[Show abstract][Hide abstract] ABSTRACT: Symptomatic long QT syndrome in pediatric patients is a life-threatening condition. Sometimes, this pathology can be misdiagnosed and erroneously managed as generalized epilepsy due to similar clinical manifestations. The presented case discusses a 13-year-old female patient with generalized epilepsy since the age of 4, admitted for two episodes of resuscitated cardiac arrest due to torsades de pointes and ventricular fibrillation. The final diagnosis of congenital long QT was established and due to the patient’s high-risk profile for future cardiac events, implantable cardiac defibrillator was subsequently indicated. Early recognition of congenital long QT and timing of cardiac therapy were crucial and potentially lower the incidence of fatal dysrhythmias commonly associated this condition. In high-risk patients, both medical and interventional therapy can be life-saving.
[Show abstract][Hide abstract] ABSTRACT: Heart failure is a clinical syndrome that manifests from various cardiac and noncardiac abnormalities. Accordingly, rapid and readily accessible methods for diagnosis and risk stratification are invaluable for providing clinical care, deciding allocation of scare resources, and designing selection criteria for clinical trials. Natriuretic peptides represent one of the most important diagnostic and prognostic tools available for the care of heart failure patients. Natriuretic peptide testing has the distinct advantage of objectivity, reproducibility, and widespread availability.The concept of tailoring heart failure management to achieve a target value of natriuretic peptides has been tested in various clinical trials and may be considered as an effective method for longitudinal biomonitoring and guiding escalation of heart failure therapies with overall favorable results.Although heart failure trials support efficacy and safety of natriuretic peptide-guided therapy as compared with usual care, the relationship between natriuretic peptide trajectory and clinical benefit has not been uniform across the trials, and certain subgroups have not shown robust benefit. Furthermore, the precise natriuretic peptide value ranges and time intervals of testing are still under investigation. If natriuretic peptides fail to decrease following intensification of therapy, further work is needed to clarify the optimal pharmacologic approach. Despite decreasing natriuretic peptide levels, some patients may present with other high-risk features (e.g. elevated troponin). A multimarker panel investigating multiple pathological processes will likely be an optimal alternative, but this will require prospective validation.Future research will be needed to clarify the type and magnitude of the target natriuretic peptide therapeutic response, as well as the duration of natriuretic peptide-guided therapy in heart failure patients.
Full-text · Article · Nov 2015 · Journal of Cardiovascular Medicine
[Show abstract][Hide abstract] ABSTRACT: Aim:
The objective of this study was to evaluate the clinical presentation, inpatient management, and in-hospital outcome of patients hospitalized for acute heart failure syndromes (AHFS) and classified as pulmonary edema (PE).
The Romanian Acute Heart Failure Syndromes (RO-AHFS) study was a prospective, national, multicenter registry of all consecutive patients admitted with AHFS over a 12-month period. Patients were classified at initial presentation by clinician-investigators into the following clinical profiles: acute decompensated HF, cardiogenic shock, PE, right HF, or hypertensive HF.
RO-AHFS enrolled 3224 patients and 28.7% (n = 924) were classified as PE. PE patients were more likely to present with pulmonary congestion, tachypnea, tachycardia, and elevated systolic blood pressure and less likely to have peripheral congestion and body weight increases. Mechanical ventilation was required in 8.8% of PE patients. PE patients received higher doses (i.e. 101.4 ± 27.1 mg) of IV furosemide for a shorter duration (i.e. 69.3 ± 22.3 hours). Vasodilators were given to 73.6% of PE patients. In-hospital all-cause mortality (ACM) in PE patients was 7.4%, and 57% of deaths occurred on day one. Increasing age, concurrent acute coronary syndromes, life-threatening ventricular arrhythmias, elevated BUN, left bundle branch block, inotrope therapy, and requirement for invasive mechanical ventilation were independent risk factors for ACM.
In this national registry, the PE profile was found to be a high-acuity clinical presentation with distinctive treatment patterns and a poor short-term prognosis. Advances in the management of PE may necessitate both the development of novel targeted therapies as well as systems-based strategies to identify high-risk patients early in their course.
Full-text · Article · Sep 2014 · Journal of Cardiovascular Medicine
[Show abstract][Hide abstract] ABSTRACT: Background:
To use CLARIFY, a prospective registry of patients with stable CAD (45 countries), to explore heart rate (HR) control and beta-blocker use.
We analyzed the CLARIFY population according to beta-blocker use via descriptive statistics with Pearson's χ(2) test for comparisons, as well as a multivariable stepwise model.
Data on beta-blocker use was available for 32,914 patients, in whom HR was 68 ± 11 bpm; patients with angina, previous myocardial infarction, and heart failure had HRs of 69 ± 12, 68 ± 11, and 70 ± 12 bpm, respectively. 75% of these patients were receiving beta-blockers. Bisoprolol (34%), metoprolol tartrate (16%) or succinate (13%), atenolol (15%), and carvedilol (12%) were mostly used; mean dosages were 49%, 76%, 35%, 53%, and 45% of maximum doses, respectively. Patients aged <65 years were more likely to receive beta-blockers than patients ≥ 75 years (P<0.0001). Gender had no effect. Subjects with HR ≤ 60 bpm were more likely to be on beta-blockers than patients with HR ≥ 70 bpm (P<0.0001). Patients with angina, previous myocardial infarction, heart failure, and hypertension were more frequently receiving beta-blockers (all P<0.0001), and those with PAD and asthma/COPD less frequently (both P<0.0001). Beta-blocker use varied according to geographical region (from 87% to 67%).
Three-quarters of patients with stable CAD receive beta-blockers. Even so, HR is insufficiently controlled in many patients, despite recent guidelines for the management of CAD. There is still much room for improvement in HR control in the management of stable CAD.
No preview · Article · Jul 2014 · International Journal of Cardiology
[Show abstract][Hide abstract] ABSTRACT: Background Dyspnea is the most common symptom in acute heart failure (AHF), yet how to best measure it has not been well defined. Prior studies demonstrate differences in dyspnea improvement across various measurement scales, yet these studies typically enroll patients well after the emergency department (ED) phase of management. Objectives The aim of this study was to determine predictors of early dyspnea improvement for three different, commonly used dyspnea scales (i.e., five-point absolute Likert scale, 10-cm visual analog scale [VAS], or seven-point relative Likert scale). Methods This was a post hoc analysis of URGENT Dyspnea, an observational study of 776 patients in 17 countries enrolled within 1 hour of first physician encounter. Inclusion criteria were broad to reflect real-world clinical practice. Prior literature informed the a priori definition of clinically significant dyspnea improvement. Resampling-based multivariable models were created to determine patient characteristics significantly associated with dyspnea improvement. Results Of the 524 AHF patients, approximately 40% of patients did not report substantial dyspnea improvement within the first 6 hours. Baseline characteristics were similar between those who did or did not improve, although there were differences in history of heart failure, coronary artery disease, and initial systolic blood pressure. For those who did improve, patient characteristics differed across all three scales, with the exception of baseline dyspnea severity for the VAS and five-point Likert scale (c-index ranged from 0.708 to 0.831 for each scale). Conclusions Predictors of early dyspnea improvement differ from scale to scale, with the exception of baseline dyspnea. Attempts to use one scale to capture the entirety of the dyspnea symptom may be insufficient.
No preview · Article · Jun 2014 · Academic Emergency Medicine
[Show abstract][Hide abstract] ABSTRACT: The present study aims to describe the epidemiology, baseline clinical characteristics, in-hospital management, and outcome of patients hospitalized for heart failure admitted directly or transferred to the ICU.
The Romanian Acute Heart Failure Syndromes (RO-AHFS) registry prospectively enrolled 3224 consecutive patients between January 2008 and May 2009 admitted with a primary diagnosis of heart failure. Participants were classified by ICU admission status (i.e. ICU+/ICU-). Independent clinical predictors of ICU admission and in-hospital mortality were identified using multivariable logistic regression analysis. Overall, 10.7% of patients required ICU level care, 32% as a direct ICU admission, with 68% as an ICU transfer during hospitalization. Patients admitted to the ICU had a mean age of 68.1 ± 11.3 years, 61% were men, 67% had an ischemic cause, and 44% presented with de-novo heart failure. ICU+ patients more frequently presented with low SBP and pulse pressure and abnormal renal function. Mechanical ventilation was required in 32.7% and intravenous inotropes were administered to 56.7% of ICU+ patients. ICU+ patients had higher in-hospital mortality compared to ICU- patients (17.3 vs. 6.5%). Patients admitted directly to the ICU had a 15.3% mortality rate compared to 18.4% in those transferred after admission. Age, serum sodium, SBP below 110 mmHg, and left-ventricular ejection fraction less than 45% were predictive of ICU admission, whereas for ICU+ patients, age, vasopressor, and mechanical ventilation utilization were predictive of mortality.
Patients admitted directly or transferred to the ICU are at a high risk of in-hospital mortality. Clinical variables commonly measured at the time of admission may facilitate disposition decision-making including early triage to the ICU.
No preview · Article · Apr 2014 · Journal of Cardiovascular Medicine
[Show abstract][Hide abstract] ABSTRACT: There is little information on the incidence and prognostic significance of arterial hypertension (HTN) in acute coronary syndromes (ACSs), especially in the east European countries. We sought to investigate a registry of ACS patients in Romania, in order to better elucidate whether hypertensive patients are at higher risk of death and deserve a tailored approach for management and follow-up. The data of this study are a framework of the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC) (ClinicalTrials.gov, NCT01218776). The present analysis focused on 2286 retrospective patients admitted to 23 hospitals in Romania with a diagnosis of ACS. Among 1450 hypertensive patients, 64.5% were admitted with a diagnosis of ST elevation myocardial infarction (STEMI), while the remaining was admitted with a diagnosis of non-STEMI (NSTEMI). When compared with non-hypertensive patients, hypertensive patients were older (mean age 60.3 vs. 66.7 years, P < 0.001), were prevalently female (25.8% vs. 35.5%, P < 0.001), and had higher rates of cardiovascular risk factors as well as higher rates of prior myocardial infarction (11.2% vs. 18.3%, P < 0.001). Additionally, they had higher rates of prior stroke (4.2% vs. 11.7%, P < 0.001) and chronic heart failure (11.5% vs. 18.4%, P < 0.001). Despite this adverse clinical profile, hypertensive patients were less likely be to be admitted with Killip class ≥2 (23.1% vs. 26.6%, P < 0.001) but they were more likely to be discharged with NYHA class ≥III (10.6% vs. 7.1%, P < 0.006). There were significant higher rates of unadjusted in-hospital mortality among hypertensive older (>65 years) patients with both STEMI and NSTEMI. Hypertensive ACS patients in Romania represent a higher risk group, since they are more often discharged with NYHA class ≥ III, are older and have an adverse clinical profile. In the elderly, the outcomes of the hypertensive patients are worse than non-hypertensive patients.
Full-text · Article · Jan 2014 · European Heart Journal Supplements
[Show abstract][Hide abstract] ABSTRACT: To present the current epidemiologic situation regarding hypertension's prevalence and control in Romania's adult population (revealed by SEPHAR II survey results) and to evaluate their tendency during the last 7 years (by comparing with the SEPHAR I survey results).
The two SEPHAR cross-sectional national surveys were conducted on a representative sample for the Romanian adult population (SEPHAR I: 2017 individuals aged 18-85 years, 45% response rate, SEPHAR II: 1975 individuals aged 18-80 years, 69% response rate), by means of questionnaire interview, blood pressure (BP) and anthropometric measurements during two study visits. Hypertension was defined as SBP at least 140 mmHg and/or DBP at least 90 mmHg at both study visits or previously diagnosed hypertension under current treatment. Controlled BP was defined as SBP less than 140 mmHg and DBP less than 90 mmHg in currently treated hypertensive individuals.
Prevalence of hypertension in Romanian is 40.41%, awareness of hypertension is 69.55%, with 59.15% hypertensive individuals under current treatment with a control rate of 25%. In the last 7 years, there has been a 10.7% decrease in hypertension's prevalence together with an increase by 57% in awareness of hypertension and an increase by 52% in treatment of hypertension, leading to almost doubling of the hypertension's control rate in all hypertensive individuals.
Although in the last 7 years, the tendency of hypertension's prevalence seems to be a descending one with an increasing trend in awareness, treatment and control of this condition, hypertension in Romania at this time still remains an 'unsolved equation'.
No preview · Article · Oct 2013 · Journal of Hypertension
[Show abstract][Hide abstract] ABSTRACT: AimsHuman stresscopin is a corticotropin-releasing factor (CRF) type 2 receptor (CRFR2) selective agonist and a member of the CRF peptide family. Stimulation of CRFR2 improves cardiac output and left ventricular ejection fraction (LVEF) in patients with stable heart failure (HF) with reduced LVEF. We examined the safety, pharmacokinetics, and effects on haemodynamics and serum biomarkers of intravenous human stresscopin acetate (JNJ-9588146) in patients with stable HF with LVEF ≤35% and cardiac index (CI) ≤2.5 L/min/m2.Methods and resultsSixty-two patients with HF and LVEF ≤35% were instrumented with a pulmonary artery catheter and randomly assigned (ratio 3:1) to receive an intravenous infusion of JNJ-9588146 or placebo. The main study was an ascending dose study of three doses (5, 15, and 30 ng/kg/min) of study drug or placebo administered in sequential 1 h intervals (3 h total). Statistically significant increases in CI and reduction in systemic vascular resistance (SVR) were observed with both the 15 ng/kg/min (2 h time point) and 30 ng/kg/min (3 h time point) doses of JNJ-9588146 without significant changes in heart rate (HR) or systolic blood pressure (SBP). No statistically significant reductions in pulmonary capillary wedge pressure (PCWP) were seen with any dose tested in the primary analysis, although a trend towards reduction was seen.Conclusion
In HF patients with reduced LVEF and CI, ascending doses of JNJ-9588146 were associated with progressive increases in CI and reductions in SVR without significant effects on PCWP, HR, or SBP.Trial registration: NCT01120210
Full-text · Article · Mar 2013 · European Journal of Heart Failure
[Show abstract][Hide abstract] ABSTRACT: The objective of the RO-AHFS registry was to evaluate the epidemiology, clinical presentation, inpatient management, and hospital course in a population hospitalized for acute heart failure syndromes.
During a 12-month period, 13 Romanian medical centers enrolled all consecutive patients hospitalized with a primary diagnosis of AHFS. Patients were classified into the following 5 clinical profiles at admission: acute decompensated heart failure, cardiogenic shock, pulmonary edema, right heart failure, and hypertensive heart failure. Statistical significance was assessed using Fisher exact test or the χ(2) test for categorical variables and a 1-way analysis of variance for continuous variables. Independent predictors of in-hospital all-cause mortality (ACM) were identified using a multivariate logistic regression model.
A total of 3,224 consecutive patients hospitalized with AHFS were enrolled. The cohort had a mean age of 69.2 ± 11.8 years and 56% were men. The mean left ventricular ejection fraction was 37.7% ± 12.5%. The percentage of patients treated with evidence-based heart failure therapies increased from admission to discharge, but even at discharge, only 56%, 66%, and 54% of patients were on a β-blocker, an angiotensin-converting enzyme inhibitors or an angiotensin receptor blocker, and a mineralocorticoid receptor antagonist, respectively. In-hospital ACM was 7.7% with substantial variation between sites (4.1%-11.0%). Increasing age, inotrope therapy, the presence of life-threatening ventricular arrhythmias, and elevated baseline blood urea nitrogen were all found to be independent risk factors for in-hospital ACM, whereas elevated systolic blood pressure and baseline treatment with a β-blocker had a protective effect.
The RO-AHFS study found substantial variation both among sites and between Romania and other European countries. National and regional registries have important clinical implications for patient care and the design and conduct of global clinical trials.
Full-text · Article · Jul 2011 · American heart journal
[Show abstract][Hide abstract] ABSTRACT: Objective
Assessment of obese patients with heart failure by left ventricular systolic dysfunction (LVEF<40%).
We included in our study 293 patients with heart failure by left ventricular systolic dysfunction. We analyzed clinical factors (heart failure etiology, functional class, risk factors – hypertension,dyslipidemia, smoking,diabetes mellitus,BMI),electrocardiographic factors (LVH presence,conduction and rhythm disturbances),echocardiographic features (LVEF,diastolic function, LVH, systolic PAP) and laboratory data (Hb,serum creatinine,uric acid,WBC count,serum BNP). Obesity was defined as presence of a BMI>30 kg/m2.
Of the 293 patients included there were 89 obese patients (30.9%)-73 males (82%) and 16 females(18%).Heart failure was ischemic at 163 patients (55.6%). At obese patients we observed a more frequent association with hypertension(78.6% of obese patients versus 55.4% nonobese patients;p=0.001); dyslipidemia (70.8% of obese patients versus 42.6%;p=0001); diabetes mellitus (43.8% vs. 14.7%;p=0,0001). Heart failure was more frequent of ischemic etiology at obese patients (66.3% vs. 50.9%; p=0.015). Likewise, EF was greater at obese patients (32.22 ±6.07% vs. 30.06±6.85%;p=0.011) and sinus rhythm was more frequent, too(78.6% vs. 67.15%; p = 0,047). There were no significant differences between BNP at obese and nonobese patients (860.04±803,97 pg/ml vs. 931.58±881,28 pg/ml;p=0,51,ns),neither between diastolic function,presence of LVH,QRS duration, enal dysfunction and other factors studied.
A significant proportion of patients with heart failure by left ventricular systolic dysfunction are obese. At obese patients with heart failure by left ventricular systolic dysfunction there is a more frequent association with other risk factors (hypertension, dyslipidemia, diabetes mellitus) and ischemic etiology of heart failure. BNP values were not significantly different at obese patients with systolic heart failure versus nonobese patients.
Full-text · Article · Jan 2010 · Archives of Cardiovascular Diseases Supplements