Management of heart failure in cardiac amyloidosis using an ambulatory diuresis clinic.

BACKGROUND: Recurrent congestion in cardiac amyloidosis (CA) remains a management challenge, often requiring high dose diuretics and frequent hospitalizations. Innovative outpatient strategies are needed to effectively manage heart failure (HF) in patients with CA. Ambulatory diuresis has not been well studied in restrictive cardiomyopathy. Therefore, we aimed to examine the outcomes of an ambulatory diuresis clinic in the management of congestion related to CA. METHODS AND RESULTS: We retrospectively studied patients with CA seen in an outpatient HF disease management clinic for (1) safety outcomes of ambulatory intravenous (IV) diuresis and (2) health care utilization. Forty-four patients with CA were seen in the clinic a total of 203 times over 6 months. Oral diuretics were titrated at 96 (47%) visits. IV diuretics were administered at 56 (28%) visits to 17 patients. There were no episodes of severe acute kidney injury or symptomatic hypotension. There was a significant decrease in emergency department and inpatient visits and associated charges after index visit to the clinic. The proportion of days hospitalized per 1000 patient days of follow-up decreased as early as 30 days (147.3 vs 18.1/1000 patient days of follow-up, P< .001) and persisted through 180 days (33.6 vs 22.9/1000 patient days of follow-up, P< .001) pre- vs post-index visit to the clinic. CONCLUSIONS: We demonstrate the feasibility of ambulatory IV diuresis in patients with CA. Our findings also suggest that use of a HF disease management clinic may reduce acute care utilization in patients with CA. Leveraging multidisciplinary outpatient HF clinics may be an effective alternative to hospitalization in patients with HF due to CA, a population who otherwise carries a poor prognosis and contributes to high health care burden.

Effect of Heart Rate Reserve on Exercise Capacity in Patients Treated with a Continuous Left Ventricular Assist Device.

We hypothesized that an inadequate increase in heart rate (HR) during exercise was associated with low peak oxygen uptake (VO2 peak) seen in left ventricular assist device (LVAD) recipients and aimed to analyze the potential relation between HR and VO2 peak and use of drugs with negative chronotropic effect. Sixty-eight LVAD recipients (44 Heartmate 2 and 24 HeartWare Ventricular Assist Device) with support duration >1 month and a VO2 peak were included from two centers. Patients were 57 ± 13 years at time of VO2 peak and LVAD support duration was 483 ± 545 days. Peak oxygen uptake was 12 ± 4 ml/kg/min (40% ± 13% of predicted). Heart rate reserve (HRR = maximal HR - resting HR) was 59 ± 22 min (75% ± 15% of predicted for age, %HRR) and was significantly associated with VO2 peak (r = 0.244, p = 0.045). Predicted heart rate reserve was associated with %Predicted VO2 peak (P = 0.011). Chronotropic incompetence (CI) was observed in 44% and VO2 peak was clearly lower in patients with CI (10 ± 2.7 vs. 13 ± 4.6 ml/kg/min, p = 0.005). Beta-blockers (BB) were prescribed to 85% and adjusting for being on target BB-dose did not affect the correlation between %predicted VO2 peak and %HRR (r = 0.33, p = 0.024). In conclusion, almost half of LVAD recipients suffer from CI which is associated with lower VO2 peak. This relation did not seem to be affected by BB therapy.

Efficacy of Intravenous Furosemide Versus a Novel, pH-Neutral Furosemide Formulation Administered Subcutaneously in Outpatients With Worsening Heart Failure.

OBJECTIVES: This study sought to determine the efficacy and safety of a novel, pH-neutral formulation of furosemide administered subcutaneously (SC) for treatment of acute decompensated heart failure (HF). BACKGROUND: Congestion requiring intravenous (IV) administration of a diuretic agent is the main reason patients with HF present for acute medical care. METHODS: Outpatients presenting with decompensated HF were randomized to receive a single SC or IV dose of furosemide. Primary outcome was 6-h urine output, and secondary outcomes were weight change, natriuresis, and adverse events. RESULTS: Forty-one patients were randomized: 19 were treated with IV (mean dose: 123 ± 47 mg) and 21 with SC furosemide (fixed dose of 80 mg over 5 h). The 6-h urine output in the IV group was not significantly different from that in the SC furosemide group (median IV: 1,425 ml; interquartile range [IQR]: 1,075 to 1,950 ml; vs. median SC: 1,350 ml; IQR: 900 to 1,900 ml; p = 0.84). Additionally, mean weight loss was not significantly different (-1.5 ± 1.1 kg in the IV group vs. -1.5 ± 1.2 kg in the SC group; p = 0.95). Hourly urine output was significantly higher in the IV group at hour 2 (425 ml in the IV group vs. 250 ml in the SC group; p = 0.02) and higher in the SC group at hour 6 (125 ml, IV group vs. 325 ml, SC group; p = 0.005). Natriuresis was higher in the SC group (IV: 7.3 ± 35.3 mEq/l vs. SC: 32.8 ± 43.6 mEq/l; p = 0.05). There was no worsening renal function, ototoxicity, or skin irritation with either formulation. Thirty-day hospitalization rates were similar. CONCLUSIONS: In this phase II trial, we did not identify significant differences between urine output obtained with pH-neutral furosemide administered SC and that obtained by IV. This method of decongestion may allow treatment at home and reduced HF resources and warrants further investigation. (Sub-Q Versus IV Furosemide in Acute Heart Failure; NCT02579057).