Containing the Cost of Heart Failure Management: A Focus on Reducing Readmissions.

Heart failure (HF) consumes a large proportion of the total national health care budget. Incidence and prevalence of HF are increasing and may give rise to an unsustainable increase in health care spending. Hospitalizations account for the vast majority of HF-related expenses, and 20% to 25% of patients discharged with a diagnosis of HF are readmitted within 60 days. Thus, efforts to reduce HF readmissions are a reasonable target for reducing overall expenses. It is to be seen if targeting readmission rates will lead to significant cost savings, and more importantly, to improved patient outcomes.

Stress-induced cardiomyopathy: not always apical ballooning.

Apical ballooning (takotsubo syndrome) mimics acute myocardial infarction with transient apical dyskinesia and normal coronary arteries. It is often precipitated by emotional or physical stress. The prevalence of this syndrome has been increasing, probably because it is now more frequently recognized. Multiple theoretical hypotheses have been developed to explain its genesis, but the mechanism remains unclear. Rarely, cases of apical sparing and other wall motion involvement have been cited. We collected data on 12 patients who had acute myocardial infarction and normal coronary arteries with abnormal wall motion that had completely healed on repeat studies. Five patients had typical apical ballooning, and the other 7 had wall motion abnormalities in other segments. We determined that stress-induced cardiomyopathy can involve any wall of the myocardium and is not always apical ballooning.

Tenecteplase for malignant pericardial effusion.

Pericardial effusions may necessitate placement of a catheter into the pericardial space for continuous drainage. If the effusion material is fibrinous or loculated, drainage may slow or cease over time, allowing reaccumulation. Limited data exist to guide the selection of a fibrinolytic agent and the most appropriate dose. We report the case of a 79-year-old woman with malignant pericardial effusion who responded to intrapericardial administration of tenecteplase to facilitate drainage. The patient received three doses of tenecteplase--15 mg, 7.5 mg, and 7.5 mg--over 3 days, resulting in significant drainage. No adverse effects were noted except for a transient episode of hemodynamically stable atrial fibrillation. Use of fibrinolytic agents to facilitate pericardial drainage may offset the need to repeatedly replace the catheter if flow subsides despite continued presence of fluid in the pericardial space.

Containing the Cost of Heart Failure Management: A Focus on Reducing Readmissions.

Heart failure (HF) consumes a large proportion of the total national health care budget. Incidence and prevalence of HF are increasing and may give rise to an unsustainable increase in health care spending. Hospitalizations account for the vast majority of HF-related expenses, and 20% to 25% of patients discharged with a diagnosis of HF are readmitted within 60 days. Thus, efforts to reduce HF readmissions are a reasonable target for reducing overall expenses. It is to be seen if targeting readmission rates will lead to significant cost savings, and more importantly, to improved patient outcomes.

Inappropriate ICD therapy: does device configuration make a difference.

INTRODUCTION: Inappropriate implantable cardioverter defibrillator (ICD) therapy (IT) is a common complication in patients with ICD. IT is commonly triggered by supraventricular tachycardias (SVT). Dual chamber ICDs (D-ICDs) may distinguish SVT from ventricular tachycardia/ventricular fibrillation better than single chamber ICDs (S-ICDs) and may be associated with a smaller incidence of IT. METHODS: We reviewed the charts of 386 patients who had an ICD implanted for an AHA class I indication. Intracardiac electrograms were used to classify shocks as either appropriate or inappropriate. RESULTS: Of 295 patients with an S-ICD, 66 (22.3%) received IT, compared to 5 (5.4%) of 91 patients with a D-ICD. The likelihood of being event-free at 1, 2, 3, and 4 years was 96.1%, 96.1%, 96.1%, and 89% for patients with D-ICD and 80.7%, 72.7%, 69.6%, and 66.4%, respectively, for patients with S-ICD (P < 0.001). Multivariate analysis showed no significant association with age, sex, history of atrial fibrillation, history of hypertension, or ejection fraction. SVTs were the commonest cause of IT in our patients. CONCLUSION: Patients with D-ICD are less likely to receive IT as compared to patients with S-ICD.