.1241 Preamble This document has been developed as an Expert Consensus Document (ECD) by the American College of Cardiology Foundation (ACCF), American Association for Thoracic Surgery (AATS), ...Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons in collaboration with the American Heart Association (AHA), American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Failure Society of America, Society of Cardiovascular Computed Tomography, Society of Cardiac Magnetic Resonance, Society of Cardiovascular Anesthesiologists, and Mended Hearts. Often the topic is the subject of considerable ongoing investigation. ...the reader should view the ECD as the best attempt of the ACCF and document cosponsors to inform and guide clinical practice in areas where rigorous evidence may not yet be available or evidence to date is not widely applied to clinical practice. Conference calls of the writing committee were confidential and attended only by committee members.\n AR = aortic regurgitation AS = aortic stenosis AVA = aortic valve area AVR = aortic valve replacement CAD = coronary artery disease CMR = cardiac magnetic resonance COPD = chronic obstructive pulmonary disease CT = computed tomography EF = ejection fraction EOA = effective orifice area EuroSCORE = European system for cardiac operative risk evaluation LV = left ventricular LVOT = left ventricular outflow pact MDCT = multidetector computed tomography NCDR = National Cardiovascular Data Registry PARTNER = Placement of Aortic Transcatheter Valve trial PH = pulmonary hypertension RV = right ventricular SOURCE = SAPIEN Aortic Biosprosthesis European Outcome registry STS = Society of Thoracic Surgeons TAVR = transcatheter aortic valve replacement TEE = transesophageal echocardiogram TTE = transthoracic echocardiography VARC = Valve Academic Research Consortium * This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant. A person is deemed to have a significant interest in a business if the interest represents ownership of >=5% of the voting stock or share of the business entity, or ownership of >=$10,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person's gross income for the previous year. Names are listed in alphabetical order within each category of review.According to the ACCF/AHA, a person has a relevant relationship IF: a) the relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) the company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) the person or a member of the person's household, has a reasonable potential for financial, professional or other personal gain or loss as a result of the issues/content addressed in the document.AATS indicates American Association for Thoracic Surgery; ACCF, American College of Cardiology Foundation; ACE, Accreditation for Cardiovascular Excellence; AHA, American Heart Association; ASE, American Society of Echocardiography; DCRI, Duke Clinical Research Institute; EACTS, European Association for Cardio-Thoracic Surgery; HFSA, Heart Failure Society of America; NCDR-CARE, National Cardiovascular Data Registry-Carotid Artery Revascularization and Endarterectomy; NIH, National Institutes of Health; PARTNER, Placement of Aortic Transcatheter Valve Trial; PI, principal investigator; SCA, Society of Cardiovascular Anesthesiologists; SCAI, Society for Cardiovascular Angiography and Interventions; SCCT, Society of Cardiovascular Computed Tomography; SCMR, Society for Cardiovascular Magnetic Resonance; and STS, Society of Thoracic Surgeons.
Objectives To determine whether venous congestion, rather than impairment of cardiac output, is primarily associated with the development of worsening renal function (WRF) in patients with advanced ...decompensated heart failure (ADHF). Background Reduced cardiac output is traditionally believed to be the main determinant of WRF in patients with ADHF. Methods A total of 145 consecutive patients admitted with ADHF treated with intensive medical therapy guided by pulmonary artery catheter were studied. We defined WRF as an increase of serum creatinine ≥0.3 mg/dl during hospitalization. Results In the study cohort (age 57 ± 14 years, cardiac index 1.9 ± 0.6 l/min/m2 , left ventricular ejection fraction 20 ± 8%, serum creatinine 1.7 ± 0.9 mg/dl), 58 patients (40%) developed WRF. Patients who developed WRF had a greater central venous pressure (CVP) on admission (18 ± 7 mm Hg vs. 12 ± 6 mm Hg, p < 0.001) and after intensive medical therapy (11 ± 8 mm Hg vs. 8 ± 5 mm Hg, p = 0.04). The development of WRF occurred less frequently in patients who achieved a CVP <8 mm Hg (p = 0.01). Furthermore, the ability of CVP to stratify risk for development of WRF was apparent across the spectrum of systemic blood pressure, pulmonary capillary wedge pressure, cardiac index, and estimated glomerular filtration rates. Conclusions Venous congestion is the most important hemodynamic factor driving WRF in decompensated patients with advanced heart failure.
Sodium Nitroprusside for Advanced Low-Output Heart Failure Mullens, Wilfried, MD; Abrahams, Zuheir, MD, PhD; Francis, Gary S., MD, FACC ...
Journal of the American College of Cardiology,
07/2008, Volume:
52, Issue:
3
Journal Article
Peer reviewed
Open access
Sodium Nitroprusside for Advanced Low-Output Heart Failure Wilfried Mullens, Zuheir Abrahams, Gary S. Francis, Hadi N. Skouri, Randall C. Starling, James B. Young, David O. Taylor, W. H. Wilson Tang ...Inotropic drugs are often preferred over vasodilators in patients with end-stage, low-output heart failure. We reviewed consecutive patients admitted between 2000 and 2005 with acute decompensated heart failure with a cardiac index ≤2 l/min/m2 . Compared with control patients, treatment with sodium nitroprusside was associated with greater improvement in hemodynamics, higher rates of transitioning oral vasodilators at discharge, and lower rates of all-cause mortality and all-cause mortality/cardiac transplant without increase in rehospitalization, inotropic use, or worsening renal function.
Elevated Intra-Abdominal Pressure in Acute Decompensated Heart Failure: A Potential Contributor to Worsening Renal Function? Wilfried Mullens, Zuheir Abrahams, Hadi N. Skouri, Gary S. Francis, David ...O. Taylor, Randall C. Starling, Emil Paganini, W. H. Wilson Tang We measured intra-abdominal pressure (IAP) using a simple transvesical technique in 40 consecutive patients admitted for acute decompensated heart failure without overt abdominal symptoms. Among them, 60% had elevated IAP (≥8 mm Hg). Elevated IAP was directly associated with worse renal function, and intensive medical therapy resulted in improvement in both hemodynamic measures and IAP. However, reduction in IAP is better correlated with improvement in renal function than any hemodynamic variable, suggesting a potential contribution of elevated IAP in the pathophysiology of the cardiorenal syndrome.
Recently, the American Board of Medical Specialties approved a proposal from the American Board of Internal Medicine for establishing the secondary subspecialty of Advanced Heart Failure and ...Transplant Cardiology. This step represents culmination of a process that began 4 years ago, through advocacy by the Heart Failure Society of America. It represents an essential step to ensure quality of care by specialists in a field that has grown up de facto amid rapid expansion both of the population of patients with heart failure and of diagnostic and therapeutic options for their management. The vast majority of care for most patients with heart failure will continue to be provided by general internists and cardiologists. Certification in Advanced Heart Failure and Transplant Cardiology will require a high degree of competency in all aspects of heart failure care, including technical proficiencies required to manage patients undergoing heart transplant and device implants. These specialists will play a key role in delivering the highest quality of complex care in the most cost-effective manner. In the years to come, the specialty must adapt to the ongoing rapid expansion of evidence-based knowledge in this field to continue to provide the highest level of care and the best outcomes to patients with heart failure.
Evaluation and Long-Term Prognosis of New-Onset, Transient, and Persistent Anemia in Ambulatory Patients With Chronic Heart Failure W. H. Wilson Tang, Wilson Tong, Anil Jain, Gary S. Francis, C. ...Martin Harris, James B. Young We reviewed records of 6,159 consecutive ambulatory patients with chronic heart failure followed up at a single center between 2001 and 2006, and found the prevalence of anemia (hemoglobin <12 g/dl for men, <11 g/dl for women) to be 17.2%. At 6-month follow-up, new-onset anemia developed in 16% of patients without prior anemia, whereas 43% patients with anemia at baseline had resolution of their hemoglobin levels. Higher total mortality rates were evident in patients with persistent anemia (58% vs. 31%, p < 0.0001) or with incident anemia (45% vs. 31%, p < 0.0001) compared with those with without anemia at 6 months.
Racial Analysis of Patients With Myocardial Infarction Complicated by Heart Failure and/or Left Ventricular Dysfunction Treated With Valsartan, Captopril, or Both L. Michael Prisant, Kevin L. Thomas, ...Eldrin F. Lewis, Zhen Huang, Gary S. Francis, W. Douglas Weaver, Marc A. Pfeffer, John J. V. McMurray, Robert M. Califf, Eric J. Velazquez African Americans have a high incidence of heart failure (HF). Limited retrospective observational subgroup analyses of patients with left ventricular systolic dysfunction (LVSD) suggest marginal benefit of angiotensin-converting enzyme inhibitors in the prevention of HF hospitalizations or total mortality in African Americans. We found that African Americans sustaining an acute myocardial infarction with LVSD and/or HF had similar clinical outcomes compared with white Americans. Valsartan, captopril, or the combination had comparable effects on cardiovascular morbidity and mortality in African Americans and white Americans.
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