Highlights • We performed an analysis using ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) data of patients with invasive hemodynamic data. • ...We examined outcomes of patients with heart failure and with persistent hemodynamic abnormalities. • Final pulmonary capillary wedge pressure was associated with adverse outcomes, but final cardiac index was not.
Pre-transplant amiodarone use has been postulated as a risk factor for morbidity and mortality after orthotopic heart transplantation (OHT). We assessed pre-OHT amiodarone use and tested the ...hypothesis that it is associated with impaired post-OHT outcomes.
We performed a retrospective cohort analysis of adult OHT recipients from the registry of the International Society for Heart and Lung Transplantation (ISHLT). All patients had been transplanted between 2005 and 2013 and were stratified by pre-OHT amiodarone use. We derived propensity scores using logistic regression with amiodarone use as the dependent variable, and assessed the associations between amiodarone use and outcomes with Kaplan-Meier analysis after matching patients 1:1 based on propensity score, and with Cox regression with adjustment for propensity score.
Of the 14,944 OHT patients in the study cohort, 32% (N = 4,752) received pre-OHT amiodarone. Amiodarone use was higher in recent years (29% in 2005 to 2007, 32% in 2008 to 2010, 35% in 2011 to 2013). Amiodarone-treated patients were older and more frequently had a history of sudden cardiac death (27% vs 13%) and pre-OHT mechanical circulatory support. Key donor characteristics and allograft ischemia times were similar between groups. In propensity-matched analyses, amiodarone-treated patients had higher rates of cardiac reoperation (15% vs 13%) and permanent pacemaker (5% vs 3%) after OHT and before discharge. Amiodarone-treated patients also had higher 1-year mortality (hazard ratio 1.15, 95% confidence interval 1.02 to 1.30), but the risks of early graft failure, retransplantation and rehospitalization were similar between groups.
Amiodarone use before OHT was independently associated with increased 1-year mortality. The need for amiodarone therapy should be carefully and continuously assessed in patients awaiting OHT.
Highlights • Use of heart failure medical therapies is poorly characterized after LVAD implantation. • In this analysis of a large, multicenter LVAD registry, we found that use of neurohormonal ...antagonists was low after LVAD implant but that use of loop diuretics and amiodarone remained high. • Future studies should examine associations of heart failure medication use post-LVAD implant in terms of mortality, readmission, and quality of life so that optimal medical therapy can be better understood in this population.
With increasing age of patients with heart failure, it is important to understand the potential role for orthotopic heart transplant (OHT) in elderly patients. We examined recipient and donor ...characteristics and long-term outcomes of older recipients of OHT in the United States.
Using the United Network for Organ Sharing database, we identified OHT recipients from the years 1987-2014 and stratified them by age 18-59 years old, 60-69 years old, and ≥70 years old. We compared baseline characteristics of recipients and donors and assessed outcomes across groups.
During this period, 50,432 patients underwent OHT; 71.8% (n = 36,190) were 18-59 years old, 26.8% (n = 13,527) were 60-69 years old, and 1.4% (n = 715) were ≥70 years old. Comparing the ≥70 years old group and 60-69 years old group, older patients had higher rates of ischemic etiology (53.6% vs 44.9%) and baseline renal dysfunction (61.4% vs 56.4%) and at the time of OHT were less likely to be currently hospitalized (45.0% vs 50.9%) or supported with left ventricular assist device therapy (21.0% vs 28.3%). Older recipients received organs from older donors (median age 36 years old vs 30 years old) who were more likely to have diabetes and substance use. After OHT, the median length of stay was similar between groups. At 1 year, of patients alive, patients ≥70 years old had fewer rejection episodes (17.8%) compared with patients 60-69 years old (29.5%). The 5-year mortality was 26.9% for recipients 18-59 years old, 29.3% for recipients 60-69 years old, and 30.8% for recipients ≥70 years old.
Despite advanced age and less ideal donors, OHT recipients in their 70s had similar outcomes to recipients in their 60s. Selected older patients should not routinely be excluded from consideration for OHT.
Heart transplantation is increasing in patients with adult congenital heart disease (ACHD). In this population, the association of pulmonary hypertension (PH) with post-transplant outcomes is not ...well-defined.
Using data from the United Network for Organ Sharing database (1987 to 2014), we identified ACHD patients listed for heart transplantation, and examined survival between those with and without PH (pre-transplant PH defined as transpulmonary pressure gradient >12 mm Hg).
Among 983 ACHD patients, 216 (22%) had PH. At time of listing, PH patients had a transpulmonary pressure gradient of 17.0 mm Hg vs 6.0 mm Hg (p < 0.01) in the no-PH group. Although left ventricular assist device (LVAD) use was infrequent, 3.1% of PH patients were treated with an LVAD versus 6.8% of the no-PH patients. Days from listing to transplant, days from listing to death on the waitlist and length of post-transplant hospitalization were not significantly different between the PH and no-PH groups. However, PH was associated with higher waitlist mortality (HR 1.73, CI 1.25 to 2.41). Pre-transplant PH was not associated with post-transplant mortality at 30 days (HR 0.51, CI 0.23 to 1.13), 1 year (HR 0.68, 95% CI 0.40 to 1.18) or 5 years (HR 0.84, 95% CI 0.55 to 1.29).
PH is common among ACHD patients listed for transplant and is associated with increased waitlist mortality. Conversely, PH was not associated with worse survival after transplant. Bridge-to-transplant LVAD therapy was uncommon in this ACHD population.
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.
Educating the Next Generation of Peer Reviewers Cooper, Lauren B., MD; Bellam, Naveen, MD; Vaduganathan, Muthiah, MD, MPH
Journal of the American College of Cardiology,
05/2016, Volume:
67, Issue:
17
Journal Article
Peer reviewed
Open access
Random House, New York, 1948, page 894.T.S.KuhnThe Structure of Scientific Revolutions3rd edition1996The University of Chicago Press BooksChicagoW.S.ChurchillChurchill Speaks: Collected Speeches in ...Peace and War, 1897-19631974Barnes and Noble BooksNew YorkT.F.LüscherThe codex of science: honesty, precision, and truth--and its violationsEur Heart J4201310181023T.F.LüscherB.GershJ.BrugadaU.LandmesserF.RuschitzkaP.W.SerruysThe European Heart Journal goes global: the road ahead of the editorial team 2009-2011Eur Heart J30200915T.F.LüscherConflicts of interest and the truth of scientific discoveryEur Heart J372015738740 Schedule Task Skill Developed Step 1: independent review Each fellow individually reviews a recently published paper focusing on: The top 3 strengths and weaknesses of the paper Whether the paper should be accepted or declined for publication Whether the study should affect clinical guidelines The ability to convey detailed evaluation of a paper in a very concise manner Step 3: feedback on fellows' evaluation of the paper The editor provides feedback on how the fellows have interpreted the paper Reinforce peer review skills through feedback Step 4: editorial discussion The editorial board discusses their perception of the strengths and weaknesses of the paper and the rationale for why the paper was accepted An understanding of the editorial decision-making process Step 5: guideline discussion A discussion on whether the paper should influence practice guidelines Ability to place the study in the context of existing published data Table 1 Agenda for JACC:
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.
Highlights • Elevated serum bicarbonate is a common observation in acute heart failure (AHF) patients. • In AHF, bicarbonate increased with diuretics but decreased with ultrafiltration. • Bicarbonate ...change was not associated with clinical signs of decongestion. • Adequate decongestion is a key goal in the treatment of patients with AHF. • Modest increases in bicarbonate should not prompt decrease or cessation of diuresis.
Abstract Background A subset of patients hospitalized with acute heart failure experience in-hospital worsening heart failure, defined as persistent or worsening signs or symptoms requiring an ...escalation of therapy. Methods and Results We analyzed data from the Acute Decompensated Heart Failure National Registry (ADHERE) linked to Medicare claims to develop and validate a risk model for in-hospital worsening heart failure. Our definition of in-hospital worsening heart failure included events such as escalation of medical therapy (eg, inotropic medications) more than 12 hours after admission. We considered candidate risk prediction variables routinely assessed at admission, including age, medical history, biomarkers, and renal function. We used logistic regression with robust standard errors to generate a risk model in a 66% random derivation sample; we validated the model in the remaining 34%. We evaluated the calibration and discrimination of the model in both samples. We evaluated 23,696 patients hospitalized with acute heart failure. Baseline characteristics were well matched in the derivation and validation samples, and the occurrence of in-hospital worsening heart failure was similar in both samples (15.4% and 15.6%, respectively). In the multivariable model, the strongest predictors of in-hospital worsening heart failure were increased troponin and creatinine. The model was well calibrated and had good discrimination in the derivation sample ( c statistic, 0.74) and validation sample ( c statistic, 0.72). Conclusions The ADHERE worsening heart failure risk model is a clinical tool with good discrimination for use in patients hospitalized with acute heart failure to identify those at increased risk for in-hospital worsening heart failure. This tool may be useful to target treatment strategies for patients at high risk for in-hospital worsening heart failure.
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