Volume 7 • Issue 4 • December-2021 – JCE – Journal of Cardiovascular Emergencies

New Perspectives in the Treatment of Acute and Chronic Heart Failure with Reduced Ejection Fraction

Cristian Stătescu, Radu Sascău, Alexandra Clement, Larisa Anghel — Mon, 27 Dec 2021 07:29:05 +0000

ABSTRACT
Acute and chronic heart failure with reduced ejection fraction (HFrEF) is a major public health problem, studies showing a 25% survival rate at 5 years after hospitalization. If left untreated, it is a common and potentially fatal disease. In recent years, the medical and device therapies of patients with HFrEF have significantly improved. The aim of our review is to provide an evidence-based update on new therapeutic strategies in acute and chronic settings, to prevent hospitalization and death in patients with HFrEF. We performed a systematic literature search on PubMed, EMBASE, and the Cochrane Database of Systemic Reviews, and we included a number of 23 randomized controlled trials published in the last 30 years. The benefit of betablockers and renin-angiotensin-aldosterone system inhibitors in patients with HFrEF is well known. Recent developments, such as sodium-glucose cotransporter 2 inhibitors, vericiguat, transcatheter mitral valve repair, wireless pulmonary artery pressure monitor and cardiac contractility modulation, have also proven effective in improving prognosis. In addition, other new therapeutic agents showed encouraging results, but they are currently being studied. The implementation of personalized disease management programs that directly target the cause of HFrEF is crucial in order to improve prognosis and quality of life for these patients.

Magnitude of ST-segment Elevation Is Associated with Increased Acute Inflammatory Response and Myocardial Scar in Patients with Acute Myocardial Infarction Undergoing pPCI

Mon, 27 Dec 2021 07:25:04 +0000

ABSTRACT
Background: The integrated ST segment elevation score (ISSTE) score objectively quantifies the ECG changes before and after primary percutaneous coronary intervention (pPCI) for ST segment elevation myocardial infarction (STEMI). The inflammatory response is a major component in scar formation and remodeling process of the myocardial tissue following myocardial infarction (MI). Cardiac magnetic resonance imaging (CMR) precisely quantifies the cardiac function and assesses the pattern of the myocardial scar tissue. The aim of the study was to evaluate the relations between the ISSTE score and: (1) acute inflammatory biomarkers and (2) extent of the myocardial scar determined by CMR in STEMI treated with pPCI. Material and methods: One hundred thirty STEMI patients were included in the study, who underwent pPCI in the first 12 hours from symptom debut. ISSTE-1 was calculated at presentation and 2 hours following pPCI (ISSTE-2). Inflammatory biomarkers were determined at admission and day 5, followed by LGE-CMR at 4 weeks, with quantification of cardiac function and extent of infarct size (IS) and transmurality. Patients were divided in low and high ISSTE groups based on the median values. Results: No significant differences were noted in terms of CMR parameters or inflammatory biomarkers and between the groups with low or high ISSTE-1. Significantly higher levels of day-5 hs-CRP (p = 0.03) and day-1 IL-6 (p = 0.02), MMP-9 (p = 0.05) were recorded in high ISSTE-2 groups. LV IS mass (23.11 ± 5.31 vs. 57.94 ± 8.33, p = 0.001), percentage (13.55 ± 6.22 vs. 27.15 ± 7.12, p = 0.001) and transmurality (p = 0.001) was significantly higher in ISSTE-2 group. ISSTE-2 significantly correlated with LV IS mass (r = 0.391, p <0.0001), percentage (r = 0.541, p <0.0001) high transmurality (r = 0.449, p <0.0001) and LV EF (r = -0.397, p <0.0001). Conclusions: A high ISSTE-2 score is associated with increased inflammatory response exhibited by elevated serum IL-6 and MMP-9 levels determined on the day of admission, and with persistently increased serum hs-CRP levels on day 5 of the acute event. A higher ISSTE-2 score is associated with larger myocardial scar extent expressed by IS, higher transmurality and reduced LV EF at 1-month LGE CMR follow-up.

Possible Option for Treatment of Severe Congestive Heart Failure Under Mechanical Ventilation Using Tolvaptan via Nasogastric Tube: A Single-Center Analysis

Morihiko Takeda, Nobuyuki Shiba — Mon, 27 Dec 2021 07:13:18 +0000

ABSTRACT
Background: The oral vasopressin-2 receptor antagonist tolvaptan causes aquaresis, and its effect on heart failure is proven. However, it is not recommended in patients who are unable to appropriately respond to thirst because of possible severe hypernatremia. Aim: To assess the safety and efficacy of tolvaptan treatment via nasogastric tube in patients who are unable to respond to thirst by fluid ingestion. Methods: We analyzed 70 consecutive patients with severe congestive heart failure (CHF) who were resistant to loop diuretics and treated with tolvaptan. From the 70 patients, 12 required endotracheal intubation under sedation (Group Tube; GT) and 58 did not (Group Oral; GO). We administered tolvaptan orally in GO; however, in GT, we had to administer tolvaptan via nasogastric tube to achieve pulmonary decongestion quickly. In GT, serum sodium level was monitored closely, and intravenous fluid infusion volume was controlled in the intensive care unit (ICU). Outcomes, including safety and efficacy parameters, were evaluated. Results: In both groups, tolvaptan treatment did not develop a significant rise in serum sodium level compared with baseline, and the incidence of worsening renal failure was comparable, despite greater net fluid loss and higher doses of loop diuretics used in patients of GT compared to GO. In GT, all patients achieved pulmonary decongestion and were weaned from mechanical ventilation. Conclusions: In sedated patients with severe CHF who are unable to respond to thirst by fluid ingestion, tolvaptan can be used without clinically significant hypernatremia under close monitoring in the ICU.

Predictive Value of Hematological Parameters in Non-ST Segment Elevation Myocardial Infarction and Their Relationship with the TIMI Risk Score

Ulaş Karaoğlu, Mehtap Bulut, Timor Omar — Mon, 27 Dec 2021 07:07:23 +0000

ABSTRACT
Background: Hematological parameters, such as white blood cell count (WBC), mean platelet volume (MPV), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and
WBC to MPV ratio (WMR), could provide data in prognosis, risk stratification, and optimal management in patients with acute coronary syndromes. Aim: We aimed to investigate the prognostic value of hematological parameters and their relationship with the TIMI risk score in non-ST elevation myocardial infarction (NSTEMI) patients. Material and Methods: A total of 259 adult patients with NSTEMI were included in this retrospective and observational cohort study. During a 1-year follow-up period, the efficacy of the main hematological parameters in predicting major adverse cardiovascular events (MACE) and their correlation with the TIMI risk score was analyzed. Results: Among the 259 patients, 188 (72.6%) were male, and the mean age was 60.4 ± 11.9 years. MACE was observed in 60 patients (23.2%). Elevated baseline levels of WBC, neutrophils, NLR, PLR, and WMR were associated with MACE development throughout the 1-year follow-up. Moreover, WBC, WMR, and NLR were correlated with the TIMI risk score. When the predictive power of these parameters for MACE was evaluated by ROC analysis, the AUC values for WBC, WMR, and NLR were 0.670 (95% CI 0.590–0.750), 0.666 (95% CI 0.582–0.746), and 0.689 (95% CI 0.610–0.767), respectively. Conclusion: WBC, NLR, and WMR predicted MACE in NSTEMI patients and were consistent with the TIMI risk score. On this basis, they could provide supportive data for early risk stratification and optimized therapeutic approach, particularly in high-risk patients.

Epicardial Adipose Tissue Thickness is Higher in Right Ventricular Outflow Tract Tachycardia

Ferdi Kahraman, Selcuk Kanat, Tezcan Peker, Sema Can, Mehmet Demir — Mon, 27 Dec 2021 07:02:50 +0000

ABSTRACT
Introduction: Idiopathic ventricular arrhythmias, which occur in the absence of structural heart disease, are commonly originating from the outflow tract, and 80% of the them arise from the right ventricle. Epicardial adipose tissue (EAT), which originates from the splanchnopleuric mesoderm, has been shown to be an important source of inflammatory mediators and plays an important role in cardiac autonomic function by epicardial ganglionated plexuses. EAT may potentially contribute to the pathophysiology of idiopathic right ventricular outflow tract (RVOT)tachycardia by different mechanisms. In this study, we aimed to investigate the relationship between EAT thickness and RVOT tachycardia. Methods: This study included 55 patients (32 male, 23 female) with RVOT tachycardia and 60 control subjects (38 male, 22 female). Patients who had more than three consecutive ventricular beats over 100 bpm with specific morphological features on the electrocardiogram (ECG) were diagnosed with RVOT tachycardia. EAT thickness was measured by transthoracic echocardiography. Results: EAT thickness was significantly higher in the RVOT tachycardia group (p <0.05). Ejection fraction (EF), and the thickness of the posterior wall of the left ventricle and of the interventricular septum were significantly lower, and left ventricular end-diastolic diameter, left ventricular end-systolic diameter, and left atrial diameter were significantly higher in patients who had RVOT tachycardia compared to normal subjects (p <0.05). Conclusion: Patients who were diagnosed with RVOT tachycardia had increased EAT thickness compared to normal subjects. The underlying mechanism of the condition could be mechanical, metabolic, infiltrative, or autonomic effects of the EAT.

Fatal Aortoduodenal Fistula Caused by a Ruptured Abdominal Aortic Aneurysm – a Case Report

Mon, 27 Dec 2021 06:57:17 +0000

ABSTRACT
Introduction: Ruptured abdominal aortic aneurysm (AAA) has a high mortality, even when the patients reach the hospital in time and the intervention is expeditious. Case presentation: We present the case of a 66-year-old male patient, with a known history of AAA, presenting to the emergency room in a state of hypovolemic shock due to massive bleeding in the upper and lower gastrointestinal tract and acute abdominal pain, which presented an abrupt onset one hour before presentation. The computed tomography angiography identified an aortoduodenal fistula with a trajectory toward the D3 segment of the duodenum, as well as a common iliac artery occlusion and extensive atherosclerotic stigmas. The patient was rushed to the operation room where he was resuscitated with intravenous fluids, two units of packed red blood cells, and hemostatic agents. The bleeding was stopped by clamping the aorta above the aneurysm. The duodenum was sutured, and the aorta was reconstructed with an aortobifemoral graft. Unfortunately, even though intensive care procedures continued for a few hours after surgery, all therapeutic efforts failed and the patient had succumbed.