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AIMS: Recent data from national registries suggest that acute heart failure (AHF) outcomes might vary in men and women, however, it is not known whether this observation is universal. The aim of this study was to evaluate the association of biological sex and 1-year all-cause mortality in patients with AHF in various regions of the world. METHODS AND RESULTS: We analysed several AHF cohorts including GREAT registry (22 523 patients, mostly from Europe and Asia) and OPTIMIZE-HF (26 376 patients from the USA). Clinical characteristics and medication use at discharge were collected. Hazard ratios (HRs) for 1-year mortality according to biological sex were calculated using a Cox proportional hazards regression model with adjustment for baseline characteristics (e.g. age, comorbidities, clinical and laboratory parameters at admission, left ventricular ejection fraction). In the GREAT registry, women had a lower risk of death in the year following AHF [HR 0.86 (0.79-0.94), P < 0.001 after adjustment]. This was mostly driven by northeast Asia [n = 9135, HR 0.76 (0.67-0.87), P < 0.001], while no significant differences were seen in other countries. In the OPTIMIZE-HF registry, women also had a lower risk of 1-year death [HR 0.93 (0.89-0.97), P < 0.001]. In the GREAT registry, women were less often prescribed with a combination of angiotensin-converting enzyme inhibitors and beta-blockers at discharge (50% vs. 57%, P = 0.001). CONCLUSION: Globally women with AHF have a lower 1-year mortality and less evidenced-based treatment than men. Differences among countries need further investigation. Our findings merit consideration when designing future global clinical trials in AHF.
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Insuficiência Cardíaca , Função Ventricular Esquerda , Doença Aguda , Ásia , Europa (Continente)/epidemiologia , Feminino , Humanos , Masculino , Prognóstico , Estudos Prospectivos , Sistema de Registros , Volume SistólicoRESUMO
BACKGROUND: Concentrations of the anti-angiogenic factor soluble fms-like tyrosine kinase-1 (sFlt-1) are altered in peripartum cardiomyopathy (PPCM). In this study we investigated changes in the angiogenesis balance in PPCM.MethodsâandâResults:Plasma concentrations of sFlt-1 and the pro-angiogenic placenta growth factor (PlGF) were determined in patients with PPCM during the post-partum phase (n=83), in healthy women at delivery (n=30), and in patients with acute heart failure (AHF; n=65). Women with cardiac failure prepartum or associated with any form of hypertension, including pre-eclampsia, were excluded. Compared with non-pregnant women, in women with AHF and PPCM, median PlGF concentrations were greater (19 [IQR 16-22] and 98 [IQR 78-126] ng/mL, respectively; P<0.001) and the sFlt-1/PlGF ratio was lower (9.8 [6.6-11.3] and 1.2 [0.9-2.8], respectively; P<0.001). The sFlt-1/PlGF ratio was lower in PPCM than in normal deliveries (1.2 [0.9-2.8] vs. 94.8 [68.8-194.1], respectively; P<0.0001). The area under the curve for PlGF (cut-off value: 50ng/mL) and/or the sFlt-1/PlGF ratio (cut-off value: 4) to distinguish PPCM from either normal delivery or AHF was >0.94. Median plasma concentrations of the anti-angiogenic factor relaxin-2 were lower in PPCM and AHF (0.3 [IQR 0.3-1.7] and 0.3 [IQR 0.3-1] ng/mL, respectively) compared with normal deliveries (1,807 [IQR 1,101-4,050] ng/mL; P<0.001). CONCLUSIONS: Plasma of PPCM patients shows imbalanced angiogenesis. High PlGF and/or low sFlt-1/PlGF may be used to diagnose PPCM.
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Cardiomiopatias/sangue , Neovascularização Patológica/sangue , Fator de Crescimento Placentário/sangue , Receptor 1 de Fatores de Crescimento do Endotélio Vascular/sangue , Cardiomiopatias/diagnóstico , Feminino , Insuficiência Cardíaca/diagnóstico , Humanos , Período Periparto , GravidezAssuntos
COVID-19 , SARS-CoV-2 , Dispneia/etiologia , Humanos , Hiperventilação/complicações , SobreviventesRESUMO
BACKGROUND: The data on the childhood determinants of adult cardiovascular disease (CVD) are lacking in populations of Eastern Europe that are characterised by substantially high CVD mortality. From a public health perspective, it is important to identify high-risk individuals as early as possible in order to have the greatest benefit of preventive interventions. The aim of this study was to evaluate the associations of childhood and adulthood traditional risk factors with subclinical atherosclerosis and arterial stiffness in a Lithuanian cohort followed up for 35 years. METHODS: The study cohort consisted of 380 adults aged 48-49 from Kaunas Cardiovascular Risk Cohort study, who were followed up since childhood (12-13 years). The baseline survey (1977) included blood pressure (BP) and anthropometric measurements and sexual maturity scale. In the follow-up survey (2012), BP, anthropometric and lipids measurements, interview about smoking, measurement of carotid intima-media thickness (IMT) and determination of pulse wave velocity (PWV) were performed. Two types of general linear models were applied to test the associations of childhood and adulthood risk factors with IMT and PWV. Model 1 included only childhood variables. In model 2, adulthood variables were added to childhood variables. RESULTS: In linear regression model with childhood variables childhood systolic BP (ß = 0.014; p = 0.016) and BMI (ß = 0.006; p = 0.003) were directly associated with IMT only in women. When adulthood variables were included into regression model, the association between childhood systolic BP and IMT remained significant (ß = 0.013; p = 0.021), while childhood BMI was not associated with IMT (ß = 0.003; p = 0.143). Additionally, association of adult smoking and IMT was found in women (ß = 0.033; p = 0.018). IMT of men was directly related to adult systolic BP (ß = 0.022; p = 0.018) and inversely to HDL cholesterol level (ß = -0.044; p = 0.021). PWV was directly associated only with adult systolic BP in both genders (ß = 0.729 for men and ß = 0.476 for women; p = 0.001). CONCLUSIONS: Sex differences in the associations between childhood and adulthood risk factors and subclinical atherosclerosis were found. The results of the study support efforts to reduce conventional risk factors both in childhood and adulthood for the primary prevention of atherosclerosis.
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Aterosclerose/diagnóstico , Aterosclerose/epidemiologia , Pressão Sanguínea/fisiologia , Índice de Massa Corporal , Espessura Intima-Media Carotídea , Adolescente , Fatores Etários , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/epidemiologia , Criança , HDL-Colesterol/sangue , Estudos de Coortes , Feminino , Humanos , Lituânia/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Fatores SexuaisRESUMO
BACKGROUND: Exacerbations of chronic obstructive pulmonary disease (COPD) are common in emergency departments (ED). Guidelines recommend administration of inhaled bronchodilators, systemic corticosteroids and antibiotics along with non-invasive ventilation (NIV) for patients with respiratory acidosis. AIM: To determine compliance with guideline recommendations for patients treated for COPD in ED in Europe (EUR) and South East Asia/Australasia (SEA) and to compare management and outcomes. METHODS: In each region, an observational prospective cohort study was performed that included patients presenting to ED with the main complaint of dyspnoea during three 72-h periods. This planned sub-study included those with an ED primary discharge diagnosis of COPD. Data were collected on demographics, clinical features, treatment, disposition and in-hospital mortality. We determined overall compliance with guideline recommendations and compared treatments and outcome between regions. RESULTS: A total of 801 patients was included from 122 ED (66 EUR and 46 SEA). Inhaled bronchodilators were administered to 80.3% of patients, systemic corticosteroids to 59.5%, antibiotics to 44 and 60.6% of patients with pH <7.3 received NIV. The proportion administered systemic corticosteroids was higher in SEA (EUR vs SEA for all comparisons; 52 vs 66%, P < 0.001) as was administration of antibiotics (40 vs 49%, P = 0.02). Rates of NIV and mechanical ventilation were similar. Overall in-hospital mortality was 4.2% (SEA 3.9% vs EUR 4.5%, P = 0.77). CONCLUSION: Compliance with guideline recommended treatments, in particular administration of corticosteroids and NIV, was sub-optimal in both regions. Improved compliance has the potential to improve patient outcome.
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Tratamento de Emergência , Guias de Prática Clínica como Assunto , Doença Pulmonar Obstrutiva Crônica/terapia , Idoso , Idoso de 80 Anos ou mais , Australásia , Serviço Hospitalar de Emergência , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/diagnósticoRESUMO
Increasing attention has recently been paid to discrepancies between office and ambulatory blood pressure (BP) control in patients with chronic kidney disease (CKD), but information on mechanisms underlying circadian BP variations in CKD remains scarce. We described circadian BP patterns and their predictors in patients with CKD stages 1 to 5 referred for kidney function testing in a French tertiary hospital: 1122 ambulatory BP measurements from 635 participants. Factors associated with daytime and nighttime systolic BP (SBP) as well as with nocturnal SBP dipping (ratio of average nighttime to daytime SBP) were analyzed with linear mixed regression models. Participants (mean age 55 ± 16 years; 36% female, mean GFR 51 ± 22 mL/min/1.73m2) had a mean daytime and nighttime SBP of 130 ± 17 and 118 ± 18 mm Hg, respectively. The prevalence of impaired dipping (nighttime over daytime SBP ratio ≥ 0.9) increased from 32% in CKD stage 1 to 68% in CKD stages 4-5. After multivariable adjustment, measured GFR, diabetes, and sub-Saharan African origin were more strongly associated with nighttime than with daytime SBP, which led to significant associations with altered nocturnal BP dipping. For a 1 SD decrease in measured GFR, nighttime BP was 2.87 mmHg (95%CI, 1.44-4.30) higher and nocturnal SBP dipping ratio was 1.55% higher (95%CI, 0.85-2.26%). In conclusion, the prevalence of impaired nocturnal BP dipping increases substantially across the spectrum of CKD. Along with sub-Saharan African origin and diabetes, lower measured GFR was a robust and specific predictor of higher nighttime BP and blunted nocturnal BP decline.
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OBJECTIVES: Optimal blood pressure (BP) control is key to prevent cardiovascular complications in patients with chronic kidney disease (CKD). We described the prevalence and factors associated with masked hypertension in CKD. METHODS: We analyzed 1113 ambulatory 24-h BP monitoring (ABPM) records of 632 patients referred for kidney function evaluation. Masked hypertension was defined as office BP less than 140/90âmmHg but daytime BP at least 135/85âmmHg or nighttime BP at least 120/70âmmHg. Factors associated with masked hypertension were assessed with mixed logistic regression models. RESULTS: At inclusion, 424 patients (67%) had controlled office BP, of whom 56% had masked hypertension. In multivariable analysis conducted in all visits with controlled office BP ( n â=â782), masked hypertension was positively associated with male sex [adjusted OR (95% confidence interval) 1.91 (1.16-3.27)], sub-Saharan African origin [2.51 (1.32-4.63)], BMI [1.11 (1.01-1.17) per 1âkg/m 2 ], and albuminuria [1.29 [1.12 - 1.47] per 1 log unit), and was negatively associated with plasma potassium (0.42 [0.29 - 0.71] per 1âmmol/L) and 24-h urinary potassium excretion (0.91 [0.82 - 0.99] per 10âmmol/24âh) as well as the use of renin-angiotensin-aldosterone (RAAS) blockers (0.56 [0.31 - 0.97]) and diuretics (0.41 [0.27 - 0.72]). CONCLUSION: Our findings support the routine use of ABPM in CKD, as more than half of the patients with controlled office BP had masked hypertension. Weight control, higher potassium intake (with caution in advanced CKD), correction of hypokalemia, and larger use of diuretics and RAAS blockers could be potential levers for better out-of-office BP control.
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Hipertensão Mascarada , Insuficiência Renal Crônica , Humanos , Masculino , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/fisiopatologia , Insuficiência Renal Crônica/epidemiologia , Feminino , Pessoa de Meia-Idade , Hipertensão Mascarada/epidemiologia , Hipertensão Mascarada/tratamento farmacológico , Hipertensão Mascarada/fisiopatologia , Prevalência , Monitorização Ambulatorial da Pressão Arterial , Idoso , Fatores de Risco , Pressão Sanguínea/efeitos dos fármacos , Adulto , Anti-Hipertensivos/uso terapêuticoRESUMO
The incidence of congenital coronary artery anomalies is estimated to range between 1% and 2% in the general population. The separate types of coronary artery anomalies are even rarer - the left main coronary artery arising from the right coronary sinus and passing between the thoracic aorta and the pulmonary artery is one of them. In this case, the segment of the artery that courses between the aorta and the pulmonary artery is prone to compression, especially during heavy exercise. Outcomes may be fatal due to myocardial hypoperfusion, which is associated with sudden cardiac death especially among children, young adults, and athletes. Nowadays, innate coronary artery anomalies may be incidentally diagnosed in older age using new investigation methods such as computed tomography angiography.
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Anomalias dos Vasos Coronários/diagnóstico por imagem , Idoso , Angiografia Coronária , Anomalias dos Vasos Coronários/epidemiologia , Feminino , Humanos , Incidência , Lituânia/epidemiologia , Tomografia Computadorizada por Raios XAssuntos
Cardiomiopatias/complicações , Glicopeptídeos/sangue , Doença Pulmonar Obstrutiva Crônica/mortalidade , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Idoso , Biomarcadores/sangue , Cardiomiopatias/fisiopatologia , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Miocárdio/patologia , Peptídeo Natriurético Encefálico/sangue , Projetos Piloto , Prognóstico , Doença Pulmonar Obstrutiva Crônica/complicações , Análise de Regressão , Índice de Gravidade de Doença , Troponina/sangueRESUMO
OBJECTIVE: Limited information is currently available on the impact of vasoactive medications in intensive care (ICU) and long-term outcomes. The main objective of our study was to describe the association between the use of inotropes and/or vasopressors and ICU mortality. Secondary objectives were to evaluate the association between the use of vasoactive drugs and in-hospital as well as 1-year all-cause mortality in ICU survivors. METHODS: FROG-ICU was a prospective, observational, multi-centre cohort designed to investigate long-term mortality of critically ill adult patients. Cox proportional hazards models were used to evaluate the association between the use of inotropes and/or vasopressors and ICU mortality, as well as in-hospital and 1-year all-cause mortality in a propensity-score matched cohort. RESULTS: The study included 2087 patients, 939 of whom received inotropes and/or vasopressors during the initial ICU stay. Patients treated with vasoactive medications were older and had a more severe clinical presentation. In a propensity score-matched cohort of 1201 patients, ICU mortality was higher in patients who received vasoactive medications (HR of 1.40 [1.10-1.78], p = 0.007). One thousand six hundred thirty-five patients survived the index ICU hospitalisation. There was no significant difference according to the use of inotropes and/or vasopressors in the propensity-score matched cohort on in-hospital mortality (HR of 0.94 [0.60-1.49], p = 0.808) as well as one-year all-cause mortality (HR 0.94 [0.71-1.24], p = 0.643). CONCLUSION: Inotropic and/or vasopressor therapy is a strong predictor of in-ICU death. However, the use of inotropes and/or vasopressors during ICU admission was not associated with a worse prognosis after ICU discharge.
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Cardiotônicos , Estado Terminal , Vasoconstritores , Adulto , Cardiotônicos/efeitos adversos , Cardiotônicos/uso terapêutico , Estudos de Coortes , Estado Terminal/mortalidade , Estado Terminal/terapia , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Prognóstico , Estudos Prospectivos , Vasoconstritores/efeitos adversos , Vasoconstritores/uso terapêuticoRESUMO
BACKGROUND AND IMPORTANCE: Marked differences have been described between women and men in disease prevalence, clinical presentation, response to treatment and outcomes. However, such data are scarce in the acutely ill. An awareness of differences related to biological sex is essential for the success of clinical care and outcomes in patients presenting with acute dyspnea, the most frequent cause of emergency department (ED) admission. OBJECTIVES: The aim of the present study was to assess the effect of biological sex on 1-year all-cause mortality in patients presenting with acute dyspnea to the ED. DESIGN, SETTINGS AND PARTICIPANTS: Consecutive adult patients presenting with acute dyspnea in two Lithuanian EDs were included. Clinical characteristics, laboratory data and medication use at discharge were collected. Follow-up at 1 year was performed via national data registries. OUTCOMES MEASURE AND ANALYSIS: The primary outcome of the study was 1-year all-cause mortality. Hazard ratios (HRs) for 1-year mortality according to biological sex were calculated using a Cox proportional hazards regression model, with and without adjustment for the following confounders: age, systolic blood pressure, creatinine, sodium and hemoglobin. MAIN RESULTS: A total of 1455 patients were included. Women represented 43% of the study population. Compared to men, women were older [median (interquartile range [IQR]) age 74 (65-80) vs. 68 (59-77) years, P < 0.0001]. The duration of clinical signs before admission was shorter for women [median (IQR) duration 4 (1-14) vs. 7(2-14) days, P = 0.006]. Unadjusted 1-year all-cause mortality was significantly lower in women (21 vs. 28%, P = 0.001). Adjusted HR of 1-year all-cause mortality was lower in women when compared to men [HR 0.68 (0.53-0.88), P = 0.0028]. Additional sensitivity analyses confirmed the survival benefit for women in subgroups including age greater and lower than 75 years, the presence of comorbidities and causes of dyspnea (cardiac or noncardiac). CONCLUSION: Women have better 1-year survival than men after the initial ED presentation for acute dyspnea. Understanding the biological sex-related differences should lead toward precision medicine, and improve clinical decision-making to promote gender equality in health.
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Dispneia , Serviço Hospitalar de Emergência , Doença Aguda , Adulto , Idoso , Feminino , Hospitalização , Humanos , Masculino , Sistema de RegistrosRESUMO
PURPOSE: This study was designed to evaluate the role of biologically active adrenomedullin (bio-ADM) in congestion assessment and risk stratification in acute dyspnea. METHODS: This is a sub-analysis of the Lithuanian Echocardiography Study of Dyspnea in Acute Settings. Congestion was assessed by means of clinical (peripheral edema, rales) and sonographic (estimated right atrial pressure) parameters. Ninety-day mortality was chosen for outcome analysis. RESULTS: There were 1188 patients included. Bio-ADM concentration was higher in patients with peripheral edema at admission (48.2 [28.2-92.6] vs 35.4 [20.9-59.2] ng/L, P < .001). There was a stepwise increase in bio-ADM concentration with increasing prevalence of rales: 29.8 [18.8-51.1], 38.5 [27.5-67.1], and 51.1 [33.1-103.2] ng/L in patients with no rales, rales covering less than one-half, and greater than or equal to one-half of the pulmonary area, respectively (P < 0.001). Bio-ADM concentration demonstrated gradual elevation in patients with normal, moderately, and severely increased estimated right atrial pressure: 25.1 [17.6-42.4] ng/L, 36.1 [23.1-50.2], and 47.1 [30.7-86.7] ng/L, respectively (P < .05). Patients with bio-ADM concentration >35.5 ng/L were at more than twofold increased risk of dying (P < .001). Survival in those with high bio-ADM was significantly modified by neurohormonal blockade at admission (P < .05), especially if NT-proBNP levels were lower than the median (P = .002 for interaction). CONCLUSION: Bio-ADM reflects the presence and the degree of pulmonary, peripheral, and intravascular volume overload and is strongly related to 90-day mortality in acute dyspnea. Patients with high bio-ADM levels demonstrated survival benefit from neurohormonal blockade.
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Adrenomedulina , Sons Respiratórios , Biomarcadores , Dispneia/etiologia , Humanos , Seleção de PacientesRESUMO
Activation of the sympathetic nervous system is responsible for the body's "fight or flight" reaction. The physiological responses to the activation of the sympathetic nervous system and adrenal medulla are mediated through the action of the endogenous catecholamines norepinephrine (or noradrenaline) and epinephrine (or adrenaline) on adrenergic receptors. Adrenergic receptors belong to the superfamily of G protein-coupled receptors (GPCR). Adrenoceptors are divided into alpha1, alpha2, beta1, beta2 and beta3 receptors. Norepinephrine stimulates both subtypes of α receptors and ß1 receptors. Epinephrine stimulates all subtypes ofα and ß adrenoreceptors. α1 adrenergic receptors, coupled to stimulatory Gq proteins, activate the enzyme phospholipase C and are mainly found in the smooth muscle cells of blood vessels and urinary tract, where they induce constriction. α2 receptors are coupled to inhibitory Gi proteins, that inactivate adenylyl cyclase, decreasing cyclic adenosine monophosphate (AMP) production. They are mainly found in the central nervous system, where their activation results in a decreased arterial blood pressure. ß1 adrenoreceptors predominate in the heart, activate the Gs-adenylyl cyclase -cAMP-protein kinase A signaling cascade, and induce positive inotropic and chronotropic effects. ß2 adrenoreceptors are distributed extensively throughout the body, but are expressed predominantly in bronchial smooth muscle cells. ß2 adrenergic receptors activate adenylyl cyclase, dilate blood vessels and bronchioles, relax the muscles of the uterus, bladder and gastrointestinal duct, and also decrease platelet aggregation and glycogenolysis. ß3 receptors can couple interchangeably to both stimulating and inhibiting G proteins. They are abundantly expressed in white and brown adipose tissue, and increase fat oxidation, energy expenditure and insulin-mediated glucose uptake. This review details the regulation of cardiac and vascular function by adrenergic receptors.
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Sistema Cardiovascular/efeitos dos fármacos , Catecolaminas/farmacologia , Receptores Adrenérgicos/fisiologia , Animais , Fenômenos Fisiológicos Cardiovasculares/efeitos dos fármacos , Sistema Cardiovascular/fisiopatologia , Feminino , Coração/efeitos dos fármacos , Coração/fisiologia , Humanos , MasculinoRESUMO
Stress cardiomyopathy (SCM) is a syndrome characterized by transient regional systolic dysfunction of the left ventricle in the absence of angiographic evidence of coronaropathy. This abnormality is associated with high levels of catecholamines. Stress cardiomyopathy is also called Takotsubo (TS) cardiomyopathy. Pheochromocytoma crisis can occur spontaneously or can be precipitated by manipulation of the tumor, trauma, certain medications or stress for example during non-adrenal surgery. The main drugs leading to pheochromocytoma crisis include D2 dopamine receptor antagonists, noncardioselective ß-adrenergic receptor blockers, tricyclic antidepressants and related neurotransmitter uptake blockers, sympathomimetics, certain peptide and steroid hormones and several agents used during induction of anesthesia. Patients can develop symptoms of heart failure associated with tachyarrhythmia, cardiogenic shock with hypotension and collapse, or apparent acute coronary syndromes. This review describes pathophysiology, epidemiology, diagnosis criteria and management of SCM.
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Neoplasias das Glândulas Suprarrenais/fisiopatologia , Coração/fisiologia , Feocromocitoma/fisiopatologia , Cardiomiopatia de Takotsubo , Neoplasias das Glândulas Suprarrenais/complicações , Neoplasias das Glândulas Suprarrenais/diagnóstico , Neoplasias das Glândulas Suprarrenais/terapia , Cardiomiopatias/diagnóstico , Cardiomiopatias/etiologia , Cardiomiopatias/terapia , Coração/fisiopatologia , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/terapia , Humanos , Feocromocitoma/complicações , Feocromocitoma/diagnóstico , Feocromocitoma/terapia , Estresse Psicológico/complicações , Estresse Psicológico/diagnóstico , Estresse Psicológico/terapia , Cardiomiopatia de Takotsubo/diagnóstico , Cardiomiopatia de Takotsubo/etiologia , Cardiomiopatia de Takotsubo/terapiaRESUMO
AIMS: Readmission and mortality are the most common and often combined endpoints in acute heart failure (AHF) trials, but an association between these two outcomes is poorly investigated. The aim of this study was to determine whether unplanned readmission is associated with a greater subsequent risk of death in patients with acute dyspnoea due to cardiac and non-cardiac causes. METHODS AND RESULTS: Derivation cohort (1371 patients from the LEDA study) and validation cohort (1986 patients from the BASEL V study) included acute dyspnoea patients admitted to the emergency department. Cox regression analysis was used to determine the association of 6 month readmission and the risk of 1 year all-cause mortality in AHF and non-AHF patients and those readmitted due to cardiovascular and non-cardiovascular causes. In the derivation cohort, 666 (49%) of patients were readmitted at 6 months and 282 (21%) died within 1 year. Six month readmission was associated with an increased 1 year mortality risk in both the derivation cohort [adjusted hazard ratio (aHR) 3.0 (95% confidence interval, CI 2.2-4.0), P < 0.001] and the validation cohort (aHR 1.8, 95% CI 1.4-2.2, P < 0.001). The significant association was similarly observed in AHF (aHR 3.2, 95% CI 2.1-4.9, P < 0.001) and other causes of acute dyspnoea (aHR 2.9, 95% CI 1.9-4.5, P < 0.001), and it did not depend on the aetiology [aHR 2.2, 95% CI 1.6-3.1 for cardiovascular readmissions; aHR 4.1, 95% CI 2.9-5.7 for non-cardiovascular readmissions (P < 0.001 for both)] or timing of readmission. CONCLUSIONâS: Our study demonstrated a long-lasting detrimental association between readmission and death in AHF and non-AHF patients with acute dyspnoea. These patients should be considered 'vulnerable patients' that require personalized follow-up for an extended period.
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Insuficiência Cardíaca , Readmissão do Paciente , Estudos de Coortes , Dispneia/epidemiologia , Dispneia/etiologia , Insuficiência Cardíaca/complicações , Hospitalização , HumanosRESUMO
INTRODUCTION: Lung function in survivors of SARS-Co-V2 pneumonia is poorly known, but concern over the possibility of sequelae exists. METHODS: Retrospective study on survivors with confirmed infection and pneumonia on chest-CT. Correlations between PFT and residual radiologic anomalies at three months taking into account initial clinical and radiological severity and steroid use during acute phase. RESULTS: 137 patients (69 men, median age 59 (Q1 50; Q3 68), BMI 27.5 kg/m2 (25.1; 31.7)) were assessed. Only 32.9% had normal PFT, 75 had altered DLCO. Median (Q1; Q3) values were: VC 79 (66; 92) % pred, FEV1 81 (68; 89), TLC 78 (67; 85), DLCO 60 (44; 72), and KCO 89 (77; 105). Ground glass opacities (GGO) were present in 103 patients (75%), reticulations in 42 (30%), and fibrosis in 18 (13%). There were significantly lower FEV1 (p = 0.0089), FVC (p = 0.0010), TLC (p < 0.0001) and DLCO (p < 0.0001) for patients with GGO, lower TLC (p = 0.0913) and DLCO (p = 0.0181) between patients with reticulations and lower FVC (p = 0.0618), TLC (p = 0.0742) DLCO (p = 0.002) and KCO (p = 0.0114) between patients with fibrosis. Patients with initial ≥50% lung involvement had significantly lower FEV1 (p = 0.0019), FVC (p = 0.0033), TLC (p = 0.0028) and DLCO (p = 0.0003) compared to patients with ≤10%. There was no difference in PFT and residual CT lesions between patients who received steroids and those who did not. CONCLUSION: The majority of patients have altered PFT at three months, even in patients with mild initial disease, with significantly lower function in patients with residual CT lesions. Steroids do not seem to modify functional and radiological recovery. Long-term follow-up is needed.
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COVID-19/diagnóstico por imagem , COVID-19/fisiopatologia , Volume Expiratório Forçado , Pulmão/diagnóstico por imagem , Capacidade Vital , Feminino , Humanos , Pulmão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Radiografia Torácica , Testes de Função Respiratória , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores de Tempo , Tomografia Computadorizada por Raios XRESUMO
Since the outbreak of the coronavirus (COVID-19) pandemic, most attention has focused on containing transmission and addressing the surge of critically ill patients in acute care settings. As we enter the second phase of the pandemic, emphasis must evolve to post-acute care of COVID-19 survivors. Persisting cardiorespiratory symptoms have been reported at several months after the onset of the infection. Information is lacking on the pathophysiology of exercise intolerance after COVID-19. Previous outbreaks of coronaviruses have been associated with persistent dyspnea, muscle weakness, fatigue and reduced quality of life. The extent of Covid-19 sequelae remains to be evaluated, but persisting cardiorespiratory symptoms in COVID-19 survivors can be described as two distinct entities. The first type of post-Covid symptoms are directly related to organ injury in the acute phase, or the complications of treatment. The second type of persisting symptoms can affect patients even with mild initial disease presentation without evidence of organ damage. The mechanisms are still poorly qualified to date. There is a lack of correlation between initial symptom severity and residual symptoms at exertion. We report exercise hyperventilation as a major limiting factor in COVID-19 survivors. The origin of this hyperventilation may be related to an abnormality of ventilatory control, by either hyperactivity of activator systems (automatic and cortical ventilatory control, peripheral afferents, and sensory cortex) or failure of inhibitory systems (endorphins) in the aftermath of pulmonary infection. Hyperventilation-induced hypocapnia can cause a multitude of extremely disabling symptoms such as dyspnea, tachycardia, chest pain, fatigue, dizziness and syncope at exertion.
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OBJECTIVE: Asthma exacerbations are common presentations to ED. Key guideline recommendations for management include administration of inhaled bronchodilators, systemic corticosteroids and titrated oxygen therapy. Our aim was to compare management and outcomes between patients treated for asthma in Europe (EUR) and South East Asia/Australasia (SEA) and compliance with international guidelines. METHODS: In each region, prospective, interrupted time series studies were performed including adult (age >18 years) patients presenting to ED with the main complaint of dyspnoea during three 72 h periods. This was a planned sub-study that included those with an ED primary diagnosis of asthma. Data was collected on demographics, clinical features, treatment in ED, diagnosis, disposition and in-hospital outcome. The results of interest were differences in treatment and outcome between EUR and SEA cohorts. RESULTS: Five hundred and eighty-four patients were identified from 112 EDs (66 EUR and 46 SEA). The cohorts had similar demographics and co-morbidity patterns, with 89% of the cohort having a previous diagnosis of asthma. There were no significant differences in treatment between EUR and SEA patients - inhaled beta-agonists were administered in 86% of cases, systemic corticosteroids in 66%, oxygen therapy in 44% and antibiotics in 20%. Two thirds of patients were discharged home from the ED. CONCLUSION: The data suggests that compliance with guideline-recommended therapy in both regions, particularly corticosteroid administration, is sub-optimal. It also suggests over-use of antibiotics.
Assuntos
Asma/terapia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Avaliação de Processos e Resultados em Cuidados de Saúde/métodos , Resultado do Tratamento , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Sudeste Asiático/epidemiologia , Asma/epidemiologia , Australásia/epidemiologia , Broncodilatadores/uso terapêutico , Estudos de Coortes , Serviço Hospitalar de Emergência/organização & administração , Europa (Continente)/epidemiologia , Feminino , Guias como Assunto , Humanos , Análise de Séries Temporais Interrompida , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Estudos ProspectivosRESUMO
OBJECTIVE: The primary objective of this study was to describe the epidemiology and management of dyspneic patients presenting to emergency departments (EDs) in an international patient population. Our secondary objective was to compare the EURODEM and AANZDEM patient populations. PATIENTS AND METHODS: An observational prospective cohort study was carried out in Europe and the Asia-Pacific region. The study included consecutive patients presenting to EDs with dyspnea as the main complaint. Data were collected on demographics, comorbidities, chronic treatment, clinical signs and investigations, treatment in the ED, diagnosis, and disposition from ED. RESULTS: A total of 5569 patients were included in the study. The most common ED diagnoses were lower respiratory tract infection (LRTI) (24.9%), heart failure (HF) (17.3%), chronic obstructive pulmonary disease (COPD) exacerbation (15.8%), and asthma (10.5%) in the overall population. There were more LRTI, HF, and COPD exacerbations in the EURODEM population, whereas asthma was more frequent in the AANZDEM population. ICU admission rates were 5.5%. ED mortality was 0.6%. The overall in-hospital mortality was 5.0%. In-hospital mortality rates were 8.7% for LRTI, 7.6% for HF, and 5.6% for COPD patients. CONCLUSION: Dyspnea as a symptom in the ED has high ward and ICU admission rates. A variety of causes of dyspnea were observed in this study, with chronic diseases accounting for a major proportion.