Background and importance Acute heart failure (AHF) is one of the main causes of unplanned hospitalization in patients >65 years of age and is associated with adverse outcomes in this population. Observational studies suggest that intravenous diuretic therapy given in the first hour of presentation for AHF was associated with favorable outcomes. ObjectivesTo study the short-term prognostic associations of the timing of intravenous diuretic therapy in patients admitted to the emergency department (ED) for acute AHF. Design, settings and participantsPatients treated in the ED with intravenous diuretics were selected from the Estratificação de Doentes com InsuFIciência Cardíaca Aguda (EDIFICA) registry, a prospective study including AHF hospitalized patients. Early and non-early furosemide treatment groups were considered using the 1-h cutoff: door-to-furosemide ≤1 h and >1 h.Outcomes measure and analysis Primary outcomes were a composite of heart failure re-hospitalizations or cardiovascular death at 30-and 90-days. Main resultsFour-hundred ninety-three patients were included in the analysis. The median (interquartile range) door-to-furosemide time was 85 (41-220) min, and 210 (43%) patients had diuretics in the first hour. Patients in the ≤1 h group had higher evaluation priority according to the Manchester Triage System, presented more often with acute pulmonary edema, warm-wet clinical profile, higher blood pressure, and signs of left-side heart failure, while >1 h group had higher Get With the Guidelines-heart failure risk score, more frequent signs of right-side heart failure, higher circulating B-type natriuretic peptides and lower albumin. Door-to-furosemide ≤ 1 h was independently associated with lower 30-day heart failure hospitalizations and composite of heart failure hospitalizations or cardiovascular death (adjusted analysis Heart Failure Hospitalizations: odds ratios (OR) 3.65; 95% confidence interval (CI), 1.22-10.9; P = 0.020; heart failure hospitalizations or cardiovascular death: OR 3.15; 95% CI, 1.49-6.64; P < 0.001). These independent associations lost significance at 90 days.Conclusion Door-to-furosemide ≤1 h was associated with a lower short-term risk of heart failure hospitalizations or cardiovascular death in AHF patients. Our findings add to the existing evidence that early identification and intravenous diuretic therapy of AHF patients may improve outcomes.
Objective: Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute myocardial infarction, caused by a non-traumatic and non-iatrogenic separation of the coronary arterial wall, especially amongst young women with no conventional cardiovascular risk factors. The most common factors associated with SCAD are fibromuscular dysplasia (FMD), postpartum, multiparity, connective tissue disorders, systemic inflammatory conditions and hormonal therapy. After extensive diagnostic workup some cases are labeled as idiopathic. In the literature reported cases of aortic, cervical and carotid arterial dissections, but not SCAD, were associated with Cushing syndrome. Design and method: We describe a 46-year-old woman with a past medical history of Cushing disease (ACTH-producing pituitary tumor) treated surgically in 2009 that presented with SCAD. Results: A nulliparous, hypertensive, obese and non-smoker 46-year-old woman with a surgically treated Cushing disease in 2009, presented to the emergency department with a retrosternal chest pain with radiation to the left arm lasting for 30 minutes, nausea and diaphoresis. No ischemic changes were seen in the electrocardiogram but serum high sensitive troponin I test rose to a pic level of, 96.3 ng/L (normal range <16 ng/L). Cardiac catheterization revealed diffuse distal stenosis of the anterior descending coronary artery, compatible with spontaneous dissection type 2, with Thrombolysis in Myocardial Infarction (TIMI) II flow. The patient was treated conservatively, with anticoagulation during hospitalization and single anti-aggregation without reported complications. Further investigations were performed to explore possible etiologies or associations for SCAD. Serum inflammatory, auto-immune and immunologic workups were negative. Angio-CT scan of the abdomen and supra-aortic trunks showed no signs of FMD or inflammatory changes. Conclusions: Cushing Syndrome is not considered a traditional risk factor for SCAD. As there are reported cases of arterial dissections in the literature associated with this entity and common causes of SCAD were excluded we hypothesized that the patient past medical history may have contributed to SCAD. In fact, high cortisol levels may increase blood vessel fragility, making vessel walls more vulnerable. To the best of our knowledge there are no other reported cases in the literature of Cushing syndrome associated SCAD.
IgA Nephropathy (IgAN) is the most prevalent biopsy-proven primary glomerular disease worldwide. Historically, thrombotic microangiopathy (TMA) was associated with IgAN in cases of severe hypertension or advanced chronic kidney disease, but recent data suggest that complement activation plays a crucial role in the development of TMA in IgAN. We report a case of Crescentic IgAN with complement-mediated TMA (C-TMA) in a 27-year old male patient with a pathological missense mutation in heterozygosity in the CFH gene and a rare variant in the C3 gene, treated with steroids, cyclophosphamide and plasmapheresis without recovery of kidney function. We also discuss other treatment possibilities and kidney transplant options. Additionally, we will review the latest advances that are enhancing our understanding of the association between IgAN and TMA.
The superior vena cava syndrome refers to a medical emergency resulting from superior vena cava compression, which develops in 2%-4% of non-Hodgkin lymphomas. Primary mediastinal (thymic) large B-cell lymphoma is an unusual and aggressive non-Hodgkin lymphoma that can present with superior vena cava syndrome. We report the case of a Caucasian 21-year-old female, who presented with acute superior vena cava syndrome, having started 2 weeks before. Chest computerized tomography disclosed an anterior mediastinal mass (18 × 14 cm). Thoraco - abdominopelvic magnetic resonance imaging was performed in order to differentiate compression versus mass invasion. A gross anterior mediastinal mass (109 × 60 × 105 mm) occupying the totality of the prevascular space was found, extending from the sternal furcula to the pericardium, fully embedding the superior vena cava. A computerized tomography guided biopsy was performed. Histopathological and immunohistochemical analysis was consistent with Primary mediastinal (thymic) large B-cell lymphoma. Primary mediastinal (thymic) large B-cell lymphoma has unique clinicopathologic aspects and it should be considered in a young patient with Superior vena cava syndrome. Prompt recognition, a timely diagnosis and appropriate treatment are crucial for prognosis.
An epidemic of Coronavirus disease 2019 outbroke in December 2019 in China, Wuhan, which is becoming a Public Health Emergency of International Concern. As this entity has become one of the worst infectious disease outbreaks of recent times, with mortality estimates in general population ranging from 1.4% to 8%, it is crucial to better understand the prognostic factors which can be associated to the outcome of this disease. However, as the pandemic is still unfortunately under progression, there are limited data with regard to the prognostic factors. Hence, this review seeks to gather and provide the existing data of the literature of all the prognosis factors of COVID-19 infection such as older age, obesity, comorbidities, lymphocytopenia, d-dimers elevation, thrombocytopenia, elevated levels of high-sensitivity cardiac troponin, C-reactive protein elevation and imaging features of COVID-19.
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