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Aims: A high-intensity care (HIC) strategy with rapid guideline-directed medical therapy (GDMT) up-titration and close follow-up visits improved outcomes, compared to usual care (UC), in patients recently hospitalized for acute heart failure (AHF). Hypotension is a major limitation to GDMT implementation. We aimed to assess the impact of baseline systolic blood pressure (SBP) on the effects of HIC versus UC and the role of early SBP changes in STRONG-HF., Methods and Results: A total of 1075 patients hospitalized for AHF with SBP ≥100 mmHg were included in STRONG-HF. For the purpose of this post-hoc analysis, patients were stratified by tertiles of baseline SBP (<118, 118-128, and ≥129 mmHg) and, in the HIC arm, by tertiles of changes in SBP from the values measured before discharge to those measured at 1 week after discharge (≥2 mmHg increase, ≤7 mmHg decrease to <2 mmHg increase, and ≥8 mmHg decrease). The primary endpoint was 180-day heart failure rehospitalization or death. The effect of HIC versus UC on the primary endpoint was independent of baseline SBP evaluated as tertiles (p interaction  = 0.77) or as a continuous variable (p interaction  = 0.91). In the HIC arm, patients with increased, stable and decreased SBP at 1 week reached 83.5%, 76.2% and 75.3% of target doses of GDMT at day 90. The risk of the primary endpoint was not significantly different between patients with different SBP changes at 1 week (adjusted p = 0.46)., Conclusions: In STRONG-HF, the benefits of HIC versus UC were independent of baseline SBP. Rapid GDMT up-titration was performed also in patients with an early SBP drop, resulting in similar 180-day outcome as compared to patients with stable or increased SBP., (© 2024 European Society of Cardiology.)

Background: Mechanical thrombectomy (MT) for acute ischemic stroke can be performed under local anesthesia, with or without conscious sedation (CS), or under general anesthesia (GA). The hemodynamic consequence of anesthetic drugs may explain why GA may be associated with worse outcomes. We evaluated the association between hypotension duration during MT and the 90 day functional outcome under both anesthetic regimens., Methods: Patients were included in this retrospective study if they had an ischemic stroke treated by MT under GA or CS. The main exposure variable was the time below 90% of the reference value of arterial pressure measured before MT. The primary outcome was poor functional outcome defined as a 90 day modified Rankin Score ≥3., Results: 371 patients were included in the study. GA was performed in 42%. A linear association between the duration of arterial hypotension and outcome was observed. The odds ratio for poor functional outcome of 10 min under 90% of the baseline mean arterial pressure was 1.13 (95% CI 1.06 to 1.21) without adjustment and 1.11 (95% CI 1.02 to 1.21) after adjustment for confounding factors. The functional outcome was poorer for patients treated under GA compared with CS, but the association with the depth of hypotension remained similar under both conditions., Conclusion: In this study, we observed a linear association between the duration of hypotension during MT and the functional outcome at 90 days. An aggressive and personalized strategy for the treatment of hypotension should be considered. Further trials should be conducted to address this question., Competing Interests: Competing interests: EG received consultancy fees from Magnisense and Adrenomed and research grant from Retia Medical., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Cardiac output (CO) optimisation during surgery reduces post-operative morbidity. Various methods based on pulse pressure analysis have been developed to overcome difficulties to measure accurate CO variations in standard anaesthetic settings. Several of these methods include, among other parameters, the ratio of pulse pressure to mean arterial pressure (PP/MAP). The aim of this study was to evaluate whether the ratio of radial pulse pressure to mean arterial pressure (ΔPPrad/MAP) could track CO variations (ΔCO) induced by various therapeutic interventions such as fluid infusions and vasopressors boluses [phenylephrine (PE), norepinephrine (NA) or ephedrine (EP)] in the operating room. Trans-oesophageal Doppler signal and pressure waveforms were recorded in patients undergoing neurosurgery. CO and PPrad/MAP were recorded before and after fluid challenges, PE, NA and EP bolus infusions as medically required during their anaesthesia. One hundred and three patients (mean age: 52 ± 12 years old, 38 men) have been included with a total of 636 sets of measurement. During fluids challenges (n = 188), a positive correlation was found between ΔPPrad/MAP and ΔCO (r = 0.22, p = 0.003). After PE (n = 256) and NA (n = 121) boluses, ΔPPrad/MAP positively tracked ΔCO (r = 0.53 and 0.41 respectively, p < 0.001). By contrast, there was no relation between ΔPPrad/MAP and ΔCO after EP boluses (r = 0.10, p = 0.39). ΔPPrad/MAP tracked ΔCO variations during PE and NA vasopressor challenges. However, after positive fluid challenge or EP boluses, ΔPPrad/MAP was not as performant to track ΔCO which could make the use of this ratio difficult in current clinical practice.

VPloop, the graphical representation of pressure versus velocity, and its characteristic angles, GALA and β, can be used to monitor cardiac afterload during anesthesia. Ideally VPloop should be measured from pressure and velocity obtained at the same arterial location but standard of care usually provide either radial or femoral pressure waveforms. The purpose of this study was to look at the influence of arterial sites and the use of a transfer function (TF) on VPloop and its related angles. Invasive pressure signals were recorded in 25 patients undergoing neuroradiology intervention under general anesthesia with transesophageal flow velocity monitoring. Pressures were recorded in the descending thoracic aorta, abdominal aorta, femoral and radial arteries. We compared GALA and β from VPloops generated from each location and in high and low risk patients. GALA was similar in the central locations (55°[49-63], 52°[47-61] and 54°[45-62] from descending thoracic to femoral artery, median[interquartile], p = 0.10), while there was a difference in β angle (16°[4-27] to 8°[3-15], p < 0.0001). GALA and β obtained from radial waveforms were different (39°[31-47] compared to 46°[36-54] and 6°[2-14] compared to 16°[4-27] for GALA and β angles respectively, p < 0.001) which was corrected by the use of a TF (45°[32-55] and 17°[5-28], p = ns). GALA and β are underestimated when measured with a radial catheter. Using pressure waveforms from femoral locations alters VPloops, GALA and β in a smaller extend. The use of a TF on radial pressure allows to correctly plot VPloops and their characteristic angles for routine clinical use.

Background Studies on the role of blood pressure ( BP ) variability specifically during mechanical thrombectomy ( MT ) are sparse and limited. Moreover, pulse pressure ( PP ) has not been considered as a potent hemodynamic parameter to describe BP variability during MT . We assessed the impact of PP variability on functional outcome in acute ischemic stroke patients with large vessel occlusion during MT . Methods and Results Acute ischemic stroke patients presenting with large vessel occlusion from January 2012 to June 2016 were included. BP data during MT were prospectively collected in the ETIS (Endovascular Treatment in Ischemic Stroke) registry. Logistic regression models were used to assess the association between PP coefficients of variation and functional outcome at 3 months (modified Rankin Scale). Among the 343 included patients, PP variability was significantly associated with worse 3-month modified Rankin Scale in univariable (odds ratio [OR] =1.56, 95% confidence interval [CI]: 1.24-1.96 per 1-unit increase, P=0.0002) and multivariable ordinal logistic regression (adjusted OR =1.40, 95% CI : 1.09-1.79, P=0.008). PP variability was also associated with unfavorable outcome (modified Rankin Scale 3-6) in univariable ( OR =1.53, 95% CI : 1.17-2.01, P=0.002) and multivariable analysis (adjusted OR =1.42, 95% CI : 1.02-1.98, P=0.04). There was an association between PP variability and 3-month all-cause mortality in univariable analysis ( OR = 1.37, 95% CI : 1.01-1.85 per 1-unit increase of the coefficient of variation of the PP , P=0.04), which did not remain significant after adjustment for potential confounders. Conclusions PP variability during MT is an independent predictor of worse clinical outcome in acute ischemic stroke patients. These findings support the need for a close monitoring of BP variability during MT . Whether pharmacological interventions aiming at reducing BP variability during MT could impact functional outcome needs to be determined.

Most techniques previously used to assess left ventricular (LV) end-systolic elastance (E(es)) and ventricular-arterial coupling (C(LV-A)) relied on invasive measurements and data acquisition over a wide range of loading conditions. Our goals were to 1) assess the feasibility of noninvasive assessment of E(es) and C(LV-A) using real-time three-dimensional echocardiography (RT3DE) and arterial tonometry; 2) test the ability of this approach to detect changes in LV contractility; and 3) study its reproducibility. We studied pharmacologically induced changes in inotropic state (5 and 10 μg·kg(-1)·min(-1) dobutamine) in normal volunteers (N = 8) and compared 10 normal volunteers with 10 patients with dilated cardiomyopathy (DCM; ejection fraction < 35%). RT3DE LV images, calibrated carotid artery tonometry, and Doppler tracings were obtained to noninvasively estimate E(es) and C(LV-A), using two alternative calculations. Dobutamine caused a significant stepwise increase in blood pressure, heart rate, ejection fraction, and E(es) and a decreased C(LV-A). In patients with DCM, E(es) was significantly reduced and C(LV-A) elevated, compared with controls. Both inter- and intraobserver variability were good for all measured parameters, as reflected by intraclass correlation coefficients (>0.8) and coefficients of variation (<20%). While both E(es) estimates showed significant differences between DCM patients and controls, one estimate resulted in no overlap and better reproducibility (interobserver intraclass correlation coefficient: 0.83 vs. 0.47, coefficients of variation: 20 vs. 29%). This is the first study to test the feasibility of using RT3DE-derived LV volumes in conjunction with arterial tonometry to noninvasively quantify LV elastance and C(LV-A). This approach was found to be sensitive enough to detect expected differences in LV contractility and reproducible. Due to its noninvasive nature, this methodology may have clinical implications in various disease states.

Introduction: During general anesthesia, arterial hypotension is frequent and may be an important contributor to perioperative morbidity. We assessed the effect of a 5 μg bolus of Norepinephrine (NA) when compared with 50 μg bolus of Phenylephrine (PE) administered to treat hypotension during maintenance anesthesia, on MAP, derived cardiac output and arterial stiffness parameters.Methods: Patients scheduled for a neurosurgical procedure under general anesthesia were prospectively included. Monitoring included invasive blood pressure, esophageal Doppler, and arterial tonometer used to estimate central aortic pressure with arterial stiffness parameters, such as augmentation index (Aix). After initial resuscitation, hypotensive episodes were corrected by a bolus administration of NA or PE in a peripheral venous line.Results: There were 269 bolus administrations of vasopressors (149 NA, 120 PE) in 47 patients with no adverse effects detected. A decrease in stroke volume (SV) was observed with PE compared with NA (-18 ± 9% vs. -14 ± 7%, P < 0.001). This decrease was associated with an increase in Aix, which was greater for PE than for NA (+10 ± 8% vs. +6 ± 6%, P < 0.0001), and a decrease in total arterial compliance greater for PE compared to NA (Ctot = SV/Central Pulse Pressure) (-35 ± 9% vs. -29 ± 10%, P < 0.001).Discussion: This study suggests that 5 μg of NA administered as a bolus in a peripheral venous line could treat general anesthesia-induced arterial hypotension with a smaller decrease in SV and arterial compliance when compared to PE. [ABSTRACT FROM AUTHOR]

Background. Maintaining adequate organ perfusion during high-risk surgery requires continuous monitoring of cardiac output to optimise haemodynamics. Oesophageal Doppler Cardiac Output monitoring (DCO) is commonly used in this context, but has some limitations. Recently, the cardiac output estimated by pulse pressure analysis- (PPCO) was developed. This study evaluated the agreement of cardiac output variations estimated with 9 non-commercial algorithms of PPCO compared with those obtained with DCO. Methods. High-risk patients undergoing neurosurgery were monitored with invasive blood pressure and DCO. For each patient, 9 PPCO algorithms and DCO were recorded before and at the peak effect for every haemodynamic challenge. Results. Sixty-two subjects were enrolled; 284 events were recorded, including 134 volume expansions and 150 vasopressor boluses. Among the 9 algorithms tested, the Liljestrand- Zander model led to the smallest bias (0.03 litre min-1 [-1.31, +1.38] (0.21 litre min-1 [-1.13; 1.54] after volume expansion and 20.13 litre min-1 [-1.41, 1.15] after vasopressor use). The corresponding percentage of the concordance was 91% (86% after volume expansion and 94% after vasopressor use). The other algorithms, especially those using the Winkessel concept and the area under the pressure wave, were profoundly affected by the vasopressor. Conclusions. Among the 9 PPCO algorithms examined, the Liljestrand-Zander model demonstrated the least bias and best limits of agreement, especially after vasopressor use. Using this particular algorithm in association with DCO calibration could represent a valuable option for continuous cardiac output monitoring of high risk patients. [ABSTRACT FROM AUTHOR]

Background CNAP® provides continuous non-invasive arterial pressure ( AP) monitoring. We assessed its ability to detect minimal and maximal APs during induction of general anaesthesia and tracheal intubation. Methods Fifty-two patients undergoing surgery under general anaesthesia were enrolled. Invasive pressure monitoring was established at the radial artery, and CNAP monitoring using a finger sensor recording was begun before induction. Statistical analysis was conducted with the Bland- Altman method for comparison of repeated measures and intraclass correlation coefficient ( ICC). Results Patients' median age was 67 years [interquartile range (59-76)], median American Society of Anesthesiologists score was 3 [interquartile range (2-3)]. Bias was 5 and −7 mm Hg for peak and nadir systolic AP ( SAP), with upper and lower limits of agreement of (42:−32) and (27;−42), respectively. The corresponding ICC values were 0.74 [95% confidence interval ( CI) = 0.57-0.84] and 0.60 (95% CI = 0.44-0.73). Time lags to reach these values were 7.5 s (95% CI = −10.0 to 60.0) for the highest SAP and 10 s (95% CI = −12.5 to 72.5) for the lowest SAP. Bias, lower and upper limits of agreement for diastolic, and mean AP were −14 (−36 to 9) and −12 (−37 to 13) for the nadir value and −7 (−29 to 15) and −2 (−28 to 25) for the peak value. Conclusions The CNAP monitor could detect acute change in AP within a reasonable time lag. Precision of its measurements is not satisfactory, and therefore, it could only serve as a clue to the occurrence of changes in AP. [ABSTRACT FROM AUTHOR]