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Journal Cover   JACC : Heart Failure
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   Full-text available via subscription Subscription journal
   ISSN (Online) 2213-1779
   Published by American College of Cardiology Foundation Homepage  [1 journal]
  • Characteristics, Treatments, and Outcomes of Hospitalized Heart Failure
           Patients Stratified by Etiologies of Cardiomyopathy
    • Authors: Shore S; Grau-Sepulveda MV, Bhatt DL, et al.
      Abstract: ObjectivesThe authors sought to describe characteristics, treatments, and in-hospital outcomes of hospitalized heart failure (HF) patients stratified by etiology.BackgroundWhether characteristics and outcomes of HF patients differ by cardiomyopathy etiology is unknown.MethodsThe authors analyzed data on 156,013 hospitalized HF patients from 319 U.S. hospitals participating in Get With The Guidelines–HF between 2005 and 2013. Characteristics, treatments, and in-hospital outcomes were assessed by HF etiology. Standard regression techniques adjusted for site and patient-level characteristics were used to examine association between HF etiology and in-hospital outcomes.ResultsMedian age was 75 years, 69.2% were white, and 49.5% were women. Overall, 92,361 patients (59.2%) had ischemic cardiomyopathy and 63,652 patients (40.8%) had nonischemic cardiomyopathy (NICM). Hypertensive (n = 28,141; 48.5%) and idiopathic (n = 17,808; 30.7%) cardiomyopathies accounted for the vast majority of NICM patients. Post-partum (n = 209; 0.4%), viral (n = 447; 0.8%), chemotherapy (n = 721; 1.2%), substance abuse (n = 2,653; 4.6%), familial (n = 556; 1.0%), and other (n = 7,523; 13.0%) etiologies were far less frequent. There were significant differences in baseline characteristics between those with ischemic cardiomyopathy compared with NICM with respect to age (76 years vs. 72 years), sex (44.4% vs. 56.9% women), and ejection fraction (38% vs. 45%). Risk-adjusted quality of care provided to eligible patients varied minimally by etiology. Similarly, in-hospital mortality did not differ among ischemic compared with NICM patients. However, among NICM patients, only hypertensive cardiomyopathy had a lower mortality rate compared with idiopathic NICM (adjusted odds ratio: 0.83; 95% confidence interval: 0.71 to 0.97).ConclusionsCharacteristics of hospitalized HF patients vary by etiology. Both risk-adjusted quality of care and in-hospital outcomes did not differ by etiology.
      PubDate: Sun, 01 Nov 2015 00:00:00 GMT
  • A Systematic Review and Meta-Analysis of Long-Term Outcomes After
           Septal Reduction Therapy in Patients With Hypertrophic
    • Authors: Liebregts M; Vriesendorp PA, Mahmoodi BK, et al.
      Abstract: ObjectivesThe aim of this meta-analysis was to compare long-term outcomes after myectomy and alcohol septal ablation (ASA) in patients with hypertrophic cardiomyopathy (HCM).BackgroundSurgical myectomy and ASA are both accepted treatment options for medical therapy–resistant obstructive HCM. Previous meta-analyses only evaluated short-term outcomes.MethodsA systematic review was conducted for eligible studies with a follow-up of at least 3 years. Primary outcomes were all-cause mortality and (aborted) sudden cardiac death (SCD). Secondary outcomes were periprocedural complications, left ventricular outflow tract gradient, and New York Heart Association functional class after ≥3 months, and reintervention. Pooled estimates were calculated using a random-effects meta-analysis.ResultsSixteen myectomy cohorts (n = 2,791; mean follow-up, 7.4 years) and 11 ASA cohorts (n = 2,013; mean follow-up, 6.2 years) were included. Long-term mortality was found to be similarly low after ASA (1.5% per year) compared with myectomy (1.4% per year, p = 0.78). The rate of (aborted) SCD, including appropriate implantable cardioverter defibrillator shocks, was 0.4% per year after ASA and 0.5% per year after myectomy (p = 0.47). Permanent pacemaker implantation was performed after ASA in 10% of the patients compared with 4.4% after myectomy (p 
      PubDate: Sun, 01 Nov 2015 00:00:00 GMT
  • HeartWare Left Ventricular Assist Device Pump Thrombosis A Shift Away
           From Ramp ∗
    • Authors: Rame J; Birati EY.
      Abstract: Ventricular assist device (VAD) thrombosis is a frequent and potentially devastating complication of mechanical circulatory support. Recent studies have shown an abrupt increase in the incidence of HeartMate II device thrombosis (Thoratec Corporation, Pleasanton, California) (1,2), whereas the incidence of HeartWare (HeartWare Inc., Framingham, Massachusetts) ventricular assist device (HVAD) thrombosis remains stable (3,4). With the increase in the number of patients treated with durable mechanical circulatory support, the magnitude of this complication will continue to rise, mandating a pragmatic approach for diagnosis and treatment. In this issue of JACC: Heart Failure, Jorde et al. (5) summarize the patterns of power consumption available from log-file analysis of the HVAD system during an acute syndrome of pump thrombosis, and it is in this context that it becomes clinically relevant.
      PubDate: Sun, 01 Nov 2015 00:00:00 GMT
  • Tackling Early Heart Failure Deaths and Readmissions by Estimating
           Congestion ∗
    • Authors: Voors AA; ter Maaten JM.
      Abstract: Patients who are discharged after a hospital admission for heart failure enter a vulnerable phase with a very high risk for early death or heart failure readmission (1). This is a major problem for patients, doctors, and society. The underlying cause for high readmission rates is still incompletely understood, although incomplete decongestion at discharge is frequently suggested to play an important role. Heart failure guidelines recommend a detailed and careful assessment of congestion pre-discharge (2,3). This includes assessing signs and symptoms and performing a chest radiograph, but the sensitivity and specificity of these methods to accurately estimate congestion are limited (4). Unfortunately, standardized metrics or (de)congestion scores are currently lacking. Several papers were recently published on multiple surrogates used to assess decongestion during hospitalization for acute heart failure. A frequently described surrogate is a rise in hemoglobin during a heart failure admission, indicated as hemoconcentration. Three large studies showed that hemoconcentration was associated with greater weight and fluid loss, greater reductions in filling pressures, and less residual congestion (5–7). A consistent finding among these 3 trials was a clear association between a greater hemoconcentration and a reduction in early post-discharge events and heart failure readmission in particular. Diuretic response during hospitalization was recently proposed as another surrogate for decongestion (8–10). A good diuretic response was associated with greater weight and fluid loss and less use of inotropes during hospitalization. Moreover, diuretic response was strongly and independently associated with a reduction in early post-discharge events and lower rates of heart failure rehospitalization. These 2 examples illustrate that an indirect metric to establish decongestion might be of great value during hospitalization, either to guide therapy or for its prognostic value. However, these metrics were applied during the in-hospital phase, but data on assessment or measures of congestion post-discharge are scarce. In this issue of JACC: Heart Failure, Duarte et al. (11) examine the prognostic value of plasma volume estimation shortly after discharge for a hospitalization for acute heart failure. The authors performed a retrospective analysis on the EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study). EPHESUS included patients with systolic heart failure after an acute myocardial infarction. Plasma volume variation between discharge and after 1 month was established by the Strauss formula (estimated plasma volume variation [ΔePVS]), which incorporates both hemoglobin and hematocrit ratios. An estimation of plasma volume at 1 month (ePVS) was also studied. A decrease in estimated plasma volume (ΔePVS) 1 month after discharge was independently associated with a decreased risk of early cardiovascular events, defined as cardiovascular death, hospitalization for heart failure, or both. A lower estimated plasma volume at 1 month (ePVS) was similarly associated with fewer events and provided greater significant prognostic gain than ΔePVS. On the basis of these findings, the authors concluded that the use of a simple estimation of plasma volume as a parameter of congestion status provides important prognostic information beyond usual clinical variables and may have clinical implications for patient management (i.e., taking serial hemoglobin/hematocrit measurements after discharge).
      PubDate: Sun, 01 Nov 2015 00:00:00 GMT
  • Mechanical Pre-Conditioning With Acute Circulatory Support Before
           Reperfusion Limits Infarct Size in Acute Myocardial Infarction
    • Authors: Kapur NK; Qiao X, Paruchuri V, et al.
      Abstract: ObjectivesThis study tested the hypothesis that first reducing myocardial work by unloading the left ventricle (LV) with a novel intracorporeal axial flow catheter while delaying coronary reperfusion activates a myocardial protection program and reduces infarct size.BackgroundIschemic heart disease is a major cause of morbidity and mortality worldwide. Primary myocardial reperfusion remains the gold standard for the treatment of an acute myocardial infarction (AMI); however, ischemia–reperfusion injury contributes to residual myocardial damage and subsequent heart failure. Stromal cell-derived factor (SDF)-1α is a chemokine that activates cardioprotective signaling via Akt, extracellular regulated kinase, and glycogen synthase kinase-3β.MethodsAMI was induced by occlusion of the left anterior descending artery (LAD) via angioplasty for 90 min in 50-kg male Yorkshire swine (n = 5/group). In the primary reperfusion (1° Reperfusion) group, the LAD was reperfused for 120 min. In the primary unloading (1° Unloading) group, after 90 min of ischemia the axial flow pump was activated and the LAD left occluded for an additional 60 min, followed by 120 min of reperfusion. Myocardial infarct size and kinase activity were quantified.ResultsCompared with 1° Reperfusion, 1° Unloading reduced LV wall stress and increased myocardial levels of SDF-1α, CXCR4, and phosphorylated Akt, extracellular regulated kinase, and glycogen synthase kinase-3β in the infarct zone. 1° Unloading increased antiapoptotic signaling and reduced myocardial infarct size by 43% compared with 1° Reperfusion (73 ± 13% vs. 42 ± 8%; p = 0.005). Myocardial levels of SDF-1 correlated inversely with infarct size (R = 0.89; p < 0.01).ConclusionsCompared with the contemporary strategy of primary reperfusion, mechanically conditioning the myocardium using a novel axial flow catheter while delaying coronary reperfusion decreases LV wall stress and activates a myocardial protection program that up-regulates SDF-1α/CXCR4 expression, increases cardioprotective signaling, reduces apoptosis, and limits myocardial damage in AMI.
      PubDate: Sun, 01 Nov 2015 00:00:00 GMT
  • New Treatments for Left Ventricular Assist Device-Associated Bleeding'
    • Authors: Strueber M.
      Abstract: In 2004, our program in Hannover, Germany, was among the first centers in the world gaining clinical experience with a new ventricular assist device (VAD) called the HeartMate II (HMII) (Thoratec Corporation, Pleasanton, California). At that time, hopes were not high because the pilot trial was designed to cover a 180-day bridge-to-transplant approach. There were concerns about pump thrombosis; therefore, anticoagulation protocols were maximized at that time.
      PubDate: Sun, 01 Nov 2015 00:00:00 GMT
  • Inhibition of ADAMTS-13 by Doxycycline Reduces von Willebrand Factor
           Degradation During Supraphysiological Shear Stress Therapeutic
           Implications for Left Ventricular Assist Device-Associated Bleeding
    • Authors: Bartoli CR; Kang J, Restle DJ, et al.
      Abstract: ObjectivesThe aim of this study was to investigate a potential therapy for left ventricular assist device (LVAD)–associated bleeding.BackgroundNonsurgical bleeding is the most frequent complication of LVAD support. Recent evidence has demonstrated that supraphysiological shear stress from continuous-flow LVADs accelerates von Willebrand factor (vWF) metabolism by the action of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS-13) (the vWF protease). An acquired vWF deficiency causes bleeding. This suggests that ADAMTS-13 is a clinical target to reduce vWF degradation. We tested the hypothesis that inhibition of ADAMTS-13 with doxycycline, an inexpensive, clinically approved drug, reduces vWF degradation during shear stress.MethodsWhole blood was collected from human donors (n = 15), and purified, recombinant ADAMTS-13 protein was obtained. An enzyme-linked immunosorbent assay (ELISA) was used to quantify the dose relationship between doxycycline and ADAMTS-13 activity prior to shear stress (n = 10). To determine the effect of shear stress, plasma and recombinant ADAMTS-13 were exposed to LVAD-like supraphysiological shear stress (approximately 175 dyne/cm2). vWF multimers and degradation fragments were characterized with electrophoresis and immunoblotting (n = 10). Förster resonance energy transfer was used to quantify plasma ADAMTS-13 activity (n = 10). An ELISA was used to quantify vWF:collagen binding activity. Platelet aggregometry was performed with adenosine 5′-diphosphate, collagen, and ristocetin (vWF-platelet pathway) agonism (n = 10).ResultsDoxycycline significantly decreased plasma ADAMTS-13 activity (p = 0.01) and the activity of recombinant human ADAMTS-13 protein by 21%. After plasma was exposed to shear stress, the same pattern of vWF degradation was observed as previously reported for LVAD patients, and vWF:collagen binding activity decreased significantly (p = 0.002). Doxycycline significantly decreased ADAMTS-13 activity (p = 0.04) and the activity of recombinant ADAMTS-13 by 18%, protected large vWF multimers from degradation, and significantly decreased the levels of the 5 smallest vWF fragments by 12 ± 2% (p 
      PubDate: Sun, 01 Nov 2015 00:00:00 GMT
  • Identification and Management of Pump Thrombus in the HeartWare Left
    • Authors: Jorde UP; Aaronson KD, Najjar SS, et al.
      Abstract: ObjectivesThe study sought to characterize patterns in the HeartWare (HeartWare Inc., Framingham, Massachusetts) ventricular assist device (HVAD) log files associated with successful medical treatment of device thrombosis.BackgroundDevice thrombosis is a serious adverse event for mechanical circulatory support devices and is often preceded by increased power consumption. Log files of the pump power are easily accessible on the bedside monitor of HVAD patients and may allow early diagnosis of device thrombosis. Furthermore, analysis of the log files may be able to predict the success rate of thrombolysis or the need for pump exchange.MethodsThe log files of 15 ADVANCE trial patients (algorithm derivation cohort) with 16 pump thrombus events treated with tissue plasminogen activator (tPA) were assessed for changes in the absolute and rate of increase in power consumption. Successful thrombolysis was defined as a clinical resolution of pump thrombus including normalization of power consumption and improvement in biochemical markers of hemolysis. Significant differences in log file patterns between successful and unsuccessful thrombolysis treatments were verified in 43 patients with 53 pump thrombus events implanted outside of clinical trials (validation cohort).ResultsThe overall success rate of tPA therapy was 57%. Successful treatments had significantly lower measures of percent of expected power (130.9% vs. 196.1%, p = 0.016) and rate of increase in power (0.61 vs. 2.87, p < 0.0001). Medical therapy was successful in 77.7% of the algorithm development cohort and 81.3% of the validation cohort when the rate of power increase and percent of expected power values were 
      PubDate: Sun, 01 Nov 2015 00:00:00 GMT
  • Limiting Infarct Size in ST-Segment Myocardial Infarction The Holy Grail
           of Reperfusion Therapy ∗
    • Authors: Bates ER.
      Abstract: Acute thrombotic occlusion of a coronary artery usually produces myocardial ischemia that can result in myocardial infarction if reperfusion is not restored. Reperfusion injury from reintroduction of blood and oxygen into the ischemic area at risk can result in additional myocyte cell death (1,2). Whereas early reperfusion therapy has been shown to reduce infarct size by decreasing ischemic injury time and results in lower morbidity and mortality rates (3), little progress has been made in decreasing the additional impact of reperfusion injury on infarct size despite 3 decades of effort (1,2,4). Although many interventions targeting reperfusion injury have seemed promising in experimental studies, they have failed to reduce infarct size consistently or improve clinical outcome in clinical trials and have not been endorsed by clinical practice guideline committees as effective therapeutic strategies (5). Nevertheless, reperfusion injury is a popular pre-clinical research area and the enthusiasts remain optimistic that a therapeutic breakthrough will eventually be achieved.
      PubDate: Sun, 01 Nov 2015 00:00:00 GMT
  • Prognostic Value of Estimated Plasma Volume in Heart Failure
    • Authors: Duarte K; Monnez J, Albuisson E, et al.
      Abstract: ObjectivesThe purpose of this study was to assess the prognostic value of the estimation of plasma volume or of its variation beyond clinical examination in a post-hoc analysis of EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study).BackgroundAssessing congestion after discharge is challenging but of paramount importance to optimize patient management and to prevent hospital readmissions.MethodsThe present analysis was performed in a subset of 4,957 patients with available data (within a full dataset of 6,632 patients). The study endpoint was cardiovascular death or hospitalization for heart failure (HF) between months 1 and 3 after post-acute myocardial infarction HF. Estimated plasma volume variation (ΔePVS) between baseline and month 1 was estimated by the Strauss formula, which includes hemoglobin and hematocrit ratios. Other potential predictors, including congestion surrogates, hemodynamic and renal variables, and medical history variables, were tested. An instantaneous estimation of plasma volume at month 1 was defined and also tested.ResultsMultivariate analysis was performed with stepwise logistic regression. ΔePVS was selected in the model (odds ratio: 1.01; p = 0.004). The corresponding prognostic gain measured by integrated discrimination improvement was significant (7.57%; p = 0.01). Nevertheless, instantaneous estimation of plasma volume at month 1 was found to be a better predictor than ΔePVS.ConclusionsIn HF complicating myocardial infarction, congestion as assessed by the Strauss formula and an instantaneous derived measurement of plasma volume provided a predictive value of early cardiovascular events beyond routine clinical assessment. Prospective trials to assess congestion management guided by this simple tool to monitor plasma volume are warranted.
      PubDate: Sun, 01 Nov 2015 00:00:00 GMT
  • Inside This Issue
    • PubDate: Sun, 01 Nov 2015 00:00:00 GMT
  • The Heart Failure Overweight/Obesity Survival Paradox The Missing Sex Link
    • Authors: Vest AR; Wu Y, Hachamovitch R, et al.
      Abstract: ObjectivesThis study sought to determine whether body mass index (BMI) has a differential impact on survival for females versus males with advanced systolic heart failure (HF).BackgroundFemales have a survival advantage in HF, the mechanisms of which are unclear. There is also a proposed “obesity survival paradox” in which excess adiposity promotes HF survival.MethodsWe reviewed 3,811 patients with left ventricular ejection fraction ≤40% who had undergone cardiopulmonary exercise testing between 1995 and 2011. The endpoint was all-cause mortality. Multivariable analysis was performed using a Cox proportional hazards model. Because of the nonlinearity of BMI, a restricted cubic spline was used. An interaction term was added to investigate the impact of BMI on mortality by sex.ResultsThe unadjusted data demonstrated an overall obesity survival paradox in HF. This survival paradox disappeared for males after adjustment for potential confounders, with overweight and obese males showing higher adjusted mortality hazard ratios compared with normal weight males. Conversely, females in the overweight BMI range (25.0 to 29.9 kg/m2) had the lowest adjusted mortality (hazard ratio: 0.84; 95% confidence interval: 0.77 to 0.93; p = 0.0005 compared with normal weight females) with a nadir in mortality hazard just below BMI 30 kg/m2. The multivariable model supported a differential impact of BMI on mortality in males versus females (p for interaction 
      PubDate: Sun, 01 Nov 2015 00:00:00 GMT
  • The Obesity Paradox in Heart Failure Is it All About Fitness, Fat, or
           Sex' ∗
    • Authors: Lavie CJ; Ventura HO.
      Abstract: Substantial evidence points out that obesity impacts most of the cardiovascular (CV) disease (CVD) risk factors, including adversely effecting lipids, increasing arterial pressure, elevating glucose, and increasing the risk of metabolic syndrome and diabetes mellitus, and increasing systemic inflammation (1). Obesity also has many deleterious effects on CV structure and function and hemodynamics (Figure 1) and increases the risk of most CVD (2,3). Because overweight and obese patients develop more hypertension and coronary heart disease (CHD), 2 of the major risk factors for heart failure (HF), not surprisingly, these patients also develop HF much more commonly than do the lean counterparts.
      PubDate: Sun, 01 Nov 2015 00:00:00 GMT
  • Bundle Up for Value-Based Heart Failure Care
    • PubDate: Sun, 01 Nov 2015 00:00:00 GMT
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