Anticoagulation Bridging in Patients With Left Ventricular Assist Device: A Regional Analysis of HeartMate 3 Recipients.

Advances in left ventricular assist device technologies have led to an improvement in pump hemocompatibility and outcomes. Because of concerns of thromboembolic complications in prior generations of left ventricular assist devices, bridging with parenteral anticoagulants was routinely. Management strategies of subtherapeutic INRs and their effects on the current generation of devices deserve review. We performed analysis of the MOMENTUM 3 trial including 6 centers in the mid-America region. Patients with subtherapeutic INRs (INR < 2) occurring after the index admission underwent chart review to determine the management strategies taken by clinicians. Strategies were divided into two groups, bridging or nonbridging. Of the 225 patients included in the analysis, 130 (58%) patients had a total of 235 subtherapeutic international normalized ratio (INR) events. Most (n = 179, 76.2%) of these INRs were not bridged (n = 100 warfarin dose adjustment, n = 79 no change in warfarin dose). Among those INRs (n = 56, 23.8%) treated with bridging, approximately half (n = 30, 53.6%) were treated with subcutaneous agents and other half (n = 26, 46.4%) were treated with intravenous agents. There was no difference in individual outcomes or composite endpoints of death, rehospitalization, CVA, or bleeding events between the groups.

Pharmacologic Therapy for Heart Failure With Reduced Ejection Fraction: Closing the Gap Between Clinical Guidelines and Practice.

Despite the great progress made in the management of heart failure (HF) with reduced ejection fraction (HFrEF), its prevalence continues to rise owing to an aging population and an epidemic of hypertension, obesity and coronary artery disease. For decades, angiotensin converting enzyme inhibitors and beta blockers have been the mainstay of HFrEF therapy. The recent addition of sacubitril/valsartan and ivabradine to the HF armamentarium has the potential to transform our therapeutic approach to HFrEF, while simultaneously raising some questions and uncertainties on their applicability. In this paper, we review the pathophysiology of HFrEF, discuss already established and novel evidenced-based pharmacologic therapies available for these patients. We also share some therapeutic strategies aimed to optimize HF therapy in specific undertreated patient populations including the elderly and patients with chronic kidney disease, while offering insight on how to tailor therapy in the "real-world."