx), whereas BIA calculated resistance (Rz) and reactance (Xc). The primary goal was to compare amino-terminal pro-B-type NP (NT-proBNP), IVCu, and BIA for identifying ADHF. The ADHF group showed significantly (P<.001) higher NT-proBNP values (5801 vs 599 pg/mL), higher maximum IVC diameter (2.26 vs 1.58 cm), higher minimum IVC diameter (1.67 vs 0,7 cm), and lower CIx (27% vs 59%), as well as lower Rz (458.8 vs 627.1 Ohm) and lower Xc (23.5 vs 38.4 Ohm) compared with the non-ADHF group. The estimated area under the curve for ADHF diagnosis was 0.84 for NT-proBNP, 0.90 for maximum IVC diameter, 0.93 for minimum IVC diameter, and 0.90 for CIx, as well as 0.83 and 0.80 for Rz and Xc respectively, without finding significant difference. Cutoff values for diagnosis of ADHF with IVCu and BIA are proposed. Amino-terminal pro-B-type NP values significantly varied in patients with renal impairment, independently of ADHF status, whereas neither IVCu nor BIA did. CONCLUSIONS: Inferior vena cava ultrasonography and BIA analysis are as useful as NT-proBNP to ADHF diagnosis, validated in an elderly population with kidney disease.

Guía de práctica clínica sobre tratamiento de la insuficiencia cardiaca crónica / Clinical practice guide on chronic heart failure treatment

El objetivo general de la Guía de Práctica Clínica es proporcionar a los agentes encargados de la asistencia y cuidados de este tipo de pacientes, una herramienta que les permita tomar las mejores decisiones sobre algunos de los problemas que ocasionan su atención y que no han sido resueltos. Esta Guía ha sido desarrollada para generar recomendaciones sobre el tratamiento de la insuficiencia cardiaca crónica (ICC). Abarca los siguientes aspectos: TRATAMIENTO FARMACOLÓGICO: - Inhibidores de la enzima convertidora de la angiotensina ( o antagonistas de los receptores de la angiotensina), Betabloqueantes y antagonistas de la aldosterona en pacientes mayores de 65 años con disfunción sistólica. En pacientes con con fracción de eyección preservada o ligeramente deprimida. - Efectividad de la eplerona frente a espironolactona. - Eficacia del sacubitrilo/valsartán sustituyendo a un inhibidor de la enzima convertidora de la angiotensina (o a un antagonista del receptor de la angiotensina II), junto a betabloqueante y antagonistas de la aldosterona. TRATAMIENTO NO FARMACOLÓGICO: -Control temprano tras el alta hospitalaria. -Eficacia de las medidas higiénico-dietéticas. -Monitorización mediante péptidos natriuréticos para control del tratamiento farmacológico. -Eficacia de los programas de telemedicina. -Eficacia de las rehabilitación cardiaca basada en el ejercicio. -Eficacia de los desfibriladores automáticos implantables en mayores de 65 años.

Dificultad respiratoria en un varón tratado con heparina / No disponible

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Insuficiencia cardiaca terminal; último acto / End-stage heart failure; final days

OBJETIVO: Conocer las características de los pacientes con insuficiencia cardiaca (IC) en estadio terminal o refractario que ingresan en una planta hospitalaria de Medicina Interna y fallecen durante el ingreso, así como la atención prestada y el grado de control sintomático alcanzado en sus últimos días de vida. MÉTODOS: Estudio observacional descriptivo transversal en un hospital terciario de Madrid; se revisaron las historias clínicas de los 48 pacientes ingresados con IC terminal en la primera mitad del año 2009 en el Servicio de Medicina Interna del Hospital Universitario La Princesa. En los 19 fallecidos, se analizó retrospectivamente el grado de control sintomático y la comunicación con el equipo médico. RESULTADOS: La IC terminal es frecuente en pacientes ingresados en servicios de Medicina Interna (20,2%); son pacientes mayores (media de 89 años) con elevada comorbilidad y nulo seguimiento en unidades de paliativos. Presentaron mayor mortalidad que los pacientes con IC no terminal, tanto en el primer ingreso (20 IC terminal vs.13% IC no terminal) como acumulada a los 3 meses (39 vs.13%, p < 0,0001). Frecuentemente presentaban cardiopatía estructural avanzada y función sistólica conservada. Los pacientes que fallecieron presentaron cifras de tensión arterial (TA) más bajas y mayor deterioro funcional. El principal síntoma en los últimos días de vida fue la disnea. El tratamiento sintomático se instauró en la mayoría de los casos, prácticamente en la mitad fue en forma de rescate y mayoritariamente el día del fallecimiento o el día previo. El control total sintomático se consiguió en el 61% de los pacientes según la valoración médica y en el 58% según la percepción del enfermo. En la mitad no se refleja la orden de no RCP en la historia clínica. CONCLUSIONES: El estadio final de la IC representa un escenario habitual en los hospitales de agudos. La dificultad para reconocer el pronóstico, así como la falta de guías de manejo específico, hace que el manejo no sea óptimo

OBJECTIVE: To identify characteristics of patients with end-stage heart failure or refractory heart disease admitted to an Internal Medicine ward who died during hospitalization, as well as the medical care and the level of symptom control achieved in their last days of life. METHODS: Descriptive cross-sectional study in a tertiary Hospital in Madrid, identifying48 patients with the diagnosis of end-stage heart disease, admitted in the first six months of 2009 to the Internal Medicine department of the ''Hospital Universitario La Princesa''. In 19patients who died, The level of symptom control and communication with the medical team were analyzed retrospectively in 19 patients who died. RESULTS: End-stage heart failure is a common diagnosis in patients admitted to Internal Medicine (20.2%); they are usually elderly patients (mean age 89 years), with high comorbidity, and are rarely followed up by palliative care units. They had a higher mortality rate in the first admission to hospital than those patients who did not meet end-stage criteria (20% vs 13%), and also a higher cumulative mortality at three months (39% vs 13%, P < .0001). They frequently presented advanced structural heart disease and preserved left ventricular ejection fraction. Patients who died had lower blood pressure levels, and more functional impairment. The mayor symptom in the last days of life was dyspnoea. Symptomatic treatment was established in most of the cases, and in half of them it was as a rescue treatment. The treatment was established mostly on the same day as death or the day before. complete control of symptoms was achieved in 61% of patients from a medical point of view, and 58% from the patient's perception. Half of the medical histories did not mention an order of no cardiopulmonary resuscitation. CONCLUSIONS: The final stage of heart failure is a common scenario in acute tertiary hospitals. The difficulty in recognizing the prognosis, and the lack of clinical guidelines, means that these patients may receive suboptimal management

Colestasis intrahepática e insuficiencia hepática debidas a amiloidosis / Intrahepatic cholestasis and hepatic failure due to hepatic amyloidosis

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