Risk of intraoperative hypotension with loop diuretics: a randomized controlled trial.

BACKGROUND: There is growing concern regarding the safety of blood pressure-lowering medications administered during the perioperative period. Whether loop diuretics also induce intraoperative hypotension is uncertain. Our objective was to compare the effects of continuing or withholding furosemide on the day of noncardiac elective surgery on intraoperative hypotension among chronic users of furosemide. METHODS: A double blind, randomized, placebo controlled trial was conducted at 3 North American university centers between September 2000 and December 2006. Participants were randomly assigned in a 1:1 ratio to receive either furosemide or placebo on the day of surgery. The primary outcome was risk of developing intraoperative hypotension. A priori secondary outcomes included risk of heart failure; composite cardiovascular event (myocardial infarction, arrhythmia, stroke or transient ischemic attack, or death); and change in renal function and electrolytes. RESULTS: Of the 212 patients enrolled, 193 patients underwent surgery. There was no significant difference in risk of developing intraoperative hypotension between the furosemide (49%) and placebo (51.9%) groups (relative risk [RR], 0.95; 95% confidence interval [CI], 0.72-1.24; P = .78). The intraoperative administration of vasopressors and fluids were similar between both groups. The risk of developing postoperative cardiovascular events was not significantly different between those randomized to furosemide (4.8%) or placebo (2.8%) (RR, 1.73; 95% CI, 0.42-7.06; P = .49). There was no significant difference in renal function or electrolytes between the 2 groups. CONCLUSION: Among elective, noncardiac surgeries in patients chronically treated with furosemide, the administration of furosemide on the day of surgery did not significantly increase the risk for intraoperative hypotension.

Venous thromboembolism prophylaxis in hospitalized heart failure patients.

BACKGROUND: Venous thromboembolism (VTE) is a concerning problem for hospitalized heart failure (HF) patients. Current recommendations are that all hospitalized New York Heart Association Class III or IV HF patients should receive VTE prophylaxis. Our purpose was to describe the rate of use and the characteristics of patients receiving VTE prophylaxis in the Acute Decompensated Heart Failure National Registry (ADHERE). METHODS AND RESULTS: HF hospitalization episodes in ADHERE were analyzed. Patients were excluded from analysis if they were receiving Coumadin or intravenous heparin, had elevated troponin levels, underwent cardiac catheterization or dialysis before or during hospitalization, or were initially admitted to the intensive care unit. VTE prophylaxis was defined as low-molecular-weight or subcutaneous unfractionated heparin administered at any time during hospitalization and intravenous vasoactive therapy was defined as any inotrope, inodilator, or vasodilator. Chi-square, analysis of variance, and Wilcoxon tests were used for univariate and multivariate analyses. Logistic regression was used to evaluate outcomes. A total of 155,073 entries were evaluated, with 71,376 eligible for VTE prophylaxis; 21,847 (31%) received VTE prophylaxis. VTE prophylaxis patients were more often African American (28% versus 21%) or admitted from the emergency department (84% versus 79%), compared with those who did not receive VTE prophylaxis (both P < .0001). Medical history and initial presentation characteristics were similar, except edema, which was more likely in VTE prophylaxis patients (71% versus 66%, P < .0001). Patients receiving VTE prophylaxis more often received an intravenous vasoactive agent (23% versus 18%), angiotensin-converting enzyme inhibitor (61% versus 54%), or beta-blocker (63% versus 58%) during their hospitalization and were more likely discharged on an angiotensin-converting enzyme inhibitor (53% versus 49%) or beta-blocker (57% versus 54%) than non-VTE prophylaxis patients, all P < .0001. VTE prophylaxis patients were more often admitted to the intensive care unit (4.8% versus 2.5%, P < .0001) and had longer median hospital stays (4.2 versus 3.8 days, P < .0001). Mortality was similar between cohorts (3.0% versus 2.9%, P = .69). CONCLUSIONS: Despite recommendations that all hospitalized New York Heart Association III and IV CHF patients receive venous thromboembolic disease prophylaxis, less than one third of eligible patients receive this guideline recommended therapy.

Acoustic cardiography augments prolonged QRS duration for detecting left ventricular dysfunction.

BACKGROUND: Prolonged QRS duration has been used as a marker for left ventricular (LV) systolic dysfunction (SD) and is used in the evaluation of patients presenting with known or suspected heart failure. The goal of this study was to compare the abilities of QRS duration and simultaneous digital ECG and heart sounds, that is acoustic cardiographic, parameters to identify patients with LV dysfunction. METHODS: Our learning population consisted of 171 patients with possible chronic compensated or mildly decompensated heart failure who presented to an ambulatory cardiology clinic for echocardiographic examination. We defined LVSD as a LV ejection fraction < 50%, and estimated LV filling pressures from diastolic measurements. These patients also had acoustic cardiographic recordings from which we obtained a variety of individual ECG and acoustic cardiographic parameters. We used the product of four of these parameters to obtain a diagnostic score for LV dysfunction. We then compared the diagnostic performances of QRS duration and the score on a test population of patients who presented to an emergency department with possible heart failure. RESULTS: In the learning population, the sensitivities/specificities of QRS duration > or =120 ms and the score for prediction of LVSD were 51%/92% and 77%/90%, respectively. In the test population, the score remained superior to QRS duration for detecting LVSD as well as acute decompensated heart failure. CONCLUSIONS: Improved identification of LVSD and clinical heart failure can be achieved with a cost-effective bedside screening tool with the simple combination of simultaneously acquired digital ECG and heart sound data.