1
|
Do AS, Khan MA, Ross L, Ravinsky R, Milam AJ, Lee SJ, Durra O, Johnson JP. Urgent Spinal Surgery in a Lateral Decubitus on a Patient with a Left Ventricular Assist Device on Full Anticoagulation: A Case Report. Cureus 2024; 16:e55266. [PMID: 38558610 PMCID: PMC10981535 DOI: 10.7759/cureus.55266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 04/04/2024] Open
Abstract
This case report aims to demonstrate the feasibility of performing spinal surgery in patients with a left ventricular assist device (LVAD), who are traditionally considered unsuitable candidates due to the need for anticoagulation and the challenges associated with the prone position. A case of a patient with an LVAD undergoing microdiscectomy in the left lateral decubitus position is presented. The procedure was carried out by a specialized interdisciplinary team with appropriate monitoring. The patient underwent the procedure safely, demonstrating that spinal surgery can be performed in patients with LVAD without reversing anticoagulation or resorting to the prone position. This approach mitigates the risk of thrombotic events and hemodynamic instability. This case study suggests that spinal surgery, specifically microdiscectomy, can be safely performed in patients with LVAD using the left lateral decubitus position. This finding has significant implications for patients who are unable to ambulate and therefore struggle to qualify for a heart transplant.
Collapse
Affiliation(s)
- Angelique S Do
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Monis A Khan
- Department of Neurologic and Orthopedic Surgery, University of Arizona, Phoenix, USA
| | - Lindsey Ross
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Robert Ravinsky
- Department of Orthopaedics and Physical Medicine, Medical University of South Carolina, Charleston, USA
| | - Adam J Milam
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Seung J Lee
- Department of Neurosurgery, Mayo Clinic, Jacksonville, USA
| | - Omar Durra
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, USA
| | - J Patrick Johnson
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| |
Collapse
|
2
|
Codina P, Dobarro D, de Juan‐Bagudá J, De Frutos F, Lupón J, Bayes‐Genis A, Gonzalez‐Costello J. Heart failure risk scores in advanced heart failure patients: insights from the LEVO-D registry. ESC Heart Fail 2023; 10:2875-2881. [PMID: 37991427 PMCID: PMC10567651 DOI: 10.1002/ehf2.14400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/05/2023] [Accepted: 05/02/2023] [Indexed: 11/23/2023] Open
Abstract
AIMS The prevalence of advanced heart failure (HF) is increasing due to the growing number of patients with HF and their better treatment and survival. There is a scarcity of data on the accuracy of HF web-based risk scores in this selected population. This study aimed to assess mortality prediction performance of the Meta-Analysis Global Group in Chronic HF (MAGGIC-HF) risk score and the model of the Barcelona Bio-HF Risk Calculator (BCN-Bio-HF) containing N terminal pro brain natriuretic peptide in HF patients receiving intermittent inotropic support with levosimendan as destination therapy. METHODS AND RESULTS Four hundred and three advanced HF patients from 23 tertiary hospitals in Spain receiving intermittent inotropic support with levosimendan as destination therapy were included. Discrimination for all-cause mortality was compared by area under the curve (AUC) and Harrell's C-statistic at 1 year. Calibration was assessed by calibration plots comparing observed versus expected events based on estimated risk by each calculator. The included patients were predominantly men, aged 71.5 [interquartile range 64-78] years, with reduced left ventricular ejection fraction (27.5 ± 9.4%); ischaemic heart disease was the most prevalent aetiology (52.5%). Death rate at 1 year was 26.8%, while the predicted 1-year mortality by BCN-Bio-HF and MAGGIC-HF was 17.0% and 22.1%, respectively. BCN-Bio-HF AUC was 0.66 (Harrell's C-statistic 0.64), and MAGGIC-HF AUC was 0.62 (Harrell's C-statistic 0.61). CONCLUSIONS The two evaluated risk scores showed suboptimal discrimination and calibration with an underestimation of risk in advanced HF patients receiving levosimendan as destination therapy. There is a need for specific scores for advanced HF.
Collapse
Affiliation(s)
- Pau Codina
- Hospital Universitari Germans Trias i PujolBadalonaSpain
- Department of MedicineUniversitat Autonoma de BarcelonaBarcelonaSpain
| | - David Dobarro
- Hospital Álvaro Cunqueiro. Complexo Hospitalario Universitario de VigoVigoSpain
| | - Javier de Juan‐Bagudá
- Department of CardiologyUniversity Hospital 12 de Octubre, Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12)MadridSpain
- Department of Medicine, Faculty of Biomedical and Health ScienceUniversidad Europea de MadridMadridSpain
- CIBERCV, Instituto de Salud Carlos IIIMadridSpain
| | - Fernando De Frutos
- Department of Cardiology, Hospital Universitari de Bellvitge, BIOHEART‐Cardiovascular Diseases Research GroupBellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de LlobregatBarcelonaSpain
| | - Josep Lupón
- Hospital Universitari Germans Trias i PujolBadalonaSpain
- Department of MedicineUniversitat Autonoma de BarcelonaBarcelonaSpain
- CIBERCV, Instituto de Salud Carlos IIIMadridSpain
| | - Antoni Bayes‐Genis
- Hospital Universitari Germans Trias i PujolBadalonaSpain
- Department of MedicineUniversitat Autonoma de BarcelonaBarcelonaSpain
- CIBERCV, Instituto de Salud Carlos IIIMadridSpain
| | - José Gonzalez‐Costello
- CIBERCV, Instituto de Salud Carlos IIIMadridSpain
- Department of Cardiology, Hospital Universitari de Bellvitge, BIOHEART‐Cardiovascular Diseases Research GroupBellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de LlobregatBarcelonaSpain
- Department of Clinical Sciences, School of MedicineUniversitat de BarcelonaBarcelonaSpain
| | | |
Collapse
|
3
|
Garcia Brás P, Gonçalves AV, Reis JF, Moreira RI, Pereira-da-Silva T, Rio P, Timóteo AT, Silva S, Soares RM, Ferreira RC. Cardiopulmonary Exercise Testing in Patients with Heart Failure: Impact of Gender in Predictive Value for Heart Transplantation Listing. Life (Basel) 2023; 13:1985. [PMID: 37895367 PMCID: PMC10608092 DOI: 10.3390/life13101985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/22/2023] [Accepted: 09/27/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Exercise testing is key in the risk stratification of patients with heart failure (HF). There are scarce data on its prognostic power in women. Our aim was to assess the predictive value of the heart transplantation (HTx) thresholds in HF in women and in men. METHODS Prospective evaluation of HF patients who underwent cardiopulmonary exercise testing (CPET) from 2009 to 2018 for the composite endpoint of cardiovascular mortality and urgent HTx. RESULTS A total of 458 patients underwent CPET, with a composite endpoint frequency of 10.5% in females vs. 16.0% in males in 36-month follow-up. Peak VO2 (pVO2), VE/VCO2 slope and percent of predicted pVO2 were independent discriminators of the composite endpoint, particularly in women. The International Society for Heart Lung Transplantation recommended values of pVO2 ≤ 12 mL/kg/min or ≤14 if the patient is intolerant to β-blockers, VE/VCO2 slope > 35, and percent of predicted pVO2 ≤ 50% showed a higher diagnostic effectiveness in women. Specific pVO2, VE/VCO2 slope and percent of predicted pVO2 cut-offs in each sex group presented a higher prognostic power than the recommended thresholds. CONCLUSION Individualized sex-specific thresholds may improve patient selection for HTx. More evidence is needed to address sex differences in HF risk stratification.
Collapse
Affiliation(s)
- Pedro Garcia Brás
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - António Valentim Gonçalves
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - João Ferreira Reis
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Rita Ilhão Moreira
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Tiago Pereira-da-Silva
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Pedro Rio
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Ana Teresa Timóteo
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
- NOVA Medical School, Faculdade de Ciências Médicas (NMS|FCM), 1169-056 Lisbon, Portugal
| | - Sofia Silva
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Rui M. Soares
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| | - Rui Cruz Ferreira
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal (R.M.S.)
| |
Collapse
|
4
|
Garcia Brás P, Gonçalves AV, Reis JF, Moreira RI, Pereira-da-Silva T, Rio P, Timóteo AT, Silva S, Soares RM, Ferreira RC. Age Differences in Cardiopulmonary Exercise Testing Parameters in Heart Failure with Reduced Ejection Fraction. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1685. [PMID: 37763804 PMCID: PMC10535443 DOI: 10.3390/medicina59091685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 09/09/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Cardiopulmonary exercise testing (CPET) is a cornerstone of risk stratification in heart failure with reduced ejection fraction (HFrEF). However, there is a paucity of evidence on its predictive power in older patients. The aim of this study was to evaluate the prognostic power of current heart transplantation (HTx) listing criteria in HFrEF stratified according to age groups. Materials and Methods: Consecutive patients with HFrEF undergoing CPET between 2009 and 2018 were followed-up for cardiac death and urgent HTx. Results: CPET was performed in 458 patients with HFrEF. The composite endpoint occurred in 16.8% of patients ≤50 years vs. 14.1% of patients ≥50 years in a 36-month follow-up. Peak VO2 (pVO2), VE/VCO2 slope and percentage of predicted pVO2 were strong independent predictors of outcomes. The International Society for Heart and Lung Transplantation thresholds of pVO2 ≤ 12 mL/kg/min (≤14 if intolerant to β-blockers), VE/VCO2 slope > 35 and percentage of predicted pVO2 ≤ 50% presented a higher overall diagnostic effectiveness in younger patients (≤50 years). Specific thresholds for each age subgroup outperformed the traditional cut-offs. Conclusions: Personalized age-specific thresholds may contribute to an accurate risk stratification in HFrEF. Further studies are needed to address the gap in evidence between younger and older patients.
Collapse
Affiliation(s)
- Pedro Garcia Brás
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - António Valentim Gonçalves
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - João Ferreira Reis
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Rita Ilhão Moreira
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Tiago Pereira-da-Silva
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Pedro Rio
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Ana Teresa Timóteo
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
- NOVA Medical School, Faculdade de Ciências Médicas (NMS|FCM), 1169-056 Lisbon, Portugal
| | - Sofia Silva
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Rui M. Soares
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| | - Rui Cruz Ferreira
- Cardiology Department, Santa Marta Hospital, Central Lisbon Hospital University Center, 1169-024 Lisbon, Portugal
| |
Collapse
|
5
|
Garcia Brás P, Gonçalves AV, Reis JF, Moreira RI, Pereira-da-Silva T, Rio P, Timóteo AT, Silva S, Soares RM, Ferreira RC. Cardiopulmonary Exercise Testing in the Age of New Heart Failure Therapies: Still a Powerful Tool? Biomedicines 2023; 11:2208. [PMID: 37626705 PMCID: PMC10452308 DOI: 10.3390/biomedicines11082208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/28/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND New therapies with prognostic benefits have been recently introduced in heart failure with reduced ejection fraction (HFrEF) management. The aim of this study was to evaluate the prognostic power of current listing criteria for heart transplantation (HT) in an HFrEF cohort submitted to cardiopulmonary exercise testing (CPET) between 2009 and 2014 (group A) and between 2015 and 2018 (group B). METHODS Consecutive patients with HFrEF who underwent CPET were followed-up for cardiac death and urgent HT. RESULTS CPET was performed in 487 patients. The composite endpoint occurred in 19.4% of group A vs. 7.4% of group B in a 36-month follow-up. Peak VO2 (pVO2) and VE/VCO2 slope were the strongest independent predictors of mortality. International Society for Heart and Lung Transplantation (ISHLT) thresholds of pVO2 ≤ 12 mL/kg/min (≤14 if intolerant to β-blockers) and VE/VCO2 slope > 35 presented a similar and lower Youden index, respectively, in group B compared to group A, and a lower positive predictive value. pVO2 ≤ 10 mL/kg/min and VE/VCO2 slope > 40 outperformed the traditional cut-offs. An ischemic etiology subanalysis showed similar results. CONCLUSION ISHLT thresholds showed a lower overall prognostic effectiveness in a contemporary HFrEF population. Novel parameters may be needed to improve risk stratification.
Collapse
Affiliation(s)
- Pedro Garcia Brás
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
| | - António Valentim Gonçalves
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
| | - João Ferreira Reis
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
| | - Rita Ilhão Moreira
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
| | - Tiago Pereira-da-Silva
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
| | - Pedro Rio
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
| | - Ana Teresa Timóteo
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
- NOVA Medical School, Faculdade de Ciências Médicas (NMS|FCM), 1169-056 Lisbon, Portugal
| | - Sofia Silva
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
| | - Rui M. Soares
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
| | - Rui Cruz Ferreira
- Cardiology Department, Hospital de Santa Marta, Centro Hospitalar Universitário de Lisboa Central, 1169-024 Lisbon, Portugal
| |
Collapse
|
6
|
Zhang J, Li W, Xiao J, Hui J, Li Y. Prognostic significance of carbohydrate antigen 125 in stage D heart failure. BMC Cardiovasc Disord 2023; 23:108. [PMID: 36841766 PMCID: PMC9960178 DOI: 10.1186/s12872-023-03139-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 02/21/2023] [Indexed: 02/27/2023] Open
Abstract
BACKGROUND The predictive value of carbohydrate antigen 125 (CA125) has not been examined in stage D heart failure (HF) patients, regardless of left ventricular ejection fraction (LVEF). We sought to quantify the prognostic usefulness in predicting death and HF readmission in this cohort. METHODS According to CA125 levels above and below the median (65.7 U/ml), 176 stage D HF patients including more than half (50.6%) had LVEF > 40% were divided into 2 groups. RESULTS A total of 106 (60.2%) deaths and 102 deaths due to the cardiovascular disease were identified. All-cause death/HF readmission and MACE occurred in 157 patients (89.2%) during 18 months (16-20) of follow-up. By the Kaplan-Meier method, subjects with CA125 ≥ 65.7 U/ml exhibited higher 1-year mortality rate (59.3% vs. 31.0%, P < 0.001) and 1-year death/HF rehospitalization rate (94.2% vs. 80.6%, P < 0.001). In univariate Cox analysis, CA125 (categorized) was a significant prognostic factor for all-cause death, cardiovascular mortality, death/HF readmission and MACE. Based on multivariate Cox analysis, elevated CA125 was still significant for all-cause death, cardiovascular mortality, death/HF readmission and MACE. CONCLUSIONS In stage D HF patients, elevated CA125 levels were highly predictive of all-cause death, cardiovascular mortality, all-cause death/HF readmission and MACE, which can be used for better risk stratification.
Collapse
Affiliation(s)
- Ji Zhang
- Department of Cardiology, Wujin Hospital Affiliated With Jiangsu University, The Wujin Clinical College of Xuzhou Medical University, No. 2, Yongning Road, Changzhou, Jiangsu Province, China.
| | - Wenhua Li
- Department of Cardiology, Wujin Hospital Affiliated With Jiangsu University, The Wujin Clinical College of Xuzhou Medical University, No. 2, Yongning Road, Changzhou, Jiangsu Province, China
| | - Jianqiang Xiao
- Department of Cardiology, Wujin Hospital Affiliated With Jiangsu University, The Wujin Clinical College of Xuzhou Medical University, No. 2, Yongning Road, Changzhou, Jiangsu Province, China
| | - Jie Hui
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yi Li
- School of Math and Statistics, Nanjing Audit University, Nanjing, China
| |
Collapse
|
7
|
Blum M, Gelfman LP, McKendrick K, Pinney SP, Goldstein NE. Enhancing Palliative Care for Patients With Advanced Heart Failure Through Simple Prognostication Tools: A Comparison of the Surprise Question, the Number of Previous Heart Failure Hospitalizations, and the Seattle Heart Failure Model for Predicting 1-Year Survival. Front Cardiovasc Med 2022; 9:836237. [PMID: 35479267 PMCID: PMC9035562 DOI: 10.3389/fcvm.2022.836237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Background Score-based survival prediction in patients with advanced heart failure (HF) is complicated. Easy-to-use prognostication tools could inform clinical decision-making and palliative care delivery. Objective To compare the prognostic utility of the Seattle HF model (SHFM), the surprise question (SQ), and the number of HF hospitalizations (NoH) within the last 12 months for predicting 1-year survival in patients with advanced HF. Methods We retrospectively analyzed data from a cluster-randomized controlled trial of advanced HF patients, predominantly with reduced ejection fraction. Primary outcome was the prognostic discrimination of SHFM, SQ (“Would you be surprised if this patient were to die within 1 year?”) answered by HF cardiologists, and NoH, assessed by receiver operating characteristic (ROC) curve analysis. Optimal cut-offs were calculated using Youden’s index (SHFM: <86% predicted 1-year survival; NoH ≥ 2). Results Of 535 subjects, 82 (15.3%) had died after 1-year of follow-up. SHFM, SQ, and NoH yielded a similar area under the ROC curve [SHFM: 0.65 (0.60–0.71 95% CI); SQ: 0.58 (0.54–0.63 95% CI); NoH: 0.56 (0.50–0.62 95% CI)] and similar sensitivity [SHFM: 0.76 (0.65–0.84 95% CI); SQ: 0.84 (0.74–0.91 95% CI); NoH: 0.56 (0.45–0.67 95% CI)]. As compared to SHFM, SQ had lower specificity [SQ: 0.33 (0.28–0.37 95% CI) vs. SHFM: 0.55 (0.50–0.60 95% CI)] while NoH had similar specificity [0.56 (0.51–0.61 95% CI)]. SQ combined with NoH showed significantly higher specificity [0.68 (0.64–0.73 95% CI)]. Conclusion SQ and NoH yielded comparable utility to SHFM for 1-year survival prediction among advanced HF patients, are easy-to-use and could inform bedside decision-making.
Collapse
Affiliation(s)
- Moritz Blum
- Department of Internal Medicine and Cardiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- *Correspondence: Moritz Blum,
| | - Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- James J. Peters Veterans Affairs Medical Center, Geriatric Research Education and Clinical Center, Bronx, NY, United States
| | - Karen McKendrick
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sean P. Pinney
- Department of Medicine, University of Chicago Medicine, Chicago, IL, United States
| | - Nathan E. Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| |
Collapse
|
8
|
de Jonge N, Damman K, Ramjankhan FZ, van der Kaaij NP, van den Broek SAJ, Erasmus ME, Kuijpers M, Manintveld O, Bekkers JA, Constantinescu AC, Brugts JJ, Oerlemans MIF, van Laake LW, Caliskan K. Listing criteria for heart transplantation in the Netherlands. Neth Heart J 2021; 29:611-622. [PMID: 34524619 PMCID: PMC8630329 DOI: 10.1007/s12471-021-01627-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2021] [Indexed: 12/01/2022] Open
Abstract
The updated listing criteria for heart transplantation are presented on behalf of the three heart transplant centres in the Netherlands. Given the shortage of donor hearts, selection of those patients who may expect to have the greatest benefit from a scarce societal resource in terms of life expectancy and quality of life is inevitable. The indication for heart transplantation includes end-stage heart disease not remediable by more conservative measures, accompanied by severe physical limitation while on optimal medical therapy, including ICD/CRT‑D. Assessment of this condition requires cardiopulmonary stress testing, prognostic stratification and invasive haemodynamic measurements. Timely referral to a tertiary centre is essential for an optimal outcome. Chronic mechanical circulatory support is being used more and more as an alternative to heart transplantation and to bridge the progressively longer waiting time for heart transplantation and, thus, has become an important treatment option for patients with advanced heart failure.
Collapse
Affiliation(s)
- N de Jonge
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - K Damman
- Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - F Z Ramjankhan
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - N P van der Kaaij
- Department of Cardiothoracic Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - S A J van den Broek
- Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - M E Erasmus
- Department of Cardiothoracic Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - M Kuijpers
- Department of Cardiothoracic Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - O Manintveld
- Department of Cardiology, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - J A Bekkers
- Department of Cardiothoracic Surgery, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - A C Constantinescu
- Department of Cardiology, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - J J Brugts
- Department of Cardiology, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - M I F Oerlemans
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - L W van Laake
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - K Caliskan
- Department of Cardiology, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
9
|
Michaels A, Aurora L, Peterson E, Liu B, Pinto YM, Sabbah HN, Williams K, Lanfear DE. Risk Prediction in Transition: MAGGIC Score Performance at Discharge and Incremental Utility of Natriuretic Peptides. J Card Fail 2019; 26:52-60. [PMID: 31751788 PMCID: PMC10062381 DOI: 10.1016/j.cardfail.2019.11.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/08/2019] [Accepted: 11/12/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Risk stratification for hospitalized patients with heart failure (HF) remains a critical need. The Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score is a robust model derived from patients with ambulatory HF. Its validity at the time of discharge and the incremental value of natriuretic peptides (NPs) in this setting is unclear. METHODS This was a single-center study examining a total of 4138 patients with HF from 2 groups; hospital discharge patients from administrative data (n = 2503, 60.5%) and a prospective registry of patients with ambulatory HF (n = 1635, 39.5%). The ambulatory registry patients underwent N-terminal pro-B-type NP (BNP) measurement at enrollment, and in the hospitalize discharge cohort clinical BNP levels were abstracted. The primary endpoint was all-cause mortality within 1 year. MAGGIC score performance was compared between cohorts utilizing Cox regression and calibration plots. The incremental value of NPs was assessed using calculated area under the curve and net reclassification improvement (NRI). RESULTS The hospitalized and ambulatory cohorts differed with respect to primary outcome (777 and 100 deaths, respectively), sex (52.1% vs 41.7% female) and race (35% vs 49.5% African American). The MAGGIC score showed poor discrimination of mortality risk in the hospital discharge (C statistic: 0.668, hazard ratio [HR]: 1.1 per point, 95% confidence interval [CI]: 0.652, 0.684) but fair discrimination in the ambulatory cohorts (C statistic: 0.784, HR: 1.16 per point, 95% CI: 0.74, 0.83), respectively, a difference that was statistically significant (P = .001 for C statistic, 0.002 for HR). Calibration assessment indicated that the slope and intercept (of MAGGIC-predicted to observed mortality) did not statistically differ from ideal in either cohort and did not differ between the cohorts (all P > .1). NP levels did not significantly improve prediction in the hospitalized cohort (P = .127) but did in the ambulatory cohort (C statistic: 0.784 [95% CI: 0.74, 0.83] vs 0.82 [95% CI: 0.78, 0.85]; P = .018) with a favorable NRI of 0.354 (95% CI: 0.202-0.469; P = .002). CONCLUSION The MAGGIC score showed poor discrimination when used in patients with HF at hospital discharge, which was inferior to its performance in patients with ambulatory HF. Discrimination within the hospital discharge group was not improved by including hospital NP levels.
Collapse
Affiliation(s)
- Alexander Michaels
- Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan; Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Lindsey Aurora
- Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan; Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Edward Peterson
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, Michigan
| | - Bin Liu
- Department of Public Health Sciences, Henry Ford Hospital, Detroit, Michigan
| | - Yigal M Pinto
- Department of Cardiology, University of Amsterdam, Amsterdam, The Netherlands
| | - Hani N Sabbah
- Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan; Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Keoki Williams
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan; Center for Individualized and Genomic Medicine Research, Henry Ford Hospital, Detroit, Michigan
| | - David E Lanfear
- Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan; Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan; Center for Individualized and Genomic Medicine Research, Henry Ford Hospital, Detroit, Michigan.
| |
Collapse
|
10
|
Kittleson MM, Shah P, Lala A, McLean RC, Pamboukian S, Horstmanshof DA, Thibodeau J, Shah K, Teuteberg J, Gilotra NA, Taddei-Peters WC, Cascino TM, Richards B, Khalatbari S, Jeffries N, Stevenson LW, Mann D, Aaronson KD, Stewart GC. INTERMACS profiles and outcomes of ambulatory advanced heart failure patients: A report from the REVIVAL Registry. J Heart Lung Transplant 2019; 39:16-26. [PMID: 31522912 DOI: 10.1016/j.healun.2019.08.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 07/17/2019] [Accepted: 08/20/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Ambulatory patients with advanced heart failure (HF) are often considered for advanced therapies, including durable mechanical circulatory support (MCS). The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profiles are a commonly used descriptor of disease severity in patients receiving MCS devices, but their role in defining the prognosis of ambulatory patients is less well established, especially for Profiles 6 and 7. METHODS Registry Evaluation of Vital Information on Ventricular Assist Devices in Ambulatory Life is a prospective observational study of 400 outpatients from 21 MCS and cardiac transplant centers. Eligible patients had New York Heart Association Class II to IV symptoms despite optimal medical and electrical therapies with a recent HF hospitalization, heart transplant listing, or evidence of high neurohormonal activation. RESULTS The cohort included 33 INTERMACS Profile 4 (8%), 83 Profile 5 (21%), 155 Profile 6 (39%), and 129 Profile 7 (32%). Across INTERMACS profiles, there were no differences in age, gender, ejection fraction, blood pressure, or use of guideline-directed medical therapy. A lower INTERMACS profile was associated with more hospitalizations, greater frailty, and more impaired functional capacity and quality of life. The composite end point of death, durable MCS, or urgent transplant at 12 months occurred in 39%, 27%, 24%, and 14% subjects with INTERMACS Profiles 4, 5, 6, and 7, respectively (p = 0.004). CONCLUSIONS Among ambulatory patients with advanced HF, a lower INTERMACS profile was associated with a greater burden of HF across multiple dimensions and a higher composite risk of durable MCS, urgent transplant, or death. These profiles may assist in risk assessment and triaging ambulatory patients to advanced therapies.
Collapse
Affiliation(s)
- Michelle M Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.
| | - Palak Shah
- Department of Medicine, Inova Heart and Vascular Institute, Falls Church, Virgina, USA
| | - Anuradha Lala
- Department of Internal Medicine, Mount Sinai Hospital, New York, New York, USA
| | - Rhondalyn C McLean
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Salpy Pamboukian
- Department of Medicine, University of Alabama, Birmingham, Alabama, USA
| | - Douglas A Horstmanshof
- Interagency Autism Coordinating Committee Advanced Cardiac Care Deptartment, INTEGRIS Baptist Medical Center, Oklahoma City, Oklahoma, USA
| | - Jennifer Thibodeau
- Department of Internal Medicine, University of Texas Southwest Medical Center, Dallas, Texas, USA
| | - Keyur Shah
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virgina, USA
| | - Jeffrey Teuteberg
- Department of Medicine, Stanford University, Palo Alto, California, USA
| | - Nisha A Gilotra
- Department of Cardiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Wendy C Taddei-Peters
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Thomas M Cascino
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Blair Richards
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Shokoufeh Khalatbari
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Neal Jeffries
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Lynne W Stevenson
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Douglas Mann
- Department of Internal Medicine, Washington University, St. Louis, Missouri, USA
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Garrick C Stewart
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | |
Collapse
|
11
|
Blackstone EH, Rajeswaran J, Cruz VB, Hsich EM, Koprivanac M, Smedira NG, Hoercher KJ, Thuita L, Starling RC. Continuously Updated Estimation of Heart Transplant Waitlist Mortality. J Am Coll Cardiol 2019; 72:650-659. [PMID: 30071995 DOI: 10.1016/j.jacc.2018.05.045] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 05/07/2018] [Accepted: 05/09/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Heart transplant allocation in the United States is made on the basis of coarse tiers, defined by mechanical circulatory devices and therapy for advanced heart failure, updated infrequently as a patient's condition deteriorates. Thus, many patients die awaiting heart transplantation. What is needed is a tool that continuously updates risk of mortality as a patient's condition changes to inform clinical decision making. OBJECTIVES This study sought to develop a decision aid that aggregates adverse events and measures of end-organ function into a continuously updated waitlist mortality estimate. METHODS From 2008 to 2013, 414 patients were listed for heart transplantation at Cleveland Clinic, Cleveland, Ohio. The endpoint was waitlist death. Pre-listing patient characteristics and events and laboratory results during listing were analyzed. At each event or measurement change, mortality was recomputed from the resulting model. RESULTS There were 77 waitlist deaths, with 1- and 4-year survival of 85% and 57%, respectively. When time-varying events and measurements were incorporated into a mortality model, pre-listing patient characteristics became nonsignificant. Neurological events (hazard ratio [HR]: 13.5; 95% confidence interval [CI]: 7.63 to 23.8), new requirement for dialysis (HR: 3.67; 95% CI: 1.88 to 7.14), more respiratory complications (HR: 1.79 per episode; 95% CI: 1.23 to 2.59), and higher serum bilirubin (p < 0.0001) and creatinine (p < 0.0001) yielded continuously updated estimates of patient-specific mortality across the waitlist period. CONCLUSIONS Mortality risk for patients with advanced heart failure who are listed for transplantation is related to adverse events and end-organ dysfunction that change over time. A continuously updated mortality estimate, combined with clinical evaluation, may inform status changes that could reduce mortality on the heart transplant waiting list.
Collapse
Affiliation(s)
- Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vincent B Cruz
- Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Eileen M Hsich
- Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicholas G Smedira
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Katherine J Hoercher
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Randall C Starling
- Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
12
|
Validation and Recalibration of Seattle Heart Failure Model in Japanese Acute Heart Failure Patients. J Card Fail 2019; 25:561-567. [DOI: 10.1016/j.cardfail.2018.07.463] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 06/18/2018] [Accepted: 07/26/2018] [Indexed: 11/22/2022]
|
13
|
Doumouras BS, Lee DS, Levy WC, Alba AC. An Appraisal of Biomarker-Based Risk-Scoring Models in Chronic Heart Failure: Which One Is Best? Curr Heart Fail Rep 2019; 15:24-36. [PMID: 29404976 DOI: 10.1007/s11897-018-0375-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW While prediction models incorporating biomarkers are used in heart failure, these have shown wide-ranging discrimination and calibration. This review will discuss externally validated biomarker-based risk models in chronic heart failure patients assessing their quality and relevance to clinical practice. RECENT FINDINGS Biomarkers may help in determining prognosis in chronic heart failure patients as they reflect early pathologic processes, even before symptoms or worsening disease. We present the characteristics and describe the performance of 10 externally validated prediction models including at least one biomarker among their predictive factors. Very few models report adequate discrimination and calibration. Some studies evaluated the additional predictive value of adding a biomarker to a model. However, these have not been routinely assessed in subsequent validation studies. New and existing prediction models should include biomarkers, which improve model performance. Ongoing research is needed to assess the performance of models in contemporary patients.
Collapse
Affiliation(s)
- Barbara S Doumouras
- Heart Failure and Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
| | - Douglas S Lee
- Institute for Clinical Evaluative Sciences, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, University of Toronto, Toronto, ON, Canada
| | | | - Ana C Alba
- Heart Failure and Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
14
|
Samman-Tahhan A, Hedley JS, McCue AA, Bjork JB, Georgiopoulou VV, Morris AA, Butler J, Kalogeropoulos AP. INTERMACS Profiles and Outcomes Among Non-Inotrope-Dependent Outpatients With Heart Failure and Reduced Ejection Fraction. JACC-HEART FAILURE 2018; 6:743-753. [PMID: 30098970 DOI: 10.1016/j.jchf.2018.03.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 03/27/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This study sought to evaluate INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profiles for prognostic use among ambulatory non-inotrope-dependent patients with heart failure with reduced ejection fraction (HFrEF). BACKGROUND Data for INTERMACS profiles and prognoses in ambulatory patients with HFrEF are limited. METHODS We evaluated 3-year outcomes in 969 non-inotrope-dependent outpatients with HFrEF (EF: ≤40%) not previously receiving advanced HF therapies. Patients meeting an INTERMACS profile at baseline were classified as profile 7 (n = 348 [34.7%]); 146 patients (14.5%) were classified profile 6; and 52 patients (5.2%) were classified profile 4 to 5. Remaining patients were classified "stable Stage C" (n = 423 [42.1%]). RESULTS Three-year mortality rate was 10.0% among stable Stage C patients compared with 21.8% among INTERMACS profile 7 (hazard ratio [HR] vs. Stage C: 2.45; 95% confidence interval [CI]: 1.64 to 3.66), 26.0% among profile 6 (HR: 3.93; 95% CI: 1.64 to 3.66), and 43.8% among profile 4 to 5 (HR: 6.35; 95% CI: 3.51 to 11.5) patients. Hospitalization rates for HF were 4-fold higher among INTERMACS profile 7 (38 per 100 patient-years; rate ratio [RR] vs. Stage C: 3.88; 95% CI: 2.70 to 5.35), 6-fold higher among profile 6 patients (54 per 100 patient-years; RR: 5.69; 95% CI: 3.72 to 8.71), and 10-fold higher among profile 4 to 5 patients (69 per 100 patient-years; RR: 9.96; 95% CI: 5.15 to 19.3) than stable Stage C patients (11 per 100 patient-years). All-cause hospitalization rates had similar trends. INTERMACS profiles offered better prognostic separation than NYHA functional classifications. CONCLUSIONS INTERMACS profiles strongly predict subsequent mortality and hospitalization burden in non-inotrope-dependent outpatients with HFrEF. These simple profiles could therefore facilitate and promote advanced HF awareness among clinicians and planning for advanced HF therapies.
Collapse
Affiliation(s)
- Ayman Samman-Tahhan
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | | | - Andrew A McCue
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jonathan B Bjork
- Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Vasiliki V Georgiopoulou
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Alanna A Morris
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Javed Butler
- Division of Cardiology, Department of Medicine, Stony Brook University School of Medicine, Stony Brook, New York
| | - Andreas P Kalogeropoulos
- Division of Cardiology, Department of Medicine, Stony Brook University School of Medicine, Stony Brook, New York.
| |
Collapse
|
15
|
Application of competing risks analysis improved prognostic assessment of patients with decompensated chronic heart failure and reduced left ventricular ejection fraction. J Clin Epidemiol 2018; 103:31-39. [PMID: 30009940 DOI: 10.1016/j.jclinepi.2018.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 05/15/2018] [Accepted: 07/05/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The Kaplan-Meier method may overestimate absolute mortality risk (AMR) in the presence of competing risks. Urgent heart transplantation (UHT) and ventricular assist device implantation (VADi) are important competing events in heart failure. We sought to quantify the extent of bias of the Kaplan-Meier method in estimating AMR in the presence of competing events and to analyze the effect of covariates on the hazard for death and competing events in the clinical model of decompensated chronic heart failure with reduced ejection fraction (DCHFrEF). STUDY DESIGN AND SETTING We studied 683 patients. We used the cumulative incidence function (CIF) to estimate the AMR at 1 year. CIF estimate was compared with the Kaplan-Meier estimate. The Fine-Gray subdistribution hazard analysis was used to assess the effect of covariates on the hazard for death and UHT/VADi. RESULTS The Kaplan-Meier estimate of the AMR was 0.272, whereas the CIF estimate was 0.246. The difference was more pronounced in the patient subgroup with advanced DCHF (0.424 vs. 0.338). The Fine-Gray subdistribution hazard analysis revealed that established risk markers have qualitatively different effects on the incidence of death or UHT/VADi. CONCLUSION Competing risks analysis allows more accurately estimating AMR and better understanding the association between covariates and major outcomes in DCHFrEF.
Collapse
|
16
|
Crespo-Leiro MG, Metra M, Lund LH, Milicic D, Costanzo MR, Filippatos G, Gustafsson F, Tsui S, Barge-Caballero E, De Jonge N, Frigerio M, Hamdan R, Hasin T, Hülsmann M, Nalbantgil S, Potena L, Bauersachs J, Gkouziouta A, Ruhparwar A, Ristic AD, Straburzynska-Migaj E, McDonagh T, Seferovic P, Ruschitzka F. Advanced heart failure: a position statement of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2018; 20:1505-1535. [DOI: 10.1002/ejhf.1236] [Citation(s) in RCA: 373] [Impact Index Per Article: 62.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 05/17/2018] [Accepted: 05/21/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Maria G. Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC); Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC; La Coruña Spain
| | - Marco Metra
- Cardiology; University of Brescia; Brescia Italy
| | - Lars H. Lund
- Department of Medicine, Unit of Cardiology; Karolinska Institute; Stockholm Sweden
| | - Davor Milicic
- Department for Cardiovascular Diseases; University Hospital Center Zagreb, University of Zagreb; Zagreb Croatia
| | | | | | - Finn Gustafsson
- Department of Cardiology; Rigshospitalet; Copenhagen Denmark
| | - Steven Tsui
- Transplant Unit; Royal Papworth Hospital; Cambridge UK
| | - Eduardo Barge-Caballero
- Complexo Hospitalario Universitario A Coruña (CHUAC); Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC; La Coruña Spain
| | - Nicolaas De Jonge
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Maria Frigerio
- Transplant Center and De Gasperis Cardio Center; Niguarda Hospital; Milan Italy
| | - Righab Hamdan
- Department of Cardiology; Beirut Cardiac Institute; Beirut Lebanon
| | - Tal Hasin
- Jesselson Integrated Heart Center; Shaare Zedek Medical Center; Jerusalem Israel
| | - Martin Hülsmann
- Department of Internal Medicine II; Medical University of Vienna; Vienna Austria
| | | | - Luciano Potena
- Heart and Lung Transplant Program; Bologna University Hospital; Bologna Italy
| | - Johann Bauersachs
- Department of Cardiology and Angiology; Medical School Hannover; Hannover Germany
| | - Aggeliki Gkouziouta
- Heart Failure and Transplant Unit; Onassis Cardiac Surgery Centre; Athens Greece
| | - Arjang Ruhparwar
- Department of Cardiac Surgery; University of Heidelberg; Heidelberg Germany
| | - Arsen D. Ristic
- Department of Cardiology of the Clinical Center of Serbia; Belgrade University School of Medicine; Belgrade Serbia
| | | | | | - Petar Seferovic
- Department of Internal Medicine; Belgrade University School of Medicine and Heart Failure Center, Belgrade University Medical Center; Belgrade Serbia
| | - Frank Ruschitzka
- University Heart Center; University Hospital Zurich; Zurich Switzerland
| |
Collapse
|
17
|
Nguyen LS, Coutance G, Ouldamar S, Zahr N, Brechot N, Galeone A, Bougle A, Lebreton G, Leprince P, Varnous S. Performance of existing risk scores around heart transplantation: validation study in a 4-year cohort. Transpl Int 2018; 31:520-530. [PMID: 29380444 DOI: 10.1111/tri.13122] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/04/2018] [Accepted: 01/23/2018] [Indexed: 11/30/2022]
Abstract
Several risk scores exist to help identify best candidate recipients for heart transplantation (HTx). This study describes the performance of five heart failure risk scores and two post-HTx mortality risk scores in a French single-centre cohort. All patients listed for HTx through a 4-year period were included. Waiting-list risk scores [Heart Failure Survival Score (HFSS), Seattle Heart Failure Model (SHFM), Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC), Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) and Get With The Guidelines-Heart Failure (GWTG-HF)] and post-HTx scores Index for Mortality Prediction After Cardiac Transplantation (IMPACT and CARRS) were computed. Main outcomes were 1-year mortality on waiting list and after HTx. Performance was assessed using receiver operator characteristic (ROC), calibration and goodness-of-fit analyses. The cohort included 414 patients. Waiting-list mortality was 14.0%, and post-HTx mortality was 16.3% at 1-year follow-up. Heart failure risk scores had adequate discrimination regarding waiting-list mortality (ROC AUC for HFSS = 0.68, SHFM = 0.74, OPTIMIZE-HF = 0.72, MAGGIC = 0.70 and GWTG = 0.77; all P-values <0.05). On the contrary, post-HTx risk scores did not discriminate post-HTx mortality (AUC for IMPACT = 0.58, and CARRS = 0.48, both P-values >0.50). Subgroup analysis on patients undergoing HTx after ventricular assistance device (VAD) implantation (i.e. bridge-to-transplantation) (n = 36) showed an IMPACT AUC = 0.72 (P < 0.001). In this single-centre cohort, existing heart failure risk scores were adequate to predict waiting-list mortality. Post-HTx mortality risk scores were not, except in the VAD subgroup.
Collapse
Affiliation(s)
- Lee S Nguyen
- Cardiac and Thoracic Surgery Department, Cardiology Institute, Pitié Salpétrière University Hospital, Paris, France
| | - Guillaume Coutance
- Cardiac and Thoracic Surgery Department, Cardiology Institute, Pitié Salpétrière University Hospital, Paris, France
| | - Salima Ouldamar
- Cardiac and Thoracic Surgery Department, Cardiology Institute, Pitié Salpétrière University Hospital, Paris, France
| | - Noel Zahr
- Pharmacology Department, Pitié Salpétrière University Hospital, Paris, France
| | - Nicolas Brechot
- Critical Care Medicine, Cardiology Institute, Pitié Salpétrière University Hospital, Paris, France
| | - Antonella Galeone
- Cardiac and Thoracic Surgery Department, Cardiology Institute, Pitié Salpétrière University Hospital, Paris, France
| | - Adrien Bougle
- Anesthesiology & Intensive Care Medicine Department, Cardiology Institute, Pitié-Salpétrière University Hospital, Paris, France
| | - Guillaume Lebreton
- Cardiac and Thoracic Surgery Department, Cardiology Institute, Pitié Salpétrière University Hospital, Paris, France
| | - Pascal Leprince
- Cardiac and Thoracic Surgery Department, Cardiology Institute, Pitié Salpétrière University Hospital, Paris, France
| | - Shaida Varnous
- Cardiac and Thoracic Surgery Department, Cardiology Institute, Pitié Salpétrière University Hospital, Paris, France
| |
Collapse
|
18
|
Abstract
PURPOSE OF REVIEW Extended survival with LVADs has generated interest in implantation for ambulatory patients with advanced heart failure (HF) prior to dependence on inotropes, though we remain limited in our ability to define and advance indications in this less sick advanced HF population. RECENT FINDINGS The MedaMACS and ROADMAP studies have informed prognosis and decision-making for ambulatory patients with advanced HF. Sicker INTERMACS profiles are consistently associated with high risk of death or rescue LVAD. Appropriately selected patients in profile 4 should be considered for LVADs based on their high mortality and poor quality of life. These studies also shed light on discordant perceptions of HF disease severity between patients and their physicians. For ambulatory patients with HF not at imminent risk of death, shared decision-making about LVAD requires measured and individualized consideration of risk and benefit beyond survival. Future studies, including the ongoing REVIVAL study, should provide additional prognostic information in this patient population and should aid patients, caregivers, and physicians as they contemplate complex decisions regarding LVAD therapy.
Collapse
|
19
|
Ambardekar AV, Thibodeau JT, DeVore AD, Kittleson MM, Forde-McLean RC, Palardy M, Mountis MM, Cadaret L, Teuteberg JJ, Pamboukian SV, Xie R, Stevenson LW, Stewart GC. Discordant Perceptions of Prognosis and Treatment Options Between Physicians and Patients With Advanced Heart Failure. JACC-HEART FAILURE 2017; 5:663-671. [PMID: 28822745 DOI: 10.1016/j.jchf.2017.04.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/13/2017] [Accepted: 04/25/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES This study assessed patient and physician perceptions of heart failure (HF) disease severity and treatment options. BACKGROUND The prognosis for ambulatory patients with advanced HF on medical therapy is uncertain, yet has important implications for decision making regarding transplantation and left ventricular assist device (LVAD) placement. METHODS Ambulatory patients with advanced HF (New York Heart Association functional class III to IV, Interagency Registry for Mechanically Assisted Circulatory Support profiles 4 to 7) on optimized medical therapy were enrolled across 11 centers. At baseline, treating cardiologists rated patients for perceived risk for transplant, LVAD, or death in the upcoming year. Patients were also surveyed about their own perceptions of life expectancy and willingness to undergo various interventions. RESULTS At enrollment, physicians regarded 111 of 161 patients (69%) of the total cohort to be at high risk for transplant, LVAD, or death, whereas only 23 patients (14%) felt they were at high risk. After a mean follow-up of 13 months, 61 patients (38%) experienced an endpoint of 33 deaths (21%), 13 transplants (8%), and 15 LVAD implants (9%). There was poor discrimination between risk prediction among both patients and physicians. Among physician-identified high-risk patients, 77% described willingness to consider LVAD, but 63% indicated that they would decline 1 or more other simpler forms of life-sustaining therapy such as ventilation, dialysis, or a feeding tube. CONCLUSIONS Among patients with advanced HF, physicians identified most to be at high risk for transplantation, LVAD, or death, whereas few patients recognized themselves to be at high risk. Patients expressed inconsistent attitudes toward lifesaving treatments, possibly indicating poor understanding of these therapies. Educational interventions regarding disease severity and treatment options should be introduced prior to the need for advanced therapies such as intravenous inotropic therapy, transplantation, or LVAD.
Collapse
Affiliation(s)
| | - Jennifer T Thibodeau
- Department of Internal Medicine and Cardiology, University of Texas Southwestern, Dallas, Texas
| | - Adam D DeVore
- Division of Cardiology, Duke University Medical School, Durham, North Carolina
| | | | | | - Maryse Palardy
- Department of Internal Medicine and Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - Maria M Mountis
- Division of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Linda Cadaret
- Division of Cardiology, University of Iowa, Iowa City, Iowa
| | - Jeffrey J Teuteberg
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Salpy V Pamboukian
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rongbing Xie
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lynne W Stevenson
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Garrick C Stewart
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
20
|
Becnel MF, Ventura HO, Krim SR. Changing our Approach to Stage D Heart Failure. Prog Cardiovasc Dis 2017; 60:205-214. [PMID: 28801124 DOI: 10.1016/j.pcad.2017.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Accepted: 08/06/2017] [Indexed: 11/19/2022]
Abstract
Despite the tremendous progress made in the management of heart failure (HF), many patients reach advanced stages. This paper aims to present a practical approach to the stage D HF patient who is no longer responding to optimal medical therapy. We discuss all available therapies for this patient population. We also offer some important caveats with regard to identification, risk stratification, evaluation and treatment including early patient referral to a center with an advanced HF program. Given the changing landscape of heart transplantation and an impending change in the allocation system, we also intend to engage a discussion on the need for a paradigm shift towards left ventricular assist device therapy in this population.
Collapse
Affiliation(s)
- Miriam F Becnel
- Division of Cardiology, John Ochsner Heart and Vascular Institute, New Orleans, LA, United States; Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, United States.
| | - Hector O Ventura
- Division of Cardiology, John Ochsner Heart and Vascular Institute, New Orleans, LA, United States; Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, United States; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, United States.
| | - Selim R Krim
- Division of Cardiology, John Ochsner Heart and Vascular Institute, New Orleans, LA, United States; Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, United States; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA, United States.
| |
Collapse
|
21
|
Lanfear DE, Levy WC, Stehlik J, Estep JD, Rogers JG, Shah KB, Boyle AJ, Chuang J, Farrar DJ, Starling RC. Accuracy of Seattle Heart Failure Model and HeartMate II Risk Score in Non-Inotrope-Dependent Advanced Heart Failure Patients: Insights From the ROADMAP Study (Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device and Medical Management in Ambulatory Heart Failure Patients). Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003745. [PMID: 28465311 DOI: 10.1161/circheartfailure.116.003745] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 03/29/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND Timing of left ventricular assist device (LVAD) implantation in advanced heart failure patients not on inotropes is unclear. Relevant prediction models exist (SHFM [Seattle Heart Failure Model] and HMRS [HeartMate II Risk Score]), but use in this group is not established. METHODS AND RESULTS ROADMAP (Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device and Medical Management in Ambulatory Heart Failure Patients) is a prospective, multicenter, nonrandomized study of 200 advanced heart failure patients not on inotropes who met indications for LVAD implantation, comparing the effectiveness of HeartMate II support versus optimal medical management. We compared SHFM-predicted versus observed survival (overall survival and LVAD-free survival) in the optimal medical management arm (n=103) and HMRS-predicted versus observed survival in all LVAD patients (n=111) using Cox modeling, receiver-operator characteristic (ROC) curves, and calibration plots. In the optimal medical management cohort, the SHFM was a significant predictor of survival (hazard ratio=2.98; P<0.001; ROC area under the curve=0.71; P<0.001) but not LVAD-free survival (hazard ratio=1.41; P=0.097; ROC area under the curve=0.56; P=0.314). SHFM showed adequate calibration for survival but overestimated LVAD-free survival. In the LVAD cohort, the HMRS had marginal discrimination at 3 (Cox P=0.23; ROC area under the curve=0.71; P=0.026) and 12 months (Cox P=0.036; ROC area under the curve=0.62; P=0.122), but calibration was poor, underestimating survival across time and risk subgroups. CONCLUSIONS In non-inotrope-dependent advanced heart failure patients receiving optimal medical management, the SHFM was predictive of overall survival but underestimated the risk of clinical worsening and LVAD implantation. Among LVAD patients, the HMRS had marginal discrimination and underestimated survival post-LVAD implantation. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01452802.
Collapse
Affiliation(s)
- David E Lanfear
- From Henry Ford Hospital, Detroit, MI (D.E.L.); University of Washington, Seattle, WA (W.C.L.); University of Utah, Salt Lake City (J.S.); Houston Methodist Hospital, TX (J.D.E.); Duke University, Durham, NC (J.G.R.); Virginia Commonwealth University, Richmond (K.B.S.); Thomas Jefferson University, University Hospital, Philadelphia, PA (A.J.B.); St. Jude Medical, Pleasanton, CA (J.C., D.J.F.); and Cleveland Clinic, OH (R.C.S.).
| | - Wayne C Levy
- From Henry Ford Hospital, Detroit, MI (D.E.L.); University of Washington, Seattle, WA (W.C.L.); University of Utah, Salt Lake City (J.S.); Houston Methodist Hospital, TX (J.D.E.); Duke University, Durham, NC (J.G.R.); Virginia Commonwealth University, Richmond (K.B.S.); Thomas Jefferson University, University Hospital, Philadelphia, PA (A.J.B.); St. Jude Medical, Pleasanton, CA (J.C., D.J.F.); and Cleveland Clinic, OH (R.C.S.)
| | - Josef Stehlik
- From Henry Ford Hospital, Detroit, MI (D.E.L.); University of Washington, Seattle, WA (W.C.L.); University of Utah, Salt Lake City (J.S.); Houston Methodist Hospital, TX (J.D.E.); Duke University, Durham, NC (J.G.R.); Virginia Commonwealth University, Richmond (K.B.S.); Thomas Jefferson University, University Hospital, Philadelphia, PA (A.J.B.); St. Jude Medical, Pleasanton, CA (J.C., D.J.F.); and Cleveland Clinic, OH (R.C.S.)
| | - Jerry D Estep
- From Henry Ford Hospital, Detroit, MI (D.E.L.); University of Washington, Seattle, WA (W.C.L.); University of Utah, Salt Lake City (J.S.); Houston Methodist Hospital, TX (J.D.E.); Duke University, Durham, NC (J.G.R.); Virginia Commonwealth University, Richmond (K.B.S.); Thomas Jefferson University, University Hospital, Philadelphia, PA (A.J.B.); St. Jude Medical, Pleasanton, CA (J.C., D.J.F.); and Cleveland Clinic, OH (R.C.S.)
| | - Joseph G Rogers
- From Henry Ford Hospital, Detroit, MI (D.E.L.); University of Washington, Seattle, WA (W.C.L.); University of Utah, Salt Lake City (J.S.); Houston Methodist Hospital, TX (J.D.E.); Duke University, Durham, NC (J.G.R.); Virginia Commonwealth University, Richmond (K.B.S.); Thomas Jefferson University, University Hospital, Philadelphia, PA (A.J.B.); St. Jude Medical, Pleasanton, CA (J.C., D.J.F.); and Cleveland Clinic, OH (R.C.S.)
| | - Keyur B Shah
- From Henry Ford Hospital, Detroit, MI (D.E.L.); University of Washington, Seattle, WA (W.C.L.); University of Utah, Salt Lake City (J.S.); Houston Methodist Hospital, TX (J.D.E.); Duke University, Durham, NC (J.G.R.); Virginia Commonwealth University, Richmond (K.B.S.); Thomas Jefferson University, University Hospital, Philadelphia, PA (A.J.B.); St. Jude Medical, Pleasanton, CA (J.C., D.J.F.); and Cleveland Clinic, OH (R.C.S.)
| | - Andrew J Boyle
- From Henry Ford Hospital, Detroit, MI (D.E.L.); University of Washington, Seattle, WA (W.C.L.); University of Utah, Salt Lake City (J.S.); Houston Methodist Hospital, TX (J.D.E.); Duke University, Durham, NC (J.G.R.); Virginia Commonwealth University, Richmond (K.B.S.); Thomas Jefferson University, University Hospital, Philadelphia, PA (A.J.B.); St. Jude Medical, Pleasanton, CA (J.C., D.J.F.); and Cleveland Clinic, OH (R.C.S.)
| | - Joyce Chuang
- From Henry Ford Hospital, Detroit, MI (D.E.L.); University of Washington, Seattle, WA (W.C.L.); University of Utah, Salt Lake City (J.S.); Houston Methodist Hospital, TX (J.D.E.); Duke University, Durham, NC (J.G.R.); Virginia Commonwealth University, Richmond (K.B.S.); Thomas Jefferson University, University Hospital, Philadelphia, PA (A.J.B.); St. Jude Medical, Pleasanton, CA (J.C., D.J.F.); and Cleveland Clinic, OH (R.C.S.)
| | - David J Farrar
- From Henry Ford Hospital, Detroit, MI (D.E.L.); University of Washington, Seattle, WA (W.C.L.); University of Utah, Salt Lake City (J.S.); Houston Methodist Hospital, TX (J.D.E.); Duke University, Durham, NC (J.G.R.); Virginia Commonwealth University, Richmond (K.B.S.); Thomas Jefferson University, University Hospital, Philadelphia, PA (A.J.B.); St. Jude Medical, Pleasanton, CA (J.C., D.J.F.); and Cleveland Clinic, OH (R.C.S.)
| | - Randall C Starling
- From Henry Ford Hospital, Detroit, MI (D.E.L.); University of Washington, Seattle, WA (W.C.L.); University of Utah, Salt Lake City (J.S.); Houston Methodist Hospital, TX (J.D.E.); Duke University, Durham, NC (J.G.R.); Virginia Commonwealth University, Richmond (K.B.S.); Thomas Jefferson University, University Hospital, Philadelphia, PA (A.J.B.); St. Jude Medical, Pleasanton, CA (J.C., D.J.F.); and Cleveland Clinic, OH (R.C.S.)
| |
Collapse
|
22
|
Roderick KV, Abelson AL, Nielsen L, Price LL, Quinn R. Evaluation of red blood cell distribution width as a prognostic indicator in cats with acquired heart disease, with and without congestive heart failure. J Feline Med Surg 2017; 19:648-656. [PMID: 27225272 PMCID: PMC11128818 DOI: 10.1177/1098612x16649988] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives Congestive heart failure secondary to cardiomyopathy is a common manifestation of cardiac disease in cats, carrying a variable prognosis. The objective of this retrospective study was to evaluate the relationship between red blood cell distribution width (RDW) and survival time in feline patients with acquired heart disease with and without congestive heart failure (CHF). Methods Three hundred and forty-nine client-owned cats with echocardiograms and complete blood count, including RDW measurement, performed between March 2006 and December 2011, were included in the study. Patient characteristics, including signalment, hematocrit, RDW, echocardiographic parameters and survival, were recorded. Comparisons between RDW in cats with asymptomatic acquired heart disease and those with CHF were made. Survival was documented and compared at 30 days and 6 months. Results CHF was present in 80 cats and absent in 269 cats. Cats with CHF had an increase in mortality compared with cats without CHF at 30 days and 6 months ( P = 0.007 and P = 0.04, respectively). RDW was not significantly associated with survival in cats with or without CHF at 30 days or 6 months. A significant difference was found between median RDW values in cats with CHF vs cats without CHF (16.3% vs 15.8%; P = 0.02). The median RDW value was significantly higher in cats with unclassified cardiomyopathy compared with cats with other types of cardiomyopathy (16.3% vs 15.8%; P = 0.03). Conclusions and relevance Single RDW values did not predict mortality in cats with acquired heart disease but may be useful in determining if cats have decompensated heart disease and CHF. Human studies indicate that incremental increases in serial RDW measurements are associated with decreased survival; serial RDW measurements in cats may be an area of future study.
Collapse
Affiliation(s)
- Kursten V Roderick
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, USA
- Angell Animal Medical Center, MA, USA
| | - Amanda L Abelson
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, USA
| | | | - Lori Lyn Price
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, MA, USA
- Tufts Clinical and Translational Science Institute, Tufts University, MA, USA
| | | |
Collapse
|
23
|
Abstract
Heart failure presents unique challenges to the clinician who desires to provide excellent and humane care near the end of life. Accurate prediction of mortality in the individual patient is complicated by a chronic disease that is punctuated by recurrent acute episodes and sudden death. Health care providers continue to have difficulty communicating effectively with terminally ill patients and their caregivers regarding end-of-life care preferences, all of which needs to occur earlier rather than later. This article also discusses various means of providing palliative care, and specific issues regarding device therapy, cardiopulmonary resuscitation, and palliative sedation with concurrent discussion of the ethical ramifications and pitfalls of each.
Collapse
Affiliation(s)
- John Arthur McClung
- Division of Cardiology, Westchester Medical Center, New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA.
| |
Collapse
|
24
|
Abstract
Heart failure is a complex clinical syndrome. The natural history of this syndrome is progressive. Advanced heart failure is present when a patient has signs and symptoms of heart failure that are refractory to therapy. Patients with the most advanced disease and worst prognosis can be identified using iterative, integrated clinical assessment of symptom burden, effort intolerance, and cardiac dysfunction. Recognizing the transition to advanced heart failure is necessary for referral to an advanced heart disease program. Advanced heart disease specialists can tailor medical therapies, perform risk stratification, and evaluate candidacy for mechanical support, transplantation, or end-of-life palliative treatment options.
Collapse
Affiliation(s)
- Sunit-Preet Chaudhry
- Department of Medicine, Center for Advanced Heart Disease, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Garrick C Stewart
- Department of Medicine, Center for Advanced Heart Disease, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
| |
Collapse
|
25
|
Laszczyńska O, Severo M, Friões F, Lourenço P, Silva S, Bettencourt P, Lunet N, Azevedo A. Validity of the Seattle Heart Failure Model for prognosis in a population at low coronary heart disease risk. J Cardiovasc Med (Hagerstown) 2017; 17:653-8. [PMID: 25022930 DOI: 10.2459/jcm.0000000000000048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIM Validation of the Seattle Heart Failure Model (SHFM) for predicting the risk of death in a population different than the derivation cohort. METHODS In a retrospective analysis of a cohort of chronic heart failure patients with left ventricular systolic dysfunction, consecutively referred between 2000 and 2011, we computed the score, according to characteristics at referral. We compared the observed risk of death with that predicted by the model, using receiver operating characteristic (ROC) curves to assess discrimination and a goodness-of-fit test for the comparison of predicted and observed risks. RESULTS In 565 patients, 68.5% were men, the median age was 70 years, 46.0% had ischemic cause, 89.7% moderate-severe left ventricular systolic dysfunction and 61.2% New York Heart Association class II. The risk of death increased progressively with the model's score, with an area under the ROC curve between 0.69 and 0.72 when considering different follow-up periods. The model underestimated the risk of death (observed vs. predicted: 12.2 vs. 10.4%, P < 0.001; 28.1 vs. 25.1%, P < 0.001; and 43.4 vs. 35.7%, P < 0.001 at 1, 3 and 5 years, respectively). Accurate predictions, with nonsignificant differences between observed and predicted risks in a goodness-of-fit test, were obtained after recalibration. CONCLUSION In this study, the SHFM substantially underestimated the absolute risk of death in ambulatory chronic heart failure patients, mostly nonischemic and elderly. After adjustment for sample-specific circumstances, the recalibrated model demonstrated to be credible in clinical practice and may provide useful information to physicians.
Collapse
Affiliation(s)
- Olga Laszczyńska
- aInstitute of Public Health of the University of Porto bDepartment of Clinical Epidemiology, Predictive Medicine and Public Health, University of Porto Medical School cHeart Failure Clinic, Department of Internal Medicine, Centro Hospitalar de São João dCardiovascular Research and Development Unit, University of Porto Medical School, Porto, Portugal
| | | | | | | | | | | | | | | |
Collapse
|
26
|
Stewart GC, Kittleson MM, Patel PC, Cowger JA, Patel CB, Mountis MM, Johnson FL, Guglin ME, Rame JE, Teuteberg JJ, Stevenson LW. INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) Profiling Identifies Ambulatory Patients at High Risk on Medical Therapy After Hospitalizations for Heart Failure. Circ Heart Fail 2016; 9:CIRCHEARTFAILURE.116.003032. [DOI: 10.1161/circheartfailure.116.003032] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 10/07/2016] [Indexed: 11/16/2022]
Abstract
Background—
INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profiles provide important prognostic information for patients with advanced heart failure (HF) receiving mechanical support. The value of INTERMACS profiling has not been shown for patients followed on medical therapy for advanced HF at centers that also offer mechanical circulatory support.
Methods and Results—
This prospective, observational study enrolled 166 patients with chronic New York Heart Association class III–IV HF, ejection fraction ≤30%, and ≥1 HF hospitalization in the previous year, excluding patients listed for transplant or receiving chronic intravenous inotropic therapy. Subjects were followed for at least 12 months or until death, mechanical support, or transplant. Baseline features, quality of life, and outcomes were compared according to INTERMACS profile. Mean age was 57 years, ejection fraction 18%, and 57% had HF >5 years, whereas 23% of subjects were INTERMACS profile 4, 32% profile 5, and 45% profile 6/7. At 1 year, only 47% of this ambulatory advanced HF cohort remained alive on medical therapy. Patients in INTERMACS profile 4 were more likely to die or require mechanical support, with only 52% of these patients alive without support after the first 6 months. Profile 6/7 patients had 1-year survival of 84%, similar to outcomes for contemporary destination left ventricular assist device recipients. Quality of life using the indexed EuroQol score was poor across profiles 4 to 7, although severe limitation was less common than for ambulatory patients enrolled in INTERMACS before ventricular assist device implantation.
Conclusions—
Ambulatory patients with systolic HF, a heavy symptom burden, and at least 1 recent HF hospitalization are at high risk for death or left ventricular assist device rescue. INTERMACS profiles help identify ambulatory patients with advanced HF who may benefit from current mechanical support devices under existing indications.
Collapse
Affiliation(s)
- Garrick C. Stewart
- From the Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (G.C.S., L.W.S.); Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.); Department of Medicine, University of Texas Southwestern, Dallas, (P.C.P.); Department of Medicine, University of Michigan, Ann Arbor (J.A.C.); Department of Medicine, Division of Cardiology Duke University, Durham, NC (C.B.P.); Department of Cardiovascular Medicine, Cleveland Clinic
| | - Michelle M. Kittleson
- From the Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (G.C.S., L.W.S.); Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.); Department of Medicine, University of Texas Southwestern, Dallas, (P.C.P.); Department of Medicine, University of Michigan, Ann Arbor (J.A.C.); Department of Medicine, Division of Cardiology Duke University, Durham, NC (C.B.P.); Department of Cardiovascular Medicine, Cleveland Clinic
| | - Parag C. Patel
- From the Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (G.C.S., L.W.S.); Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.); Department of Medicine, University of Texas Southwestern, Dallas, (P.C.P.); Department of Medicine, University of Michigan, Ann Arbor (J.A.C.); Department of Medicine, Division of Cardiology Duke University, Durham, NC (C.B.P.); Department of Cardiovascular Medicine, Cleveland Clinic
| | - Jennifer A. Cowger
- From the Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (G.C.S., L.W.S.); Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.); Department of Medicine, University of Texas Southwestern, Dallas, (P.C.P.); Department of Medicine, University of Michigan, Ann Arbor (J.A.C.); Department of Medicine, Division of Cardiology Duke University, Durham, NC (C.B.P.); Department of Cardiovascular Medicine, Cleveland Clinic
| | - Chetan B. Patel
- From the Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (G.C.S., L.W.S.); Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.); Department of Medicine, University of Texas Southwestern, Dallas, (P.C.P.); Department of Medicine, University of Michigan, Ann Arbor (J.A.C.); Department of Medicine, Division of Cardiology Duke University, Durham, NC (C.B.P.); Department of Cardiovascular Medicine, Cleveland Clinic
| | - Maria M. Mountis
- From the Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (G.C.S., L.W.S.); Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.); Department of Medicine, University of Texas Southwestern, Dallas, (P.C.P.); Department of Medicine, University of Michigan, Ann Arbor (J.A.C.); Department of Medicine, Division of Cardiology Duke University, Durham, NC (C.B.P.); Department of Cardiovascular Medicine, Cleveland Clinic
| | - Frances L. Johnson
- From the Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (G.C.S., L.W.S.); Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.); Department of Medicine, University of Texas Southwestern, Dallas, (P.C.P.); Department of Medicine, University of Michigan, Ann Arbor (J.A.C.); Department of Medicine, Division of Cardiology Duke University, Durham, NC (C.B.P.); Department of Cardiovascular Medicine, Cleveland Clinic
| | - Maya E. Guglin
- From the Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (G.C.S., L.W.S.); Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.); Department of Medicine, University of Texas Southwestern, Dallas, (P.C.P.); Department of Medicine, University of Michigan, Ann Arbor (J.A.C.); Department of Medicine, Division of Cardiology Duke University, Durham, NC (C.B.P.); Department of Cardiovascular Medicine, Cleveland Clinic
| | - J. Eduardo Rame
- From the Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (G.C.S., L.W.S.); Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.); Department of Medicine, University of Texas Southwestern, Dallas, (P.C.P.); Department of Medicine, University of Michigan, Ann Arbor (J.A.C.); Department of Medicine, Division of Cardiology Duke University, Durham, NC (C.B.P.); Department of Cardiovascular Medicine, Cleveland Clinic
| | - Jeffrey J. Teuteberg
- From the Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (G.C.S., L.W.S.); Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.); Department of Medicine, University of Texas Southwestern, Dallas, (P.C.P.); Department of Medicine, University of Michigan, Ann Arbor (J.A.C.); Department of Medicine, Division of Cardiology Duke University, Durham, NC (C.B.P.); Department of Cardiovascular Medicine, Cleveland Clinic
| | - Lynne W. Stevenson
- From the Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (G.C.S., L.W.S.); Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.); Department of Medicine, University of Texas Southwestern, Dallas, (P.C.P.); Department of Medicine, University of Michigan, Ann Arbor (J.A.C.); Department of Medicine, Division of Cardiology Duke University, Durham, NC (C.B.P.); Department of Cardiovascular Medicine, Cleveland Clinic
| |
Collapse
|
27
|
Meyers DE, Goodlin SJ. End-of-Life Decisions and Palliative Care in Advanced Heart Failure. Can J Cardiol 2016; 32:1148-56. [DOI: 10.1016/j.cjca.2016.04.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/14/2016] [Accepted: 04/25/2016] [Indexed: 12/21/2022] Open
|
28
|
Is cardiopulmonary exercise testing essential to indicate ventricular assist device implantation in patients with INTERMACS profile 4-7? J Artif Organs 2016; 19:226-32. [PMID: 26992711 DOI: 10.1007/s10047-016-0893-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 03/04/2016] [Indexed: 10/22/2022]
Abstract
Cardiopulmonary exercise testing (CPXT) is a promising tool for predicting 2-year cardiac death or ventricular assist device (VAD) implantation in patients assigned to INTERMACS profile 4-7. However, CPXT is not available in all hospitals. We evaluated 130 patients <65 years old with advanced heart failure assigned to INTERMACS profile 4-7 who underwent CPXT. CPXT scores (0-8 points), which we created recently, and the Seattle HF Model (SHFM) scores were both significant predictors of 2-year cardiac death or VAD implantation (14 events) by Cox-regression analysis (P < 0.05 for both) and had comparable areas under the curve (AUCs) in receiver operating characteristic analyses (0.811 vs. 0.737, P > 0.05). The combination score: age <46 years and serum sodium concentration <137 mEq/L, both of which were significant predictors of cardiac death or VAD implantation by uni/multivariate Cox-regression analyses, had a significantly higher AUC than did CPXT scores (0.909, P < 0.05). In a validation study, the AUC of the combination score was comparable with that of SHFM among 52 patients <65 years old receiving adaptive servo-ventilator treatment (0.753 vs. 0.794, P > 0.05). In conclusion, VAD indication may be discussed without CPXT in patients <65 years old with INTERMACS profile 4-7 at least in the current Japanese situation.
Collapse
|
29
|
Ambardekar AV, Forde-McLean RC, Kittleson MM, Stewart GC, Palardy M, Thibodeau JT, DeVore AD, Mountis MM, Cadaret L, Teuteberg JJ, Pamboukian SV, Cantor RS, Lindenfeld J. High early event rates in patients with questionable eligibility for advanced heart failure therapies: Results from the Medical Arm of Mechanically Assisted Circulatory Support (Medamacs) Registry. J Heart Lung Transplant 2016; 35:722-30. [PMID: 26987599 DOI: 10.1016/j.healun.2016.01.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 12/17/2015] [Accepted: 01/10/2016] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The prognosis of ambulatory patients with advanced heart failure (HF) who are not yet inotrope dependent and implications for evaluation and timing for transplant or destination therapy with a left ventricular assist device (DT-LVAD) are unknown. We hypothesized that the characteristics defining eligibility for advanced HF therapies would be a primary determinant of outcomes in these patients. METHODS Ambulatory patients with advanced HF (New York Heart Association class III-IV, Interagency Registry for Mechanically Assisted Circulatory Support profiles 4-7) were enrolled across 11 centers from May 2013 to February 2015. Patients were stratified into 3 groups: likely transplant eligible, DT-LVAD eligible, and ineligible for both transplant and DT-LVAD. Clinical characteristics were collected, and patients were prospectively followed for death, transplant, and left ventricular assist device implantation. RESULTS The study enrolled 144 patients with a mean follow-up of 10 ± 6 months. Patients in the ineligible cohort (n = 43) had worse congestion, renal function, and anemia compared with transplant (n = 51) and DT-LVAD (n = 50) eligible patients. Ineligible patients had higher mortality (23.3% vs 8.0% in DT-LVAD group and 5.9% in transplant group, p = 0.02). The differences in mortality were related to lower rates of transplantation (11.8% in transplant group vs 2.0% in DT-LVAD group and 0% in ineligible group, p = 0.02) and left ventricular assist device implantation (15.7% in transplant group vs 2.0% in DT-LVAD group and 0% in ineligible group, p < 0.01). CONCLUSIONS Ambulatory patients with advanced HF who were deemed ineligible for transplant and DT-LVAD had markers of greater HF severity and a higher rate of mortality compared with patients eligible for transplant or DT-LVAD. The high early event rate in this group emphasizes the need for timely evaluation and decision making regarding lifesaving therapies.
Collapse
Affiliation(s)
| | | | | | - Garrick C Stewart
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Maryse Palardy
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jennifer T Thibodeau
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Adam D DeVore
- Division of Cardiology, Duke University Medical School, Durham, North Carolina
| | - Maria M Mountis
- Division of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Linda Cadaret
- Division of Cardiology, University of Iowa, Iowa City, Iowa
| | - Jeffrey J Teuteberg
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Ryan S Cantor
- Division of Cardiothoracic Surgery, and Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | | |
Collapse
|
30
|
AbouEzzeddine OF, French B, Mirzoyev SA, Jaffe AS, Levy WC, Fang JC, Sweitzer NK, Cappola TP, Redfield MM. From statistical significance to clinical relevance: A simple algorithm to integrate brain natriuretic peptide and the Seattle Heart Failure Model for risk stratification in heart failure. J Heart Lung Transplant 2016; 35:714-21. [PMID: 27021278 DOI: 10.1016/j.healun.2016.01.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 12/21/2015] [Accepted: 01/10/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Heart failure (HF) guidelines recommend brain natriuretic peptide (BNP) and multivariable risk scores, such as the Seattle Heart Failure Model (SHFM), to predict risk in HF with reduced ejection fraction (HFrEF). A practical way to integrate information from these 2 prognostic tools is lacking. We sought to establish a SHFM+BNP risk-stratification algorithm. METHODS The retrospective derivation cohort included consecutive patients with HFrEF at the Mayo Clinic. One-year outcome (death, transplantation or ventricular assist device) was assessed. The SHFM+BNP algorithm was derived by stratifying patients within SHFM-predicted risk categories (≤2.5%, 2.6% to ≤10%, >10%) according to BNP above or below 700 pg/ml and comparing SHFM-predicted and observed event rates within each SHFM+BNP category. The algorithm was validated in a prospective, multicenter HFrEF registry (Penn HF Study). RESULTS Derivation (n = 441; 1-year event rate 17%) and validation (n = 1,513; 1-year event rate 12%) cohorts differed with the former being older and more likely ischemic with worse symptoms, lower EF, worse renal function and higher BNP and SHFM scores. In both cohorts, across the 3 SHFM-predicted risk strata, a BNP >700 pg/ml consistently identified patients with approximately 3-fold the risk that the SHFM would have otherwise estimated, regardless of stage of HF, intensity and duration of HF therapy and comorbidities. Conversely, the SHFM was appropriately calibrated in patients with a BNP <700 pg/ml. CONCLUSION The simple SHFM+BNP algorithm displays stable performance across diverse HFrEF cohorts and may enhance risk stratification to enable appropriate decision-making regarding HF therapeutic or palliative strategies.
Collapse
Affiliation(s)
- Omar F AbouEzzeddine
- Department of Cardiovascular Diseases, Mayo Clinic and Foundation, Rochester, Minnesota, USA; Mayo Graduate School, Mayo Clinic and Foundation, Rochester, Minnesota, USA
| | - Benjamin French
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic and Foundation, Rochester, Minnesota, USA; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Wayne C Levy
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - James C Fang
- Division of Cardiovascular Medicine, University Hospital, Salt Lake City, Utah, USA
| | - Nancy K Sweitzer
- Division of Cardiology, University of Arizona, Tucson, Arizona, USA
| | - Thomas P Cappola
- Penn Cardiovascular Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Margaret M Redfield
- Department of Cardiovascular Diseases, Mayo Clinic and Foundation, Rochester, Minnesota, USA.
| |
Collapse
|
31
|
Mehra MR, Canter CE, Hannan MM, Semigran MJ, Uber PA, Baran DA, Danziger-Isakov L, Kirklin JK, Kirk R, Kushwaha SS, Lund LH, Potena L, Ross HJ, Taylor DO, Verschuuren EA, Zuckermann A. The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update. J Heart Lung Transplant 2016; 35:1-23. [DOI: 10.1016/j.healun.2015.10.023] [Citation(s) in RCA: 856] [Impact Index Per Article: 107.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 10/18/2015] [Indexed: 01/06/2023] Open
|
32
|
Vakil KP, Roukoz H, Tung R, Levy WC, Anand IS, Shivkumar K, Rector TS, Vaseghi M, Tholakanahalli V. Mortality prediction using a modified Seattle Heart Failure Model may improve patient selection for ventricular tachycardia ablation. Am Heart J 2015; 170:1099-104. [PMID: 26678631 DOI: 10.1016/j.ahj.2015.09.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 09/09/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Catheter ablation is frequently used as a palliative option to reduce shock burden in patients with ventricular tachycardia (VT). A risk prediction tool that accurately predicts short-term survival could improve patient selection for VT ablation. OBJECTIVE The objective of the study is to assess utility of the Seattle Heart Failure Model (SHFM) to predict 6-month mortality in patients undergoing VT ablation. METHODS Data on patients who underwent VT ablation at 2 tertiary institutions were retrospectively compiled. The SHFM score at the time of ablation, including 2 added VT variables, was used to predict 6-month mortality. The predicted number of deaths was compared to the observed number to assess model calibration. Model discrimination of those who died within 6 months was assessed by both K- and C-statistics. RESULTS Mean age of the 243 patients was 63 ± 12 years; 89% were male. Mean SHFM score for the cohort was 1.3 ± 1.3. The Kaplan-Meier probability of death within 6 months was 14% (34 patients). The number of deaths estimated by the SHFM at 6 months was 31 (13%) giving a predicted to observed ratio of 0.91 (95% CI 0.64-1.30). The K-statistic for 6-month mortality predictions was 0.77 (95% CI 0.73-0.81), whereas the C-statistic was 0.84 (95% CI 0.78-0.92). Patients with an SHFM score ≥4.0 had an estimated positive predictive value of 80% (95% CI 28%-99%) for dying within 6 months of VT ablation. CONCLUSION The SHFM was well calibrated to a sample of patients who underwent VT ablation and provided good discrimination of short-term deaths. This model could be useful as a prognostic tool to improve patient selection for VT ablation.
Collapse
Affiliation(s)
- Kairav P Vakil
- Division of Cardiology, University of Minnesota, Minneapolis, MN; Division of Cardiology, Veterans Affairs Health Care System, Minneapolis, MN.
| | - Henri Roukoz
- Division of Cardiology, University of Minnesota, Minneapolis, MN
| | - Roderick Tung
- Division of Cardiology, University of California, Los Angeles, CA
| | - Wayne C Levy
- Division of Cardiology, University of Washington, Seattle, WA
| | - Inder S Anand
- Division of Cardiology, University of Minnesota, Minneapolis, MN; Division of Cardiology, Veterans Affairs Health Care System, Minneapolis, MN
| | | | - Thomas S Rector
- Center for Chronic Disease Outcomes Research, Veterans Affairs Health Care System and Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Marmar Vaseghi
- Division of Cardiology, University of California, Los Angeles, CA
| | - Venkatakrishna Tholakanahalli
- Division of Cardiology, University of Minnesota, Minneapolis, MN; Division of Cardiology, Veterans Affairs Health Care System, Minneapolis, MN
| |
Collapse
|
33
|
Rodríguez-Reyes H, Muñoz Gutiérrez M, Márquez MF, Pozas Garza G, Asensio Lafuente E, Ortíz Galván F, Lara Vaca S, Mariona Montero VA. [Sudden cardiac death. Risk stratification, prevention and treatment]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2015; 85:329-36. [PMID: 26253348 DOI: 10.1016/j.acmx.2015.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 06/01/2015] [Indexed: 11/19/2022] Open
Affiliation(s)
| | | | - Manlio F Márquez
- Servicio de Electrocardiología, Instituto Nacional de Cardiología Ignacio Chávez, México, México
| | - Gerardo Pozas Garza
- Servicio de Cardiología, Hospital San José Tecnológico de Monterrey, Monterrey, México
| | | | - Fernando Ortíz Galván
- Centro Universitario del Sur (CUSUR), Universidad de Guadalajara, Cd. Guzmán, Jalisco, México
| | - Susano Lara Vaca
- Servicio de Arritmias, Centro Médico IMSS, León Guanajuato, México
| | | |
Collapse
|
34
|
Abstract
Angiotensin-converting enzyme inhibitors (ACEIs) have been the cornerstone in systolic heart failure (HF) regimens over the past 25 years. Their ability to block the renin–angiotensin–aldosterone system and their vasodilatory properties has repeatedly been shown to lower morbidity and mortality in patients with HF having reduced ejection fractions. In August 2014, the New England Journal of Medicine published a large trial studying a novel LCZ696 (angiotensin–neprilysin inhibition) agent against enalapril, an ACEI. In the phase III trial, LCZ696 demonstrated superiority to enalapril in composite death from cardiovascular causes and hospitalization for HF. The trial was stopped early due to overwhelming benefit of the study agent. This article provides an extensive review of the mechanism of action, pharmacokinetic properties, clinical efficacy, safety, and tolerability of LCZ696.
Collapse
Affiliation(s)
- Antony Q. Pham
- Arnold and Marie Schwartz College of Pharmacy and Health Sciences, LIU Pharmacy, Brooklyn, NY, USA
- Department of Veterans Affairs—Manhattan Campus, New York Harbor Healthcare System, New York, NY, USA
| | - Yesha Patel
- Arnold and Marie Schwartz College of Pharmacy and Health Sciences, LIU Pharmacy, Brooklyn, NY, USA
| | - Brittany Gallagher
- Department of Veterans Affairs—Manhattan Campus, New York Harbor Healthcare System, New York, NY, USA
| |
Collapse
|
35
|
Incremental and independent value of cardiopulmonary exercise test measures and the Seattle Heart Failure Model for prediction of risk in patients with heart failure. J Heart Lung Transplant 2015; 34:1017-23. [PMID: 25940075 DOI: 10.1016/j.healun.2015.03.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 02/17/2015] [Accepted: 03/16/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Multivariable risk scores and exercise measures are well-validated risk prediction methods. Combining information from a functional evaluation and a risk model may improve accuracy of risk predictions. We analyzed whether adding exercise measures to the Seattle Heart Failure Model (SHFM) improves risk prediction accuracy in systolic heart failure. METHODS We used a sample of patients from the Heart Failure and A Controlled Trial Investigating Outcomes of Exercise TraiNing (HF-ACTION) study (http://www.clinicaltrials.gov; unique identifier: NCT00047437) to examine the addition of peak oxygen consumption, expired volume per unit time/volume of carbon dioxide slope, 6-minute walk distance, or cardiopulmonary exercise duration to the SHFM. Multivariable Cox proportional hazards models were used to test the association between the combined end point (death, left ventricular assist device, or cardiac transplantation) and the addition of exercise variables to the SHFM. RESULTS The sample included 2,152 patients. The SHFM and all exercise measures were associated with events (all p < 0.0001) in proportional hazards models. There was statistically significant improvement in risk estimation when exercise measures were added to the SHFM. However, the improvement in the C index for the addition of peak volume of oxygen consumption (+0.01), expired volume per unit time/volume of carbon dioxide slope (+0.02), 6-minute walk distance (-0.001), and cardiopulmonary exercise duration (+0.001) to the SHFM was small or slightly worse than the SHFM alone. Changes in risk assignment with the addition of exercise variables were minimal for patients above or below a 15% 1-year mortality. CONCLUSIONS Exercise performance measures and the SHFM are independently useful for predicting risk in systolic heart failure. Adding cardiopulmonary exercise testing measures and 6MWD to the SHFM offers only minimal improvement in risk reassignment at clinically meaningful cut points.
Collapse
|
36
|
Physical and psychological symptom profiling and event-free survival in adults with moderate to advanced heart failure. J Cardiovasc Nurs 2015; 29:315-23. [PMID: 23416942 DOI: 10.1097/jcn.0b013e318285968a] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
UNLABELLED : Heart failure (HF) is a heterogeneous symptomatic disorder. The goal of this study was to identify and link common profiles of physical and psychological symptoms to 1-year event-free survival in adults with moderate to advanced HF. METHODS Multiple valid, reliable, and domain-specific measures were used to assess physical and psychological symptoms. Latent class mixture modeling was used to identify distinct symptom profiles. Associations between observed symptom profiles and 1-year event-free survival were quantified using Cox proportional hazards modeling. RESULTS The mean age of the participants (n = 202) was 57 ± 13 years, 50% were men, and 60% had class III/IV HF. Three distinct profiles, mild (41.7%), moderate (30.2%), and severe (28.1%), that captured a gradient of both physical and psychological symptom burden were identified (P < .001 for all comparisons). Controlling for the Seattle HF Score, adults with the moderate symptom profile were 82% more likely (hazard ratio, 1.82; 95% confidence interval, 1.07-3.11; P = .028) and adults with the severe symptom profile were more than twice as likely (hazard ratio, 2.06; 95% confidence interval, 1.21-3.52; P = .001) to have a clinical event within 1 year than patients with the mild symptom profile. CONCLUSIONS Profiling patterns among physical and psychological symptoms identifies HF patient subgroups with significantly worse 1-year event-free survival independent of prognostication based on objective clinical HF data.
Collapse
|
37
|
Sartipy U, Goda A, Yuzefpolskaya M, Mancini DM, Lund LH. Utility of the Seattle Heart Failure Model in patients with cardiac resynchronization therapy and implantable cardioverter defibrillator referred for heart transplantation. Am Heart J 2014; 168:325-31. [PMID: 25173544 DOI: 10.1016/j.ahj.2014.03.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Accepted: 03/25/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The Seattle Heart Failure Model (SHFM) predicts survival in heart failure but may underestimate risk in severe heart failure, and the performance has not been evaluated explicitly in patients with cardiac resynchronization therapy (CRT) and/or implantable cardioverter defibrillator (ICD) referred for heart transplantation. We aimed to assess the utility of the SHFM by validation in patients with CRT and/or ICD referred for heart transplantation. METHODS We assessed the SHFM performance in 382 patients with CRT and/or ICD referred for heart transplantation. Outcome was survival free from urgent transplantation or left ventricular assist device. Model discrimination and calibration were assessed graphically and by formal tests. RESULTS During a mean follow-up of 2.3 years, 195 events occurred. One-, 2-, and 3-year observed event-free survival was 77%, 62%, and 52%, and the observed to predicted event-free survival ratio was 0.89, 0.80, and 0.76. Calibration plots demonstrated results deviating from the ideal calibration line at 1, 2, and 3 years. The SHFM score adequately assigned patients in discrete risk strata, according to Kaplan-Meier estimated survival. Time-dependent receiver operating characteristic curve analyses demonstrated good discrimination overall, which was slightly better for 1-year (area under the curve [AUC] 0.774) compared with 2-year (AUC 0.742) and 3-year (AUC 0.728) event-free survival. CONCLUSIONS The SHFM has good discrimination but underestimates risk of adverse outcomes in patients with CRT and/or ICD referred for heart transplantation. The SHFM may be used to assess relative risk and changes over time, but when assessing absolute percentage of event-free survival, the overestimation of event-free survival should be accounted for.
Collapse
|
38
|
Alraies MC, Eckman P. Adult heart transplant: indications and outcomes. J Thorac Dis 2014; 6:1120-8. [PMID: 25132979 DOI: 10.3978/j.issn.2072-1439.2014.06.44] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 06/03/2014] [Indexed: 12/14/2022]
Abstract
Cardiac transplantation is the treatment of choice for many patients with end-stage heart failure (HF) who remain symptomatic despite optimal medical therapy. For carefully selected patients, heart transplantation offers markedly improved survival and quality of life. Risk stratification of the large group of patients with end-stage HF is essential for identifying patients who are most likely to benefit, particularly as the number of suitable donors is insufficient to meet demand. The indications for heart transplant and review components of the pre-transplant evaluation, including the role for exercise testing and risk scores such as the Heart Failure Survival Score (HFSS) and Seattle Heart Failure Model (SHFM) are summarized. Common contraindications are also discussed. Outcomes, including survival and common complications such as coronary allograft vasculopathy are reviewed.
Collapse
Affiliation(s)
- M Chadi Alraies
- Department of Medicine, Division of Cardiovascular Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Peter Eckman
- Department of Medicine, Division of Cardiovascular Medicine, University of Minnesota, Minneapolis, MN, USA
| |
Collapse
|
39
|
Sartipy U, Goda A, Mancini DM, Lund LH. Assessment of a University of California, Los Angeles 4-variable risk score for advanced heart failure. J Am Heart Assoc 2014; 3:e000998. [PMID: 24906370 PMCID: PMC4309113 DOI: 10.1161/jaha.114.000998] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND The 4-variable risk score from University of California, Los Angeles (UCLA) demonstrated superior discrimination in advanced heart failure, compared to established risk scores. However, the model has not been externally validated, and its suitability as a selection tool for heart transplantation (HT) and left ventricular assist device (LVAD) is unknown. METHODS AND RESULTS We calculated the UCLA risk score (based on B-type natriuretic peptide, peak VO2, New York Heart Association class, and use of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker) in 180 patients referred for HT. The outcome was survival free from urgent transplantation or LVAD. The model-predicted survival was compared to Kaplan-Meier's estimated survival at 1, 2, and 3 years. Model discrimination and calibration were assessed. During a mean follow-up of 2.1 years, 37 (21%) events occurred. One-, 2- and 3-year observed event-free survival was 88%, 81%, and 75%, and the observed/predicted ratio was 0.97, 0.96, and 0.97, respectively. Time-dependent receiver operating characteristic curve analyses demonstrated good discrimination overall (1-year area under curve, 0.801; 2-year, 0.774; 3-year, 0.837), but discrimination between the 2 highest risk groups was poor. The difference between observed and predicted survival ranged from -14 to +17 percentage points, suggesting poor model calibration. Fairly similar results were found when the analyses were repeated in 715 patients after multivariate imputation of missing data. CONCLUSIONS The UCLA 4-variable risk model calibration was inconsistent and high-risk discrimination was poor in an external validation cohort. Further model assessment is warranted before widespread use.
Collapse
Affiliation(s)
- Ulrik Sartipy
- Department of Cardiothoracic Surgery and Anesthesiology, Karolinska University Hospital, Stockholm, Sweden (U.S.) Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (U.S.)
| | - Ayumi Goda
- Cardiology Department, Kyorin University, Tokyo, Japan (A.G.)
| | - Donna M Mancini
- Center for Advanced Cardiac Care, Columbia University Medical Center, New York, NY (D.M.M.)
| | - Lars H Lund
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (L.H.L.) Department of Medicine, Karolinska Institutet, Stockholm, Sweden (L.H.L.)
| |
Collapse
|
40
|
Abstract
Background—
A paradoxical inspiratory rise in right atrial pressure (in contrast to the normal fall during inspiration), Kussmaul sign, has been described in congestive heart failure (CHF). However, the clinical and hemodynamic characteristics and clinical outcomes of patients with CHF and Kussmaul physiology have not been studied.
Methods and Results—
This is a single-center study of consecutive ambulant patients with CHF (New York Heart Association class III/IV) referred for assessment for heart transplantation between November 2011 and April 2013. Kussmaul physiology was defined as inspiratory rise in right atrial pressure during right heart catheterization. Clinical, biochemical, echocardiographic, and hemodynamic correlates were studied and outcomes assessed in patients with or without Kussmaul physiology after a mean follow-up of 379±227 days. Ninety ambulant patients (age, 53±12 years; 86% men) with CHF were studied. Kussmaul physiology was demonstrated in 39 (43%) patients, and it was associated with higher pulmonary pressures and lower cardiac index and pulmonary capacitance (all
P
<0.05). Patients with Kussmaul physiology were more likely to be treated with higher doses of diuretics, while higher filling pressures, N-terminal pro–B natriuretic peptide levels, and hyponatremia reflected greater neurohormonal activation. Echocardiography revealed greater left and right ventricular dimensions/volumes, restrictive transmitral filling pattern, and lower left ventricular ejection fraction and lower tricuspid annular plane systolic excursion. Peak oxygen uptake was low and comparable in both groups, but ventilation slope was higher in patients with Kussmaul physiology who also had a higher incidence of post-transplant right ventricular failure and overall mortality (
P
<0.05).
Conclusions—
Kussmaul physiology is common in patients with CHF referred for heart transplantation and is associated with adverse cardiopulmonary hemodynamics. As a result of the latter, Kussmaul physiology is associated with poorer clinical outcomes. Kussmaul physiology may be useful during assessment of right heart function and pulmonary pressures before transplantation.
Collapse
Affiliation(s)
- Adnan M. Nadir
- From the Department of Cardiology, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Roger Beadle
- From the Department of Cardiology, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Hoong Sern Lim
- From the Department of Cardiology, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| |
Collapse
|
41
|
Petretta M, Petretta A, Pellegrino T, Nappi C, Cantoni V, Cuocolo A. Role of nuclear cardiology for guiding device therapy in patients with heart failure. World J Meta-Anal 2014; 2:1-16. [DOI: 10.13105/wjma.v2.i1.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 11/20/2013] [Accepted: 12/19/2013] [Indexed: 02/05/2023] Open
Abstract
Heart failure is a dynamic condition with high morbidity and mortality and its prognosis should be reassessed frequently, particularly in patients for whom critical treatment decisions may depend on the results of prognostication. In patients with heart failure, nuclear cardiology techniques are useful to establish the etiology and the severity of the disease, while fewer studies have explored the potential capability of nuclear cardiology to guide cardiac resynchronization therapy (CRT) and to select patients for implantable cardioverter defibrillators (ICD). Left ventricular synchrony may be assessed by radionuclide angiography or gated single-photon emission computed tomography myocardial perfusion scintigraphy. These modalities have shown promise as predictors of CRT outcome using phase analysis. Combined assessment of myocardial viability and left ventricular dyssynchrony is feasible using positron emission tomography and could improve conventional response prediction criteria for CRT. Preliminary data also exists on integrated positron emission tomography/computed tomography approach for assessing myocardial viability, identifying the location of biventricular pacemaker leads, and obtaining left ventricular functional data, including contractile phase analysis. Finally, cardiac imaging with autonomic radiotracers may be useful in predicting CRT response and for identifying patients at risk for sudden cardiac death, therefore potentially offering a way to select patients for both CRT and ICD therapy. Prospective trials where imaging is combined with image-test driven therapy are needed to better define the role of nuclear cardiology for guiding device therapy in patients with heart failure.
Collapse
|
42
|
Rosenbaum AN, John R, Liao KK, Adatya S, Colvin-Adams MM, Pritzker M, Eckman PM. Survival in elderly patients supported with continuous flow left ventricular assist device as bridge to transplantation or destination therapy. J Card Fail 2014; 20:161-7. [PMID: 24412524 DOI: 10.1016/j.cardfail.2013.12.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 12/11/2013] [Accepted: 12/18/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Published data on mechanical circulatory support for elderly patients in continuous flow devices are sparse and suggest relatively poor survival. This study investigated whether LVADs can be implanted in selected patients over the age of 65 years with acceptable survival compared with published outcomes. METHODS AND RESULTS A single-center retrospective analysis was conducted in 64 consecutive patients ≥65 years of age implanted with a continuous-flow left ventricular assist device (CF-LVAD) as either bridge to transplantation or destination therapy from August 2005 to January 2012. Baseline laboratory and hemodynamic characteristics and follow-up data were obtained. Median survival was 1,090 days. Survival was 85%, 74%, 55%, and 45% at 6 months and 1, 2, and 3 years, respectively. Our cohort had a baseline mean Seattle Heart Failure Model (SHFM) score of 2.6 ± 0.9. Observed survival was significantly better than SHFM-predicted medical survival. Stratification by age subsets, renal function, SHFM, implantation intention, or etiology did not reveal significant differences in survival. The most common cause of death was sepsis and nonlethalcomplication was bleeding. CONCLUSIONS Our experience with patients over the age of 65 receiving CF-LVADs suggests that this group demonstrates excellent survival. Further research is needed to discern the specific criteria for risk stratification for LVAD support in the elderly.
Collapse
Affiliation(s)
- Andrew N Rosenbaum
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Ranjit John
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Kenneth K Liao
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Sirtaz Adatya
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Monica M Colvin-Adams
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Marc Pritzker
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Peter M Eckman
- Cardiovascular Division, Department of Medicine, University of Minnesota, Minneapolis, Minnesota.
| |
Collapse
|
43
|
Scrutinio D, Ammirati E, Guida P, Passantino A, Raimondo R, Guida V, Sarzi Braga S, Canova P, Mastropasqua F, Frigerio M, Lagioia R, Oliva F. The ADHF/NT-proBNP risk score to predict 1-year mortality in hospitalized patients with advanced decompensated heart failure. J Heart Lung Transplant 2013; 33:404-11. [PMID: 24485712 DOI: 10.1016/j.healun.2013.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 10/24/2013] [Accepted: 12/11/2013] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND The acute decompensated heart failure/N-terminal pro-B-type natriuretic peptide (ADHF/NT-proBNP) score is a validated risk scoring system that predicts mortality in hospitalized heart failure patients with a wide range of left ventricular ejection fractions (LVEFs). We sought to assess discrimination and calibration of the score when applied to patients with advanced decompensated heart failure (AHF). METHODS We studied 445 patients hospitalized for AHF, defined by the presence of severe symptoms of worsening HF at admission, severely depressed LVEF, and the need for intravenous diuretic and/or inotropic drugs. The primary outcome was cumulative (in-hospital and post-discharge) mortality and post-discharge 1-year mortality. Separate analyses were performed for patients aged ≤ 70 years. A Seattle Heart Failure Score (SHFS) was calculated for each patient discharged alive. RESULTS During follow-up, 144 patients (32.4%) died, and 69 (15.5%) underwent heart transplantation (HT) or ventricular assist device (VAD) implantation. After accounting for the competing events (VAD/HT), the ADHF/NT-proBNP score's C-statistic for cumulative mortality was 0.738 in the overall cohort and 0.771 in patients aged ≤ 70 years. The C-statistic for post-discharge mortality was 0.741 and 0.751, respectively. Adding prior (≤6 months) hospitalizations for HF to the score increased the C-statistic for post-discharge mortality to 0.759 in the overall cohort and to 0.774 in patients aged ≤ 70 years. Predicted and observed mortality rates by quartiles of score were highly correlated. The SHFS demonstrated adequate discrimination but underestimated the risk. The ADHF/NT-proBNP risk calculator is available at http://www.fsm.it/fsm/file/NTproBNPscore.zip. CONCLUSIONS Our data suggest that the ADHF/NT-proBNP score may efficiently predict mortality in patients hospitalized with AHF.
Collapse
Affiliation(s)
- Domenico Scrutinio
- Division of Cardiology and Cardiac Rehabilitation, "S. Maugeri" Foundation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Institute of Cassano Murge. Bari.
| | - Enrico Ammirati
- Cardiothoracic and Vascular Department, Niguarda Ca' Granda Hospital, Milan; San Raffaele Scientific Institute and University, Milan
| | - Pietro Guida
- Division of Cardiology and Cardiac Rehabilitation, "S. Maugeri" Foundation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Institute of Cassano Murge. Bari
| | - Andrea Passantino
- Division of Cardiology and Cardiac Rehabilitation, "S. Maugeri" Foundation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Institute of Cassano Murge. Bari
| | - Rosa Raimondo
- Division of Cardiology and Cardiac Rehabilitation, "S. Maugeri" Foundation, IRCCS, Institute of Tradate, Varese, Italy
| | - Valentina Guida
- Cardiothoracic and Vascular Department, Niguarda Ca' Granda Hospital, Milan
| | - Simona Sarzi Braga
- Division of Cardiology and Cardiac Rehabilitation, "S. Maugeri" Foundation, IRCCS, Institute of Tradate, Varese, Italy
| | - Paolo Canova
- Cardiothoracic and Vascular Department, Niguarda Ca' Granda Hospital, Milan
| | - Filippo Mastropasqua
- Division of Cardiology and Cardiac Rehabilitation, "S. Maugeri" Foundation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Institute of Cassano Murge. Bari
| | - Maria Frigerio
- Cardiothoracic and Vascular Department, Niguarda Ca' Granda Hospital, Milan
| | - Rocco Lagioia
- Division of Cardiology and Cardiac Rehabilitation, "S. Maugeri" Foundation, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Institute of Cassano Murge. Bari
| | - Fabrizio Oliva
- Cardiothoracic and Vascular Department, Niguarda Ca' Granda Hospital, Milan
| |
Collapse
|
44
|
Abstract
BACKGROUND Risk stratification is an integral component of clinical decision making in heart failure (HF). Women with HF have unique characteristics compared with men, and it is unknown whether common prognostic factors are equally useful in both populations. We aimed to investigate whether sex-specific risk models are more accurate for risk prediction in patients with advanced HF. METHODS AND RESULTS Patients with advanced HF referred to University of California, Los Angeles (UCLA; n=2255), were stratified by sex into derivation (referred in 2000-2007) and validation (referred in 2008-2011) cohorts. Cox regression analysis was used to ascertain key variables predictive of the primary end point of death/urgent transplantation/ventricular assist device in the derivation cohorts and confirmed in the validation cohorts in men, women, and the total population. Women were younger, with higher ejection fraction and better event-free survival. Despite differences in baseline characteristics, the 4 strongest predictors of outcome in both women and men, as well as in the total cohort, were B-type natriuretic peptide, peak oxygen consumption by cardiopulmonary exercise testing (pkVO2), New York Heart Association (NYHA) classification, and use of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. In addition, the UCLA model performed better than the Seattle Heart Failure Model (SHFM) and the Heart Failure Survival Score (HFSS) in our cohort (c-indices of 0.791[UCLA] versus 0.758 [SHFM], 0.607 [noninvasive HFSS], and 0.625 [invasive HFSS]). CONCLUSIONS A simple risk model assessing 4 clinical variables-B-type natriuretic peptide, pkVO2, NYHA, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use-is well suited to provide prognostic information in both men and women with advanced HF.
Collapse
Affiliation(s)
- Jennifer Chyu
- Division of Cardiology, University of Washington, Seattle
| | | | | | | |
Collapse
|
45
|
Vakil KP, Dardas T, Dhar S, Moorman A, Anand I, Maggioni A, Linker DT, Mozaffarian D, Levy WC. Impact of renal dysfunction on the Seattle Heart Failure Model. J Heart Lung Transplant 2013; 33:163-9. [PMID: 24315784 DOI: 10.1016/j.healun.2013.10.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Revised: 10/10/2013] [Accepted: 10/16/2013] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Renal dysfunction (RD) is a strong predictor of mortality in patients with heart failure (HF). However, its impact on the discrimination of the Seattle Heart Failure Model (SHFM) is poorly understood. METHODS Serum creatinine (SCr) and creatinine clearance (CrCl) were reviewed for patients from four of the six cohorts originally used to derive and validate the SHFM. Patients were followed for death. The independent prediction of adding SCr or CrCl to the SHFM was assessed using multivariable Cox proportional hazards and the incremental value for prediction by changes in the ROC curves for 1- and 2-year event prediction. RESULTS Among 7,146 patients (mean age 63 ± 11 years), 1,511 deaths occurred during a mean follow-up of 2.04 years. SCr and CrCl had a modest positive correlation with SHFM (r = 0.30, p = 0.002). In combination with SHFM, SCr (hazard ratio [HR] per mg/dl 1.25, 95% CI 1.13 to 1.38, p < 0.0001) and CrCl (HR per 10 ml/min 0.95, 95% CI 0.93 to 0.97, p < 0.0001) were both multivariable predictors of events. When stratified by absolute risk based on the SHFM, SCr or CrCl provided more additional information in lower risk patients and less or no additional information in higher risk patients. The addition of SCr and the SHFM*SCr, or CrCl and the SHFM*CrCl interaction to the SHFM was associated with almost no change in the 1- and 2-year area under ROC curves for the SHFM score. CONCLUSIONS Compared with the SHFM alone, RD is independently predictive of mortality only in lower risk patients. Overall discrimination is only minimally improved with addition of SCr or CrCl to the SHFM.
Collapse
Affiliation(s)
- Kairav P Vakil
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota.
| | - Todd Dardas
- Division of Cardiology, University of Washington, Seattle, Washington
| | - Sunil Dhar
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Alec Moorman
- Division of Cardiology, University of Washington, Seattle, Washington
| | - Inder Anand
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Aldo Maggioni
- Division of Cardiology, Italian Association of Hospital Cardiologists Research Center, Florence, Italy
| | - David T Linker
- Division of Cardiology, University of Washington, Seattle, Washington
| | - Dariush Mozaffarian
- Division of Cardiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Wayne C Levy
- Division of Cardiology, University of Washington, Seattle, Washington
| |
Collapse
|
46
|
Alba AC, Agoritsas T, Jankowski M, Courvoisier D, Walter SD, Guyatt GH, Ross HJ. Risk Prediction Models for Mortality in Ambulatory Patients With Heart Failure. Circ Heart Fail 2013; 6:881-9. [DOI: 10.1161/circheartfailure.112.000043] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Ana C. Alba
- From the Heart Failure and Transplantation Program, Toronto General Hospital, University Health Network, Ontario, Canada (A.C.A., H.J.R.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (T.A., S.D.W., G.H.G.); Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland (M.J.); and Center for Health Behavior Monitoring and Intervention, University of Rhode Island, Kingston, RI (D.C.)
| | - Thomas Agoritsas
- From the Heart Failure and Transplantation Program, Toronto General Hospital, University Health Network, Ontario, Canada (A.C.A., H.J.R.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (T.A., S.D.W., G.H.G.); Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland (M.J.); and Center for Health Behavior Monitoring and Intervention, University of Rhode Island, Kingston, RI (D.C.)
| | - Milosz Jankowski
- From the Heart Failure and Transplantation Program, Toronto General Hospital, University Health Network, Ontario, Canada (A.C.A., H.J.R.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (T.A., S.D.W., G.H.G.); Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland (M.J.); and Center for Health Behavior Monitoring and Intervention, University of Rhode Island, Kingston, RI (D.C.)
| | - Delphine Courvoisier
- From the Heart Failure and Transplantation Program, Toronto General Hospital, University Health Network, Ontario, Canada (A.C.A., H.J.R.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (T.A., S.D.W., G.H.G.); Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland (M.J.); and Center for Health Behavior Monitoring and Intervention, University of Rhode Island, Kingston, RI (D.C.)
| | - Stephen D. Walter
- From the Heart Failure and Transplantation Program, Toronto General Hospital, University Health Network, Ontario, Canada (A.C.A., H.J.R.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (T.A., S.D.W., G.H.G.); Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland (M.J.); and Center for Health Behavior Monitoring and Intervention, University of Rhode Island, Kingston, RI (D.C.)
| | - Gordon H. Guyatt
- From the Heart Failure and Transplantation Program, Toronto General Hospital, University Health Network, Ontario, Canada (A.C.A., H.J.R.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (T.A., S.D.W., G.H.G.); Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland (M.J.); and Center for Health Behavior Monitoring and Intervention, University of Rhode Island, Kingston, RI (D.C.)
| | - Heather J. Ross
- From the Heart Failure and Transplantation Program, Toronto General Hospital, University Health Network, Ontario, Canada (A.C.A., H.J.R.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (T.A., S.D.W., G.H.G.); Department of Internal Medicine, Jagiellonian University Medical College, Krakow, Poland (M.J.); and Center for Health Behavior Monitoring and Intervention, University of Rhode Island, Kingston, RI (D.C.)
| |
Collapse
|
47
|
Abstract
PURPOSE OF REVIEW Advanced heart failure (AHF) is an increasingly important field. Both the population of AHF patients and the therapeutic and diagnostic interventions available are expanding, creating a host of difficult ethical challenges. This article discusses these important issues and proposes an approach to caring for AHF patients. RECENT FINDINGS Recent guidelines and clinical trials describe the benefits of costly and invasive therapies for AHF, such as ventricular assist devices and cardiac resynchronization therapy which prolong life and improve symptoms but may create burdens and conflict over deactivation at the end of life. Prognostication, informed consent, and early involvement of palliative care are central to addressing the decision-making challenges raised by these devices. Societal concerns such as cost-effectiveness and distributive justice will play an increasingly important role in the dissemination of these devices. SUMMARY More research, increased end-of-life education, emphasis on advance directives, a more comprehensive informed consent process, and a true multidisciplinary approach are needed to provide optimal care for patients with AHF.
Collapse
|
48
|
Lewis EF. Assessing the impact of heart failure therapeutics on quality of life and functional capacity. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:425-36. [PMID: 23625508 DOI: 10.1007/s11936-013-0249-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OPINION STATEMENT Chronic heart failure (CHF) is an increasingly common disorder with major impact on morbidity and mortality. Goals of therapy include improving survival, attenuating progression of disease, improving functional capacity, and improving health-related quality of life (HRQL). Although there are multiple HRQL instruments that are psychometrically valid, concerns exist on the ability to reliably measure HRQL concepts. Nevertheless, there has been an emphasis on improving HRQL and thus novel therapies and clinical trials have included HRQL assessment routinely. Nonpharmacologic interventions have made a greater impact on HRQL, including the use of transcutaneous aortic valve replacement, left ventricular assist devices, and cardiac resynchronization devices. Pharmacologic therapies have resulted in modest improvements in HRQL and these improvements are often not clinically meaningful to the patient and not lasting beyond 6 months. As novel therapies are developed for CHF patients, researchers must: (a) identify mechanisms that may meaningfully improve HRQL, (b) develop better instruments to measure HRQL, and (c) target the right population with enough impairment in their sense of well-being to enable an intervention to work. The recent publication of the Food and Drug Administration Draft Guidance for Use of Patient-Reported Outcome measures in clinical trials has served as the foundation for more robust trial design using these HRQL measures.
Collapse
Affiliation(s)
- Eldrin F Lewis
- Center for Advanced Heart Disease, Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA,
| |
Collapse
|
49
|
Lockie T, Redwood S. Future Directions for Percutaneous Mechanical Circulatory Support Devices. Interv Cardiol Clin 2013; 2:485-494. [PMID: 28582108 DOI: 10.1016/j.iccl.2013.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Outcomes of patients in cardiogenic shock remain high, but the development of novel percutaneous mechanical circulatory support devices offers additional therapeutic options. Hand in hand with innovations in device technology, however, must also come development of integrated circulatory support networks focusing on rapid assessment of patients, multidisciplinary discussion, and timely therapeutic intervention. This article summarizes some of the recent developments in device technology; potential procedures for patient risk stratification, device selection, and response to therapy; management of vascular access to reduce insertion point complications; and some of the expanding potential roles of percutaneous mechanical circulatory support devices.
Collapse
Affiliation(s)
- Tim Lockie
- Cardiothoracic Centre, St Thomas' Hospital, Guys & St Thomas' NHS Trust, Westminster Bridge Road, London SE1 7EH, UK
| | - Simon Redwood
- King's College London British Heart Foundation Centre of Excellence, The Rayne Institute, St Thomas' Hospital Campus, London, UK.
| |
Collapse
|
50
|
Allen LA, Magid DJ, Gurwitz JH, Smith DH, Goldberg RJ, Saczynski J, Thorp ML, Hsu G, Sung SH, Go AS. Risk factors for adverse outcomes by left ventricular ejection fraction in a contemporary heart failure population. Circ Heart Fail 2013; 6:635-46. [PMID: 23709659 DOI: 10.1161/circheartfailure.112.000180] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although heart failure (HF) is a syndrome with important differences in response to therapy by left ventricular ejection fraction (LVEF), existing risk stratification models typically group all HF patients together. The relative importance of common predictor variables for important clinical outcomes across strata of LVEF is relatively unknown. METHODS AND RESULTS We identified all members with HF between 2005 and 2008 from 4 integrated healthcare systems in the Cardiovascular Research Network. LVEF was categorized as preserved (LVEF ≥ 50% or normal), borderline (41%-49% or mildly reduced), and reduced (≤ 40% or moderately to severely reduced). We used Cox regression models to identify independent predictors of death and hospitalization by LVEF category. Among 30094 ambulatory adults with HF, mean age was 74 years and 46% were women. LVEF was preserved in 49.5%, borderline in 16.2%, and reduced in 34.3% of patients. During a median follow-up of 1.8 years (interquartile range, 0.8-3.1), 8060 (26.8%) patients died, 8108 (26.9%) were hospitalized for HF, and 20272 (67.4%) were hospitalized for any reason. In multivariable models, nearly all tested covariates performed similarly across LVEF strata for the outcome of death from any cause, as well as for HF-related and all-cause hospitalizations. CONCLUSIONS We found that in a large, diverse contemporary HF population, risk assessment was strikingly similar across all LVEF categories. These data suggest that, although many HF therapies are uniquely applied to patients with reduced LVEF, individual prognostic factor performance does not seem to be significantly related to level of left ventricular systolic function.
Collapse
Affiliation(s)
- Larry A Allen
- Institute for Health Research, Kaiser Permanente Colorado, Denver, CO, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|