OBJECTIVE To assess the benefit of proactive palliative medicine consultation for delineation of goals of care and quality-of-life preferences before implantation of left ventricular assist devices ...as destination therapy (DT). PATIENTS AND METHODS We retrospectively reviewed the cases of patients who received DT between January 15, 2009, and January 1, 2010. RESULTS Of 19 patients identified, 13 (68%) received proactive palliative medicine consultation. Median time of palliative medicine consultation was 1 day before DT implantation (range, 5 days before to 16 days after). Thirteen patients (68%) completed advance directives. The DT implantation team and families reported that preimplantation discussions and goals of care planning made postoperative care more clear and that adverse events were handled more effectively. Currently, palliative medicine involvement in patients receiving DT is viewed as routine by cardiac care specialists. CONCLUSION Proactive palliative medicine consultation for patients being considered for or being treated with DT improves advance care planning and thus contributes to better overall care of these patients. Our experience highlights focused advance care planning, thorough exploration of goals of care, and expert symptom management and end-of-life care when appropriate.
Highlights • Binding of albumin to diuretics are key to delivery to the nephron, and low albumin levels diminish intravascular oncotic pressures necessary to maintain intravascular volume for ...effective diuresis. • Based on prospectively collected data from two acute heart failure clinical trials (DOSE-AHF and ROSE-AHF), this may not be the case in acute heart failure populations largely free of nephrotic syndrome or cirrhosis. • Our data from two well characterized cohorts of patients with acute heart failure suggest that serum albumin may not be a helpful tool to guide decongestion strategies or determine effectiveness of therapy.
Abstract Objectives This study evaluated the prevalence, profile, and prognosis of severe obesity in a large contemporary acute heart failure (AHF) population. Background Better prognosis has been ...reported for obese heart failure (HF) patients than nonobese HF patients, but in other cardiovascular populations, this effect has not been demonstrated for severely obese patients. Methods A cohort of 795 participants with body mass index (BMI) measured at time of admission and complete follow-up were identified from enrollment in 3 contemporary AHF trials (DOSE Diuretic Strategies Optimization Evaluation, CARRESS-HF Cardiorenal Rescue Study in Acute Decompensated Heart Failure, and ROSE Renal Optimization Strategies Evaluation in Acute Heart Failure). Patients were divided into 4 BMI categories according to standard World Health Organization criteria, as follows: normal weight: 18.5 to 25 kg/m2 n = 128; overweight: 25 to 29.9 kg/m2 n = 209; mild-to-moderate obese: 30 to 39.9 kg/m2 n = 301; and severely obese: ≥40 kg/m2 n = 157). The relationship between BMI and 60-day composite outcome (death, rehospitalization, or unscheduled provider visit) was investigated. Results Patients with severe obesity (19.7%) were younger, more often female, hypertensive, diabetic, and more likely to have higher blood pressures and left ventricular ejection fraction, and lower N-terminal pro-B-type natriuretic peptide and troponin I levels than other BMI category patients. Following admission for AHF, patients with normal weight showed the highest risk of 60-day composite outcome, followed by patients who were severely obese. Overweight and mild-moderately obese patients showed lowest risk. Conclusions Nearly one-fifth of AHF patients enrolled in contemporary randomized clinical trials are severely obese. A U-shaped curve for short-term prognosis according to BMI is seen in AHF. These findings may help to better inform both HF clinical care and future clinical trial planning.
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