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Journal Cover JACC : Heart Failure
  [SJR: 4.318]   [H-I: 18]   [4 followers]  Follow
   Full-text available via subscription Subscription journal
   ISSN (Online) 2213-1779
   Published by American College of Cardiology Homepage  [1 journal]
  • A Suprainstitutional Network for Remote Extracorporeal Life Support A
           Retrospective Cohort Study
    • Authors: Aubin H; Petrov G, Dalyanoglu H, et al.
      Abstract: ObjectivesThis study sought to evaluate patient outcome within the Düsseldorf Extracorporeal Life Support (ECLS) Network, a suprainstitutional network for rapid-response remote ECLS and to define survival-based predictors.BackgroundMobile venoarterial extracorporeal membrane oxygenation (vaECMO) used for ECLS has become a treatment option for a patient population with an otherwise fatal prognosis. However, outcome data remain scarce and institutional standards required to manage these patients are still poorly defined.MethodsThis retrospective cohort study analyzes the outcome of 115 patients consecutively treated between July 2011 and October 2014 within the Düsseldorf ECLS Network due to refractory circulatory failure.ResultsOf the 115 patients (56 ± 15 years of age, vaECMO initiation under cardiopulmonary resuscitation [CPR] 77%, CPR duration 45 [range 5 to 90] min), 50 patients (44%) survived to primary discharge and 38 patients (33%) were alive after a median follow-up of 1.5 years (95% confidence interval [CI]: 1.2 to 1.7). Thirty-seven (97%) of the long-term survivors showed a favorable neurological outcome. Risk factors associated with mortality during vaECMO were CPR duration (hazard ratio [HR]: 1.006; 95% CI: 1.00 to 1.01) and ischemic stroke (HR: 2.63; 95% CI: 1.52 to 4.56). Risk factors associated with mortality after vaECMO weaning were renal failure (HR: 6.60; 95% CI: 2.72 to 16.01) and sepsis (HR: 3.6; 95% CI: 1.50 to 8.69). Visceral ischemia had a negative impact (HR: 0.30; 95% CI: 0.11 to 0.84) whereas assist device implantation promoted successful vaECMO weaning (HR: 2.95; 95% CI: 1.65 to 5.25). Further, 3 distinct risk groups with significant differences in survival could be identified, demonstrating that in patients with no or short CPR mortality was not conditioned by age, whereas in patients with prolonged CPR young age was associated with increased survival.ConclusionsThis study illustrates the implementation of a suprainstitutional ECLS Network. Further, our data suggest that mobile vaECMO is beneficial for a larger patient population than actually expected, especially regarding young patients presenting with prolonged CPR or patients regardless of age with no or short CPR.
      PubDate: Thu, 01 Sep 2016 00:00:00 GMT
  • The Mentor’s Mentor The Life of Galen Wagner
    • PubDate: Thu, 01 Sep 2016 00:00:00 GMT
  • Defining the Obvious: Maybe It Is Not So Easy ∗
    • Authors: Greenberg B.
      Abstract: The clinical course of patients with chronic heart failure (HF) is usually stable…until it is not. This, of course, is a fanciful way of saying that the natural history of chronic HF varies considerably among patients and that it often changes abruptly over time. There has been increasing interest in identifying and studying episodes of worsening heart failure (WHF) that occur during the course of hospitalization for acute heart failure (AHF) (1). Yet even though symptomatic worsening occurs commonly in ambulatory patients, there has been surprisingly little attention paid to the significance of these events.
      PubDate: Thu, 01 Sep 2016 00:00:00 GMT
  • The Importance of Worsening Heart Failure in Ambulatory Patients
           Definition, Characteristics, and Effects of Amino-Terminal Pro-B-Type
           Natriuretic Peptide Guided Therapy
    • Authors: Mallick A; Gandhi PU, Gaggin HK, et al.
      Abstract: ObjectivesThe goal of this study was to define and assess the significance of worsening heart failure (WHF) in patients with chronic ambulatory heart failure with reduced ejection fraction (HFrEF).BackgroundWHF has been identified as a potentially relevant clinical event in patients with acute heart failure (HF) and is increasingly used as an endpoint in clinical trials. No standardized definition of WHF exists. It remains uncertain how WHF relates to risk for other HF events or how treatment may affect WHF.MethodsA total of 151 symptomatic patients with chronic HFrEF were randomized to standard of care HF management or a goal to lower N-terminal pro–B-type natriuretic peptide (NT-proBNP) concentrations ≤1,000 pg/ml in addition to standard of care. WHF was prospectively defined as: 1) new or progressive symptoms and/or signs of decompensated HF; and 2) unplanned intensification of diuretic therapy.ResultsOver a mean follow-up of 10 months, 45 subjects developed WHF. At baseline, patients developing incident WHF had higher ejection fraction (31% vs. 25%; p = 0.03), were more likely to have jugular venous distension and edema (p < 0.02), were less likely to receive angiotensin-converting enzyme inhibitors or received these agents at lower doses (p < 0.04), and also received higher loop diuretic doses (p < 0.001). Occurrence of WHF was strongly associated with subsequent HF hospitalization/cardiovascular death (hazard ratio, landmark analysis: 18.8; 95% confidence interval: 5.7 to 62.5; p < 0.001). NT-proBNP–guided care reduced the incidence of WHF in adjusted analyses (hazard ratio: 0.52; p = 0.06) and improved event-free survival (log-rank test p = 0.04).ConclusionsIn chronic HFrEF, WHF was associated with substantial risk for morbidity and mortality. NT-proBNP–guided care reduced risk for WHF.
      PubDate: Thu, 01 Sep 2016 00:00:00 GMT
  • The Relationship of Plasma NT-proBNP to Age and Outcomes in Heart
           Failure ∗
    • Authors: Richards A.
      Abstract: N-terminal pro–B-type natriuretic peptide (NT-proBNP) is recommended as a biomarker for diagnosis in acute and chronic symptomatic heart failure (HF) and for prognosis at all stages of HF (1,2). Meta-analyses of controlled trials also suggest titration of therapy in chronic HF according to serial measurements of NT-proBNP, as an adjunct to guideline-mandated management, improves outcomes (2,3). From the outset of marker-guided trials investigators have hypothesized the efficacy of a marker-guided approach may be modified by age and indeed benefits appear to be confined to those under 75 years of age (3–7). In this issue of JACC: Heart Failure, Stienen et al. (8) have combined data from several cohorts of patients (totaling 1,235) admitted with acute decompensated HF to investigate whether the relationship between plasma NT-proBNP and post-discharge outcome alters with age.
      PubDate: Thu, 01 Sep 2016 00:00:00 GMT
  • Targeting N-Terminal Pro-Brain Natriuretic Peptide in Older Versus
           Younger Acute Decompensated Heart Failure Patients
    • Authors: Stienen S; Salah K, Eurlings LW, et al.
      Abstract: ObjectivesThe aim of this study was to analyze the prognostic value and attainability of N-terminal pro-brain natriuretic peptide (NT-proBNP) levels in young and elderly acute decompensated heart failure (ADHF) patients.BackgroundLess-effective NT-proBNP-guided therapy in chronic heart failure (HF) has been reported in elderly patients. Whether this can be attributed to differences in prognostic value of NT-proBNP or to differences in attaining a prognostic value is unclear. The authors studied this question in ADHF patients.MethodsOur study population comprised 7 ADHF cohorts. We defined absolute (75 years) and young patients (age ≤75 years). Thereafter, we compared percentages of elderly and young patients attaining NT-proBNP levels (= attainability).ResultsA total of 1,235 patients (59% male, 45% >75 years of age) was studied. Admission levels of NT-proBNP were significantly higher in elderly versus younger patients. The prognostic value of absolute and relative NT-proBNP levels was similar in elderly and young patients. Attainability was significantly lower in elderly patients for all absolute levels and a >50% relative reduction, but not for >30% and >70%. For absolute levels, attainability differences between age groups were decreased to a large extent after correction for admission NT-proBNP and anemia at discharge. For relative levels, attainability differences disappeared after correction for HF etiology and anemia at discharge.ConclusionsIn young and elderly ADHF patients, it is not the prognostic value of absolute and relative NT-proBNP levels that is different, but the attainability of these levels that is lower in the elderly. This can largely be attributed to factors other than age.
      PubDate: Thu, 01 Sep 2016 00:00:00 GMT
  • Rationale and Design of the ATHENA-HF Trial Aldosterone Targeted
           Neurohormonal Combined With Natriuresis Therapy in Heart Failure
    • Authors: Butler J; Hernandez AF, Anstrom KJ, et al.
      Abstract: Although therapy with mineralocorticoid receptor antagonists (MRAs) is recommended for patients with chronic heart failure (HF) with reduced ejection fraction and in post-infarction HF, it has not been studied well in acute HF (AHF) despite being commonly used in this setting. At high doses, MRA therapy in AHF may relieve congestion through its natriuretic properties and mitigate the effects of adverse neurohormonal activation associated with intravenous loop diuretics. The ATHENA-HF (Aldosterone Targeted Neurohormonal Combined with Natriuresis Therapy in Heart Failure) trial is a randomized, double-blind, placebo-controlled study of the safety and efficacy of 100 mg/day spironolactone versus placebo (or continued low-dose spironolactone use in participants who are already receiving spironolactone at baseline) in 360 patients hospitalized for AHF. Patients are randomized within 24 h of receiving the first dose of intravenous diuretics. The primary objective is to determine if high-dose spironolactone, compared with standard care, will lead to greater reductions in N-terminal pro−B-type natriuretic peptide levels from randomization to 96 h. The secondary endpoints include changes in the clinical congestion score, dyspnea relief, urine output, weight change, loop diuretic dose, and in-hospital worsening HF. Index hospital length of stay and 30-day clinical outcomes will be assessed. Safety endpoints include risk of hyperkalemia and renal function. Differences among patients with reduced versus preserved ejection fraction will be determined. (Study of High-dose Spironolactone vs. Placebo Therapy in Acute Heart Failure [ATHENA-HF]; NCT02235077)
      PubDate: Thu, 01 Sep 2016 00:00:00 GMT
  • Can Big Data Simplify the Complexity of Modern Medicine' Prediction
           of Right Ventricular Failure After Left Ventricular Assist Device
           Support as a Test Case ∗
    • Authors: Ahmad T; Testani JM, Desai NR.
      Abstract: Everything should be made as simple as possible, but not simpler.—Albert Einstein (1)The delivery of high-quality and patient-centered care relies on accurate risk prediction and phenotyping of disease (2). Cardiologists pride themselves on being particularly data-driven; appropriate management of patients with heart disease relies heavily on analysis of large clinical trials and registries rather than clinical gestalt and mechanistic feasibility. As a consequence, numerous promising therapeutic strategies have fallen by the wayside under the weight of contradictory data from large unbiased studies, and the bar for approval of new treatments is arguably higher than it is for other disease states (3). Despite this, contemporary clinical care and investigation continues to lag behind the needs of patients or providers because of a reliance on crude risk prediction models and traditional statistical methods that fail to capture disease complexity. To illustrate, stroke prediction for patients with atrial fibrillation is based on a handful of variables that comprise the CHA2DS2-VASc score; the predictive capabilities of this instrument fail to take into account the complexity of the stroke phenotype, and the dynamic interplay between multiple biological and clinical variables that occur on the patient level (4). Instead of acceding to such simplified constructs that are designed for ease of use at the bedside, there as a growing demand for use of increases in computing power to assist with more accuracy and precision in the diagnosis and treatment of heart disease.
      PubDate: Thu, 01 Sep 2016 00:00:00 GMT
  • A Bayesian Model to Predict Right Ventricular Failure Following
           Left Ventricular Assist Device Therapy
    • Authors: Loghmanpour NA; Kormos RL, Kanwar MK, et al.
      Abstract: ObjectivesThis study investigates the use of a Bayesian statistical model to address the limited predictive capacity of existing risk scores derived from multivariate analyses. This is based on the hypothesis that it is necessary to consider the interrelationships and conditional probabilities among independent variables to achieve sufficient statistical accuracy.BackgroundRight ventricular failure (RVF) continues to be a major adverse event following left ventricular assist device (LVAD) implantation.MethodsData used for this study were derived from 10,909 adult patients from the Inter-Agency Registry for Mechanically Assisted Circulatory Support (INTERMACS) who had a primary LVAD implanted between December 2006 and March 2014. An initial set of 176 pre-implantation variables were considered. RVF post-implant was categorized as acute (14 days) in onset. For each of these endpoints, a separate tree-augmented naïve Bayes model was constructed using the most predictive variables employing an open source Bayesian inference engine.ResultsThe acute RVF model consisted of 33 variables including systolic pulmonary artery pressure (PAP), white blood cell count, left ventricular ejection fraction, cardiac index, sodium levels, and lymphocyte percentage. The early RVF model consisted of 34 variables, including systolic PAP, pre-albumin, lactate dehydrogenase level, INTERMACS profile, right ventricular ejection fraction, pro-B-type natriuretic peptide, age, heart rate, tricuspid regurgitation, and body mass index. The late RVF model included 33 variables and was predicted mostly by peripheral vascular resistance, model for end-stage liver disease score, albumin level, lymphocyte percentage, and mean and diastolic PAP. The accuracy of all Bayesian models was between 91% and 97%, with an area under the receiver operator characteristics curve between 0.83 and 0.90, sensitivity of 90%, and specificity between 98% and 99%, significantly outperforming previously published risk scores.ConclusionsA Bayesian prognostic model of RVF based on the large, multicenter INTERMACS registry provided highly accurate predictions of acute, early, and late RVF on the basis of pre-operative variables. These models may facilitate clinical decision making while screening candidates for LVAD therapy.
      PubDate: Thu, 01 Sep 2016 00:00:00 GMT
  • Cheating Death With ECMO Coming Soon to a Theater Near You ∗
    • Authors: Shah AS.
      Abstract: The study by the Dusseldorf Extracorporeal Life Support (ECLS) Network in this issue of JACC: Heart Failure(1) adds to the inconvenient truth that extracorporeal membrane oxygenation (ECMO) is moving from an anecdotal therapy to a public health commodity. Much in the way that cardiopulmonary resuscitation began as an experimental technique in the basement of Baltimore City Hospital to part of elementary school education, ECMO is poised to evolve into a fundamental resuscitative therapy. It has 1 major problem: it is phenomenally expensive. Although ECMO creates exciting opportunities, it simultaneously creates troubling questions for clinicians, policymakers, and the public.
      PubDate: Thu, 01 Sep 2016 00:00:00 GMT
  • Does Survival on the Heart Transplant Waiting List Depend on the
           Underlying Heart Disease'
    • Authors: Hsich EM; Rogers JG, McNamara DM, et al.
      Abstract: ObjectivesThe aim of this study was to identify differences in survival on the basis of type of heart disease while awaiting orthotopic heart transplantation (OHT).BackgroundPatients with restrictive cardiomyopathy (RCM), congenital heart disease (CHD), or hypertrophic cardiomyopathy (HCM) may be at a disadvantage while awaiting OHT because they often are poor candidates for mechanical circulatory support and/or inotropes.MethodsThe study included all adults in the Scientific Registry of Transplant Recipients database awaiting OHT from 2004 to 2014, and outcomes were evaluated on the basis of type of heart disease. The primary endpoint was time to all-cause mortality, censored at last patient follow-up and time of transplantation. Multivariate Cox proportional hazards modeling was performed to evaluate survival by type of cardiomyopathy.ResultsThere were 14,447 patients with DCM, 823 with RCM, 11,799 with ischemic cardiomyopathy (ICM), 602 with HCM, 964 with CHD, 584 with valvular disease, and 1,528 in the “other” category (including 1,216 for retransplantation). During median follow-up of 3.7 months, 4,943 patients died (1,253 women, 3,690 men). After adjusting for possible confounding variables including age, renal function, inotropes, mechanical ventilation, and mechanical circulatory support, the adjusted hazard ratios by diagnoses relative to DCM were 1.70 for RCM (95% confidence interval [CI]: 1.43 to 2.02), 1.10 for ICM (95% CI: 1.03 to 1.18), 1.23 for HCM (95% CI: 0.98 to 1.54), 1.30 for valvular disease (95% CI: 1.07 to 1.57), 1.37 for CHD (95% CI: 1.17 to 1.61), and 1.51 for “other” diagnoses (95% CI: 1.34 to 1.69). Sex was a significant modifier of mortality for ICM, RCM, and “other” diagnoses (p < 0.05 for interaction).ConclusionsIn the United States, patients with RCM, CHD, or prior heart transplantation had a higher risk for death while awaiting OHT than patients with DCM, ICM, HCM, or valvular heart disease.
      PubDate: Thu, 01 Sep 2016 00:00:00 GMT
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