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3.
J Card Fail ; 26(2): 166-179, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31704198

RESUMO

BACKGROUND: Nutraceuticals are pharmacologically active substances extracted from vegetable or animal food and administered to produce health benefits. We recently reviewed the current evidence for nutraceuticals in patients diagnosed with heart failure as part of the writing of the Australian Guidelines for the prevention, diagnosis, and management of heart failure. METHODS: A systematic search for studies that compared nutraceuticals to standard care in adult patients with heart failure was performed. Studies were included if >50 patients were enrolled, with ≥6 months follow-up. If no studies met criteria then studies <50 patients and <6 months follow-up were included. The primary outcomes included mortality/survival, hospitalization, quality of life, and/or exercise tolerance. Iron was not included in this review as its role in heart failure is already well established. RESULTS: Forty studies met the inclusion criteria. The strongest evidence came from studies of polyunsaturated fatty acids, which modestly decreased mortality and cardiovascular hospitalizations in patients with mostly New York Heart Association class II and III heart failure across a range of left ventricular ejection fraction. Coenzyme Q10 may decrease mortality and hospitalization, but definite conclusions cannot be drawn. Studies that examined nitrate-rich beetroot juice, micronutrient supplementation, hawthorn extract, magnesium, thiamine, vitamin E, vitamin D, L-arginine, L-carnosine, and L-carnitine were too small or underpowered to properly appraise clinical outcomes. CONCLUSION: Only one nutraceutical, omega-3 polyunsaturated fatty acid, received a positive recommendation in the Australian heart failure guidelines. Although occasionally showing some promise, all other nutraceuticals are inadequately studied to allow any conclusion on efficacy. Clinicians should favor other treatments that have been clearly shown to decrease mortality.

4.
Eur J Cardiovasc Nurs ; 19(1): 55-63, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31328532

RESUMO

BACKGROUND: Frailty is an important predictive measure of mortality and rehospitalisation in people with heart failure. To date, there are no frailty instruments validated for use in people with heart failure. AIM: The aim of this study was to evaluate the convergent and discriminant validity of three versions of the frailty phenotype in those with heart failure. METHODS: A single site, prospective cohort study was undertaken among individuals with a confirmed diagnosis of heart failure. Frailty was assessed concurrently using three versions of the frailty phenotype: the original frailty phenotype and two modified versions; the Survey of Health, Ageing and Retirement in Europe frailty instrument (SHARE-FI) and the St Vincent's frailty instrument. Convergent and discriminant validity were assessed by reporting the correlations between each version and related heart failure subconstructs, and by evaluating the ability of each version to discriminate between normal and abnormal scores of other physical and psychosocial scales specific to heart failure-related subconstructs. RESULTS: The New York Heart Association classes were moderately correlated with the St Vincent's frailty instrument (r=0.47, P⩽0.001), SHARE-FI (r=0.42, P⩽0.001) and the frailty phenotype (r=0.42, P⩽0.001). The SHARE-FI and the St Vincent's frailty instrument were both able to discriminate consistently between normal and abnormal scores in three out of five of the physical and psychosocial subconstructs that were assessed. The SHARE-FI was also able to discriminate between inpatients and outpatients who were classified as frail. CONCLUSIONS: Both the SHARE-FI and the St Vincent's frailty instrument displayed good convergent and discriminant validity.

5.
Expert Rev Respir Med ; 14(2): 219-227, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31815560

RESUMO

Introduction: Lung transplantation is an effective treatment for certain types of end-stage lung disease. Frailty is a complex clinical syndrome associated with decreased physiological reserve and an increased risk for suboptimal health outcomes.Area covered: This article reviews the current literature on frailty in lung transplantation, with an emphasis on frailty measures, prevalence and impact of frailty on morbidity and mortality prior to and following lung transplantation. Pubmed, EMBASE, CINAHL and Cochrane systematic review databases were searched to September 2019. The search included the MeSH terms 'frail elderly' or 'frailty' or 'sarcopenia' and 'lung disease' or 'lung transplantation'. Studies were included if: the population were undergoing evaluation for, listed for or received a lung transplant; frailty was prospectively assessed during lung transplant evaluation using systematically defined criteria; used human subjects and; published in English. The prevalence of frailty varied from 0% - 58%. The frailty phenotype and short physical performance battery were the most common measures. Frailty was associated with delisting and death pre-transplantation. Frailty was associated with an increased risk of early mortality post-lung transplantation.Expert opinion: Frailty is identified often in lung transplant candidates and is associated with adverse pre and post-transplantation outcomes. Further research is necessary to identify potential frailty interventions.

6.
ASAIO J ; 66(2): 132-138, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30913099

RESUMO

At fixed speed, the spontaneous increase in pump flow accompanying exercise in patients with continuous flow left ventricular assist devices (cfLVADs) is slight in comparison to normal physiologic response, limiting exercise capacity. We systematically exercised 14 patients implanted with an isolated HeartWare HVAD undergoing routine right heart catheterization at baseline and at maximal safe pump speed. In addition to hemodynamics, mixed venous oxygen saturation (SvO2), echocardiography and noninvasive mean arterial pressure, and heart rate were measured. Significantly greater pump flows were achieved with maximum pump speed compared with baseline speed at rest (mean ± standard deviation [SD]: 5.0 ± 0.7 vs. 4.6 ± 0.8 L/min) and peak exercise (6.7 ± 1.0 vs. 5.9 ± 0.9 L/min, p = 0.001). Pulmonary capillary wedge pressure was significantly reduced with maximum pump speed compared to baseline pump speed at rest (10 ± 4 vs. 15 ± 5 mmHg, p < 0.001) and peak exercise (27 ± 8 vs. 30 ± 8 mmHg, p = 0.002). Mixed venous oxygen saturation decreased with exercise (p < 0.001) but was unaffected by changes in pump speed. In summary, although higher pump speeds synergistically augment the increase in pump flow associated with exercise and blunt the exercise-induced rise in left heart filling pressures, elevated filling pressures and markedly diminished SvO2 persist at maximal safe pump speed, suggesting that physiologic flow increases are not met by isolated cfLVADs in the supported failing heart.

7.
Heart Fail Rev ; 25(2): 195-205, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31222538

RESUMO

To appraise published studies on the use of supplemental oxygen in chronic heart failure. Chronic breathlessness is a characterizing symptom of symptomatic heart failure resulting in substantial disability and healthcare utilization and is the primary reason for emergency room visits and hospitalizations. In spite of the variable evidence, oxygen therapy is commonly administered both acutely and chronically. Moreover, the role of oxygen therapy to relieve chronic breathlessness in heart failure is not well described, particularly in normoxemic or mild or intermittent hypoxemic states. In fact, several studies have shown the detrimental effects of oxygen therapy with normal oxygen saturation levels. A systematic review using PRISMA guidelines. Four databases PubMed, Embase, CINAHL, and Web of Science were systematically searched from January 2001 to January 2019 investigating the use of oxygen in heart failure. Duplicate articles were removed from the review. Titles and abstracts were screened for inclusion and exclusion criteria. The remaining full-text articles were reviewed and hand-searched for additional references. The quality of the full-text articles was assessed using standardized critical appraisal instruments by the Joanna Briggs Institute. A total of 11 studies, including three intervention and eight non-interventions studies, were included in this review from 1072 non-duplicated records retrieved. Sample size ranged from 4 to 5862. In spite of common usage, this review suggests that there are scant data available to justify the use of oxygen in individuals with non-hypoxemic chronic heart failure and chronic breathlessness.

9.
Heart Fail Rev ; 2019 Dec 24.
Artigo em Inglês | MEDLINE | ID: mdl-31873843

RESUMO

To provide a conceptual rationale for targeted self-management strategies for breathlessness in chronic heart failure. Breathlessness is a defining symptom of chronic heart failure and is the primary cause for hospital readmissions and emergency room visits, resulting in extensive health care utilization. Chronic breathlessness, punctuated by acute physiological decompensation, is a sentinel symptom of the heart failure syndrome and often intensifies towards the end of life. Drawing upon evidence-based guidelines, physiological mechanisms and existing conceptual models for the management of breathlessness is proposed. Key elements of this model include adherence to evidence-based approaches (pharmacological and non-pharmacological management to optimize heart failure treatment), self-monitoring of symptoms, identification of modifiable factors (such as fluid overload), and targeted strategies for breathlessness including distraction and gas flow. Self-management is an essential component in heart failure management which could positively influences health outcomes and quality of life. Refining programs to focus on breathlessness may have the potential to reduce symptom burden and improve quality of life.

10.
Heart Lung Circ ; 2019 Sep 23.
Artigo em Inglês | MEDLINE | ID: mdl-31708454

RESUMO

BACKGROUND: The New South Wales (NSW) Heart Failure Snapshot sought to provide a contemporaneous profile of patients admitted with acute heart failure. We have previously reported the baseline results, and this paper reports the 30-day and 12-month outcomes. METHODS: A prospective audit of consecutive patients admitted to 24 teaching hospitals across NSW and the Australian Capital Territory in July-August 2013 with acute heart failure. Follow-up data were obtained by integration of hospital administrative records and follow-up phone calls with the patients. RESULTS: Eight hundred eleven (811) patients were recruited across the 24 sites. The NSW HF Snapshot was an elderly cohort (77 ± 14 yrs) with high comorbidity (mean Charlson Comorbidity Index 3.5 ± 2.6), and 71% were frail at baseline. Twenty-four per cent (24%) of patients were readmitted within 30-days post discharge. One hundred seventy-eight (178) patients died within 12 months post discharge. The independent predictors of death were frailty (Hazard Ratio 1.98 [95% Confidence interval 1.18-3.30]; p < 0.01) Charlson Comorbidity Index (HR 1.06 [95% CI 1.00-1.13]; p = 0.05); New York Heart Association (NYHA) class 4 (HR 2.62 [95% CI 1.32-5.22]; p < 0.01); eGFR<30 ml/min/1.73 m2 (HR 2.16 [95% CI 1.45-3.21]; p < 0.01); hypokalaemia at discharge (HR 2.55 [95% CI 1.44-4.51]; p < 0.01) and readmission within 30 days of baseline admission (HR 2.13 [95% CI 1.49-3.13]; p < 0.01). CONCLUSION: In one of the largest prospective audits of acute heart failure outcomes in Australia, we found that short-term readmissions and mortality at 12 months remain high but were largely driven by patient-level factors.

12.
Circ Heart Fail ; 12(10): e006191, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31610725

RESUMO

BACKGROUND: Assessment of left ventricular (LV) recovery under continuous-flow LV assist device therapy is hampered by concomitant pump support. We describe derivation of noninvasive pressure-volume loops in continuous-flow LV assist device patients and demonstrate an application in the assessment of recovery. METHODS AND RESULTS: Using pump controller parameters and noninvasive arterial pressure waveforms, central aortic pressure, outflow conduit pressure gradient, and instantaneous LV pressure were calculated. Instantaneous LV volumes were calculated from echocardiographic LV end-diastolic volume accounting for the integral of pump flow with respect to time and aortic ejection volume derived from the pump speed waveform. Pressure-volume loops were derived during pump speed adjustment and following bolus intravenous milrinone to assess changes in loading conditions and contractility, respectively. Fourteen patients were studied. Baseline noninvasive LV end-diastolic pressure correlated with invasive pulmonary arterial wedge pressure (r2=0.57, root mean square error 5.0 mm Hg, P=0.003). Measured noninvasively, milrinone significantly increased LV ejection fraction (40.3±13.6% versus 36.8±14.2%, P<0.0001), maximum dP/dt (623±126 versus 555±122 mm Hg/s, P=0.006), and end-systolic elastance (1.03±0.57 versus 0.89±0.38 mm Hg/mL, P=0.008), consistent with its expected inotropic effect. Milrinone reduced myocardial oxygen consumption (0.15±0.06 versus 0.16±0.07 mL/beat, P=0.003) and improved myocardial efficiency (43.7±14.0% versus 41.2±15.5%, P=0.001). Reduced pump speed caused increased LV end-diastolic volume (190±80 versus 165±71 mL, P<0.0001) and LV end-diastolic pressure (14.3±10.2 versus 9.9±9.3 mm Hg, P=0.024), consistent with a predictable increase in preload. There was increased myocardial oxygen consumption (0.16±0.07 versus 0.14±0.06 mL O2/beat, P<0.0001) despite unchanged stroke work (P=0.24), reflecting decreased myocardial efficiency (39.2±12.7% versus 45.2±17.0%, P=0.003). CONCLUSIONS: Pressure-volume loops are able to be derived noninvasively in patients with the HeartWare HVAD and can detect induced changes in load and contractility.

14.
Br J Clin Pharmacol ; 85(12): 2772-2783, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31471973

RESUMO

AIMS: Metformin may have clinical benefits in dialysis patients; however, its safety in this population is unknown. This systematic review evaluated the safety of metformin in dialysis patients. METHODS: MEDLINE, Embase, CENTRAL, PsycINFO and the Cochrane Library were searched for randomised controlled trials and observational studies evaluating metformin use in dialysis patients. Three authors reviewed the studies and extracted data. The primary outcomes were mortality, occurrence of lactic acidosis and myocardial infarction (MI) in patients taking metformin during dialysis treatment for ≥12 months (long term). Risk of bias was assessed using Risk Of Bias In Nonrandomised Studies of Interventions (ROBINS-1). Overall quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS: Fifteen observational studies were eligible; 7 were prospective observational studies and 8 were case reports/case series. No randomised controlled trials were identified. The 7 prospective observational studies (n = 194) reported on cautious metformin use in patients undergoing maintenance dialysis. Only 3 provided long-term follow-up data. In 2 long-term studies of metformin therapy (≤1000 mg/d) in patients undergoing peritoneal dialysis (PD), 1 reported 6 deaths (6/83; 7%) due to major cardiovascular events (3 MI) and the other reported no deaths (0/35). One long-term study of metformin therapy (250 mg to 500 mg thrice weekly) in patients undergoing haemodialysis reported 4 deaths (4/61; 7%) due to major cardiovascular events (2 MI). These findings provide very low-quality evidence as they come from small observational studies. CONCLUSION: The evidence regarding the safety of metformin in people undergoing dialysis is inconclusive. Appropriately designed randomised controlled trials are needed to resolve this uncertainty.

15.
Transplantation ; 2019 Aug 02.
Artigo em Inglês | MEDLINE | ID: mdl-31397799

RESUMO

BACKGROUND: Frailty is a clinically recognized syndrome of decreased physiological reserve and a key contributor to suboptimal clinical outcomes in various lung disease groups. Interstitial lung disease (ILD) is fast approaching chronic obstructive pulmonary disease (COPD) as the number one indication for lung transplantation worldwide. Our aim was to assess whether frailty is a predictor of mortality in patients with interstitial lung disease referred for lung transplantation in an Australian cohort. METHODS: Consecutive patients with ILD referred or on the waiting list for lung transplantation from May 2013 to December 2017 underwent frailty assessment using the modified Fried Frailty Phenotype (FFP). Frailty was defined as a positive response to three or more of the following five components; weak grip strength, slowed walking speed, poor appetite, physical inactivity and exhaustion. RESULTS: 100 patients (82M: 18F; age 59 ± 7 years, range 30 - 70) underwent frailty assessment. 24 / 100 (24%) were assessed as frail. Frailty was associated with anemia, hypoalbuminemia, low creatinine and the use of supplemental oxygen (all p<0.05). Frailty was independent of age, gender, measures of pulmonary dysfunction (PaO2, FVC % predicted, TLC, TLC % predicted, DLCO or DLCO % predicted), cognitive impairment or depression. Frailty and DLCO % predicted were independent predictors of increased all-cause mortality: one-year actuarial survival was 86% ± 4% in the nonfrail group compared with 58% ± 10% for the frail group (p = 0.002) . CONCLUSIONS: Frailty is common among patients referred for lung transplant with a diagnosis of ILD and is associated with a marked increase in mortality.

16.
J Thorac Dis ; 11(Suppl 6): S938-S945, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31183173

RESUMO

Recent advancement in organ perfusion technology has led to increase clinical transplantation of marginal donor organs and allow for distant procurement of cardiac allograft beyond the time limitation of cold static storage. Ex-situ heart perfusion also provides essential nutrients to maintain cell integrity, thereby reducing the risk of ischaemic injury for functional preservation and provides a platform to assess organ viability and feasibility, with the potential for pharmacotherapy to recover these hearts. Notably, the use of NMP has led to the first distant procurement cardiac transplantation from a donation after circulatory death (DCD) in 2014, which resulted in the adoption of DCD heart transplantation in 4 centres between the United Kingdom and Australia. To date, over 100 DCD heart transplants have been performed utilising cardiac perfusion system with an estimated 10-15% increase in transplant activity in the individual units. This review aims to provide an overview of current experience and outcomes using cardiac perfusion technology, including future technologies and recent advancement within the field.

17.
Transplant Direct ; 5(5): e450, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31165085

RESUMO

Background: Type 2 diabetes mellitus (T2DM) is prevalent in patients undergoing heart transplant, and in those without preexisting T2DM, posttransplant diabetes mellitus may develop. Both T2DM and posttransplant diabetes mellitus have been associated with increased morbidity and mortality following heart transplantation. Empagliflozin is an effective glucose-lowering therapy that reduces the incidence of major cardiovascular events in patients with T2DM. The safety and efficacy of empagliflozin in transplant patients with diabetes mellitus has yet to be established. Methods: Clinical outcomes were retrospectively examined in 22 heart transplant recipients treated with empagliflozin and compared with those of 79 heart transplant patients with diabetes mellitus receiving alternative glucose-lowering therapies. Results: Three adverse events were recorded in empagliflozin-treated patients, leading to treatment discontinuation in 1. There were no genitourinary infections. Treatment with empagliflozin for 12 months was associated with reductions in weight, body mass index, glycated hemoglobin, and frusemide dose that were not seen in the control group. There were no large changes observed in blood pressure (systolic or diastolic) or renal function (serum urea, creatinine, or estimated glomerular filtration rate) after 12 months of treatment with empagliflozin or alternative glucose-lowering therapies. Conclusions: Empagliflozin appears safe and effective in the management of selected patients with diabetes mellitus following heart transplantation.

19.
J Am Coll Cardiol ; 73(12): 1447-1459, 2019 04 02.
Artigo em Inglês | MEDLINE | ID: mdl-30922476

RESUMO

BACKGROUND: Transplantation of hearts retrieved from donation after circulatory death (DCD) donors is an evolving clinical practice. OBJECTIVES: The purpose of this study is to provide an update on the authors' Australian clinical program and discuss lessons learned since performing the world's first series of distantly procured DCD heart transplants. METHODS: The authors report their experience of 23 DCD heart transplants from 45 DCD donor referrals since 2014. Donor details were collected using electronic donor records (Donate Life, Australia) and all recipient details were collected from clinical notes and electronic databases at St. Vincent's Hospital. RESULTS: Hearts were retrieved from 33 of 45 DCD donors. A total of 12 donors did not progress to circulatory arrest within the pre-specified timeframe. Eight hearts failed to meet viability criteria during normothermic machine perfusion, and 2 hearts were declined due to machine malfunction. A total of 23 hearts were transplanted between July 2014 and April 2018. All recipients had successful implantation, with mechanical circulatory support utilized in 9 cases. One case requiring extracorporeal membrane oxygenation subsequently died on the sixth post-operative day, representing a mortality of 4.4% over 4 years with a total follow-up period of 15,500 days for the entire cohort. All surviving recipients had normal cardiac function on echocardiogram and no evidence of acute rejection on discharge. All surviving patients remain in New York Heart Association functional class I with normal biventricular function. CONCLUSIONS: DCD heart transplant outcomes are excellent. Despite a higher requirement for mechanical circulatory support for delayed graft function, primarily in recipients with ventricular assist device support, overall survival and rejection episodes are comparable to outcomes from contemporary brain-dead donors.


Assuntos
Causas de Morte , Transplante de Coração , Choque , Coleta de Tecidos e Órgãos , Obtenção de Tecidos e Órgãos , Adulto , Austrália , Seleção do Doador/métodos , Feminino , Sobrevivência de Enxerto , Transplante de Coração/métodos , Transplante de Coração/estatística & dados numéricos , Humanos , Masculino , Coleta de Tecidos e Órgãos/métodos , Coleta de Tecidos e Órgãos/estatística & dados numéricos , Obtenção de Tecidos e Órgãos/métodos , Obtenção de Tecidos e Órgãos/organização & administração
20.
Transplantation ; 103(5): 875-889, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30801513

RESUMO

Over the last decade, organ donation and transplantation rates have increased in Australia and worldwide. Donor and recipient characteristics for most organ types have generally broadened, resulting in the need to consider more complex data in transplant decision-making. As a result of some of these pressures, the Australian software used for donor and recipient data management is currently being updated. Because of the in-built capacity for improved data management, organ allocation processes will have the opportunity to be significantly reviewed, in particular the possible use of risk indices (RIs) to guide organ allocation and transplantation decisions. We aimed to review RIs used in organ allocation policies worldwide and to compare their use to current Australian protocols. Significant donor, recipient, and transplant variables in the indices were summarized. We conclude that Australia has the opportunity to incorporate greater use of RIs in its allocation policies and in transplant decision-making processes. However, while RIs can assist with organ allocation and help guide prognosis, they often have significant limitations which need to be properly appreciated when deciding how to best use them to guide clinical decisions.


Assuntos
Tomada de Decisões , Técnicas de Apoio para a Decisão , Transplante de Órgãos/normas , Alocação de Recursos/métodos , Aloenxertos/estatística & dados numéricos , Austrália , Humanos , Transplante de Órgãos/estatística & dados numéricos , Prognóstico , Alocação de Recursos/normas , Medição de Risco/métodos , Software , Obtenção de Tecidos e Órgãos/normas , Obtenção de Tecidos e Órgãos/estatística & dados numéricos , Resultado do Tratamento , Listas de Espera
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