Composite endpoints can encode multiple pieces of information and are increasingly adopted in clinical trials. Advocacy for using composite endpoints began decades ago in cardiovascular trials, leading to incorporation of patient-oriented outcomes and consideration of a hierarchical ranking system. The use of composite endpoints in coronavirus disease (COVID-19) trials has evolved similarly. We conducted a literature review to investigate the use of composite endpoints in acute heart failure and COVID-19 clinical trials. The results showed more frequent use of patient-oriented outcomes and ordinal composite endpoints in COVID-19 trials, which might be driven by global consensus on a set of common outcome measures.

Recombinant angiotensin II is an emerging drug therapy for refractory hypotension. Its use is relevant to patients with disruption of the renin–angiotensin–aldosterone system denoted by elevated direct renin levels. We present a child that responded to recombinant angiotensin II in the setting of right ventricular hypertension and multi-organism septic shock.

A previously healthy 4-year-old female presented in cardiogenic shock with pneumococcal meningitis. Findings on echocardiogram raised suspicion for takotsubo cardiomyopathy. With supportive care, left ventricular systolic function normalised. Findings on cardiac imaging helped determine the aetiology and avoid further invasive studies or unnecessary treatment.

There are a variety of causes of acute heart failure in children including myocarditis, genetic/metabolic conditions, and congenital heart defects. In cases with a structurally normal heart and a negative personal and family history, myocarditis is often presumed to be the cause, but we hypothesise that genetic disorders contribute to a significant portion of these cases. We reviewed our cases of children who presented with acute heart failure and underwent genetic testing from 2008 to 2017. Eighty-seven percent of these individuals were found to have either a genetic syndrome or pathogenic or likely pathogenic variant in a cardiac-related gene. None of these individuals had a personal or family history of cardiomyopathy that was suggestive of a genetic aetiology prior to presentation. All of these individuals either passed away or were listed for cardiac transplantation indicating genetic testing may provide important information regarding prognosis in addition to providing information critical to assessment of family members.

Severe valvulitis owing to acute Kawasaki disease leading to severe mitral regurgitation is a rare event in infants. Further, there is less information about underlying ruptured mitral chordae tendineae causing severe mitral regurgitation. We encountered ruptured mitral chordae tendineae in three female patients after Kawasaki disease. The age at the onset of Kawasaki disease ranged from 3 to 8 months, and detection of ruptured mitral chordae tendineae was from 24 to 90 days. Two patients had acute heart failure, and one was asymptomatic. One patient underwent mitral annuloplasty, and the others responded to medication. These ruptured mitral chordae tendineae occurred after the remission of the initial acute Kawasaki disease, in the early course and the convalescent of acute Kawasaki disease. Further, the recurrent fever was also detected in them. The ruptured mitral chordae tendineae in an infant within 6 months can be detected by systolic heart murmur around the convalescent stage of acute Kawasaki disease, although the prevalence is very low.

Introduction: Diagnosing the undifferentiated dyspneic emergency department (ED) patient remains a challenge for clinicians; in order to rule in or out acute heart failure (AHF) natriuretic peptide biomarker testing has evolved and is recommended by cardiology international guidelines to be utilized in these presentations. However there is equipoise in the emergency community for its use, largely due to perceived modest test specificity. We sought to analyze this apparent clinical dichotomy as part of a multicenter trial of undifferentiated dyspneic ED patients. Methods: Patients with dyspnea presenting between October 2010 and October 2013 to one of four ED sites -2 Canadian, 1 American, 1 New Zealand- were assessed by certified staff emergency physicians (EPs) and their chest Xray reviewed. Those patients with undifferentiated dyspnea with a potential for AHF (ie further investigated or treated for AHF but investigated and/or treated for another cause) were consented and enrolled. Two of the sites (American, New Zealand) had NT-proBNP assay ordered as a standard of care for these patients; the other 2 sites did not. At the end of Emergency care, the EP recorded the primary diagnosis of the dypnea-either “AHF” or “Not AHF.” Blinded adjudication was carried out by 2 cardiologists after reviewing sequential records: first, with index ED records but no NT-proBNP result; second, with the NT-proBNP result and lastly, with follow up 60 day records (deemed the gold standard diagnosis). EP accuracy between NT-proBNP and no NT-proBNP sites and NT-proBNP accuracy using standard cutpoints were calculated, as were the number of adjudicated cases influenced by exposure to NT-proBNP. Results: 197 patients were enrolled, 107 at NTproBNP sites and 90 at the other 2 sites. EP accuracy was 76% for either site. NT-proBNP used as a binary test with recommended age-stratified cutoffs had 80% accuracy, applied to 70% of patients (30% remained in “gray zone”).Cardiology adjudicators reversed 16% of initial diagnoses upon exposure to NT-proBNP result, ultimately diagnosing 41% of patients with AHF. Conclusion: This study supports the clinical equipoise amongst emergency physicians compared to cardiologists for the use of NT-proBNP in diagnosing acute heart failure in the undifferentiated dyspneic Emergency patient.

Acute heart failure is a common and serious complication of congenital and acquired heart disease, and it is associated with significant morbidity, mortality, and costs. When a patient is admitted to the hospital with acute heart failure, there are several important goals for the hospital admission, including maintaining adequate perfusion, establishing the underlying aetiology for the heart failure, patient and family education, and discharge from the hospital in a stable condition. The pathway to home discharge is variable and may include inotropic therapy, mechanical circulatory support, and/or heart transplantation. This review will cover the epidemiology, presentation, and management of acute heart failure in children.

Acute heart failure is a highly prevalent geriatric syndrome presenting one of the most frequent reasons for visits to the emergency department and hospital admission, and is associated with a high morbidity and mortality and acute functional impact. The present study reviews some of the features that characterize diagnosis and immediate management of acute heart failure in older people, as well as recommendations about the management of co-morbidity, risk stratification and the decisión-making process, and the design of care plans in this older age group within the setting of hospital emergency departments.

We describe a case of influenza A myocarditis and transient left ventricular wall thickening in a 14-year-old girl presenting with acute heart failure. Admission echocardiogram revealed significant left ventricular hypertrophy with depressed left ventricular systolic function. The aetiology of the ventricular thickening was demonstrated to be myocardial oedema using cardiac magnetic resonance imaging. The natural course of this unusual clinical presentation of acute myocarditis and the importance of cardiac magnetic resonance imaging in this challenging clinical setting are discussed.