Post-discharge rise in BNP and rehospitalization for heart failure.

BACKGROUND: The B­type natriuretic peptide (BNP) level on discharge of patients hospitalized with decompensated heart failure (HF) is widely considered as the "baseline" value, and treatment should be targeted to maintain this level. The prognostic value of an increase in BNP level from discharge to the 1­month follow-up in predicting rehospitalization has not been previously explored. METHODS: The Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial data were utilized to determine whether an increase in BNP level from discharge to the 1­month follow-up is associated with a higher risk of rehospitalization. The study endpoints were all-cause rehospitalization up to 6 months following randomization. RESULTS: Among 44 patients (mean age, 56 years, 71% men) who had their BNP levels checked on discharge and at the 1­month follow-up, the average BNP level on discharge of the whole cohort was 467 pg/ml, which increased to 919 pg/ml at 1 month (p = 0.001). The median and interquartile range of the magnitude of rise in BNP level from discharge to 1­month follow-up was higher in rehospitalized compared with non-rehospitalized patients (329 [11, 956] vs. 44 [-90, 316] pg/ml, p = 0.039, in both groups, respectively). Receiver operator characteristic curves showed that the magnitude of the rise in BNP from discharge to the 1­month follow-up had an area under the curve of 0.686 (p = 0.0255) in predicting all-cause rehospitalization. Rehospitalized and non-rehospitalized patients had similar degree of clinical congestion and comparable BNP level on hospital discharge. CONCLUSION: The magnitude of the rise in BNP level from discharge to the 1­month follow-up is a useful prognostic factor that predicts rehospitalization in patients with HF.

Longer-than-average length of stay in acute heart failure : Determinants and outcomes.

BACKGROUND: Increased length of stay (LOS) during acute heart failure (HF) hospitalization is associated with readmission and mortality. METHODS: The ESCAPE trial data were utilized to identify determinants and post-discharge outcomes of patients with acute systolic HF requiring longer-than-average LOS (≥7 days). The study endpoints were 6­month all-cause mortality, all-cause rehospitalization, and the composite endpoint of death, cardiac rehospitalization, and cardiac transplant. RESULTS: Among the 424 patients with recorded LOS, 216 (50.9%) and 208 (49.1%) had LOS ≥ or <7 days, respectively. Independent determinants of longer-than-average LOS included older age (OR per 10-year increase: 1.759, 95% CI: 1.120-2.763, p = 0.014), higher blood urea nitrogen (OR per 5 mg/dl increase: 1.202, 95% CI: 1.024-1.410, p = 0.024), greater inferior vena cava diameter (OR per 1 cm increase: 2.453, 95% CI: 1.175-5.121, p = 0.017), and lower sodium (OR per 4 mmol/l increase: 0.494, 95% CI: 0.268-0.911, p = 0.024). We found a significant correlation between right-sided failure (right atrial pressure) and LOS (r = 0.229, p = 0.001) but not left-sided failure (pulmonary capillary wedge pressure, r = 0.099, p = 0.177). Patients with longer-than-average LOS had a significantly higher mortality (25.9% vs. 12%, univariate OR: 2.562, 95% CI: 1.528-4.296, p < 0.001), higher all-cause rehospitalization (63% vs. 53.4%, univariate OR: 1.486, 95% CI: 1.008-2.190, p = 0.046) and higher frequency of the composite endpoint of death, cardiac rehospitalization, and cardiac transplant (61.6% vs. 45.2%, univariate OR: 1.943, 95% CI: 1.320-2.862, p = 0.001) compared with an LOS of <7 days. Cox proportional hazard analysis showed that a longer-than-average LOS was an independent predictor of 6­month all-cause mortality (HR: 1.930, 95% CI: 1.112-3.350, p = 0.019). CONCLUSION: In acute HF, right ventricular failure and renal dysfunction predict longer-than-average LOS, which is a proxy for more severe HF and is associated with worse postdischarge outcomes.

Extent of jugular venous distension and lower extremity edema are the best tools from history and physical examination to identify heart failure exacerbation.

INTRODUCTION: We aimed to identify the best tools from history and physical examination that predict severity of heart failure (HF) exacerbation among patients with an ejection fraction (EF) ≤ 30%. METHODS: Patients enrolled in the ESCAPE trial were divided into tertiles according to the combined value of pulmonary capillary wedge pressure (PCWP) and right atrial pressure (RAP) which we used as a marker of volume loading of both pulmonary and systemic compartments. Variables of congestion from history and physical examination were examined across tertiles. RESULTS: There were significant differences across tertiles (tertile 1: PCWP + RAP < 31 mm Hg, tertile 2: PCWP + RAP 31-42 mm Hg and tertile 3: PCWP + RAP > 42 mm Hg) with respect to baseline B­type natriuretic peptide (P = 0.016), blood urea nitrogen (P = 0.022), sodium (P = 0.015), left ventricular ejection fraction (P = 0.005), and inferior vena cava diameter during inspiration (P < 0.001) and expiration (P < 0.001). With respect to variables of congestion from history and physical examination, we found significant differences across tertiles predominantly in signs of right sided failure, specifically, the frequency of jugular venous distension (JVD, P < 0.001) and JVD > 12 cmH2O (p < 0.001), lower extremity edema (P = 0.001) and lower extremity edema of at least grade 2 + (P = 0.029), and positive hepatojugular reflux (HJR, P = 0.022) but no differences in patients' symptoms such as degree of dyspnea, orthopnea or fatigue. With regards to post-discharge outcomes, there was a significant difference across tertiles in all-cause mortality (P = 0.029) and rehospitalization for HF (P = 0.031) at 6 months following randomization. Receiver operator characteristic curves showed that admission PCWP + RAP had an area under the curve of 0.623 (P = 0.0075) and 0.617 (P = 0.0048), respectively, in predicting 6­month all-cause mortality and rehospitalization for HF. CONCLUSION: The presence and extent of JVD and lower extremity edema, and a positive HJR are better than other signs and symptoms in identifying severity of HF exacerbation among patients with EF ≤ 30%.

Admission-to-discharge temperature reduction in decompensated heart failure is associated with rehospitalization.

INTRODUCTION: Decreasing body temperature on first follow-up visit-relative to discharge-predicts early rehospitalization in heart failure (HF). We studied whether admission-to-discharge temperature reduction was associated with increased HF rehospitalization in the ESCAPE trial. METHODS: We compared patients with or without ≥1 °C decrease in temperature from admission-to-discharge. The study endpoint was rehospitalization due to HF for up to 6 months after discharge. RESULTS: Among 354 patients (average age 57 years, 73% men) with recorded admission and discharge temperature, 22 (6.2%) had an admission-to-discharge temperature reduction ≥1 ºC. Patients with admission-to-discharge temperature reduction ≥1 ºC had higher frequency of rehospitalization for HF (68.2% vs. 44.3%, estimated odds ratio [OR] 2.697, 95% confidence interval [CI] 1.072-6.787, P = 0.029) despite a significantly higher admission temperature. On multivariate analysis, admission-to-discharge temperature reduction ≥1 ºC predicted rehospitalization for HF (OR 2.02, 95% CI 1.028-3.966, P = 0.041) after adjustment for age, BMI, baseline Na, creatinine, ejection fraction and discharge NYHA class. A standard logistic model treating temperature change as a continuous variable, and a model using a restricted cubic spline, did not demonstrate a statistically significant relationship between temperature reduction and HF rehospitalization. Subsequently, an altered logistic model was fit expressing the log odds of HF rehospitalization as a piecewise linear function of temperature decrease; this model did demonstrate statistical significance (P = 0.013) with an estimated odds ratio of 1.140 per 0.1 ºC beyond 0.5 ºC. CONCLUSION: Admission-to-discharge temperature reduction ≥1 ºC is an unfavorable prognostic sign associated with future rehospitalization due to HF.

Rise in BNP despite appropriate acute decompensated heart failure treatment : Patient characteristics and outcomes.

INTRODUCTION: B-type natriuretic peptide (BNP) tends to decrease in response to successful treatment of decompensated heart failure (HF). We identified characteristics and outcomes of patients whose BNP levels rise during admission despite appropriate decongestive therapy. METHODS: Patients enrolled in the ESCAPE trial admitted with acute systolic HF were divided into two groups according to whether or not BNP increased during the period from admission (T0) to discharge (T1). The study endpoint was 6­month all-cause mortality. RESULTS: Of 245 patients (age 56 years, 75 % men) admitted with acute systolic HF, 67 (27.3 %) had a higher BNP at T1 relative to T0. Despite similar degrees of congestion at T0, patients with BNP rise at T1 had less degree of decongestion from T0 to T1 as evident in the lower frequency of patients who had resolution of jugular venous distension (39.7 vs. 59.5 %, P = 0.01) and orthopnea (32.2 vs. 48.8 %, P = 0.029) at T1, in addition to lower reduction in IVC diameter during inspiration (P = 0.001) and expiration (P = 0.002) and less weight loss (P = 0.04). Patients with BNP rise at T1 were more likely to die (29.9 vs. 15.7 %, univariate OR 2.28, 95 % CI 1.177-4.414, P = 0.015) despite a lower BNP at T0 (492 vs. 1260 pg/ml, P < 0.001). Cox proportional hazard analysis revealed that a higher BNP at T1 independently predicts 6­month mortality (hazard ratio 1.95, 95 % CI 1.067-3.578, P = 0.03) after adjustment for age, sodium, creatinine, and NYHA class-all at discharge. Kaplan-Meier analysis comparing survival in patients with or without BNP rise on discharge showed a significant intergroup difference (log-rank P value = 0.017). CONCLUSION: Higher BNP levels on discharge identifies a subset of patients with lower degree of decongestion from T0 to T1 and higher 6­month mortality.

The value of occlusive balloons in the management of abnormal placentation: A retrospective study.

Abnormal placentation is a potential cause of maternal morbidity and mortality from massive postpartum bleeding. The objective of this study was to investigate the efficacy of occlusive balloons when used as an adjunct to surgery in reducing blood loss and transfusion requirements. A retrospective study of 42 patients was performed involving consecutive cases of abnormal placentation who delivered with either conventional surgery with preoperatively placed occlusive balloons or conventional surgery alone. No differences were noted between the control group and the group of patients who had occlusive balloons with regard to estimated blood loss (P = 0.767), packed red blood cells transfused (P = 0.799), amount of crystalloids infused (P = 0.435), total procedure duration (P = 0.076), and length of ICU stay (P = 0.315) or total hospital stay (P = 0.254). Prophylactic intravascular balloon catheters did not benefit women with abnormal placentation when compared with conventional surgery alone.

The value of coronary angiography in the work-up of atrial myxomas.

Atrial myxomas are the most common primary cardiac tumors. They are highly vascular with evidence of neovascularization and a characteristic"tumor blush" in approximately half of the cases. Although the visualization of feeding vessels has several clinical and therapeutic implications, there is still no consensus on the indication of preoperative coronary angiography to assess tumor vascularity except in patients with angina or those older than 40 years to rule out coronary artery disease. Herein, I present a case of an incidentally discovered right atrial mass receiving vascular supply from the right coronary artery. The mass was successfully excised and the diagnosis of cardiac myxoma was confirmed via histopathology. A review of the value of coronary angiography in detecting myxoma neovascularization is provided, which suggests that it can offer additional valuable information that can alter the surgical approach and therefore may be considered prior to myxoma resection.

Underutilization of Donor Hearts: An Observational Study.

BACKGROUND: Utilization of donor hearts remains insufficient. In this observational study, we explored the rate and reasons of rejection of cardiac donors in 1 organ procurement organization. METHODS: Donors were enrolled in the study for 1 year, from October 5, 2014, through October 4, 2015. Data on demographics, medical history, and diagnostic tests were collected. We compared continuous variables between groups using a Mann-Whitney U test, and categorical variables using the χ2test. Multivariate logistic regression analysis was performed to identify factors predicting transplantation. RESULTS: Of 134 adult hearts, only 39.5% were transplanted. Moreover, almost half (46.9%) of non-transplanted hearts were normal by all data available. In 12 (31.5%) of all hearts, coronary artery disease was discovered by pathology, making them unusable for transplantation. Overall, 26 normal hearts (19.4%) were not accepted for transplantation. The most common abnormality of hearts not suitable for transplantation was a decreased left ventricular ejection fraction (LVEF). In about one-fifth of donors with low LVEF on the first echocardiogram, LVEF improved on a second echocardiogram. In a majority of cases with low LVEF, echocardiogram was never repeated. CONCLUSIONS: Almost 20% of normal donor hearts were not transplanted. Coronary artery disease was the most common abnormality in seemingly normal hearts. Coronary angiography should be performed more liberally in potential donors. Decreased LVEF was the most common reason for not using a heart. Since impaired LVEF may be reversible, repeated echocardiogram is encouraged in order to maximize the rate of transplantation.