Natriuretic Equation to Predict Loop Diuretic Response in Patients With Heart Failure.

BACKGROUND: Most acute decompensated heart failure admissions are driven by congestion. However, residual congestion is common and often driven by the lack of reliable tools to titrate diuretic therapy. The authors previously developed a natriuretic response prediction equation (NRPE), which predicts sodium output using a spot urine sample collected 2 h after loop diuretic administration. OBJECTIVES: The purpose of this study was to validate the NRPE and describe proof-of-concept that the NRPE can be used to guide diuretic therapy. METHODS: Two cohorts were assembled: 1) the Diagnosing and Targeting Mechanisms of Diuretic Resistance (MDR) cohort was used to validate the NRPE to predict 6-h sodium output after a loop diuretic, which was defined as poor (<50 mmol), suboptimal (<100 mmol), or excellent (>150 mmol); and 2) the Yale Diuretic Pathway (YDP) cohort, which used the NRPE to guide loop diuretic titration via a nurse-driven automated protocol. RESULTS: Evaluating 638 loop diuretic administrations, the NRPE showed excellent discrimination with areas under the curve ≥0.90 to predict poor, suboptimal, and excellent natriuretic response, and outperformed clinically obtained net fluid loss (p < 0.05 for all cutpoints). In the YDP cohort (n = 161) using the NRPE to direct therapy mean daily urine output (1.8 ± 0.9 l vs. 3.0 ± 0.8 l), net fluid output (-1.1 ± 0.9 l vs. -2.1 ± 0.9 l), and weight loss (-0.3 ± 0.3 kg vs. -2.5 ± 0.3 kg) improved substantially following initiation of the YDP (p < 0.001 for all pre-post comparisons). CONCLUSIONS: Natriuretic response can be rapidly and accurately predicted by the NRPE, and this information can be used to guide diuretic therapy during acute decompensated heart failure. Additional study of diuresis guided by the NRPE is warranted.

Psychological stress in heart failure: a potentially actionable disease modifier.

Psychological stress is common in patients with heart failure, due in part to the complexities of effective disease self-management and progressively worsening functional limitations, including frequent symptom exacerbations and hospitalizations. Emerging evidence suggests that heart failure patients who experience higher levels of stress may have a more burdensome disease course, with diminished quality of life and increased risk for adverse events, and that multiple behavioral and pathophysiological pathways are involved. Furthermore, the reduced quality of life associated with heart failure can serve as a life stressor for many patients. The purpose of this review is to summarize the current state of the science concerning psychological stress in patients with heart failure and to discuss potential pathways responsible for the observed effects. Key knowledge gaps are also outlined, including the need to understand patterns of exposure to various heart failure-related and daily life stressors and their associated effects on heart failure symptoms and pathophysiology, to identify patient subgroups at increased risk for stress exposure and disease-related consequences, and the effect of stress specifically for patients who have heart failure with preserved ejection fraction. Stress is a potentially modifiable factor, and addressing these gaps and advancing the science of stress in heart failure is likely to yield important insights about actionable pathways for improving patient quality of life and outcomes.

Dying to know: prognosis communication in heart failure.

Prognosis communication in heart failure is often narrowly defined as a discussion of life expectancy, but as clinical guidelines and research suggest, these discussions should provide a broader understanding of the disease, including information about disease trajectory, the experiences of living with heart failure, potential burden on patients and families, and mortality. Furthermore, despite clinical guidelines recommending early discussions, evidence suggests that these discussions occur infrequently or late in the disease trajectory. We review the literature concerning patient, caregiver, and clinician perspectives on discussions of this type, including the frequency, timing, desire for, effects of, and barriers to their occurrence. We propose an alternate view of prognosis communication, in which the patient and family/caregiver are educated about the nature of the disease at the time of diagnosis, and a process of engagement is undertaken so that the patient's full participation in their care is marshalled, and the care team engages the patient in the informed decision making that will guide care throughout the disease trajectory. We also identify and discuss evidence gaps concerning (i) patient preferences and readiness for prognosis information along the trajectory; (ii) best practices for communicating prognosis information; and (iii) effects of prognosis communication on patient's quality of life, mental health, engagement in critical self-care, and clinical outcomes. Research is needed to determine best practices for engaging patients in prognosis communication and for evaluating the effects of this communication on patient engagement and clinical outcomes.

Access and Outcomes Among Hypertrophic Cardiomyopathy Patients in a Large Integrated Health System.

Background Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiomyopathy. Current guidelines endorse management in expert centers, but patient socioeconomic status can affect access to specialty care. The effect of socioeconomic status and specialty care access on HCM outcomes has not been examined. Methods and Results We conducted a retrospective cohort study that examined outcomes among HCM patients receiving care in the Yale New Haven Health System between June 2011 and December 2017. Patients were assigned to lower or higher socioeconomic status groups (LSES/HSES) based on medical insurance provider and to receivers of specialty care (SC) at Yale's Inherited Cardiomyopathy clinic or general cardiology care (GC). The primary outcome was all-cause death, and the secondary outcome was all-cause hospitalization. We identified 953 HCM patients; 820 (86%) were HSES and 133 (14%) were LSES. Forty-three (4.5%) patients died from cardiac and noncardiac causes. LSES patients within the general cardiology care cohort had significantly higher all-cause mortality compared with HSES patients (adjusted hazard ratio, [95% CI]=10.06 [4.38-23.09]; P<0.001). This was not noted in the specialty care cohort (adjusted hazard ratio, [95% CI]=2.87 [0.56-14.73]; P=0.21). The moderator effect of specialty care on mortality difference between LSES versus HSES, however, did not reach statistical significance (hazard ratio, 0.29 [0.05-1.77]; P=0.18). Specialist care was associated with increased hospitalization (adjusted hazard ratio, [95% CI]=3.28 [1.11-9.73]; P=0.03 for LSES; 2.19 [1.40-3.40]; P=0.001 for HSES). Conclusions Socioeconomically vulnerable HCM patients had higher mortality when not referred to specialty care. Further study is needed to understand the underlying causes.

Evaluation of a guideline directed medical therapy titration program in patients with heart failure with reduced ejection fraction.

INTRODUCTION: Heart failure is associated with recurrent hospitalizations and high mortality. Guideline directed medical treatment (GDMT), including beta blockers (BBs), angiotensin converting enzyme inhibitors (ACE-Is), angiotensin receptor blockers (ARBs) and aldosterone antagonists (AAs) has shown to improve outcomes. Current guidelines recommend the use of these medication classes at maximally tolerated dosages. Despite the evidence, < 25% of patients with heart failure with reduced left ventricular ejection fraction (HFrEF) are on the appropriate medical regimen titrated to the target doses. As such, we sought to assess the utility of a focused GDMT clinic to reduce this gap. METHODS: We conducted a retrospective chart review through existing patient data in a single center teaching hospital of patients referred to a focused GDMT clinic primarily staffed with heart failure trained nurse specialists, physician assistants and cardiologists. Management guidelines were developed with protocols for the initiation and uptitration of all therapeutic agents considered as GDMT.Our primary objective was to determine whether enrollment into a dedicated nursing led guideline directed medical therapy clinic would increase the proportion of patients with heart failure with reduced ejection fraction on appropriate medications as well as medication dosages in patients, the percentage of patients on the following medications and percentage at target doses: Renin-Angiotensin-Aldosterone System Blockers, Evidence Based Beta Blockers, and Aldosterone Antagonists. Our secondary objective was to determine if there was any clinical benefit on objective measures including renal function, hospital admissions, mortality and implantable defibrillator shocks. RESULTS: Between October 2015 and March 2017, 63 patients were identified by requisition forms, in which 61 were able to be identified based on legibility of identifying information. Mean duration of follow up was 264.44 ±â€¯162.68 days over 7 ±â€¯3.94 days. Mean ejection fraction was 21.8 ±â€¯7.3%. New onset cardiomyopathies (diagnosed within 30 days) compiled 21% of the patient population while those with demonstrated cardiomyopathies (> 90 days) compiled 48% of the patient population. Patients with NYHA class III heart failure compiled 65% of the patient population.There was a statistically significant increase in the mean number of GDMT at any dose (2.31 ±â€¯0.76 to 2.74 ±â€¯0.66; p < 0.001) and mean number of GDMT at target doses (0.54 ±â€¯0.79 to 1.52 ±â€¯1.1; p < 0.001). Percentage of the population that were on no target doses at initial visit was 62% which was reduced to 18% after intervention.Clinical improvement was reflected in significant improvement in ejection fraction from 21.8 ±â€¯7.8% to 36.2 ±â€¯14.3% (p < 0.001). Increases in sodium and chloride were statistically small but significant. There a significant reduction in heart failure hospitalizations in comparison to a year prior to after the initial encounter in the clinic (p < 0.001). CONCLUSION: This pilot study showed that a nurse directed GDMT titration program successfully increased the number of GDMT that patients were able to tolerate in a timely fashion, all the while enhancing ejection fraction, sodium and chloride levels, with a reduction in rehospitalization rates.

Essential Elements of Early Post Discharge Care of Patients with Heart Failure.

PURPOSE OF REVIEW: Heart failure is associated with an enormous burden on both patients and health care systems in the USA. Several national policy initiatives have focused on improving the quality of heart failure care, including reducing readmissions following hospitalization, which are common, costly, and, at least in part, preventable. The transition from inpatient to ambulatory care setting and the immediate post-hospitalization period present an opportunity to further optimize guideline concordant medical therapy, identify reversible issues related to worsening heart failure, and evaluate prognosis. It can also provide opportunities for medication reconciliation and optimization, consideration of device-based therapies, appropriate management of comorbidities, identification of individual barriers to care, and a discussion of goals of care based on prognosis. RECENT FINDINGS: Recent studies suggest that attention to detail regarding patient comorbidities, barriers to care, optimization of both diuretic and neurohormonal therapies, and assessment of prognosis improve patient outcomes. Despite the fact that the transition period appears to be an optimal time to address these issues in a comprehensive manner, most patients are not referred to programs specializing in this approach post hospital discharge. The objective of this review is to provide an outline for early post discharge care that allows clinicians and other health care providers to care for these heart failure patients in a manner that is both firmly rooted in the guidelines and patient-centered. Data regarding which intervention is most likely to confer benefit to which subset of patients with this disease is lacking and warrants further study.

Measured Physical Activity and 30-Day Rehospitalization in Heart Failure Patients.

BACKGROUND: Patients hospitalized with decompensated heart failure are at high risk for readmission within 30 days of discharge. Since physical inactivity is associated with increased health care utilization in other diseases, it may predict rehospitalization in heart failure. METHODS: In a single-center, prospective study, physical activity was measured following hospital discharge using an accelerometer on the wrist. We then related this activity to the 30-day all-cause rehospitalization rate in heart failure. Each minute of activity was dichotomized into higher or lower intensity, based on a threshold of 3000 vector magnitude units. Counts above this threshold corresponded to a higher level of physical activity. Logistic regression and Kaplan-Meier survival analyses were used to relate the activity group to 30-day readmissions. RESULTS: Ninety-five patients admitted to a heart failure unit were screened; 61 met inclusion criteria and provided consent. Fifty patients were evaluated. Forty-six percent were male, mean age was 71 ± 15 years, and 46% had left ventricular ejection fraction <40%. Thirty-day all-cause hospitalizations occurred in 13 of these 50 patients (26%). Sixty-six percent and 34% were dichotomized into the higher and lower physical activity groups, respectively, over the first week; the latter were more likely to be readmitted within 30 days, with an OR = 5.0 (95% CI, 1.3-19.1), P = .02. CONCLUSION: Physical inactivity is related to 30-day all-cause readmissions for heart failure. Further studies are necessary to assess causality and to determine whether treatments directed at increasing physical activity could reduce readmission rate.

A Survey of Knowledge and Perspectives of Ventricular Assist Device Therapy: Evaluating the Timing of Advanced Heart Failure Referral.

BACKGROUND: While advancements in ventricular assist device (VAD) therapy have improved survival and quality of life for select patients with advanced heart failure (HF), variations in provider knowledge and opinions may ultimately serve as barriers to therapy. METHODS AND RESULTS: A 12-item survey assessing experience, knowledge, and perspectives of VAD therapy was sent to 106 practicing cardiologists at three neighboring institutions. We received 34 responses for a total response rate of 32.1%. The majority of respondents elected to refer patients with refractory disease for VAD therapy, while only 29.4% elected to refer when standard medical therapy is withdrawn due to hypotension. CONCLUSIONS: While providers are well-informed on the fundamentals of advanced therapy, identifying patients with advanced HF who may benefit from referral remains an educational challenge. An automated referral program that identifies patients with advanced HF based on validated clinical parameters could increase appropriately timed referrals to HF specialists to further improve survival and quality of life outcomes with advanced therapy.

Bicuspid aortic valve masquerading as unicuspid aortic valve: A case of markedly compensated congestive heart failure in a young patient.

Bicuspid aortic valve is a relatively common cause of congestive heart failure in young patients. In a young population, symptoms mnay not correlate with the severity of disease. We report a case of bicuspid aortic valve presenting with clinical features of unicuspid aortic valve, and mild symptoms despite severe hemodynamic compromise.

Effect of spironolactone on endothelial function in patients with congestive heart failure on conventional medical therapy.

We prospectively studied the effect of spironolactone, an aldosterone antagonist, on endothelial function in patients with advanced congestive heart failure (CHF) using the brachial artery reactivity method. Twenty patients optimized on conventional CHF therapy were treated with spironolactone, and brachial artery flow- mediated dilation was measured at baseline and at 4 and 8 weeks. Spironolactone improved endothelial function at 4 weeks, and sustained the improvement at 8 weeks, in patients with CHF on conventional medical therapy, presumably due to reversal of aldosterone impairment of endothelial nitric oxide activity.

Propafenone versus ibutilide for post operative atrial fibrillation following cardiac surgery: neither strategy improves outcomes compared to rate control alone (the PIPAF study).

BACKGROUND: It is unclear whether acute conversion of atrial fibrillation (AF) with anti-arrhythmic drugs following cardiac surgery restores and/or maintains sinus rhythm or reduces hospital length of stay (LOS). MATERIAL/METHODS: A randomized prospective pilot study was conducted in 2 teaching hospitals from 3/28/98 to 8/2/99 to study the effect of the early use of ibutilide or propafenone on the duration of AF, rhythm at discharge, and LOS. A total of 42 stable patients with new AF after surgery were randomized to oral propafenone (600mg, single dose; n=20), ibutilide (1 mg up to 2 doses if necessary; n=10), or rate control only (n=12). Agents used for rate control were left to the discretion of the primary physician but beta-blockers were encouraged. RESULTS: Pre-randomization distribution of diabetes, CHF, previous AF, and the use of beta-blockers were similar in all groups. At 24 hours 0%, 65% and 34% of patients in the ibutilide (p=0.01), propafenone (p=ns), and rate control groups respectively remained in AF. Although ibutilide decreased AF duration, recurrence rates were 90%, 41%, and 58% in those groups (p=ns compared to rate control). Of the 3 patients who did not convert, all received propafenone. There was no difference in LOS or rhythm at discharge. CONCLUSIONS: Ibutilide but not propafenone decreases the duration of AF after cardiac surgery and neither appears to affect LOS or rhythm at discharge. This data suggests that post operative AF is transient and routine anti-arrhythmic therapy is not necessary for the majority of patients.