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Critical cardiac care: update 2010

Heart Failure (HF)


This session revisited heart failure, renal failure, acute respiratory failure and arrhythmias in acute cardiac patients.

Dr. Markku Nieminen from Helsinki highlighted the importance of the patient characteristics in patients admitted with congestive heart failure. In several registries, coronary artery disease has been identified as the most common cause of heart failure, followed by hypertension, valvular dysfunction and atrial fibrillation. He stated the importance of mitral regurgitation in the survival of these patients and warned that the intensity of regurgitation is dynamic and may increase in patients with volume overload; hyponatremia also plays a role in survival. He reviewed new agents such as Tolvaptan, adenosine receptor antagonists, neseritide and others that are excellent drugs in improving diuresis or dyspnea but there are still questions on the benefits of survival. Therefore, until new evidence is obtained, he recommended treating patients following the 2008 guidelines on acute heart failure

Dr. Michel Joannidis from Innsbruck reviewed the definition of acute renal failure and pointed out that in general, it is not “acute” but rather the manifestation of some long-term kidney disease that becomes apparent due to other comorbidity. He announced a new classification by the end of this year that will combine the RIFLE and AKIN criteria. Overall, an increase of 0.3 mg/dL of creatinine is a marker of renal failure and the time the patient stays in renal failure is a determinant of survival, as well as the time the patient has a decreased urinary output. He also pointed out the value of two biomarkers, cystatin C and NGAL, both in serum and in urine in patients with severe diseases such as sepsis. Both biomarkers increase rapidly, as does creatinine, and predict patients who will require continuous renal replacement therapy. Nevertheless, these two biomarkers have not been extensively studied in cardiogenic shock. Finally, he reviewed the results of the Renal trial published last year on the different intensity of renal replacement therapy to conclude that the intensity has to be tailored to the patient’s needs, and may be initiated at 25ml/kg/h and increase if necessary, but it is important not to delay this treatment.

Dr. Marco Maggiorini from Zurich described the pathophysiology of heart failure and what leads to pulmonary oedema. In his talk, he insisted on the need to reduce pulmonary venous pressure by adequate treatment of heart failure using diuretics, vasodilators and inotropes. The role of the pulmonary artery catheter was also analyzed and its use should be reserved for patients with cardiogenic shock with very low cardiac output. Finally, he explained the use of non-invasive ventilation, either with CPAP or with inspiratory positive pressure. No new data has been presented in the last 5 years, so the indications remain as they were.

Dr. Antonis Manolis from Athens gave an extensive description of all the arrhythmias that are frequently diagnosed in critically ill patients, separating those with acute coronary syndromes from other cardiac conditions. He stated that atrial fibrillation is the most common arrhythmia and pointed out the need to prevent it in patients undergoing surgery with several drugs (among them betablockers, statins, etc). No new studies, drugs or techniques were presented.

References


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Critical cardiac care: update 2010

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.