BackgroundCongestion is the main cause of morbidity in patients with heart failure. Treatment of fluid overload is often challenging in everyday clinical practice.ObjectiveThe aim of this study was to determine the diuretic effect of acetazolamide in patients with exacerbations of chronic heart failure, in addition to their stable diuretic therapy.MethodsThis was a single-center, unblinded study. Patients hospitalized with chronic heart failure exacerbations, with left ventricular ejection fraction (EF) < 50% and signs of volume overload, with a stable dose of diuretics anticipated by the attending physician over the next 4 days, were considered eligible for the study. On day 1, patients were randomized to receive acetazolamide orally, once daily (dose-adjusted to body weight) or no treatment (control group) as add-on diuretic therapy, on days 2 and 3. Diuresis, natriuresis, fluid balance, and symptoms were assessed daily, up to day 4.ResultsTwenty patients (mean ± standard deviation age 72 ± 11.6 years; 85% men; mean EF 33.8 ± 11.4%; mean N-terminal pro-B-type natriuretic peptide 8064 ± 5593 pg/mL; mean intravenous furosemide dose 105 ± 55 mg) were enrolled. Diuresis, natriuresis, fluid balance, and symptoms were stable on days 1–4 in the control group. An increase in diuresis and natriuresis, and a greater change in fluid balance after administration of acetazolamide, were observed in patients randomized to acetazolamide. On day 4, there was a significant difference in fluid balance between the acetazolamide and control groups (−666 ± 1194 mL vs. +332 ± 705 mL; p = 0.035), and dyspnea was lower in patients receiving acetazolamide (visual scale, p < 0.001; 5-point Likert scale, 1.444 vs. 2.222; p = 0.04)ConclusionsIn this pilot study, the addition of acetazolamide to the background diuretic regimen in patients with chronic heart failure exacerbations produced an additional diuretic effect and alleviation of dyspnea.

Impaired antiplatelet response to clopidogrel but not to aspirin may contribute to smaller anti-inflammatory response in patients with ST-elevation myocardial infarction.

Background and Aims There is little information on the incremental prognostic importance of frailty beyond conventional prognostic variables in heart failure (HF) populations from different country income levels. Methods A total of 3429 adults with HF (age 61 ± 14 years, 33% women) from 27 high-, middle- and low-income countries were prospectively studied. Baseline frailty was evaluated by the Fried index, incorporating handgrip strength, gait speed, physical activity, unintended weight loss, and self-reported exhaustion. Mean left ventricular ejection fraction was 39 ± 14% and 26% had New York Heart Association Class III/IV symptoms. Participants were followed for a median (25th to 75th percentile) of 3.1 (2.0–4.3) years. Cox proportional hazard models for death and HF hospitalization adjusted for country income level; age; sex; education; HF aetiology; left ventricular ejection fraction; diabetes; tobacco and alcohol use; New York Heart Association functional class; HF medication use; blood pressure; and haemoglobin, sodium, and creatinine concentrations were performed. The incremental discriminatory value of frailty over and above the MAGGIC risk score was evaluated by the area under the receiver-operating characteristic curve. Results At baseline, 18% of participants were robust, 61% pre-frail, and 21% frail. During follow-up, 565 (16%) participants died and 471 (14%) were hospitalized for HF. Respective adjusted hazard ratios (95% confidence interval) for death among the pre-frail and frail were 1.59 (1.12–2.26) and 2.92 (1.99–4.27). Respective adjusted hazard ratios (95% confidence interval) for HF hospitalization were 1.32 (0.93–1.87) and 1.97 (1.33–2.91). Findings were consistent among different country income levels and by most subgroups. Adding frailty to the MAGGIC risk score improved the discrimination of future death and HF hospitalization. Conclusions Frailty confers substantial incremental prognostic information to prognostic variables for predicting death and HF hospitalization. The relationship between frailty and these outcomes is consistent across countries at all income levels.

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Background Right-sided infective endocarditis (IE) ( 5-10% of all IE cases)is the most frequently observed in intravenous drug abusers (IVDA) with tricuspid valve as the most predominant site. Isolated pulmonary valve IE is an extremely rare entity in adults. Case report 27-year-old women, IVDA for 15 years, was admitted to the hospital due to fever and severe shortness of breath. Her past history was significant for isolated pulmonary valve IE of methicillin-susceptible Staphylococcus aureus 9 months before with mild pulmonary regurgitation and normal right ventricular (RV) function at discharge after medical treatment. At admission on physical examination, the patient showed tachycardia 140/’, tachypnoea, hypotension and crackles. Initial chest X-ray documented massive bilateral infiltrates. Laboratory tests showed highly elevated inflammatory markers and anaemia. Transthoracic echocardiography (TTE) revealed large (36 x 20 mm) very mobile vegetations on the pulmonary valve (Fig A), pulmonary trunk dilatation, mild pulmonary regurgitation and moderate pericardial effusion. No sign of IE was found on the tricuspid valve (Fig C), which presented anterior leaflet prolapse with mild regurgitation. Computed tomography (CT) revealed numerous cavitary infiltrates in both lungs surrounded by ground-glass opacification. Blood cultures were positive for methicillin-resistant Staphylococcus aureus. The patient was started on vancomycin. On day seven the patient status worsened with symptoms of heart failure and elevated pro-BNP up to 2833pg/ml. TTE revealed severe pulmonary regurgitation (Fig B) with pulmonary hypertension and RV dysfunction (Fig D). Repeated CT showed pulmonary embolism (PE), RV enlargement and multiple abscesses in both lungs. The patient was consulted with cardio surgeon but the intervention was denied and medical treatment was continued with vancomycin, gentamicin, rifampin, glicocorticoids, enoxaparin, betablockers, digoxin and diuretics. Under serial TTE and CT control antibiotics were continued up to 10 weeks. Ultimately patient was discharged in relatively good condition without any symptoms of heart or respiratory failure with smaller vegetation (15-16mm) on the pulmonary valve but with severe pulmonary regurgitation and mild RV enlargement and dysfunction in TTE and significant regression of pulmonary lesions and PE in CT. Discussion With respect to the high recurrence rate of right-sided IE in IVADs surgery should generally be avoided. A prolonged course of parental antibiotics is recommended in cases with lung abscesses. Conclusions We report a case of recurrent isolated pulmonary valve IE and extensive complications but with a positive outcome. Pulmonary valve IE is very rare in IVADs but requires early as well as serial multimodality imaging in the diagnostic workup. Abstract P1326 Figure. TTE of complicated pulmonary valve IE