C. Baldi

Inferior Vena Cava and Hemodynamic Congestion

Background: Among the indices able to replace invasive central venous pressure (CVP) measurement for patients with acute decompensated heart failure (ADHF) the diameters of the inferior vena cava (IVC) and their respiratory fluctuationsj so-called IVC collapsibility index (IVCCI) measured by echocardiography, have recently gained ground as a quite reliable proxy of CVP. Objectives: The aims of our study were to compare three different ways of evaluating cardiac overload by using the IVC diameters and/or respiratory fluctuations and by calculating the inter-method agreement Patients and Methods: Medical records of patients hospitalized for right or bi-ventricular acute decompensated heart failure from January to December 2013 were retrospectively evaluated. The predictive significance of the IVC expiratory diameter and IVC collapsibility index (IVCCI) was analyzed using three different methodsj namely a) the criteria for the indirect estimate of right atrial pressure by Rudski et al. (J Am Soc Echocardiogr. 2010); b) the categorization into three IVCCI classes by Stawicki et al. (J Am Coll Surg. 2009); and c) the subdivision based on the value of the maximum IVC diameter by Pellicori et al. (JACC Cardiovasc Imaging. 2013). Results: Among forty-seven enrolled patientsj those classified as affected by persistent congestion were 22 (46.8%) using Rudski’s criteria1 or 16 (34%) using Stawicki’s criteriaj or 13 (27.6%) using Pellicori’s criteria. The inter-rater agreement was rather poor by comparing Rudski’s criteria with those of Stawicki (Cohen’s kappa = 0.369; 95% CI 0.197 to 0.54) as well as by comparing Rudski’s criteria with those of Pellicori (Cohen’s kappa = 0.299; 95% CI 0.135 to 0.462). Further a substantially unsatisfactory concordance was also found for Stawicki’s criteria compared to those of Pellicori (Cohen’s kappa= 0.468; 95% CI 0.187 to 0.75). Conclusions: The abovementioned IVC ultrasonographic criteria for hemodynamic congestion appear clearly inconsistent. Alternatively, a sequential or simultaneous combination of clinical scores of congestion IVC ultrasonographic indicesj and circulating levels of natriuretic peptides could be warranted.

Cardiorenal syndrome type 2: from diagnosis to optimal management.

The deterioration of renal function, which is linked to chronic heart failure by a chronological and causal relationship (ie, the so-called cardiorenal syndrome [CRS] type 2), has recently become a matter of growing debate. This debate has concerned the efficacy, safety, and cost effectiveness of the therapies that have been implemented thus far for this syndrome (for example, the intravenous [IV] loop diuretics, such as repeated IV boluses or slow IV infusions, as well as mechanical fluid removal, particularly by means of isolated ultrafiltration [IUF]). Further controversies have also emerged concerning the optimal dosage and timing of some evidence-based drugs, such as angiotensin-converting-enzyme inhibitors. The present review summarizes the currently used diagnostic tools for detecting renal damage in CRS type 2. Subsequently, the meaning of worsening renal function is outlined, as well as the sometimes inconsistent therapeutic schemes that have been implemented in order to prevent or counteract worsening renal function. The need to elaborate upon more detailed and comprehensive scientific recommendations for targeted prevention and/or therapy of CRS type 2 is also underlined. The measures usually adopted (such as the more accurate modulation of loop diuretic dose, combined with the exploitation of other diuretics that are able to achieve a sequential blockade of the nephron, as well as the use of IV administration for loop diuretics) are briefly presented. The concept of diuretic resistance is illustrated, along with the paramount operational principles of IUF in diuretic-resistant patients. Some controversies regarding the comparison of IUF with stepped diuretic therapy in patients with CRS type 2 are also addressed.

The Relation Between Global Longitudinal Strain and Serum Natriuretic Peptide Is More Strict Than That Found Between the Latter and Left Ventricular Ejection Fraction: A Retrospective Study in Chronic Heart Failure.

Background In chronic heart failure (CHF), the finding of elevated levels of the N-terminal fragment of the pro B-type natriuretic peptide (NT-proBNP) is a marker of pathological increase in myocardial ventricular wall stress and detrimental rise in ventricular filling pressures. However, the ensemble of data concerning the relationship between longitudinal deformation indices and NT-proBNP is still rather vague and approximate. Methods We carried out a retrospective study that involved 118 patients with CHF admitted to our clinic for CHF outpatients. For inclusion in the study, the CHF patients were required to have undergone at least a determination of global longitudinal strain (GLS) by means of speckle tracking echocardiography and to have practiced at least a determination of NT-proBNP. As regards the two determinations, the one echocardiographic and the other laboratory-based, the former should have been done not more than 24 hours before or after the latter. Results Correlation between log (NT-proBNP) and GLS was highly significant (r = 0.8386; P < 0.0001). The observed correlation between log (NT-proBNP) and left ventricular ejection fraction (LVEF) was also significant, but explained a smaller magnitude of the variance (r = -0.5465; P < 0.0001). In multiple linear regression analysis, GLS was shown to be the strongest independent predictor of log (NT-proBNP), within a parsimonious model including age, body mass index, estimated glomerular filtration rate, left atrial volume index, and LVEF (β (regression coefficient) = 305, rpartial = 0.7076; P < 0.0001). By using the median value of NT-proBNP (299.5 pg/mL) as a discriminating value for identifying relatively low (i.e., below the median) and relatively high (i.e., above the median) levels of NT-proBNP, GLS was associated with the upper quartiles, whereas LVEF was associated with lower quartiles of NT-proBNP. However, the C statistics for GLS were significantly higher than for LVEF (area under the curve (AUC): 0.949 (GLS) vs. 0.730 (LVEF); P = 0.0030). Conclusions In CHF patients, GLS shows a stronger association with NT-proBNP levels with respect to LVEF. Thus, in both CHF with preserved and reduced LVEF, GLS is more accurate compared with LVEF in predicting increased levels of NT-proBNP.

The MacNew Questionnaire Is a Helpful Tool for Predicting Unplanned Hospital Readmissions After Coronary Revascularization

Background The MacNew questionnaire is a neuro-behavioral tool which is easy and immediately usable. This self-reported questionnaire filled out by the patient allows the physician to achieve helpful information concerning the ways for optimizing the therapy and patient’s lifestyles. In this retrospective study, our aim was to assess whether relatively high scores found using the MacNew questionnaire in patients who had undergone percutaneous or surgical revascularization were associated with a decreased risk of unscheduled hospitalizations during the follow-up. Methods A retrospective analysis concerning 210 patients was carried out. The clinical sheets of these patients were examined as regards the information provided in the specific questionnaires (MacNew Italian version) routinely administered during the hospitalization prescribed for recovering from recent interventions of coronary percutaneous or surgery revascularization. Every patient undergoing the psychological test with MacNew questionnaire was followed up for 3 years. Results Using univariate analysis, a global score’s high value (i.e., above the median of the whole examined population) was shown to be associated with a significantly decreased risk of rehospitalization (HR (hazard ratio): 0.4312; 95% CI: 0.3463 - 0.5370; P < 0.0001). After adjustment for age, gender and myocardial infarction as initiating event, using a multivariate Cox proportional hazards regression model, the protection exerted by a high MacNew score against the risk of hospitalizations remained significant (HR: 0.0885; 95% CI: 0.0317 - 0.2472; P < 0.0001). Conclusions A relatively elevated MacNew global score appears to be associated with a significantly decreased risk of unscheduled hospitalizations after coronary revascularization over a 3-year follow-up.