César Belziti

Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema: A Meta-Analysis of Randomized Controlled Trials

BACKGROUNDnThe evidence of individual studies in acute cardiogenic pulmonary edema (ACPE) supporting noninvasive ventilation (NIV) is still inconclusive, particularly regarding noninvasive positive pressure ventilation (NIPPV).nnnMETHODSnWe carried out a meta-analysis. We searched in the Embase, Medline, Cinahl, Dare, Coch, Central, and CNKI databases and congress abstracts for trials comparing continuous positive airway pressure (CPAP) or NIPPV with standard therapy (ST). To assess treatment effects, we carried out direct comparison using a random effects model and adjusted indirect comparison.nnnRESULTSnAt total of 34 studies (3,041 patients) were included. In direct comparisons, both CPAP and NIPPV reduced the risk of death (relative risk [RR] 0.64, 95% CI 0.44-0.93; RR 0.80, 95% CI 0.58-1.10; respectively) compared with ST, although only CPAP had a significant effect. There were no significant differences between NIPPV and CPAP. Pooled results of direct and adjusted indirect comparisons showed that compared with ST, both CPAP and NIPPV significantly reduced mortality (RR 0.63, 95% CI 0.44-0.89; RR 0.73, 95% CI 0.55-0.97; respectively).nnnCONCLUSIONSnOur findings suggest that among ACPE patients, NIV delivered through either NIPPV or CPAP reduced mortality.

Empeoramiento de la función renal en pacientes hospitalizados por insuficiencia cardiaca aguda descompensada: incidencia, predictores y valor pronóstico

Insuficiencia cardiaca. Volumen 63, Numero 03, Marzo 2010 nnnnnSumarionImprimirnTexto completonAnterior | SiguientenDescargar PDFnBuscar en medline articulos de:n Cesar A. Belziti Rodrigo Bagnati Paola Ledesma Norberto Vulcano Sandra Fernandez nnnnnnBuscar: Busqueda avanzada nEmpeoramiento de la funcion renal en pacientes hospitalizados por insuficiencia cardiaca aguda descompensada: incidencia, predictores y valor pronostico nCesar A. Belzitia; Rodrigo Bagnatia; Paola Ledesmaa; Norberto Vulcanoa; Sandra Fernandeza nna Servicio de Cardiologia. Hospital Italiano de Buenos Aires. Buenos Aires. Argentina.nnnnRev Esp Cardiol.2010; 63(03) :294-302 nnnnIntroduccion y objetivos. La insuficiencia cardiaca aguda descompensada (ICAD) es causa frecuente de hospitalizacion y se asocia con riesgo de empeoramiento de la funcion renal (EFR). El objetivo fue determinar la incidencia, los predictores y el pronostico a 1 ano de los pacientes ingresados por ICAD con EFR. Metodos. Se analizaron de forma retrospectiva los datos de 200 pacientes consecutivos ingresados por ICAD. Se considero EFR cuando la creatinina serica aumento durante la hospitalizacion 0,3 mg/dl y = 25% con respecto al valor al ingreso. Resultados. El 23% de los pacientes sufrio un EFR. En el analisis multivariable, ser mayor de 80 anos �odds ratio (OR) = 2,72; intervalo de confianza (IC) del 95%, 1,86-3,42�, la tasa de filtrado glomerular < 60 ml/min/1,73 m2 �OR = 2,05; IC del 95%, 1,53-2,27� y la presion arterial sistolica al ingreso < 90 mmHg �OR = 1,61; IC del 95%, 1,17-3,22� se asociaron independientemente con el EFR. La mortalidad o reingreso por ICAD a 1 ano, analizada por la prueba de rangos logaritmicos, fue mayor en el grupo con EFR (p < 0,01). La mediana de hospitalizacion fue 9 dias para los pacientes con EFR y 4 dias para aquellos sin EFR (p < 0,05). En el analisis multivariable, el EFR se mantuvo asociado independientemente con mortalidad o reingreso por ICAD (hazard ratio = 1,65; IC del 95%, 1,12-2,67; p = 0,003). Conclusiones. El EFR es una complicacion frecuente en los pacientes ingresados por ICAD, se asocia con internaciones mas prolongadas, mayor mortalidad o reingreso por ICAD. Existen variables clinicas para identificar al ingreso hospitalario a la poblacion con mayor riesgo de EFR.

Worsening Renal Function in Patients Admitted With Acute Decompensated Heart Failure: Incidence, Risk Factors and Prognostic Implications

INTRODUCTION AND OBJECTIVESnAcute decompensated heart failure (ADHF) is a common cause of hospital admission and is associated with an increased risk of worsening renal function (WRF). The aims of this study were to investigate the incidence and predictors of WRF in patients admitted for ADHF and to assess the prognostic significance of WRF at 1 year.nnnMETHODSnA retrospective analysis of data on 200 consecutive patients admitted with ADHF was carried out. By definition, WRF occurred when the serum creatinine level increased during hospitalization by 0.3 mg/dL and by > or =25% from admission.nnnRESULTSnOverall, 23% of patients developed WRF. On multivariate analysis, age >80 years (odds ratio [OR]=2.72; 95% confidence interval [CI], 1.86-3.42), admission glomerular filtration rate <60 mL/min per 1.73 m2 (OR=2.05; 95% CI, 1.53-2.27) and admission systolic pressure <90 mmHg (OR=1.61, 95% CI, 1.17-3.22) were independently associated with WRF. The rate of mortality or readmission for heart failure (HF) at 1 year was higher in the WRF group (P< .01 by log-rank test). The median hospital stay was 9 days for patients with WRF and 4 days for those without (P< .05). On multivariate analysis, WRF remained independently associated with mortality or HF rehospitalization (hazard ratio=1.65; 95% CI, 1.12-2.67; P=.003).nnnCONCLUSIONSnIn patients admitted for ADHF, WRF was a common complication and was associated with a longer hospital stay and an increased risk of mortality or HF hospitalization. Clinical characteristics at admission can help identify patients at an increased risk of WRF.

Usefulness of MRI in takotsubo cardiomyopathy: a review of the literature

Takotsubo cardiomyopathy (TC) is a disease that can be misinterpreted as a more serious acute coronary syndrome. Its clinical characteristics resemble those of a myocardial infarct, while its imaging characteristics are critical on correctly characterizing and diagnosing the disease. From angiography, where coronary anatomy is evaluated, to cardiac magnetic resonance (CMR), where morphology and tissue characterization is assessed, the array of imaging options is quite extent. In particular, CMR has achieved great improvements (stronger magnetic fields, better coils, etc.) in the last decade which in turn has made this imaging technology more attractive in the evaluation and diagnosis of TC. With its superior soft tissue resolution and dynamic imaging capabilities, CMR is currently, perhaps, the most useful imaging technique in TC as apical ballooning or medio-basal wall motion abnormalities (WMA), presence of wall edema and late gadolinium enhancement (LGE) characteristics are critical in the diagnosis and characterization of this pathology. In this review, CMRs role in TC will be evaluated in light of the current available evidence in medical literature, while also revising the clinical and physiopathologic characteristics of TC.

Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio as predictors of survival after heart transplantation: NLR and PLR after heart transplantation

The aim of this study was to evaluate whether neutrophil‐to‐lymphocyte ratio (NLR) and platelet‐to‐lymphocyte ratio (PLR) predict outcome in heart failure (HF) patients undergoing heart transplantation (HTX).

Assessment of fractional excretion of urea for early diagnosis of cardiac surgery associated acute kidney injury

Abstract Background: Acute kidney injury (AKI) is a common complication after cardiac surgery (CS). Recently, neutrophil gelatinase-associated lipocalin (NGAL) was shown to predict AKI development earlier than serum creatinine, but it is not widely used in clinical practice. Fractional excretion of urea (FeU) has been referred to as a useful tool to discriminate between prerenal and established AKI. The aim of our study is to evaluate the sensitivity and specificity of FeU, in the early diagnosis of AKI in patients undergoing CS. Methods: We performed a prospective study on adults undergoing CS. AKI was defined by AKIN criteria. Individuals suffering from CKD, were excluded. Sensitivity and specificity of FeU, fractional excretion of sodium (FeNa) and urine NGAL, measured at 1, 6 and 24u2009h following CS, were assessed. Results: We included 66 patients (26% female) aging 68u2009±u200911 years. AKI prevalence was 24% and mortality was 3.28%. Patients with AKI had a significantly lower FeU compared to those without AKI (23.89u2009±u20090.67% vs. 34.22u2009±u20090.58%; pu2009<u20090.05) 6u2009h after CS, but not at the 1- and 24-h time points. NGAL was also statistically significant between both groups. FeU showed a 75% sensitivity and 79.5% specificity; the AUC was 0.786. ROC analysis of FeU and NGAL yielded similar values (pu2009=u2009NS). Conclusion: FeU is useful as an early biomarker to predict AKI after CS and it is comparable to the new biomarker NGAL.

New-Onset Liver Failure: Pitfalls of an Unusual Diagnosis

Introduction: Heart failure is the second most common cause of ascites after cirrhosis. There are cardiac and noncardiac etiologies of ascites, and the multimodality imaging approach is a rich tool to redefine the final diagnosis. Case Presentation: We present a case-series where 3 patients were referred to our hospital for further hepatology assessment due to severe abdominal ascites and liver failure. Constrictive pericarditis was diagnosed in all of them. Nowadays, constrictive pericarditis is a well-known disease, but sometimes its clinical presentation may delay the treatment and worsen the prognosis. Our 3 cases had similar clinical scenarios and hemodynamic patterns when undergoing right-heart catheterization, but they had different anatomical pericardium-compromise, requiring different surgical strategies. Conclusions: Nowadays, multimodality imaging, especially cardiac magnetic resonance imaging and cardiac computed tomography, allows us to study a wide spectrum of the same disease in terms of anatomical compromise and cardiac physiology in order to stratify different prognosis and treatment options. We describe 3 unusual clinical cases where the initial differential diagnosis denoted noncardiac etiologies. The level of serum NT-proBNP proved pivotal to the redefinition of the clinical scenario and differentiation between the cardiac and noncardiac etiologies of new-onset ascites. A multidisciplinary approach in this setting between internists, hepatologists, and cardiologists was helpful to establish the final diagnosis in all the patients.

Validación de un instrumento para la evaluación de la interpretación de los resultados de estudios de investigación en los residentes de un hospital universitario.

La informacion medica que hoy en dia se publica en revistas de interes cientifico es abundante. En este contexto, la habilidad para interpretar criticamente los estudios de investigacion resulta ser esencial con el objeto de ofrecer a los pacientes una atencion medica de alta calidad [1,2]. Evaluar adecuadamente lo relevante de esta informacion requiere que el medico sea capaz de reconocer los distintos disenos de investigacion, interpretar las pruebas estadisticas mas frecuentemente utilizadas y comprender como se informan los resultados. Un estudio [1] realizado en 11 programas de residencias de Medicina Interna en Connecticut (EE. UU.) y otro en Dinamarca [3], ambos utilizando una prueba de eleccion de opciones multiples, han demostrado que los medicos sin entrenamiento formal en epidemiologia y estadistica presentaban una pobre comprension de las pruebas estadisticas mas utilizadas y una interpretacion limitada de los resultados de las investigaciones. Solo el 21% de los medicos era capaz de analizar correctamente los articulos de investigacion presentados. A partir de estos estudios y de una encuesta realizada a los directores de programa de residencias en EE. UU. [4] surge una fuerte recomendacion de tener en cuenta un entrenamiento mas efectivo en este campo en el diseno de los programas de formacion del medico residente. En este escenario nos hemos propuesto desarrollar y validar un instrumento que permita conoValidacion de un instrumento para la evaluacion de la interpretacion de los resultados de estudios de investigacion en los residentes de un hospital universitario

Acute Kidney Injury After Cardiac Transplantation: Foe or Common Innocent Bystander?

BACKGROUNDnHeart transplantation (HT) is regarded as the treatment of choice for end-stage heart failure (ESHF) patients. Severe acute kidney injury (AKI) after HT is a frequent clinical problem with devastating consequences for HT recipients.nnnMETHODSnData from 112 ESHF patients undergoing HT in 2010-2015 were retrospectively reviewed. The primary end point was the development of AKI stage III, and secondary outcomes were in-hospital and 1-year mortality according to Kidney Disease Improving Global Outcomes criteria.nnnRESULTSnIn total, 81 patients (72.3%) developed AKI, of which 33 (29.4%) developed AKI stage I, 18 (16%) stage II, and 30 (26.7%) stage III; within this group, 27 recipients (24%) required renal replacement therapy (RRT). Overall hospital mortality was 14%. However, when stratifying by AKI stage, hospital mortality increased from 0% to 46% comparing recipients without AKI and those with AKI stage III, respectively (Pxa0= .001). In the same way, 1-year mortality increased from 6% to 53% for recipients without AKI compared with those who developed AKI stage III (log-rank test for trend: Pxa0= .001). Recipients that required RRT had a 1-year mortality of 59.2% compared with 5.8% in those without RRT requirement.nnnCONCLUSIONSnThe findings indicate that AKI stage III is common after HT and adversely affects early and late mortality. Clinical variables together with perioperative hemodynamic assessment could add more powerful prognostic information to predict severe AKI before HT and therefore evaluate potential heart-kidney recipients.

Hypertrophic Cardiomyopathy, All Phenotypes in one

Hypertrophic cardiomyopathy (HCM) is an intrinsic myocardial disorder characterized by cardiac hypertrophy (wall thickness ≥ 15 mm), that is not explained by conditions of pressure overload (eg, hypertension, severe aortic stenosis).1 HCM is the most common genetic primary cardiomyopathy, with a prevalence estimated to be about one in 500 adults in the general population.2 More than 450 mutations have been identified in the 20 genes that cause different phenotypes. In most cases, HCM is associated with sarcomere protein gene mutations, and exhibits multiple phenotypic expressions. We present a case that combines all phenotypes.3