2012 August 15

Role of heart rate as a marker and mediator of poor outcome for patients with heart failure.

Curr Heart Fail Rep Start a Discussion »

Aug 152012

Role of heart rate as a marker and mediator of poor outcome for patients with heart failure.

Curr Heart Fail Rep. 2012 Jun;9(2):133-8

Authors: Kapoor JR, Heidenreich PA

Abstract

Tachycardia has been associated with worse outcomes for patients with heart failure and is also thought to have a direct adverse impact on the myocardium. This report highlights the current evidence for heart rate as both a risk factor and mediator for poor outcome for patients with heart failure. We summarize the large number of studies evaluating heart rate in patients with systolic dysfunction and newer studies that examine patients with preserved systolic function. The effect on outcomes in heart failure of medications known to slow the heart rate such as ?-blockers and the more recently developed drug ivabradine are discussed. The data clearly show that a high heart rate is a marker of increased mortality. There is also a strong suggestion that a higher heart rate directly worsens outcome and that this can be mitigated by heart rate-reducing medications.

PMID: 22351045 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

International consensus guidelines for nutrition therapy in pancreatitis.

JPEN J Parenter Enteral Nutr Start a Discussion »

Aug 152012

International consensus guidelines for nutrition therapy in pancreatitis.

JPEN J Parenter Enteral Nutr. 2012 May;36(3):284-91

Authors: Mirtallo JM, Forbes A, McClave SA, Jensen GL, Waitzberg DL, Davies AR, International Consensus Guideline Committee Pancreatitis Task Force

Abstract

Guidelines for nutrition support in pancreatitis have been inconsistently adapted to clinical practice. The International Consensus Guideline Committee (ICGC) established a pancreatitis task force to review published guidelines for pancreatitis in nutrition support. A PubMed search using the terms pancreatitis, acute pancreatitis, chronic pancreatitis, nutrition support, parenteral nutrition, enteral nutrition, and guidelines was conducted for the period from January 1999 to May 2011. Eleven guidelines were identified for review. The ICGC used the following process to develop unified guideline statements: summarize the strength of evidence (grading) of the guidelines; establish level of evidence for ICGC statements as high, intermediate, and low; assign published guideline levels of evidence; and define an ICGC grading system. International Pancreatitis Guideline Grades were established as follows: platinum-high level of evidence and consistent agreement among the guidelines; gold-acceptable level of evidence and no conflicting statements in guidelines; and silver-single existing guideline statement with no conflict in other guidelines. Eighteen ICGC statements were derived from the 11 published pancreatitis guidelines. Uniform agreement from widely disparate groups (United States, Europe, Japan, and China) resulted in 4 platinum-level guideline statements for nutrition in pancreatitis: nutrition support therapy (NST) is generally not needed for mild to moderate disease, NST is needed for severe disease, enteral nutrition (EN) is preferred over parenteral nutrition (PN), and use PN when EN is contraindicated or not feasible. This methodology provides a template for future ICGC nutrition guideline development.

PMID: 22457421 [PubMed - indexed for MEDLINE]

Link to Article at PubMed

Accuracy of the MDRD (Modification of Diet in Renal Disease) Study and CKD-EPI (CKD Epidemiology Collaboration) Equations for Estimation of GFR in the Elderly.

Am J Kidney Dis Start a Discussion »

Aug 152012

Accuracy of the MDRD (Modification of Diet in Renal Disease) Study and CKD-EPI (CKD Epidemiology Collaboration) Equations for Estimation of GFR in the Elderly.

Am J Kidney Dis. 2012 Aug 11;

Authors: Kilbride HS, Stevens PE, Eaglestone G, Knight S, Carter JL, Delaney MP, Farmer CK, Irving J, O'Riordan SE, Dalton RN, Lamb EJ

Abstract

BACKGROUND: Glomerular filtration rate (GFR) is a measure of kidney function, commonly estimated using equations that adjust serum creatinine concentration for age, race, and sex. The Modification of Diet in Renal Disease (MDRD) Study equation is widely used, but underestimates GFR at higher levels. The serum creatinine-based Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI(cr)) equation generally provides more accurate estimation at GFR >60 mL/min/1.73 m(2). Newer equations have been reported using cystatin C concentration either alone (CKD-EPI(cys)) or in combination with creatinine concentration (CKD-EPI(cr-cys)). None of these equations has been well validated in older people. We tested the accuracy of these equations in people 74 years or older compared with GFR measured by a reference method. STUDY DESIGN: Diagnostic test evaluation in a prospective cohort. SETTING & PARTICIPANTS: Participants (n = 394; median age, 80 [range, 74-97] years) recruited from nephrology clinics and the community. INDEX TEST: GFR estimated using the MDRD Study, CKD-EPI(cr), CKD-EPI(cys) and CKD-EPI(cr-cys) equations. REFERENCE TEST: GFR measured using an iohexol clearance method. RESULTS: Median measured GFR was 53.4 (range, 7.2-100.9) mL/min/1.73 m(2). MDRD Study-, CKD-EPI(cr)-, and CKD-EPI(cr-cys)-estimated GFRs overestimated GFR (median differences of 3.5 [P< 0.001], 1.7 [P < 0.001], and 0.8 [P = 0.02] mL/min/1.73 m(2), respectively); the CKD-EPI(cys) equation was unbiased. Accuracy (percentage of estimates within 30% of measured GFR [P(30)]) was 81%, 83%, 86%, and 86% for the MDRD Study, CKD-EPI(cr), CKD-EPI(cys), and CKD-EPI(cr-cys) equations, respectively. Accuracy of the MDRD Study equation was inferior (P = 0.004) to the CKD-EPI(cr) equation at GFR >60 mL/min/1.73 m(2). LIMITATIONS: Those of non-European ancestry were not included. For practical reasons, only a 4-hour sampling protocol was used for iohexol clearance. CONCLUSIONS: The CKD-EPI(cr) equation appeared less biased and was more accurate than the MDRD Study equation. No equation achieved an ideal P(30) in the overall population. Our data suggest that GFR estimation is as satisfactory in older people of European ancestry as it has been reported to be in younger individuals.

PMID: 22889713 [PubMed - as supplied by publisher]

Link to Article at PubMed

Risk factors and outcomes for prolonged vs. brief fever – a prospective cohort study.

Crit Care Start a Discussion »

Aug 152012

Risk factors and outcomes for prolonged vs. brief fever - a prospective cohort study.

Crit Care. 2012 Aug 13;16(4):R150

Authors: Seguin P, Roquilly A, Mimoz O, Le Maguet P, Asehnoune K, Biederman S, Carise E, Malledant Y, Group A

Abstract

ABSTRACT: INTRODUCTION: Prolonged fever occurs with infectious and noninfectious diseases but is poorly studied in intensive care units. The aims of this prospective multicenter noninterventional study were to determine the incidence and etiologies of prolonged fever in critically ill patients and compare outcomes for prolonged fever and short-lasting fever. METHODS: The study involved 2 periods of 2 months each with 507 patients hospitalized [greater than or equal to]24 hours. Fever was defined by at least one episode of temperature [greater than or equal to]38.3degreesC and prolonged fever as lasting >5 days. Backward stepwise logistic regression was performed to identify the independent factors associated with prolonged fever vs short-lasting fever. RESULTS: Prolonged or short-lasting fever occurred in 87 (17%) and 278 (55%) patients, respectively. Infectious and noninfectious causes were found in 54 (62%) and 27 (31%) of 87 patients, respectively; in 6 patients (7%) prolonged fever remained unexplained. The two most common sites of infection were ventilator-associated pneumonia (n = 25) and intra-abdominal infection (n = 13). Noninfectious fever (n = 27) was neurogenic in 19 (70%) patients and mainly associated with cerebral injury (84%). Independent risk factors for prolonged fever were cerebral injury at admission (OR = 5.03; CI 95%, 2.51-10.06), severe sepsis (OR = 2.79; CI 95%, 1.35-5.79), number of infections (OR = 2.35; CI 95%, 1.43-3.86), and mechanical ventilation duration (OR = 1.05; CI 95%, 1.01-1.09). Older patients were less likely to develop prolonged fever. ICU mortality did not differ between the 2 groups. CONCLUSIONS: Prolonged fever was common, mainly due to severe infections, particularly ventilator-associated pneumonia, and mixed infectious causes were frequent, warranting systematic and careful search for multiple causes. Neurogenic fever was also particularly frequent.

PMID: 22889136 [PubMed - as supplied by publisher]

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Interleukin-6 is the strongest predictor of 30-day mortality in patients with cardiogenic shock due to myocardial infarction.

Crit Care Start a Discussion »

Aug 152012

Interleukin-6 is the strongest predictor of 30-day mortality in patients with cardiogenic shock due to myocardial infarction.

Crit Care. 2012 Aug 13;16(4):R152

Authors: Andrie RP, Becher UM, Frommold R, Tiyerili V, Schrickel JW, Nickenig G, Schwab JO

Abstract

ABSTRACT: INTRODUCTION: Cardiogenic shock (CS) remains the leading cause of death in patients hospitalized for myocardial infarction (MI). Systemic inflammation with inappropriate vasodilatation is observed in many patients with CS and may contribute to an excess mortality rate. The purpose of this study was to determine the predictive role of serial measurements of Nt-proBNP, interleukin-6 (IL-6) and procalcitonin (PCT) for 30-day mortality in patients with CS due to MI. METHODS: The present study is a prospective single-center-study including 87 patients with MI complicated by CS treated with acute revascularization and intra-aortic-balloon-counterpulsation (IABP) support. Predictive values of plasma levels at admission (T0), after 24 hours (T1), and after 72 hours (T2) were examined according to 30-day mortality. RESULTS: Significant differences between survivors (n=59) and non-survivors (n=28) were seen for Nt-proBNP at T0, for IL-6 at T0 and T1, and for PCT at T1 and T2. According to ROC analyses, highest accuracy predicting 30-day mortality was seen at T0 for IL-6, at T1 for PCT, and at T2 for PCT. In univariate analysis significant values were found for Nt-proBNP at T1, for IL-6 and PCT at all points of time. Within the multivariate analysis, age, creatinine and IL-6 were significant determinants of 30-day mortality in which IL-6 showed the highest level of significance. CONCLUSIONS: In patients with MI complicated by CS, IL-6 represented a reliable independent early prognostic marker of 30-day mortality. PCT revealed a significant value at later points of time whereas Nt-proBNP seemed to be of lower relevance.

PMID: 22889197 [PubMed - as supplied by publisher]

Link to Article at PubMed

Vasopressin and terlipressin in adult vasodilatory shock: a systematic review and meta-analysis of nine randomized controlled trials.

Crit Care Start a Discussion »

Aug 152012

Vasopressin and terlipressin in adult vasodilatory shock: a systematic review and meta-analysis of nine randomized controlled trials.

Crit Care. 2012 Aug 14;16(4):R154

Authors: Serpa Neto A, Nassar Junior AP, Cardoso SO, Manettta JA, Pereira VG, Esposito DC, Damasceno MC, Russell JA

Abstract

ABSTRACT: INTRODUCTION: Catecholamines are the most used vasopressors in vasodilatory shock. However, the development of adrenergic hyposensitivity and the subsequent loss of catecholamine pressor activity necessitate the search for other options. Our aim was to evaluate the effects of vasopressin and its analogue terlipressin compared with cathecolamine infusion alone in vasodilatory shock. METHODS: Systematic review and meta-analysis of publications between 1966 and 2011. The Medline and CENTRAL databases were searched for studies on vasopressin and terlipressin in critically ill patients. The meta-analysis was limited randomized controlled trials evaluating the use of vasopressin and/or terlipressin compared to cathecolamine in adult patients with vasodilatory shock. The assessed outcomes were: overall survival, changes in the hemodynamic and biochemical variables, a decrease of catecholamine requirements, and adverse events. RESULTS: Nine trials covering 998 participants were included. A meta-analysis using a fixed-effect model showed a reduction in norepinephrine requirement among patients receiving terlipressin or vasopressin infusion compared with control (standardized mean difference, -1.58 [95% CI, -1.73 - -1.44]; p < 0.0001). Overall, vasopressin and terlipressin, as compared with norepinephrine, reduced mortality (relative risk, RR: 0.87 [0.77 - 0.99]; p = 0.04). Vasopressin compared with norepinephrine decreased mortality in adult patients (RR: 0.87 [0.76 - 1.00]; p = 0.05) and in patients with septic shock (42.5 vs. 49.2%, respectively; RR, 0.87 [95% CI, 0.75 - 1.00]; p = 0.05; number needed to treat, 1 to 15). There was no difference between in adverse events between the vasopressin and control groups (RR: 0.98 [0.65 - 1.47]; p = 0.92). CONCLUSIONS: Vasopressin use in vasodilatory shock is safe, associated with reduced mortality, and facilitates weaning of catecholamines. In patients with septic shock vasopressin compared to norepinephrine may decrease mortality also.

PMID: 22889256 [PubMed - as supplied by publisher]

Link to Article at PubMed

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