A novel echocardiographic hemodynamic classification of heart failure based on stroke volume index and left atrial pressure.

BACKGROUND AND AIM: Dividing patients with heart failure (HF) based solely on ejection fraction (EF) may over simplify the hemodynamic states of these patients. We describe a novel echo-derived hemodynamic HF model based on flow (stroke volume index [SVI]) and left atrial pressure (E:E') correlates. METHODS: A retrospective analysis of patients admitted with HF with both reduced (HFrEF) and preserved EF (HFpEF). Patients were subdivided into four hemodynamic groups based on echocardiographic SVI (< or ≥35 mL/m2 ) and E/E' (≥ or <15). Group A: normal flow and normal filling pressure, Group B: normal flow but high filling pressure, Group C: low flow and low filling pressure, and Group D: low flow and high filling pressure. RESULTS: A total of 176 patients were enrolled, 123 patients had HFrEF and 53 patients had HFpEF. Baseline characteristics were not statistically significant in both groups. In HFrEF, most patients were in group D compared to a heterogeneous distribution in HFpEF (P<.0001). In HFrEF, there was a trend toward an increase in B-type natriuretic peptide levels with a decrease in SVI and increase in E/E' (P=.05) but not in HFpEF. There was no difference in death, major adverse cardiac events, but a higher readmissions rate in the HFpEF group at 30 days and 18 months. CONCLUSIONS: Hemodynamic subgroups differ between HFrEF and HFpEF. There is no difference in major adverse cardiovascular events between both groups with increased readmissions in HPpEF patients. Larger studies may help assess the impact of echo-derived hemodynamic state on clinical outcome.

ß-Blocker premedication does not increase the frequency of allergic reactions from coronary CT angiography: Results from the Advanced Cardiovascular Imaging Consortium.

BACKGROUND: ß-Blockers are often used for heart rate control during coronary CT angiography (CTA). Increased frequency and severity of allergic reactions to radiocontrast media (RCM) have been reported with concomitant use of ß-blockers. OBJECTIVES: The objectives of this study were to determine whether there is a higher incidence of allergic reactions to low-osmolar nonionic RCM in patients undergoing coronary CTA with concomitant ß-blockers and to define the overall incidence and severity of allergic reactions in patients undergoing coronary CTA with and without a history of allergy to RCM. METHODS: Patients undergoing coronary CTA at 47 institutions participating in the Advanced Cardiovascular Imaging Consortium registry were analyzed. The incidence and severity of allergic reactions were compared between those patients who did and those who did not receive ß-blockers, as well as in subgroups of patients with and without a history of prior allergy to RCM. RESULTS: The incidence of allergic reaction in patients who received ß-blockers was 45 of 23,867 (0.19%) compared with those who did not receive ß-blockers, which was 9 of 5232 (0.17%; P = .84; odds ratio = 1.1). Of the patients with history of allergy to RCM, 4 of 706 patients (0.6%) on ß-blockers experienced allergic reactions compared to 1 of 77 patients (1.3%) without ß-blockers (P = .40; odds ratio = 0.43). CONCLUSIONS: ß-Blocker pretreatment had no effect on the frequency or severity of allergic reaction in patients undergoing coronary CTA, even in patients with a past history of allergy to RCM.

Brain metastases in patients diagnosed with a solid primary cancer during childhood: experience from a single referral cancer center.

OBJECT: Metastasis to the brain is frequent in adult cancer patients but rare among children. Advances in primary tumor treatment and the associated prolonged survival are said to have increased the frequency of brain metastasis in children. The authors present a series of cases of brain metastases in children diagnosed with a solid primary cancer, evaluate brain metastasis trends, and describe tumor type, patterns of occurrence, and prognosis. METHODS: Patients with brain metastases whose primary cancer was diagnosed during childhood were identified in the 1990-2012 Tumor Registry at The University of Texas M.D. Anderson Cancer Center. A review of their hospital records provided demographic data, history, and clinical data, including primary cancer sites, number and location of brain metastases, sites of extracranial metastases, treatments, and outcomes. RESULTS: Fifty-four pediatric patients (1.4%) had a brain metastasis from a solid primary tumor. Sarcomas were the most common (54%), followed by melanoma (15%). The patients' median ages at diagnosis of the primary cancer and the brain metastasis were 11.37 years and 15.03 years, respectively. The primary cancer was localized at diagnosis in 48% of patients and disseminated regionally in only 14%. The primary tumor and brain metastasis presented synchronously in 15% of patients, and other extracranial metastases were present when the primary cancer was diagnosed. The remaining patients were diagnosed with brain metastasis after initiation of primary cancer treatment, with a median presentation interval of 17 months after primary cancer diagnosis (range 2-77 months). At the time of diagnosis, the brain metastasis was the first site of systemic metastasis in only 4 (8%) of the 51 patients for whom data were available. Up to 70% of patients had lung metastases when brain metastases were found. Symptoms led to the brain metastasis diagnosis in 65% of cases. Brain metastases were single in 60% of cases and multiple in 35%; 6% had only leptomeningeal disease. The median Kaplan-Meier estimates of survival after diagnoses of primary cancer and brain metastasis were 29 months (95% CI 24-34 months) and 9 months (95% CI 6-11 months), respectively. Untreated patients survived for a median of 0.9 months after brain metastasis diagnosis (95% CI 0.3-1.5 months). Those receiving treatment survived for a median of 8 months after initiation of therapy (95% CI 6-11 months). CONCLUSIONS: The results of this study challenge the current notion of an increased incidence of brain metastases among children with a solid primary cancer. The earlier diagnosis of the primary cancer, prior to its dissemination to distant sites (especially the brain), and initiation of presumably more effective treatments may support such an observation. However, although the actual number of cases may not be increasing, the prognosis after the diagnosis of a brain metastasis remains poor regardless of the management strategy.