Physical activity and relationship to physical function, quality of life, and cognitive function in older patients with acute decompensated heart failure.

BACKGROUND: Volitional physical activity level is predictive of a variety of health outcomes, but has not been examined in patients recently hospitalized for acute decompensated HF (ADHF). METHODS: Ten to 14 days after index hospitalization for ADHF, 93 participants wore a wrist-mounted triaxial accelerometer (ActiGraph GT3X+) to objectively quantify sedentary behavior, light physical activity, and moderate-to-vigorous physical activity. Levels were compared to 2 groups of age-matched NHANES participants: healthy and chronic, stable HF. The relationship between physical activity levels and physical function [Short Physical Performance Battery (SPPB)], HF-specific quality-of-life (QOL) [Kansas City Cardiomyopathy Questionnaire (KCCQ)], and cognition [Montreal Cognitive Assessment (MOCA)] were examined. RESULTS: ADHF participants accumulated a median 1,008 (IQR 896, 1,109) minutes of sedentary time, 88 (57, 139) minutes of light physical activity, and 10 (6, 25) minutes of moderate-to-vigorous physical activity per day. Sedentary time, light physical activity, or moderate-to-vigorous activity did not differ by sex or EF subtype. ADHF participants spent only 9% of awake time nonsedentary, compared to 34% and 27% for healthy adults and adults with chronic, stable HF, respectively. Among ADHF participants, SPPB, KCCQ, and MOCA scores did not differ among quartiles of total physical activity. CONCLUSIONS: Older patients recently hospitalized for ADHF have very low levels of physical activity and high levels of sedentary time, both of which may be potential targets for interventions in this high-risk population. Physical activity level was not significantly associated with objectively measured physical function, QOL, or cognition, suggesting that this measure provides independent information regarding the patient experience of living with HF. TRIAL REGISTRATION: NCT02196038, https://clinicaltrials.gov/ct2/show/NCT02196038.

Left Ventricular Assist Device Decommissioning Compared with Explantation for Ventricular Recovery: A Systematic Review.

Left ventricular assist device (LVAD) withdrawal with ventricular recovery represents the optimal outcome for patients previously implanted with an LVAD. The aim of this systematic review was to examine the patient outcomes of device withdrawal via minimally invasive pump decommissioning as compared with reoperation for pump explantation. An electronic search was performed to identify all studies in the English literature assessing LVAD withdrawal. All identified articles were systematically assessed for inclusion and exclusion criteria. Overall, 44 studies (85 patients) were included in the analysis, of whom 20% underwent decommissioning and 80% underwent explantation. The most commonly used LVAD types included the HeartMate II (decommissioning 23.5% vs. explantation 60.3%; p = 0.01) and HeartWare HVAD (decommissioning 76.5% vs. explantation 17.6%; p < 0.001). At median follow-up of 389 days, there were no significant differences in the incidence of cerebrovascular accidents (p = 0.88), infection (p = 0.75), and survival (p = 0.20). However, there was a trend toward a higher recurrence of heart failure in patients who underwent decommissioning as compared with explantation (decommissioning 15.4% vs. explantation 8.2%, cumulative hazard; p = 0.06). Decommissioning appears to be a feasible alternative to LVAD explantation in terms of overall patient outcomes.

Percutaneous coronary intervention versus coronary artery bypass grafting in heart transplant recipients with coronary allograft vasculopathy: a systematic review and meta-analysis of 1,520 patients.

BACKGROUND: Transplant coronary artery vasculopathy (TCAV) is the major cause of late allograft failure and death in heart transplant recipients. The aim of this systematic review was to examine the outcomes of percutaneous coronary interventions (PCIs) as compared to coronary artery bypass grafting (CABG) surgery in the management of TCAV. Our secondary objective was to compare the use and outcomes of drug eluting stents (DES) as compared to bare metal stents (BMS) in this patient population. METHODS: Electronic search was performed to identify all studies in the English literature examining PCI as compared to CABG for TCAV in heart transplant recipients. All identified articles were systematically assessed for inclusion and exclusion criteria. RESULTS: Of the 4,989 studies identified, 29 studies were included. Among 1,520 patients who developed TCAV, 1,470 patients underwent PCI and 50 patients underwent CABG. There were no significant differences in baseline demographics and comorbidities among the PCI and CABG cohorts. Compared to the PCI cohort, patients who underwent CABG had a higher early mortality (CABG 36.4% vs. PCI 4.3%, P<0.001) and overall mortality (CABG 42.3% vs. PCI 21.4%, P=0.049). When comparing DES versus BMS cohorts, there were no significant differences in the rate of in-stent stenosis (DES 14.5% vs. BMS 24.4%, P=0.476), overall mortality (DES 17.4% vs. BMS 30.8%, P=0.302) or cardiac related mortality (DES 7.7% vs. BMS 21.8%, P=0.415). CONCLUSIONS: CABG and PCI are both feasible modalities for revascularization in patients with TCAV where PCI is associated with lower mortality. There were no differences in outcomes among patients who underwent PCI with DES as compared to BMS. Potential bias may exist due to heterogeneity in available data. Further studies are needed to delineate evidence-based guidelines to tailor the appropriate therapy, CABG or PCI, to the appropriate patient.

Left ventricular dysfunction mimicking Takotsubo cardiomyopathy following cardiac surgery.

Left ventricular dysfunction with apical ballooning consistent with Takotsubo cardiomyopathy was encountered in a 68-year-old woman at 5 h after an uneventful mitral valve replacement and tricuspid valve repair. Preoperatively, the patient had emotional stress as well as worsening congestive heart failure, which might have contributed to this rare postoperative complication. Following diagnosis by transthoracic echocardiography (TTE), and characteristic findings of apical ballooning and a preserved basal contraction of the left ventricle, intra-aortic balloon pumping (IABP) was initiated to minimize the use of inotropic drugs. The patient was successfully weaned from both the IABP and pharmacological support. Follow up with serial TTE showed a gradual recovery of the left ventricle to normal systolic function. The mechanism of onset and pathophysiology of Takotsubo cardiomyopathy remain unclear, especially in postoperative cardiac surgery patients. Since excessive catecholamine stimulation has been proposed as a possible mechanism of Takotsubo cardiomyopathy, early mechanical circulatory assistance after cardiac surgery is advised to minimize catecholamine use in this rare complication.

Dissociation between hospital performance of the smoking cessation counseling quality metric and cessation outcomes after myocardial infarction.

BACKGROUND: Recognizing the importance of smoking cessation after acute myocardial infarction (AMI), the Centers for Medicare & Medicaid Services and the Joint Commission on Accreditation of Healthcare Organizations currently uses documentation of smoking cessation counseling (SCC) as a metric of hospitals' quality of AMI care. Yet, the association between hospitals' performance of this quality measure and subsequent tobacco cessation rates has not been established. METHODS: We analyzed 889 consecutive smokers treated for AMI at 19 hospitals in PREMIER (Prospective Registry Evaluating Myocardial Infarction: Events and Recovery) between January 1, 2003, and June 28, 2004. Patients were followed up for 1 year after hospitalization. Multivariate regression modeling was performed to determine the association between hospital-level documented SCC rates and tobacco cessation rates after discharge. RESULTS: On a hospital level, the median medical record-documented SCC rate was 72.0% (interquartile range, 59.6%-90.1%). At 1 year, the median smoking cessation rate was 55.6% (interquartile range, 37.5%-61.9%). Although patients with documented SCC were more likely to recall receiving SCC at 1 month (86.1% vs 70.8%, P < .001), their rate of quitting at 1 year was lower than that of patients without documented SCC (50.1% vs 60.7%, P = .02; relative risk, 0.76; 95% confidence interval, 0.61-0.94). At the hospital level, there was no correlation between SCC documentation and successful quitting at 6 months (r = -0.19, P = .11) or 1 year (r = -0.13, P = .45). CONCLUSIONS: The performance metric for SCC, as it is currently structured, does not correlate with actual smoking cessation at 6 months or 1 year. Revision of this performance measure should be considered to more effectively reflect the goal of promoting smoking cessation.