Towards Precision in HF Pharmacotherapy.

PURPOSE OF REVIEW: Heart failure (HF) is a disease state with great heterogeneity, which complicates the therapeutic process. Identifying more precise HF phenotypes will allow for the development of more targeted therapies and improvement in patient outcomes. This review explores the future for precision medicine in HF treatment. RECENT FINDINGS: Rather than a continuous disease spectrum with a uniform pathogenesis, HF has phenotypes with different underlying pathophysiologic features. The challenge is to establish clinical phenotypic characterizations to direct therapy. Phenomapping, a process of using machine learning algorithms applied to clinical data sets, has been used to identify phenotypically distinct and clinically meaningful HF groups. As powerful technologies extend our knowledge, future analyses may be able to compile more comprehensive phenotypic profiles using genetic, epigenetic, proteomic, and metabolomic measurements. Identifying clinical characterizations of particular HF patients that would be uniquely or disproportionately responsive to a specific treatment would allow for more direct selection of optimal therapy, reduce trial-and-error prescribing, and help avoid adverse drug reactions.

Discharge Diuretic Dose and 30-Day Readmission Rate in Acute Decompensated Heart Failure.

BACKGROUND: Loop diuretics play a crucial role in symptom management in patients with fluid overload. There is a paucity of data regarding optimal diuretic dose at hospital discharge for acute decompensated heart failure (ADHF) patients requiring loop diuretics. OBJECTIVE: To compare all-cause 30-day readmission in ADHF patients on chronic loop diuretics who had an increase in loop diuretic dose at discharge (relative to their preadmission dose) with patients without a change or a decrease in loop diuretic dose at discharge. METHODS: This was a multicenter, retrospective cohort study. Institutional review board approval was obtained. Patients admitted with a primary discharge diagnosis of heart failure, evidence of fluid overload, and reduced ejection fraction were included. Patients were divided into 2 groups based on total daily loop diuretic dose at discharge: those discharged on an increased dose and those discharged on a dose less than or equal to their preadmission dose. RESULTS: A total of 131 patient admissions met inclusion criteria; 50 had an increase in loop diuretic dose at discharge, and 81 were discharged with no change or a decrease in diuretic dose. Patients in the increased dose group had an all-cause 30-day readmission rate of 20% compared with 38% of patients with no change or a decrease in diuretic dose (adjusted odds ratio = 0.320; 95% CI = 0.117-0.873). CONCLUSION: In patients admitted for ADHF with reduced ejection fraction and evidence of fluid overload, an increase in loop diuretic dose at discharge was associated with a reduced rate of 30-day hospital readmission.

Efficacy and Safety of High-Dose Subcutaneous Unfractionated Heparin Prophylaxis for the Prevention of Venous Thromboembolism in Obese Hospitalized Patients.

BACKGROUND: Obese patients experience a higher risk of venous thromboembolism (VTE) than their nonobese counterparts, which may warrant a more aggressive approach to thromboprophylaxis in this population. OBJECTIVE: The purpose of this study was to compare rates of nosocomial VTE in obese patients treated with high-dose versus conventional-dose subcutaneous unfractionated heparin sodium (UFH) for thromboprophylaxis. METHODS: A retrospective, single-center, cohort study was conducted to evaluate obese, adult, hospitalized patients admitted between April 2011 and April 2014 who received heparin 5,000 or 7,500 units subcutaneously every 8 hours for thromboprophylaxis. The primary outcome assessed the rate of nosocomial VTE in obese patients treated with high-dose heparin (7,500 units subcutaneously q 8 h) versus conventional-dose heparin (5,000 units subcutaneously q 8 h). Additionally, a secondary outcome assessed safety by quantifying bleeding events. RESULTS: Nosocomial VTE occurred in 2/196 (1.02%) patients who received high-dose heparin thromboprophylaxis and in 5/2,182 (0.23%) patients who received conventional-dose heparin (p = .05). Bleeding occurred in 0/196 (0%) patients in the high-dose heparin group and in 2/2,182 (0.09%) patients in the conventional-dose heparin group (p = .67). All bleeding events were minor. CONCLUSIONS: This study failed to demonstrate a statistically significant reduction in the rate of nosocomial VTE in obese patients who received high-dose heparin thromboprophylaxis. Despite receiving a higher heparin dose, no increased risk of bleeding was observed in the high-dose group. Further investigation is needed to identify the optimal heparin dose for thromboprophylaxis in obese patients.

Getting under the skin of adverse drug reactions.

Cutaneous drug reactions are among the most commonly reported adverse drug reactions. Drugs prescribed by orthopedic surgeons, such as antibiotics, opiates, and nonsteroidal anti-inflammatory drugs, are common offenders. Cutaneous drug reactions can range from those that are common, mild nuisances to those that are rare, severe, and life-threatening. Medications should be considered part of a differential diagnosis for any dermatologic condition. It is important to recognize the different clinical features and common drugs that are related to each type of reaction. This review characterizes the different forms of cutaneous drug reactions and the clinical features, proposed mechanisms, and drugs frequently associated with each.