Clinical presentation and outcomes of acute heart failure in the critically ill patient: A prospective, observational, multicentre study / Presentación clínica y resultados de la insuficiencia cardíaca aguda en el paciente crítico: estudio prospectivo, observacional y multicéntrico

Aims To assess the clinical profile and factors associated with 30-day mortality in patients with acute heart failure (AHF) admitted to the intensive care unit (ICU). Design Prospective, multicentre cohort study. Scope Thirty-two Spanish ICUs. Patients Adult patients admitted to the ICU between April and June 2017. Intervention Patients were classified into three groups according to AHF status: without AHF (no AHF); AHF as the primary reason for ICU admission (primary AHF); and AHF developed during the ICU stay (secondary AHF). Main variables of interest Incidence of AHF and 30-day mortality. Results A total of 4330 patients were included. Of these, 627 patients (14.5%) had primary (n=319; 7.4%) or secondary (n=308; 7.1%) AHF. Among the main precipitating factors, fluid overload was more common in the secondary AHF group than in the primary group (12.9% vs 23.4%, p<0.001). Patients with AHF had a higher risk of 30-day mortality than those without AHF (OR 2.45; 95% CI: 1.93–3.11). APACHE II, cardiogenic shock, left ventricular ejection fraction, early inotropic therapy, and diagnostic delay were independently associated with 30-day mortality in AHF patients. Diagnostic delay was associated with a significant increase in 30-day mortality in the secondary group (OR 6.82; 95% CI 3.31–14.04). Conclusions The incidence of primary and secondary AHF was similar in this cohort of ICU patients. The risk of developing AHF in ICU patients can be reduced by avoiding modifiable precipitating factors, particularly fluid overload. Diagnostic delay was associated with significantly higher mortality rates in patients with secondary AHF (AU)

Objetivos Evaluar el perfil clínico y los factores asociados con la mortalidad a 30 días en pacientes con insuficiencia cardíaca aguda (ICA) ingresados en Unidades de Cuidados Intensivos (UCI). Diseño Prospectivo, multicéntrico. Ámbito 32 UCI españolas. Pacientes Pacientes adultos ingresados en UCI entre abril y junio de 2017. Intervención Los pacientes se clasificaron en tres grupos según el estado de la ICA: sin ICA (no ICA), ICA como motivo principal de ingreso en UCI (ICA-primaria), e ICA desarrollada durante la estancia en UCI (ICA-secundaria). Principales variables de interés Incidencia de ICA y mortalidad a los 30 días. Resultados Se incluyeron 4.330 pacientes, de estos, 627 (14,5%) tenían ICA-primaria (n = 319; 7,4%) o secundaria (n = 308; 7,1%). Entre los principales factores precipitantes, la sobrecarga hídrica fue más común en el grupo ICA-secundaria que el ICA-primaria (12,9 vs. 23,4%, p < 0,001). Los pacientes con ICA tuvieron un mayor riesgo de mortalidad que los que no tenían ICA (OR 2,45; IC 95%: 1,93-3,11). APACHE II, choque cardiogénico, fracción de eyección del ventrículo izquierdo, tratamiento precoz con inotrópicos y el retraso diagnóstico se asociaron de forma independiente con la mortalidad en los pacientes con ICA. El retraso diagnóstico se asoció con un aumento significativo de mortalidad en el grupo secundario (OR 6,82; IC 95%: 3,31-14,04). Conclusiones La incidencia de ICA primaria y secundaria fue similar. El riesgo de desarrollar ICA en pacientes críticos puede reducirse evitando factores precipitantes modificables, en particular la sobrecarga de líquidos. El retraso diagnóstico se asoció con mayor mortalidad en pacientes con ICA-secundaria (AU)

Clinical presentation and outcomes of acute heart failure in the critically ill patient: A prospective, observational, multicentre study.

AIMS: To assess the clinical profile and factors associated with 30-day mortality in patients with acute heart failure (AHF) admitted to the intensive care unit (ICU). DESIGN: Prospective, multicentre cohort study. SCOPE: Thirty-two Spanish ICUs. PATIENTS: Adult patients admitted to the ICU between April and June 2017. INTERVENTION: Patients were classified into three groups according to AHF status: without AHF (no AHF); AHF as the primary reason for ICU admission (primary AHF); and AHF developed during the ICU stay (secondary AHF). MAIN VARIABLES OF INTEREST: Incidence of AHF and 30-day mortality. RESULTS: A total of 4330 patients were included. Of these, 627 patients (14.5%) had primary (n=319; 7.4%) or secondary (n=308; 7.1%) AHF. Among the main precipitating factors, fluid overload was more common in the secondary AHF group than in the primary group (12.9% vs 23.4%, p<0.001). Patients with AHF had a higher risk of 30-day mortality than those without AHF (OR 2.45; 95% CI: 1.93-3.11). APACHE II, cardiogenic shock, left ventricular ejection fraction, early inotropic therapy, and diagnostic delay were independently associated with 30-day mortality in AHF patients. Diagnostic delay was associated with a significant increase in 30-day mortality in the secondary group (OR 6.82; 95% CI 3.31-14.04). CONCLUSIONS: The incidence of primary and secondary AHF was similar in this cohort of ICU patients. The risk of developing AHF in ICU patients can be reduced by avoiding modifiable precipitating factors, particularly fluid overload. Diagnostic delay was associated with significantly higher mortality rates in patients with secondary AHF.

Trombosis no oclusiva de stent asociada a parada cardiocirculatoria / Non-occlusive stent thrombosis associated to cardiocirculatory arrest

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[Non-compacted cardiomyopathy: an uncommon cause of ventricular tachycardia]. / Miocardiopatía no compactada: una causa poco frecuente de taquicardia ventricular.

We present the case of a patient who was previously diagnosed of hypertrophic cardiomyopathy. The patient was admitted to our coronary unit due to a sustained ventricular tachycardia picture. A coronariography was performed as part of the ventricular tachycardia study protocol. It showed angiographically normal epicardic arteries. In the ventriculography, there was a pattern of dilated cardiomyopathy with prominent left ventricular trabeculation, which suggested the diagnosis of non-compacted cardiomyopathy (NCC). The findings of the transthoracic echocardiography, that showed a dilated and hypertrophic left ventricle, with very depressed systolic function, and ventricular myocardium with a thick internal non-compacted endocardium, with a meshwork of multiple trabeculations and intracardic recesses in communication with the ventricular cavity, confirmed this diagnosis. There continues to be little knowledge on NCC and thus it is probably underdiagnosed. It must be considered in the differential diagnosis of patients diagnosed of hypertrophic or dilated cardiomyopathy.

Miocardiopatía no compactada: una causa poco frecuente de taquicardia ventricular / Non-compacted cardiomyopathy: an uncommon cause of ventricular tachycardia

Presentamos el caso de un paciente, diagnosticado previamente de miocardiopatía hipertrófica, que ingresó en nuestra Unidad Coronaria por un cuadro de taquicardia ventricular sostenida. Como parte del protocolo de estudio de la taquicardia ventricular se le realizó una coronariografía que mostró arterias epicárdicas angiográficamente normales. En la ventriculografía se apreció un patrón de micardiopatía dilatada con llamativa trabeculación del ventrículo izquierdo, sugiriendo el diagnóstico de miocardiopatía no compactada (MNC). Los hallazgos de la ecocardiografía transtorácica, en la que se apreció un ventrículo izquierdo dilatado e hipertrófico con una función sistólica muy deprimida, y un miocardio ventricular con una gruesa capa interna endocárdica no compactada, con una malla de múltiples trabeculaciones y recesos intramiocárdicos en comunicación con la cavidad ventricular, confirmaron este diagnóstico. La MNC sigue siendo una patología poco conocida, y probablemente por ello infradiagnosticada. Hay que considerarla en el diagnóstico diferencial de pacientes afectos de miocardiopatía hipertrófica o dilatada

We present the case of a patient who was previously diagnosed of hypertrophic cardiomyopathy. The patient was admitted to our coronary unit due to a sustained ventricular tachycardia picture. A coronariography was performed as part of the ventricular tachycardia study protocol. It showed angiographically normal epicardic arteries. In the ventriculography, there was a pattern of dilated cardiomyopathy with prominent left ventricular trabeculation, which suggested the diagnosis of non-compacted cardiomyopathy (NCC). The findings of the transthoracic echocardiography, that showed a dilated and hypertrophic left ventricle, with very depressed systolic function, and ventricular myocardium with a thick internal non-compacted endocardium, with a meshwork of multiple trabeculations and intracardic recesses in communication with the ventricular cavity, confirmed this diagnosis. There continues to be little knowledge on NCC and thus it is probably underdiagnosed. It must be considered in the differential diagnosis of patients diagnosed of hypertrophic or dilated cardiomyopathy

[The thrombolytic treatment of acute myocardial infarct in an emergency department]. / Tratamiento trombolítico del infarto agudo de miocardio en el área de urgencias.

INTRODUCTION AND OBJECTIVES: Although the importance of the early use of thrombolytic therapy in acute myocardial infarction has been demonstrated, it is usual to detect an unacceptable delay in its administration. We measured the in-hospital delay and, when it was determined we designed a protocol to reduce it. METHOD: From January-92 to December-94 we performed a prospective analysis of the measured delay for patients with a diagnosis on admission of acute myocardial infarction or unstable angina within 24 hours of the onset of symptoms. To ensure a homogeneous population, we established a triage system: priority I, delay of the therapy not admissible and so immediate administration of thrombolytic agent (performed in the emergency department); priority II, need for a careful evaluation of the risk/benefit ratio for thrombolytic therapy and administration, when indicated, after admission to the coronary care unit, and priority III, thrombolytic therapy whether indicated or contraindicated. All data were evaluated periodically in order to detect possible failures and to correct them. RESULTS: A total of 1,462 patients with a diagnosis of acute myocardial infarction (n = 1,006) or unstable angina (n = 456) were included. The administration of lytic therapy in the emergency department reduced the In-Hospital delay for thrombolysis by 54% from a median of 65 minutes (45 and 110) to 30 minutes (15 and 60) (p < 0.001) in priority I patients (40% of the patients diagnosed with AMI). For all cases with thrombolytic therapy this time was reduced from 87.5 minutes (50 and 155) to 50 minutes (25 and 110) minutes (p < 0.001). CONCLUSIONS: Awareness of our in-hospital delay, establishing a triage system in the emergency department and administering thrombolytic drugs in the this area has made it possible to provide this therapy to selected patients as early as possible.

[Intracranial hemorrhage following thrombolytic therapy in acute myocardial infarct]. / Hemorragia intracraneal tras la terapéutica trombolítica en el infarto agudo de miocardio.

INTRODUCTION: Intracranial hemorrhage in acute myocardial infarction, under thrombolytic therapeutic, ranges from 0.3 to 3% in different trials. We carried out a study to stabilised the incidence of this complication in ours patients, as well as to analyze its characteristics and asses the presence the predictive factors. METHODS: We retrospectively reviewed 997 consecutive patients with acute myocardial infarction treated with thrombolytic agents. We used two different protocols in two consecutive periods of time. Protocols differ in the age of the patients, the thrombolytic agent and its interval of applications. We analyze the intracranial hemorrhage incidence rate in each period, as well as its relations with the age of the patients, the sex and the thrombolytic agent used. We also analyze the possible predictive risk factors: cerebral-vascular disease, hypertension, diabetes, etc. RESULTS: The overall rate of intracranial hemorrhage was 1.6%, higher in the patients of the second period (0.9% vs 1.9%, p = NS). The age over 70 years don't show a significant increase of this incidence (1.7% vs 1.5%). The APSAC group have shown a greater rate of hemorrhage (4%) than streptokinase (0.8%) and rTPA (1.2%). Cerebral-vascular disease and hypertension background were the two factors more frequently related to hemorrhage. The mortality rate was 68.7%. CONCLUSION: The intracranial hemorrhage is a severe complication of thrombolytic therapy with a relative low incidence, but in our experience, higher than described in multicenter studies. There are several factors related that we would to take into account when is applied this therapy.

[Comparative study of protected alveolar lavage versus occluded telescopic catheter in patients with suspected pneumonia and under mechanic ventilation]. / Estudio comparativo del lavado alveolar protegido frente al catéter telescópico ocluido en pacientes con sospecha de neumonía y en ventilación mecánica.

BACKGROUND: The pneumonias associated to mechanical ventilation present great difficulty in diagnosis and have a high mortality. The invasive diagnostic technique of choice in these patients is bronchial curettage by a double telescopic catheter with distal occlusion (OTC) based on its good sensitivity/specificity relation. Recently, the use of a variant of the classical bronchoalveolar lavage (BRL), bronchoalveolar lavage or protected alveolar lavage (PAL) has appeared in the diagnosis of conventional bacterial pneumonia. This new technique provides good specificity of OTC by its use with "protected" catheters and a high sensitivity due to exploration of a greater area of the lung. METHODS: Twenty patients receiving mechanical ventilation (MV) suspected of pneumonia in whom 21 fibrobronchoscopies (FB) were performed with OTC and PAL were studied with quantification of the cultures obtained being carried out. The OTC was performed according to the usual technique and PAL by the instillation of 40 ml of saline serum administered through a Combicath type catheter. RESULTS: OTC and PAL provided diagnostic results which coincided in 8 cases: the same germs were isolated at significant concentrations in six patients and in the two remaining cases direct immunofluorescence for Legionella was positive. PAL was diagnosed in 4 more cases with the diagnosis of viral inclusion bodies being possible in one upon cytologic examination. The count of cells with intracellular bacteria (ICB) was greater than 7% and was always related with positivity in the PAL. CONCLUSIONS: A greater sensitivity was observed with the protected alveolar lavage technique. Moreover, this technique makes virologic investigation and the counting of cells with intracellular bacteria, which may be a marker of rapid diagnosis of bacterial pneumonia, possible.