Risk Prediction in Transition: MAGGIC Score Performance at Discharge and Incremental Utility of Natriuretic Peptides.

BACKGROUND: Risk stratification for hospitalized patients with heart failure (HF) remains a critical need. The Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score is a robust model derived from patients with ambulatory HF. Its validity at the time of discharge and the incremental value of natriuretic peptides (NPs) in this setting is unclear. METHODS: This was a single-center study examining a total of 4138 patients with HF from 2 groups; hospital discharge patients from administrative data (n = 2503, 60.5%) and a prospective registry of patients with ambulatory HF (n = 1635, 39.5%). The ambulatory registry patients underwent N-terminal pro-B-type NP (BNP) measurement at enrollment, and in the hospitalize discharge cohort clinical BNP levels were abstracted. The primary endpoint was all-cause mortality within 1 year. MAGGIC score performance was compared between cohorts utilizing Cox regression and calibration plots. The incremental value of NPs was assessed using calculated area under the curve and net reclassification improvement (NRI). RESULTS: The hospitalized and ambulatory cohorts differed with respect to primary outcome (777 and 100 deaths, respectively), sex (52.1% vs 41.7% female) and race (35% vs 49.5% African American). The MAGGIC score showed poor discrimination of mortality risk in the hospital discharge (C statistic: 0.668, hazard ratio [HR]: 1.1 per point, 95% confidence interval [CI]: 0.652, 0.684) but fair discrimination in the ambulatory cohorts (C statistic: 0.784, HR: 1.16 per point, 95% CI: 0.74, 0.83), respectively, a difference that was statistically significant (P = .001 for C statistic, 0.002 for HR). Calibration assessment indicated that the slope and intercept (of MAGGIC-predicted to observed mortality) did not statistically differ from ideal in either cohort and did not differ between the cohorts (all P > .1). NP levels did not significantly improve prediction in the hospitalized cohort (P = .127) but did in the ambulatory cohort (C statistic: 0.784 [95% CI: 0.74, 0.83] vs 0.82 [95% CI: 0.78, 0.85]; P = .018) with a favorable NRI of 0.354 (95% CI: 0.202-0.469; P = .002). CONCLUSION: The MAGGIC score showed poor discrimination when used in patients with HF at hospital discharge, which was inferior to its performance in patients with ambulatory HF. Discrimination within the hospital discharge group was not improved by including hospital NP levels.

Heart transplant recipients with confirmed 2019 novel coronavirus infection: The Detroit experience.

A chronic immunosuppressed state as in solid organ transplant recipients is a reported risk factor for the novel 2019 coronavirus infection. Patients with a history of orthotopic heart transplant (OHT) at a tertiary care transplant center in Detroit, Michigan were retrospectively reviewed from March until May 2020. Clinical parameters and outcomes of 5 OHT recipients and one combined heart-lung recipient with confirmed SARS-CoV-2 were obtained. The cohort was predominately African American males with median age of 59 years (interquartile range, 48.25-73.25). All patients were classified as having mild-moderate disease; none required intubation or ICU admission with no deaths. The most common presenting symptoms were fever and shortness of breath 83% (n = 5), followed by cough and chills 67% (n = 4). All admitted patients (n = 5) received hydroxychloroquine and 3 received high-dose steroids. Antimetabolites were held for 2 patients (33.3%). The calcineurin inhibitor trough goal was decreased in only 1 patient; 3 other patients, without change in goal, required calcineurin inhibitor dosage reduction. Two patients requiring readmission presented 7 and 23 days after initial symptoms onset. In conclusion, our experience with OHT patients infected by the SARS-CoV-2 virus did not have an elevated risk of severe infection. Impact of modifying immunosuppression remains unclear.

Patient Selection for Destination LVAD Therapy: Predicting Success in the Short and Long Term.

PURPOSE OF REVIEW: In this review, we discuss risk assessment of advanced heart failure (HF) patients as a referral guide for advanced HF therapies, including left ventricular assist device (LVAD) support and cardiac transplant. RECENT FINDINGS: The frequency of LVAD implantation for the purpose of permanent "destination" therapy is growing and survival on LVAD support is now approximating 50% at 5 years. Ambulatory HF patients with HF functional limitations, end-organ dysfunction, inability to tolerate HF medications, frequent cardiac admissions, and ventricular dysrhythmias are at high risk for mortality with medical management alone. Simultaneously, LVAD survival is superior in patients implanted prior to the onset of cardiogenic shock and/or multisystem dysfunction. Early referral (< 7% annual predicted mortality) of patients with systolic heart failure to an advanced heart failure specialist is critical for achieving long-term survival.

Cardiac Reverse Remodeling Mediated by HeartMate 3 Left Ventricular Assist Device: Comparison to Older Generation Devices.

Currently, the fully magnetically levitated left ventricular assist device (LVAD) HeartMate 3 (HM3) is the only commercially available device for advanced heart failure (HF) patients. However, the left ventricular (LV) functional and structural changes following mechanical unloading and circulatory support (MCS) with the HM3 have not been investigated. We compared the reverse remodeling induced by the HM3 to older generation continuous-flow LVADs. Chronic HF patients (n = 405) undergoing MCS with HeartWare Ventricular Assist Device (HVAD, n = 115), HM3 (n = 186), and HeartMate II (HM2, n = 104) at four programs were included. Echocardiograms were obtained preimplant and at 1, 3, 6, and 12 months following LVAD implantation. There were no differences in the postimplant serial LV ejection fraction (LVEF) between the devices. The postimplant LV internal diastolic diameter (LVIDd) was significantly lower for HM2 at 3 and 6 months compared with HVAD and HM3. The proportion of patients achieving "cardiac reverse remodeling responder" status (defined as LVEF improvement to ≥40% and LVIDD ≤5.9 cm) was 11.9%, and was similar between devices. HeartMate 3 appears to result in similar cardiac reverse remodeling as older generation CF-LVADs, suggesting that the fully magnetically levitated device technology could provide an effective platform to further study and promote cardiac reverse remodeling.

Heart Failure in Cardiac Rehabilitation: A REVIEW AND PRACTICAL CONSIDERATIONS.

PURPOSE: Exercise cardiac rehabilitation (CR) represents an evidence-based therapy for patients with heart failure with reduced ejection fraction (HFrEF) and this article provides a concise review of the relevant exercise testing and CR literature, including aspects unique to their care. CLINICAL CONSIDERATIONS: A hallmark feature of HFrEF is exercise intolerance (eg, early-onset fatigue). Drug therapies for HFrEF target neurohormonal pathways to blunt negative remodeling of the cardiac architecture and restore favorable loading conditions. Guideline drug therapy includes ß-adrenergic blocking agents; blockade of the renin-angiotensin system; aldosterone antagonism; sodium-glucose cotransport inhibition; and diuretics, as needed. EXERCISE TESTING AND TRAINING: Various assessments are used to quantify exercise capacity in patients with HFrEF, including peak oxygen uptake measured during an exercise test and 6-min walk distance. The mechanisms responsible for the exercise intolerance include abnormalities in ( a ) central transport (chronotropic response, stroke volume) and ( b ) the diffusion/utilization of oxygen in skeletal muscles. Cardiac rehabilitation improves exercise capacity, intermediate physiologic measures (eg, endothelial function and sympathetic nervous system activity), health-related quality of life (HRQoL), and likely clinical outcomes. The prescription of exercise in patients with HFrEF is generally similar to that for other patients with cardiovascular disease; however, patients having undergone an advanced surgical therapy do present with features that require attention. SUMMARY: Few patients with HFrEF enroll in CR and as such, many miss the derived benefits, including improved exercise capacity, a likely reduction in risk for subsequent clinical events (eg, rehospitalization), improved HRQoL, and adoption of disease management strategies.

National Landscape of Hospitalizations in Patients with Left Ventricular Assist Device. Insights from the National Readmission Database 2010-2015.

The number of patients with left ventricular assist devices (LVAD) has increased over the years and it is important to identify the etiologies for hospital admission, as well as the costs, length of stay and in-hospital complications in this patient group. Using the National Readmission Database from 2010 to 2015, we identified patients with a history of LVAD placement using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code V43.21. We aimed to identify the etiologies for hospital admission, patient characteristics, and in-hospital outcomes. We identified a total of 15,996 patients with an LVAD, the mean age was 58 years and 76% were males. The most common cause of hospital readmission after LVAD was heart failure (HF, 13%), followed by gastrointestinal (GI) bleed (11.8%), device complication (11.5%), and ventricular tachycardia/fibrillation (4.2%). The median length of stay was 6 days (3-11 days) and the median hospital costs was $12,723 USD. The in-hospital mortality was 3.9%, blood transfusion was required in 26.8% of patients, 20.5% had acute kidney injury, 2.8% required hemodialysis, and 6.2% of patients underwent heart transplantation. Interestingly, the most common cause of readmission was the same as the diagnosis for the preceding admission. One in every four LVAD patients experiences a readmission within 30 days of a prior admission, most commonly due to HF and GI bleeding. Interventions to reduce HF readmissions, such as speed optimization, may be one means of improving LVAD outcomes and resource utilization.

Performance of the Meta-Analysis Global Group in Chronic Heart Failure Score in Black Patients Compared With Whites.

BACKGROUND: Risk stratification is critical in heart failure (HF) and the Meta-Analysis Global Group in Chronic HF (MAGGIC) score is a validated tool derived from ~40,000 patients. However, few of these patients self-identified as black, raising uncertainty regarding performance in blacks with HF. METHODS AND RESULTS: This study analyzed a racially diverse group of 4046 patients (1646 black and 2400 white) from a single center from 2007 to 2015. Baseline characteristics were collected to tabulate MAGGIC score and test its discrimination and calibration within race groups. The primary end point was all-cause mortality. Death was detected using system records and the social security death master file. Discrimination was tested using Cox models of MAGGIC score stratified by race, and combined analysis including MAGGIC, race, and MAGGIC×race. Calibration was assessed using linear regression models and plots of observed versus predicted data. Overall, 901 (21%) patients died during 1-year follow-up. MAGGIC score discrimination was similar in both race groups in terms of C statistic (0.707±0.027 versus 0.725±0.014, for black versus white; P=0.556) and the hazard ratio (HR) per MAGGIC point was 1.12 in black patients (95% CI, 1.10-1.14) and 1.13 in white patients (95% CI, 1.12-1.14). Race was a significant correlate of survival, with better survival in black patients compared with white (HR, 0.66; 95% CI, 0.56-0.78), but the interaction of MAGGIC×race was not significant (ß=-0.013; P=0.16), and adding race to the model did not improve discrimination (C statistic for MAGGIC versus MAGGIC+race, 0.721 versus 0.722; P=0.79). In calibration testing, the slope was not significantly different from 1 in either group, but the groups differed from each other, and it was closer to unity among black patients (0.94 versus 1.4; P=0.004). CONCLUSIONS: These data support the use of the MAGGIC score to risk stratify black patients with HF.

Prognostic Utility of the HEART Score in the Observation Unit.

The evaluation of individuals with possible acute myocardial infarction (AMI) is time consuming and costly. Risk stratification early during an acute care encounter presents an opportunity for increased delivery of high-value care. We sought to evaluate if the HEART score could be used in the triage of low-risk versus high-risk patients directly home without cardiac testing. Retrospective review of 838 patients placed in an observation unit for evaluation of AMI was done at a single-center, tertiary care teaching hospital. Primary outcome was major adverse cardiac event-death, AMI, or revascularization-at 30 days from the index encounter. Participants' average age was 60.1 years, 40% were male, and 67% were African American. Complete data were available for all 838 patients, including 30-day follow-up at study completion. The primary endpoint was met in 14 patients (1.7%), all of whom were in the high-risk group, with HEART score ≥4. Of the low-risk patients, 8 (2.8%) had a positive functional study, 5 underwent subsequent coronary angiography, with none (0%) found to have obstructive coronary disease. In conclusion, our results suggest that patients with a HEART score ≤3 being evaluated for chest pain are at extremely low risk for major adverse cardiac events and may be safely discharged without provocative testing. Positive cardiac testing in this population is more likely to represent a false-positive finding, resulting in unnecessary testing. These findings should be prospectively validated.

The Comparison of Physician to Computer Interpreted Electrocardiograms on ST-elevation Myocardial Infarction Door-to-balloon Times.

OBJECTIVE: The purpose of the project was to study the impact that immediate physician electrocardiogram (ECG) interpretation would have on door-to-balloon times in ST-elevation myocardial infarction (STEMI) as compared with computer-interpreted ECGs. METHODS: This was a retrospective cohort study of 340 consecutive patients from September 2003 to December 2009 with STEMI who underwent emergent cardiac catheterization and percutaneous coronary intervention. Patients were stratified into 2 groups based on the computer-interpreted ECG interpretation: those with acute myocardial infarction identified by the computer interpretation and those not identified as acute myocardial infarction. Patients (n = 173) from September 2003 to June 2006 had their initial ECG reviewed by the triage nurse, while patients from July 2006 to December 2009 (n = 167) had their ECG reviewed by the emergency department physician within 10 minutes. Times for catheterization laboratory activation and percutaneous coronary intervention were recorded in all patients. RESULTS: Of the 340 patients with confirmed STEMI, 102 (30%) patients were not identified by computer interpretation. Comparing the prior protocol of computer ECG to physician interpretation, the latter resulted in significant improvements in median catheterization laboratory activation time {19 minutes [interquartile range (IQR): 10-37] vs. 16 minutes [IQR: 8-29]; P < 0.029} and in median door-to-balloon time [113 minutes (IQR: 86-143) vs. 85 minutes (IQR: 62-106); P < 0.001]. CONCLUSION: The computer-interpreted ECG failed to identify a significant number of patients with STEMI. The immediate review of ECGs by an emergency physician led to faster activation of the catheterization laboratory, and door-to-balloon times in patients with STEMI.