Cerebrovascular Accidents During Mechanical Circulatory Support: New Predictors of Ischemic and Hemorrhagic Strokes and Outcome.

BACKGROUND AND PURPOSE: Left ventricular assist devices (LVADs) have emerged as an effective treatment for patients with advanced heart failure refractory to medical therapy. Post-LVAD strokes are an important cause of morbidity and reduced quality of life. Data on risks that distinguish between ischemic and hemorrhagic post-LVAD strokes are limited. The aim of this study was to determine the incidence of post-LVAD ischemic and hemorrhagic strokes, their association with stroke risk factors, and their effect on mortality. METHODS: Data are collected prospectively on all patients with LVADs implanted at Brigham and Women's Hospital. We added retrospectively collected clinical data for these analyses. RESULTS: From 2007 to 2016, 183 patients (median age, 57; 80% male) underwent implantation of HeartMate II LVAD as a bridge to transplant (52%), destination therapy (39%), or bridge to transplant candidacy (8%). A total of 48 strokes occurred in 39 patients (21%): 28 acute ischemic strokes in 24 patients (13%) and 20 intracerebral hemorrhages in 19 patients (10.3%). First events occurred at a median of 238 days from implantation (interquartile range, 93-515) among those who developed post-LVAD stroke. All but 9 patients (4.9%) were on warfarin (goal international normalized ratio, 2-3.5) and all received aspirin (81-325 mg). Patients with chronic obstructive pulmonary disease were more likely to have an ischemic stroke (odds ratio, 2.96; 95% confidence interval, 1.14-7.70). Dialysis-dependent patients showed a trend toward a higher risk of hemorrhagic stroke (odds ratio, 6.31; 95% confidence interval, 0.99-40.47). Hemorrhagic stroke was associated with higher mortality (odds ratio, 3.92; 95% confidence interval, 1.34-11.45) than ischemic stroke (odds ratio, 3.17; 95% confidence interval, 1.13-8.85). CONCLUSIONS: Stroke is a major cause of morbidity and mortality in patients on LVAD support. Chronic obstructive pulmonary disease increases the risk of ischemic stroke, whereas dialysis may increase the risk of hemorrhagic stroke. Although any stroke increases mortality, post-LVAD hemorrhagic stroke was associated with higher mortality compared with ischemic stroke.

Spot Urine Sodium as Triage for Effective Diuretic Infusion in an Ambulatory Heart Failure Unit.

BACKGROUND: Admission for diuresis remains a common and costly event in patients with advanced heart failure (HF). We tested whether spot urine sodium could identify patients likely to respond to ambulatory diuretic infusion without hospitalization. METHODS AND RESULTS: We prospectively followed 176 consecutive patients with advanced heart failure receiving intravenous furosemide for congestion in an ambulatory clinic. Spot urine sodium was measured in 1st voided urine after diuretic infusion and compared with 3-hour urine output and subsequent risk of 30-day hospitalization or emergency department (ED) visit. Spot urine sodium was significantly associated with urine output in a model adjusted for age, renal function, and blood urea nitrogen (P = .02). Higher urine sodium was associated with lower risk of hospitalization or ED visit within 30 days (odds ratio [OR] 0.82 [95% confidence interval 0.72-0.94] per 10 mmol/L increase; P < .001), in a model adjusted for hemoglobin (OR 0.80 [0.66-0.97]; P = .02) and systolic blood pressure (OR 0.82 [0.67-1.0]; P = .05). Spot urine sodium ≥65 mmol/L and urine output ≥1200 mL identified a lower-risk group for outpatient management. CONCLUSION: High spot urine sodium after diuretic administration identifies HF patients likely to respond to an ambulatory diuretic infusion with lower rates of hospitalization or ED visits at 30 days.

Early aspirin use and the development of cardiac allograft vasculopathy.

BACKGROUND: Cardiac allograft vasculopathy (CAV) remains a leading cause of morbidity and mortality after orthotopic heart transplantation (OHT). Little is known about the influence of aspirin on clinical expression of CAV. METHODS: We followed 120 patients with OHT at a single center for a median of 7 years and categorized them by the presence or absence of early aspirin therapy post-transplant (aspirin treatment ≥6 months in the first year). The association between aspirin use and time to the primary end-point of angiographic moderate or severe CAV (International Society for Heart and Lung Transplantation grade ≥2) was investigated. Propensity scores for aspirin treatment were estimated using boosting models and applied by inverse probability of treatment weighting (IPTW). RESULTS: Despite a preponderance of risk factors for CAV among patients receiving aspirin (male sex, ischemic heart disease as the etiology of heart failure, and smoking), aspirin therapy was associated with a lower rate of moderate or severe CAV at 5 years. Event-free survival was 95.9% for patients exposed to aspirin compared with 79.6% for patients without aspirin exposure (log-rank p = 0.005). IPTW-weighted Cox regression revealed a powerful inverse association between aspirin use and moderate to severe CAV (adjusted hazard ratio 0.13; 95% confidence interval 0.03-0.59), which was directionally consistent for CAV of any severity (adjusted hazard ratio 0.50; 95% confidence interval 0.23-1.08). CONCLUSIONS: This propensity score-based comparative observational analysis suggests that early aspirin exposure may be associated with a reduced risk of development of moderate to severe CAV. These findings warrant prospective validation in controlled investigations.

Intravenous Diuretic Therapy for the Management of Heart Failure and Volume Overload in a Multidisciplinary Outpatient Unit.

OBJECTIVES: This study sought to evaluate the effectiveness of intravenous (IV) diuretic treatment for volume management in heart failure (HF). BACKGROUND: Limited data exist regarding IV diuretics for the outpatient treatment of volume overload in HF patients. METHODS: We analyzed 60 consecutive patients with chronic HF and clinical evidence of worsening congestion who received a bolus and 3-h IV infusion of furosemide at an outpatient HF clinic. Diuretic dosing was derived from the maintenance oral loop diuretic dose with a standardized conversion algorithm. Outcomes included urine output during the visit, weight loss at 24 h, and hospitalization and mortality at 30 days. Safety outcomes included hypokalemia and worsening of renal function. Outcomes were analyzed across subgroups defined by maintenance diuretic dose and ejection fraction (EF). RESULTS: The median age of the cohort was 70 years (interquartile range [IQR]: 58 to 80 years), and the median daily loop diuretic dose was 240 mg (IQR: 80 to 800 mg) oral furosemide or equivalent. Twenty-six patients (43.3%) were women, and 36 (60%) had an EF ≤45%. For the entire cohort, the median urine output and 24-h weight loss were 1.1 l (IQR: 0.6 to 1.4 l) and 1.1 kg (IQR: 0.2 to 1.9 kg), respectively. Outcomes were similar across patients with varying maintenance diuretic doses (<40 mg, 40 to 160 mg, 160 to 300 mg, or >300 mg of furosemide or equivalent) and in patients with reduced or preserved EF. Transient worsening of renal function and hypokalemia occurred in 10 patients (8.9%) and 4 patients (3.5%). Although hospitalization was reported as imminent for 28 patients (52.8%), the observed rate of all-cause hospitalization was 31.7% at 30 days with no deaths. CONCLUSIONS: Short courses of IV diuretics for volume management in patients with HF were safe and associated with significant urine output and weight loss across a wide range of maintenance diuretic doses and EF. This strategy may provide an alternative to hospitalization for the management of selected HF patients.

Cognitive and other predictors of change in quality of life one year after treatment for chronic myelogenous leukemia or myelodysplastic syndrome.

The role of cognitive function in quality of life is important among the growing numbers of survivors after cancer treatment. The authors conducted a prospective cohort study of 106 adults evaluated 5.6 months (median) after diagnosis and 77 of 83 (93%) survivors 12 months later with neuropsychological assessments yielding information about simple reaction time to stimuli and other aspects of cognitive function and with two quality of life measures. The two most consistent predictors of change in quality of life were baseline quality of life ratings and simple reaction time. This novel finding about simple reaction time warrants further confirmation.

Patient- and practice-related determinants of emergency department length of stay for patients with psychiatric illness.

STUDY OBJECTIVE: To identify patient and clinical management factors related to emergency department (ED) length of stay for psychiatric patients. METHODS: This was a prospective study of 1,092 adults treated at one of 5 EDs between June 2008 and May 2009. Regression analyses were used to identify factors associated with ED length of stay and its 4 subcomponents. Secondary analyses considered patients discharged to home and those who were admitted or transferred separately. RESULTS: The overall mean ED length of stay was 11.5 hours (median 8.2 hours). ED length of stay varied by discharge disposition, with patients discharged to home staying 8.6 hours (95% confidence interval 7.7 to 9.5 hours) and patients transferred to a hospital outside the system of care staying 15 hours (95% confidence interval 12.7 to 17.6 hours) on average. Older age and being uninsured were associated with increased ED length of stay, whereas race, sex, and homelessness had no association. Patients with a positive toxicology screen result for alcohol stayed an average of 6.2 hours longer than patients without toxicology screens, an effect observed primarily in the periods before disposition decision. Diagnostic imaging was associated with an average 3.2-hour greater length of stay, prolonging both early and late components of the ED stay. Restraint use had a similar effect, leading to a length of stay 4.2 hours longer than that of patients not requiring restraints. CONCLUSION: Psychiatric patients spent more than 11 hours in the ED on average when seeking care. The need for hospitalization, restraint use, and the completion of diagnostic imaging had the greatest effect on postassessment boarding time, whereas the presence of alcohol on toxicology screening led to delays earlier in the ED stay. Identification and sharing of best practices associated with each of these factors would provide an opportunity for improvement in ED care for this population.

Bottlenecks in the emergency department: the psychiatric clinicians' perspective.

OBJECTIVE: To ask psychiatric clinicians for their perspectives on the rate-limiting steps (RLS) in patient care in the Emergency Department (ED) and to compare them to the patient's actual length of stay. METHOD: Prospective cohort study of clinicians' perspectives on the RLS among 1092 adult ED patients. Medical records were abstracted for ED time and other data. RESULTS: Clinicians identified five RLS: limited availability of staff, limited availability of beds after discharge, need for clinical stability, need for additional history and patient's financial issues. The last RLS was the only one not associated with increased wait times in the ED. There were significant differences in the patterns of RLS by trainee status and hospital. For example, significantly higher proportions of trainees reported that RLS in patient care were due to the need for clinical stability and additional history and lack of bed availability. In contrast, non-trainee clinicians were more likely to cite problems with the availability of ED staff as an RLS. CONCLUSIONS: Most of the RLS in patient care identified by clinicians were associated with actual increases in ED wait time for their patients. Next steps include asking clinicians for possible solutions to the delays their patients experience.

Characteristics of adult psychiatric patients with stays of 24 hours or more in the emergency department.

OBJECTIVE: This study identified characteristics of adult psychiatric patients who remained for 24 or more hours in the emergency departments of general hospitals in Massachusetts. METHODS: Data were collected starting in June 2008 on a prospective cohort of 1,076 patients who presented for emergency psychiatric evaluation at one of five hospitals. RESULTS: A total of 90 patients (8%) stayed 24 or more hours (median=31 hours). More than 90% (N=1,018) of all patients had health insurance. Characteristics associated with extended stays included homelessness, transfer to another hospital, public insurance, and use of restraints or sitters (p<.05). The two academic medical centers had higher proportions of extended-stay patients than the three community hospitals (12% and 15% versus 1%, 7%, and 7%, respectively; p<.001). CONCLUSIONS: Despite overall high rates of health insurance coverage, publicly insured patients waited longer than those with private insurance. Future reforms of Massachusetts' mandatory health insurance program should consider treatment capacity as well.