Dimensionless index and outcome in patients with aortic valve disease.

PURPOSE: Assessment of aortic stenosis (AS) is based on aortic valve (AV) gradients and calculation of aortic valve area (AVA). These parameters are influenced by flow and dependent on geometric assumptions. The dimensionless index (DI), the ratio of the LVOT time-velocity integral to that of the AV jet, is simple to perform, and is less susceptible to error but has only been examined in small selected groups of AS patients. The objective of this study was to assess the DI and prognosis in a large cohort. METHODS: All subjects who underwent echocardiography with an assessment of the AV that included DI were included. Association between AV parameters including mean gradient, AVA, DI and AV resistance and mortality and cardiovascular hospitalizations was examined. RESULTS: A total of 9393 patients (mean age 71 ± 16 years; 53% male) were included. 731 (7.7%) patients had DI less than .25. Increasing age and a diagnosis of heart failure were significantly associated with lower DI. Subjects with low DI had significantly lower ventricular function, a higher incidence of mitral and tricuspid regurgitation, worse diastolic function and more elevated pulmonary pressures. Decreasing DI was associated with significantly decreased survival and event-free survival which remained highly significant on multivariate analysis. CONCLUSIONS: In a large population of patients with AV disease, decreased DI, was associated with increased mortality and decreased event-free survival. The easily obtained DI identifies a broad range of AS subjects with worse prognosis and should be integrated into the assessment of these complex patients.

The impact of aging on cardiac remodeling in chronic mitral regurgitation.

BACKGROUND: Chronic mitral regurgitation (MR) is a volume overload state that causes dilatation of the left sided cardiac chambers. The presence of significant dilatation is considered an indication for mitral valve intervention, however, aging may affect left ventricular (LV) remodeling independently of valvular disease. The objective of this study was to examine age-related changes in cardiac remodeling in a broad population of patients with chronic MR. METHODS: Consecutive subjects that underwent echocardiography examinations recorded in the echocardiography database of a university-affiliated laboratory were retrieved. Subjects were categorized into none/mild, moderate or severe MR. For purposes of analysis of differences with aging, the population was divided into groups above and below 70 years of age and standard echocardiographic measurements were compared between the groups. RESULTS: A total of 3492 subjects with at least moderate MR (mean age: 76 years, 52% female) were included in the study and compared to 18,250 subjects with none or mild MR. Older patients had significantly smaller LV end-diastolic diameters and volumes and significantly larger left atrial (LA) volumes when compared to the younger group. LA volume index increased in both age groups as MR severity increased, while LV end-diastolic volume increased with increasing MR only in the younger population. CONCLUSIONS: Cardiac remodeling in chronic MR is significantly influenced by age. Guideline based recommendations of timing of mitral valve interventions in asymptomatic MR patients, based on assessment of LA and LV remodeling, may need to take age into account.

The association between myocardial contraction fraction assessed by echocardiography and mortality.

BACKGROUND: Left ventricular ejection fraction (EF) is the most commonly used echocardiographic measurement of LV systolic function. Myocardial contraction fraction (MCF) may be a more accurate assessment of LV systolic function than EF. Limited data are available regarding the prognostic value of MCF compared to EF in a population referred for echocardiography. OBJECTIVES: To assess whether MCF was predictive of all-cause mortality in a population referred for echocardiography. METHODS: All consecutive subjects undergoing echocardiography in a university-affiliated laboratory during a 5-year period were retrieved for analysis. MCF was calculated by dividing LV stroke volume (LV end diastolic volume-LV end systolic volume) by LV myocardial volume and multiplied by 100. All cause mortality was the primary endpoint. Multivariate Cox proportional hazards regression analysis was used to evaluate independent variables associated with survival. RESULTS: 18,149 continuous subjects (median age 60 years, 53% male) were included. Median MCF in the cohort was 52% (interquartile range 40-64) while median EF was 64% (56-69). Any reduction in MCF from a value of 60 was significantly associated with survival on multivariable analysis. When echo parameters including EF, e:e', elevated TR gradient and significant MR were added to the model, MCF less than 50% remained significantly associated with mortality. MCF was also independently associated with both death and cardiovascular hospitalization. The AUC for MCF was .66 (95% confidence interval (CI): .65-.67) while for EF the AUC was only .58 (95% CI: .57-.59), a statistically significant difference (p < .0001). CONCLUSIONS: Reduced MCF is independently associated with mortality in a large population referred for echocardiography.

Mild Tricuspid Regurgitation: A Marker of Disease Burden Independently Associated with Increased Mortality.

INTRODUCTION: Tricuspid regurgitation (TR) is a common finding which appears to be associated with a worse prognosis. There are conflicting data regarding the prognostic impact of mild TR. We examined the clinical characteristics and echocardiographic properties of subjects with TR and its impact on clinical outcome with particular emphasis on subjects with mild TR. METHODS: Consecutive echocardiography examinations during 5 years were evaluated for TR severity and outcome including mortality and cardiovascular hospitalizations. RESULTS: The study included 21,429 subjects; 45% of the subjects had mild TR, 15% had moderate TR, and 6.5% had severe TR. Primary organic TR was evident in 7% of the subjects, a percentage that increased with increasing TR severity. TR severity was incrementally associated with older subjects with an increasing number of comorbidities and echocardiographic abnormalities. 29% of the subjects died at a median follow-up duration of 8.7 years. Increasing severity of TR was independently and incrementally associated with mortality. Subjects with mild TR had a 25% increased mortality rate compared to subjects with minimal TR (HR 1.25, 95% CI: 1.12-1.39, p < 0.001) after adjustment for significant clinical parameters. TR severity was also an independent incrementally graded predictor of cardiovascular hospitalization and mortality (mild TR: HR 1.23, 95% CI: 1.12-1.34, p < 0.001). CONCLUSIONS: TR is associated with older and sicker patients with numerous comorbidities. TR severity is a predictor of a worse clinical outcome. Mild TR was independently associated with decreased survival. TR should be considered a marker of a disease burden with a poor prognosis.

Echocardiographic Characteristics and Clinical Outcomes of the Hyperdynamic Heart: A 'Super-Normal' Heart is not a Normal Heart.

A hyperdynamic heart is defined as a left ventricular (LV) with an ejection fraction (EF) above the normal range. Is this favorable? We looked at the diastolic properties of subjects with a hyperdynamic heart and its impact on outcome. Consecutive echocardiography examinations during 5 years were evaluated by EF subgroups, including a hyperdynamic heart (EF >70%). All examinations with significant LV hypertrophy or valve disease were excluded. The study included 16,994 subjects. A total of 720 subjects (4.2%) had a hyperdynamic heart. Subjects with a hyperdynamic heart were older, more likely to be women, and more likely to have hypertension, diabetes, and obesity. A total of 20% of patients had a diagnosis of heart failure. This group had a higher heart rate, smaller ventricular size, and the highest relative wall thickness. All indexes of diastolic dysfunction were significantly more prevalent in the hyperdynamic group. This included a higher LV mass, larger left atrial volume, reduced relaxation (smaller mitral e'), longer deceleration time, and higher LV end-diastolic pressures (high mitral E/e' ratio) and peak tricuspid regurgitation gradient. Diastolic dysfunction, defined by an abnormal functional or structural parameter, was present in 78% of the subjects. Survival was significantly lower in the group with a hyperdynamic heart. The Cox regression analysis after adjustment demonstrated reduced survival during a median 9-year follow-up in the hyperdynamic group compared with those with a normal EF (hazard ratio 1.56, 95% confidence interval 1.38 to 1.76, p <0.001). In conclusion, subjects with a hyperdynamic systolic function have increased prevalence of diastolic dysfunction and reduced survival. A hyperdynamic heart is not a normally functioning heart.

Dialysis Therapy for Volume Overload: A Feasible Option to Reduce Heart Failure Hospitalizations in Advanced Heart Failure.

BACKGROUND: Advanced heart failure (HF) carries a high rate of recurrent HF hospitalizations and a very high mortality rate. Mechanical devices and heart transplantation are limited to a select few. Dialysis may be a good alternative for advanced HF patients with volume overload despite maximal pharmacological therapy. OBJECTIVES: To assess the net clinical outcome of peritoneal dialysis or hemodialysis in patients with advanced HF. METHODS: We analyzed all advanced HF patients who were referred for dialysis due to volume overload in our institution. Patients were followed for complications, HF hospitalizations, and survival. RESULTS: We assessed 35 patients; 10 (29%) underwent peritoneal dialysis and 25 (71%) underwent hemodialysis; 71% were male; median (interquartile range) age was 74 (67-78) years. Estimated glomerular filtration rate was 20 (13-32) ml/min per 1.73 m2. New York Heart Association functional capacity was III. Median follow-up time was 719 days (interquartile range 658-780). One-year mortality rate was 8/35 (23%) and overall mortality rate was 16/35 (46%). Three patients (9%) died during the first year due to line or peritoneal dialysis related sepsis, and 6 (17%) died during the entire follow-up. The median number of HF hospitalizations was significantly reduced during the year on dialysis compared to the year prior to dialysis (0.0 [0.0-1.0] vs. 2.0 [0.0-3.0], P < 0.001). CONCLUSIONS: Dialysis is reasonably safe and significantly reduced HF hospitalization in advanced HF patients. Dialysis could be a good alternative for advanced HF patients with intractable volume overload.

Patiromer for the management of hyperkalemia in heart failure with reduced ejection fraction: the DIAMOND trial.

AIMS: To investigate the impact of patiromer on the serum potassium level and its ability to enable specified target doses of renin-angiotensin-aldosterone system inhibitor (RAASi) use in patients with heart failure and reduced ejection fraction (HFrEF). METHODS AND RESULTS: A total of 1642 patients with HFrEF and current or a history of RAASi-related hyperkalemia were screened and 1195 were enrolled in the run-in phase with patiromer and optimization of the RAASi therapy [≥50% recommended dose of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, and 50 mg of mineralocorticoid receptor antagonist (MRA) spironolactone or eplerenone]. Specified target doses of the RAASi therapy were achieved in 878 (84.6%) patients; 439 were randomized to patiromer and 439 to placebo. All patients, physicians, and outcome assessors were blinded to treatment assignment. The primary endpoint was between-group difference in the adjusted mean change in serum potassium. Five hierarchical secondary endpoints were assessed. At the end of treatment, the median (interquartile range) duration of follow-up was 27 (13-43) weeks, the adjusted mean change in potassium was +0.03 mmol/l in the patiromer group and +0.13 mmol/l in the placebo group [difference in the adjusted mean change between patiromer and placebo: -0.10 mmol/l (95% confidence interval, CI -0.13, 0.07); P < 0.001]. Risk of hyperkalemia >5.5 mmol/l [hazard ratio (HR) 0.63; 95% CI 0.45, 0.87; P = 0.006), reduction of MRA dose (HR 0.62; 95% CI 0.45, 0.87; P = 0.006), and total adjusted hyperkalemia events/100 person-years (77.7 vs. 118.2; HR 0.66; 95% CI 0.53, 0.81; P < 0.001) were lower with patiromer. Hyperkalemia-related morbidity-adjusted events (win ratio 1.53, P < 0.001) and total RAASi use score (win ratio 1.25, P = 0.048) favored the patiromer arm. Adverse events were similar between groups. CONCLUSION: Concurrent use of patiromer and high-dose MRAs reduces the risk of recurrent hyperkalemia (ClinicalTrials.gov: NCT03888066).

The Relationship Between Body Mass Index and In-hospital Survival in Patients Admitted With Acute Heart Failure.

Background: The association between Body Mass Index (BMI) and clinical outcomes following acute heart failure (AHF) hospitalization is debated in the literature. Our objective was to study the real-world relationship between BMI and in-hospital mortality in patients who were admitted with AHF. Methods: In this retrospective, multi-center study, we utilized the National Inpatient Sample (NIS) database to identify a sampled cohort of patients who were hospitalized with AHF between October 2015 and December 2016. Outcomes of interest included in-hospital mortality and length of stay (LOS). Patients were divided into 6 BMI (kg/m2) subgroups according to the World Health Organization (WHO) classification: (1) underweight ≤ 19, (2) normal weight 20-25, (3) overweight 26-30, (4) obese I 31-35, (5) obese II 36-39, and (6) extremely obese ≥40. A multivariable logistic regression model was used to identify predictors of in-hospital mortality and to identify predictors of LOS. Results: A weighted total of 219,950 hospitalizations for AHF across the US were analyzed. The mean age was 66.3 ± 31.5 years and most patients (51.8%) were male. The crude data showed a non-linear complex relationship between BMI and AHF population outcomes. Patients with elevated BMI exhibited significantly lower in-hospital mortality compared to the underweight and normal weight study participants (5.5, 5,5, 2,8, 1.6, 1.4, 1.6% in groups by BMI ≤ 19, 20-25, 26-30, 31-35, 36-39, and, ≥40 respectively, p < 0.001) and shorter LOS. In the multivariable regression model, BMI subgroups of ≤ 25kg/m2 were found to be independent predictors of in-hospital mortality. Age and several comorbidities, and also the Deyo Comorbidity Index, were found to be independent predictors of increased mortality in the study population. Conclusion: A reverse J-shaped relationship between BMI and mortality was documented in patients hospitalized for AHF in the recent years confirming the "obesity paradox" in the real-world setting.

Percutaneous Mitral Valve Repair in Cancer Patients with Heart Failure and Severe Mitral Regurgitation.

BACKGROUND: Cancer patients with heart failure (HF) and severe mitral regurgitation (MR) are often considered to be at risk for surgical mitral valve repair/replacement. Severe MR inducing symptomatic HF may prevent delivery of potentially cardiotoxic chemotherapy and complicate fluid management with other cancer treatments. OBJECTIVES: To evaluate the outcome of percutaneous mitral valve repair (PMVR) in oncology patients with HF and significant MR. METHODS: Our study comprised 145 patients who underwent PMVR, MitraClip, at Hadassah Medical Center between August 2015 and September 2019, including 28 patients who had active or history of cancer. Data from 28 cancer patients were compared to 117 no-cancer patients from the cohort. RESULTS: There was no significant difference in the mean age of cancer patients and no-cancer patients (76 vs. 80 years, P = 0.16); 67% of the patients had secondary (functional) MR. Among cancer patients, 21 had solid tumor and 7 had hematologic malignancies. Nine patients (32%) had active malignancy at the time of PMVR. The mean short-term risk score of the patients was similar in the two groups, as were both 30-day and 1-year mortality rates (7% vs. 4%, P = 0.52) and (29% vs. 16%, P = 0.13), respectively. CONCLUSIONS: PMVR in cancer patients is associated with similar 30-day and 1-year survival rate compared with patients without cancer. PMVR should be considered for cancer patients presenting with HF and severe MR and despite their malignancy. This approach may allow cancer patients to safely receive planned oncological treatment.

The Ratio of Hemoglobin to Red Cell Distribution Width: A Strong Predictor of Clinical Outcome in Patients with Heart Failure.

BACKGROUND: Hemoglobin (Hb) is a standard and widely available clinical parameter that predicts clinical outcomes in heart failure (HF) patients. Red cell distribution width (RDW) is also a routinely measured clinical parameter that is predictive of clinical outcomes in HF. The ratio between Hb and RDW has yet to be evaluated in HF. METHODS: We evaluated the predictive value of the Hb/RDW ratio on clinical outcomes in patients with HF. All patients diagnosed with chronic HF at a health maintenance organization were evaluated for Hb/RDW ratio and followed for cardiac-related hospitalizations and death. RESULTS: The study cohort included 6888 HF patients. The mean Hb/RDW ratio was 0.85 ± 0.18; median was 0.85 (interquartile range 0.72-0.98). Patients with a lower Hb/RDW ratio were more likely to be women and had more comorbidities. The overall two year-mortality rate was 23.2%. Decreasing quantiles of the Hb/RDW ratio were associated with reduced survival rates and reduced event-free survival from death or cardiovascular-hospitalizations. Multivariable Cox regression analysis after adjustment for significant predictors demonstrated that low Hb/RDW ratio was a significant predictor of mortality, with a graded increased risk as Hb/RDW ratio decreased. Lower Hb/RDW ratio was also a significant independent predictor of the combined endpoint of death or cardiovascular hospitalizations. A sensitivity analysis evaluating Hb/RDW ratio as a continuous parameter using restricted cubic splines demonstrated a continuous increase in the mortality risk with decreasing Hb/RDW ratio, p < 0.0001 for the linear model. CONCLUSIONS: Hb/RDW ratio is a significant prognostic tool for predicting HF mortality and cardiovascular hospitalizations.

Increased estimated fat-free mass and fat mass associated with improved clinical outcome in heart failure.

BACKGROUND: Increased weight measured by body mass index is associated with better clinical outcomes in heart failure (HF). The effect of specific components of body mass on outcome is limited. We evaluated the impact of fat-free mass and fat mass on mortality and cardiovascular hospitalization in a large real-world cohort of patients with chronic HF. METHODS: Body measurements were assessed in patients with chronic HF. Fat-free mass, fat mass and waist circumference were calculated based on specifically derived formulas. RESULTS: The cohort included 6328 HF patients. Mean follow-up was 744 days. Increased body composition indices including body mass index, fat-free mass index and fat mass index, per cent body fat and waist circumference were associated with better survival. Cox regression analysis after adjustment for other significant parameters demonstrated that these indices were all associated with improved survival. The strongest association was seen with fat-free mass index with a graded increase in survival; lowest death in the highest quartile compared to reference second quartile (hazard ratio 0.79, 95% confidence interval 0.67-0.93, P < .01). There was no interaction with sex or HF type. Analysis of the clinical outcome of death and cardiovascular hospitalization demonstrated that a worse prognosis was in the lowest quartile of all the indices. A sensitivity analysis, analysing these indices as continuous parameters using restricted cubic splines, demonstrated a clear continuous association between these indices and increased survival in both sexes. CONCLUSIONS: Body mass including fat-free mass and fat mass was associated with improved survival in patients with HF.

Coenzyme Q10 in the Treatment of Heart Failure with Preserved Ejection Fraction: A Prospective, Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Heart failure with preserved ejection fraction (HFpEF) is common in elderly people and is increasing in prevalence. No specific treatment for this condition exists. Coenzyme Q10 (CoQ10) is an essential cofactor for energy production, with reduced levels being noted in HF. Previous studies have suggested a possible role for CoQ10 in the treatment of HF. This study examined the effect of CoQ10 supplementation on diastolic function in HFpEF patients. METHODS: We conducted a prospective, randomized, double-blind, placebo-controlled trial including patients aged > 55 years presenting with New York Heart Association class II-IV heart failure symptoms and left ventricular ejection fraction > 50%, with impaired diastolic function. Echocardiography and levels of serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) were performed at baseline and following 4 months of CoQ10 or placebo supplementation. RESULTS: A total of 39 patients were enrolled-19 in the CoQ10 group and 20 in the placebo group. Baseline clinical characteristics were similar between groups, while compliance was high and also similar between the CoQ10 and placebo groups. There was no significant effect of treatment on indices of diastolic function (difference in the lateral E/e' ratio: -0.86 ± 6.57 in the CoQ10 group, +0.18 ± 3.76 in the placebo group; p = 0.561) or on serum NT-proBNP levels (- 72 pg/mL vs. - 42 pg/mL; p = 0.195). CONCLUSIONS: In this pilot trial in elderly patients with HFpEF, treatment with CoQ10 did not significantly affect echocardiographic indices of diastolic function and serum NT-proBNP levels. TRIAL REGISTRATION: This trial was registered in the US National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier: NCT02779634).

The Impact of COVID-19 Pandemic on Management and Outcome in Patients with Heart Failure.

BACKGROUND: The COVID-19 pandemic has adversely affected the provision of health care and disease management around the world. COVID-19 carries a high morbidity and mortality rate in elderly and people with comorbidities, including heart failure (HF). The present study addressed the clinical management and outcomes of HF patients during the pandemic. METHODS: We evaluated the clinical management and survival rate of HF patients during the COVID-19 pandemic in Israel (March 2020-April 2021). RESULTS: The cohort included 6748 patients with a diagnosis of HF during the study period. During this period, 843 HF patients (12.5%) were infected with COVID-19, and 194 died from COVID-19, a 23% mortality rate. Patients infected with COVID-19 had a higher percentage of diabetes and obesity. Predictors of mortality included age, male sex, reduced functional capacity, renal dysfunction, and absence of renin-angiotensin system inhibition. During the pandemic, there was a marked decrease in the usage of medical services in the cohort. Cardiovascular hospitalizations, all hospitalization, and emergency room visits were significantly decreased compared to the two years prior to the pandemic, particularly during the lockdowns. There was also an initial decrease in HF clinic visits. Mortality rates were very similar during the pandemic compared to previous years. There was a decline in non-COVID-19 deaths, which were replaced with deaths due to COVID-19. This may result from competing effects and reduced exposure to respiratory infections and other insults due to social distancing. CONCLUSIONS: Mortality rates in HF patients infected with COVID-19 were high. The COVID-19 pandemic resulted in the reduced usage of health services but without increased overall mortality.

HFA of the ESC position paper on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider Part 3: at the hospital and discharge.

The growing population of left ventricular assist device (LVAD)-supported patients increases the probability of an LVAD- supported patient hospitalized in the internal or surgical wards with certain expected device related, and patient-device interaction complication as well as with any other comorbidities requiring hospitalization. In this third part of the trilogy on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider, definitions and structured approach to the hospitalized LVAD-supported patient are presented including blood pressure assessment, medical therapy of the LVAD supported patient, and challenges related to anaesthesia and non-cardiac surgical interventions. Finally, important aspects to consider when discharging an LVAD patient home and palliative and end-of-life approaches are described.

Heart Failure Association of the European Society of Cardiology position paper on the management of left ventricular assist device-supported patients for the non-left ventricular assist device specialist healthcare provider: Part 2: at the emergency department.

The improvement in left ventricular assist device (LVAD) technology and scarcity of donor hearts have increased dramatically the population of the LVAD-supported patients and the probability of those patients to present to the emergency department with expected and non-expected device-related and patient-device interaction complications. The ageing of the LVAD-supported patients, mainly those supported with the 'destination therapy' indication, increases the risk for those patients to suffer from other co-morbidities common in the older population. In this second part of the trilogy on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider, definitions and structured approach to the LVAD-supported patient presenting to the emergency department with bleeding, neurological event, pump thrombosis, chest pain, syncope, and other events are presented. The very challenging issue of declaring death in an LVAD-supported patient, as the circulation is artificially preserved by the device despite no other signs of life, is also discussed in detail.

HFA of the ESC Position paper on the management of LVAD supported patients for the non LVAD specialist healthcare provider Part 1: Introduction and at the non-hospital settings in the community.

The accepted use of left ventricular assist device (LVAD) technology as a good alternative for the treatment of patients with advanced heart failure together with the improved survival of the LVAD-supported patients on the device and the scarcity of donor hearts has significantly increased the population of LVAD-supported patients. The expected and non-expected device-related and patient-device interaction complications impose a significant burden on the medical system exceeding the capacity of the LVAD implanting centres. The ageing of the LVAD-supported patients, mainly those supported with the 'destination therapy' indication, increases the risk for those patients to experience comorbidities common in the older population. The probability of an LVAD-supported patient presenting with medical emergency to a local emergency department, internal, or surgical ward of a non-LVAD implanting centre is increasing. The purpose of this trilogy is to supply the immediate tools needed by the non-LVAD specialized physician: ambulance clinicians, emergency ward physicians, general cardiologists, internists, anaesthesiologists, and surgeons, to comply with the medical needs of this fast-growing population of LVAD-supported patients. The different issues discussed will follow the patient's pathway from the ambulance to the emergency department and from the emergency department to the internal or surgical wards and eventually to the discharge home from the hospital back to the general practitioner. In this first part of the trilogy on the management of LVAD-supported patients for the non-LVAD specialist healthcare provider, after the introduction on the assist devices technology in general, definitions and structured approach to the assessment of the LVAD-supported patient in the ambulance and emergency department is presented including cardiopulmonary resuscitation for LVAD-supported patients.

Guidance on the management of left ventricular assist device (LVAD) supported patients for the non-LVAD specialist healthcare provider: executive summary.

The accepted use of left ventricular assist device (LVAD) technology as a good alternative for the treatment of patients with advanced heart failure together with the improved survival of patients on the device and the scarcity of donor hearts has significantly increased the population of LVAD supported patients. Device-related, and patient-device interaction complications impose a significant burden on the medical system exceeding the capacity of LVAD implanting centres. The probability of an LVAD supported patient presenting with medical emergency to a local ambulance team, emergency department medical team and internal or surgical wards in a non-LVAD implanting centre is increasing. The purpose of this paper is to supply the immediate tools needed by the non-LVAD specialized physician - ambulance clinicians, emergency ward physicians, general cardiologists, and internists - to comply with the medical needs of this fast-growing population of LVAD supported patients. The different issues discussed will follow the patient's pathway from the ambulance to the emergency department, and from the emergency department to the internal or surgical wards and eventually back to the general practitioner.

The need for palliative and support care services for heart failure patients in the community.

BACKGROUND: Palliative care is a care option considered appropriate for those with heart failure, but is uncommon partially due to a lack of timely identification of those needing palliative care. A standard mechanism that triggers which heart failure patients should receive palliative care is not available. The Gold Standards Framework (GSF) identifies those needing palliative care but has not been investigated with heart failure patients. OBJECTIVES: To describe palliative care provided in the community and determine whether the GSF can identify heart failure patients in need of palliative care. METHODS: Descriptive study. A total of 252 heart failure patients in the community completed a demographic characteristics questionnaire, the Edmonton symptom assessment scale-revised and the Minnesota living with heart failure questionnaire. Clinical data were collected from the medical chart and the primary physician completed the GSF prognostic indicator guidance. RESULTS: Participants had a mean age of 76.9 years (standard deviation 10.9), most at New York Heart Association level III (n=152, 60%). Fewer than half received pain medications (n=76, 30%), anxiolytics (n=35, 14%), antidepressants (n=64, 25%) or sleep medications (n=65, 26%). Eight patients spoke with a psychologist or psychologist (3%). One had an advanced directive and 16 (6%) had a record of discussions with their family caregivers. Three (1%) had end-of-life discussions with their healthcare providers. Most healthcare providers responded 'no' to the 'surprise question' (n=160, 63%). Sensitivity and specificity of the gold standards framework was poor. CONCLUSIONS: Few community dwelling heart failure patients received most aspects of palliative care. The gold standards framework was not a good indicator of those who should receive palliative care.

Prevalence and impact of concomitant malignancy on outcomes among ambulatory heart failure population.

INTRODUCTION: Heart failure (HF) and cancer are medical conditions with a rising prevalence resulting in increased co-occurrence. We assessed the impact of cancer on clinical outcome in patients with HF and the prognostic impact of specific types of cancers on different HF subpopulations. METHODS: All patients with HF were evaluated for the occurrence of malignant neoplasm at a health maintenance organization and were followed for cardiac-related hospitalizations and death. RESULTS: The study cohort included 7106 HF patients, 1564 of them (22%) had a diagnosis of malignant neoplasm. HF patients with concomitant cancer were older, had more comorbidities and were more likely to have NYHA class III/IV (42% vs. 37%, P < .01), compared with patients with no malignancy. The overall 2-year mortality rate of the entire HF cohort was 23.2%. Survival rate by Kaplan-Meier analysis demonstrated that the presence of a malignancy was directly associated with reduced survival: 67.2 ± 1.2% vs 79.5 ± 0.5%, P < .001. Malignancy was associated with an increase in mortality with a hazard ratio (HR) of 1.36, 95% confidence interval (CI) 1.21-1.54, P < .001. The strongest impact of malignancy on outcomes was related to age; among patients <70 years old, the increase in the risk of mortality was the highest with a HR of 2.07, 95% CI 1.54-2.80, P < .001. CONCLUSIONS: Malignancy is common among patients with HF. Patients with concomitant HF and malignancies have poor outcomes, and the impact of cancer on outcome is stronger among young patients.