Asher Kimchi

Left ventricular performance in septic shock: Reversible segmental and global abnormalities

Left ventricular dysfunction has been implicated in the pathogenesis of septic shock, but little is known about its natural history, cause, and prognostic significance. Left ventricular performance was assessed by serial radionuclide and hemodynamic studies in 35 patients with culture-proven septic shock. The mean age (+/- S.D.) of the group was 64 +/- 18 years; 16 of the subjects were women, and 15 had antecedent heart disease. On the first study, the left ventricular stroke work index was depressed in 33 (94%) patients, and nineteen (54%) had a left ventricular ejection fraction less than 0.48. Twenty-two (63%) of the patients had segmental and four had generalized wall motion abnormalities. Conventional hemodynamic parameters were of no value in predicting the patients who had a depressed left ventricular ejection fraction or segmental abnormalities. Patients with underlying heart disease had a much higher frequency (87%) of segmental dysfunction than those without underlying heart disease (45%; p = 0.016), but no differences were noted in the left ventricular ejection fraction or left ventricular stroke work index of these two groups. Segmental abnormalities and low ejection fractions were seen more often in patients with a large left ventricular end-diastolic volume index. Only five subjects had a systemic vascular resistance index greater than 2580 dynes X sec X cm-5 per m2, and the correlation between systemic vascular resistance index and left ventricular ejection fraction was poor. No difference was found in the mean coronary perfusion pressure of those with segmental abnormalities and those with normal wall motion.(ABSTRACT TRUNCATED AT 250 WORDS)

Right ventricular performance in septic shock: A combined radionuclide and hemodynamic study

Twenty-five patients with septic shock underwent simultaneous radionuclide ventriculography and right heart catheterization to clarify the role of the right ventricle in this syndrome. A depressed right ventricular ejection fraction (less than 38%) was present in 13 patients and was found in patients with elevated cardiac output (4 of 6 patients) and with normal or low cardiac output (9 of 19 patients). Right ventricular dysfunction was seen with or without acute respiratory failure. In eight patients, a depressed right ventricular ejection fraction was seen in combination with an abnormal left ventricular ejection fraction (less than 48%), but in five patients, right ventricular ejection fraction impairment occurred with normal left ventricular ejection fraction. There was no significant correlation between abnormal right ventricular afterload and depressed right ventricular ejection fraction. No clinical or hemodynamic finding could be used to identify patients with diminished right ventricular ejection fraction. On follow-up study in 17 surviving patients, right ventricular ejection fraction improved in 6 and was unchanged in 11. Improvement in right ventricular ejection fraction occurred more frequently in patients without pulmonary hypertension or respiratory distress. The results suggest that right ventricular dysfunction in septic shock may be more common than previously suspected. It may be caused by abnormalities in right ventricular afterload in some patients and depressed myocardial contractility in others. The findings are of therapeutic importance since interventions that diminish right ventricular afterload and increase right ventricular contractility would be appropriate in patients with septic shock and right ventricular dysfunction.

Effectiveness of remote patient monitoring after discharge of hospitalized patients with heart failure the better effectiveness after transition-heart failure (BEAT-HF) randomized clinical trial

IMPORTANCE It remains unclear whether telemonitoring approaches provide benefits for patients with heart failure (HF) after hospitalization. OBJECTIVE To evaluate the effectiveness of a care transition intervention using remote patient monitoring in reducing 180-day all-cause readmissions among a broad population of older adults hospitalized with HF. DESIGN, SETTING, AND PARTICIPANTS We randomized 1437 patients hospitalized for HF between October 12, 2011, and September 30, 2013, to the intervention arm (715 patients) or to the usual care arm (722 patients) of the Better Effectiveness After Transition-Heart Failure (BEAT-HF) study and observed them for 180 days. The dates of our study analysis were March 30, 2014, to October 1, 2015. The setting was 6 academic medical centers in California. Participants were hospitalized individuals 50 years or older who received active treatment for decompensated HF. INTERVENTIONS The intervention combined health coaching telephone calls and telemonitoring. Telemonitoring used electronic equipment that collected daily information about blood pressure, heart rate, symptoms, and weight. Centralized registered nurses conducted telemonitoring reviews, protocolized actions, and telephone calls. MAIN OUTCOMES AND MEASURES The primary outcome was readmission for any cause within 180 days after discharge. Secondary outcomes were all-cause readmission within 30 days, all-cause mortality at 30 and 180 days, and quality of life at 30 and 180 days. RESULTS Among 1437 participants, the median age was 73 years. Overall, 46.2% (664 of 1437) were female, and 22.0% (316 of 1437) were African American. The intervention and usual care groups did not differ significantly in readmissions for any cause 180 days after discharge, which occurred in 50.8% (363 of 715) and 49.2% (355 of 722) of patients, respectively (adjusted hazard ratio, 1.03; 95% CI, 0.88-1.20; P = .74). In secondary analyses, there were no significant differences in 30-day readmission or 180-day mortality, but there was a significant difference in 180-day quality of life between the intervention and usual care groups. No adverse events were reported. CONCLUSIONS AND RELEVANCE Among patients hospitalized for HF, combined health coaching telephone calls and telemonitoring did not reduce 180-day readmissions. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01360203.

Reversal of Rest Myocardial Asynergy During Exercise: A Radionuclide Scintigraphic Study

UNLABELLED While exercise-induced segmental left ventricular wall motion abnormalities are well described, the phenomenon of improvement in certain asynergic segments during exercise in some patients remains a curiosity. To assess this unexpected finding, results were analyzed in 85 patients with wall motion abnormalities at rest who underwent two view (45 degrees left anterior oblique and anterior) exercise radionuclide ventriculography and exercise thallium-201 myocardial perfusion imaging. Wall motion was scored with a 5 point system (from 3 [normal] to - 1 [dyskinesia]); normalization or increase of 2 or more points with exercise signified improvement. Forty-eight patients (56%) had no change or further deterioration of wall motion at peak exercise, 15 (18%) showed both improvement of wall motion and deterioration and 22 (26%) showed only improvement of wall motion. Wall motion improvement during exercise was found in 57 (20%) of 279 segments with asynergy at rest. Of these 57 segments improving with exercise, 45 (79%) showed mild and 12 (21%) showed severe asynergy at rest. Only seven segments (12%) were associated with pathologic Q waves. Thallium-201 perfusion was normal in 44 segments (77%) while only 6 segments (11%) had reversible and only 7 (12%) had nonreversible thallium-201 defects. IN CONCLUSION 1) wall motion that is abnormal at rest can sometimes improve with exercise; 2) this phenomenon generally occurs in zones without a Q wave or nonreversible thallium-201 defect. Hence, segments with abnormal wall motion at rest that show improvement with exercise appear to represent viable nonischemic segments.

The efficacy of sonographic measurement of inferior vena cava diameter as an estimate of central venous pressure

BackgroundCentral venous pressure (CVP) and right atrial pressure (RAP) are important parameters in the complete hemodynamic assessment of a patient. Sonographic measurement of the inferior vena cava (IVC) diameter is a non-invasive method of estimating these parameters, but there are limited data summarizing its diagnostic accuracy across multiple studies. We performed a comprehensive review of the existing literature to examine the diagnostic accuracy and clinical utility of sonographic measurement of IVC diameter as a method for assessing CVP and RAP.MethodsWe performed a systematic search using PubMed of clinical studies comparing sonographic evaluation of IVC diameter and collapsibility against gold standard measurements of CVP and RAP. We included clinical studies that were performed in adults, used current imaging techniques, and were published in English.ResultsTwenty one clinical studies were identified that compared sonographic assessment of IVC diameter with CVP and RAP and met all inclusion criteria. Despite substantial heterogeneity in measurement techniques and patient populations, most studies demonstrated moderate strength correlations between measurements of IVC diameter and collapsibility and CVP or RAP, but more favorable diagnostic accuracy using pre-specified cut points. Findings were inconsistent among mechanically ventilated patients, except in the absence of positive end-expiratory pressure.ConclusionSonographic measurement of IVC diameter and collapsibility is a valid method of estimating CVP and RAP. Given the ease, safety, and availability of this non-invasive technique, broader adoption and application of this method in clinical settings is warranted.

Multiple model analytics for adverse event prediction in remote health monitoring systems

Remote health monitoring systems (RHMS) are gaining an important role in healthcare by collecting and transmitting patient vital information and providing data analysis and medical adverse event prediction (e.g. hospital readmission prediction). Reduction in the readmission rate is typically achieved by early prediction of the readmission based on the data collected from RHMS, and then applying early intervention to prevent the readmission. Given the diversity of patient populations and the continuous nature of patient monitoring, a single static predictive model is insufficient for accurately predicting adverse events. To address this issue, we propose a multiple prediction modeling technique that includes a set of accurate prediction models rather than one single universal predictor. In this paper, we propose a novel analytics framework based on the physiological data collected from RHMS, advanced clustering algorithms and multiple-model-classification. We tested our proposed method on a subset of data collected through a remote health monitoring system from 600 Heart Failure patients. Our proposed method provides significant improvements in prediction accuracy and performance over single predictive models.