Mental health and transcatheter aortic valve replacement: A scoping systematic review.

OBJECTIVE: To systematically review the literature on mental health symptoms before and after transcatheter aortic valve replacement (TAVR) and describe reported clinical associations with these symptoms. METHODS: Using the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) guidelines, we reviewed studies involving pre- or post-TAVR mental health assessments or psychiatric diagnoses. RESULTS: Eighteen studies were included. Before TAVR, clinically significant depression and anxiety prevalence is 15-30% and 25-30%, respectively, with only a third of these meeting diagnostic thresholds. These symptoms generally improve over the year post-TAVR. Depression is associated with functional impairment, multimorbidity, and lower physical activity; few associations have been described in relation to anxiety. Inconsistent evidence finds depression associated with post-TAVR mortality. One notable study found persistent depression independently predictive of 12-month mortality, and another found depression and cognition to have additive value in predicting mortality risk. CONCLUSIONS: Mental health symptoms occur in a significant proportion of the TAVR population. Although symptoms tend to improve, the associations with depression, particularly persistent depression, call for further investigation to examine their associated outcomes. Research is also needed to understand the relationships between mental health conditions and cognition in TAVR-related outcomes.

Person-Centered Models for Cardiovascular Care: A Review of the Evidence: A Scientific Statement From the American Heart Association.

Cardiovascular disease remains the leading cause of death and disability in the United States and globally. Disease burden continues to escalate despite technological advances associated with improved life expectancy and quality of life. As a result, longer life is associated with multiple chronic cardiovascular conditions. Clinical guidelines provide recommendations without considering prevalent scenarios of multimorbidity and health system complexities that affect practical adoption. The diversity of personal preferences, cultures, and lifestyles that make up one's social and environmental context is often overlooked in ongoing care planning for symptom management and health behavior support, hindering adoption and compromising patient outcomes, particularly in groups at high risk. The purpose of this scientific statement was to describe the characteristics and reported outcomes in existing person-centered care delivery models for selected cardiovascular conditions. We conducted a scoping review using Ovid MEDLINE, Embase.com, Web of Science, CINAHL Complete, Cochrane Central Register of Controlled Trials through Ovid, and ClinicalTrials.gov from 2010 to 2022. A range of study designs with a defined aim to systematically evaluate care delivery models for selected cardiovascular conditions were included. Models were selected on the basis of their stated use of evidence-based guidelines, clinical decision support tools, systematic evaluation processes, and inclusion of the patient's perspective in defining the plan of care. Findings reflected variation in methodological approach, outcome measures, and care processes used across models. Evidence to support optimal care delivery models remains limited by inconsistencies in approach, variation in reimbursement, and inability of health systems to meet the needs of patients with chronic, complex cardiovascular conditions.

Long-term milrinone therapy as a bridge to heart transplantation: Safety, efficacy, and predictors of failure.

BACKGROUND: Studies of long-term inotrope use in advanced HF have previously provided limited and conflicting results. This study aimed to evaluate the safety and efficacy of long-term milrinone use and identify predictors of failure to bridge to orthotropic heart transplant (OHT) in a cohort of end-stage heart failure (HF) patients listed for heart transplantation and receiving inotrope therapy. METHODS: The study included 150 adults listed for OHT at a single center from 2001 to 2017 who received milrinone therapy for ≥30 days. Multivariate Cox proportional hazards models were used to identify factors associated with "failure" (left ventricular assist device, intra-aortic balloon pump, status downgrade due to instability, death) vs. "success" (OHT, recovery) during bridging to OHT. RESULTS: "Failure" occurred in 33 (22%) patients. Factors independently associated with failure included male sex (HR = 7.6; p = 0.004), no implantable cardioverter-defibrillator (HR = 3.8; p = 0.009), and lack of guideline-directed medical therapy (GDMT) with a beta-blocker (HR = 7.8; p = 0.002) or angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (HR = 6.3; p < 0.001). Patients who received fewer guideline-directed medications had a higher cumulative probability of failure. Adverse events included central line-associated bloodstream infection (2.55 per 1000 line-days) and arrhythmia (1.59 per 1000 treatment-days). CONCLUSIONS: Our findings suggest that long-term milrinone therapy in selected patients is associated with a high rate of successful bridging to OHT and a low rate of adverse events. Patients intolerant of GDMT are more likely to fail to bridge to OHT without mechanical support. Sex differences in outcomes associated with milrinone therapy should be explored.

Patterns of Resuscitation Care and Survival After In-Hospital Cardiac Arrest in Patients With Advanced Cancer.

PURPOSE: Little is known regarding patterns of resuscitation care in patients with advanced cancer who suffer in-hospital cardiac arrest (IHCA). METHODS: In the Get With The Guidelines - Resuscitation registry, 47,157 adults with IHCA with and without advanced cancer (defined as the presence of metastatic or hematologic malignancy) were identified at 369 hospitals from April 2006 through June 2010. We compared rates of return of spontaneous circulation (ROSC) and survival to discharge between groups using multivariable models. We also compared duration of resuscitation effort and resuscitation quality measures. RESULTS: Overall, 6,585 patients with IHCA (14.0%) had advanced cancer. Patients with advanced cancer had lower multivariable-adjusted rates of ROSC (52.3% [95% CI, 49.5% to 55.3%] v 56.6% [95% CI, 53.8% to 59.5%]; P < .001) and survival to discharge (7.4% [95% CI, 6.6% to 8.4%] v 13.4% [95% CI, 12.1% to 14.8%]; P < .001). Among nonsurvivors who died during resuscitation, patients with advanced cancer had better performance on most resuscitation quality measures. Among patients with ROSC, patients with advanced cancer were made Do Not Attempt Resuscitation (DNAR) more frequently within 48 hours (adjusted relative risk, 1.30 [95% CI, 1.24 to 1.37]; P < .001). Adjustment for DNAR status explained some of the immediate effect of advanced cancer on survival; however, survival remained significantly lower in patients with cancer. CONCLUSION: Patients with advanced cancer can expect lower survival rates after IHCA compared with those without advanced cancer, and they are more frequently made DNAR within 48 hours of ROSC. These findings have important implications for discussions of resuscitation care wishes with patients and can better inform end-of-life discussions.

Angina Severity, Depression, and Response to Percutaneous Revascularization in Patients With Chronic Total Occlusion of Coronary Arteries.

OBJECTIVES: This study sought to quantify depression rates in patients referred for percutaneous coronary intervention (PCI) for chronic total occlusion (CTO), assess its relationship to baseline angina symptoms, and compare angina improvement after CTO-PCI between depressed and non-depressed patients. BACKGROUND: Depression is common among patients with chronic angina, and portends poor prognosis. CTOs are a common cause of angina. The relationships between angina, depression, and CTO intervention are unknown. METHODS: We collected baseline and 30-day post-PCI data on angina (Seattle Angina Questionnaire [SAQ7]), dyspnea (Rose Dyspnea Scale [RDS]), and depression status (Patient Health Questionnaire [PHQ-2]) on 45 consecutive patients referred for CTO-PCI between October 2013 and October 2014. RESULTS: Depression (PHQ-2 score ≥3) was present in 18/45 patients (40%) at baseline. Baseline SAQ7 Summary and SAQ7 Angina Frequency scores for depressed patients were 35.4 (range, 28.4-42.4) and 54.4 (range, 43.0-65.8), compared with 67.3 (range, 57.5-77.1) and 77.8 (range, 68.5-87.1) for non-depressed patients (P<.001 and P=.01, respectively). Following CTO-PCI, the mean improvement in SAQ7 Summary and SAQ7 Angina Frequency scores was 48.5 (range, 35.4-61.5) and 32.8 (range, 21.0-44.5) for patients with depression, compared with 16.5 (range, 5.87-27.2) and 12.6 (range, 3.0-22.2) for patients without depression (P<.001 and P=.01, respectively). Following PCI, the presence of depression was reduced (72% relative reduction vs. baseline; P=.01). CONCLUSIONS: Depression identifies patients more limited by angina and more likely to respond to CTO-PCI compared with non-depressed patients. Depression screening may be indicated for patients with CTO, as 67% of CTO patients were not receiving treatment for depression.

Use of a heart team in decision-making for patients with complex coronary disease at hospitals in Michigan prior to guideline endorsement.

BACKGROUND: Revascularization decisions can profoundly impact patient survival, quality of life, and procedural risk. Although use of Heart Teams to make revascularization decisions is growing, data on their implementation in the real-world are limited. Our objective was to assess the prevalence of Heart Teams and their association with collaboration in routine practice. METHODS: A survey of cardiologists and cardiac surgeons at 31 hospitals in Michigan was performed in May, 2011--prior to the recommendation for using Heart Teams in national guidelines. This survey included all percutaneous coronary intervention-performing hospitals in Michigan participating in the Blue Cross/Blue Shield of Michigan Cardiovascular Consortium and Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative. It targeted both the use of Heart Teams and multidisciplinary Case Conferences. RESULTS: There were 53 physician survey respondents from 27 hospitals with 4 hospitals not responding. Among respondents, 11 (40.7%) hospitals reported no Heart Teams or Case Conferences while 7 (25.9%) hospitals reported either a Heart Team or Case Conference. However, there was disagreement about the presence of a Heart Team at seven hospitals, and about Case Conferences at nine hospitals. Hospitals with definite Heart Teams reported significantly greater levels of collaboration between cardiologists and cardiac surgeons. CONCLUSION: The overall presence of Heart Teams prior to their recommendation in national guidelines was limited. Even among hospitals with a potential Heart Team, there was substantial disagreement between respondents about their presence. Further refinement of the definition of a Heart Team and measures of successful implementation are needed.