Executive Summary: HFSA 2010 Comprehensive Heart Failure Practice Guideline

Time of eating and mortality in U.S. adults with heart failure: Analyses of the National Health and Nutrition Examination Survey 2003-2018

BACKGROUND AND AIMS

Promising associations have been demonstrated between delayed last eating occasion and cardiorespiratory fitness in adults with heart failure (HF), however, it is unknown if time of eating is associated with clinical endpoints such as mortality. This study aimed to examine associations between time of eating variables and all-cause and cardiovascular mortality in the National Health and Nutrition Examination Survey (NHANES).

METHODS AND RESULTS

Participants self-disclosed HF diagnosis. Two dietary recalls were obtained and categorical variables were created based on mean time of first eating occasion (8:31 AM), last eating occasion (7:33 PM) and eating window (11.02 h). Mortality was obtained through linkage to the National Death Index. Covariate-adjusted Cox proportional hazard regression models were created examining the association between time of eating and mortality. Participants (n = 991) were 68 (95 % CI 67-69) years of age, 52.6 (95 % CI 49.0-56.3)% men and had a body mass index of 32.5 (95 % CI 31.8-33.2) kg/m2 with follow up time of 68.9 (95 % CI 64.8-72.9) person-months. When models were adjusted for time of eating variables and all other covariates, extending the eating window beyond 11.02 h was associated with decreased risk of cardiovascular (HR 0.36 [95 % CI 0.16-0.81]), but not all-cause mortality. Time of first and last eating occasions were not associated with mortality.

CONCLUSIONS

In adults with HF, an extended eating window is associated with reduced risk for cardiovascular mortality. Randomized controlled trials should examine if extending the eating window can improve prognostic indicators such as cardiorespiratory fitness in this population.

Depression, anxiety, and quality of life as predictors of rehospitalization in patients with chronic heart failure

BACKGROUND

Chronic heart failure (CHF) is a severe condition, often co-occurring with depression and anxiety, that strongly affects the quality of life (QoL) in some patients. Conversely, depressive and anxiety symptoms are associated with a 2-3 fold increase in mortality risk and were shown to act independently of typical risk factors in CHF progression. The aim of this study was to examine the impact of depression, anxiety, and QoL on the occurrence of rehospitalization within one year after discharge in CHF patients.

METHODS

148 CHF patients were enrolled in a 10-center, prospective, observational study. All patients completed two questionnaires, the Hospital Anxiety and Depression Scale (HADS) and the Questionnaire Short Form Health Survey 36 (SF-36) at discharge timepoint.

RESULTS

It was found that demographic and clinical characteristics are not associated with rehospitalization. Still, the levels of depression correlated with gender (p ≤ 0.027) and marital status (p ≤ 0.001), while the anxiety values ​​were dependent on the occurrence of chronic obstructive pulmonary disease (COPD). However, levels of depression (HADS-Depression) and anxiety (HADS-Anxiety) did not correlate with the risk of rehospitalization. Univariate logistic regression analysis results showed that rehospitalized patients had significantly lower levels of Bodily pain (BP, p = 0.014), Vitality (VT, p = 0.005), Social Functioning (SF, p = 0.007), and General Health (GH, p = 0.002). In the multivariate model, poor GH (OR 0.966, p = 0.005) remained a significant risk factor for rehospitalization, and poor General Health is singled out as the most reliable prognostic parameter for rehospitalization (AUC = 0.665, P = 0.002).

CONCLUSION

Taken together, our results suggest that QoL assessment complements clinical prognostic markers to identify CHF patients at high risk for adverse events.

CLINICAL TRIAL REGISTRATION

The study is registered under http://clinicaltrials.gov (NCT01501981, first posted on 30/12/2011), sponsored by Charité - Universitätsmedizin Berlin.

Role of muscle FOXO gene in exercise against the skeletal muscle and cardiac age-related defects and mortality caused by high-salt intake in Drosophila

FOXO has long been associated with aging, exercise, and tissue homeostasis, but it remains unclear what the role is of the muscle FOXO gene in E against high-salt intake(HSI)-induced age-related defects of the skeletal muscle, heart, and mortality. In this research, overexpression and RNAi of the FOXO gene in the skeletal and heart muscle of Drosophila were constructed by building Mhc-GAL4/FOXO-UAS-overexpression and Mhc-GAL4/FOXO-UAS-RNAi system. The skeletal muscle and heart function, the balance of oxidation and antioxidant, and mitochondrial homeostasis were measured. The results showed that exercise reversed the age-related decline in climbing ability and downregulation of muscle FOXO expression induced by HSI. Muscle-specific FOXO-RNAi (FOXO-RNAi) and -overexpression (FOXO-OE) promoted or slowed the age-related decline in climbing ability, heart function, and skeletal muscle and heart structure damage, which was accompanied by the inhibition or activation of FOXO/PGC-1α/SDH and FOXO/SOD pathway activity, and oxidative stress (ROS) increased or decreased in both skeletal muscle and heart. The protective effect of exercise on the skeletal muscle and heart was blocked by FOXO-RNAi in aged HSI flies. FOXO-OE prolonged its lifespan, but it did not resist the HSI-induced lifespan shortening. Exercise did not improve HSI-induced lifespan shortening in FOXO-RNAi flies. Therefore, current results confirmed that the muscle FOXO gene played a vital role in exercise against age-related defects of the skeletal muscle and heart induced by HSI because it determined the activity of muscle FOXO/SOD and FOXO/PGC-1α/SDH pathways. The muscle FOXO gene also played an important role in exercise against HSI-induced mortality in aging flies.

Co-Administration of Albumin and Furosemide in Acute Heart Failure with Diuretics Resistance

Acute heart failure is a frequent cause of hospital admission in Portugal, and has an increasing tendency given the aging population. Although most admissions for acute heart failure are caused by congestive conditions, not all patients have a congestive phenotype, reflecting the complexity of a process with multiple pathophysiological pathways. The use of diuretics, usually loop diuretics, is the mainstay of treatment for congestion. However, many patients develop resistance, thus constituting a challenge with no consensual solution to date, despite extensive debate over the years. Despite its frequent use in clinical practice, the co-administration of albumin and furosemide remains controversial in the management of patients with acute heart failure, hypoalbuminemia, and diuretic resistance. This review addresses the pathophysiological mechanisms of congestion in patients with acute heart failure and explores the theoretical basis that supports the co-administration of albumin and furosemide in this clinical context. It is intended to clarify the potential benefit of the combined approach in this specific population and identify possible gaps in the literature that could be the subject of future studies.

The effects of thiamine supplementation on patients with heart failure: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Micronutrients can benefit patients with heart failure (HF). Thiamine is a critical vitamin, while the impact of thiamine supplementation on patients with HF remains unclear. Systematic review and meta-analysis were conducted to evaluate the effects of thiamine supplementation on clinical outcomes in patients with HF.

METHODS

Databases including Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Scopus, and CNKI were searched from inception to June 29th 2022. Randomized controlled trials (RCTs) comparing thiamine supplementation with placebo were included. Meta-analysis was conducted with the software Review Manager 5.4. The quality assessment was performed according to Cochrane Risk of Bias Tool 2.0.

RESULTS

Eight studies including 384 patients were included in this review. The results of overall systematic review showed no benefit of thiamine supplementation in HF patients. Compared with the control group, the experimental group had no statistically significant improvements in LVEF (Mean Difference, - 0.19; 95 % CI, - 2.78 to 0.96; I² = 49 %; P = 0.10) in patients with chronic heart failure (CHF). Other outcomes including NYHA class, BNP or NT-proBNP, thiamine status, symptom changes, and quality of life were not improved by thiamine supplementation in CHF patients. Similarly, no improvements in clinical outcomes were found in patients with acute heart failure (AHF) in the studies included.

CONCLUSIONS

This systematic review and meta-analysis found no evidence to support the effects of thiamine supplementation in patients with HF, though thiamine supplementation is promising in improving cardiac functions, thiamine status and relieving HF-related symptoms. More well-designed RCTs with large sample sizes are required.

A multidisciplinary approach to heart failure care in the hospital: improving the patient journey

Despite advancements in care for patients with heart failure (HF), morbidity and mortality remain high. Hospitalizations and readmissions for HF have been the focus of significant attention among health care providers and payers, with an eye towards reducing health care costs. However, considerable variability exists with regard to inpatient workflows and management for patients with HF, which represents a significant opportunity to improve care. Here we provide a summary of optimal inpatient management strategies for HF, focusing on the multidisciplinary team of emergency medicine providers, admitting hospitalists, cardiovascular consultants, pharmacists, nurses, and social workers. The patient journey serves as the template for this review article, from the initial presentation in the emergency department, to decongestion and stabilization, optimization of guideline-directed medical therapy, and discharge and appropriate disposition. Lastly, this review aims not to be proscriptive but rather to provide best practices that are clinically relevant and actionable, with the goal of improving care for patients during the sentinel hospitalization for HF.

Prognostic value of 6-min walk test compared to cardiopulmonary exercise test in patients with severe heart failure

AIMS

The 6-min walk test (6MWT) and cardiopulmonary exercise test (CPET) are both predictive in heart failure (HFrEF). Although 6MWT substitutes for CPET in HFrEF patients, as submaximal testing may be preferable, its prognostic superiority still needs to be verified, particularly in regard to beta blockers (BBs). We aimed to compare the prognostic role of CPET and 6MWT and investigate whether BB therapy influences the predictive value.

METHODS

This is a single-center, retrospective study. Advanced HFrEF patients were followed up for 3 years: events were cardiovascular death or urgent heart transplantation. We analyzed the predictive capacity of CPET and 6MWT in patients, and subdivided according to use of BBs.

RESULTS

In a group of 251 HFrEF patients, we found a correlation between meters and peak VO2 (r2 = 0.94). Over the 3-year follow-up, 74 events were recorded. Both CPET and 6MWT variables were correlated with outcome at univariate analysis (meter and VE/VCO2 slope, peak VO2, VO2 at ventilatory anaerobic threshold, percentage predicted of peak VO2), but only percentage predicted of peak VO2 (pppVO2) was an independent predictor. In 103 HFrEF patients on BBs (23 nonsurvivors), neither pppVO2 nor meter were predictive, while in 148 patients not treated with BB (51 with events) pppVO2 was selected as an independent prognostic parameter (P = 0.001).

CONCLUSIONS

6MWT is a valid alternative to CPET, although the percentage of predicted of peak VO2 emerged as the strongest predictor. Nonetheless, our results suggest that both functional derived parameters are not predictive among those patients treated with BBs. Further studies are necessary to confirm these findings.

Biomarkers in Acute Heart Failure Syndromes: An Update

Heart failure is one of the leading healthcare problems in the world. Clinical data lacks sensitivity and specificity in the diagnosis of heart failure. Laboratory biomarkers are a non-invasive method of assessing suspected decompensated heart failure. Biomarkers such as natriuretic peptides have shown promising results in the management of heart failure. The literature does not provide comprehensive guidance in the utilization of biomarkers in the setting of acute heart failure syndrome. Many conditions that manifest with similar pathophysiology as acute heart failure syndrome may demonstrate positive biomarkers. The following is a review of biomarkers in heart failure, enlightening their role in diagnosis, prognosis and management of heart failure.

Towards Predictive Analysis on Disease Progression: A Variational Hawkes Process Model

Massively available longitudinal data about long-term disease trajectories of patients provides a golden mine for the understanding of disease progression and efficient health service delivery. It calls for quantitative modeling of disease progression, which is a tricky problem due to the complexity of the disease progression process as well as the irregularity of time documented in trajectories. In this study, we tackle the problem with the goal of predictively analyzing disease progression. Specifically, we propose a novel Variational Hawkes Process (VHP) model to generalize disease progression and predict future patient states based on the clinical observational data of past disease trajectories. First, Hawkes Process captures the intensity of irregular visits in a trajectory documented on medical facilities and controls the aforementioned information flowing into future visits. Thereafter, the captured intensity is incorporated into a Variational Auto-Encoder to generate the representation of the future partial disease trajectory for a target patient in a predictive manner. To further improve the prediction performance, we equip the proposed model with a disease trajectory discriminator to distinguish the generated trajectories from real ones. We evaluate the proposed model on two public datasets from the MIMIC-III database pertaining to heart failure and sepsis patients, respectively, and one real-world dataset from a Chinese hospital pertaining to heart failure patients with multiple admissions. Experimental results demonstrate that the proposed model significantly outperforms state-of-the-art baselines, and may derive a set of practical implications that can benefit a wide spectrum of management and applications on disease progression.

Impact of hyperthyroidism on in-hospital outcomes of patients with heart failure

Congestive heart failure (CHF) exacerbations are a frequent cause of hospitalization. Thyroid hormones impact myocardial function; elevated levels of thyroxine, as seen in hyperthyroidism (HT), can worsen CHF symptoms. We retrospectively evaluated the Hospital Corporation of America (HCA) Enterprise Data Warehouse and examined mortality and length of stay (LOS) in patients hospitalized with CHF with and without a diagnosis of HT. 55,031 patients with CHF were identified. The presence of HT was not significantly associated with mortality (p = 0.24) nor LOS (p = 0.32). A significant difference in the distribution of sex (p = 0.001) and age (p = 0.002) was noted, with a higher percentage of females and a lower median age in patients with HT. There was a significant difference in LOS (p = 0.04) for patients with a cardiovascular comorbidity, who had a mean LOS of 6.33 days versus 5.31 days for patient without HT.

Drug-Therapy Problems and Predictors among Hospitalized Heart-Failure Patients: A Prospective Observational Study

BACKGROUND

Heart-failure patients are at high risk of experiencing drug-therapy problems, owing to polypharmacy, comorbidities, and usually advanced age. Drug-therapy problems can lead to poor clinical outcomes, increased health-care costs and decreased quality of life, and thus strategies for identifying, resolving, and preventing them are urgently needed. Therefore, this study aimed at investigating the incidence and predictors of drug-therapy problems among hospitalized heart-failure patients.

METHODS

This hospital-based prospective observational study was conducted from February 1 to May 31, 2014 at Jimma University Specialized Hospital. Patients of either sex aged 18 years and above with chronic heart failure and complete medical records were enrolled. Patients with high-output heart failure, <1 day of hospital stay, unwilling to give written informed consent, and unconscious without caregivers were excluded. Data were collected from medication charts, laboratory reports, patients/caregivers, morning multidisciplinary meetings, and ward rounds. Multivariate binary logistic regression analysis was done to identify independent predictors of drug-therapy problems.

RESULTS

A total of 104 heart-failure patients (mean age 51.20±15.66 years, females 51.9%) were consecutively enrolled, and 95 (91.3%) had experienced at least one drug-therapy problem (total 268, mean 2.82±1.39 encounters per patient). Of these problems, 45.5% were the need for additional drugs, followed by noncompliance (22.0%), inappropriate dosing (9.3%), unnecessary drugs (9.0%), ineffective drugs (8.2%), and adverse drug reactions (6.0%). None of the independent variables was found to be an independent predictor of having at least one drug-therapy problem. However, the number of clinical/pharmacological risk factors (AOR 7.93), female sex (AOR 3.24), and length of hospital stay (AOR 12.98) were predictors of noncompliance.

CONCLUSION

Patients suffered from a large number of drug-therapy problems. Drugs with survival benefit were underused. Noncompliance and the need for additional drug therapy were the most frequently identified drug-therapy problems. Numbers of clinical/pharmacological risk factors, length of hospital stay, and female sex were identified as predictors for noncompliance.

Predicting maximal oxygen uptake from the 6 min walk test in patients with heart failure

Aims

A cardiopulmonary exercise (CPX) test is considered the gold standard in evaluating maximal oxygen uptake. This study aimed to evaluate the predictive validity of equations provided by Burr et al., Ross et al., Adedoyin et al., and Cahalin et al. in predicting peak VO₂ from 6 min walk test (6MWT) distance in patients with heart failure (HF).

Methods and Results

New York Heart Association Class I–III HF patients performed a maximal effort CPX test and two 6MWTs. Correlations between CPX VO_{2 peak} and the predicted VO_{2 peak}, coefficient of determination (R²), and mean absolute percentage error (MAPE) scores were calculated. P‐values were set at 0.05. A total of 106 participants aged 62.5 ± 11.5 years completed the tests. The mean VO_{2 peak} from CPX testing was 16.4 ± 3.9 mL/kg/min, and the mean 6MWT distance was 419.2 ± 93.0 m. The predicted mean VO_{2 peak} (mL/kg/min) by Burr et al., Ross et al., Adedoyin et al., and Cahalin et al. was 22.8 ± 8.8, 14.6 ± 2.1, 8.30 ± 1.4, and 16.6 ± 2.8. A significant correlation was observed between the CPX test VO_{2 peak} and predicted values. The mean difference (0.1 mL/kg/min), R² (0.97), and MAPE (0.14) values suggest that the Cahalin et al. equation provided the best predictive validity.

Conclusions

The equation provided by Cahalin et al. is simple and has a strong predictive validity, and researchers may use the equation to predict mean VO_{2 peak} in patients with HF. Based on our observation, equations to predict individual maximal oxygen uptake should be used cautiously.

The Impact of Nurse-Led Cardiac Rehabilitation on Quality of Life and Biophysiological Parameters in Patients With Heart Failure: A Randomized Clinical Trial

BACKGROUND

Cardiovascular diseases are the leading cause of mortality in the Indian subcontinent, accounting for 38% of deaths annually. One cardiovascular disease in particular, heart failure, is a growing public health problem both in India and worldwide.

PURPOSE

Heart failure is a chronic, progressive disease with increasing rates of incidence and prevalence. This study was conducted to determine the influence of a nurse-led cardiac rehabilitation program on quality of life and biophysiological parameters in patients with chronic heart failure. In this study, it was hypothesized that participants in the cardiac rehabilitation program would report significantly more-positive changes in quality of life and biophysiological parameters than their peers who did not participate in this program.

METHODS

In this randomized controlled trial, the participants were patients with chronic heart failure who had been admitted to a tertiary care hospital in India. The participants assigned to the intervention group received both nurse-led cardiac rehabilitation and routine care. In addition, intervention group participants received a booklet on cardiac rehabilitation, Healthy Way to Healthy Heart, at discharge and fortnightly telephone reminders about good cardiac rehabilitation practices. A standard questionnaire was used to collect targeted information on participants' general and disease-specific quality of life at 1 and 3 months postintervention. Biophysiological parameters such as body mass index, blood pressure, and serum cholesterol values were also measured.

RESULTS

Two thirds of the participants in each group (65% in the intervention group and 66% in the control group) were between 51 and 70 years old. The mean score for the mental component summary of generic quality of life steadily decreased in the control group and steadily increased in the intervention group at the first and second posttests.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Nurses working in cardiology units play a pivotal role in educating and managing the health status of patients with heart failure. Providing cardiac rehabilitation to patients with heart failure benefits the quality of life of these patients. Nurses working in cardiology units should encourage patients with heart failure to practice cardiac rehabilitation for a longer period to further improve their quality of life.

Psychometric Features of the Polish Version of TSK Heart in Elderly Patients with Coronary Artery Disease

Background and objectives: Recommendations for the control of stable patients with coronary artery disease (CAD) related to an adequate level of physical activity (PA). Practical experience shows that the PA level in most people with CAD is definitely too low in relation to the guidelines. The cause may be psychological factors and among them the fear of movement-kinesiophobia. The aim of this project was to examine the evaluation of psychometric features of the Polish version of the Tampa Scale for Kinesiophobia Heart (TSK Heart), used in people with CAD. Materials and methods: The study involved 287 patients with stable CAD: 112 women and 175 men. Age: 63.50 (SD = 11.49) years. Kinesiophobia was assessed using TSK Heart, physical activity (PA)-using the International Physical Activity Questionnaire (IPAQ), and anxiety and depression was examined using the Hospital Anxiety and Depression Scale (HADS). The structure of TSK was examined using principal component analysis (PCA), internal cohesion (Cronbach's alpha, AC), and content validity was calculated by linear regression. Results: PCA showed a three-factor TSK structure. One-dimensionality and satisfactory reliability were found: TSK Heart: AC = 0.878. Kinesiophobia as a predictor of PA: R2 = 0.162 (p = 0.000000). Anxiety and depression-TSK: R2 = 0.093 (p = 0.00000). Conclusions: The Polish version of TSK Heart for cardiac patients is characterized by good psychometric features. The use of it can improve the cooperation of rehabilitation teams for patients with CAD.

Nurses as educators in the comprehensive heart failure care programme-Are we ready for it?

Aim

To assess education frequency and nurses' comfort when educating patients hospitalized in different hospital units to prepare them for self-care.

Design

A cross-sectional survey. The study included nurses working in units where HF patients were hospitalized.

Results

The average score for comfort of education was 5.43 (between "slightly comfortable" and "very comfortable"). The most comfortable topics were "Daily weight monitoring" (5.81 ± 1.25), "Signs/symptoms of worsening condition" (5.77 ± 1.19) and "Fluid restriction" (5.76 ± 1.23). The respondents felt least comfortable when teaching about "Medications" (5.06 ± 1.35) and "Low-sodium diet" (5.31 ± 1.42). The mean score obtained for education frequency was 5.21 (SD 2.51). The nurses most frequently educated their patients on such topics as "Daily weight monitoring" (5.82), "Signs/symptoms of worsening condition" (5.9) and "Fluid restriction" (5.92).

Conclusions

Polish nurses are not ready to perform comprehensive HF care tasks without preparation.

A Tailored Dietary Sodium Intervention Using Technology and Psychosocial Support: A Pilot Study

BACKGROUND

In patients with heart failure (HF), high dietary sodium intake is common and associated with HF symptoms, poor health-related quality of life (HRQOL), and high hospitalization rates.

PURPOSE

The aims of this study were to examine the feasibility of a tailored dietary intervention with a practical tool (MyFitnessPal) and to obtain preliminary data about the effects on sodium intake, factors affecting sodium intake (knowledge, skills, experiences, confidence, perceived benefits and barriers, and depressive symptoms), HF symptoms, and HRQOL.

METHODS

A 6-session intervention was delivered to 11 participants. Paired t tests were used to compare the baseline outcomes with those at 3 months.

RESULTS

Participants completed 98% of intervention sessions, and 91% used MyFitnessPal. Sodium intake was reduced, and factors affecting sodium intake, symptoms, and HRQOL were improved (all P < .05).

CONCLUSION

The intervention was feasible and warrants further research to test the effects of the intervention on the outcomes using larger, heterogeneous samples.

Life and priorities before death: A narrative inquiry of uncertainty and end of life in people with heart failure and their family members

BACKGROUND

Most patients with advanced heart failure are ill-prepared and poorly supported during the end of life. To date, research has focused primarily on generalized patient accounts of the management or self-care phase of the syndrome. Little research has examined the end of life in depth or from the perspectives of family members.

AIMS

The purpose of this study is to describe how people diagnosed with heart failure and their family members describe uncertainty related to impending death.

METHODS AND RESULTS

A narrative inquiry was undertaken using a social constructionist perspective. Twenty participants took part in over 60 interviews: 12 participants with heart failure (eight male and four female; mean = 67.3 years) and eight family members (mean = 61.6 years) engaged in two in-depth interviews, approximately 3-4 months apart, followed by a telephone follow-up 2-3 months later. Six key themes/storylines were identified. These included: prognosis messages received from physicians; whenever I die, I die; loss isn't new to me but … ; carrying on amidst the fragility of life; ultimately living not knowing; and the need to prepare.

CONCLUSION

The six key storylines of death and dying with advanced heart failure were consistent for both patients and family members. There was a desire for better communication with physicians. Many participants were critical of how the prognosis of advanced heart failure was communicated to them, even if they anticipated the news. Participants wanted frank, open conversations with their healthcare providers that both acknowledged that they were at end of life but did not remove all hope.

Sudden cardiac death in patients with myocarditis: Evaluation, risk stratification, and management

Myocarditis is a major cause of sudden cardiac death (SCD) and dilated cardiomyopathy (DCM) in young adults. Cardiac magnetic resonance is the established tool for the diagnosis of myocarditis, and late gadolinium enhancement detected on cardiac magnetic resonance imaging is the strongest independent predictor of SCD, all-cause mortality, and cardiac mortality. Several other factors have been associated with SCD or cardiac transplantation including New York Heart Association functional class III/IV, reduced left ventricular ejection fraction <35%, and right ventricular ejection fraction ≤45%. A fragmented QRS and a prolonged QTc interval on an electrocardiogram are predictors of VAs. The postulated mechanism of VA in acute myocarditis is ion channel dysfunction and inflammation that alter intracellular signaling, producing interstitial edema and fibrosis and thereby causing conduction abnormalities. VAs in chronic myocarditis are generally due to scar-mediated reentry. Treatment of myocarditis is tailored toward supportive care and symptomatic relief. The subset of patients who develop DCM should be treated with heart failure medications according to professional guideline recommendations. Indications for an implantable cardioverter-defibrillator are similar to those for nonischemic cardiomyopathy; however, an implantable cardioverter-defibrillator should be held in the acute phase of myocarditis to allow left ventricular ejection fraction recovery, and a wearable cardioverter-defibrillator may be beneficial for some patients. Antiarrhythmic medications are reserved for patients with symptomatic nonsustained or sustained VAs. Radiofrequency ablation appears to be an effective treatment option for VAs; however, more data on its safety and effectiveness are needed. This review addresses risk factors of SCD and VAs in patients with myocarditis with special emphasis on treatment and prevention of these outcomes.

Adherence to diet and medication and the associated factors among patient with chronic heart failure in a multi-ethnic society

OBJECTIVE

To investigate diet adherence, medication adherence and self-care behaviour among patients with chronic heart failure (CHF) in a multi-ethnic society and identify the significant factors associated with their diet and medication adherence.

METHODS

A cross-sectional descriptive correlational study was conducted with a convenience sample of 107 patients with CHF recruited from two cardiology wards of a public tertiary hospital in Singapore. Study variables were measured using the Dietary Sodium Restriction Questionnaire, the Medication Adherence Rating Scale-5 items and the European Heart Failure Self-care Behaviour Scale-12 items.

RESULTS

Our sample reported positive attitudes towards diet adherence, poor self-care behaviour, and good medication adherence. The multiple linear regression results indicated that lower income, Chinese ethnicity, diabetic complications, current smoking, lower New York Heart Association classification I and II, and poorer self-care behaviour predicted poorer diet adherence. In addition, absence of hypertension, having non-myocardial infarction as a cause of CHF, and moderately diminished ejection fraction were identified as significant predictors of poorer medication adherence.

CONCLUSION

The findings from this study have established the need to improve current education and rehabilitation programmes for patients with CHF by addressing those factors significantly influencing their adherence to diet and medication.

Technology Solutions to Support Care Continuity in Home Care: A Focus Group Study

BACKGROUND

Elevated hospital readmission rates from home care are an indicator of poor care quality, and rates are particularly high for patients with heart failure. Readmissions may be avoided by optimizing continuity of care.

PURPOSE

To explore perceptions among home care clinicians of the barriers they face and the information they need to improve care continuity for patients with heart failure.

METHODS

Focus groups were conducted with teams of home care clinicians at a large certified home healthcare agency in the Northeastern United states.

RESULTS

In total, there were 61 participants across 6 focus groups. Three overarching themes emerged: continuity of care and communication on care transitions, maintaining continuity of care during a home care episode (with subthemes tracking signs and symptoms and patient teaching), and health information technology (HIT) characteristics to support communication and care continuity.

CONCLUSIONS

Our study highlights areas of improvement for HIT solutions that could support care delivery for patients with heart failure in a home care setting.

IMPLICATIONS

Home care agencies planning to introduce technology can use these findings to assess if and how potential systems can support nurses to provide continuity of care across healthcare organizations and home care visits.

Evaluating Pharmacist Impact on Guideline-Directed Medical Therapy in Patients With Reduced Ejection Fraction Heart Failure

BACKGROUND

Limited literature exists evaluating the ability of a pharmacist to quickly and effectively initiate and manage dose titrations of guideline-directed medication therapy (GDMT) in an outpatient setting.

METHODS

This pilot study aimed to investigate the impact of pharmacist-managed, outpatient heart failure management on patients' heart failure outcomes, and health-care-related costs. Retrospective chart review performed on patients referred to pharmacist practicing under collaborative practice agreement. End points included time to achieve individualized target doses of GDMT; beta-blocker dose tolerance; and the clinic's impact on left ventricular ejection fraction (LVEF), hospital admission, and emergency department encounter rates. Descriptive statistics were used to report nominal data. Wilcoxon signed-rank test was used to evaluate continuous variables.

RESULTS

Thirty-six patients completed full titration utilizing an average of 4.9 visits over 12.7 weeks. Seventy-eight percent (n = 28) achieved full beta-blocker titration. Seventy-six percent of patients had LVEF >35% after titration versus 43% at baseline. A significant reduction in all-cause hospital admissions was seen during both 13-week and 12-month comparison periods (P < .05). We estimated >US$50 000 annual revenue generation from 0.2 full-time equivalent pharmacist.

CONCLUSIONS

Although hypothesis generating, our results support the idea that pharmacist-managed medication titration clinics are effective at completing titration, improving LVEF, and generating revenue.

Modernizing the World Health Organization List of Essential Medicines for Preventing and Controlling Cardiovascular Diseases

The World Health Organization (WHO) Model List of Essential Medicines (EML) is a key tool for improving global access to medicines for all conditions, including cardiovascular diseases (CVDs). The WHO EML is used by member states to determine their national essential medicine lists and policies and to guide procurement of medicines in the public sector. Here, we describe our efforts to modernize the EML for global CVD prevention and control. We review the recent history of applications to add, delete, and change indications for CVD medicines, with the aim of aligning the list with contemporary clinical practice guidelines. We have identified 4 issues that affect decisions for the EML and may strengthen future applications: 1) cost and cost-effectiveness; 2) presence in clinical practice guidelines; 3) feedback loops; and 4) community engagement. We share our lessons to stimulate others in the global CVD community to embark on similar efforts.

Using video education to improve outcomes in heart failure

BACKGROUND

Heart Failure (HF) guidelines recommend HF self-care education. An optimal method of educating HF patients does not currently exist.

OBJECTIVES

To evaluate the effectiveness of supplementing usual HF education with video education and evaluate patients' satisfaction with video education.

METHODS

A mixed methods design was used. A convenience sample of 70 patients was recruited from an academic medical center. Participants completed the Atlanta Heart Failure Knowledge Test and the Self-care of Heart Failure Index before and after receiving video education, to measure HF knowledge, self-efficacy, and self-care respectively. Video usage and satisfaction with video education data were collected. All-cause 30-day readmissions data were compared to a historical group.

RESULTS

HF knowledge and self-care maintenance scores increased significantly. Self-efficacy, self-care management and all-cause 30-day readmissions did not significantly improve. Most HF patients were highly satisfied.

CONCLUSION

Supplementing usual HF education with VE was associated with improved HF knowledge and self-care maintenance.

Echocardiographic assessment of myocardial function and mechanics during veno-venous extracorporeal membrane oxygenation

BACKGROUND

Transthoracic echocardiography (TTE) plays a fundamental role in the management of patients supported with extra-corporeal membrane oxygenation (ECMO). In light of fluctuating clinical states, serial monitoring of cardiac function is required. Formal quantification of ventricular parameters and myocardial mechanics offer benefit over qualitative assessment. The aim of this research was to compare unenhanced (UE) versus contrast-enhanced (CE) quantification of myocardial function and mechanics during ECMO in a validated ovine model.

METHODS

Twenty-four sheep were commenced on peripheral veno-venous ECMO. Acute smoke-induced lung injury was induced in 21 sheep (3 controls). CE-TTE with Definity using Cadence Pulse Sequencing was performed. Two readers performed image analysis with TomTec Arena. End diastolic area (EDA, cm2), end systolic area (ESA, cm2), fractional area change (FAC, %), endocardial global circumferential strain (EGCS, %), myocardial global circumferential strain (MGCS, %), endocardial rotation (ER, degrees) and global radial strain (GRD, %) were evaluated for UE-TTE and CE-TTE.

RESULTS

Full data sets are available in 22 sheep (92%). Mean CE EDA and ESA were significantly larger than in unenhanced images. Mean FAC was almost identical between the two techniques. There was no significant difference between UE and CE EGCS, MGCS and ER. There was significant difference in GRS between imaging techniques. Unenhanced inter-observer variability was from 0.48-0.70 but significantly improved to 0.71-0.89 for contrast imaging in all echocardiographic parameters.

CONCLUSION

Semi-automated methods of myocardial function and mechanics using CE-TTE during ECMO was feasible and similar to UE-TTE for all parameters except ventricular areas and global radial strain. Addition of contrast significantly decreased inter-observer variability of all measurements.

Torsemide versus furosemide after acute decompensated heart failure: a retrospective observational study

BACKGROUND

Loop diuretics are recommended by clinical practice guidelines to treat volume overload in acute decompensated heart failure (ADHF). The effectiveness of switching furosemide to torsemide versus optimizing the furosemide dose following ADHF has not yet been evaluated.

METHODS

This retrospective observational study aimed to assess the impact of switching furosemide to torsemide versus optimizing the furosemide dose after ADHF on HF-related hospitalization within 1 month and 6 months of discharge. The study included patients previously on furosemide admitted with ADHF to the Heart Hospital in Qatar between January 1, 2016 and June 30, 2017. The study included 2 groups: (1) patients discharged on torsemide; and (2) patients discharged on an optimized furosemide dose. Cox proportional hazard regression analysis was used to determine the association between diuretic use and hospitalization.

RESULTS

Of the 232 patients included, 45 received torsemide and 187 received an optimized furosemide dose upon discharge. The majority of patients included were males (54%) with a mean age of 67 ± 12 years, and presented with HF with reduced ejection fraction (57%) and had a history of coronary artery disease (68%). The 1-month and 6-month HF-related hospitalization did not differ between the torsemide and optimized furosemide groups (aHR = 0.72; 95% CI 0.23-2.3, p = 0.57; aHR = 0.94, 95% CI 0.45-1.8, p = 0.87), respectively.

CONCLUSION

Switching furosemide to torsemide after ADHF was not associated with reduced HF-related hospitalization compared to receiving an optimized furosemide dose. Larger prospective clinical trials are needed to confirm the findings of this study.

Gastrostomy tubes appear to be safe following pediatric orthotopic heart transplant

BACKGROUND

Gastrostomy tube (GT) placement is a common pediatric surgical procedure typically indicated for oral aversion. This may develop in patients with congenital heart disease (CHD) who require an orthotopic heart transplant (OHT). The safety profile of GT placement in OHT patients who are immunosuppressed is unknown. Given the potential increased risk of wound site complications on a patient receiving immunosuppression, we sought to determine the safety profile of GT placement in pediatric patients with OHT.

MATERIALS AND METHODS

We performed a retrospective case series of all pediatric OHT recipients who subsequently underwent GT placement from January 1, 2009, to August 1, 2018, at the University of Virginia Children's Hospital. Major GT complications of wound breakdown, wound infection, peristomal GT leakage, ileus, or persistent emesis, and minor GT complication including the presence of granulation tissue are reported.

RESULTS

Six patients who had a pediatric OHT subsequently underwent GT placement over the study period. There were no major 30-day or 90-day GT complications. One patient had excessive granulation tissue at their GT site. There were no accounts of acute kidney injury, urinary tract infection, sepsis, or pneumonia.

CONCLUSION

Gastrostomy tube (GT) placement appears to be safe in pediatric OHT patients who are on immunosuppressive medications and unable to feed orally. This is the first study documenting the safety profile of GTs in pediatric OHT patients and may aid clinicians to make decisions regarding this intervention.

Influence of depression and gender on symptom burden among patients with advanced heart failure: Insight from the pain assessment, incidence and nature in heart failure study

INTRODUCTION

Patients with advanced heart failure (HF) experience many burdensome symptoms that increase patient suffering.

METHODS

Comparative secondary analysis of 347 patients with advanced HF. Symptom burden was measured with the Memorial Symptom Assessment Scale-HF. Depression was measured using the Patient Health Questionnaire-9.

RESULTS

Mean number of symptoms was 13.6. The three most frequent symptoms were non-cardiac pain, shortness of breath, and lack of energy. Patients with depression reported higher symptom burden. Symptom burden differed when compared by gender. Women reported higher symptom burden for other pain, dry mouth, swelling of the arms and legs, sweats, feeling nervous, nausea, and vomiting. Men reported higher symptom burden with sexual problems.

CONCLUSIONS

Given the high rates of symptoms and distress, interventions are needed to alleviate the symptom burden of patients with advanced HF. Reported symptom burden in patients with advanced heart failure was higher when depressive symptoms were present. Women reported varied number and severity of symptoms than men.

Thermoeffector Responses at a Fixed Rate of Heat Production in Heart Failure Patients

PURPOSE

Heart failure (HF) patients seem to exhibit altered thermoregulatory responses during exercise in the heat. However, the extent to which these responses are altered due to physiological impairments independently of biophysical factors associated with differences in metabolic heat production (Hprod), evaporative heat balance requirements (Ereq), and/or body size is presently unclear. Therefore, we examined thermoregulatory responses in 10 HF patients and 10 age-matched controls (CON) similar in body size during exercise at a fixed rate of Hprod and therefore Ereq in a 30°C environment.

METHODS

Rectal temperature, local sweat rate, and cutaneous vascular conductance were measured throughout 60 min of cycle ergometry. Whole-body sweat rate was estimated from pre-post nude body weight corrected for fluid intake.

RESULTS

Despite exercising at the same rate of Hprod (HF, 338 ± 43 W; CON, 323 ± 31 W; P = 0.25), the rise in rectal temperature was greater (P < 0.01) in HF (0.81°C ± 0.16°C) than in CON (0.49°C ± 0.27°C). In keeping with a similar Ereq (HF, 285 ± 40 W; CON, 274 ± 28 W; P = 0.35), no differences in whole-body sweat rate (HF, 0.45 ± 0.11 L·h; CON, 0.41 ± 0.07 L·h; P = 0.38) or local sweat rate (HF, 0.96 ± 0.17 mg·cm·min; CON, 0.79 ± 0.15 mg·cm·min; P = 0.50) were observed between groups. However, the rise in cutaneous vascular conductance was lower in HF than in CON (HF, 0.83 ± 0.42 au·mm Hg; CON, 2.10 ± 0.79 au·mm Hg; P < 0.01). In addition, the cumulative body heat storage estimated from partitional calorimetry was similar between groups (HF, 154 ± 106 kJ; CON, 196 ± 174 kJ; P = 0.44).

CONCLUSIONS

Collectively, these findings demonstrate that HF patients exhibit a blunted skin blood flow response, but no differences in sweating. Given that HF patients had similar body heat storage to that of CON at the same Hprod, their greater rise in core temperature can be attributed to a less uniform internal distribution of heat between the body core and periphery.

Importance of comorbidities in the treatment of primary care patients with heart failure-Baseline results of the observational RECODE-HF Study

BACKGROUND

Both non-cardiac and cardiac comorbidities are related to the prognosis of chronic heart failure (HF), but so far little is known about the impact of comorbidities on treatment difficulties in routine care.

OBJECTIVES

To investigate which comorbidities are associated with treatment difficulties in primary care. We hypothesized that somatic comorbidities as well as psychosocial distress are associated with treatment difficulties.

METHODS

In this baseline analysis of data of the observational RECODE-HF study, HF patients were recruited via primary care practices in two German sites. They received a questionnaire by mail to measure psychosocial distress. Each patient's GP was interviewed by phone regarding the patient's comorbidities and treatment difficulties. Logistic regression analyses controlled for GP cluster effects were calculated to investigate the association between comorbidities/psychosocial distress and treatment difficulties.

RESULTS

The 3282 patients of 285 GPs included in the analysis were aged 74.2 (±10.1) years and had a mean number of 4.6 (±2.4) comorbidities. GPs reported treatment difficulties in 32.5% of the patients. Allergies/drug intolerance [odds ratio (ORs)=2.0], asthma/chronic obstructive pulmonary disease (ORs=1.4), renal insufficiency (ORs=1.3), atherosclerosis/peripheral arterial occlusive disease (ORs=1.3) and cardiac arrhythmias (ORs=1.2) as well as patient-reported psychosocial distress (ORs=1.2), HF severity (ORs=3.7-1.6) and age (ORs=0.98) were associated with treatment difficulties.

CONCLUSION

Five somatic comorbidity groups as well as patient-reported psychosocial distress were significantly associated with a higher risk of GP-reported treatment difficulties. Further efforts to address comorbidities in clinical guidelines could be built on these results.

Folic acid supplementation improves vascular endothelial function, yet not skin blood flow during exercise in the heat, in patients with heart failure

Heart failure (HF) patients are susceptible to heat strain during exercise, secondary to blunted skin blood flow (SkBF) responses, which may be explained by impaired nitric oxide (NO)-dependent vasodilation. Folic acid improves vascular endothelial function and SkBF through NO-dependent mechanisms in healthy older individuals and patients with cardiovascular disease. We examined the effect of folic acid supplementation (5 mg/day for 6 wk) on vascular function [brachial artery flow-mediated dilation (FMD)] and SkBF responses [cutaneous vascular conductance (CVC)] during 60 min of exercise at a fixed metabolic heat production (300 Ẇ_Hprod) in a 30°C environment in 10 patients with HF (New York Heart Association Class I-II) and 10 healthy controls (CON). Serum folic acid concentration increased in HF [preintervention (pre): 1.4 ± 0.2; postintervention (post): 8.9 ± 6.7 ng/ml, P = 0.01] and CON (pre: 1.3 ± 0.6; post: 5.2 ± 4.9 ng/ml, P = 0.03). FMD improved by 2.1 ± 1.3% in HF ( P < 0.01), but no change was observed in CON postintervention ( P = 0.20). During exercise, the external workload performed on the cycle ergometer to attain the fixed level of heat production for exercise was similar between groups (HF: 60 ± 13; CON: 65 ± 20 external workload, P = 0.52). Increases in CVC during exercise were similar in HF (pre: 0.89 ± 0.43; post: 0.83 ± 0.45 au/mmHg, P = 0.80) and CON (pre: 2.01 ± 0.79; post: 2.03 ± 0.72 au/mmHg, P = 0.73), although the values were consistently lower in HF for both pre- and postintervention measurement intervals ( P < 0.05). These findings demonstrate that folic acid improves vascular endothelial function in patients with HF but does not enhance SkBF during exercise at a fixed metabolic heat production in a warm environment.

Cost-Effectiveness of a Home Visit Program for Patients with Heart Failure in Brazil: Evidence from a Randomized Clinical Trial

OBJECTIVE

Estimate the cost-effectiveness of a nurse-led home visit (HV) intervention as compared with the standard HF management, within a randomized clinical trial in Brazil.

STUDY DESIGN

Cost-effectiveness study within a randomized trial.

METHODS

To assess the cost-effectiveness of four home visits and four telephone calls by nurses in the management of patients with HF within a randomized clinical trial (RCT: NCT01213875) in a perspective Public (PHS-Public Healthcare System) and private healthcare systems of Brazil during time frame of 24 weeks. The outcome was a composite endpoint hospital readmission rate (first visit to the emergency room (ER) and hospital readmission), or all-cause death and incremental cost-effectiveness ratio (ICER) of the study intervention to conventional management.

RESULTS

Home-based intervention was associated with a reduction in composite endpoint (RR 0.73; 95% confidence interval 0.54 - 0.99; P = 0.049), but at greater cost from the PHS perspective. The ICER at 24 weeks was R$585 per hospital readmission visit prevented. Within the private health insurance framework, home visits were associated with lower costs and lower readmission rates. Results were sensitive to the relative risk of the study intervention, admissions and intervention costs.

CONCLUSIONS

In Brazil, an intervention based on nurse-led home visits of patients with HF showed a favorable cost-effectiveness profile within the framework of the PHS and was dominant within the private healthcare system. Our analysis suggests that implementation of this program could not only benefit patients, but also provide a financial incentive to health administrators.

Guideline-Directed Medical Therapy and Survival Following Hospitalization in Patients with Heart Failure

BACKGROUND

Modification of guideline-directed medical therapy (GDMT) in hospitalized patients with heart failure (HF) has not been extensively evaluated.

METHODS

The community surveillance arm of the Atherosclerosis Risk in Communities Study identified 6959 HF hospitalizations from 2005-2011. Predictors of GDMT modification and survival were assessed using multivariable logistic regression and Cox proportional hazards models.

RESULTS

For 5091 hospitalizations, patient mean age was 75 years, 53% were female, 69% were white, and 81% had acute decompensated heart failure (ADHF). Regarding ejection fraction (EF), 31% of patients had HF with reduced EF (HFrEF), 24% had HF with preserved EF (HFpEF), and 44% were missing EF values. At admission, 52% of patients received angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), 66% β-blockers (BBs), 9% aldosterone-receptor antagonists, 16% digoxin, 10% hydralazine, and 29% nitrates. Modification of GDMT occurred in up to 23% of hospitalizations. Significant predictors of GDMT initiation included ADHF and HFrEF; discontinuation of medications was observed with select comorbidities. In HFrEF, initiation of any GDMT was associated with reduced 1-year all-cause mortality (adjusted hazard ratio [HR] 0.41, 95% confidence interval [CI] 0.23-0.71) as was initiation of ACEI/ARBs, BBs, and digoxin. Discontinuation of any therapy versus maintaining GDMT was associated with greater mortality (HR 1.30, 95% CI 1.02-1.66). Similar trends were observed in HFpEF.

CONCLUSIONS

Our study suggests that GDMT initiation is associated with increased survival, and discontinuation of therapy is associated with reduced survival in hospitalized patients with HF. Future studies should be conducted to confirm the impact of GDMT therapy modification in this population.

The effect of nurse-led education on hospitalisation, readmission, quality of life and cost in adults with heart failure. A systematic review

OBJECTIVE

The purpose of this systematic review was to highlight the effect of nurse-led 1:1 patient education sessions on Quality of Life (QoL), readmission rates and healthcare costs for adults with heart failure (HF) living independently in the community.

METHOD

A systematic review of randomised control trials was undertaken. Using the search terms nurse, education, heart failure, hospitalisation, readmission, rehospitalisation, economic burden, cost, expenditure and quality of life in PubMed, CINAHL and Google Scholar databases were searched. Papers pertaining to nurse-led 1:1 HF disease management of education of adults in the community with a history of HF were reviewed.

RESULT

The results of this review identified nurse-led education sessions for adults with HF contribute to reduction in hospital readmissions, reduction in hospitalisation and a cost benefit. Additionally, higher functioning and improved QoL were also identified.

CONCLUSION

These results suggest that nurse-led patient education for adults with HF improves QoL and reduces hospital admissions and readmissions.

PRACTICE IMPLICATIONS

Nurse-led education can be delivered utilising diverse methods and impact to reduce readmission as well as hospitalisation.

Palliative care in heart failure

Palliative care (PC) is now recommended by all major cardiovascular societies for advanced heart failure (HF). PC is a philosophy of care that uses a holistic approach to address physical, psychosocial, and spiritual needs in patients with a terminal disease process. In HF, PC has been shown to improve symptoms and quality of life, facilitate advanced care planning, decrease hospital readmissions, and decrease hospital-associated healthcare costs. Although PC is still underutilized in HF, uptake is increasing. Specific strategies for successfully implementing PC in HF include early PC involvement, multidisciplinary collaboration, exploring patient values for end-of-life care, medical therapy (including both the addition of symptom-directed medications, as well as the removal of life-prolonging medications), and considerations regarding device therapy and mechanical support. Barriers to PC in HF include difficulties predicting the disease trajectory, patient and physician misconceptions, and lack of PC-trained physicians. Moving forward, PC will continue to be a key part of advanced HF care as our knowledge of this area grows.

Efficacy of a social support and problem-solving intervention on heart failure self-care: A pilot study

OBJECTIVE

The purpose of this study was to examine the preliminary effects of a coping partnership intervention comprised of social support and problem-solving on HF self-care maintenance, management, and confidence.

METHODS

A 3-group randomized controlled pilot study was conducted. The intervention group received 1 home visit, weekly (month 1), and biweekly (months 2 and 3) telephone calls. The attention group received telephone calls starting at week 2, following a similar pattern. The control group received usual care only. The Self-care of Heart Failure Index, was administered at baseline, 5, 9, and 13 weeks. Linear mixed modeling examined intervention effect on study outcomes.

RESULTS

A total of 66 participants completed the study. The participants were mean age 61 years; 54.2% male; 56% Non-Caucasian; and 43.9% New York Heart Association HF Class II. Significant treatment-by-time interaction effects were noted for self-care maintenance (F=4.813; p=0.010) and self-care confidence (F=4.469; p=0.014). There was no significant treatment-by-time interaction effect on self-care management.

CONCLUSIONS

Coping partnership interventions that strengthen support and social problem- solving may improve self-care maintenance and confidence in individuals with HF.

PRACTICE IMPLICATIONS

Clinicians should consider including these components in HF patient education and clinical follow-up.

Continuous Cardiac Inotropes in Patients With End-Stage Heart Failure: An Evolving Experience

Heart failure (HF) experts recommend initiation of continuous inotrope therapy, such as milrinone or dobutamine, for clinically decompensating patients with stage D HF. Although originally intended to serve solely as a bridge to more definitive surgical therapies, more and more patients are receiving inotrope therapy for purely palliative purposes. In these cases, questions arise regarding care at the end of life. What criteria determine ongoing clinical benefit? Should the inotrope be continued until death? Should inotrope dosing be increased within recommended guidelines to improve symptoms? What is the role of inotropes in hospice care? Here, we describe such a case as a springboard to contemplate the evolving role of inotrope therapies and how hospice and palliative providers may interface with this rapidly developing face of advanced HF care.