Acute heart failure: differential diagnosis and treatment.

Acute heart failure is a heterogeneous clinical syndrome and is the first cause of unplanned hospitalization in people >65 years. Patients with heart failure may have different clinical presentations according to clinical history, pre-existing heart disease, and pattern of intravascular congestion. A comprehensive assessment of clinical, echocardiographic, and laboratory data should aid in clinical decision-making and treatment. In some cases, a more accurate evaluation of patient haemodynamics via a pulmonary artery catheter may be necessary to undertake and guide escalation and de-escalation of therapy, especially when clinical, echo, and laboratory data are inconclusive or in the presence of right ventricular dysfunction. Similarly, a pulmonary artery catheter may be useful in patients with cardiogenic shock undergoing mechanical circulatory support. With the subsequent de-escalation of therapy and haemodynamic stabilization, the implementation of guideline-directed medical therapy should be pursued to reduce the risk of subsequent heart failure hospitalization and death, paying particular attention to the recognition and treatment of residual congestion.

Evolution of clinical diagnosis in patients presenting with unexplained cardiac arrest or syncope due to polymorphic ventricular tachycardia.

BACKGROUND: A systematic evaluation of patients with unexplained cardiac arrest (UCA) yields a diagnosis in 50% of the cases. However, evolution of clinical phenotype, identification of new disease-causing mutations, and description of new syndromes may revise the diagnosis. OBJECTIVE: To assess the evolution in diagnosis among patients with initially UCA. METHODS: Diagnoses were reviewed for all patients with UCA recruited from the Cardiac Arrest Survivors with Preserved Ejection Fraction Registry with at least 1 year of follow-up. RESULTS: After comprehensive investigation of 68 patients (age 45.2 ± 14.9 years; 63% men), the initial diagnosis was as follows: idiopathic ventricular fibrillation (n = 34 [50%]), a primary arrhythmic disorder (n = 21 [31%]), and an occult structural cause (n = 13 [19%]). Patients were followed for 30 ± 17 months, during which time the diagnosis changed in 12 (18%) patients. A specific diagnosis emerged for 7 patients (21%) with an initial diagnosis of idiopathic ventricular fibrillation. A structural cardiomyopathy evolved in 2 patients with an initial diagnosis of primary electrical disorder, while the specific structural cardiomyopathy was revised for 1 patient. Two patients with an initial diagnosis of a primary arrhythmic disorder were subsequently considered to have a different primary arrhythmic disorder. A follow-up resting electrocardiogram was the test that most frequently changed the diagnosis (67% of the cases), followed by genetic testing (17%). CONCLUSIONS: The reevaluation of patients presenting with UCA may lead to a change in diagnosis in up to 20%. This emphasizes the need to actively monitor the phenotype and also has implications for the treatment of these patients and the screening of their relatives.