Abstract Heart failure (HF) afflicts nearly 6 million Americans, resulting in one million emergency department (ED) visits and over one million annual hospital discharges. An aging population and ...improved survival from cardiovascular diseases is expected to further increase HF prevalence. Emergency providers play a significant role in the management of patients with acute heart failure (AHF). It is crucial that emergency physicians and other providers involved in early management understand the latest developments in diagnostic testing, therapeutics and alternatives to hospitalization. Further, clinical trials must be conducted in the ED in order to improve the evidence base and drive optimal initial therapy for AHF. Should ongoing and future studies suggest early phenotype-driven therapy improves in-hospital and post-discharge outcomes, ED treatment decisions will need to evolve accordingly. The potential impact of future studies which incorporate risk-stratification into ED disposition decisions cannot be underestimated. Predictive instruments that identify a cohort of patients safe for ED discharge, while simultaneously addressing barriers to successful outpatient management, have the potential to significantly impact quality of life and resource expenditures.
Both hyperkalemia and hypokalemia may be related to heart failure (HF) therapy and are associated with adverse outcomes. Abnormalities in serum potassium levels in hospitalized patients with HF and ...reduced ejection fraction (EF) have not been previously investigated. A post hoc analysis was performed in 1,907 hospitalized patients with worsening HF and reduced EF in the placebo arm of the Efficacy of Vasopressin Antagonism in HF Outcome Study with Tolvaptan (EVEREST) trial. Serum potassium was measured at randomization and at discharge or day 7. The co-primary end points were all-cause mortality (ACM) and cardiovascular mortality or the first HF hospitalization (CVM + HFH). The association between inhospital change in potassium levels and time to outcomes was evaluated using multivariate Cox regression models. Study participants had a mean age of 65.6 ± 12.0 years and were on optimal guideline-directed medical therapies, including β blockers (77%), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (85%), and aldosterone antagonists (55%). Baseline potassium concentration was 4.3 ± 0.6 mEq/l, and hyperkalemia or hypokalemia was seen in 6.5% of the participants. On average, serum potassium level increased by 0.21 ± 0.66 mEq/l, p <0.0001, during hospitalization. Inhospital potassium change was not associated with either the primary or the secondary end point over a median follow-up of 9.9 months. In conclusion, in patients with reduced EF hospitalized for worsening HF, serum potassium abnormalities are common at baseline (within 48 hours of admission) and potassium levels increase during hospitalization, despite aggressive diuretic therapy. However, they are not associated with all-cause or CVM or HFH. Inhospital changes in potassium may limit the implementation of evidence-based therapies such as mineralocorticoid receptor antagonists.
Endothelial Dysfunction, Arterial Stiffness, and Heart Failure Marti, Catherine N., MD; Gheorghiade, Mihai, MD; Kalogeropoulos, Andreas P., MD, PhD ...
Journal of the American College of Cardiology,
10/2012, Letnik:
60, Številka:
16
Journal Article
Recenzirano
Odprti dostop
Outcomes for heart failure (HF) patients remain suboptimal. No known therapy improves mortality in acute HF and HF with preserved ejection fraction; the most recent HF trial results have been ...negative or neutral. Improvement in surrogate markers has not necessarily translated into better outcomes. To translate breakthroughs with potential therapies into clinical benefit, a better understanding of the pathophysiology establishing the foundation of benefit is necessary. Vascular function plays a central role in the development and progression of HF. Endothelial function and nitric oxide availability affect myocardial function, systemic and pulmonary hemodynamics, and coronary and renal circulation. Arterial stiffness modulates ventricular loading conditions and diastolic function, key components of HF with preserved ejection. Endothelial function and arterial stiffness may therefore serve as important physiological targets for new HF therapies and facilitate patient selection for improved application of existing agents.
Objectives This study sought to investigate post-transplantation outcomes as a function of race and panel reactive antibody (PRA). Background PRA screening is used to determine the presence of ...pre-formed antibodies to population-wide human leukocyte antigens (HLAs) in patients being evaluated for heart transplantation (HT). Racial/ethnic differences in long-term survival after HT have been described. However, whether there are significant racial/ethnic differences in PRA among adults awaiting HT is poorly characterized. Methods We identified patients age ≥18 years in the Organ Procurement and Transplantation database with race/ethnicity of white, black, Hispanic, or Asian and listed for HT between 2000 and 2012 (N = 19,704). A PRA value of ≥10% was used to define clinically meaningful sensitization. Results Blacks had a higher peak PRA than did all other groups and were more likely to be sensitized. Black HT recipients were more likely to experience graft failure than were Hispanic, white, and Asian recipients (31% vs. 27%, 26%, and 21%, respectively; p < 0.001). The median follow-up was 1,207 days (interquartile range: 373 to 2,364 days), with a trend toward a shorter median time to graft failure in the Asian group than in the black, Hispanic, and white groups (p = 0.065). Sensitized blacks had the lowest rate of allograft survival, whereas nonsensitized Asians had the highest survival. Using Cox proportional regression to adjust for other clinical variables, black race (HR: 1.3; 95% confidence interval CI: 1.2 to 1.5), Hispanic ethnicity (HR: 1.2; 95% CI: 1.0 to 1.5), and sensitization (HR: 1.2; 95% CI: 1.1 to 1.4) remained predictors of higher rates of graft failure. Conclusions Race/ethnicity and level of sensitization are important predictors of graft survival.
Abstract Background The impact of abnormal spirometric findings on risk for incident heart failure among older adults without clinically apparent lung disease is not well elucidated. Methods We ...evaluated the association of baseline lung function with incident heart failure, defined as first hospitalization for heart failure, in 2125 participants of the community-based Health, Aging, and Body Composition (Health ABC) Study (age, 73.6 ± 2.9 years; 50.5% men; 62.3% white; 37.7% black) without prevalent lung disease or heart failure. Abnormal lung function was defined either as forced vital capacity (FVC) or forced expiratory volume in 1st second (FEV1 ) to FVC ratio below lower limit of normal. Percent predicted FVC and FEV1 also were assessed as continuous variables. Results During follow-up (median, 9.4 years), heart failure developed in 68 of 350 (19.4%) participants with abnormal baseline lung function, as compared with 172 of 1775 (9.7%) participants with normal lung function (hazard ratio HR 2.31; 95% confidence interval CI, 1.74-3.07; P <.001). This increased risk persisted after adjusting for previously identified heart failure risk factors in the Health ABC Study, body mass index, incident coronary heart disease, and inflammatory markers (HR 1.83; 95% CI, 1.33-2.50; P <.001). Percent predicted (%) FVC and FEV1 had a linear association with heart failure risk (HR 1.21; 95% CI, 1.11-1.32 and 1.18; 95% CI, 1.10-1.26, per 10% lower %FVC and %FEV1 , respectively; both P <.001 in fully adjusted models). Findings were consistent in sex and race subgroups and for heart failure with preserved or reduced ejection fraction. Conclusions Abnormal spirometric findings in older adults without clinical lung disease are associated with increased heart failure risk.
Abstract Heart failure patients are classified by ejection fraction (EF) into distinct groups: heart failure with preserved ejection fraction (HFpEF) or heart failure with reduced ejection fraction ...(HFrEF). Although patients with heart failure commonly have multiple comorbidities that complicate management and may adversely affect outcomes, their role in the HFpEF and HFrEF groups is not well-characterized. This review summarizes the role of noncardiac comorbidities in patients with HFpEF versus HFrEF, emphasizing prevalence, underlying pathophysiologic mechanisms, and outcomes. Pulmonary disease, diabetes mellitus, anemia, and obesity tend to be more prevalent in HFpEF patients, but renal disease and sleep-disordered breathing burdens are similar. These comorbidities similarly increase morbidity and mortality risk in HFpEF and HFrEF patients. Common pathophysiologic mechanisms include systemic and endomyocardial inflammation with fibrosis. We also discuss implications for clinical care and future HF clinical trial design. The basis for this review was discussions between scientists, clinical trialists, and regulatory representatives at the 10th Global CardioVascular Clinical Trialists Forum.
Contemporary epidemiology of chronic graft failure (GF) after heart transplantation (HT) is not well described. Moreover, differences in the epidemiology of GF based on race/ethnicity remain poorly ...understood, despite clear evidence of inferior survival of ethnic minorities after HT.
The incidence of GF and the population-attributable risk (PAR) of independent risk factors for GF were assessed in 15,255 patients (76% men; mean age 52 ± 12 years) who underwent primary HT from 2004 to 2012.
During a median follow-up of 4.7 years (interquartile range, 2.3-7.1 years), GF developed in 2,926 patients (19.2%), corresponding to an incidence rate of 39.8/1,000 person-years (95% confidence interval, 38.4-41.3). Blacks were more likely to develop GF than Hispanics or whites, with incidence rates of 55.1, 42.2, and 36.5/1,000 person-years, respectively. After multivariable adjustment, black race was associated with a higher risk of GF (hazard ratio, 1.4; 95% confidence interval, 1.2-1.6; p < 0.001). Blacks and Hispanics were more likely to have risk factors for GF, including low education, public insurance, allosensitization, higher human leukocyte antigen mismatch, non-adherence, and history of rejection requiring hospitalization (all p < 0.001). Rejection requiring hospitalization carried the highest population-attributable risk in all groups, with the highest fraction in blacks (25.8%) compared with whites (18.6%) and Hispanics (15.6%). Socioeconomic and donor risk factors conferred relatively less risk of GF.
Black HT recipients have the highest risk of GF, with immunologic factors conferring the greatest proportion of that risk. Racial differences in risk factors for GF after HT require further study.
Abstract Objectives The purpose of this study was to assess the frequency and correlates of documented advance directives (ADs) among patients hospitalized for heart failure (HF). Background ...Discussing ADs with patients with HF is critical for identifying treatment goals consistent with patients’ values and preferences and for facilitating health care team communication. Methods We retrospectively identified electronic medical records of adult patients admitted to 2 large tertiary care hospitals with either the primary or secondary discharge diagnosis of HF from September 2008 to August 2013 to assess the presence of ADs in electronic medical records. We performed analyses including HF as either the primary or secondary admission diagnosis and HF as the primary admission diagnosis only. Multivariable models were constructed to investigate independent predictors of documented ADs. Results Data included 44,768 admissions from 24,291 individual patients over 5 years. Mean age of patients at admission was 64.8 ± 15.9 years; 47.9% of these patients were female, 51.8% were black. The median length of stay for all admissions was 5 (3 to 10) days; 12.7% of patients had documented ADs. Older age, female sex, white race, higher socioeconomic status, higher risk for adverse in-hospital outcomes, length of stay ≥5 days, hospice discharge, palliative care consultation, and a do-not-resuscitate order were all associated with a significantly higher chance of having documented ADs. A significant increase in ADs over time was noted, but more than 80% of patients did not have ADs in medical records at the end of the study period. Conclusions In a diverse population of hospitalized patients with HF, most did not have a documented AD in the medical records. Although several factors were associated with a higher probability, major opportunities exist for all subgroups of patients with HF to improve documentation of ADs.
A high cardiothoracic ratio (CTR) is a marker of an enlarged heart and is associated with poor outcomes in patients with heart failure (HF). To what extent this association is independent of other ...confounders is not well known. However, to study this, propensity score matching was used to design a study in which HF patients with normal (≤0.50) and high (>0.50) CTRs were well balanced on all measured baseline covariates. In the Digitalis Investigation Group trial (n = 7,788), 4,690 patients had high (>0.50) CTRs. Propensity scores for high CTR were calculated for each patient and were then used to match 2,586 pairs of patients with normal and high CTRs. Matched Cox regression analyses were used to estimate associations of high CTR with mortality and hospitalization during 37 months of median follow-up. All-cause mortality occurred in 28.5% (rate 919 per 10,000 patient-years of follow-up) of patients with normal CTRs and 34.3% (rate 1,185 per 10,000 patient-years) of patients with high CTRs (hazard ratio 1.35, 95% confidence interval CI 1.21 to 1.51, p <0.0001). All-cause hospitalization occurred in 64.8% (rate 3,513 per 10,000 patient-years) of patients with normal CTRs and 66.2% (rate 3,932 per 10,000 patient-years) of patients with high CTRs (hazard ratio 1.10, 95% CI 1.01 to 1.20, p = 0.032). Respective hazard ratios for other outcomes were 1.48 (95% CI 1.30 to 1.68, p <0.0001) for cardiovascular mortality, 1.57 (95% CI 1.28 to 1.92, p <0.0001) for HF mortality, 1.18 (95% CI 1.08 to 1.30, p = 0.001) for cardiovascular hospitalization, and 1.27 (95% CI 1.13 to 1.44, p <0.0001) for HF hospitalization. In conclusion, a baseline CTR >0.50 was associated with increased mortality and morbidity in ambulatory patients with chronic HF.
Abstract Cardiac resynchronization therapy (CRT) improves survival, symptoms, quality of life, exercise capacity, and cardiac structure and function in patients with New York Heart Association (NYHA) ...functional class II or ambulatory class IV heart failure (HF) with wide QRS complex. The totality of evidence supports the use of CRT in patients with less severe HF symptoms. CRT is recommended for patients in sinus rhythm with a widened QRS interval (≥150 ms) not due to right bundle branch block (RBBB) who have severe left ventricular (LV) systolic dysfunction and persistent NYHA functional class II-III symptoms despite optimal medical therapy (strength of evidence A). CRT may be considered for several other patient groups for whom evidence of benefit is clinically significant but less substantial, including patients with a QRS interval of ≥120 to <150 ms and severe LV systolic dysfunction who have persistent mild to severe HF despite optimal medical therapy (strength of evidence B), some patients with atrial fibrillation, and some with ambulatory class IV HF. Several evidence gaps remain that need to be addressed, including the ideal threshold for QRS duration, QRS morphology, lead placement, degree of myocardial scarring, and the modality for evaluating dyssynchrony. Recommendations will evolve over time as additional data emerge from completed and ongoing clinical trials.
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