Diastolic heart failure

Diagnosing Diastolic Heart Failure With Ultrasound: The FOAMed Report

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Also, use of albumin in spontaneous bacterial peritonitis.

Calling all ultrasound guru wannabes: EM Curious gives an excellent overview on the diagnosis of diastolic heart failure using bedside ultrasound. And for even more practice, check out tips from the team at The Ultrasound Podcast.

You know how to treat hyperkalemia in your sleep. But did you know that dextrose lasts 1 hour? And the insulin you gave lasts 4 to 6? Get some quick pearls of wisdom on how to avoid the insulin-induced hypoglycemia that can occur up to 10% of the time during the management of hyperkalemia.

Speaking of ultrasound, did you know you can use it to confirm ETT placement? ALiEM shows us a novel, nifty technique to do so. And check outa recent systematic review and meta-analysis on use of ultrasound to confirm placement. Now if only we could get ultrasound to do our taxes for us …

Work through a great case of chest pain, bradycardia, and hypotension.

What is the evidence for levophed in septic shock? Here’s a great summary and podcast.

And finally, the evidence for albumin as a volume resuscitator in shock can be mixed at best. However, use of albumin in spontaneous bacterial peritonitis has been demonstrated to reduce mortality and renal impairment. Check out a summary of the evidence at the University of Washington’s EM Journal Club.

A Heart-Failure Prevention Strategy Put to the Test.

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An intervention based on biomarker screening yields improved rates of left ventricular dysfunction but uncertain clinical benefit.
The prevalence of heart failure (HF) is rising, despite progress in understanding and treating risk factors. In a nonblinded trial, 1374 adults (average age, 65; 45% men) with ≥1 risk factor for HF (≥3, 27%) underwent annual B-type natriuretic peptide (BNP) screening and were randomized to either BNP-guided intervention or usual care, in which BNP results were unavailable to providers. Intervention-group participants with elevated BNP levels (≥50 pg/mL) were referred for echocardiography and collaborative specialist–primary care. The primary endpoint was the composite of new-onset HF and left ventricular (LV) systolic dysfunction, with or without symptoms; because of slower-than-anticipated enrollment, LV diastolic dysfunction was added to the composite endpoint after trial inception.

During mean follow-up of 4.2 years, the revised primary endpoint occurred significantly less frequently in the intervention group than in the usual-care group (5.3% vs. 8.7%; odds ratio, 0.55). The rate of asymptomatic LV dysfunction was also lower in the intervention group (4.3% vs. 6.6%; OR, 0.57; P=0.01). The risk for symptomatic HF did not differ significantly between the two groups (1.0% vs. 2.1%; OR, 0.48; P=0.12), but the risk for emergency cardiovascular hospitalization was significantly lower in the intervention group (22.3 vs. 40.4 per 1000 patient-years). Of note, renin-angiotensin-aldosterone–inhibitor use was more common in the intervention group than in the usual-care group (56.5% vs. 49.6%).

COMMENT

This study is important as a relatively rigorous attempt to assess a preventive strategy for heart failure, but the results should not change practice. The lack of blinding could explain some of the outcome differences; the importance of asymptomatic left ventricular dysfunction — especially echocardiographic diastolic abnormalities — is of questionable importance to patients; and the feasibility of implementing the intervention in large populations remains unclear. Nonetheless, these findings should initiate a robust discussion about HF prevention, including the value of biomarkers for this purpose.

 

Source: NEJM