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JACC : Heart Failure
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     ISSN (Online) 2213-1779
     Published by American College of Cardiology Foundation Homepage  [1 journal]
  • Inside This Issue
    • PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • Prognostic Benefit of Optimum Left Ventricular Lead Position in Cardiac
           Resynchronization Therapy Follow-Up of the TARGET Study Cohort (Targeted
           Left Ventricular Lead Placement to guide Cardiac Resynchronization
           Therapy)
    • Authors: Kydd AC; Khan FZ, Watson WD, et al.
      Abstract: ObjectivesThis study was conducted to assess the impact of left ventricular (LV) lead position on longer-term survival after cardiac resynchronization therapy (CRT).BackgroundAn optimal LV lead position in CRT is associated with improved clinical outcome. A strategy of speckle-tracking echocardiography can be used to guide the implanter to the site of latest activation and away from segments of low strain amplitude (scar). Long-term, prospective survival data according to LV lead position in CRT are limited.MethodsData from a follow-up registry of 250 consecutive patients receiving CRT between June 2008 and July 2010 were studied. The study population comprised patients recruited to the derivation group and the subsequent TARGET (Targeted Left Ventricular Lead Placement to guide Cardiac Resynchronization Therapy) randomized, controlled trial. Final LV lead position was described, in relation to the pacing site determined by pre-procedure speckle-tracking echocardiography, as optimal (concordant/adjacent) or suboptimal (remote). All-cause mortality was recorded at follow-up.ResultsAn optimal LV lead position (n = 202) conferred LV remodeling response superior to that of a suboptimal lead position (change in LV end-systolic volume: –24 ± 15% vs. –12 ± 17% [p < 0.001]; change in ejection fraction: +7 ± 8% vs. +4 ± 7% [p = 0.02]). During long-term follow-up (median: 39 months; range: 
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • Is Heart Rate Important for Patients With Heart Failure in Atrial
           Fibrillation'
    • Authors: Cullington D; Goode KM, Zhang J, et al.
      Abstract: ObjectivesThis study sought to investigate the relationship between resting ventricular rate and mortality in patients with chronic heart failure (CHF) and reduced left ventricular ejection fraction (LVEF) who were in sinus rhythm (SR) or atrial fibrillation (AF).BackgroundSlower heart rates are associated with better survival in patients with CHF in SR, but it is not clear whether this is true for those in AF.MethodsWe assessed 2,039 outpatients with CHF and LVEF ≤50% undergoing baseline assessment, of whom 24% (n = 488) were in AF; and 841 outpatients reassessed after attempted treatment optimization at 1 year, of whom 22% (n = 184) were in AF. Cox proportional hazards models were used to assess the relationships between heart rate and survival in patients with CHF and AF or sinus rhythm. We analyzed heart rate and rhythm data recorded at the baseline review and after 1-year follow-up. Proportional hazards assumptions were checked by Schoenfeld and Martingale residuals.ResultsThe median survival for those in AF was 6.1 years (interquartile range [IQR]: 5.3 to 6.9 years) and 7.3 years (IQR: 6.5 to 8.1 years) for those in SR. In univariable analysis, patients with AF had a worse survival (hazard ratio [HR]: 1.26, 95% confidence interval [CI]: 1.08 to 1.47; p = 0.003) but after covariate adjustment, survival rates were similar. After adjusting Cox regression models, there was no association between heart rate (per 10 beats/min increments) and survival in patients with AF before (HR: 0.94, 95% CI: 0.88 to 1.00, p = 0.07) or after (HR: 1.00, 95% CI: 0.99 to 1.00, p = 0.84) therapy optimization. For patients in SR, higher heart rates were associated with worse survival, both before (HR: 1.10, 95% CI: 1.05 to 1.15, p 
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • The Association Between Atrial Fibrillation and Sudden Cardiac Death The
           Relevance of Heart Failure
    • Authors: Reinier K; Marijon E, Uy-Evanado A, et al.
      Abstract: ObjectivesThe purpose of this study was to evaluate the role of congestive heart failure (CHF) in the association between atrial fibrillation (AF) and sudden cardiac death (SCD).BackgroundRecent studies have reported the possibility of an independent association between AF and SCD. We hypothesized that a history of CHF is a significant confounder of this association.MethodsIn a prospective case-control analysis from the community (The Oregon-SUDS [Sudden Unexpected Death Study], 2002 to 2012), SCD cases (n = 652) with clinical records available (including electrocardiography and/or echocardiography) were compared with age- and sex-matched control patients with coronary artery disease. The association between AF and SCD was analyzed using multivariable logistic regression and propensity score matching.ResultsCases (age 67.3 ± 11.7 years, 65% male) were more likely than control patients (age 67.2 ± 11.4 years, 65% male) to have a history of AF (p = 0.0001), myocardial infarction (p = 0.007), CHF (p < 0.0001), stroke (p 
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • Atrial Fibrillation and Sudden Cardiac Death Is Heart Failure the
           Middleman' ∗
    • Authors: Piccini JP; Daubert JP.
      Abstract: Atrial fibrillation (AF) is a world-wide epidemic, affecting more than 33 million individuals across the globe (1). Beyond its impact on quality of life, AF is associated with increased risks of stroke, heart failure, cognitive impairment, and death (2,3). Emerging evidence suggests that AF may be associated with an increased risk of sudden cardiac death (SCD) as well (4,5).
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • Pre-Capillary Pulmonary Hypertension and Right Ventricular Dilation
           Predict Clinical Outcome in Cardiac Resynchronization Therapy
    • Authors: Chatterjee NA; Upadhyay GA, Singal G, et al.
      Abstract: ObjectivesThis study examined the prognostic significance of pre- and post-capillary components of pulmonary hypertension (PH) in patients receiving cardiac resynchronization therapy (CRT).BackgroundPH is common in patients with left ventricular systolic dysfunction (LVSD) receiving CRT. The impact of PH subtype on clinical outcome in CRT is unknown.MethodsThe study population consisted of 101 patients (average age 66 ± 13 years, left ventricular ejection fraction 0.23 ± 0.07, and New York Heart Association functional class 3.2 ± 0.4) who underwent right heart catheterization in the 6 months before CRT. PH was defined as a mean pulmonary artery pressure ≥25 mm Hg; a significant pre-capillary contribution to elevated mean pulmonary artery pressure was defined as a transpulmonary gradient (TPG) ≥12 mm Hg. Clinical endpoints were assessed at 2 years and included all-cause mortality and a composite of death, left ventricular assist device, or cardiac transplantation.ResultsPatients with TPG ≥12 mm Hg were more likely to experience all-cause mortality (hazard ratio [HR]: 3.2; 95% confidence interval [CI]: 1.3 to 7.4; p = 0.009) and the composite outcome (HR: 3.0; 95% CI: 1.4 to 6.3; p = 0.004) compared with patients with TPG 42 mm) were associated with the composite clinical outcome (p = 0.05 and p = 0.04, respectively).ConclusionsHigh TPG PH and RV dilation are independent predictors of adverse outcomes in patients with LVSD who are receiving CRT. RV pulmonary vascular dysfunction may be a therapeutic target in select patients receiving CRT.
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • Association of Cardiorespiratory Fitness With Left Ventricular Remodeling
           and Diastolic Function The Cooper Center Longitudinal Study
    • Authors: Brinker SK; Pandey A, Ayers CR, et al.
      Abstract: ObjectivesThis study sought to compare the cross-sectional associations between fitness and echocardiographic measures of cardiac structure and function.BackgroundCardiorespiratory fitness is inversely associated with heart failure risk. However, the mechanism through which fitness lowers heart failure risk is not fully understood.MethodsWe included 1,678 men and 1,247 women from the Cooper Center Longitudinal Study who received an echocardiogram from 1999 to 2011. Fitness was estimated by Balke protocol (in metabolic equivalents) and also categorized into age-specific quartiles, with quartile 1 representing low fitness. Cross-sectional associations between fitness (in metabolic equivalents) and relative wall thickness, left ventricular end-diastolic diameter indexed to body surface area, left atrial volume indexed to body surface area, left ventricular systolic function, and E/e′ ratio were determined using multivariable linear regression analysis.ResultsHigher levels of mid-life fitness (metabolic equivalents) were associated with larger indexed left atrial volume (men: beta = 0.769, p < 0.0001; women: beta = 0.879, p value ≤0.0001) and indexed left ventricular end-diastolic diameter (men: beta = 0.231, p < 0.001; women: beta = 0.264, p < 0.0001). Similarly, a higher level of fitness was associated with a smaller relative wall thickness (men: beta = –0.002, p = 0.04; women: beta = –0.005, p 
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • Fatness, Fitness, Stiffness, and Age How Does it Lead to Heart
           Failure' ∗
    • Authors: Borlaug BA.
      Abstract: There is no proven effective treatment for heart failure with preserved ejection fraction (HFpEF) (1), making prevention even more important. To design preventive trials, we must first understand which people are at the highest risk for HFpEF, and why they are so vulnerable. HFpEF is associated with older age, obesity, diastolic dysfunction, hypertension, concentric left ventricular (LV) remodeling, and insulin resistance/metabolic stress (1,2). For the most part, each of these risk factors is associated with ≥1 of the others (3,4). In addition, adiposity, hypertension, and metabolic stress are associated with and appear to accelerate age-associated LV stiffening, which is also typical of HFpEF (1–8). This then begs the question: Is there a common unifying thread that might tie these factors together'
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • Contemporary Profile of Acute Heart Failure in Southern Nigeria Data
           From the Abeokuta Heart Failure Clinical Registry
    • Authors: Ogah OS; Stewart S, Falase AO, et al.
      Abstract: ObjectivesThe aim of this study was to determine the contemporary profile, clinical characteristics, and intrahospital outcomes of acute heart failure (AHF) in an African urban community.BackgroundThere are limited data on the current burden and characteristics of AHF in Nigerian Africans.MethodsComprehensive and detailed clinical and sociodemographic data were prospectively collected from 452 consecutive patients presenting with AHF to the only tertiary hospital in Abeokuta, Nigeria (population about 1 million) over a 2-year period.ResultsThe mean age was 56.6 ± 15.3 years (57.3 ± 13.4 years for men, 55.7 ± 17.1 years for women), and 204 patients (45.1%) were women. Overall, 415 subjects (91.8%) presented with de novo AHF. The most common risk factor for heart failure was hypertension (pre-existing in 64.3% of patients). Type 2 diabetes mellitus was present in 41 patients (10.0%). Hypertensive heart failure was the most common etiological cause of heart failure, responsible for 78.5% of cases. Dilated cardiomyopathy (7.5%), cor pulmonale (4.4%), pericardial disease (3.3%), rheumatic heart disease (2.4%), and ischemic heart disease were less common (0.4%) causes. The majority of subjects (71.2%) presented with left ventricular dysfunction (mean left ventricular ejection fraction 43.9 ± 9.0%), with valvular dysfunction and abnormal left ventricular geometry frequently documented. The mean duration of hospital stay was 11.4 ± 9.1 days, and intrahospital mortality was 3.8%.ConclusionsCompared with those in high-income countries, patients presenting with AHF in Abeokuta, Nigeria, are relatively younger and still of working age. It is also more common in men and associated with severe symptoms because of late presentation. Intrahospital mortality is similar to that in other parts of the world.
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • Biomarkers of Myocardial Stress and Fibrosis as Predictors of Mode of
           Death in Patients With Chronic Heart Failure
    • Authors: Ahmad T; Fiuzat M, Neely B, et al.
      Abstract: ObjectivesThe aim of this study was to determine whether biomarkers of myocardial stress and fibrosis improve prediction of the mode of death in patients with chronic heart failure.BackgroundThe 2 most common modes of death in patients with chronic heart failure are pump failure and sudden cardiac death. Prediction of the mode of death may facilitate treatment decisions. The relationship between amino-terminal pro-brain natriuretic peptide (NT-proBNP), galectin-3, and ST2, biomarkers that reflect different pathogenic pathways in heart failure (myocardial stress and fibrosis), and mode of death is unknown.MethodsHF-ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) was a randomized controlled trial of exercise training versus usual care in patients with chronic heart failure due to left ventricular systolic dysfunction (left ventricular ejection fraction ≤35%). An independent clinical events committee prospectively adjudicated mode of death. NT-proBNP, galectin-3, and ST2 levels were assessed at baseline in 813 subjects. Associations between biomarkers and mode of death were assessed using cause-specific Cox proportional hazards modeling, and interaction testing was used to measure differential associations between biomarkers and pump failure versus sudden cardiac death. Discrimination and risk reclassification metrics were used to assess the added value of galectin-3 and ST2 in predicting mode of death risk beyond a clinical model that included NT-proBNP.ResultsAfter a median follow-up period of 2.5 years, there were 155 deaths: 49 from pump failure, 42 from sudden cardiac death, and 64 from other causes. Elevations in all biomarkers were associated with increased risk for both pump failure and sudden cardiac death in both adjusted and unadjusted analyses. In each case, increases in the biomarker had a stronger association with pump failure than sudden cardiac death, but this relationship was attenuated after adjustment for clinical risk factors. Clinical variables along with NT-proBNP levels were stronger predictors of pump failure (C statistic: 0.87) than sudden cardiac death (C statistic: 0.73). Addition of ST2 and galectin-3 led to improved net risk classification of 11% for sudden cardiac death, but not pump failure.ConclusionsClinical predictors along with NT-proBNP levels were strong predictors of pump failure risk, with insignificant incremental contributions of ST2 and galectin-3. Predictability of sudden cardiac death risk was less robust and enhanced by information provided by novel biomarkers.
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • The Burden of Acute Heart Failure on U.S. Emergency Departments
    • Authors: Storrow AB; Jenkins CA, Self WH, et al.
      Abstract: ObjectivesThe goal of this study was to examine 2006 to 2010 emergency department (ED) admission rates, hospital procedures, lengths of stay, and costs for acute heart failure (AHF).BackgroundPatients with AHF are often admitted and are associated with high readmissions and cost.MethodsWe utilized Nationwide Emergency Department Sample AHF data from 2006 to 2010 to describe admission proportion, hospital length of stay (LOS), and ED charges as a surrogate for resource utilization. Results were compared across U.S. regions, patient insurance status, and hospital characteristics.ResultsThere were 958,167 mean yearly ED visits for AHF in the United States. Fifty-one percent of the patients were female, and the median age was 75.1 years (interquartile range [IQR]: 62.5 to 83.7 years). Overall, 83.7% (95% confidence interval: 83.1% to 84.2%) were admitted; the median LOS was 3.4 days (IQR: 1.9 to 5.8 days). Comparing 2006 with 2010, there was a small decrease in median LOS (0.09 days), but the proportion admitted did not change. Odds of admission, adjusting for age, sex, hospital characteristic (academic and safety net status), and insurance (Medicare, Medicaid, private, self-pay/no charge) were highest in the Northeast. Median ED charges were $1,075 (IQR: $679 to $1,665) in 2006 and $1,558 (IQR: $1,018 to $2,335) in 2010. Patients without insurance were more likely to be discharged from the ED, but when admitted, were more likely to receive a major diagnostic or therapeutic procedure.ConclusionsA very high proportion of ED patients with AHF are admitted nationally, with significant variation in disposition and procedural decisions based on region of the country and type of insurance, even after adjusting for potential confounding.
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • Emergency Departments, Acute Heart Failure, and Admissions One Size Does
           Not Fit All ∗
    • Authors: Pang PS; Schuur JD.
      Abstract: Nearly 130 million visits to emergency departments (EDs) occur every year in the United States (1). Whether patients should have gone to the ED in the first place is frequently debated, because the ED is often viewed as an overcrowded, overused, misused, and costly resource. Yet patients rarely present to the ED for unnecessary reasons (2). Judging appropriateness of ED visits often suffers from hindsight bias or misapplication of methods to judge appropriate use (2–4). Although emergency care may be more expensive than office-based care, when the populations served, patient complexity, 24/7 access, and proportion of total healthcare costs are considered, emergency care adds value, and would be costly to replace (5). Yet there remains ample room to improve the acute care for many conditions. One critical area of focus is on whom to admit versus discharge. Although only 13.3% of U.S. ED patients were admitted in 2010, the ED is the source of more than one-half of hospital admissions—the most expensive resource in healthcare (1,6).
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • Long-Term Mortality After Cardiac Allograft Vasculopathy Implications of
           Percutaneous Intervention
    • Authors: Agarwal S; Parashar A, Kapadia SR, et al.
      Abstract: ObjectivesThis study compared the prognosis of patients with proximal cardiac allograft vasculopathy (CAV) treated with percutaneous intervention (PCI) to the prognosis of those with severe CAV not amenable to PCI.BackgroundCAV is a progressive form of arterial narrowing affecting patients with orthotopic heart transplants (OHTs). PCI has been used to treat patients with focal CAV, but its efficacy remains unclear.MethodsOf 853 patients undergoing OHT and subsequent coronary angiographies at the Cleveland Clinic, all patients with at least moderate CAV (>30%) on any coronary angiogram following OHT were included. Of remaining patients with no/mild CAV, 200 patients were randomly chosen to represent the comparison group. All angiograms of the included patients were reviewed and graded according to the International Society of Heart and Lung Transplantation (ISHLT) nomenclature.ResultsOf the 393 included patients, 100 patients underwent definitive intervention for CAV. Of these 100 patients, 90 patients underwent PCI only, 6 patients underwent coronary artery bypass grafting, and 4 patients underwent repeat OHT. We observed a progressive increase in long-term mortality with worsening CAV. Patients with ISHLT grade 3 CAV had the highest long-term mortality compared with other groups. In addition, there was a significant reduction in the risk for mortality at 2-year follow-up (adjusted odds ratio: 0.26; 95% confidence interval [CI]: 0.08 to 0.82) and 5-year follow-up (adjusted odds ratio: 0.28; 95% CI: 0.09 to 0.93) after PCI compared with patients diagnosed with ISHLT grade 3 CAV, who were deemed unsuitable for PCI. Furthermore, statin use was associated with a significant survival benefit in patients with CAV (hazard ratio: 0.21; 95% CI: 0.07 to 0.61).ConclusionsWorsening severity of CAV was associated with progressively worse long-term survival among heart transplant recipients. Among patients with CAV, long-term survival in those with CAV amenable to PCI was greater than that in those with severe CAV not treatable with PCI.
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • Effect of Rosuvastatin on Repeat Heart Failure Hospitalizations The CORONA
           Trial (Controlled Rosuvastatin Multinational Trial in Heart Failure)
    • Authors: Rogers JK; Jhund PS, Perez A, et al.
      Abstract: ObjectivesThis study sought to examine the effect of statin therapy hospitalizations for heart failure (HFH) in patients in the CORONA (Controlled Rosuvastatin Multinational Trial in Heart Failure) trial.BackgroundHFH is an important, frequently recurrent event. Conventional time-to-first event analyses do not take account repeat events. We used a number of statistical approaches to examine the effect of treatment on first and repeat HFH in the CORONA trial.MethodsIn the CORONA trial, 5,011 patients ≥60 years of age with chronic New York Heart Association functional classes II to IV systolic heart failure resulting from ischemia were randomized to receive rosuvastatin or placebo. Poisson, Andersen-Gill, and negative binomial methods (NB) were used to analyze the effect of rosuvastatin on HFH, and the NB and a parametric joint frailty model (JF) were used to examine this effect while accounting for the competing risk of cardiovascular (CV) death. Rosuvastatin/placebo rate ratios were calculated, both unadjusted and adjusted.ResultsA total of 1,291 patients had 1 or more HFH (750 of these had a single HFH only), and there were a total of 2,408 HFHs. The hazard ratio for the conventional time-to-first event analysis for HFH was 0.91 (95% confidence interval [CI]: 0.82 to 1.02, p = 0.105). In contrast, the NB on repeat hospitalizations gave an unadjusted RR (RR) for HFH of 0.86 (95% CI: 0.75 to 0.99, p = 0.030), adjusted 0.82 (95% CI: 0.72 to 0.92, p = 0.001), and after including CV death as the last event, adjusted RR of 0.85 (95% CI: 0.77 to 0.94, p = 0.001). The JF gave an adjusted RR of 0.82 (95% CI: 0.73 to 0.92, p = 0.001). Similar results were found in analyses of all CV hospitalizations and all-cause hospitalizations.ConclusionsWhen repeat events were included, rosuvastatin was shown to reduce the risk of HFH by approximately 15% to 20%, equating to approximately 76 fewer admissions per 1,000 patients treated over a median 33 months of follow-up. Including repeat events could increase the ability to detect treatment effects in heart failure trials.
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • The Effect of Multiple Micronutrient Supplementation on Left Ventricular
           Ejection Fraction in Patients With Chronic Stable Heart Failure A
           Randomized, Placebo-Controlled Trial
    • Authors: McKeag NA; McKinley MC, Harbinson MT, et al.
      Abstract: ObjectivesThis study sought to investigate the effect of a multiple micronutrient supplement on left ventricular ejection fraction (LVEF) in patients with heart failure.BackgroundObservational studies suggest that patients with heart failure have reduced intake and lower concentrations of a number of micronutrients. However, there have been very few intervention studies investigating the effect of micronutrient supplementation in patients with heart failure.MethodsThis was a randomized, double-blind, placebo-controlled, parallel-group study involving 74 patients with chronic stable heart failure that compared multiple micronutrient supplementation taken once daily versus placebo for 12 months. The primary endpoint was LVEF assessed by cardiovascular magnetic resonance imaging or 3-dimensional echocardiography. Secondary endpoints were Minnesota Living With Heart Failure Questionnaire score, 6-min walk test distance, blood concentrations of N-terminal prohormone of brain natriuretic peptide, C-reactive protein, tumor necrosis factor alpha, interleukin-6, interleukin-10, and urinary levels of 8-iso-prostaglandin F2 alpha.ResultsBlood concentrations of a number of micronutrients increased significantly in the micronutrient supplement group, indicating excellent compliance with the intervention. There was no significant difference in mean LVEF at 12 months between treatment groups after adjusting for baseline (mean difference: 1.6%, 95% confidence interval: −2.6 to 5.8, p = 0.441). There was also no significant difference in any of the secondary endpoints at 12 months between treatment groups.ConclusionsThis study provides no evidence to support the routine treatment of patients with chronic stable heart failure with a multiple micronutrient supplement. (Micronutrient Supplementation in Patients With Heart Failure [MINT-HF]; NCT01005303)
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • Micronutrients for Chronic Heart Failure End of the Road or Path to
           Enlightenment' ∗
    • Authors: Witte KA; Byrom R.
      Abstract: Patients and many physicians strongly believe in the positive effects of combined multiple micronutrient supplementation for the prevention and treatment of cardiovascular disease. This belief extends to patients with chronic heart failure (CHF), more than 60% of whom take some form of over-the-counter micronutrient supplementation (1).
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • Editorial Mentorship
    • Authors: O'Connor C.
      Abstract: One of the aspects of medicine I enjoy most is mentoring. Mentoring gives us the opportunity to give back to our profession by sharing our experiences with those who, because of less experience and fewer years under their belt, are not as knowledgeable about the complexities of medicine that they are practicing. It is also important to realize that you are never too old to be a mentee. To accept the knowledge and experience of those who have traveled before you by listening, learning, and engaging in dialogue and communication about aspects of activities and the practice of medicine that cannot be transcribed in the written word is a gift at any stage in your career. I am, therefore, deeply grateful to the mentoring that I have experienced as an Editor Mentee of Dr. Anthony DeMaria.
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • Understanding the Heterogeneity in Volume Overload and Fluid Distribution
           in Decompensated Heart Failure Is Key to Optimal Volume Management Role
           for Blood Volume Quantitation
    • Authors: Miller WL; Mullan BP.
      Abstract: ObjectivesThis study sought to quantitate total blood volume (TBV) in patients hospitalized for decompensated chronic heart failure (DCHF) and to determine the extent of volume overload, and the magnitude and distribution of blood volume and body water changes following diuretic therapy.BackgroundThe accurate assessment and management of volume overload in patients with DCHF remains problematic.MethodsTBV was measured by a radiolabeled-albumin dilution technique with intravascular volume, pre-to-post–diuretic therapy, evaluated at hospital admission and at discharge. Change in body weight in relation to quantitated TBV was used to determine interstitial volume contribution to total fluid loss.ResultsTwenty-six patients were prospectively evaluated. Two patients had normal TBV at admission. Twenty-four patients were hypervolemic with TBV (7.4 ± 1.6 liters) increased by +39 ± 22% (range, +9.5% to +107%) above the expected normal volume. With diuresis, TBV decreased marginally (+30 ± 16%). Body weight declined by 6.9 ± 5.2 kg, and fluid intake/fluid output was a net negative 8.4 ± 5.2 liters. Interstitial compartment fluid loss was calculated at 6.2 ± 4.0 liters, accounting for 85 ± 15% of the total fluid reduction.ConclusionsTBV analysis demonstrated a wide range in the extent of intravascular overload. Dismissal measurements revealed marginally reduced intravascular volume post-diuretic therapy despite large reductions in body weight. Mobilization of interstitial fluid to the intravascular compartment with diuresis accounted for this disparity. Intravascular volume, however, remained increased at dismissal. The extent, composition, and distribution of volume overload are highly variable in DCHF, and this variability needs to be taken into account in the approach to individualized therapy. TBV quantitation, particularly serial measurements, can facilitate informed volume management with respect to a goal of treating to euvolemia.
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
  • In Search of Euvolemia in Heart Failure ∗
    • Authors: Katz SD.
      Abstract: In preparation for the writing of this editorial, I consulted my copy of the Stedman’s Medical Dictionary (23rd Edition, copyright 1976) and was surprised to find that the word “euvolemia” was nowhere to be found. A subsequent search in PubMed (search terms “euvolemia” or “euvolemic” in any field) revealed that the first published article with these terms appeared in a 1979 study of renal physiology in rats. The word euvolemia appears in the heart failure consensus guideline statements from the American College of Cardiology/American Heart Association, Heart Failure Society of America, and European Society of Cardiology. In each of the guideline documents, euvolemia is not strictly defined, but is used in context to describe the “ideal volume status” for the patient (also referred to as the “dry weight”), and is proposed as an appropriate goal for titration of diuretic therapy in heart failure patients. This usage is based on the Greek origins of the prefix “eu,” most often translated as “good” or “well.”
      PubDate: Sun, 01 Jun 2014 00:00:00 GMT
       
 
 
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