The worst symptom as defined by patients during heart failure hospitalization: implications for response to therapy.

BACKGROUND: Patients perceive different symptoms of heart failure decompensation. It is not known whether the nature of the worst symptom relates to hemodynamic profile, response to therapy, or improvement in clinical trials. METHODS AND RESULTS: Patients in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness trial were hospitalized with advanced heart failure, ejection fraction ≤30%, and at least 1 sign and 1 symptom of elevated filling pressures. Visual analog scales (VAS) for symptoms were completed by 371 patients, who selected their worst symptom as difficulty breathing, fatigue, abdominal discomfort, or body swelling and also scored breathing and global condition at baseline and discharge. The dominant symptom identified was difficulty breathing by 193 (52%) patients, fatigue by 118 (32%), and abdominal discomfort and swelling each by 30 (8%) patients, combined as right-sided congestion for analysis. Clinical and hemodynamic assessments were not different between groups except that right-sided congestion was associated with more hepatomegaly, ascites, third heart sounds, and jugular venous distention. This group also had greater reduction in jugular venous distention and trend toward higher blood urea nitrogen after therapy. By discharge, average improvements in worst symptom and global score were 28 points and 24 points. For those with ≥10 points in improvement in worst symptom, 84% also improved global assessment ≥10 points. Initial fatigue was associated with less improvement (P = .002) during and after hospitalization, but improvements in symptom scores were sustained when re-measured during 6 months after discharge. CONCLUSION: In most patients hospitalized with clinical congestion, therapy will improve symptoms regardless of the worst symptom perceived, with more evidence of baseline fluid retention and reduction during therapy for worst symptoms of abdominal discomfort or edema. Improvement in trials should be similar when tracking worst symptom, dyspnea, or global assessment.

Prevalence of noncardiac findings in patients undergoing cardiac magnetic resonance imaging.

PURPOSE: We sought to determine the prevalence of clinically significant non-cardiac abnormalities found in pediatric and adult patients undergoing cardiac magnetic resonance imaging (CMRI), and understand the impact of age on it's occurrence. METHODS: We retrospectively reviewed all patients undergoing CMRI between May 2004 and July 2007. Findings were considered significant if they required radiographic or clinical follow-up. RESULTS: A total of 408 patients underwent CMRI during the study period. Twenty two (16%) pediatric patients (age < 19 years, n = 135) were found to have a total of 22 non- cardiac abnormalities, 3 of which were clinically significant. Sixty four (23%) adult patients (age > 19 years, n = 273) were found to have a total of 77 non-cardiac abnormalities, 33 of which were clinically significant. The prevalence of clinically significant non-cardiac abnormalities was 2% in the pediatric cohort and 11% in the adult cohort (P = 0.05). Within the adult population, the prevalence of significant non-cardiac abnormalities increased with advancing age (P = 0.05). CONCLUSIONS: In a population of unselected patients undergoing CMRI, unanticipated noncardiac abnormalities were frequently seen. A small number of these were significant, with the prevalence increasing with age.

Fulminant cardiogenic shock due to cardiac sarcoidosis.

This case describes a 57-year-old man with unrecognized cardiac sarcoidosis who presented with progressive heart failure leading to cardiogenic shock. He required extracorporeal membrane oxygenation (ECMO) as a bridge to orthotopic heart transplantation. The case highlights the potential acute and severe electrical and hemodynamic manifestations of cardiac sarcoidosis.

Framework to Classify Reverse Cardiac Remodeling With Mechanical Circulatory Support: The Utah-Inova Stages.

BACKGROUND: Variable definitions and an incomplete understanding of the gradient of reverse cardiac remodeling following continuous flow left ventricular assist device (LVAD) implantation has limited the field of myocardial plasticity. We evaluated the continuum of LV remodeling by serial echocardiographic imaging to define 3 stages of reverse cardiac remodeling following LVAD. METHODS: The study enrolled consecutive LVAD patients across 4 study sites. A blinded echocardiographer evaluated the degree of structural (LV internal dimension at end-diastole [LVIDd]) and functional (LV ejection fraction [LVEF]) change after LVAD. Patients experiencing an improvement in LVEF ≥40% and LVIDd ≤6.0 cm were termed responders, absolute change in LVEF of ≥5% and LVEF <40% were termed partial responders, and the remaining patients with no significant improvement in LVEF were termed nonresponders. RESULTS: Among 358 LVAD patients, 34 (10%) were responders, 112 (31%) partial responders, and the remaining 212 (59%) were nonresponders. The use of guideline-directed medical therapy for heart failure was higher in partial responders and responders. Structural changes (LVIDd) followed a different pattern with significant improvements even in patients who had minimal LVEF improvement. With mechanical unloading, the median reduction in LVIDd was -0.6 cm (interquartile range [IQR], -1.1 to -0.1 cm; nonresponders), -1.1 cm (IQR, -1.8 to -0.4 cm; partial responders), and -1.9 cm (IQR, -2.9 to -1.1 cm; responders). Similarly, the median change in LVEF was -2% (IQR, -6% to 1%), 9% (IQR, 6%-14%), and 27% (IQR, 23%-33%), respectively. CONCLUSIONS: Reverse cardiac remodeling associated with durable LVAD support is not an all-or-none phenomenon and manifests in a continuous spectrum. Defining 3 stages across this continuum can inform clinical management, facilitate the field of myocardial plasticity, and improve the design of future investigations.

Multiscale analysis of restoration priorities for marine shoreline planning.

Planners are being called on to prioritize marine shorelines for conservation status and restoration action. This study documents an approach to determining the management strategy most likely to succeed based on current conditions at local and landscape scales. The conceptual framework based in restoration ecology pairs appropriate restoration strategies with sites based on the likelihood of producing long-term resilience given the condition of ecosystem structures and processes at three scales: the shorezone unit (site), the drift cell reach (nearshore marine landscape), and the watershed (terrestrial landscape). The analysis is structured by a conceptual ecosystem model that identifies anthropogenic impacts on targeted ecosystem functions. A scoring system, weighted by geomorphic class, is applied to available spatial data for indicators of stress and function using geographic information systems. This planning tool augments other approaches to prioritizing restoration, including historical conditions and change analysis and ecosystem valuation.

Unrecognized Left Heart Failure in LVAD Recipients: The Role of Routine Invasive Hemodynamic Testing.

The role of routine right heart catheterizations (RHCs) in left ventricular assist device (LVAD) patients is undefined. We analyzed 105 continuous-flow LVAD recipients who underwent an RHC approximately 3 months after implant. In 38 patients, LVAD speed was ramped with the goal of optimizing hemodynamics. Our cohort consisted of 71 (68%) HeartMate II (HMII) and 34 (32%) HeartWare (HVAD) patients. Thirty patients (29%) had either a reduced cardiac index (CI ≤ 2.2 L/min/m), elevated pulmonary capillary wedge pressure (PCWP > 18 mm Hg), or both. A subgroup of 38 patients (19 with abnormal hemodynamics) underwent LVAD ramping. With LVAD ramping, normalization of hemodynamics was achieved in 13 (68%) patients with abnormal hemodynamics. In ramped patients, the CI increased from 2.1 L/min/m (2.0-2.3) to 2.5 L/min/m (2.3-2.6; p = 0.004), and the PCWP dropped from 21 mm Hg (20-26) to 18 mm Hg (14-21, p < 0.001). The 6-minute walk distance improved from 338 m (253-394) to 353 m (320-442, p = 0.041). A 400 rpm change in HMII speed was like a 130 rpm change in HVAD speed and led to a change in cardiac output (CO) of 0.3 L/min. The correlation between device-reported flow and measured CO for both the HMII (Rs = 0.50, p < 0.001) and HVAD (Rs = 0.47, p < 0.001) was moderate. At 3 months after LVAD implant, most patients have normal hemodynamics. Of those patients with abnormal hemodynamics, LVAD ramping results in normalization of hemodynamics and improvement in 6-minute walk distance.

Management of right heart failure in the critically ill.

Right ventricular failure complicates several commonly encountered conditions in the intensive care unit. Right ventricular dilation and paradoxic movement of the interventricular septum on echocardiography establishes the diagnosis. Right heart catheterization is useful in establishing the specific cause and aids clinicians in management. Principles of treatment focus on reversal of the underlying cause, optimization of right ventricular preload and contractility, and reduction of right ventricular afterload. Mechanical support with right ventricular assist device or veno-arterial extracorporeal membrane oxygenation can be used in select patients who fail to improve with optimal medical therapy.

Enrollment and events of hospice patients with heart failure vs. cancer.

CONTEXT: Hospice care is traditionally used for patients with advanced cancer, but it is increasingly considered for patients with end-stage heart failure. OBJECTIVES: We compared enrollment patterns and clinical events of hospice patients with end-stage heart failure with those of patients with advanced cancer. METHODS: Using Medicare data linked with pharmacy and cancer registry data, we identified patients who were diagnosed with either heart failure or advanced cancer between 1997 and 2004, admitted to hospice at least once after their diagnosis, and died during the study period. We compared patterns of referral, use of acute services, and site of death of hospice patients with heart failure with those of patients with advanced cancer. Logistic regression models were constructed to determine the factors associated with late hospice enrollment as well as the use of and death in acute care. RESULTS: We identified 1580 heart failure patients and 3840 advanced cancer patients: mean ages were 86 and 80 years, 82% and 68% were women, and 97% and 94% were white, respectively. Compared with patients with advanced cancer, those with heart failure were more frequently referred to hospice from hospitals (35% vs. 24%) and nursing facilities (9% vs. 7%) (both P<0.01). Discharge from hospice before death was similar for patients with heart failure and patients with advanced cancer (10% vs. 9%, P=0.03). Among patients remaining in hospice, patients with heart failure were more likely to have been enrolled within three days of death (20% vs.11%, P<0.01). The prevalence of death in acute care settings was low in both groups after hospice enrollment (4% heart failure vs. 2% advanced cancer, P<0.01). Although the median interval between enrollment and death was shorter for heart failure patients (12 vs. 20 days, P<0.001), emergency department visits and hospitalizations after hospice enrollment were more frequent in patients with heart failure (13% vs. 10% and 9% vs. 6%, respectively, both P<0.01). CONCLUSION: Compared with patients with advanced cancer, referral to hospice is more often initiated during acute care encounters for patients with end-stage heart failure, who also more frequently return to acute care settings even after hospice enrollment.