Background: Left ventricular (LV) diastolic dysfunction (DD) is a hallmark of heart failure with preserved ejection fraction (HFpEF). Right ventricular (RV) function is a strong and independent prognostic factor in this population, but its correlation with LV DD has not yet been explored. 3D echocardiography allows for accessible, accurate, reproducible analyses of RV function. Our study aims to assess the association between LV diastolic function and RV function (measured via automated 3D echocardiography software) Hypothesis: The RV enlarges and its systolic function decreases, in a graded fashion, with increasing degrees of LV DD Methods: We conducted a prospective, single-center, cross-sectional cohort study in patients with clinically indicated echocardiography and 3D RV assessment. We excluded patients with non-WHO group 2 pulmonary hypertension, non-sinus rhythm during echocardiogram, and those with a LVEF <40%. We conducted an interim analysis of the first 187 patients. Patients were stratified according to DD grading, and different RV parameters were compared using ANOVA Results: 187 patients underwent interim analysis, 65% were women. Mean age 60±17 years, 64% African-American, 16% Hispanic, 12% Caucasian. Mean BMI 29±6 kg/m 2 . Mean LVEF and LV GLS were 57±10% and -17.7±3.6, respectively. A graded worsening in RV systolic function and morphology were noted in patients with DD. Patients with grade II/ III DD had worse RV EDV (146±42 mL), RV FAC (32±9%), TAPSE (19±5 mm), and RVEF (40±9%), than patients without DD (RV EDV 114±36 mL, p=0.0011; RV FAC 39±7.4%, p<0.001; TAPSE 21±5 mm, p<0.001; and RVEF 47±8%, p<0.001), and grade I DD Conclusion: Our results suggest that there is a graded worsening in the RV function and morphology as LV diastolic function worsens in patients with preserved EF. This denotes the importance of widespread, accurate, and reproducible RV assessment during standard echocardiography
Abstract Funding Acknowledgements Type of funding sources: None. Background Heart failure (HF) is a complex clinical syndrome that is a frequent cause of morbidity and mortality. Although half of patients with HF have a preserved ejection fraction (HFpEF), the majority of studies have examined the prognostic impact of left heart parameters instead of the right. We thus evaluated associations of right heart hemodynamics and echocardiographic measures with outcomes in HFpEF subjects. Purpose To perform long-term mortality analysis of patients with decompensated HFpEF using strain imaging and right heart catheterization hemodynamics. Methods This was a retrospective cross-sectional study which included patients hospitalized for acute heart failure exacerbation as the primary admitting diagnosis based on clinical and laboratory parameters as determined by the primary medical team. Patients included were only those with HFpEF and with available echocardiographic and right heart catheterization (RHC) hemodynamic data done during the index admission. 2D strain analysis software was used to automatically calculate right ventricular free wall strain (RVFWS), fractional area change (FAC), and left ventricular global longitudinal strain (LVGLS). Demographic and clinical parameters were obtained including RHC hemodynamics. The outcome of interest was long term 6-year all-cause mortality. Right and left ventricular echocardiographic strain and hemodynamic parameters were compared between patients with mortality and those who survived using independent T tests and non-parametric methods as appropriate. Multivariable logistic regression was used to identify echocardiographic and hemodynamic factors independently associated with all-cause mortality. Results From a total of 100 patients, 47% were Caucasian and 53% were female. The mean age was 67.4 ± 14.3. There was an 18% long term all cause mortality rate. Of the right sided echocardiographic strain parameters, only RVFWS was statistically significantly lower among those who died (12.0 vs 15.7 p = 0.038). Meanwhile, 4 chamber LVGLS was significantly lower (13.8 vs 15.1 p = 0.016) and mean right atrial (RA) pressure was higher (13.6 vs 10.7 p = 0.076) although this did not reach statistical significance. Looking at echocardiographic strain and hemodynamic parameters as predictors of mortality, after adjusting for age, gender and race accounting for the major differences in these parameters between the survival groups, only RVFWS (OR 1.90, 95% CI 1.12-3.28; p = 0.02) and RA pressure (OR 1.85, 95% CI 1.12-3.28; p = 0.016) remained independently associated with long term all-cause mortality with C statistic of 0.751 for the overall predictive model. Conclusion Among patients with HFpEF admitted for acute heart failure exacerbation, baseline RVFWS and RA hemodynamic pressure measurements were independently associated with long term all-cause mortality. This suggests that right heart diagnostic parameters may hold more prognostic utility in HFpEF. Abstract Figure. Abstract Figure.
Acute Kidney Injury (AKI) after percutaneous coronary intervention (PCI) is an independent predictor of poor clinical outcomes, including mortality. Given the concern that SGLT2i may exacerbate post-PCI AKI vis-a-vis afferent arteriolar constriction which may amplify the risk of tubular ischemia, most clinical guidelines recommend withholding SGLT2i during the peri-PCI period. In contrast, post-hoc pooled analyses of randomized trials with SGLT2i show a significant reduction in AKI risk over time. This analysis examines kidney outcomes in patients undergoing PCI for acute coronary syndrome (ACS) with concurrent use of SGLT2i. We searched the TriNetX database to identify patients > 18 years old, with either ST-Elevation Myocardial Infarction (STEMI) or Non-STEMI, who underwent PCI from January 2019 to January 2023. Exclusion criteria include dialysis dependence, cardiogenic shock or the need for mechanical circulatory support. Patients were stratified into the SGLT2i cohort (on SGLT2i for at least 3 months before PCI) and no SGLT2i group (not taking SGLT2i before or up to 30 days after PCI). 1:1 nearest-neighbor propensity score matching was used to balance inter-group covariates. The primary outcome of interest was a clinical kidney composite (incidence of acute kidney injury (AKI) and new dialysis initiation) within 30 days post-PCI. There were 5507 (1786 had NSTEMI, 3721 had STEMI) patients in each cohort. Both groups were balanced in demographics, baseline comorbidities, and medication use (apart from more patients on insulin in non-SGLT2i and renin-angiotensin blockers in the SGLT2i group. In the SGLT2i group compared to the no SGLT2i group, the clinical kidney composite was significantly lower in those with baseline eGFR <15 cc/min (OR 0.54, 95% CI: 0.33 - 0.89, p=0.014) and those with eGFR 30 – 59 cc/min (OR 0.83, 95% CI: 0.73 - 0.95), with no difference in those with baseline eGFR 60 – 90 cc/min (OR 1.15, 95% CI: 0.97 - 1.36, p=0.102). SGLT2i exhibits a renoprotective effect peri-procedurally during PCI for ACS, with higher benefits in lower eGFR strata. Further research is necessary to identify appropriate use in patients at high risk for post PCI AKI with SGLT2i in addition to standard of care.
Background Current guidelines suggest the use of loop diuretics as the preferred agent for decongestion in patients with heart failure. However, there is no clear evidence as to superiority of one loop diuretic over the other. The understanding of pharmacokinetic and pharmacodynamic superiority of torsemide over furosemide has generated the hypothesis that these features could result in better clinical outcomes.
Few case series have described the simultaneous development of angioedema in patients with coronavirus 19 disease (COVID-19). Most of these reports were described in at-risk patients for developing bradykinin angioedema. Therefore, we aim to describe 5 African American patients who developed simultaneous COVID-19 and angioedema.This was a case series of hospitalized patients with simultaneous angioedema and COVID-19 infection in a single center from May 2020 to February 2022. We used descriptive statistics. The study was approved by the institutional review board.Their median age was 55 years (range 28-66); all patients were African American, and 3/5 were males. All patients developed angioedema within a week of hospitalization. Two subjects had prior history of ACEI-related angioedema but were not exposed to ACEI recently, whereas 1 subject was on chronic lisinopril therapy for the last 3 years. All patients had orofacial involvement; the most common locations were lips (5/5) and tongue (3/5). None had histaminergic features of angioedema (either skin rash or peripheral eosinophilia). 4/5 subjects had respiratory symptoms and chest imaging features of COVID-19 pneumonia, whereas 3/5 subjects developed severe COVID-19 infection. Most patients were treated with standard combination of H1 and H2 blockers, and corticosteroids. A total of 2/5 subjects were intubated; one patient developed refractory tongue swelling, received tracheostomy for extubation, and died due to COVID-19 pneumonia. The median length of angioedema improvement was 44 hours (range 20-168 hours). The median length of hospital stay was 15 days (range 1-49).We described 5 cases of angioedema in COVID-19 patients that shared risk factors and features of bradykinin-related angioedema.
Our prior analysis demonstrated no significant difference in risk of mortality or disease progression among patients with COVID-19. With the availability of findings from randomized controlled trials (RCTs), we provide an updated review of RCTs which explored the outcomes among hospitalized patients with COVID-19 treated with Angiotensin Converting Enzyme inhibitor (ACEis)/Angiotensin Receptor Blockers (ARBs) versus control.This systematic review and meta-analysis covers RCTs exploring mortality, intensive care unit admission, and mechanical ventilation outcomes among hospitalized COVID-19 patients treated with ACEi/ARBs.Ten studies were included in this meta-analysis. For mortality with ACEi/ARB utilization among hospitalized COVID-19 patients, the pooled risk ratio (RR) was 0.97 (95% CI 0.64-1.47, p = 0.89) with heterogeneity of 26%. Further, the pooled RR for ACEi/ARB use on ICU admission and mechanical ventilation were 0.55 (0.55-1.08, p = 0.13) with a heterogeneity of 0% and 1.02 (0.78-1.32, p = 0.91) with a heterogeneity of 0%, respectively.Among hospitalized patients with COVID-19, the use of ACEi/ARB was not associated with increased risk of mortality, ICU admission, or mechanical ventilation compared to control. These findings support continuation of ACEi/ARB for whom baseline clinical indications for these agents exist.
Introduction: Recent data suggest comparable diagnostic performance of cardiac specific troponin (cTn) in chronic kidney disease (CKD) compared to those without CKD, including when shorter time interval between tests is considered for high sensitivity (hs) assays. Objective: We performed a descriptive analysis of the adherence to recommended testing frequency across CKD stages in a large nationally representative dataset from the US Veterans Health Administration (VHA). Methods: The Loma Linda VA IRB approved the study under expedited review. Unique admissions for non-ST elevation myocardial infarction (NSTEMI) between 1999 and 2022in the VHA system with available cTn lab values (n=104, 390) were evaluated. ANOVA was utilized to compare time between first and second cTn values across CKD groups. After 2012, criteria for cTn interval reduced from 6-9 hours to 3-6 hours for hs-cTn. Criteria were considered met if time interval between cTn checks was < 9 hours before 2012, < 6 h after 2012. All analyses performed using R statistical software. Results: Troponin I was the assay utilized in 80% of the sample; high-sensitivity (hs) assays made up the minority (<1%) and were primarily used after 2012. Average time interval between first and second cTn checks (across all assays over entire observation period) was 8.1, 8.4, 8.5, 9.3, 9.6, 7.9, 8.1 hours for CKD G1, G2, G3a, G3b, G4, G5, ESKD, respectively (p = 0.001, for trend) (Figure). When cardiac catheterization is performed, cTn criteria met was associated with shorter time to cardiac catheterization (48.5h vs. 52.4h, p < 0.001), irrespective of baseline CKD stage. Conclusions: Consistent application of guideline supported practices in NSTEMI care was noted across CKD stages in VHA hospitals, associated with timely diagnostic measures.
In critically ill patients with coronavirus disease 2019, there has been considerable debate about when to intubate patients with acute respiratory failure. Early expert recommendations supported early intubation. However, as we learned more about this disease, the risks versus benefits of early intubation are less clear. We report our findings from an observational study aimed to compare the difference in outcomes of critically ill patients with coronavirus disease 2019 who were intubated early versus later in the disease course. Early need for intubation was defined as intubation either at admission or within 2 days of having a documented Fio2 greater than or equal to 0.5. In the final sample of 111 patients, 76 (68%) required early intubation. The mean age among those who received early intubation was significantly higher (69.79 ± 12.15 vs 65.03 ± 8.37 years; p = 0.038). Also, the patients who required early intubation had significantly higher Sequential Organ Failure Assessment scores at admission (6.51 vs 3.48; p ≤ 0.0001). The outcomes were equivocal among both groups. In conclusion, we suggest that the timing of intubation has no impact on clinical outcomes among patients with coronavirus disease 2019 pneumonia.
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