Serum albumin concentration and heart failure risk The Health, Aging, and Body Composition Study.

BACKGROUND: How serum albumin levels are associated with risk for heart failure (HF) in the elderly is unclear. METHODS: We evaluated 2,907 participants without HF (age 73.6 +/- 2.9 years, 48.0% male, 58.7% white) from the community-based Health ABC Study. The association between baseline albumin and incident HF was assessed with standard and competing risks proportional hazards models controlling for HF predictors, inflammatory markers, and incident coronary events. RESULTS: During a median follow-up of 9.4 years, 342 (11.8%) participants developed HF. Albumin was a time-dependent predictor of HF, with significance retained for up to 6 years (baseline hazard ratio [HR] per -1 g/L 1.14, 95% CI 1.06-1.22, P < .001; annual rate of HR decline 2.1%, 95% CI 0.8%-3.3%, P = .001). This association persisted in models controlling for HF predictors, inflammatory markers, and incident coronary events (baseline HR per -1 g/L 1.13, 95% CI 1.05-1.22, P = .001; annual rate of HR decline 1.8%, 95% CI 0.5%-3.0%, P = .008) and when mortality was accounted for in adjusted competing risks models (baseline HR per -1 g/L 1.13, 95% CI 1.05-1.21, P = .001; annual rate of HR decline 1.9%, 95% CI 0.7%-3.1%, P = .002). The association of albumin with HF risk was similar in men (HR per -1 g/L 1.13, 95% CI 1.05-1.23, P = .002) and women (HR per -1 g/L 1.12, 95% CI 1.04-1.22, P = .005) and in whites and blacks (HR per -1 g/L 1.13, 95% CI 1.04-1.22, P< .01 for both races) in adjusted models. CONCLUSIONS: Low serum albumin levels are associated with increased risk for HF in the elderly in a time-dependent manner independent of inflammation and incident coronary events.

Reorganizing a hospital ward as an accountable care unit.

Traditional hospital wards are not specifically designed as effective clinical microsystems. The feasibility and sustainability of doing so are unclear, as are the possible outcomes. To reorganize a traditional hospital ward with the traits of an effective clinical microsystem, we designed it to have 4 specific features: (1) unit-based teams, (2) structured interdisciplinary bedside rounds, (3) unit-level performance reporting, and (4) unit-level nurse and physician coleadership. We called this type of unit an accountable care unit (ACU). In this narrative article, we describe our experience implementing each feature of the ACU. Our aim was to introduce a progressive approach to hospital care and training.

Ventilatory inefficiency reflects right ventricular dysfunction in systolic heart failure.

BACKGROUND: An increased minute ventilation (VE)/carbon dioxide production (VCO2) relationship, an expression of ventilatory inefficiency (VI), is associated with increased morbidity and mortality in patients with left ventricular systolic dysfunction (LVSD). A direct link between VI and a specific cardiac abnormality has not been established. METHODS: We analyzed cardiopulmonary exercise test (CPET) data from patients (N=83) with severe LVSD (ischemic and nonischemic; left ventricular ejection fraction [LVEF] 19%±7%) and at least moderate exercise intolerance. Subjects were stratified into two groups based on the (VE/VCO2 ratio at anaerobic threshold (VE/VCO2@AT) (group 1 VE/VCO2@AT≤34; group 2 VE/VCO2@AT>34). Clinical, CPET, echocardiographic, and hemodynamic data were compared between groups. RESULTS: Group 2 subjects had lower exercise capacity (peak (VO2, 45.7%±11.8% vs 50.4±8.9% predicted; P<.05), with a significantly lower oxygen pulse (71.6%±24.5% vs 85.4±18.5% predicted) and maximum systolic BP (122±19 mm Hg vs 138±22 mm Hg; P<.001 for both), suggesting a more blunted stroke volume to exercise vs group 1. There were no differences in left ventricular (LV) size, LVEF, or mitral regurgitation between the two groups. In sharp contrast, group 2 had larger right ventricular (RV) dimensions (4.5±1.1 cm vs 3.9±0.8 cm) and more severe RV systolic dysfunction (RV fractional area change 26%±11% vs 33%±12%; tricuspid annular plane systolic excursion [TAPSE] 1.6±0.5 cm vs 2.0±0.5 cm; all P<.001) vs group 1. Multivariable analysis revealed that only TAPSE and Doppler-estimated pulmonary artery systolic pressure were independently associated with VE/VCO2@AT and the (VE/VCO2slope. The VE/VCO2@AT, VE/VCO2 slope, and TAPSE had nearly identical predictive value for death or transplant. CONCLUSIONS: The present study suggests that VI is a functional, noninvasive marker of more advanced right-sided heart dysfunction in patients with severe LVSD.

Usefulness of cardiac index and peak exercise oxygen consumption for determining priority for cardiac transplantation.

Decisions regarding cardiac transplantation listing are difficult in patients with heart failure who have relatively discordant peak exercise oxygen consumption (Vo(2)) and cardiac index (CI) values. One hundred five patients with heart failure who underwent cardiopulmonary exercise testing and right-sided cardiac catheterization for transplantation evaluation were studied. Patients were divided into 4 groups on the basis of peak Vo(2) and CI: group 1, Vo(2) > or = 12 ml/min/kg, CI > or = 1.8 L/min/m(2) (n = 30); group 2, Vo(2) > or = 12 ml/min/kg, CI <1.8, L/min/m(2) (n = 27); group 3, Vo(2) <12 ml/min/kg, CI > or = 1.8 L/min/m(2) (n = 25); and group 4, Vo(2) <12 ml/min/kg, CI <1.8 L/min/m(2) (n = 23). Groups were compared for event-free (death or ventricular assist device) survival. The overall CI was 1.9 + or - 0.4 L/min/m(2) and peak Vo(2) was 12.4 + or - 2.8 ml/min/kg; values in the 4 groups were as follows: group 1, peak Vo(2) 14.7 + or - 2.1 ml/min/kg, CI 2.2 + or - 0.3 L/min/m(2); group 2, peak VO(2) 14.2 + or - 1.3 ml/min/kg, CI 1.5 + or - 0.2 L/min/m(2); group 3, peak Vo(2) 10.2 + or - 1.3 ml/min/kg, CI 2.1 + or - 0.3 L/min/m(2); and group 4, peak Vo(2) 9.7 + or - 2.0 ml/min/kg, CI 1.6 + or - 0.2 L/min/m(2). After a median follow-up period of 3.7 years, 28 patients (26.0%) had events. Event-free survival was 96%, 95%, 96%, and 79% for 6 months (p = 0.04); 88%, 81%, 90%, and 73% for 12 months (p = 0.09); 88%, 73%, 85%, and 65% for 18 months (p = 0.11); and 83%, 73%, 79%, and 53% for 24 months (p = 0.06) for groups 1 to 4, respectively. Median survival was 5.1, 3.0, 3.9, and 2.6 years, respectively, in groups 1 to 4 (p = 0.052). In conclusion, almost half the patients had relatively discordant peak Vo(2) and CI measurements. Patients with lower peak Vo(2) values but relatively preserved CI values had survival comparable to post-transplantation survival, whereas those with low CI but preserved Vo(2) had a lower survival rate. These results suggest that the former group may be safely monitored on medical therapy, whereas the latter may benefit from early listing.

Newly recognized ocular side effects of erlotinib.

An 85-year-old man had a bilateral periorbital rash and conjunctivitis leading to lower eyelid ectropion and epiphora within 6 weeks of treatment with erlotinib (Tarceva, Genentech, Inc., San Francisco, CA, and OSI Pharmaceuticals, Melville, NY), a second-line antineoplastic agent. The treatment was discontinued secondary to toxicity, and the periorbital rash completely resolved within 6 weeks of cessation of the drug. To our knowledge, the periorbital rash resulting in bilateral lower eyelid ectropion associated with epiphora is a newly recognized side effect of erlotinib that is completely reversible with discontinuation of the drug. The rash and ectropion should be treated palliatively, and surgical intervention should be avoided unless the patient cannot be removed from treatment.