Proteasome inhibitors such as carfilzomib are indicated in multiple myeloma patients showing relapse and/or refractoriness of clonal activity. However, this therapy has been associated with a significant incidence of cardiotoxicity, especially in patients with known cardiovascular risk factors. Here we report a case of a 60-year-old woman with multiple myeloma, who developed severe congestive heart failure with positive myocardial injury biomarkers together with impaired LVEF and GLS, after treatment with carfilzomib. Therefore, chemotherapeutic drug was discontinued and neurohormonal blocking and diuretic therapy was started resulting in amelioration of symptoms, without changes in LVEF but with significant GLS improvement. Although high-grade cardiotoxicity is relatively rare in patients with non previous cardiac risk factors, it was a predictable side effect of carfilzomib use. Recognition of this syndrome is critical to instauration of appropriate therapy and prevention of morbimortality.

Objetivo: Describir las características clínicas, bioquímicas y tratamiento de pacientes con falla cardiaca descompensada con fracción de eyección reducida hospitalizados en el año 2015 en el Hospital Militar Central De Bogotá. Metodología: Estudio descriptivo en el que se revisaron registros clínicos de pacientes mayores de 18 años hospitalizados por falla cardiaca descompensada con fracción de eyección reducida en el año 2015. Se registraron variables clínicas, bioquímicas, ecocardiográficas y de tratamiento. Se realizó análisis univariado, reportando para variables cualitativas proporciones, para variables cuantitativas medidas de tendencia central y para variables que no siguen distribución normal, medianas y cuartiles 1 y 3. Resultados: Se analizaron registros de 114 pacientes, con edad promedio 74,8 años, 69,3% hombres. La etiología de la falla cardiaca fue hipertensiva 66,7% e isquémica 60,5%, la no adherencia al tratamiento fue el principal factor precipitante de descompensación, se encontró alta adherencia a guías de manejo al egreso, con medicación en dosis subóptimas, y titulación ambulatoria en el 32% de los pacientes, el 38% reingresaron al menos una vez dentro de los primeros 30 días. Un 25,4% requirió manejo en UCI con mortalidad del 18% y para reingresos tempranos del 16%, siendo de 3% para pacientes con ingresos tardíos. Conclusión: En este estudio el perfil clínico es semejante a los reportados en otras series. La adherencia a guías de manejo es adecuada pero en dosis subóptimas. Existe un alto porcentaje de reingreso registrados y de mortalidad intrahospitalaria

Measurement of cardiac output (CO) is often performed in the assessment of critically ill patients with undifferentiated shock. Doppler echocardiography has been shown to be a reliable method for estimating cardiac output when images are acquired by cardiac sonographers and interpreted by cardiologists. However, few studies have assessed the accuracy of CO measurements by Doppler echocardiography performed by non-cardiac intensivists. The purpose of this study was to compare the accuracy of CO measurements by Doppler echocardiography performed by non-cardiac intensivists vs. measurements by pulmonary artery catheter (PAC). METHODS: A prospective observational study of critically ill patients with a PAC in place was conducted. Patients in sinus rhythm and without severe mitral or aortic regurgitation were included. Two non-cardiac intensivists who were not caring for the patients and were blinded to the patients' clinical and hemodynamic data performed transthoracic goal-directed echocardiograms on all subjects. Stroke volume (SV) was calculated using a 3-beat average of the Left Ventricular Outflow Tract (LVOT) Velocity Time Integral measured by pulsed-wave Doppler and the 2-dimensional diameter of the LVOT, and CO was calculated by multiplying SV by heart rate. Simultaneously, ICU-trained nurses obtained 3 different PAC-CO measurements by thermodilution, which were subsequently averaged. Association analysis was performed using linear regression and Pearson correlation. RESULTS: Eighty-six simultaneous PAC-CO and Echo-CO measurements were obtained in 32 consecutive patients. The patients' mean age was 66 years and most common comorbidities included acute coronary syndrome (50%), respiratory failure on mechanical ventilation (37%), and post-cardiac surgery (87%). Most patients (56%) had a left ventricular ejection fraction (LVEF) <40%, and the average LVEF was 31%. A strong correlation between Echo-CO and PAC-CO was seen (Pearson correlation R¼0.89; p<0.001). The linear regression coefficient was 1.09 (95%CI 0.97-1.21; p<0.001) with an R2 of 0.79, suggesting a strong linear correlation. Both mechanically ventilated patients (n¼50) and those breathing spontaneously (n¼36) had a strong Echo-CO to PAC-CO correlation (R¼0.83 and 0.92, respectively; p<0.001 for both subgroups). CONCLUSIONS: Cardiac output measured by non-cardiac intensivists using goal-directed echocardiography had a strong correlation with gold standard measurements by thermodilution using a pulmonary artery catheter. CLINICAL IMPLICATIONS: Noninvasive measurement of cardiac output in critically ill patients using Doppler echocardiography is an accurate technique when performed by non-cardiac intensivists.

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