End-of-Life Care in Patients With Heart Failure Whellan, David J., MD, MHS; Goodlin, Sarah J., MD; Dickinson, Michael G., MD ...
Journal of cardiac failure,
02/2014, Letnik:
20, Številka:
2
Journal Article
Recenzirano
Abstract Stage D heart failure (HF) is associated with poor prognosis, yet little consensus exists on the care of patients with HF approaching the end of life. Treatment options for end-stage HF ...range from continuation of guideline-directed medical therapy to device interventions and cardiac transplantation. However, patients approaching the end of life may elect to forego therapies or procedures perceived as burdensome, or to deactivate devices that were implanted earlier in the disease course. Although discussing end-of-life issues such as advance directives, palliative care, or hospice can be difficult, such conversations are critical to understanding patient and family expectations and to developing mutually agreed-on goals of care. Because patients with HF are at risk for rapid clinical deterioration or sudden cardiac death, end-of-life issues should be discussed early in the course of management. As patients progress to advanced HF, the need for such discussions increases, especially among patients who have declined, failed, or been deemed to be ineligible for advanced HF therapies. Communication to define goals of care for the individual patient and then to design therapy concordant with these goals is fundamental to patient-centered care. The objectives of this white paper are to highlight key end-of-life considerations in patients with HF, to provide direction for clinicians on strategies for addressing end-of-life issues and providing optimal patient care, and to draw attention to the need for more research focusing on end-of-life care for the HF population.
THE COMMON LAND MODEL Dai, Yongjiu; Zeng, Xubin; Dickinson, Robert E. ...
Bulletin of the American Meteorological Society,
08/2003, Letnik:
84, Številka:
8
Journal Article
Recenzirano
Odprti dostop
The Common Land Model (CLM) was developed for community use by a grassroots collaboration of scientists who have an interest in making a general land model available for public use and further ...development. The major model characteristics include enough unevenly spaced layers to adequately represent soil temperature and soil moisture, and a multilayer parameterization of snow processes; an explicit treatment of the mass of liquid water and ice water and their phase change within the snow and soil system; a runoff parameterization following the TOPMODEL concept; a canopy photosynthesis–conductance model that describes the simultaneous transfer of CO₂ and water vapor into and out of vegetation; and a tiled treatment of the subgrid fraction of energy and water balance. CLM has been extensively evaluated in offline mode and coupling runs with the NCAR Community Climate Model (CCM3). The results of two offline runs, presented as examples, are compared with observations and with the simulation of three other land models the Biosphere–Atmosphere Transfer Scheme (BATS), Bonan's Land Surface Model (LSM), and the 1994 version of the Chinese Academy of Sciences Institute of Atmospheric Physics LSM (IAP94).
Celotno besedilo
Dostopno za:
BFBNIB, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
•Both sinusoidal seasonal variation and overall declining patterns were observed.•These patterns were associated with specific clinical characteristics.•Greatest seasonal variation: male, low ...comorbidity/NYHA, high BMI, not hospitalized.•Downward trajectories (40–80 mins) throughout the year: female and hospitalization.
The purpose of the present study was to determine the presence and magnitude of seasonal variation in daily physical activity (PA) in those with heart failure (HF).
Retrospective study and dynamic factor analysis (DFA) of Patient Activity data from Medtronic implanted cardioverter defibrillator and cardiac resynchronization devices (ICD/CRTs).
In a data set of 435 patients, distinct states/trends were identified by DFA including a classic, sinusoidal pattern of seasonal variation and a pattern of decline over the course of 12 months, which were associated with specific clinical characteristics. Overall, model fitting was good.
Those with low comorbidities, better NYHA Class, higher BMI, no hospitalization, and male sex demonstrated greater seasonal variation of at least 40 min per day between winter (lowest PA) and spring/summer (highest PA). Those with female sex and hospitalization demonstrated overall downward trajectories of approximately 40 and 80 min, respectively, over the course of the year.
The Fontan circulation is a palliation for patients with a functionally univentricular heart. It is characterized by gradual attrition over time. An increase in pulmonary vascular resistance could be ...a key factor in the long-term failure of the Fontan circulation. In this study we aimed to identify pulmonary vascular remodeling in patients with a Fontan circulation.
Pulmonary vascular histomorphometric analysis and immunohistochemistry were performed in lung tissue obtained at autopsy from 12 Fontan patients. These patients had died either peri-operatively (Group A: death during or <15 days after Fontan completion; n = 5) or in mid to long-term follow-up (Group B: death >5 years after Fontan completion; n = 7). Two age-matched control groups (n = 10 and n = 14, respectively) were included.
Intra-acinar pulmonary vessels in the Fontan Group B patients showed decreased medial thickness (p = 0.028) compared with age-matched controls, whereas intimal thickness was increased (p = 0.002). Intimal thickness in the Fontan Group B patients correlated with age at death (r = 0.964, p < 0.001) and with the length of time that the Fontan circulation had been in place (r = 0.714, p = 0.036). Immunohistochemistry revealed a reduction of vascular smooth muscles cells in the medial layer of the intra-acinar pulmonary vessels. The eccentric intimal thickening was composed of mainly acellular fibrosis with collagen deposition.
We observed a unique pattern of adverse pulmonary vascular remodeling in patients with a long-standing Fontan circulation who had died during follow-up. This remodeling pattern may play a major role in long-term attrition of the Fontan circulation.
•Remote patient monitoring (RPM) via external devices has not shown consistent benefit in large randomized trials.•RPM via cardiac implantable electronic devices has not demonstrated improved ...clinical outcomes in trials. Multisensor algorithms may be better.•RPM via an implantable pulmonary arterial pressure monitor showed improved patient outcomes in a single randomized trial. Further research is underway.•RPM is a tool and not a treatment. How RPM is used is likely important and may explain the variability in trial results.
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After several neutral telehealth trials, the positive findings and subsequent Food and Drug Administration approval of an implantable pulmonary arterial pressure monitor (PAPM) led to renewed interest in remote patient monitoring (RPM). Here we seek to provide contemporary guidance on the appropriate use of RPM technology.
Although early trials of external RPM devices suggested benefit, subsequent multicenter trials failed to demonstrate improved outcomes. Monitoring features of cardiac implantable electronic devices (CIEDs) also did not deliver improved HF outcomes, newer, multisensor algorithms may be better. Earlier technologies using direct pressure measurement via implanted devices failed to show benefit owing to complications or failure. Recently, 1 PAPM showed benefit in a randomized controlled trial. Although not showing cost reduction, cost-benefit analysis of that device suggests that it may meet acceptable standards. Additional research is warranted and is in progress. Consumer-owned electronic devices are becoming more pervasive and hold hope for future benefit in HF management. Practical aspects around RPM technology include targeting of risk populations, having mechanisms to ensure patient adherence to monitoring, and health care team structures that act on the data.
Based on available evidence, routine use of external RPM devices is not recommended. Implanted devices that monitor pulmonary arterial pressure and/or other parameters may be beneficial in selected patients or when used in structured programs, but the value of these devices in routine care requires further study. Future research is also warranted to better understand the cost-effectiveness of these devices.
Pulmonary arterial hypertension (PAH) is a progressive pulmonary vasoproliferative disorder characterized by the development of unique neointimal lesions, including concentric laminar intima fibrosis ...and plexiform lesions. Although the histomorphology of neointimal lesions is well described, the pathogenesis of PAH and neointimal development is largely unknown. After three decades of PAH pathobiology research the focus has shifted from vasoconstriction towards a mechanism of cancer-like angioproliferation. In this concept the role of disturbed blood flow is seen as an important trigger in the development of vascular remodeling. For instance, in PAH associated with congenital heart disease, increased pulmonary blood flow (i.e., systemic-to-pulmonary shunt) is an essential trigger for the occurrence of neointimal lesions and PAH development. Still, questions remain about the exact role of these blood flow characteristics in disease progression. PAH animal models are important for obtaining insight in new pathobiological processes and therapeutical targets. However, as for any preclinical model the pathophysiological mechanism and clinical course has to be comparable to the human disease that it mimics. This means that animal models mimicking human PAH ideally are characterized by: a hit recognized in human disease (e.g., altered pulmonary blood flow), specific vascular remodeling resembling human neointimal lesions, and disease progression that leads to right ventriclular dysfunction and death. A review that underlines the current knowledge of PAH due to disturbed flow is still lacking. In this review we will summarize the current knowledge obtained from PAH animal models associated with disturbed pulmonary blood flow and address questions for future treatment strategies for PAH.
Pulmonary arterial hypertension (PAH) is hallmarked by the development of neointimal lesions. The transcription factor Egr-1 seems to play a critical role in neointimal formation in experimental PAH ...and was identified as a putative target for intervention. In this study we investigated whether Egr-1 is also associated with neointimal-type vascular remodeling in different forms of human PAH or pulmonary hypertension.
Using immunohistochemistry, we studied Egr-1 expression specifically in a wide morphologic spectrum of pulmonary arteries in the lung tissue of 72 patients with different forms and stages of PAH, specifically idiopathic PAH (n = 18), advanced-stage congenital heart disease‒associated PAH (PAH-CHD) (n = 21), early-stage PAH-CHD (n = 19) and non-neointimal hypoxic pulmonary hypertension (PH) (n = 4), and controls (n = 10).
In PAH patients, pulmonary vascular expression of Egr-1 protein was abundant, whereas it was sporadic in non-neointimal (hypoxic) PH patients and controls. In PAH-CHD, protein expression was more pronounced in patients with advanced vascular lesions compared to those with less advanced lesions, such as medial hypertrophy.
Pulmonary vascular Egr-1 expression is significantly increased in patients with PAH, appears specifically associated with neointimal-type vascular remodeling, and correlates with disease progression. These data translate the critical role of Egr-1 in the development of experimental PAH to human pulmonary vascular disease forms.
Aims
During right heart catheterization, pulmonary artery wedge pressure (PAWP) is often assumed to reflect left ventricular filling pressure. We sought to determine the impact of atrial fibrillation ...(AF) on the relationship between PAWP and left ventricular filling pressure, as measured by left ventricular end‐diastolic pressure (LVEDP).
Methods and results
We performed simultaneous left and right heart catheterization in 123 patients (mean age 69 years, 28% with AF) referred for suspicion of pulmonary hypertension (PH). The correlation between PAWP and LVEDP was moderate (R2 = 0.42). The relationship between PAWP and LVEDP was modified by heart rhythm (P for interaction <0.01). In sinus rhythm, PAWP underestimated LVEDP (Bland–Altman mean difference: −2.96 mmHg, limits of agreement 6.6 to −12.5; R2 = 0.54), whereas in AF, PAWP overestimated LVEDP (Bland–Altman mean difference: 4.76 mmHg; limits of agreement: 12.2 to –3.3; R2 = 0.58). These differences impacted the differentiation between pre‐ and post‐capillary PH, dependent on the use of either PAWP or LVEDP. In AF, post‐capillary PH based on PAWP would have been classified as pre‐capillary PH in 35% of patients if based on LVEDP. The opposite is true for sinus rhythm where 31% of pre‐capillary PH based on PAWP would have been classified as post‐capillary PH if based on LVEDP.
Conclusion
The relationship between PAWP and LVEDP varies by heart rhythm, with PAWP being higher than LVEDP among AF patients and lower than LVEDP among patients in sinus rhythm. Rhythm status and influences on the PAWP–LVEDP relationship should be considered when distinguishing between pre‐capillary and post‐capillary PH.
Female heart disease has for a long time been an underrecognized problem in the field of cardiology. With an ever-growing number of these patients getting pregnant, cardiac dysfunction during ...pregnancy is an increasingly large medical problem. Previous work has shown that maternal heart disease may have an adverse effect on pregnancy outcome in both mother and child. The placenta forms the connection and it is postulated that cardiac dysfunction negatively affects the placenta, and consequently, neonatal outcome. Given the paucity of data in this field, more research on the influence of cardiac (mal)function on placental (mal)function is needed. The present review describes placental function in women with various types of cardiac dysfunction, thereby aiming to provide more insight into possible underlying mechanisms of placental malfunction. Organ dysfunction in patients with heart failure is for an important part based on reduced perfusion and venous congestion. This has been shown in other organs such as kidneys, liver and brain. In pregnant women with cardiac dysfunction, placental dysfunction may follow similar patterns. Moreover, other factors, such as pre-existing hypertension and chronic hypoxia may lead to further impairment of placental function, through abnormal vascular remodeling of the uterine spiral arteries. The pathophysiology of placental dysfunction in pregnant women with cardiac dysfunction may thus be multifactorial. It is therefore important to monitor closely cardiac and placental function in such high-risk pregnancies. Gaining a better understanding of the underlying pathophysiological mechanisms may have important clinical implications in terms of pregnancy counseling, monitoring and outcome.
This study examined associations between epicardial adipose tissue (EAT), invasive hemodynamics, and exercise capacity in patients with heart failure with preserved ejection fraction (HFpEF).
EAT is ...increased in patients with HFpEF and may play a role in the pathophysiology of this disorder.
Patients with heart failure and a left ventricular ejection fraction >45% who underwent right and left heart catheterization with simultaneous echocardiography were included. Pulmonary capillary wedge pressure (PCWP), left ventricular end-diastolic pressure (LVEDP), right ventricular end-diastolic pressure (RVEDP), and pulmonary vascular resistance (PVR) were invasively measured. Obesity was defined as body mass index (BMI) ≥30 kg/m2. EAT thickness alongside the right ventricle was measured on echocardiographic long- and short-axis views. Cardiopulmonary exercise testing was performed to obtain maximal oxygen uptake (VO2-max).
This study examined 75 patients, mean age 74 ± 9 years; 68% were women, mean BMI was 29 ± 6 kg/m2, and 36% were obese. Higher BMI was strongly associated with increased EAT (r = 0.74; p < 0.001). Increased EAT was associated with higher RVEDP, independent of PVR (odds ratio OR: 1.16; 95% confidence interval CI: 1.02 to 1.34; p = 0.03), but not independent of obesity (p = 0.10). Increased EAT and higher RVEDP were both associated with lower VO2-max (r = −0.43; p < 0.001 and r = −0.43; p = 0.001, respectively). Increased EAT remained associated with lower VO2-max after adjustment for PVR (OR: 0.64; 95% CI: 0.49 to 0.84; p = 0.002) and obesity (OR: 0.69; 95% CI: 0.53 to 0.92; p = 0.01). EAT thickness was not associated with left-sided filling pressures (i.e., PCWP and LVEDP).
In HFpEF, obesity and increased EAT were associated with higher right-sided filling pressures and with reduced exercise capacity.
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