Sepsis-associated myocardial dysfunction: diagnostic and prognostic impact of cardiac troponins and natriuretic peptides

Research status and advances in dexmedetomidine for sepsis‑induced multiple organ dysfunction syndrome (Review)

Sepsis‑induced organ dysfunction syndrome (ODS) arises from a dysregulated response to infection, leading to multiple life‑threatening organ dysfunctions, and is a common complication in critically ill patients. Sepsis results in varying degrees of injury to the brain, lungs, kidneys and liver, culminating in immune dysfunction and multiple ODS (MODS). Current evidence indicates a direct correlation between the severity of organ injury and the prognosis of septic patients. Understanding the mechanisms of MODS in sepsis and developing effective management strategies are vital research areas. The protective effects of dexmedetomidine (DEX) on sepsis are well established, demonstrating its capacity to mitigate injuries to the brain, lungs, kidneys, liver and immune system. The present study reviews recent research progress on the role and mechanisms of action of DEX in the treatment of sepsis.

Beyond first-day biomarkers: The critical role of peak cardiac troponin I in sepsis prognosis

BACKGROUND

Sepsis is a global health challenge with high mortality rates. It demands timely risk identification and biomarker-based strategies to optimize ICU management and outcomes.

OBJECTIVES

To explore the prognostic value of cardiac troponin I (cTnI) and B-type natriuretic peptide (BNP) in predicting 28-day mortality in septic patients.

METHODS

We analyzed clinical data of septic ICU patients at Shanghai General Hospital. We used Cox models and ROC curves to assess the association between cTnI and BNP levels and 28-day mortality, and their prognostic accuracy.

RESULTS

A total of 333 septic patients were included in this study (mean age [SD], 64.7 [15.2] years; 65.8 % male), of whom 63 (18.9 %) patients died during 28 days. Elevated peak cTnI levels, identified in 233 patients (70.0 %), were independently associated with higher 28-day mortality in septic patients, even after adjusting for SOFA scores, BNP, and other confounding variables. (adjusted HR 2.33, 95 % CI 1.08-5.04, P = 0.03). However, neither first-day cTnI nor BNP levels remained independent predictors of 28-day mortality. Sensitivity analyses for the magnitude of cTnI elevation as a predictive variable also yielded similar results. Compared to first-day cTnI, first-day BNP, and peak BNP, the peak cTnI had the most significant and modest area under the ROC curve (AUC: 0.64 [0.57-0.71]).

CONCLUSION

Elevated peak cTnI or the magnitude of cTnI, rather than first-day, could independently predict the risk of 28-day mortality in septic patients. This finding highlighted the importance of dynamic monitoring cTnI levels for risk stratification identification and management in septic patients.

The Use of Biomarkers to Track and Treat Critical Illness

Biomarkers are objectively measurable parameters that provide clinicians with timely information to guide diagnosis and patient management beyond that which can be obtained from routinely available data. The literature contains thousands of articles on biomarkers in veterinary medicine. Specifically reviewed are the acute kidney injury markers neutrophil gelatinase-associated lipocalin, cystatin, clusterin, and kidney-injury molecule-1; the cardiac troponins and natriuretic peptides as biomarkers of heart disease; the acute phase protein C-reactive protein; procalcitonin; inflammatory cytokines; the markers of neutrophil extracellular trap formation cell-free DNA and nucleosomes; and markers of injury to the endothelium and endothelial glycocalyx including hyaluronan.

Significance of Right Ventricular Dysfunction in Predicting Short-Term Survival Among Patients With Sepsis and Septic Shock: A Prognostic Analysis

Objective: This study sought to evaluate the association between right ventricular (RV) dysfunction and short-term in-hospital mortality among patients with sepsis and septic shock. Methods: A prospective cohort study was conducted on adult patients admitted at Burapha University Hospital for sepsis and septic shock from October 1, 2022, through June 30, 2023, who underwent echocardiography within 72 h after admission. RV dysfunction and other echocardiographic findings were analyzed and defined using the American Society of Echocardiography criteria. The primary outcome examined in this study was 28-day in-hospital mortality. Secondary outcomes included maximal blood lactate levels, length of intensive care unit (ICU) stay, and duration of mechanical ventilation. Results: A total of 104 patients (mean age: 69.54 ± 14.88 years) were enrolled in this study. Among the included patients, 32 (30.8%) developed septic shock whereas 20 (19.2%) exhibited RV dysfunction. Cox regression analysis showed that patients with RV dysfunction had a 28-day in-hospital mortality rate 5.53 times higher than that of patients with normal RV function (95% confidence intervals: 1.98-15.42; p=0.001). Regarding the secondary outcomes, patients with RV dysfunction exhibited a significantly higher mean serum lactate level (5.72 ± 4.96 vs. 3.74 ± 3.29 mmol/L; p=0.034) and length of ICU stay (6.50 ± 2.86 vs. 2.84 ± 1.56 days; p=0.020) than did those with normal RV function. Conclusions: RV dysfunction was associated with increased short-term mortality among patients with sepsis and septic shock. Assessing RV function among these patients facilitates precise prognostication and aids in guiding treatment strategies aimed at reducing mortality. Trial Registration: ClinicalTrials.gov identifier: NCT06193109.

IDENTIFICATION AND VERIFICATION OF FEATURE BIOMARKERS ASSOCIATED WITH CHOLINE METABOLISM IN SEPSIS-INDUCED CARDIOMYOPATHY

ABSTRACT

Background: Sepsis-induced cardiomyopathy ( SIC ), one of the most common complications of sepsis, seriously affects the prognosis of critically ill patients. Choline metabolism is an important biological process in the organism, and the mechanism of its interaction with SIC is unclear. The aim of this study was to reveal the choline metabolism genes (CMGs) associated with SIC and to provide effective targets for the treatment of SIC . Methods: Through a comprehensive analysis of the microarray dataset GSE79962 (comprising 20 SIC patients and 11 healthy controls) from the GEO database, suspected co-expression modules and differentially expressed genes (DEGs) in SIC were identified. Hub CMGs were obtained by intersecting choline metabolism database with DEGs and key model genes. Afterward, hub CMGs most significantly involved in prognosis were further analyzed for the verification of major pathways of enrichment analysis. Finally, the expression of hub CMGs in in vivo and in vitro SIC model was verified by immunohistochemistry staining and quantitative real-time polymerase chain reaction analysis (qPCR). Results: Weighted gene co-expression network analysis identified 1 hub gene panel and 3,867 hub genes, which were intersected with DEGs and CMGs to obtain the same 3 hub CMGs:HIF-1α, DGKD, and PIK3R1. Only HIF-1α shows significant association with mortality ( P = 0.009). Subsequent differential analysis based on the high and low HIF-1α expression yielded 63 DEGs and then they were uploaded into Cytoscape software to construct a protein-protein interaction network and 6 hub genes with the highest priority were obtained (CISH, THBS1, IMP1, MYC, SOCS3, and VCAN). Finally, a multifactorial COX analysis revealed a significant correlation between HIF-1α and survival in SIC patients, which was further validated by in vitro and in vivo experiments. Conclusion: Our findings will provide new insights into the pathogenesis of SIC , and HIF-1α may have important applications as a potential biomarker for early detection and therapeutic intervention in SIC .

Infection-Related Hospitalization and Incident Heart Failure: The Atherosclerosis Risk in Communities Study

BACKGROUND

The immune response to infections may become dysregulated and promote myocardial damage contributing to heart failure (HF). We examined the relationship between infection-related hospitalization (IRH) and HF, HF with preserved ejection fraction, and HF with reduced ejection fraction.

METHODS AND RESULTS

We studied 14 468 adults aged 45 to 64 years in the ARIC (Atherosclerosis Risk in Communities) Study who were HF free at visit 1 (1987-1989). IRH was identified using select International Classification of Diseases (ICD) codes in hospital discharge records and was treated as a time-varying exposure. HF incidence was defined as the first occurrence of either a hospitalization that included an ICD, Ninth Revision (ICD-9) discharge code of 428 (428.0-428.9) among the primary or secondary diagnoses or a death certificate with an ICD-9 code of 428 or an ICD, Tenth Revision (ICD-10) code of I50 among any of the listed diagnoses or underlying causes of death. We used multivariable-adjusted Cox proportional hazards models to assess the association between IRH and incident HF, HF with reduced ejection fraction, and HF with preserved ejection fraction. Median follow-up time was 27 years, 55% were women, 26% were Black, mean age at baseline was 54±6 years, 46% had an IRH, and 3565 had incident HF. Hazard ratio (HR) for incident HF events among participants who had an IRH compared with those who did not was 2.35 (95% CI, 2.19-2.52). This relationship was consistent across different types of infections. Additionally, IRH was associated with both HF with reduced ejection fraction and HF with preserved ejection fraction: 1.77 (95% CI, 1.35-2.32) and 2.97 (95% CI, 2.36-3.75), respectively.

CONCLUSIONS

IRH was associated with incident HF, HF with reduced ejection fraction, and HF with preserved ejection fraction. IRH might represent a modifiable risk factor for HF pathophysiology.

Cardiac biomarker concentrations in cats with elevated pancreatic lipase concentrations

BACKGROUND

Cardiac biomarker concentrations are elevated in dogs with pancreatitis, but it is unknown if this is also the case for cats.

METHODS

The serum feline pancreatic lipase immunoreactivity (fPLI) of serum samples from 60 cats was quantified using the Spec fPL assay. Serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin I (HST) concentrations were also measured using commercial assays.

RESULTS

Five of 20 cats with fPLI concentrations of 8.8 mg/L or more had above reference interval NT-proBNP concentrations. Serum NT-proBNP concentrations were not correlated with fPLI concentrations (p = 0.31) and were not different in each diagnostic category for fPLI results (p = 0.24). Serum HST concentrations were positively correlated with fPLI concentrations (r = 0.278, 95% confidence interval: 0.02‒0.50, p = 0.03). However, they were not significantly different in each diagnostic category for fPLI results (p = 0.16).

LIMITATIONS

Unidentified co-variates could contribute to the association between fPLI and cardiac biomarker concentrations.

CONCLUSIONS

Cats with elevated fPLI concentrations may have elevated cardiac biomarker concentrations.

KW-2449 Ameliorates Cardiac Dysfunction in a Rat Model of Sepsis-Induced Cardiomyopathy

KW-2449 is a novel multitargeted kinase inhibitor that has been reported to alleviate chronic inflammation and altered immunity during the treatment of autoimmune diseases. The aim of the study was to investigate the effect of KW-2449 on sepsis-induced cardiomyopathy (SIC). A rat model of moderate SIC was induced using the cecal ligation and puncture (CLP) method. KW-2449 was administered to rats at 10 mg/kg for 3 consecutive days by intraperitoneal injection. At 24 hours after CLP, echocardiography, electrocardiogram, and hemodynamic analyses were performed. Blood and cardiac tissues were collected for further analysis. RNA sequencing (RNA-seq) analyses were used to identify the key genes affected by KW-2449 treatment during SIC. KW-2449 improved the liver dysfunction in septic rats. KW-2449 significantly improved left ventricular (LV) systolic function and hemodynamics compared to the CLP group. KW-2449 suppressed the systemic inflammatory response, decreased myocardial inflammation and cell apoptosis in the CLP rats. RNA-seq analyses indicated that there were a total of 2256 differentially expressed genes in the CLP group compared to the Control group, among which 63 genes were down-regulated and 59 genes were up-regulated by KW-2449. Specifically, Pparα was identified as a key target gene of KW-2449 in the treatment of SIC by RNA-seq analysis.KW-2449 also significantly upregulated the protein expression of Pparα in the LV tissue of septic rats. KW-2449 reduced systemic inflammation, cardiac inflammation, and improved cardiac dysfunction in the CLP-induced SIC rat model. The underlying mechanism of the cardio-protective role of KW-2449 in the CLP-induced SIC might be related to Pparα.

Diagnostic and Prognostic Value of Soluble Triggering Receptor Expressed on Myeloid Cells-1 (sTREM-1) for Septic Cardiomyopathy

Purpose

The early diagnosis of septic cardiomyopathy remains a challenge. The present work aims to evaluate the diagnostic and prognostic value of plasma soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) levels in septic cardiomyopathy when compared with traditional myocardial biomarkers.

Methods

In the 143 sepsis enrolled patients, 67 and 76 patients were classified as non-septic cardiomyopathy and septic cardiomyopathy, respectively. Their blood samples were harvested up to 14th day after hospital admission for measurements of sTREM-1 and other biomarkers, such as N-terminal pronatriuretic peptide (NT-proBNP), highly sensitive troponin (TNT-HS), myoglobin (MYO), creatine kinase isoenzyme (CK-MB), etc. All the data were collected at 8:00 a.m. The area under the receiver operating characteristic curve was obtained to assess the diagnostic accuracy of those biomarkers. The Log rank test was utilized to evaluate the prognostic value of sTREM-1 on septic cardiomyopathy.

Results

Circulating sTREM-1 showed a high specificity (88.1%) and moderate sensitivity (64.5%) to distinguish patients with septic cardiomyopathy in the 143 septic patients. The diagnostic efficiency of sTREM-1 was higher than inflammatory biomarkers and traditional myocardial markers. Logistic regression revealed that plasma sTREM-1 was an independent predictor of septic cardiomyopathy. Furthermore, in the whole septic cardiomyopathy cohorts, the sTREM-1 levels in the non-survivors were significantly higher than those of survivors during ICU stay. In addition, the left ventricular systolic dysfunction had a high odds ratio (3.968) to predict 90-day mortality in septic patients with cardiomyopathy.

Conclusion

High plasma sTREM-1 level may be a diagnostic marker in predicting ICU poor outcome of patients with septic cardiomyopathy.

The Impact of Extracellular Histones and Absence of Toll-like Receptors on Cardiac Functional and Electrical Disturbances in Mouse Hearts

In polymicrobial sepsis, the extracellular histones, mainly released from activated neutrophils, significantly contribute to cardiac dysfunction (septic cardiomyopathy), as demonstrated in our previous studies using Echo-Doppler measurements. This study aims to elucidate the roles of extracellular histones and their interactions with Toll-like receptors (TLRs) in cardiac dysfunction. Through ex vivo assessments of ECG, left ventricle (LV) function parameters, and in vivo Echo-Doppler studies in mice perfused with extracellular histones, we aim to provide comprehensive insights into the mechanisms underlying sepsis-induced cardiac dysfunction. Langendorff-perfused hearts from both wild-type and TLR2, TLR3, or TLR4 knockout (KO) mice were examined. Paced mouse hearts were perfused with histones to assess contractility and relaxation. Echo-Doppler studies evaluated cardiac dysfunction after intravenous histone injection. Histone perfusion caused defects in contractility and relaxation, with TLR2 and TLR3 KO mice being partially protected. Specifically, TLR2 KO mice exhibited the greatest reduction in Echo-Doppler abnormalities, while TLR4 KO exacerbated cardiac dysfunction. Among individual histones, H1 induced the most pronounced abnormalities in cardiac function, apoptosis of cardiomyocytes, and LDH release. Our data highlight significant interactions between histones and TLRs, providing insights into histones especially H1 as potential therapeutic targets for septic cardiomyopathy. Further studies are needed to explore specific histone-TLR interactions and their mechanisms.

Identification of 18β-glycyrrhetinic acid as an AGT inhibitor against LPS-induced myocardial dysfunction via high throughput screening

Sepsis induced myocardial dysfunction (SIMD) is a serious complication of sepsis. There is increasing evidence that the renin-angiotensin system (RAS) is activated in SIMD. Angiotensinogen (AGT) is a precursor of the RAS, and the inhibition of AGT may have significant cardiovascular benefits. But until now, there have been no reports of small molecule drugs targeting AGT. In this study, we designed a promoter-luciferase based system to screen for novel AGT inhibitors to alleviate SIMD. As a result of high-throughput screening, a total of 5 compounds from 351 medicinal herb-derived natural compounds were found inhibiting AGT. 18β-glycyrrhetinic acid (18βGA) was further identified as a potent suppressor of AGT. In vitro experiments, 18βGA could inhibit the secretion of AGT by HepG2 cells and alleviate the elevated level of mitochondrial oxidative stress in cardiomyocytes co-cultured with HepG2 supernatants. In vivo, 18βGA prolonged the survival rate of SIMD mice, enhanced cardiac function, and inhibited the damage of mitochondrial function and inflammation. In addition, the results showed that 18βGA may reduce AGT transcription by downregulating hepatocyte nuclear factor 4 (HNF4) and that further alleviated SIMD. In conclusion, we provided a more efficient screening strategy for AGT inhibitors and expanded the novel role of 18βGA as a promising lead compound in rescuing cardiovascular disease associated with RAS overactivation.

30- and 60-Day Readmission Rates for Children With Heart Failure in the United States

BACKGROUND

Studies on readmission for pediatric heart failure (HF) patients is sparse.

OBJECTIVES

This study evaluated 30- and 60-day readmission rates in pediatric HF patients from 2010 to 2019.

METHODS

The authors used data from the Nationwide Readmission Database to evaluate trends in 30- and 60-day hospital readmissions among pediatric patients with HF and compare them with adults with HF. Readmissions were also stratified by sex, diagnosis, neighborhood income, and hospital volume.

RESULTS

There were 84,731 hospital admissions for HF. Compared with children without HF, those with HF were older, had Medicare/Medicaid insurance, and resided in micropolitan areas and low-income neighborhoods. The 30- (19.5% vs 3.1%) and 60-day (27.5% vs 4.3%) all-cause readmission rates were higher for children with HF compared with those without HF. Compared with children without HF, lengths of stay, deaths, and costs related to their readmission were higher for children readmitted with HF (P < 0.05 for all). There was no significant decline in pediatric HF-related 30- or 60- day readmissions during the study period overall, or for those with congenital heart disease (P > 0.05), unlike adult HF readmissions (P < 0.01). Infants were at highest risk, and readmission rates for teenagers are rising.

CONCLUSIONS

The 30- and 60-day readmission rates for pediatric patients with HF in the current era is high (∼20% and 30%, respectively). Unlike adult HF, pediatric HF readmission rates have not declined. Pediatric HF patients readmitted to the hospital have higher death rates and greater resource utilization than patients without HF. National measures to decrease readmissions for pediatric patients with HF is warranted.

Identification of key genes in sepsis-induced cardiomyopathy based on integrated bioinformatical analysis and experiments in vitro and in vivo

Introduction

Sepsis is a life-threatening disease that damages multiple organs and induced by the host's dysregulated response to infection with high morbidity and mortality. Heart remains one of the most vulnerable targets of sepsis-induced organ damage, and sepsis-induced cardiomyopathy (SIC) is an important factor that exacerbates the death of patients. However, the underlying genetic mechanism of SIC disease needs further research.

Methods

The transcriptomic dataset, GSE171564, was downloaded from NCBI for further analysis. Gene expression matrices for the sample group were obtained by quartile standardization and log2 logarithm conversion prior to analysis. The time series, protein-protein interaction (PPI) network, and functional enrichment analysis via Gene Ontology and KEGG Pathway Databases were used to identify key gene clusters and their potential interactions. Predicted miRNA-mRNA relationships from multiple databases facilitated the construction of a TF-miRNA-mRNA regulatory network. In vivo experiments, along with qPCR and western blot assays, provided experimental validation.

Results

The transcriptome data analysis between SIC and healthy samples revealed 221 down-regulated, and 342 up-regulated expressed genes across two distinct clusters. Among these, Tpt1, Mmp9 and Fth1 were of particular significance. Functional analysis revealed their role in several biological processes and pathways, subsequently, in vivo experiments confirmed their overexpression in SIC samples. Notably, we found TPT1 play a pivotal role in the progression of SIC, and silencing TPT1 showed a protective effect against LPS-induced SIC.

Conclusion

In our study, we demonstrated that Tpt1, Mmp9 and Fth1 have great potential to be biomarker of SIC. These findings will facilitated to understand the occurrence and development mechanism of SIC.

Establishment of a differential diagnosis method and an online prediction platform for AOSD and sepsis based on gradient boosting decision trees algorithm

OBJECTIVE

The differential diagnosis between adult-onset Still's disease (AOSD) and sepsis has always been a challenge. In this study, a machine learning model for differential diagnosis of AOSD and sepsis was developed and an online platform was developed to facilitate the clinical application of the model.

METHODS

All data were collected from 42 AOSD patients and 50 sepsis patients admitted to Affiliated Hospital of Xuzhou Medical University from December 2018 to December 2021. In addition, 5 AOSD patients and 10 sepsis patients diagnosed in our hospital after March 2022 were collected for external validation. All models were built using the scikit-learn library (version 1.0.2) in Python (version 3.9.7), and feature selection was performed using the SHAP (Shapley Additive exPlanation) package developed in Python.

RESULTS

The results showed that the gradient boosting decision tree(GBDT) optimization model based on arthralgia, ferritin × lymphocyte count, white blood cell count, ferritin × platelet count, and α1-acid glycoprotein/creatine kinase could well identify AOSD and sepsis. The training set interaction test (AUC: 0.9916, ACC: 0.9457, Sens: 0.9556, Spec: 0.9578) and the external validation also achieved satisfactory results (AUC: 0.9800, ACC: 0.9333, Sens: 0.8000, Spec: 1.000). We named this discrimination method AIADSS (AI-assisted discrimination of Still's disease and Sepsis) and created an online service platform for practical operation, the website is http://cppdd.cn/STILL1/ .

CONCLUSION

We created a method for the identification of AOSD and sepsis based on machine learning. This method can provide a reference for clinicians to formulate the next diagnosis and treatment plan.

Role of toll-like receptor-mediated pyroptosis in sepsis-induced cardiomyopathy

Sepsis, a life-threatening dysregulated status of the host response to infection, can cause multiorgan dysfunction and mortality. Sepsis places a heavy burden on the cardiovascular system due to the pathological imbalance of hyperinflammation and immune suppression. Myocardial injury and cardiac dysfunction caused by the aberrant host responses to pathogens can lead to cardiomyopathy, one of the most critical complications of sepsis. However, many questions about the specific mechanisms and characteristics of this complication remain to be answered. The causes of sepsis-induced cardiac dysfunction include abnormal cardiac perfusion, myocardial inhibitory substances, autonomic dysfunction, mitochondrial dysfunction, and calcium homeostasis dysregulation. The fight between the host and pathogens acts as the trigger for sepsis-induced cardiomyopathy. Pyroptosis, a form of programmed cell death, plays a critical role in the progress of sepsis. Toll-like receptors (TLRs) act as pattern recognition receptors and participate in innate immune pathways that recognize damage-associated molecular patterns as well as pathogen-associated molecular patterns to mediate pyroptosis. Notably, pyroptosis is tightly associated with cardiac dysfunction in sepsis and septic shock. In line with these observations, induction of TLR-mediated pyroptosis may be a promising therapeutic approach to treat sepsis-induced cardiomyopathy. This review focuses on the potential roles of TLR-mediated pyroptosis in sepsis-induced cardiomyopathy, to shed light on this promising therapeutic approach, thus helping to prevent and control septic shock caused by cardiovascular disorders and improve the prognosis of sepsis patients.

METTL3 achieves lipopolysaccharide-induced myocardial injury via m6A-dependent stabilization of Myh3 mRNA

Septic cardiomyopathy (SCM) was an important pathological component of severe sepsis and septic shock. N6-methyladenosine (m6A) modification was a common RNA modification in both mRNA and non-coding RNAs and was proved to be involved in sepsis and immune disorders. Therefore, the purpose of this study was to investigate the role and mechanism of METTL3 in lipopolysaccharide-induced myocardial injury. We firstly analyzed the expression changes of various m6A-related regulators in human samples in the GSE79962 data and the Receiver Operating Characteristic curve of significantly changed m6A enzymes, showing that METTL3 had a high diagnostic ability in patients with SCM. Western blotting confirmed the high expression of METTL3 in LPS-treated H9C2 cells, which was consistent with the above results in human samples. In vitro and in vivo, the deficiency of METTL3 could improve the cardiac function, cardiac tissue damage, myocardial cell apoptosis and reactive oxygen species levels in LPS-treated H9C2 cells and LPS-induced sepsis rats, respectively. In addition, we obtained 213 differential genes through transcriptome RNA-seq analysis, and conducted GO enrichment analysis and KEGG pathway analysis through DAVID. We also found that the half-life of Myh3 mRNA was significantly reduced after METTL3 deletion and that Myh3 carried several potential m6A modification sites. In conclusion, we found that downregulation of METTL3 reversed LPS-induced myocardial cell and tissue damage and reduced cardiac function, mainly by increasing Myh3 stability. Our study revealed a key role of METTL3-mediated m6A methylation in septic cardiomyopathy, which may offer a potential mechanism for the therapy of septic cardiomyopathy.

[Natriuretic peptides in intensive care medicine]

Natriuretic peptides must be interpreted in their clinical context, especially in intensive care medicine. This overview presents the diagnostic, prognostic, and therapeutic significance of B‑type natriuretic peptide (BNP) and N‑terminal pro B‑type natriuretic peptide (NT-proBNP) in patients with cardiac dysfunction, kidney failure, sepsis, pulmonary embolism, acute respiratory distress syndrome (ARDS), acute exacerbations of chronic obstructive pulmonary disease (AECOPD), and weaning from a respirator.

Cardiac Troponin I and Electrocardiographic Evaluation in Hospitalized Cats with Systemic Inflammatory Response Syndrome

Several studies conducted on humans demonstrate the increase in cardiac troponins and the onset of arrhythmias in the course of systemic inflammatory response syndrome (SIRS). The aim of the current study was to assess the blood concentration of cardiac troponin I (cTnI) and electrocardiographic findings in SIRS-affected cats. Seventeen shorthair cats hospitalized with SIRS were enrolled (Group 1). SIRS diagnosis was performed based on the detection of at least two of the four criteria such as abnormal body temperature, abnormal heart rate (i.e., tachycardia or bradycardia), abnormal respiratory rate (i.e., tachypnea or bradypnea), and alterations of white blood cell number (i.e., leukocytes or band neutrophils). Ten cats screened for elective surgery such as neutering or dental procedures were evaluated as a control population (Group 2). They were considered healthy based on history, physical examination, hematological and biochemical profile, urinalysis, coprological exam, thyroxine assay, blood pressure measurement, and echocardiography. A physical examination, complete blood cell count, biochemistry test (including an electrolyte panel), electrocardiographic examination, and cTnI assay were carried out in each cat enrolled. Traumatic events, gastrointestinal, neoplastic, respiratory, and neurological disorders were identified as causes of SIRS in Group 1. In Group 1, a significantly higher concentration of cTnI than that in Group 2 was recorded (p = 0.004). In 37.5% of cats with SIRS, ventricular premature complexes occurring in couplets with multiform configuration were detected. Similarly, to humans, data herein reported would indicate possible cardiac damage present in cats with SIRS diagnosis.

Xuebijing injection protects sepsis induced myocardial injury by mediating TLR4/NF-κB/IKKα and JAK2/STAT3 signaling pathways

OBJECTIVE

Compelling evidence has demonstrated that Xuebijing (XBJ) exerted protective effects against SIMI. The aims of this study were to investigate whether TLR4/IKKα-mediated NF-κB and JAK2/STAT3 pathways were involved in XBJ's cardio-protection during sepsis and the mechanisms.

METHODS

In this study, rats were randomly assigned to three groups: Sham group; CLP group; XBJ group. Rats were treated with XBJ or sanitary saline after CLP. Echocardiography, myocardial enzymes and HE were used to detect cardiac function. IL-1β, IL-6 and TNF-α in serum were measured using ELISA kits. Cardiomyocyte apoptosis were tested by TUNEL staining. The protein levels of Bax, Bcl-2, Bcl-xl, Cleaved-Caspase 3, Cleaved-Caspase 9, Cleaved-PARP, TLR4, p-NF-κB, p-IKKα, p-JAK2 and p-STAT3 in the myocardium were assayed by western blotting. And finally, immunofluorescence was used to assess the level of p-JAK2 and p-STAT3 in heart tissue.

RESULTS

The results of echocardiography, myocardial enzyme and HE test showed that XBJ could significantly improve SIMI. The IL-1β, IL-6 and TNF-α levels in the serum were markedly lower in the XBJ group than in the CLP group (p<0.05). TUNEL staining's results showed that XBJ ameliorated CLP-induced cardiomyocyte apoptosis. Meanwhile, XBJ downregulated the protein levels of Bax, Cleaved-Caspase 3, Cleaved-Caspase 9, Cleaved-PARP, TLR4, p-NF-κB, p-IKKα, p-JAK2 and p-STAT3, as well as upregulated the protein levels of Bcl-2, Bcl-xl (p <0.05).

CONCLUSIONS

In here, we observed that XBJ's cardioprotective advantages may be attributable to its ability to suppress inflammation and apoptosis via inhibiting the TLR4/ IKKα-mediated NF-κB and JAK2/STAT3 pathways during sepsis.

Predictors and nomogram of in-hospital mortality in sepsis-induced myocardial injury: a retrospective cohort study

BACKGROUND

Sepsis-induced myocardial injury (SIMI) is a common organ dysfunction and is associated with higher mortality in patients with sepsis. We aim to construct a nomogram prediction model to assess the 28-day mortality in patients with SIMI. .

METHOD

We retrospectively extracted data from Medical Information Mart for Intensive Care (MIMIC-IV) open-source clinical database. SIMI was defined by Troponin T (higher than the 99th percentile of upper reference limit value) and patients with cardiovascular disease were excluded. A prediction model was constructed in the training cohort by backward stepwise Cox proportional hazards regression model. The concordance index (C-index), area under the receiver operating characteristics curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI), calibration plotting and decision-curve analysis (DCA) were used to evaluate the nomogram.

RESULTS

1312 patients with sepsis were included in this study and 1037 (79%) of them presented with SIMI. The multivariate Cox regression analysis in all septic patients revealed that SIMI was independently associated with 28-day mortality of septic patients. The risk factors of diabetes, Apache II score, mechanical ventilation, vasoactive support, Troponin T and creatinine were included in the model and a nomogram was constructed based on the model. The C-index, AUC, NRI, IDI, calibration plotting and DCA showed that the performance of the nomogram was better than the single SOFA score and Troponin T.

CONCLUSION

SIMI is related to the 28-day mortality of septic patients. The nomogram is a well-performed tool to predict accurately the 28-day mortality in patients with SIMI.

RIGHT VENTRICULAR DYSFUNCTION IN SEPSIS: AN UPDATED NARRATIVE REVIEW

ABSTRACT

Sepsis is a multisystem disease process, which constitutes a significant public health challenge and is associated with high morbidity and mortality. Among other systems, sepsis is known to affect the cardiovascular system, which may manifest as myocardial injury, arrhythmias, refractory shock, and/or septic cardiomyopathy. Septic cardiomyopathy is defined as the reversible systolic and/or diastolic dysfunction of one or both ventricles. Left ventricle dysfunction has been extensively studied in the past, and its prognostic role in patients with sepsis is well documented. However, there is relatively scarce literature on right ventricle (RV) dysfunction and its role. Given the importance of timely detection of septic cardiomyopathy and its bearing on prognosis of patients, the role of RV dysfunction has come into renewed focus. Hence, through this review, we sought to describe the pathophysiology of RV dysfunction in sepsis and what have we learnt so far about its multifactorial nature. We also elucidate the roles of different biomarkers for its detection and prognosis, along with appropriate management of such patient population.

New Insights into the Fluid Management in Patients with Septic Shock

The importance of fluid resuscitation therapy during the early stages of sepsis management is a well-established principle. Current Surviving Sepsis Campaign (SSC) guidelines recommend the early administration of intravenous crystalloid fluids for sepsis-related hypotension or hyperlactatemia due to tissue hypoperfusion, within the first 3 h of resuscitation and suggest using balanced solutions (BSs) instead of normal saline (NS) for the management of patients with sepsis or septic shock. Studies comparing BS versus NS administration in septic patients have demonstrated that BSs are associated with better outcomes including decreased mortality. After initial resuscitation, fluid administration has to be judicious in order to avoid fluid overload, which has been associated with increased mortality, prolonged mechanical ventilation, and worsening of acute kidney injury. The "one size fits all" approach may be "convenient" but it should be avoided. Personalized fluid management, based on patient-specific hemodynamic indices, provides the foundations for better patient outcomes in the future. Although there is a consensus on the need for adequate fluid therapy in sepsis, the type, the amount of administered fluids, and the ideal fluid resuscitation strategy remain elusive. Well-designed large randomized controlled trials are certainly needed to compare fluid choices specifically in the septic patient, as there is currently limited evidence of low quality. This review aims to summarize the physiologic principles and current scientific evidence regarding fluid management in patients with sepsis, as well as to provide a comprehensive overview of the latest data on the optimal fluid administration strategy in sepsis.

RIP2 inhibition alleviates lipopolysaccharide-induced septic cardiomyopathy via regulating TAK1 signaling

PURPOSE

RIP2 is a member of the receptor-interacting protein family that has been associated with various pathophysiological processes, including immunity, apoptosis, and autophagy. However, no studies have hitherto reported the role of RIP2 in lipopolysaccharide (LPS)-induced septic cardiomyopathy (SCM). This study was designed to illustrate the role of RIP2 in LPS-induced SCM.

METHODS

C57 and RIP2 knockout mice received intraperitoneal injections of LPS to establish models of SCM. Echocardiography was used to assess the cardiac function of the mice. Real-time-PCR, cytometric bead array and immunohistochemical staining were used to detect the inflammatory response. Immunoblotting was used to determine the protein expression of relevant signaling pathways. Our findings were validated by treatment with a RIP2 inhibitor. Neonatal rats cardiomyocytes (NRCMs) and cardiac fibroblasts (CFs) were transfected with Ad-RIP2 to further explore the role of RIP2 in vitro.

RESULTS

RIP2 expression was upregulated in our mice models of septic cardiomyopathy and LPS-stimulated cardiomyocytes and fibroblasts. RIP2 knockout or RIP2 inhibitors attenuated LPS-induced cardiac dysfunction and reduced the inflammatory response in mice. Overexpression of RIP2 in vitro enhanced the inflammatory response, and TAK1 inhibitors attenuated the inflammatory response caused by overexpression of RIP2.

CONCLUSION

Our findings substantiate that RIP2 induces an inflammatory response by regulating the TAK1/IκBα/NF-κB signaling pathway. RIP2 inhibition by genetic or pharmacological approaches has huge prospects for application as a potential treatment strategy for inhibiting inflammation, alleviating cardiac dysfunction, and improving survival.

Epidemiology of Acute Mesenteric Ischemia: A Population-Based Investigation

BACKGROUND

There is a lack of population-based studies on acute mesenteric ischemia (AMI). We have therefore performed a nationwide epidemiological study in Estonia, addressing incidence, demographics, interventions and mortality of AMI.

METHODS

A retrospective population-based review was conducted of all adult cases of AMI accrued from the digital Estonian Health Insurance Fund and Causes of Death Registry for 2016-2020 based on international classification of diseases (ICD-10) diagnostic codes and procedure codes (NOMESCO).

RESULTS

Overall, 577 cases of AMI were identified-an annual incidence of 8.7 per 100,000. The median age was 79 (range 32-104) and 57% were female. Predominating comorbidities included hypertensive disease (81%), atherosclerosis (67%), and atrial fibrillation (52%). The majority of cases (60%) were caused by superior mesenteric artery occlusion (thrombosis 54%, embolism 12%, and unclear 34%). Inferior mesenteric artery occlusion occurred in 7%, non-occlusive mesenteric ischemia in 7%, venous thrombosis in 4%, whereas the type remained unclear in 21% of cases. 40% of patients received intervention (revascularization and/or intestinal resection) and 13% active non-operative treatment. In 21% an exploratory laparotomy or laparoscopy revealed unsalvageable bowel prompting end-of-life care, which was the only management in a further 25% of cases.

CONCLUSIONS

The population-based annual incidence of AMI in Estonia was 8.7 per 100,000 during the study period. The overall hospital mortality and 1 year mortality were 64% and 74%, respectively. In the 53% of patients who received active treatment hospital mortality was 32% and 1 year all-cause mortality was 51%.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT04867499.

Cardiovascular abnormalities in dogs with acute pancreatitis

BACKGROUND

The prevalence and clinical importance of cardiac abnormalities in dogs with acute pancreatitis (AP) is unknown.

ANIMALS

Twelve dogs with AP and 60 archived serum samples from dogs with suspected AP.

METHODS

Two-phase study.

PHASE I

Analysis of archived serum samples from dogs with clinical signs of AP and high Spec cPL concentrations. High sensitivity troponin I (TnIH) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations were measured in achieved serum samples.

PHASE II

Prospective observational study. Dogs with AP underwent echocardiography and Holter monitoring. Serum cardiac troponin I (cTnI) and plasma NT-proBNP concentrations were measured. Previously described disease severity indices were calculated for each dog.

RESULTS

Phase I: 41 of 60 dogs suspected of having AP had abnormally high TnIH concentrations and 13 of 60 had abnormally high serum NT-proBNP concentrations. Higher TnIH concentrations were observed in dogs with Spec cPL concentration >2000 μg/L as compared to those with concentrations of 1000-2000 μg/L.

PHASE II

11 of 12 dogs diagnosed with pancreatitis had abnormal cTnI concentrations (median: 0.384 ng/mL, range: 0.041-2.966 ng/mL, RI: ≤0.06 ng/mL) and 7 of 12 dogs had plasma NT-proBNP concentrations above the reference interval (median: 971 pmol/L, range: 250-2215 pmol/L, RI: ≤900 pmol/L). Supraventricular and ventricular ectopic beats occurred in 3 dogs. Echocardiographic abnormalities were detected in 5 dogs. Cardiovascular variables were not associated with indices of disease severity.

CONCLUSIONS AND CLINICAL IMPORTANCE

Myocardial injury is common in dogs with AP, but clinical consequences appeared to be uncommon in our small cohort. Cardiac biomarkers should be interpreted with caution in dogs with AP.

Serum troponin is elevated in acute decompensation and acute-on-chronic liver failure and is associated with severity of liver disease and short-term mortality

BACKGROUND

The role of high sensitive cardiac Troponin (hs-cTn) in patients with liver cirrhosis (LC) and liver-related acute events is not well established.

AIM

To assess the prognostic performance of hs-cTn I in acute decompensation (AD) and acute-on-chronic liver failure (ACLF).

METHODS

Two cohorts of consecutive patients, a derivation (retrospective) and a validation (prospective), were evaluated and 30-day-mortality was recorded. Hs-cTnI values were measured. Very low hs-cTnΙ (4 ng/L) was considered the cutoff-level.

RESULTS

A total of 296 patients with LC [69.3% male, median age 57 (IQR 51-68) years, MELD score 19 (13-25), ACLF (29.4%), AD (48.3%), and without liver-related acute events (22.3%)] were included in the derivation cohort. The 66.2% of total patients had hs-cTnI ≥4 ng/L. Patients with hs-cTnI ≥4 ng/L were older and had more severe LC compared to those with <4ng/L. The multivariate analysis demonstrated that age (p < 0.001) and MELD (p = 0.001) were independent variables associated with elevated hs-cTnI after adjustment for age, sex and hepatic encephalopathy in total patients.When ACLF and AD were analyzed separately, the mortality was higher in patients with hs-cTnI ≥ 4 ng/L compared to lower values (log-rank p = 0.036 and p = 0.019, respectively). In multivariate analysis, MELD (p < 0.001) and hs-cTnI ≥4 ng/L (p = 0.032) were independent prognostic factors of mortality in ACLF/AD groups, after adjustment for age and sex. Similar results were obtained from the validation cohort (N = 148).

CONCLUSIONS

hs-cTnI levels were higher in patients with severe liver disease. The low cutoff-point of 4 ng/L is accurate in ruling out non-survivors mainly in AD group.

Bladder paraganglioma: basic characteristics and new perspectives on perioperative management

PURPOSE

Paraganglioma and pheochromocytoma are rare neuroendocrine tumors with severe metabolic and cardiovascular complications. Bladder PGLs are rare, and their clinical management is not precise. Here, we discuss the basic characteristics and perioperative management of bladder PGLs.

METHODS

We retrospectively reviewed 20 bladder PGL cases diagnosed at Sun Yat-sen University Cancer Center. Case notes were reviewed, clinical presentations, therapies, and outcomes were collected, and data analysis was performed.

RESULTS

Ten male and ten female patients with a median age of 47.5 years (range 14-69 years) were included. Most patients (65%) had no symptoms, and PGL was detected incidentally during medical checkups. All patients were treated surgically; 4 (20%) underwent transurethral resection of bladder tumor (TURBT), and 16 (80%) underwent partial cystectomy. Strong intraoperative blood pressure fluctuations were observed in 13 patients (65%). Two patients who were treated preoperatively with α-receptor blockers also experienced severe intraoperative blood pressure fluctuations. Postoperative measurements of troponin I were available for 3 patients, and all were significantly elevated. All patients were diagnosed with bladder PGL on postoperative pathological examination. The median follow-up time was 51 months (range 2-147 months), and 2 patients were lost to follow-up at 1 and 3 months; 16 (88.9%) survived without recurrence, 2 patients (11.1%) experienced recurrence, and 1 patient died.

CONCLUSION

Most bladder paragangliomas are easily mistaken for bladder urothelial carcinoma, and robust hemodynamic instability during surgery might be a challenge for urologists. Postoperative monitoring of troponin I, regardless of the presence of clinical symptoms, is recommended for patients with bladder PGL.

Serum level of total histone 3, H3K4me3, and H3K27ac after non-emergent cardiac surgery suggests the persistence of smoldering inflammation at 3 months in an adult population

Background

Despite clinical relevance of immunological activation due to histone leakage into the serum following cardiac surgery, long-term data describing their longitudinal dynamic are lacking. Therefore, this study examines the serum levels of histone 3 (tH3) and its modifications (H3K4me3 and H3K27ac) alongside immune system activation during the acute and convalescence phases of cardiac surgery.

Methods

Blood samples from fifty-nine individuals were collected before non-emergent cardiac surgery (t_pre-op) and 24 h (t_24hr), seven days (t_7d), and three months (t_3m) post-procedure to examine serum levels of tH3, H3K4me3, and H3K27ac. Serum heat shock protein-60 (HSP-60) was a surrogate of the cellular damage marker. Serum C-reactive protein (CRP) and interleukin 6 (IL-6) assessed smoldering inflammation. TNFα and IL-6 production by whole blood in response to lipopolysaccharide (LPS) evaluated immunological activation. Electronic medical records provided demographic, peri-operative, and clinical information. Paired longitudinal analyses were employed with data expressed as mean and standard deviation (X ± SD) or median and interquartile range (Me[IQ25; 75%].

Results

Compared to pre-operative levels (tH3_Pre-op = 1.6[0.33;2.4]), post-operative serum tH3 significantly (p > 0.0001) increased after heart surgery (tH3_24hr = 2.2[0.3;28]), remained elevated at 7 days (tH3_7d = 2.4[0.37;5.3]), and at 3 months (tH3_3m = 2.0[0.31;2.9]). Serum H3K27ac was elevated at 24 h (H3K27ac_24hr = 0.66 ± 0.51; p = 0.025) and seven days (H3K27ac_7d = 0.94 ± 0.95; p = 0.032) as compared to baseline hours (H3K27ac_Pre-op = 0.55 ± 0.54). Serum H3K4me3 was significantly diminished at three months (H3K4me3_Pre-op = 0.94 ± 0.54 vs. H3K27ac_3m = 0.59 ± 0.89; p = 0.008). tH3 correlated significantly with the duration of anesthesia (r² = 0.38). In contrast, HSP-60 normalized seven days after surgery. Peri-operative intake of acetaminophen, but no acetylsalicylic acid (ASA), acid, ketorolac or steroids, resulted in the significant depression of serum H3K4me3 at 24 h (H3K4me3_acetom- = 1.26[0.71; 3.21] vs H3K4me3_acetom+ = 0.54[0.07;1.01]; W[50] = 2.26; p = 0.021). CRP, but not IL-6, remained elevated at 3 months compared to pre-surgical levels and correlated with tH3_24hrs (r² = 0.43), tH3_7d (r² = 0.71; p < 0.05), H3K4me3_7d (r² = 0.53), and H3K27ac_7d (r² = 0.49). Production of TNFα by whole blood in response to LPS was associated with serum tH3_24hrs (r² = 0.67). Diminished H3K4me3_24hrs, H3K27ac_24hrs, and H3K27ac_3m, accompanied the emergence of liver failure.

Conclusions

We demonstrated a prolonged elevation in serum histone 3 three months after cardiac surgery. Furthermore, histone 3 modifications had a discrete time evolution indicating differential immune activation.

Serum Sestrin2 Was Lower in Septic Shock Patients with Cardiomyopathy

Background

To determine the clinical significance of variations in serum sestrin2 protein levels in the development of septic cardiomyopathy in septic shock patients.

Methods

The serum sestrin2 concentrations of each sample were determined using ELISA in a total of 67 control persons and 188 patients with septic shock. Furthermore, using transthoracic echocardiography, septic shock patients were split into two groups based on whether or not cardiomyopathy had developed, and the differences in each index between the two groups were analyzed. We looked at the relationship between serum sestrin2 levels, norepinephrine dosage, and NTproBNP levels. The influencing variables for the prediction of septic cardiomyopathy linked with the development of septic cardiomyopathy and clinical prognosis in septic cardiomyopathy were determined using multivariate binary logistic regression.

Results

Assessment of left ventricular systolic function by measurement of LVEF revealed that 61/188 (32.4%) of the 188 patients with septic shock included in the research satisfied the diagnostic criteria for septic cardiomyopathy. (1) Sestrin2 protein levels showed a significant difference between septic shock and healthy controls (p < 0.01). (2) Compared to the group without septic cardiomyopathy, the group with combined septic cardiomyopathy had lower serum sestrin2 protein levels (p < 0.05), lower systolic blood pressure (p < 0.05), and higher plasma NTproBNP levels (p < 0.01) and used greater norepinephrine dosages (p < 0.01). The levels of serum sestrin2 protein revealed a little negative relationship with NTproBNP and norepinephrine dose. However, a binary logistic regression analysis revealed that none of these factors was an independent predictor of septic shock. (3) Age, lactate level, SOFA score, positive bacteremia, and sestrin2 protein were shown to be substantial discrepancies in clinical outcomes in patients with septic cardiomyopathy, becoming variables that impact clinical outcomes. Positive bacteremia (p = 0.031, OR = 5.084), SOFA score (p = 0.021, OR = 1.304), and sestrin2 protein (p =  0.039, OR = 0.897) were revealed to have independent influences in predicting clinical mortality outcome in septic cardiomyopathy using multivariate binary logistic regression.

Conclusion

High serum sestrin2 levels clearly distinguish septic shock patients from healthy controls, whereas low serum sestrin2 levels are related with cardiac dysfunction to some extent but are not an independent influence factor for septic cardiomyopathy. Low serum sestrin2 levels were shown to be useful in predicting clinical outcome in patients with septic cardiomyopathy.

Septic cardiomyopathy: characteristics, evaluation, and mechanism

Sepsis is a common clinical disease; if there is no early active treatment, it is likely to develop into multiple organ dysfunction syndrome and even cause death. Septic cardiomyopathy is a complication of sepsis-related cardiovascular failure, characterized by reversible left ventricular dilatation and decreased ventricular systolic and/or diastolic function. At present, echocardiography and biomarkers are often used to screen septic cardiomyopathy in clinics. Although there is still a lack of clear diagnostic criteria for septic cardiomyopathy, according to existing studies, the pathogenesis of several septic cardiomyopathy has been clarified, such as immune response caused by infection and mitochondrial dysfunction. This review summarizes the characteristics, pathophysiology, and diagnosis of septic cardiomyopathy and focuses on the mechanisms of infection immunity and mitochondrial dysfunction.

N-Terminal B Natriuretic Peptide as a Prognostic Marker in Sepsis Induced Myocardial Dysfunction

BACKGROUND: Sepsis-induced myocardial dysfunction (SIMD) is an increasingly recognized form of transient cardiac dysfunction in sepsis patients. AIM: The aim of the study was to evaluation of N-terminal pro brain natriuretic peptide (NT-pro BNP) as a predictor of SIMD and poor outcome in patients with sepsis or septic shock. METHODS: Forty patients were enrolled and divided into: Group 1 with sepsis; Group 2 with septic shock. Each group was subdivided according to the presence or absence of cardiomyopathy. Echocardiography, NT-pro BNP - assay on the 1st and 2nd days of admission - were performed. RESULTS: NT-pro BNP level was significant predictor for cardiomyopathy in all case group with 75% sensitivity, 70% specificity (cutoff level >334 pg/ml) on 1st day of admission and 65% sensitivity, and 80% specificity (cutoff level >325 pg/ml) on 2nd day. On subgroup analysis, pro-BNP had 70% sensitivity, 90% specificity; cutoff level >334 pg/ml for prediction of cardiomyopathy in sepsis group and 70% sensitivity and 80% specificity; cutoff level >357pg/ml in septic shock group. Pro-BNP on 2nd day was excellent predictor of mortality in septic shock group with 100% sensitivity and specificity; cutoff level >350 pg/ml. CONCLUSION: N terminal pro-BNP is a good diagnostic and prognostic indicator for cardiomyopathy and mortality in septic patients.

A multicenter prospective cohort study of cardiac ultrasound phenotypes in patients with sepsis: Study protocol for a multicenter prospective cohort trial

Background

Sepsis-induced cardiomyopathy significantly increased the mortality of patients with sepsis. The diagnostic criteria for septic cardiomyopathy has not been unified, which brings serious difficulties to clinical treatment. This study aimed to provide evidence for the early identification and intervention in patients with sepsis by clarifying the relationship between the ultrasound phenotype of septic cardiomyopathy and the prognosis of patients with sepsis.

Methods

This was a multicenter, prospective cohort study. The study population will consist of all eligible consecutive patients with sepsis or septic shock who meet the Sepsis 3.0 diagnostic criteria and were aged ≥18 years. Clinical data and echocardiographic measurements will be recorded within 2 h, at the 24th hour, at the 72nd hour, and on the 7th day after admission. The prevalence of each phenotype will be described as well, and their association with prognosis will be analyzed statistically.

Discussion

To achieve early recognition, prevent reinjury, achieve precise treatment, and reduce mortality in patients with sepsis, it is important to identify septic cardiac alterations and classify the phenotypes at all stages of sepsis. First, there is a lack of studies on the prevalence of each phenotype in Chinese populations. Second, each phenotype and its corresponding prognosis are not clear. In addition, the prognosis of patients with normal cardiac ultrasound phenotypes vs. those with suppressed or hyperdynamic cardiac phenotypes is unclear. Finally, this study was designed to collect data at four specific timing, then the timing of occurrence, duration, changes over time, impact to outcomes of each phenotype will probably be found. This study is expected to establish a standard and objective method to assess the ultrasound phenotype of septic cardiomyopathy due to its advantages of visualization, non-invasiveness and reproducibility, and to provide more precise information for the hemodynamic management of septic patients. In addition, this research will promote the clinical application of critical care ultrasound, which will play an important role in medical education and make ultrasound the best method to assess cardiac changes in sepsis.

Trial registration

https://clinicaltrials.gov/ct2/show/NCT05161104, identifier NCT05161104.

COVID-19-Associated Myocarditis: An Evolving Concern in Cardiology and Beyond

Simple Summary

Coronavirus disease-2019 (COVID-19) affects many organs in the body, including the heart. One complication of particular concern is inflammation of the heart muscle, called myocarditis. This paper presents updated research data on COVID-19-associated myocarditis. Specifically, we review the incidence, potential mechanisms, blood and imaging tests that can be used to detect the disease. We emphasize that, in contrast with early reports, recent data suggest that myocarditis in the setting of COVID-19 is relatively uncommon, yet infected individuals are at a substantially increased risk for poor outcomes. It is important to continue research in this area.

Abstract

The direct and indirect adverse effects of SARS-CoV-2 infection on the cardiovascular system, including myocarditis, are of paramount importance. These not only affect the disease course but also determine clinical outcomes and recovery. In this review, the authors aimed at providing an update on the incidence of Coronavirus disease-2019 (COVID-19)-associated myocarditis. Our knowledge and experience relevant to this area continues to evolve rapidly since the beginning of the pandemic. It is crucial for the scientific and medical community to stay abreast of current information. Contrasting early reports, recent data suggest that the overall incidence of SARS-CoV-2-associated myocarditis is relatively low, yet infected individuals are at a substantially increased risk. Therefore, understanding the pathophysiology and diagnostic evaluation, including the use of serum biomarkers and imaging modalities, remain important. This review aims to summarize the most recent data in these areas as they relate to COVID-19-associated myocarditis. Given its increasing relevance, a brief update is included on the proposed mechanisms of myocarditis in COVID-19 vaccine recipients.

Dexamethasone Improves Cardiovascular Outcomes in Critically Ill COVID-19, a Real World Scenario Multicenter Analysis

BACKGROUND

Severe COVID-19 pneumonia requiring intensive care treatment remains a clinical challenge to date. Dexamethasone was reported as a promising treatment option, leading to a reduction of mortality rates in severe COVID-19 disease. However, the effect of dexamethasone treatment on cardiac injury and pulmonary embolism remains largely elusive.

METHODS

In total 178 critically ill COVID-19 patients requiring intensive care treatment and mechanical ventilation were recruited in three European medical centres and included in the present retrospective study. One hundred thirteen patients (63.5%) were treated with dexamethasone for a median duration of 10 days (IQR 9-10). Sixty five patients (36.5%) constituted the non-dexamethasone control group.

RESULTS

While peak inflammatory markers were reduced by dexamethasone treatment, the therapy also led to a significant reduction in peak troponin levels (231 vs. 700% indicated as relative to cut off value, p = 0.001). Similar, dexamethasone resulted in significantly decreased peak D-Dimer levels (2.16 mg/l vs. 6.14 mg/l, p = 0.002) reflected by a significant reduction in pulmonary embolism rate (4.4 vs. 20.0%, p = 0.001). The antithrombotic effect of dexamethasone treatment was also evident in the presence of therapeutic anticoagulation (pulmonary embolism rate: 6 vs. 34.4%, p < 0.001). Of note, no significant changes in baseline characteristics were observed between the dexamethasone and non-dexamethasone group.

CONCLUSION

In severe COVID-19, anti-inflammatory effects of dexamethasone treatment seem to be associated with a significant reduction in myocardial injury. Similar, a significant decrease in pulmonary embolism, independent of anticoagulation, was evident, emphasizing the beneficial effect of dexamethasone treatment in severe COVID-19.

Maternal Death by COVID-19 Associated with Elevated Troponin T Levels

Cardiomyocyte injury and troponin T elevation has been reported within COVID-19 patients and are associated with a worse prognosis. Limited data report this association among COVID-19 pregnant patients. Objective: We aimed to analyze the association between troponin T levels in severe COVID-19 pregnant women and risk of viral sepsis, intensive care unit (ICU) admission, or maternal death. Methods: We performed a prospective cohort of all obstetrics emergency admissions from a Mexican National Institute. All pregnant women diagnosed by reverse transcription-polymerase chain reaction (RT-qPCR) for SARS-CoV-2 infection between October 2020 and May 2021 were included. Clinical data were collected, and routine blood samples were obtained at hospital admission. Seric troponin T was measured at admission. Results: From 87 included patients, 31 (35.63%) had severe COVID-19 pneumonia, and 6 (6.89%) maternal deaths. ROC showed a significant relationship between troponin T and maternal death (AUC 0.979, CI 0.500–1.000). At a cutoff point of 7 ng/mL the detection rate for severe pneumonia was 83.3% (95%CI: 0.500–0.100) at 10% false-positive rate. Conclusion: COVID-19 pregnant women with elevated levels of troponin T present a higher risk of death and severe pneumonia.

Risk of atrial fibrillation in patients with pneumonia

BACKGROUND

Cardiac arrhythmias have a strong association with pneumonia due to the cardiovascular response to infection. Electrocardiographic (ECG) changes in patients with pneumonia are associated with greater disease severity. Atrial fibrillation (AF) is the most common type of cardiac arrhythmia.

OBJECTIVE

This population-based cohort study investigated the incidence of AF among Taiwanese adults with pneumonia using data from the National Health Insurance Research Database in Taiwan.

METHODS

A total of 34,883 patients with pneumonia and an equal number of individuals without pneumonia were eligible after excluding those with a previous diagnosis of AF and matching 1:1 by age, sex, and comorbidities. The Cox proportional hazards model was used to estimate hazard ratios for AF in both groups.

RESULTS

Patients were more likely to develop AF throughout the 1-year follow-up period after the diagnosis of pneumonia. The incidence of AF was 1.2 (414/334,746) per 1000 person-months. Patients with pneumonia had a 4.08-fold (95% confidence interval 3.37-4.95) increased risk for AF compared to patients without pneumonia.

CONCLUSION

Patients with pneumonia exhibited an increased risk for AF, especially in the early period after diagnosis of pneumonia.

Vasostatin-1 as a potential novel circulating biomarker in patients with chronic systolic heart failure: A pilot study

BACKGROUND AND AIMS

Previous studies have shown that circulating chromogranin A (CgA) increases in patients with chronic systolic heart failure (HF). Aim of the present study is to evaluate the potential role of circulating vasostatin-1 (VS-1), a cardioregulatory fragment of CgA, as prognostic marker in patients with chronic HF.

MATERIALS AND METHODS

The plasma levels of CgA and VS-1 were determined in 80 patients with chronic systolic HF. Patients were followed-up to evaluate the occurrence of cardiovascular (CV) events.

RESULTS

CgA and VS-1 plasma levels were significantly higher in patients with CV events at follow-up. VS-1, but not CgA, was associated to NT-proBNP. No significant association of CgA and VS-1 with left ventricular ejection fraction (LVEF) was observed. CgA, NT-proBNP and age, but not VS-1, were independent predictors of CV events.

CONCLUSION

In patients with chronic systolic HF those who experienced CV events had higher levels of VS-1 and CgA. Given its established effect on cardiac cells, the association of VS-1 levels with NT-proBNP levels but not with LVEF, suggests that this fragment might provide complementary information to NT-proBNP and CgA in HF patients.

Berberine attenuates septic cardiomyopathy by inhibiting TLR4/NF-κB signalling in rats

CONTEXT

Berberine (Ber) can increase the survival rate of septic mice and inhibit inflammation, but whether it has a protective effect on septic cardiomyopathy (SCM) is unclear.

OBJECTIVE

To investigate whether Ber ameliorates SCM in a rat model and its potential mechanism.

MATERIALS AND METHODS

Male SD rats were randomly divided into three groups: control (Con, n = 6) (DD H₂O, 2 mL/100 g, ig, qd × 3 d, then saline, 10 mg/kg, ip); sepsis [LPS (lipopolysaccharide), n = 18] (LPS 10 mg/kg instead of saline, ip); and berberine intervention (Ber, n = 18) (Ber, 50 mg/kg instead of DD H₂O, ig, qd × 3 d, LPS instead of saline, ip). Hemodynamics, HE staining, ELISA and western blot were performed at 6, 24, and 48 h after intraperitoneal injection of LPS to evaluate the effect of berberine in septic rats.

RESULT

Berberine could recover myocardial injury by partially increased ± dp/dt max (1151, 445 mmHg/s) and LVEDP levels (1.49 mmHg) with LPS-induced rats, as well as an ameliorated increase of cTnT (217.53 pg/mL) in the Ber group compared with that in the LPS group (at 24 h). In addition, HE staining results showed that berberine attenuated the myocardial cell swelling induced by LPS. In contrast to the LPS group, the up-regulation of TLR4, p65 TNF-α, and IL-1β were attenuated in the Ber group.

DISCUSSION AND CONCLUSIONS

Berberine showed a protective effect on septic cardiomyopathy rats possibly through inhibiting the activation of TLR4/NF-κB signalling pathway. Whether it improves SCM through other mechanisms is our ongoing research.

Etiology of Myocardial Injury in Critically Ill Patients with Sepsis: A Cohort Study

RATIONALE

Myocardial injury occurs frequently during sepsis and is independently associated with mortality. However, its etiology remains largely unknown.

OBJECTIVE

Our aim was to assess the relative contributions of hyperinflammation, activated coagulation, and endothelial dysfunction to myocardial injury in critically ill patients with sepsis.

METHODS

We included consecutive patients with sepsis presenting to two tertiary intensive care units in the Netherlands between 2011 and 2013. High-sensitivity cardiac troponin I (hscTnI), as well as a wide range of plasma biomarkers related to inflammation, coagulation, and endothelial function were measured. Structural equation modeling (SEM) was used to construct latent variables representing each of these pathophysiological constructs, and to subsequently study their associations with troponin elevation while adjusting for confounders.

RESULTS

We analyzed 908 (88%) of 1037 eligible patients, 553 (61%) of whom had raised hs-cTnI levels upon intensive care unit admission. The latent variables included interleukin (IL)-6, IL-8 and IL-1β for inflammation; platelet count, prothrombin time and protein C for coagulation; and sE-selectin, intercellular adhesion molecule-1 and angiopoietin-2 for endothelial function. After adjustment for age and cardiovascular comorbidities, SEM analysis showed that activated coagulation was independently associated with elevated troponin during sepsis (standardized regression coefficient 0.551, 95% CI 0.257-0.845, p-value <0.001), whereas hyperinflammation and endothelial dysfunction were not (standardized regression coefficients -0.161, 95% CI -0.418-0.096, and -0.054, 95% CI -0.168-0.060, respectively).

CONCLUSIONS

Our findings suggest that myocardial injury during sepsis is mediated by systemic activation of coagulation, rather than by circulating inflammatory mediators or by activation of the endothelium. These findings may guide evaluation of strategies to protect the myocardium during sepsis. Clinical trial registered with clinicaltrials.gov (NCT01905033).

Immunohistochemistry in the Postmortem Diagnosis of Sepsis: A Systematic Review

It is not uncommon for the forensic pathologist to question whether a deceased person had experienced sepsis that could have either been the cause of or contributed to the person's death. Often, the missing typical pathologic factors or lack of clinical and circumstantial information on the death render the autopsy of a sepsis-related death a difficult task for the forensic pathologist. Several authors emphasize on how an immunohistochemical analysis could help in diagnosing death related to sepsis. The research we carried out analyzes the main scientific studies in the literature, primarily the tracing of 21 immunohistochemical antigens evaluated to help diagnose death related to sepsis. The purpose of this review was to analyze and summarize the markers studied until now and to consider the limitations of immunohistochemistry that currently exist with regard to this particular field of forensic pathology. Immunohistochemistry provided interesting and promising results, but further studies are needed in order for them to be confirmed, so that they may be applied in standard forensic practice.

Pathophysiology of sepsis-induced cardiomyopathy

Sepsis is the life-threatening organ dysfunction caused by a dysregulated host response to infection and is the leading cause of death in intensive care units. Cardiac dysfunction caused by sepsis, usually termed sepsis-induced cardiomyopathy, is common and has long been a subject of interest. In this Review, we explore the definition, epidemiology, diagnosis and pathophysiology of septic cardiomyopathy, with an emphasis on how best to interpret this condition in the clinical context. Advances in diagnostic techniques have increased the sensitivity of detection of myocardial abnormalities but have posed challenges in linking those abnormalities to therapeutic strategies and relevant clinical outcomes. Sophisticated methodologies have elucidated various pathophysiological mechanisms but the extent to which these are adaptive responses is yet to be definitively answered. Although the indications for monitoring and treating septic cardiomyopathy are clinical and directed towards restoring tissue perfusion, a better understanding of the course and implications of septic cardiomyopathy can help to optimize interventions and improve clinical outcomes.

"Acute Myocardial Infarction in the Time of COVID-19": A Review of Biological, Environmental, and Psychosocial Contributors

Coronavirus disease 2019 (COVID-19) has quickly become a worldwide health crisis.Although respiratory disease remains the main cause of morbidity and mortality in COVID patients,myocardial damage is a common finding. Many possible biological pathways may explain therelationship between COVID-19 and acute myocardial infarction (AMI). Increased immune andinflammatory responses, and procoagulant profile have characterized COVID patients. All theseresponses may induce endothelial dysfunction, myocardial injury, plaque instability, and AMI.Disease severity and mortality are increased by cardiovascular comorbidities. Moreover, COVID-19has been associated with air pollution, which may also represent an AMI risk factor. Nonetheless,a significant reduction in patient admissions following containment initiatives has been observed,including for AMI. The reasons for this phenomenon are largely unknown, although a real decreasein the incidence of cardiac events seems highly improbable. Instead, patients likely may presentdelayed time from symptoms onset and subsequent referral to emergency departments because offear of possible in-hospital infection, and as such, may present more complications. Here, we aim todiscuss available evidence about all these factors in the complex relationship between COVID-19and AMI, with particular focus on psychological distress and the need to increase awareness ofischemic symptoms.

Epidemiology of right ventricular systolic dysfunction in patients with sepsis and septic shock in the emergency department

We evaluated whether in sepsis, right ventricular (RV) systolic dysfunction (RVSD) predicts short-term all-cause mortality, independently to left ventricular (LV) global longitudinal peak systolic strain (GLS). This is a prospective observational study. We enrolled 252 septic patients (40% with shock) between October 2012 and July 2018 among those admitted to High-Dependency Unit. By echocardiography within 24 h from the admission (T1), RVSD was defined as Tricuspid Annular Plane Systolic Excursion (TAPSE) < 16 mm, while left ventricular systolic dysfunction (LVSD) was defined by bi-dimensional speckle-tracking-based global longitudinal peak systolic strain (GLS) > -14%. We assessed all-cause mortality at day-7 and at day-28 from admission. Mortality rate was 14% by day-7 and 26% by day-28 follow-up. RVSD was found in 85 patients (34%), was isolated in 29% (25/85) and coexisted with LVSD in 71% (60/85) patients. LVSD was present in 63% of patients (159/252), and was isolated in 99 patients. Day-7 mortality rate was twofold higher in the presence of RVSD (20% vs 11%), without reaching the statistical significance (p = 0.097). By day-28, mortality rate was as high as 44% with and 23% without RVSD (p = 0.001). In a Cox survival analysis, RVSD predicted higher mortality rate by day-28 follow-up (RR 2.43, 95% CI 1.47-4.00, p = 0.001), independent to shock and in addition to LVSD. In sepsis, RVSD predicted all-cause mortality by day-28 follow-up, independent to LVSD.

ST-Elevation Myocardial Infarction in the Presence of Septic Shock

Elevated cardiac enzymes are often seen in the setting of sepsis. The mechanism involves hypoperfusion and possible compromise to myocardial tissue. Electrocardiogram (ECG) changes in the setting of septic shock are less common and can vary widely. Rarely, ST-segment elevations can occur. This case describes a 54-year-old female who presented with septic shock secondary to pyelonephritis and Escherichia coli bacteremia. The patient was admitted to the intensive care unit on norepinephrine and required mechanical ventilation. A significant rise in troponin I (peak 19.8 ng/mL) was seen and ECG showed ST-segment elevations in leads I and aVL with reciprocal ST depressions in leads II, III, and aVF. The patient was taken urgently for left cardiac catheterization, which showed no evidence of obstructive coronary artery disease. When distinguishing between septic shock and cardiogenic shock, insertion of a pulmonary artery catheter may help with diagnosis and treatment of cardiogenic shock. Catheter hemodynamic monitoring can also confirm the diagnosis. In our patient's case, hemodynamic monitoring was initiated and was not consistent with cardiogenic shock. ST-segment elevations in the high lateral leads and elevated cardiac markers were likely due to severe transmural ischemia secondary to increased oxygen demand. The patient was continued on intravenous antibiotics for treatment of her septic shock. She was extubated and weaned off of norepinephrine within 48 hours. Repeat ECG performed after resolution of the infection showed normal sinus rhythm with no ST-segment changes. Cardiac dysfunction in the setting of septic shock is well described in medical literature; however, the mechanisms of dysfunction are not explicitly understood. Transient hypoperfusion, coronary vasospasm, and localized endothelial damage are possible components. It is important to think of varying etiologies, other than acute coronary syndrome when approaching patients in septic shock with acute ST-segment changes and elevated cardiac markers.

Fluid resuscitation in sepsis: the great 30 mL per kg hoax

Large volume fluid resuscitation is currently viewed as the cornerstone of the treatment of septic shock. The surviving sepsis campaign (SSC) guidelines provide a strong recommendation to rapidly administer a minimum of 30 mL/kg crystalloid solution intravenously in all patients with septic shock and those with elevated blood lactate levels. However, there is no credible evidence to support this recommendation. In fact, recent findings from experimental, observational and randomized clinical trials demonstrate improved outcomes with a more restrictive approach to fluid resuscitation. Accumulating evidence suggests that aggressive fluid resuscitation is harmful. Paradoxically, excess fluid administration may worsen shock. In this review, we critically evaluate the scientific evidence for a weight-based fluid resuscitation approach. Furthermore, the potential mechanisms and consequences of harm associated with fluid resuscitation are discussed. Finally, we recommend an individualized, conservative and physiologic guided approach to fluid resuscitation.

Cardiac Involvement in Travelers with Enteric Fever

Data regarding cardiac involvement in enteric fever among travelers are scarce. In this retrospective study, 59 patients were hospitalized with enteric fever during 2004-2017 and 28 had cardiac workups. Among those, four had evidence of cardiac involvement, including clinical myocarditis, electrocardiogram changes, or troponin elevation. Cardiac involvement was higher among patients infected with Salmonella Typhi than with Salmonella Paratyphi A (P = 0.08), with a significant relative risk of 6 (95% CI: 1.15-31.22, P = 0.03). Time from symptoms onset to effective treatment was longer for patients with cardiac involvement (13 versus 7.15 days, P < 0.05). It seems that cardiac involvement in enteric fever is not uncommon in travelers. Such involvement seems to be more common in patients with delay of effective treatment to the second week of illness. Although fatal or complicated cases are rare in travelers, the cardiac complication may be an important contributor to morbidity and mortality in this group.