Correspondence

Acute heart failure (HF) decompensation generally manifests with signs and symptoms of congestion that strongly predict poor poor patient outcome. Loop diuretics are the cornerstone of therapy to counteract fluid overload and are widely used for acute management and chronic stabilization of HF. However, a diminished response to loop diuretics is a common problem, affecting the patient's clinical course and potentially prolonging hospitalization. Diuretic resistance is defined as failure to decongest despite appropriate and escalating loop diuretic therapy. We propose a protocol for the management of diuretic resistance. The initial approach should include an assessment of causes of pseudo-diuretic resistance. Adjustments to loop diuretic therapy, such as increasing doses and frequency of administration and sequential nephron blockade, may be successful. For hospitalized patients with progressive disease there are more invasive methods for fluid removal. Switching from oral to intravenous loop diuretics is essential to avoid variable absorption and for symptomatic relief. Extracorporeal ultrafiltration is also an option since this technique is highly effective at removing plasma fluid from blood. While extracorporeal ultrafiltration is an invasive solution, peritoneal dialysis is a home-based, intermittent therapeutic option that can enable efficient management of fluid overload, preventing HF-related hospital admission, and improving quality of life. As a last resort for fluid removal, a peritoneal dialysis regimen should fully exploit its decongestive properties and should be tailored to the patient's characteristics and clinical needs.

A insuficiência cardíaca (IC) descompensada manifesta-se por sinais e sintomas de congestão, que são fortes preditores de mau prognóstico. Os diuréticos de ansa são a base do tratamento da sobrecarga hídrica nas descompensações agudas e na estabilização crónica, mas uma resposta diminuída aos mesmos é frequente na IC. Tal afeta o curso clínico e condicionais internamentos mais prolongados. A «resistência a diuréticos» é definida pela incapacidade em tratar sintomas congestivos, apesar da terapêutica adequada e crescente com diuréticos de ansa. Propomos um protocolo de atuação para ultrapassar esta resistência em que a abordagem inicial passa pela exclusão de causas de pseudo-resistência. Estratégias como o aumento da dose ou do número de administrações de diuréticos de ansa, ou o bloqueio sequencial do nefrónio, podem ser suficientes para aumentar a resposta diurética. Em doentes hospitalizados existem métodos mais invasivos para a remoção de fluidos. Nestes, a alteração de um diurético de ansa oral para endovenoso é uma abordagem fundamental para evitar a absorção errática e para o alívio sintomático. A ultrafiltração extracorporal é uma técnica invasiva muito eficaz na remoção de fluidos, que também pode ser uma opção terapêutica. A diálise peritoneal é um tratamento domiciliar intermitente que permite uma gestão eficiente da sobrecarga hídrica, evitando internamentos por IC descompensada e garantindo uma melhor qualidade de vida. A prescrição de diálise peritoneal para a remoção de fluidos, num doente sem resposta a outras medidas médicas, deve otimizar ao máximo a sua capacidade de ultrafiltração e deve ser adaptada às características do doente.

Rapid diagnosis (dx) of acutely decompensated heart failure (ADHF) may be challenging in the emergency department (ED). Point-of-care ultrasonography (US) allows rapid determination of cardiac function, intravascular volume status, and presence of pulmonary edema. We test the diagnostic test characteristics of these 3 parameters in making the dx of ADHF among acutely dyspneic patients in the ED.

This was a prospective observational cohort study at an urban academic ED. Inclusion criteria were as follows: dyspneic patients, at least 18 years old and able to consent, whose differential dx included ADHF. Ultrasonography performed by emergency sonologists evaluated the heart for left ventricular ejection fraction (LVEF), the inferior vena cava for collapsibility index (IVC-CI), and the pleura sampled in each of 8 thoracic regions for presence of B-lines. Cutoff values for ADHF were LVEF less than 45%, IVC-CI less than 20%, and at least 10 B-lines. The US findings were compared with the final dx determined by 2 emergency physicians blinded to the US results.

One hundred one participants were enrolled: 52% male, median age 62 (25%-75% interquartile, 53-91). Forty-four (44%) had a final dx of ADHF. Sensitivity and specificity (including 95% confidence interval) for the presence of ADHF were as follows: 74 (65-90) and 74 (62-85) using LVEF less than 45%, 52 (38-67) and 86 (77-95) using IVC-CI less than 20%, and 70 (52-80) and 75 (64-87) using B-lines at least 10. Using all 3 modalities together, the sensitivity and specificity were 36 (22-51) and 100 (95-100). As a comparison, the sensitivity and specificity of brain natriuretic peptide greater than 500 were 75 (55-89) and 83 (67-92).

In this study, US was 100% specific for the dx of ADHF.